A Feasibility Study of Integrating Maternal, Infant and Young Child Nutrition (MIYCN) Counseling Services in Urban Maternal, Neonatal and Child Health (MNCH) Services in Bangladesh: A Quasi-experimental Evaluation
Phase: NA
Conditions: Maternal Nutrition
Sponsor: International Food Policy Research Institute

 
 
 
A Feasibility Study of  
Integrating Maternal, Infant and Young Child Nutrition 
(MIYCN) Counseling Services in Urban Maternal, 
Neonatal and Child Health (MNCH) Services  
in Bangladesh: 
A quasi-experimental evaluation 
 
Endline Study Protocol 
 
 
 
International Food Policy Research Institute (IFPRI) 
 
 
 
 
 
October 1, 2021  
ClinicalTrials.gov: NCT03882268 

 
 
Contents 
1. 
Background .............................................................................................................................. 3 
2. 
Impact of COVID-19 on program interventions and implementation ..................................... 4 
3. 
Objectives of study .................................................................................................................. 7 
4. 
Key study outcomes ................................................................................................................. 7 
5. 
Study design............................................................................................................................. 8 
6. 
Overview of intervention and comparison facilities ................................................................ 9 
7. 
Sample size and power calculation .......................................................................................... 9 
8. 
Sampling and enrollment of study subjects ........................................................................... 10 
9. 
Data collection methods ........................................................................................................ 13 
9.1. NGO-run urban health facility assessment..................................................................... 13 
9.2. Provider survey .............................................................................................................. 14 
9.3. Case observation ............................................................................................................ 15 
9.4. Client interview .............................................................................................................. 15 
9.5. Program Manager and Field Supervisor interviews ....................................................... 16 
9.6. COVID-19 precautionary measures ............................................................................... 16 
10. 
Analysis plan ...................................................................................................................... 17 
11. 
Detailed Timeline............................................................................................................... 18 
12. 
References .......................................................................................................................... 24 
 
List of Tables 
Table 1. Description of interventions and differences between intervention and comparison 
facilities ........................................................................................................................................... 5 
Table 2. Sample size and power calculation ................................................................................. 10 
Table 3. Sampling healthcare personnel at intervention and comparison facilities ...................... 11 
Table 4. Sampling clients at intervention and comparison facilities ............................................ 12 
Table 5. Modules included in the urban facility assessment ........................................................ 13 
Table 6. Modules included in provider survey ............................................................................. 14 
Table 7. Modules included in client interview.............................................................................. 15 
Table 8. Overall study timeline ..................................................................................................... 18 
Table 9. Details of activities and study timeline for endline survey ............................................. 19 
 
List of Figures 
Figure 1: Impact Evaluation Design ............................................................................................... 8 
 
 
 
 

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1. Background 
Bangladesh is experiencing rapid urbanization, with more than a third of people (~65 million) living 
in urban areas in 2018; by 2050, this number is projected to increase to 118 million[1]. Despite 
increasing urbanization, significant gaps remain in nutrition outcomes, determinants, and quality of 
health services in urban areas, particularly for the poor. Chronic malnutrition (stunting) in urban 
areas is decreasing at a slower rate than in rural areas [2], with stunting rates remaining as high as 
50% in urban slums [3]. Furthermore, health policy heavily focuses on rural delivery of health 
services and improvements in health and nutrition outcomes for rural residents [4]. Coverage, 
standardization, and quality of maternal, infant, and young child nutrition (MIYCN) counselling is 
neglected and weak across health care delivery systems in Bangladesh [5].  
To address these gaps, Alive & Thrive (A&T) aims to develop and test effective, feasible, and 
scalable models for delivering MIYCN counselling in urban areas and evaluate their impact on 
utilization, knowledge, and behaviors. The Bangladeshi urban MIYCN model is being delivered 
through NGO platforms that currently provide health services to urban women and children. The 
intervention includes community mobilization and social and behavior change communication 
(SBCC) for MIYCN. The package of maternal nutrition interventions is aligned with the latest 
global evidence [6] and the national policies and guidelines of Bangladesh Government within 
routine maternal, newborn and child health (MNCH) services. These include building capacity for 
health providers and nutritional counselors in urban health facilities, creating friendly environment 
for MIYCN counselling in health facility settings, community mobilization for demand creation of 
MIYCN services, interpersonal counselling on diet during pregnancy and consumption of iron folic 
acid (IFA) and calcium, promotion of adequate weight-gain monitoring during pregnancy, and 
counselling on breastfeeding and complementary feeding practices.  
To assess the effectiveness of the interventions, A&T and IFPRI designed a quasi-experimental 
evaluation study with data collection taking place in three stages: 1) Baseline data collection to 
assess comparability of facilities, service quality and client’s behaviors, 2) Facility-based endline 
data collection and 3) Community-based endline survey. A&T partnered with 2 NGOs, Radda and 
Marie Stopes, whose facilities provide MNCH services in urban areas, but not affiliated with the 
Bangladesh Urban Primary Health Care Services Delivery Project (UPHCSDP). These NGOs each 
operates 4 facilities in Dhaka (8 in total) which are eligible for the study to form the intervention 

4 
 
group. The evaluation comparison group is a matched sample of 8 facilities operated by NGOs Nari 
Maitree and Shimantik (NGOs under contract with the UPHCSDP implemented by Government of 
Bangladesh). The UPHCSDP agreed to provide facilities for baseline and endline data. 
2. Impact of COVID-19 on program interventions and implementation  
In March 2020, the World Health Organization declared COVID-19 a pandemic. Bangladesh 
reported its first case on March 8, 2020. On March 26, the Government of Bangladesh issued a 
nationwide extended public holiday and strict stay-at-home order. The initial stay-at-home order 
remained in place through May 30, after which localized restrictions were enforced.  
Disruptions to field conditions and health facility operations resulted in adaptations to program 
implementation. In-person orientations and trainings to all healthcare providers was no longer 
possible; instead, A&T began providing virtual orientations to MIYCN Counselors and community 
workers (CWs) and providing newly recruited counselors and CWs with periodic technical 
refreshers and peer-to-peer training with trained counselors. Community mobilization, media 
activities, and other interventions which required in-person gatherings were suspended due to 
restrictions on social gatherings. In their place, MIYCN flyers promoting health facility counselling 
services and a script for the provision of MIYCN education and counselling services via phone were 
developed. Supportive supervision was also conducted via phone. The full description of planned 
and actual interventions at health facilities are provided in Table 1. 

