A Feasibility Study of Delivering Adolescent Nutrition Interventions Through School-Based Platforms in Ethiopia: A Cluster-Randomized Evaluation
Phase: NA
Conditions: Dietary Diversity
Sponsor: International Food Policy Research Institute

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A Feasibility Study of Delivering Adolescent Nutrition 
Interventions through School-Based Platforms in 
Ethiopia: A Cluster-Randomized Evaluation 
 
 
 
Study Protocol 
 
 
 
 
 
International Food Policy Research Institute 
 
 
January 15, 2021 
 
VERSION: 2 
 
 
Clinicaltrials.gov: NCT04121559

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Funding: We acknowledge funding support from the Bill & Melinda Gates Foundation (grant no. 
OPP1171874), through Alive & Thrive, managed by FHI Solutions LLC. Additional financial support was 
provided by CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), led by the 
International Food Policy Research Institute. 
Roles and responsibilities: 
Co-Investigators: 
Dr. Sunny S. Kim 
Research Fellow 
Poverty, Health and Nutrition Division 
International Food Policy Research Institute  
1201 I St. NW 
Washington, DC 20005-3915 
USA 
Phone: +1 202-862-4611 
Email: sunny.kim@cgiar.org  
 
 
 
 
Dr. Purnima Menon 
 
 
 
Senior Research Fellow 
 
 
 
Poverty, Health and Nutrition Division 
 
 
 
9th Floor, Aggarwal Corporate Tower 
 
 
 
Govind Lal Sikka Marg, Rajendra Place 
 
 
 
New Delhi 110008 
 
 
 
India 
 
 
 
Phone: +91 11-66219-276 
 
 
 
Email: p.menon@cgiar.org  
 
Dr. Amare Worku Tadesse  
Associate Professor of Nutrition and Public Health  
Head, Department of Public Health Sciences 
Addis Continental Institute of Public Health (ACIPH)  
Yeka Sub City, Woreda 13, House No. B227  
P.O. Box: 26751/1000 
Addis Ababa  
Ethiopia  
Phone: +251 116-390018  
Email: amarewaciph@gmail.com  
 
Protocol contributors:  Sunny Kim (Principal Investigator), Celeste Sununtnasuk (Project Manager), 
Amare Worku (Co-Principal Investigator), Yemane Berhane (ACIPH Director, 
Technical Advisor), Phuong Nguyen (Research Fellow), Purnima Menon (Co-
Principal Investigator) 
 
Sponsor: 
 
International Food Policy Research Institute (IFPRI)  
1201 I St. NW 

3 
Washington, DC 20005-3915 
USA 
Phone: +1 202-862-3915 
 

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Contents 
I. 
Introduction .......................................................................................................................................... 6 
1.1 Background and rationale ............................................................................................................... 6 
1.2 Objectives ........................................................................................................................................ 6 
1.3 Trial design ...................................................................................................................................... 7 
II. 
Methods: Participants, Interventions and Outcomes ........................................................................... 7 
2.1 Study setting ................................................................................................................................... 7 
2.2 Eligibility criteria .............................................................................................................................. 9 
2.3 Interventions ................................................................................................................................... 9 
2.4 Outcomes ...................................................................................................................................... 10 
2.5 Participant timeline ....................................................................................................................... 11 
2.6 Sample Size ................................................................................................................................... 11 
2.7 Recruitment .................................................................................................................................. 12 
III. 
Methods: Assignment of Interventions ............................................................................................... 12 
3.1 Allocation ...................................................................................................................................... 12 
3.2 Blinding (masking) ......................................................................................................................... 12 
IV. Methods: Data Collection, Management and Analysis........................................................................ 12 
4.1 Data collection methods ............................................................................................................... 12 
4.1.1 Primary school observation checklist .................................................................................. 15 
4.1.2 Teacher/Principal questionnaire ......................................................................................... 16 
4.1.3 HEW questionnaire ............................................................................................................. 16 
4.1.4 Adolescent girl questionnaire ............................................................................................. 17 
4.1.5 Parent questionnaire .......................................................................................................... 18 
4.2 COVID-19 precautionary measures ............................................................................................... 19 
4.3 Data management ......................................................................................................................... 20 
4.4 Statistical methods ........................................................................................................................ 20 
V. 
Monitoring .......................................................................................................................................... 20 
5.1 Data monitoring ............................................................................................................................ 20 
5.2 Harms ............................................................................................................................................ 20 
5.3 Auditing ......................................................................................................................................... 20 
VI. Ethics and Dissemination .................................................................................................................... 21 
6.1 Research ethics approval .............................................................................................................. 21 
6.2 Protocol amendments ................................................................................................................... 21 

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6.3 Consent or assent .......................................................................................................................... 21 
6.4 Confidentiality ............................................................................................................................... 21 
6.5 Declaration of interests ................................................................................................................. 21 
6.6 Access to data ............................................................................................................................... 22 
6.7 Ancillary and post-trial care........................................................................................................... 22 
6.8 Dissemination policy ..................................................................................................................... 22 
VII. Timeline............................................................................................................................................... 23 
7.1 Study timeline ............................................................................................................................... 23 
References ................................................................................................................................................... 26 
 
List of Tables 
Table 1. Study woredas and total number of primary schools available ....................................................... 9 
Table 2. Description of interventions for treatment and control primary schools ........................................ 9 
Table 3. Sample sizes ................................................................................................................................... 11 
Table 4. Data collection methods and topics .............................................................................................. 15 
Table 5. Description of topics to be included in the primary school observation checklist ......................... 15 
Table 6. Description of modules in the teacher/principal questionnaire .................................................... 16 
Table 8. Description of modules in the adolescent girl questionnaire ........................................................ 17 
Table 9. Description of modules in the adolescent girls’ parents’ questionnaire ........................................ 18 
 