5 
 
Table 1. Description of interventions and differences between intervention and comparison facilities 
CORE INTERVENTIONS 
PLANNED INTERVENTION  
ACTUAL INTERVENTION  
CONTROL 
At health facilities: 
Training for health providers 
and nutritional counselors 
In-person training on MIYCN SBCC 
from A&T, counseling skills training, 
general SBCC training, and supportive 
supervision training (managers only). 
Only MIYCN Counselors received the full, in-person 
training. CW training was disrupted by COVID and 
CWs received basic training only 
Adapted virtual orientations, trainings, and technical 
periodic refreshers were provided.  
High staff turnover. Replacement MIYCN Counselors 
and CWs received peer-to-peer training with trained 
counselors. 
Standard training on counseling 
skills, SBCC and supervision, if 
available 
Counseling rooms in health 
facility settings 
Counseling rooms available with 
standardized layouts, displays of 
government IYCF logo, and other 
specifications. 
As planned 
Non-standardized counseling 
rooms 
SBCC materials and job aids 
Availability of standardized MIYCN-
specific BCC materials and job aids.  
As planned, with the additional development of the 
mobile MIYCN (m-MIYCN) script and MIYCN flyer. 
Standard SBCC materials and 
job aids if available, but used for 
mixed purposes 
MIYCN counseling services and 
procedures 
Standardized MIYCN counseling 
services and procedures by a dedicated 
counselor. MIYCN counseling topics 
include diet diversity and quantity, IFA 
and calcium supplementation, weight 
gain monitoring, exclusive and early 
initiation of breastfeeding, 
complementary feeding, and water, 
sanitation and health. 
MIYCN Counselors provide routine MIYCN counseling 
services during individual appointments. Small group 
education sessions (with 4-5 women) began at health 
facilities in July 2021. General counselors provide these 
services in the absence of the MIYCN Counselor. 
Offered only at facilities where a 
counselor is available  
In the community: 
Social mobilization and 
community events  
Mass media campaigns, advocacy 
meetings, MIYCN fair, film shows, 
special day/week events (Safe 
Motherhood Day, National 
Handwashing Day, National Nutrition 
Week, World Breastfeeding Week), 
ANC camps and other community 
meetings. 
Mass media campaigns, advocacy meetings, MIYCN 
fairs and film shows were permanently suspended. Light 
community mobilization efforts include satellite clinic 
outreach (RADDA facilities only) and MIYCN flyer 
distribution, distribution of MIYCN flyers to 
community referrers (MSB facilities only), and monthly 
ANC camps for pregnant women (MSB facilities only). 
Standard community events 

6 
 
 
 
Home visits 
Promote health facility visits, referrals 
to MIYCN counselors, attendance at 
special events, and general MIYCN 
information. 
Mobile MIYCN (m-MIYCN) education (provided by 
CWs) was provided via phone to pregnant women and 
mothers in place of home visits until November 2020. 
Home visits for routine health 
services 
Staff hiring and supervision 
Hire, train, equip and support a 
dedicated MIYCN counselor 
and CW at each health facility. 
MIYCN Counselors will deliver 
standardized nutrition interventions and 
messages as part of MICYN services, 
maintain client registers for monitoring 
and reporting, and provide supervision. 
CWs will identify and mobilize 
beneficiaries needing services in the 
community 
As planned 
No additional staff hiring 
Supportive supervision of 
MIYCN Counselors and CWs 
Program Managers, Facility Managers, 
and Field Supervisors conduct 
supportive supervision of services 
provided by MIYCN Counselors and 
CWs. 
Supportive supervision of MIYCN Counselors and CWs 
was conducted via phone and included listening in on 
mobile counseling sessions, using a checklist to assess 
quality of counseling, and providing feedback. In-
person supportive supervision resumed in October 2020. 
Standard health facility 
supervision. 

7 
 
3. Objectives of study 
The primary objectives of the proposed evaluation are to answer the following questions using a quasi-
experimental evaluation design: 
• 
Is it feasible to standardize the delivery of MIYCN counseling services in existing urban health 
facilities? 
• 
Can quality of MIYCN counseling service be improved by upgrading and standardizing existing 
MIYCN counseling service in urban health facilities? 
• 
What are the impacts of standardized and upgraded MIYCN counseling service on utilization of 
MIYCN services and knowledge of clients? 
The secondary objectives are: 
• 
What are the impacts of standardized and upgraded MIYCN counseling service on behaviors of 
clients including: 
o Pregnant women: 1) consumption of diversified foods; 2) intake of IFA and calcium 
supplements during pregnancy  
o Mothers of children <1 y: age-appropriate infant feeding  
4. Key study outcomes  
The primary outcomes to be evaluated include quality measures of MIYCN counseling in urban areas  
• 
Facility readiness for nutrition services, resources, and staffing 
• 
Knowledge of service providers on key nutrition services 
• 
Quality of nutrition counseling during ANC (such as diversified diet during pregnancy, IFA and 
calcium intake, promotion of maternal weight monitoring and related counseling) and during well-child 
or sick-child contacts (such as age-appropriate feeding practices, promotion of child growth and related 
counseling). 
• 
Clients’ utilization of and satisfaction with MIYCN services 
• 
Clients’ knowledge of MIYCN topics and best practices 
The secondary outcomes to be evaluated include maternal nutrition practices and IYCF practices 
• 
Maternal dietary diversity  

8 
 
• 
Iron/folic acid supplementation: proportion of women who consumed at least 100 IFA tablets and the 
mean number of tablets consumed.  
• 
Calcium supplementation: proportion of women who consumed calcium and the mean number of 
tablets consumed. 
• 
Early initiation of breastfeeding 
• 
An indicator of age-appropriate feeding that includes exclusive breastfeeding for children <6 months, 
breastfeeding + complementary feeding for children 6-12 months. We consider children < 12 months 
as they are more likely to be exposed to the program through immunization contacts. 
5. Study design 
The study will use a quasi-experimental design, with data collection taking place in three different stages: 1) 
Baseline data collection to assess comparability of facilities, service quality and client’s behaviors, 2) 
Facility-based endline data collection and 3) Community-based endline survey (Figure 1). 
The study will use mixed data collection methods including: 1) facility assessment; 2) provider survey; 3) 
case observations (namely ANC visits, child visits [both sick child and immunization], and counseling 
sessions), 4) client interviews and 5) in-depth interview with Program Managers and Field Supervisors.  
Figure 1: Impact Evaluation Design  
 
*Baseline was conducted on 16 health facilities but were very imbalanced. 

9 
 
6. Overview of intervention and comparison facilities 
The program interventions are implemented in 8 NGO-run urban health facilities, 4 of which are operated by 
Radda and 4 of which are operated by Marie Stopes. These 8 facilities will serve as the intervention group. 
The comparison group will also consist of 8 NGO-run urban health facilities, but these are run by Nari 
Maitree and Shimantik, which operate under the Urban Primary Health Care Services Delivery Project. The 
list of facilities in the intervention and comparison groups is presented in Appendix 1. 
7. Sample size and power calculation 
Sample size has been estimated based on the baseline prevalence of the primary outcomes, the expected 
change after intervention, the power to detect those differences at 0.80, and a level of significance of 0.05. 
The outcomes used for sample size calculation were quality of nutrition service delivery (including provision 
of counseling on diet and breastfeeding practices). The sample size was calculated at 2 levels: provision of 
services (measured through case observation) and receipt of services (measured through client interviews).   
Based on data from baseline assessment, we calculated the prevalence for expected outcomes, and the intra-
cluster correlations (ICCs). We estimated that a minimum sample size of 1200 clients per group during the 
first phase of the endline survey conducted at the facilities would have at least 80 percent power to detect a 
difference of 10-19 percentage points (pp) between intervention and comparison groups in the changes over 
time for different context-specific outcomes (Table 2), e.g. maternal counselling during pregnancy and IYCF 
counselling to caregivers of young children. During the follow up in the communities, we expect a ~30-33% 
loss from the original sample, and thus estimate we will collect information from 65-70%. We expect that this 
will give us enough power to detect changes in context-specific behavioral outcomes. Instead of separating 
the sample for ANC and child contacts, we will pool them to examine context-appropriate behavior such as 
pregnant women with dietary diversity/IFA and calcium consumption and caregivers with age-appropriate 
child feedings. These detectable differences are of reasonable public health significance and based on the 
previous experience from evaluation of the A&T Bangladesh maternal nutrition study [7]. 
For facility readiness and provider knowledge, with the sample size of 8 facilities and 40-64 providers in this 
group, we will mainly report the descriptive analyses between two groups, but not report statistical test due to 
small sample size.  
 
 

10 
 
Table 2. Sample size and power calculation 
 
Control 
group, 
endline3 
Expected 
difference 
Treatment 
group, 
endline 
Power 
ICC 
Alpha 
Sample size per 
group 
Quality of services1 (measured through case observation) 
1200 
Counseling on diet 
68.0 
19.0 
87.0 
0.8 
0.103 
5 
 
Counseling on 
breastfeeding 
71.6 
17.1 
88.7 
0.8 
0.09 
5 
 
Context-appropriate behavioral outcomes2 
(measured through client interview) 
1200 at facility-based 
endline 
800 (67%) at 
community-based 
endline 
Consume 100+ IFA 
54.5 
9.5 
64.0 
0.8 
0.001 
5 
 
Dietary diversity during 
pregnancy 
74.0 
9.5 
83.5 
0.8 
0.009 
5 
 
Early initiation of 
breastfeeding 
32.8 
13.5 
46.3 
0.8 
0.024 
5 
 
1Data from AINNS study [8] 
2Data from Bangladesh DHS 2014 [9] 
3We expect to see no difference in the control group at baseline vs. endline. 
 
8. Sampling and enrollment of study subjects 
Sampling providers: The program interventions are implemented in 8 NGO-run health facilities in Dhaka, 
with another 8 serving as comparison facilities; thus, 16 facilities will be included in the survey. From each 
facility, we will interview 6-8 health providers (1 medical officer or 1 paramedic, 1-2 counselors, and 3-4 
community workers) (Table 3). We expect that the number of counselors across facilities may differ; 
counselors may already be present at some intervention and comparison facilities prior to the intervention. 
Therefore, 1 counselor may be interviewed at comparison facilities, and 1-2 counselors (1 existing counsellor 
and 1 additional A&T MIYCN Counselor) may be interviewed at intervention facilities. Similarly, dedicated 
Community Workers hired by A&T will be available at intervention facilities but not at comparison facilities. 
Due to the small numbers of Program Managers (n=2) and Field Supervisors (n=4), we plan to conduct in-
depth interviews with them to obtain some additional insights on overall intervention impact pathway, uptake 
of interventions, program performance and supportive supervision activities.   
 