List of Figures 
Figure 1. Study regions .................................................................................................................................. 8 
Figure 2. Trial flow ....................................................................................................................................... 14 
 
 
 

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I. 
Introduction 
1.1 Background and rationale 
Adolescence is a critical period of physical and psychological development and for achieving human 
potential. Rapid physical, psychosocial and cognitive growth and development is coupled with increased 
energy and nutrient requirements (Das et al., 2017; Spear 2002). Poor nutrition during adolescence can 
have adverse consequences impacting health in adulthood. The significance of nutrition during 
adolescence is especially important for girls, as poor nutrition can affect their well-being as well as the 
survival, health and well-being of their children (Das et al. 2017). Data and evidence on the nutritional 
status of adolescents in low- and middle-income countries is scarce, even though they represent some 
1.8 billion individuals. Globally, the health and nutrition status of adolescents have only modestly 
improved over the last 50 years (Akseer et al. 2017).  
In Ethiopia, where the population is very young with 40 percent under the age of 15 years (UNDP 2017), 
evidence on the nutrition of adolescent girls and their determinants is limited as literature tends to 
focus on issues of child marriage, education, economic empowerment, and sexual and reproductive 
health (Stavropoulou and Gupta-Archer 2017). There is, however, growing recognition of the 
importance of adolescent health and well-being (Patton et al. 2016). In 2015, the UN Secretary-
General’s Global Strategy for Women’s, Children’s, and Adolescents’ Health was launched, in part, to 
include adolescents as a focus of the new Sustainable Development Goals. The federal government of 
Ethiopia has adopted a package of adolescent nutrition interventions into national guidelines (see 
Ethiopia’s Federal Ministry of Health (FMOH) National Guideline on Adolescent, Maternal, Infant and 
Young Child Nutrition).  
Alive & Thrive (A&T) is an initiative that supports the scaling up of nutrition interventions to save lives, 
prevent illnesses, and contribute to healthy growth and development through improved maternal 
nutrition, breastfeeding and complementary feeding practices in several countries. In October 2017, 
A&T was awarded by the Bill & Melinda Gates Foundation’s Ethiopia Office a new five-year agreement 
to Accelerate Improvements in Maternal, Adolescent, Infant and Young Child Nutrition in Ethiopia. The 
A&T Ethiopia 3.0 investment (2018–2022) will support the government of Ethiopia to achieve targets set 
out in the national nutrition program (NNP II) and the National Nutrition Sensitive Agriculture Strategy 
(NNSAS). A&T will focus its role on strengthening systems at the national and regional level for achieving 
large scale and sustainability, and strengthening the evidence base for programs and policies. 
In Ethiopia, A&T will test the feasibility of implementing a package of locally tailored adolescent 
nutrition interventions through school-based (in-class curriculum, extracurricular activities, parent-
teacher associations and activities) and community platforms. The impacts of these nutrition-focused 
interventions will be compared with standard school and community activities in control areas.  
1.2 Objectives 
To evaluate the feasibility and impact of delivering nutrition interventions through school-based 
platforms on diet quality among adolescent girls.  
Research questions for the evaluation include: 
1) Is it feasible to integrate locally relevant adolescent nutrition interventions through school-
based platforms?  

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2) What are the barriers and opportunities for strengthening school-based nutrition interventions 
for adolescents? 
3) What are the impacts of interventions on the quality of diets (dietary diversity and less 
consumption of unhealthy snacks) among adolescent girls? 
1.3 Trial design 
The evaluation will use a two-arm cluster-randomized, non-masked trial design, consisting of two cross-
sectional surveys at baseline and endline. The unit of randomization is the primary school which includes 
grades 1-8. The baseline survey will take place in October-November 2019 (when the school year 
begins), and the endline survey will place in March-April 2021 (following the end of first semester 
classes). Program implementation was halted from March to October 2020 due to the COVID-19 
pandemic, thus the endline survey was postponed to the following school year after implementation 
was reinitiated. The study design will allow us to assess the impact of adolescent nutrition interventions 
delivered through school on adolescent girls aged 10-14 years enrolled in grades 4-8.  
II. 
Methods: Participants, Interventions and Outcomes 
2.1 Study setting 
Implementation of the adolescent nutrition study will take place in two regions: Southern Nations 
Nationalities and People’s Region (SNNPR), a primarily agrarian region, and Somali, a region with a high 
population of pastoralists (see Figure 1). The Somali region is among the poorest of Ethiopia’s nine 
administrative regions, predominantly rural, and relatively ethnically homogeneous. According to the 
most recent Ethiopian census in 2007, 38 percent of the population in Somali is pastoral compared with 
less than one percent in SNNPR (CSA 2007). SNNPR is one of the most populous regions in Ethiopia as 
well as the most diverse; more than 80 ethnic groups reside in the region. 
Study regions were selected at the request of the Government of Ethiopia, so that adolescent nutrition 
intervention packages be tested in both agrarian and pastoral settings. Pastoralists—agriculturalists who 
rely primarily on their livestock for their food and income—and the regions they live have had few 
opportunities to be studied in the past. Their migratory nature makes it particularly difficult to track 
them through surveys. Policymakers are requesting programmatic experience across regions so that 
results and interventions can be used for the scale-up of nationally accepted guidelines and targets. 
Current guidelines for the primary school system are standardized nationwide, providing further 
incentive to include diverse areas for study implementation. 
 