 
 

11 
 
Table 3. Sampling healthcare personnel at intervention and comparison facilities 
Levels 
Intervention 
facilities (n=8) 
Comparison 
facilities (n=8) 
Baseline 
Permanent facility personnel 
 
 
Medical officer 
1 
1 
Counsellor  
1 
1 
Paramedic 
1 
1 
Community worker  
3 
3 
Total: 
N=48 
N=48 
Endline: 
Quantitative survey 
Permanent facility personnel 
 
 
Medical officer 
1 
1 
Counsellor  
1 
1 
Paramedic 
1 
1 
Community worker 
3 
3 
A&T temporary hiring 
 
 
MIYCN Counsellor  
1 
0 
Community Worker 
1 
0 
Total: 
N=64 
N= 48 
Endline:  
Qualitative in-depth 
interview  
Program Manager 
2 
0 
Field Supervisor 
4 
0 
Total: 
N=6 
N=0 
 
Sampling clients: At each health facility, 4 intervals of time (8-10 AM, 10AM-12PM, 1-3 PM and 3-5 PM) 
will be chosen. Pregnant women or children visiting the facility within these 4 selected intervals will be 
randomly selected (in proportion to the case load in each interval) for interview and observation. We plan to 
sample 10 clients each day from each facility (5 pregnant women and 5 mothers with children <12 months). 
The inclusion criteria for recruiting clients are as follows: 
• 
Pregnant women who are visiting the health facilities for ANC visits (at least twice during her 
pregnancy, around half of clients) 
• 
Mothers with children <12 months of age who are visiting the health facilities for health check-ups or 
vaccination 
Exclusion criteria: 
• 
Pregnant women with severe illness or complications  
• 
Mothers with severely ill children 
For the assessment of impacts of standardized and upgraded MIYCN counseling service on coverage and 
behavior changes we will identify each facility’s catchment area and find women in the community who 
accessed services at those health facilities to sample 1600 facility clients (PW and RDW) to interview (Table 
4). During the facility interviews, we will seek their consent to be interviewed at home for the community 

12 
 
interview at a later time. Follow-up with clients for the community interview was conducted within 3 months 
following the facility interview at baseline. At endline, facility clients will be visited within one month to 
conduct the community interview. We expect that we will be able to follow 65-70% of these women. By 
doing so, we ensure that our clients will have at least one visit in the evaluation facilities (both intervention 
and control areas). We can track the number of clinic visits and thus conduct the dose response analysis.  
Table 4. Sampling clients at intervention and comparison facilities 
Levels 
Intervention 
facilities (n=8) 
Comparison 
facilities (n=8)1 
Baseline 
Case observation  
 
 
ANC 
600 
100 
IMCI 
600 
100 
Client interview  
 
 
ANC 
400 
70 
IMCI 
400 
70 
Total:  
2,000 
340 
Endline 
Case observation  
 
 
ANC 
600 
600 
IMCI 
600 
600 
Client interview  
 
 
ANC 
400 
400 
IMCI 
400 
400 
Total: 
2,000 
2,000 
 
Informed consent 
Written consent will be obtained from both clients and providers using informed consent forms. These forms 
are available in both English and Bengali, and clearly explain the purpose of the research, how the collected 
data will be used, why the respondent has been selected, interview process, risks and benefits, and steps to 
ensure the privacy, anonymity and confidentiality of the collected information. All COVID-19 transmission 
risks to study participants and the precautionary measures that will be followed during data collection to limit 
the risk of transmission will be included in the informed consent. The respondent’s right to withhold consent 
or withdraw at any time, as well as contact details for questions about the study, are clearly outlined. These 
details will be mentioned verbally to the respondent to ensure comprehension. 
 
 

13 
 
9. Data collection methods  
The survey will use mixed data collection methods including: 1) facility assessment; 2) provider survey; 3) 
case observations (include ANC visits, child visits [both sick child and immunization], and counseling 
session), 4) client interviews, and 5) in-depth interview with Program Managers and Field Supervisors. At 
endline, we will have two rounds of client interviews: one round at the health facility to measure utilization 
and one round to follow up clients (within a months later) in the community to measure behavior changes.  
9.1. NGO-run urban health facility assessment  
The urban health facility assessment will be conducted at baseline and endline for 8 intervention and 8 
comparison health facilities. The health facility questionnaire will contain modules related to facility 
infrastructure (both in terms of overall organization as well as basic amenities), services provided to women 
and children (either at the facility or through outreach activities), service readiness, case load, and availability 
of trained providers. Additional questions will focus on identification and tracking of clients and the 
catchment area for the facility (Table 5).  
There are two components to the urban facility assessment:  
- Interview with the manager of the facility to obtain information on available personnel and services 
offered. Data were also gathered from monitoring forms to assess utilization and coverage of 
MIYCN-related services. 
- A facility observation checklist will be included to obtain information on the counseling room or 
space. A predefined checklist will be developed to document the presence and condition of 
infrastructure, equipment, supplies and information, education and communication (IEC) materials in 
the counseling area.  
Table 5. Modules included in the urban facility assessment 
Module 
Topic 
Description 
1 
Characteristics of facility  
Identification, location, type, provision of in-patient or 
outpatient care, catchment areas 
2 
Facility infrastructure  
Overall organization and basic amenities 
3 
Service readiness of facility 
Including availability of counseling room, functional nutrition 
supplies, logistics, drugs, IEC materials 
4 
Services provided  
Serviced provided either at facility or through outreach 
including nutrition services for pregnant women, immunization, 
well-child care, sick under-5 children, SAM/MAM management 
5 
Caseload  
Case load for ANC, immunization, sick child, SAM/MAM, 
supplementation, referrals, counselling 
6 
Human resources 
Availability of trained providers and their qualification 
7 
Monitoring system 
How the facility monitors and track clients 

14 
 
 
9.2. Provider survey  
The provider survey will be conducted at baseline and endline. Modules for the provider questionnaire will 
include provider characteristics, workload and time commitments for services provided, exposure to training, 
knowledge (both theoretical and application based), motivation and self-efficacy, and incentives and 
remuneration (Table 6).  
Table 6. Modules included in provider survey 
Module 
Topic 
Description 
1 
Background and demographic 
characteristics 
Factors such as age, education, prior experience, etc., have 
influences on worker performance and ability to deliver 
services.  
2 
Workload and time commitment 
(both actual and perceived) 
Information on workload and time commitments are needed for 
three purposes: 1) to understand demands made by project 
interventions on workload and time commitments; 2) to 
understand how perceptions of workload, in addition to actual 
workload, influence FHW motivation and performance; 3) to 
use data on time commitments, and shifts in time commitments 
and activities due to the interventions; and 4) additional and 
different workload and time commitments due to COVID-19.  
3 
Training exposure and needs 
assessment for future training 
To effectively deliver the MIYCN service delivery package, 
providers require training to develop their competency in 
performing required duties. In addition, training is known to be 
a motivating influence on health providers. Training was also 
required to adapt and continue the implementation of the 
MIYCN service delivery package during COVID-19. 
4 
Knowledge and skills related to 
MIYCN 
A basic prerequisite for delivering the MIYCN intervention 
successfully is knowledge of providers about the core topics of 
MIYCN. Additional knowledge and skills were required during 
COVID-19. 
5 
Self-efficacy and confidence 
Self-efficacy and confidence is a basic driver of job motivation 
and job performance during normal circumstances and during 
COVID-19.  
6 
Job motivation and satisfaction 
Several factors influence provider motivation. These include 
factors that are extrinsic to the provider as well as intrinsic 
motivators. Motivation is strongly related to job performance; 
therefore, capturing perceptions related to motivation and 
motivators is important both at the baseline and endline. Job 
satisfaction is also an influence on job performance, and 
therefore important to capture. COVID-19 will also influence  
job motivation and satisfaction.   
7 
Supervisory support 
Supportive supervision is documented to be critical in provider 
performance, motivation, and training during normal 
circumstances and during COVID-19. 
8 
Incentives and remuneration 
Incentives and remuneration influences motivation and 
performance of providers during normal circumstances and 
during COVID-19. 
 

15 
 
9.3. Case observation  
Case observations will be conducted in both intervention and comparison health facilities at baseline and 
endline. The observation checklists will be used to observe the service content as well as interactions between 
the client and provider. Specifically, the counseling observation checklist will be developed based on the 
MIYCN service delivery package guidelines. In addition to content coverage, a checklist will also be used to 
assess counselors’ skills and counseling processes. Items from this checklist will be used to measure the 
quality of the counseling session. At the end of the counseling session, a short exit interview (5-10 minutes) 
will be used, to ask the respondents about services received during that visit, nutrition information provided, 
and their satisfaction with the services they received 
At baseline, 1400 case observations (1200 in intervention and 200 in control groups) were conducted, along 
with basic client information. During the facility-based endline, 1200 case observations will be conducted in 
each group. We expect to have 15 days of observations in each facility, 10 observations per day: 5 ANC visits 
(include counseling), 5 child or immunization visits (include counseling). Total: 10*15 days*8 facilities=1200 
observations in interventions and 1200 in comparison facilities. 
9.4. Client interview  
Clients who are observed at facilities will also be interviewed in their homes as a follow-up to measure 
behavior change (Table 7). During the facility interviews, we will seek their consent for the community 
interview to contact them to set up home visit within one month. We expect that we will be able to follow 65-
70% of these women. By doing so, we ensure that our clients will have at least one visit in the evaluation 
facilities (both intervention and control areas). We can track the number of facilities visits and thus conduct 
the dose response analysis. 
Table 7. Modules included in client interview 
Module 
Topic 
Description 
1 
Background and demographic 
characteristics 
Factors such age, education, religion, living standard, etc., have 
influences on client’s behaviors, including MIYCN practices 
and service utilization. This data also provides information 
about outside factors, including the COVID-19 pandemic that 
may constrain mothers’ ability to benefit from services. Data 
will be collected on household information, socioeconomic 
status, income and expenditure, and the education and other 
characteristics of the women and their husbands. 
2 
Obstetric history  
This section information on the woman’s pregnancy history 
including complications, total parity and age at first parity. 
3 
Previous ANC care/care seeking 
for the child 
This will include receipt and consumption of IFA and calcium 
and antenatal care and counselling during current pregnancy for 
pregnant women. Mothers of sick children will also be asked 
about postnatal services, morbidity and care of children, and 
vaccination history. This will help to assess if exposure to 

16 
 
Module 
Topic 
Description 
intended program is occurring as expected and assess impact 
trends by levels of exposure to interventions. 
4 
MN Dietary intake/IYCF 
practices 
Respondents will be asked to recall what they ate (ANC clients) 
or what they fed their children (mothers of sick children) on the 
previous day. Mothers of sick children will also be asked other 
questions on IYCF practices and behaviors. This will provide 
information on MIYCN behaviors. 
5 
Current MIYCN knowledge and 
perceptions 
Data on mothers’ MIYCN knowledge and perceptions can be 
used to assess trends in impact indicators and to identify 
pathways to positive behavior change. Questions on self-
efficacy will be included. 
6 
Social desirability 
 This is a factor that may affect the woman’s ability to change 
behaviors and practices around MIYCN.  
7 
Food security 
Questions on food security will be included as they are related 
to the respondent’s ability to follow counselling on diet for 
herself and her children. 
8 
Decision-making power and 
mental health 
Decision-making power and mental health are also related to the 
woman’s ability to change behaviors and practices around 
MIYCN. 
9 
Current MIYCN knowledge and 
practices 
Follow-up data on mothers’ MIYCN knowledge and practices 
can be used to identify the impact of the intervention in terms of 
promoting behavior change. For data comparability, the same 
tools will be used for this round of data collection. 
9.5. Program Manager and Field Supervisor interviews 
In-depth interviews will be conducted using a qualitative interview guide.  The interview guide will be 
developed in English and then translated into Bengali (if needed). These tools will be pretested for clarity, 
flow, and priority questions (to cover all domains with the least number of questions) and modified 
accordingly. The in-depth interviews will be conducted in English or Bengali by skilled and trained research 
assistants with accompanying researchers. Audio recordings will be transcribed (and independently translated 
into English, if needed) and compared to the original as a quality check. 
9.6. 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, Data Analysis and Technical Assistance (DATA) has developed formal guidelines 
to be followed during enumerator training and fieldwork. As part of the guidelines, all study staff will be 
tested for COVID-19 before enumerator training begins. Any individual who tests positive will be excluded 
from the training and advised to isolate and seek appropriate health services as per government and local 
guidelines. Before each day of training, participants will be screened for COVID-19-related symptoms (fever, 
dry cough, respiratory problems, or any unusual illness). If any participant presents symptoms, they will be 
advised to take a COVID-19 test and may only rejoin training after presenting a negative test result. All 