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Figure 1. Study regions 
 
Net primary school attendance is moderate nationwide, but lower in the Somali region: the net 
attendance ratio (percentage of official primary school-age population that attends primary school) is 
73.8 in SNNPR and 59.2 in Somali (compared to 71.3 nationwide) (see Table 1). While there is gender 
parity in primary school attendance in SNNPR, the net attendance ratio for girls is 5.9 percentage points 
lower than the ratio for boys in Somali. Though not ideal, primary schools offer one of the few 
opportunities for the government to reach a substantial number of adolescent girls in the 10 to 14-year 
age group through nationally scaled up programs. 
School dropout is a serious concern; in 2014, 61.8 percent of students who started primary school 
dropped out between the first and last grade (World Bank EdStats, 2019). Dropout rates are roughly the 
same for boys (62.7 percent) and girls (60.7 percent). Primary school-life expectancy is 6.2 years (6.4 for 
boys and 5.9 for girls). In 2015, there were more than 2.2 million children of primary school age who 
were not in school, 60.8 percent of which were girls (World Bank EdStats, 2019). The desirability of 
sending girls to school may be improved through additional services such as adolescent nutrition-related 
activities.   
Information on dietary diversity among adolescent girls and boys 10-14 years of age is unavailable in the 
2016 EDHS. However, body mass index (BMI) indicators are available for boys and girls ages 15-19 years 
of age. A low BMI can indicate eating too little or having an unbalanced diet that lacks adequate 
nutrients. Roughly 45 percent of adolescent girls in Somali and 17.4 percent of adolescent girls in SNNPR 
are thin (BMI <18.5 kg/m2). Thinness is more common among adolescent boys: 78.1 percent are thin in 
Somali and 45.2 percent are thin in SNNPR. 
Information on dietary intake is critical for appropriate planning of interventions that can effectively 
improve the diets and nutritional status of adolescents. But few studies have assessed dietary diversity 
among adolescents and school-aged children in Ethiopia. Those that have are limited to specific regions 
and towns across the country. Of the studies reviewed by a recent A&T landscape analysis of adolescent 
health and nutrition in Ethiopia, mean dietary diversity scores ranged from 3 food groups (Herrador et 
al. 2014) to 7 (Gali et al. 2017), with the average scores across studies being 4.5 food groups 
(Truebwasser 2017). Knowledge of healthy food choices among adolescents may also be limited. A 
Knowledge, Attitudes and Practice (KAP) survey conducted in several regions (including SNNPR and 
SNNPR 
Somali 

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Somali) of Ethiopia found that only two thirds of adolescent girls reported hearing about balanced diets. 
In Somali, 85 percent had not heard about balanced diets (FMoH and UNICEF, 2016). 
Across SNNPR and Somali regions, A&T selected seven woredas (districts) as potential intervention areas 
on the basis of having adequate school access and infrastructure. Four woredas were selected in SNNPR 
and three woredas in Somali region. In Somali, woredas with more settled communities and less security 
issues were selected; fewer woredas were also selected, compared with SNNPR, as the communities are 
more homogenous. The list of study woredas and their corresponding total numbers of primary schools 
with grades 1-8 are presented in Table 1.  
Table 1. Study woredas and total number of primary schools available 
No. Region 
Zone 
Woreda 
Population 
Kebeles 
Primary Schools 
with grades 1-8 
1 
Somali 
Fafan 
Gursum 
37,425 
15 
11 
2 
Fafan 
Harawa 
32,034 
16 
9 
3 
Fafan 
Keberi Beyah 
165,518 
29 
15 
4 
SNNPR 
Gurage 
Sodo 
175,400 
54 
32 
5 
Gurage 
Muhor Na Aklil 
119,137 
29 
34 
6 
Silti 
Dalocha 
89,807 
18 
19 
7 
Kembata Tembaro 
Doyo Gena 
78,634 
18 
23 
 
2.2 Eligibility criteria 
To be eligible for inclusion in the study, adolescent girls must be enrolled in the study primary school, be 
between 10 to 14 years of age (grades 4-8) and have received parental consent and given assent to 
participate in the study. Adolescent girls will be excluded if they or their parent/guardian are unwilling 
to participate in any part of the baseline or endline surveys.  
At the school level, the principal and science teacher, and health extension workers (HEW) responsible 
for providing nutrition education or facilitating other related activities/interventions and have given 
informed consent will be interviewed.  
2.3 Interventions 
The package of locally tailored adolescent nutrition interventions will include in-school education about 
nutrition and healthy food choices, mentoring and peer group activities related to nutrition, and parent 
education on adolescent nutrition during school and community meetings. Intervention components are 
presented in Table 2.  
Table 2. Description of interventions for treatment and control primary schools 
CORE INTERVENTIONS 
INTERVENTION PRIMARY SCHOOLS 
CONTROL PRIMARY SCHOOLS 
At school:  
 
 
• Classroom education 
about healthy diet and 
nutrition 
Classroom lessons related to nutrition, dietary 
diversity, healthy food choices and hand 
washing 
Standard health education   
• Flag events or assemblies 
about healthy diet and 
nutrition   
Flag events or school assemblies led by 
principals to provide messages on nutrition, 
dietary diversity, healthy food choices and 
hand washing 
Standard flag ceremonies or 
assemblies  

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2.4 Outcomes 
The primary outcome of the study focuses on diet quality measures: 
1) Dietary diversity among adolescent girls 
i. 
Mean number of food groups consumed by adolescent girls 
ii. 
Proportion of adolescent girls who achieve minimum dietary diversity (at least 5 food 
groups) 
The secondary outcomes relate to exposure to and utilization of key nutrition interventions, as well as 
service provider capacities. These include: 
2) Meal frequency and healthy food choices among adolescent girls (less consumption of sugary 
drinks and salty/fatty processed foods)  
3) Exposure to nutrition interventions at school and to nutrition information from school, health 
workers, and other sources among adolescent girls and their parents  
4) Nutrition knowledge and handwashing knowledge and practices among adolescent girls and 
their parents 
• Peer group mentoring on 
healthy diets and 
nutrition 
Selected adolescent girls are mentored by 
science teachers as peer mentors and hold 
weekly group discussions with other girls to 
discuss nutrition, dietary diversity, healthy 
food choices and handwashing 
None 
• BMI measurement and 
counseling 
Trained science teachers take anthropometric 
measurements of adolescent girls to calculate 
BMI and provide nutrition counseling 
None 
Parent-teacher meetings 
Parent-teacher meetings to inform and 
encourage parents about adolescent 
nutrition, dietary diversity, healthy snacks, 
and handwashing  
Parent-teacher associations 
focused on school 
performance and 
management  
Home visits by health workers 
Home visits by HEWs and/or community 
volunteers to discuss with parents about 
adolescent nutrition, dietary diversity, i 
healthy food choices, and handwashing 
Home visits for routine health 
services 
Community gatherings to 
discuss adolescent nutrition  
Community gatherings by HEWs and meetings 
with religious leaders to discuss with parents 
about adolescent nutrition, dietary diversity, 
healthy food choices, and handwashing 
None 
Training for school staff and 
other actors  
Workshop on the adolescent nutrition 
interventions above for school principals, 
science teachers, HEWs, supervisors, and 
woreda officers   
Standard education training 
Supportive supervision for 
school staff and other actors  
Biweekly supportive supervision on 
adolescent nutrition activities for schools and 
HEWs by school supervisors or woreda 
health/education office    
Standard school supervision 

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5) School teacher, principal and HEW knowledge on benefits and intervention content for dietary 
diversity and healthy foods/snacks, and handwashing  
6) Availability of resources (educational materials, healthy food environments, and training and 
supportive supervision for teachers/staff) 
2.5 Participant timeline 
Enrollment of adolescent girls will take place in October 2019, at the time of baseline survey. 
Interventions were planned to be implemented for a single school year (approximately 7 months), from 
October 2019 (when the school year/regular school classes begin) to May-June 2020 (when the regular 
school classes end for the school year).  
In March 2020, the World Health Organization declared COVID-19 a pandemic. School closures and 
disruptions to work and field conditions in Ethiopia resulted in program implementation being halted in 
March 2020. Trainings for school principals, teachers and HEWs re-initiated in November 2020, and 
interventions will be implemented through the first school semester. Adolescent girls will be assessed at 
endline in March-April 2021.  
2.6 Sample Size  
The primary study sample is adolescent girls enrolled in primary school and aged 10-14 years (grades 4-
8). The sample size was estimated based on current prevalence of the primary outcome, the expected 
change after intervention, power to detect those differences (80%), and level of significance (α=0.05). As 
the intervention was randomized at the cluster level (54 clusters) rather than the individual level, cluster 
effect was considered for sample size calculation.  
We used the number of food groups from the A&T Phase 1 endline survey for SNNPR (mean: 3.26, SD: 
1.40, categorized as 9 food groups; Arimond et al., 2010), assuming an intra-cluster correlation (ICC) of 
0.18. We calculated that a minimum sample of 189 girls per group will be able to detect a minimum of 
0.6 food group consumption increase. The sample size at endline will be rounded to 270 girls per group 
so that 10 girls per school (2 per grade) will be sampled. Based on baseline data, we observed a mean of 
3.69, SD: 1.56, categorized as 10 food groups. Assuming an ICC of 0.015, we estimated that this sample 
size will detect a minimum difference of 0.5 food groups. 
School principals, science teachers and HEWs responsible for providing nutrition education or facilitating 
other related activities/interventions will also be included in both baseline and endline surveys.  
At baseline, a light data collection at schools and subsamples of adolescent girls and their parents will be 
conducted to assess comparability between study arms. At endline, the full samples of adolescent girls 
and their parents will be surveyed (including those who participated at baseline).  
Thus, the overall study samples are presented in Table 3. 
Table 3. Sample sizes 
 
Baseline 2019 
Endline 2021 
 
Intervention 
Control 
Intervention 
Control 
Adolescent girls  
81 
81 
270 
270 
Parents of adolescents  
81 
81 
270 
270 
Principals (1 per school) 
27 
27 
27 
27 

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Science teachers (1 per school) 
27 
27 
27 
27 
HEWs (1 per school) 
27 
27 
27 
27 
Total 
243 
243 
621 
621 
 
2.7 Recruitment 
Study participants will be sampled using a school-based sampling strategy. Lists of eligible adolescent 
girls will be taken from primary school enrollment registries. Enrollment typically begins in late 
September and continues for roughly two weeks after school begins to accommodate for any delays. 
Enrollment records (available at the time of the survey) will be used to verify the birthdate/age of 
eligible students, which may be recorded from birth certificates or self-reported. Then, adolescent girls 
will be randomly selected by simple random sampling until the required sample size is reached and 
visited at home to be recruited and interviewed. 
III. 
Methods: Assignment of Interventions 
3.1 Allocation  
A cluster is defined as the primary school that includes grades 1-8. Four woredas in SNNPR (with 31 
schools) and three woredas in Somali region (with 23 schools), i.e., one school under each woreda 
school supervisor, were selected as potential intervention areas (see Figure 3). (Within woredas, there 
are designated supervisors at the education office who are responsible for supervising 1-7 schools. 
Supervisors are responsible for visiting schools one day per week (less frequently in the Somali region) 
and are provided with a checklist to ensure that schools are operating effectively. As feasible, we tried 
to select one school under the responsibility of a (unique) supervisor, to avoid study contamination and 
confusion among supervisors in conducting their duties.) The samples across the two regions will be 
pooled to estimate effects at program level. We will use stratified randomization within woreda to try to 
balance potential co-interventions and confounders. Then 27 schools will be allocated to the 
intervention arm and 27 schools will be allocated to the control arm by use of computer-generated 
pseudo-random numbers. 
3.2 Blinding (masking)   
This evaluation study will be unblinded. Adolescents in the intervention areas will not be informed about 
the results of the randomization. However, there will be no blinding of the interventions at schools or 
other points of service delivery.  
IV. 
Methods: Data Collection, Management and Analysis 
4.1 Data collection methods 
Data will be collected at the primary school and  household levels, using pretested questionnaires. The 
following set of tools will be translated from English to Ahmaric and used during the baseline and 
endline surveys: 
i. 
Primary school observation checklist 
ii. 
Teacher/Principal questionnaire 
iii. 
Health Extension Worker (HEW) questionnaire 
iv. 
Adolescent girl questionnaire 