17 
 
participants must wear face masks (provided to them) throughout the duration of training. During data 
collection, field supervisors will assess enumerators for COVID-19 symptoms each day before starting data 
collection and tested twice (once per month of data collection). As with training, any enumerator or staff who 
tests positive or presents symptoms will be immediately excluded from fieldwork and must present a negative 
COVID-19 test result before rejoining fieldwork. Any study participants with COVID-19 symptoms will be 
excluded from the study and advised to isolate and seek appropriate health services as described above. 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. 
Co- and Principal Investigators of the project will be in daily contact with DATA and in-country partners 
during data collection to assess the changing risks and government measures. 
10. Analysis plan 
All statistical analysis using quantitative data will be done using Stata 17. Data collected at baseline will be 
analysed to examine the balance on key baseline characteristics between intervention and comparison groups. 
Statistical testing for differences between the two groups will be done using a random effects regression, 
taking into account the clustering of errors within and across health facilities. 
Appropriate variables will be created for each set of outcomes. For quality of care, the key indicators will be 
facility readiness, knowledge of healthcare providers, nutrition counselling service scores, and clients’ 
utilization of and satisfaction with MIYCN services. For behaviour outcomes, the key indicators will be 
maternal nutrition practices (dietary diversity, IFA and calcium consumption) and age-appropriate IYCF 
practices. Impacts on these outcomes will be estimated using analysis of covariance which is an accepted 
impact evaluation analysis approach that is widely used. Further adjustment for geographic clustering at the 
facility level will be done using random effects. 
Qualitative interview data (transcripts) will be organized and analyzed using software such as NVivo, Excel 
or others as appropriate. Data analysis will identify the emerging deductive and inductive themes that emerge 
from the interviews under 4 study domains: intervention impact pathway, uptake of interventions, 
programmatic performance, and supportive supervision activities. Categories and subcategories under these 
domains will be identified and defined (conceptualized) to feed into a narrative complementing the 
quantitative data results.  

18 
 
11. Detailed Timeline  
Table 6. Overall study timeline  
 
Deliverables/Activities 
2019 
Jan 
Feb 
Mar 
Apr 
May 
Jun 
July 
Aug 
Sep 
Oct 
Nov 
Dec 
Discuss study design with A&T 
x 
x 
x 
 
 
 
 
 
 
 
 
 
Baseline - prepare study protocol and survey 
instrument  
x 
x 
x 
x 
x 
x 
x 
x 
x 
 
 
 
IRB application for US and Bangladesh 
 
x 
x 
 
 
 
x 
 
 
 
 
 
Contract survey firm 
 
x 
x 
x 
 
 
 
 
 
 
 
 
Baseline survey- field work (comparison facilities) 
 
 
 
 
 
 
 
 
 
x 
x 
 
Baseline survey- field work (intervention facilities) 
 
 
 
 
 
 
 
 
 
 
 
 
Baseline report- Data analyses and report writing 
 
 
 
 
 
 
 
 
 
 
 
 
COVID-19 survey 
 
 
 
 
 
 
 
 
 
 
 
 
COVID-19 draft manuscript, revised  
 
 
 
 
 
 
 
 
 
 
 
 
Endline- decisions on endline design 
 
 
 
 
 
 
 
 
 
 
 
 
Endline- prepare study protocol and survey 
instruments 
 
 
 
 
 
 
 
 
 
 
 
 
Endline – testing and validation to finalize CAPI 
 
 
 
 
 
 
 
 
 
 
 
 
Endline – Enumerator’s training 
 
 
 
 
 
 
 
 
 
 
 
 
Endline survey 
Field work 
 
 
 
 
 
 
 
 
 
 
 
 
Data analyses, slide deck  
 
 
 
 
 
 
 
 
 
 
 
 
Tables/figure/executive summary 
 
 
 
 
 
 
 
 
 
 
 
 
Additional analyses- manuscript writing 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

19 
 
Deliverables/Activities 
2020 
Jan 
Feb 
Mar 
Apr 
May 
Jun 
July 
Aug 
Sep 
Oct 
Nov 
Dec 
Discuss study design with A&T 
 
 
 
 
 
 
 
 
 
 
 
 
Baseline - prepare study protocol and survey 
instrument  
 
 
 
 
 
 
 
 
 
 
 
 
IRB application for US and Bangladesh 
 
 
 
 
 
 
 
 
 
 
 
 
Contract survey firm 
 
 
 
 
 
 
 
 
 
 
 
 
Baseline survey- field work (comparison facilities) 
 
 
 
 
 
 
 
 
 
 
 
 
Baseline survey- field work (intervention facilities) 
 
x 
x 
 
 
 
 
 
 
 
 
 
Baseline report- Data analyses and report writing 
 
 
 
x 
x 
x 
x 
x 
 
 
 
 
COVID-19 survey 
 
 
 
 
 