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v. 
Parents questionnaire  
Topics included in each of the data collection methods are presented in Table 4. 
 
 
 

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Figure 2. Trial flow 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Note: The baseline and endline surveys will include cross-sectional interviews of adolescent girls, as well as their 
parents, school principals, science teachers, and HEWs. 
2019 Baseline: Household and school-level surveys 
27 primary schools 
A&T intervention areas 
Adolescent nutrition activities 
integrated in primary schools 
27 primary schools 
Comparison areas 
Standard extracurricular 
activities in primary schools  
2021 Endline: Household and school-level surveys 
Comparison between program groups 
Randomization 
31 primary schools in SNNPR 
23 primary schools in Somali 

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Table 4. Data collection methods and topics  
Data collection 
method 
Topics included 
Primary school 
observation checklist 
Infrastructure, WASH, supplies, food environment, and nutrition education 
materials (e.g. posters) and displays 
Teacher/Principal 
questionnaire 
Teacher/principal background, school role, nutrition-related activities/ 
interventions, perceptions/beliefs, nutrition knowledge 
HEW questionnaire 
HEW background, school and community role, nutrition-related activities, 
perceptions/beliefs, nutrition knowledge 
Adolescent girl 
questionnaire 
Adolescent background, school attendance, meal and snacking patterns, 
home food environment, nutrition knowledge, WASH practices, social 
desirability, parental interaction and other influencers (including sharing 
education messages and materials), gender and marriage beliefs and decision-
making power  
Parent questionnaire  
Household roster, social involvement, exposure to nutrition information, 
dietary diversity, nutrition knowledge, gender and marriage beliefs and 
decision-making power, social desirability, home food environment, food 
security, dwelling and assets  
 
 
 
4.1.1 Primary school observation checklist 
A school observation checklist will be included to obtain information on the infrastructure of the school, 
supplies and materials, food environment and student enrollment. 
Table 5. Description of topics to be included in the primary school observation checklist 
Module 
Topic 
Description 
Respondent 
1 
School identification 
Location and school supervisor 
Enumerator 
2 
Infrastructure 
School amenities and condition 
Enumerator (direct 
observation) 
3 
Supplies, materials 
and records 
Availability of desks, books, textbooks, 
pens/pencils, computer, nutrition 
materials, etc. and records of nutrition 
activities, PTA meetings and 
community events 
Enumerator (direct 
observation and 
taken from school 
records) 
4 
Food environment 
School canteen, availability of food 
items, food points off school grounds 
Enumerator (direct 
observation) 
5 
School hours and size 
School hours, break times, and 
number of students and teachers 
Enumerator (taken 
from school records) 
6 
Student enrollment 
and attendance 
Attendance and school records of 
adolescent girls participating in the 
study 
Enumerator (taken 
from school records) 
 

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4.1.2 Teacher/Principal questionnaire 
Interviews with principals and science teachers at the primary schools will gather information on the 
individual’s role at the school, nutrition-related activities/interventions, nutrition knowledge, exposure 
to training, and supervision. 
Table 6. Description of modules in the teacher/principal questionnaire  
Module 
Topic 
Description 
Respondent 
1 
Identification 
School and respondent type 
Enumerator 
2 
Demographic 
characteristics  
Age, gender, education, language, 
years of experience 
Teacher/Principal 
3 
School role 
Position, years worked at the school, 
class(es)/grade(s) taught, subjects 
taught 
Teacher/Principal 
4 
School management 
PTA meetings, number of students, 
number of teachers, school meal 
programs, extracurricular activities 
Teacher/Principal 
5 
Perceptions and 
beliefs about 
adolescent issues 
Important subjects, student 
attendance, student nutrition/diet, 
WASH, teacher support 
Teacher/Principal 
6 
Nutrition activities in 
school  
Involvement with nutrition-related 
activities/interventions 
Teacher/Principal 
7 
Health and nutrition 
knowledge 
Nutrition knowledge, WASH 
knowledge 
Teacher/Principal 
8 
Training exposure 
Exposure to and training received on 
adolescent nutrition  
Teacher/Principal 
9 
Supervision  
Supervision received from superiors, 
woreda school supervisors, etc. 
Teacher/Principal 
 
4.1.3 HEW questionnaire 
Interviews with HEWs at the primary schools will gather information on the individual’s role at the 
school and in communities, nutrition-related activities, nutrition knowledge, exposure to training, and 
supervision. 
Table 7. Description of modules in the HEW questionnaire  
Module 
Topic 
Description 
Respondent 
1 
Identification 
Location, health post 
Enumerator 
2 
Demographic 
characteristics  
Age, education, years of experience 
and other characteristics of the HEW 
HEW 
3 
Time commitments 
and workload 
Types and frequency of activities or 
interactions with school and parent-
teacher association, content/topics 
discussed  
HEW 
5 
Health and nutrition 
knowledge 
Knowledge and importance of proper 
nutrition for adolescent girls 
HEW 

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7 
Perceptions and 
beliefs about 
adolescent issues  
Perceptions and beliefs about 
adolescent issues (e.g. health, 
nutrition, WASH) in the kebele 
HEW 
8 
Training exposure 
Exposure to and training received on 
adolescent nutrition 
HEW 
9 
Supervision and 
contact with other 
actors 
Frequency and content of supervision 
on adolescent nutrition 
services/activities 
HEW 
Note: The HEW interview for the Adolescent Nutrition study will be conducted at the same time as the HEW 
interview for the Alive & Thrive Ethiopia 3.0 Maternal Nutrition study. There is one questionnaire for both studies, 
therefore only the modules relevant to the Adolescent Nutrition study are included above. 
4.1.4 Adolescent girl questionnaire 
Interviews with adolescent girls will be conducted at baseline and endline and gather information on 
school attendance, exposure to nutrition information, dietary diversity, meal and snacking habits, WASH 
practices, health and health seeking behaviors, health and nutrition knowledge, food security, home 
food environment, parental interactions, social desirability, gender and marriage beliefs and decision-
making power, and anthropometry. 
Table 8. Description of modules in the adolescent girl questionnaire 
Module 
Topic 
Description 
Respondent 
1 
Identification 
School and grade of adolescent 
Enumerator 
2 
Adolescent and family 
background 
Age, DOB, grade level, language, 
characteristics of mother/father 
Adolescent 
3 
School attendance 
Attendance, reasons for absences, 
extracurricular activities, class 
performance 
Adolescent 
4 
Exposure to nutrition 
information  
Exposure to adolescent nutrition 
and/or WASH information at school 
and outside of school, and exposure to 
media and food/drink advertisements 
Adolescent 
5 
Dietary diversity 
Dietary diversity of the adolescent in 
the past 24 hours 
Adolescent 
6 
Meal and snacking 
habits 
Meals/snacks taken during school 
days, foods consumed before and 
during school, access to food vendors 
near school grounds 
Adolescent 
7 
WASH practices 
Handwashing, drinking water, food 
hygiene, menstruation 
Adolescent 
8 
Health and health 
seeking behaviors 
Illness, health seeking behaviors, 
weight and body image 
Adolescent 
9 
Health and nutrition 
knowledge 
General knowledge of health and 
nutrition, including WASH and 
importance of various macro and 
micronutrients 
Adolescent 
10 
Home food 
environment 
Availability of foods at home  
Adolescent 

18 
11 
Food security  
Prevalence of household hunger using 
the FANTA household food insecurity 
access scale (HFIAS) 
Adolescent 
12 
Parent-adolescent 
interactions 
Relationship and interactions with 
parents, and perceptions of parents’ 
monitoring of food and eating habits 
Adolescent 
13 
Social desirability  
Desire for social approval 
Adolescent 
14 
Gender, marriage 
beliefs and decision-
making power 
Opinions about girls’ and boys’ 
education, marriage and household 
roles, and decision-making power in 
the household 
Adolescent 
15 
Anthropometry 
Weight and height measurements 
Adolescent 
 
4.1.5 Parent questionnaire 
Interviews with parents of adolescent girls will be conducted at baseline and endline and gather 
information on school involvement, exposure to nutrition information, dietary diversity, health and 
nutrition knowledge, food security, home food environment, social desirability, gender and marriage 
beliefs and decision-making power, dwelling and assets. 
Table 9. Description of modules in the adolescent girls’ parents’ questionnaire 
Module 
Topic 
Description 
Respondent 
1 
Identification 
School and respondent type 
Enumerator 
2 
Household roster  
Information on composition of the 
household, including designation of 
the head of household, a list of all 
household members, their ages and 
sex, and their relationship to the 
adolescent girl, and the highest 
educational level attained and 
activity/employment in the past 
month of all household members at 
least 15 years of age 
Parent 
3 
School involvement 
School fees, and participation in 
parent-teacher association, school 
management committee and teacher 
meetings 
Parent 
4 
Exposure to nutrition 
information  
Exposure to adolescent nutrition 
and/or WASH information, and 
exposure to media and food/drink 
advertisements 
Parent 
5 
Dietary diversity 
Dietary diversity of the adolescent and 
household in the past 24 hours 
Parent  
6 
Home food 
environment 
Availability of foods at home  
Parent 
7 
Health and nutrition 
knowledge 
General knowledge of health and 
nutrition, including WASH and 
Parent 

19 
importance of various macro and 
micronutrients 
8 
Parent-adolescent 
interactions 
Relationship and interactions with 
adolescent, monitoring of food and 
eating habits, adolescent weight and 
body image 
Parent 
9 
Social desirability  
Desire for social approval 
Parent 
10 
Gender, marriage 
beliefs and decision-
making power 
Opinions about girls’ and boys’ 
education, marriage and household 
roles, and decision-making power in 
the household 
Parent 
11 
Food security  
Prevalence of household hunger using 
the FANTA household food insecurity 
access scale (HFIAS) 
Parent 
12 
Dwelling 
House construction (materials used for 
floor, walls, and roof), availability of 
water and electricity, sources of 
fuel/energy for cooking, WASH 
facilities 
Parent 
13 
Assets 
Ownership of durable household 
goods (in working condition), including 
tools for agricultural production 
Parent 
 