 
 
 
x 
x 
 
 
COVID-19 manuscript  
 
 
 
 
 
 
 
 
 
 
x 
x 
Endline- decisions on endline design 
 
 
 
 
 
 
 
 
 
 
 
 
Endline- prepare study protocol and survey 
instruments 
 
 
 
 
 
 
 
 
 
 
 
 
Endline – testing and validation to finalize CAPI 
 
 
 
 
 
 
 
 
 
 
 
 
Endline – Enumerator’s training 
 
 
 
 
 
 
 
 
 
 
 
 
Endline survey 
Field work 
 
 
 
 
 
 
 
 
 
 
 
 
Data analyses, slide deck  
 
 
 
 
 
 
 
 
 
 
 
 
Tables/figure/executive summary 
 
 
 
 
 
 
 
 
 
 
 
 
Additional analyses- manuscript writing 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

20 
 
Deliverables/Activities 
2021 
Jan 
Feb 
Mar 
Apr 
May 
Jun 
July 
Aug 
Sep 
Oct 
Nov 
Dec 
Discuss study design with A&T 
 
 
 
 
 
 
 
 
 
 
 
 
Baseline - prepare study protocol and survey 
instrument  
 
 
 
 
 
 
 
 
 
 
 
 
IRB application for US and Bangladesh 
 
 
 
 
 
 
 
 
 
 
 
 
Contract survey firm 
 
 
 
 
 
 
 
 
 
 
 
 
Baseline survey- field work (comparison facilities) 
 
 
 
 
 
 
 
 
 
 
 
 
Baseline survey- field work (intervention facilities) 
 
 
 
 
 
 
 
 
 
 
 
 
Baseline report- Data analyses and report writing 
 
 
 
 
 
 
 
 
 
 
 
 
COVID-19 survey 
 
 
 
 
 
 
 
 
 
 
 
 
COVID-19 manuscript  
x 
x 
x 
x 
x 
 
 
 
 
 
 
 
Endline- decisions on endline design 
 
 
 
 
 
x 
x 
 
x 
x 
 
 
Endline- prepare study protocol and survey 
instruments 
 
 
 
 
 
 
x 
x 
 
x 
x 
x 
Endline – testing and validation to finalize CAPI 
 
 
 
 
 
 
 
 
 
 
 
 
Endline – Enumerator’s training 
 
 
 
 
 
 
 
 
 
 
 
 
Endline survey 
Field work 
 
 
 
 
 
 
 
 
 
 
 
 
Data analyses, slide deck  
 
 
 
 
 
 
 
 
 
 
 
 
Tables/figure/executive summary 
 
 
 
 
 
 
 
 
 
 
 
 
Additional analyses- manuscript writing 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

21 
 
Deliverables/Activities 
2022 
Jan 
Feb 
Mar 
Apr 
May 
Jun 
July 
Aug 
Sep 
Oct 
Nov 
Dec 
Discuss study design with A&T 
 
 
 
 
 
 
 
 
 
 
 
 
Baseline - prepare study protocol and survey 
instrument  
 
 
 
 
 
 
 
 
 
 
 
 
IRB application for US and Bangladesh 
 
 
 
 
 
 
 
 
 
 
 
 
Contract survey firm 
 
 
 
 
 
 
 
 
 
 
 
 
Baseline survey- field work (comparison facilities) 
 
 
 
 
 
 
 
 
 
 
 
 
Baseline survey- field work (intervention facilities) 
 
 
 
 
 
 
 
 
 
 
 
 
Baseline report- Data analyses and report writing 
 
 
 
 
 
 
 
 
 
 
 
 
COVID-19 survey 
 
 
 
 
 
 
 
 
 
 
 
 
COVID-19 manuscript  
 
 
 
 
 
 
 
 
 
 
 
 
Endline- decisions on endline design 
 
 
 
 
 
 
 
 
 
 
 
 
Endline- prepare study protocol and survey 
instruments 
x 
 
 
 
 
 
 
 
 
 
 
 
Endline – testing and validation to finalize CAPI 
 
x 
x 
 
 
 
 
 
 
 
 
 
Endline – Enumerator’s training 
 
 
 
x 
 
 
 
 
 
 
 
 
Endline survey 
Field work 
 
 
 
 
x 
x 
 
 
 
 
 
 
Data analyses, slide deck  
 
 
 
 
 
 
x 
x 
x 
 
 
 
Tables/figure/executive summary 
 
 
 
 
 
 
 
x 
x 
x 
 
 
Additional analyses- manuscript writing 
 
 
 
 
 
 
 
 
x 
x 
 
 
 
 
 
 

22 
 
Table 7. Details of activities and study timeline for endline survey 
 
Activities 
2021 
Jan 
Feb 
Mar 
Apr 
May 
Jun 
Jul 
Aug 
Sep 
Oct 
Nov 
Dec 
Discuss study designed with A&T 
 
 
 
 
 
 
 
 
x 
x 
 
 
Prepare study protocol 
 
 
 
 
 
 
 
 
 
x 
 
 
Prepare survey questionnaire  
 
 
 
 
 
 
 
 
 
 
x 
x 
Sign contract with survey firm 
 
 
 
 
 
 
 
 
 
 
 
 
Facility selection and matching 
 
 
 
 
 
 
 
 
 
 
 
 
IRB at IFPRI 
 
 
 
 
 
 
 
 
 
 
 
 
IRB in Bangladesh  
 
 
 
 
 
 
 
 
 
 
 
 
Translating questionnaire 
 
 
 
 
 
 
 
 
 
 
 
 
Pre-test survey questionnaire, revision and finalization 
 
 
 
 
 
 
 
 
 
 
 
 
Developing CAPI form 
 
 
 
 
 
 
 
 
 
 
 
 
Training enumerators 
 
 
 
 
 
 
 
 
 
 
 
 
Data collection   
 
 
 
 
 
 
 
 
 
 
 