  
4.2 COVID-19 precautionary measures 
Since early 2020, close-range contacts between enumerators and study participants during data 
collection activities present a particular risk for spreading COVID-19 in communities with vulnerable 
populations. The collaborating survey firm, Addis Continental Institute of Public Health (ACIPH), has 
developed formal fieldwork guidelines based on directives for the prevention and control of the COVID-
19 pandemic by the Ministry of Health (MOH) and Ethiopian Public Health Institute, and UNICEF 
recommendations for surveilling and monitoring nutrition in the context of COVID-19. As part of the 
guidelines, all enumerators and study participants will wear masks (provided to them) and wash or 
sanitize their hands before and after each interview. Interviews will be conducted outside or in a well-
ventilated space and enumerators will maintain two meters of distance from the interviewee and other 
household members. Measuring boards and scales will be sanitized after every anthropometric 
measurement. Any study staff with COVID-19-related symptoms (fever, dry cough, extreme fatigue, 
respiratory problems or any unusual illness) will be immediately excluded from fieldwork and remain 
isolated as per MOH guidelines. Any study participants with COVID-19-related symptoms will be 
excluded from the study and advised to remain isolated and seek appropriate services according to 
MOH and any local guidelines.  
All survey staff will be assessed for COVID-19-related symptoms each day before enumerator training 
begins, and field supervisors will assess enumerators each day before starting data collection. In 
addition, Co- and Principal Investigators of the project will be in daily contact with ACIPH and in-country 
partners during data collection to assess the changing risks and government measures. 

20 
4.3 Data management 
A secure data file structure will be established in an IFPRI-server-based Dropbox Professional folder for 
use by the IFPRI research team and potential collaborators. Original, sensitive (non-anonymized) data 
files and documents will be stored in a folder with access restricted to senior IFPRI researchers. A do file 
will be written to anonymize survey data files and export the anonymized data to a shared Dropbox 
folder for data cleaning and analysis by research support staff and other project team members. 
All changes to the raw data output files from the Computer-Assisted Personal Interviews (CAPI) software 
will be recorded. Formatting, reshaping, and labeling of data will be documented using detailed and 
well-annotated do files. 
4.4 Statistical methods 
Data analysis will use econometric analysis to control for (any) differences at baseline and between 
intervention and comparison groups for all relevant variables of interest. Statistical testing for 
differences between the two groups will be done using a random effects regression, accounting for the 
clustering of errors within and across schools. 
The randomized study design allows for the identification of causal effects of the adolescent nutrition 
intervention through comparisons of mean outcomes between the treatment and control groups. Key 
indicators will include dietary diversity. Impact will be assessed using “difference-in-difference” (DID) 
estimation and/or analysis of covariance (ANCOVA) controlling for covariates. Data management, data 
cleaning and statistical analyses will be conducted using Stata version 16 (Statacorp, USA). The statistical 
significance for tests will be set at 5% for main effects or 10% in case of interactions. All statistical tests 
will be one-sided. 
V. 
Monitoring 
5.1 Data monitoring 
Data collection (including observational, adolescent girl, and principal/science teacher/HEW data 
collection) will be undertaken using electronic tablets. Checks will be built into the CAPI software and 
applied at the time of data entry. These will include logic checks, valid values, skip patterns, and range 
checks among others to ensure efficiency and high data quality. In addition, enumerator monitoring will 
be incorporated into the CAPI software including recording the duration of interviews and GPS location 
of enumerators during data collection. 
Field supervisors, project manager, and principal and co-principal investigators of the survey firm and 
IFPRI will closely monitor enumerators and the quality of data collected to ensure the integrity of the 
data during data collection. 
5.2 Harms 
The nutrition interventions will primarily focus on behavior change related to healthy diets, and we do 
not anticipate any harms from the study. Any adverse events or unintended effects during provision of 
interventions will be recorded and monitored, and subjects will be referred to their nearest health 
provider as appropriate. 
5.3 Auditing 
Not applicable.  

21 
VI. 
Ethics and Dissemination 
6.1 Research ethics approval 
This protocol, informed consent forms, and study questionnaires will be submitted for ethical clearance 
from the Institutional Review Boards (IRB) of FHI 360 and the International Food Policy Research 
Institute in Washington, DC. In Ethiopia, ethical clearance will be obtained from the Addis Continental 
Institute of Public Health IRB. 
A COVID-19 country risk assessment system was developed by IFPRI to help researchers and IFPRI’s IRB 
assess COVID-19 risk in countries where fieldwork is planned. In function of the level of COVID-19 risk 
identified in country, data collection methods will be adapted to minimize the transmission risk of 
COVID-19. Justification for resuming fieldwork with in-person contacts will be provided and accepted by 
the IRB.  
6.2 Protocol amendments 
All amendments to the protocol will be reported (by IFPRI Co-Investigators and ACIPH Co-Investigator) 
to and agreed upon with Alive & Thrive. Substantive changes to the protocol that may impact the safety 
of participants or the scientific validity, scope, or ethical rigor of the study will be reviewed by the IFPRI 
IRB.  
Version control using protocol version identifiers and dates will be used to track the history of 
amendments and identify the most recent protocol version. 
6.3 Consent or assent 
After explaining the study’s objectives and procedures, enumerators will seek and obtain written 
informed consent from eligible study participants and the parent/guardian of the participant. 
Participation in the study is completely voluntary. Participants are free to withdraw at any time by 
informing survey or program staff. 
All COVID-19 transmission risks to study participants (including close contact required for taking 
anthropometric measurements) and the precautionary measures that will be followed during data 
collection to limit the risk of transmission will be included in the informed consent. 
6.4 Confidentiality 
Immediately after data collection, all data will be uploaded and stored securely in an IFPRI-server-based 
Dropbox Professional folder. To protect respondent confidentiality, only senior IFPRI researchers will 
have access to data and documents containing personally identifiable information. Research support 
staff and other project team members will have access to depersonalized data—located in a separate 
IFPRI-server-based Dropbox Professional folder—where direct identifiers have been replaced by 
randomly generated numeric IDs. 
Data that is made publicly available will be carefully screened to remove any indirect and geographic 
identifiers which may breach the confidentiality of respondents. 
6.5 Declaration of interests 
The authors declare that they have no competing interests. 

22 
6.6 Access to data 
All Co- and Principal Investigators of the project (based in the US and in Ethiopia) will have full access to 
the cleaned data. Other project team members will have access to data that has had all personally 
identifiable information removed. 
In compliance with donor (Bill & Melinda Gates Foundation) open access policy requirements, fully 
anonymized datasets will be made publicly available one year after the end of the project. Metadata and 
other documentation of data collection procedures (such as the codebook, data collection instruments 
and interviewer guides/protocols) will also be made publicly available. 
6.7 Ancillary and post-trial care 
Not applicable. 
6.8 Dissemination policy 
Close engagement with the government of Ethiopia is of primary importance to the project. The A&T 
Ethiopia team will be working in close partnership with government entities on strengthening nutrition 
education in schools at the national and regional levels throughout the duration of the project. Findings 
will be disseminated through in-country events, presentations, and conferences.  
Within the research community, we aim to have the research results peer-reviewed and published in 
high quality journals. Preliminary research findings may be presented at international conferences and 
internal IFPRI seminars. 

23 
VII. Timeline 
7.1 Study timeline 
 
Deliverable/Activities 
2019 
Jan 
Feb 
Mar 
Apr 
May 
Jun 
Jul 
Aug 
Sep 
Oct 
Nov 
Dec  
1. Study protocol  
 
 
 
 
 
 
 
 
 
 
 
 
Discuss study and evaluation design with A&T 
x 
x 
x 
 
 
 
 
 
 
 
 
 
Prepare study protocol 
 
 
x 
x 
x 
x 
 
 
 
 
 
 
2. Baseline data collection tools 
 
 
 
 
 
 
 
 
 
 
 
 
Develop questionnaires/data collection tools 
 
 
 
x 
x 
x 
 
 
 
 
 
 
Select and contract survey firm 
 
 
 
 
 
x 
x 
 
 
 
 
 
Translate questionnaire 
 
 
 
 
 
 
x 
 
 
 
 
 
Program CAPI questionnaire 
 
 
 
 
 
 
x 
x 
 
 
 
 
3. Local and US-based IRB approvals 
 
 
 
 
 
 
 
 
 
 
 
 
IRB application at IFPRI 
 
 
 
 
 
 
 
x 
 
 
 
 
IRB application in Ethiopia 
 
 
 
 
 
 
x 
 
 
 
 
 
4. Baseline survey implementation 
 
 
 
 
 
 
 
 
 
 
 
 
Pretest, revise and finalize questionnaire 
 
 
 
 
 
 
 
x 
 
 
 
 
Enumerator training 
 
 
 
 
 
 
 
 
x 
 
 
 
Data collection 
 
 
 
 
 
 
 
 
 
x 
x 
 
5. Data cleaning and analyses 
 
 
 
 
 
 
 
 
 
 
 
 
Data cleaning 
 
 
 
 
 
 
 
 
 
 
x 
x 
Data analyses 
 
 
 
 
 
 
 
 
 
 
 
x 

24 
Deliverable/Activities 
2020 
Jan 
Feb 
Mar 
Apr 
May 
Jun 
Jul 
Aug 
Sep 
Oct 
Nov 
Dec 
Data analyses 
x 
 
 
 
 
 
 
 
 
 
 
 
6. Baseline results tables and datasets 
 
 
 
 
 
 
 
 
 
 
 
 
Draft and finalize baseline results 
x 
x 
 
 
 
 
 
 
 
 
 
 
Prepare clean datasets 
 
 
x 
 
 
 
 
 
 
 
 
 

25 
Deliverable/Activities 
2021 
Jan 
Feb 
Mar 
Apr 
May 
Jun 
Jul 
Aug 
Sep 
Oct 
Nov 
Dec 
7. Endline data collection tools 
 
 
 
 
 
 
 
 
 
 
 
 
Develop questionnaires/data collection tools 
x 
x 
 
 
 
 
 
 
 
 
 
 
Translate questionnaire 
 
x 
 
 
 
 
 
 
 
 
 
 
Program CAPI questionnaire 
 
x 
x 
 
 
 
 
 
 
 
 
 
8. Local and US-based IRB approvals  
 
 
 
 
 
 
 
 
 
 
 
 
Obtain IFPRI IRB approvals to conduct fieldwork 
 
 
x 
 
 
 
 
 
 
 
 
 
Obtain local IRB approvals to conduct fieldwork 
 
 
x 
 
 
 
 
 
 
 
 
 
9. Endline survey implementation  
 
 
 
 
 
 
 
 
 
 
 
 
Pretest, revise and finalize questionnaire 
 
 
x 
 
 
 
 
 
 
 
 
 
Enumerator training 
 
 
x 
 
 
 
 
 
 
 
 
 
Data collection 
 
 
x 
x 
 
 
 
 
 
 
 
 
10. Data cleaning and analyses 
 
 
 
 
 
 
 
 
 
 
 
 
Data cleaning 
 
 
 
 
x 
x 
 
 
 
 
 
 
Data analyses 
 
 
 
 
 
x 
x 
x 
x 
x 
 
 
11. Endline results tables and datasets 
 
 
 
 
 
 
 
 
 
 
 
 
Draft endline results 
 
 
 
 
 
 
x 
x 
 
 
 
 
Finalize endline report and findings 
 
 
 
 
 
 
 
x 
x 
 
 
 
Prepare clean datasets  
 
 
 
 
 
 
 
 
 
x 
 
 

26 
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