 
Data cleaning 
 
 
 
 
 
 
 
 
 
 
 
 
Data analyses 
 
 
 
 
 
 
 
 
 
 
 
 
Headline findings (PPT) 
 
 
 
 
 
 
 
 
 
 
 
 
Tables/figure/executive summary 
 
 
 
 
 
 
 
 
 
 
 
 
Additional analyses- manuscript writing 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

23 
 
Activities 
2022 
Jan 
Feb 
Mar 
Apr 
May 
Jun 
Jul 
Aug 
Sep 
Oct 
Nov 
Dec 
Discuss study designed with A&T 
 
 
 
 
 
 
 
 
 
 
 
 
Prepare study protocol 
 
 
 
 
 
 
 
 
 
 
 
 
Prepare survey questionnaire  
x 
 
 
 
 
 
 
 
 
 
 
 
Sign contract with survey firm 
x 
 
 
 
 
 
 
 
 
 
 
 
Facility selection and matching 
 
 
 
 
 
 
 
 
 
 
 
 
IRB at IFPRI 
x 
 
 
 
 
 
 
 
 
 
 
 
IRB in Bangladesh  
 
x 
 
 
 
 
 
 
 
 
 
 
Translating questionnaire 
 
x 
x 
 
 
 
 
 
 
 
 
 
Pre-test survey questionnaire, revision and finalization 
 
 
x 
x 
 
 
 
 
 
 
 
 
Developing CAPI form 
 
 
 
x 
 
 
 
 
 
 
 
 
Training enumerators 
 
 
 
x 
 
 
 
 
 
 
 
 
Data collection   
 
 
 
 
x 
x 
 
 
 
 
 
 
Data cleaning 
 
 
 
 
 
 
x 
x 
 
 
 
 
Data analyses 
 
 
 
 
 
 
 
x 
x 
x 
 
 
Headline findings (PPT) 
 
 
 
 
 
 
 
x 
 
 
 
 
Tables/figure/executive summary 
 
 
 
 
 
 
 
 
x 
x 
 
 
Additional analyses- manuscript writing 
 
 
 
 
 
 
 
 
x 
x 
 
 

24 
 
12. References  
 
1. 
UN: 2018 revision of world urbanization prospects. In.: United Nations New York; 2018. 
2. 
Richards K: Malnutrition in Bangladesh: harnessing social protection for the most vulnerable. In. 
London: Save the Children; 2015. 
3. 
NIPORT: Bangladesh Urban Health Survey. National Institute of Population Research and 
Training (NIPORT), Measure Evaluation, University of North Carolina at Chapel Hill, USA, and 
icddr, b. In.; 2013. 
4. 
Govindaraj R, Raju D, Secci F, Chowdhury S, Frere J-J: Health and Nutrition in Urban Bangladesh: 
Social Determinants and Health Sector Governance. Washington DC: International Bank for 
Reconstruction and Development / The World Bank; 2018. 
5. 
Billah SM, Saha KK, Khan ANS, Chowdhury AH, Garnett SP, Arifeen SE, Menon P. Quality of 
nutrition services in primary health care facilities: Implications for integrating nutrition into the 
health system in Bangladesh. PLoS One 2017; 12:e0178121. 
6. 
WHO: WHO recommendations on antenatal care for a positive pregnancy experience. In.: World 
Health Organization; 2016. 
7. 
Nguyen PH, Kim SS, Sanghvi T, Mahmud Z, Tran LM, Shabnam S, Aktar B, Haque R, Afsana K, 
Frongillo EA , et al. Integrating Nutrition Interventions into an Existing Maternal, Neonatal, and 
Child Health Program Increased Maternal Dietary Diversity, Micronutrient Intake, and Exclusive 
Breastfeeding Practices in Bangladesh: Results of a Cluster-Randomized Program Evaluation. J 
Nutr 2017; 147:2326-2337. 
8. 
icddrb, IDS, IFPRI: Evaluation of Accelerating Implementation of the Bangladesh National 
Nutrition Services. Initial Assessment 2016. Final report. In. Dhaka, Bangladesh: International 
Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Institute of Development Studies, 
UK (IDS), International Food Policy Research Institute (IFPRI); 2016. 
9. 
NIPORT: National Institute of Population Research and Training (NIPORT), Mitra and Associates, 
and ICF International. Bangladesh Demographic and Health Survey 2014. In. Dhaka, Bangladesh, 
and Rockville, Maryland, USA: NIPORT, Mitra and Associates, and ICF International; 2016. 
 

25 
 
 
Appendix 1: Facility selection 
 
NGOs 
Address 
Treatment group 
Shimantik 
(comparison) 
House# 671/4/5, Block-A, Sipahibagh, Kh 
Control 
325, South Goran, Hawai Goli, Goran, Kh 
Control 
Balurmat, Gandaria (near to Jurain Kobo 
Control 
462, Gulbagh, Malibagh, Dhaka-1219 
Control 
Nari Maitree 
(comparison) 
6/28, Humayan Road, Mohammedpur, Dhaka 
Control 
778, Salimullah Road, Mohammedpur, Dha 
Control 
Pall Somity Market, Sultangonj, Rayarba 
Control 
230, West Agargoan, Dhaka-1207 
Control 
RADDA 
(intervention) 
Plot-324, Khan Bahadur Ahsanullah Road, 
Intervention 
Plot-10, Main Road, Section-1, Mirpur, 
Intervention 
Plot-159/A, Road-2/1, Block-A, Section- 
Intervention 
Community Hall, Block-B, Bowniabandh, M 
Intervention 
Marie Stopes 
(intervention) 
House# 320, Road# 8/A (New), Dhanmondi- 
Intervention 
House# 2, Road# 5, Block-A, Section-10, 
Intervention 
House# 3, Road# 2, Block-E, Balurmath, 
Intervention 
153, Jalil Khan Market, Mymensingh Road 
Intervention