Evaluation of School-based Nutrition Intervention for Adolescents in Bangladesh

Study Overview
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Brief Summary
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Addressing the nutrition needs of adolescents could be an important initiative for breaking the vicious cycle of intergenerational malnutrition, chronic diseases and poverty. To respond to these diverse needs of adolescents, the Government of Bangladesh (GoB) in 2012, instituted a national policy for adolescent girls' weekly iron and folic acid (WIFA) supplementation in secondary schools to reduce anemia. Efforts are in place to roll out a national WIFA supplementation program for both in-school and out-of-school adolescent girls aged 10-19 years. Responding to the need to demonstrate the feasibility of such a new initiative before it is scaled-up, Nutrition International (NI) with funding support from the Government of Canada committed to providing technical and financial support to demonstrate to the GoB, the feasibility of a school-based delivery of nutrition interventions to improve the nutrition and health status of adolescents in Joypurhat and Sirajganj districts of Bangladesh. The project developed and began roll out of a multi-sectorial holistic and integrated nutrition approach consisting of both a nutrition-specific and nutrition-sensitive program model for improving the general health and nutrition of adolescents in schools. This was delivered in an integrated package for girls and boys including WIFA supplementation (girls only), promotion of improved water, sanitation and hygiene (WASH), behavior change interventions (BCI) on all topics, and support for menstrual hygiene management (MHM) for girls, including sale of menstrual products in schools. To evaluate the program, the GoB (Institute of Public Health and Nutrition, Ministry of Health and Family Welfare (IPHN) and The Directorate of Secondary and Higher Education, Ministry of Education (DSHE) and NI with technical assistance from the CDC Foundation and CDC planned process and outcome evaluations for the first year of the program's implementation.

Detailed Description
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The outcome evaluation was a school (cluster)-based, randomized controlled trial with three equal size intervention arms, sampling adolescents, teachers, and student leaders in 75 selected schools. The study investigated the impact of the school-based program implemented in Joypurhat and aimed to examine the effectiveness and factors influencing scalability of using the secondary school platform to deliver WIFA co-packaged with WASH, MHM, and BCI to improve the nutrition and health status of adolescents in Bangladesh. The process evaluation sampled adolescents, teachers, and student leaders from 12 schools selected through convenience sampling for qualitative interviews, and determined whether the school-based program was implemented as intended, and why and how the intervention components worked to produce an impact - specifically, assessing the level of adherence.

Official Title
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Evaluation of a Package of Nutrition Interventions to School-based Nutrition and Health Intervention for Adolescents in Bangladesh

Conditions
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Anemia, Menstrual Hygiene Management, Improved Water, Sanitation and Hygiene (WASH)

Intervention / Treatment
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* Dietary Supplement: Weekly Iron and Folic Acid Supplementation (WIFA)
* Combination Product: WASH
* Combination Product: Menstrual Hygiene Management
* Behavioral: Nutrition Behavior Change Intervention (BCI)
* Behavioral: MHM & WASH Behavior Change Intervention (BCI)


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Randomly selected adolescent girl or boy Present on the day(s) of the survey Verbal assent and parental/guardian written consent School level headteacher, assigned teacher or student leader in the various grades Exclusion Criteria: Girl or boy enrolled in grades other than grades 8 or 9 Enrolled after random selection of participants

Ages Eligible for Study
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Minimum Age: 10 Years
Maximum Age: 19 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Prevention
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Full package intervention arm<br>Dietary Supplement of Weekly Iron and Folic Acid (WIFA) Supplementation (containing 60 mg of elemental iron and 2800 µg of folic acid) and; Associated behavior change intervention (BCI) to change the knowledge, attitudes, and practices of nutrition (including dietary diversity), IFA, deworming Water, sanitation and hygiene (WASH) intervention: ensure availability (or provision) of water, sanitation, and hygiene supplies Menstrual hygiene management (MHM) intervention: support for menstrual hygiene, including sale of menstrual products in schools Associated behavior change intervention (BCI) to change the knowledge, attitudes, and practices (KAP) of WASH and menstrual hygiene management (MHM) | Dietary Supplement: Weekly Iron and Folic Acid Supplementation (WIFA)<br>* Weekly school provision of WIFA tablets to adolescent girls<br>* Other names: Behavior Change Intervention;Combination Product: WASH<br>* Ensure availability (or provision) of water, sanitation, and hygiene supplies for adolescent girls and boys<br>Combination Product: Menstrual Hygiene Management<br>* Support for adolescent girls' menstrual hygiene<br>Behavioral: Nutrition Behavior Change Intervention (BCI)<br>* Changing the knowledge, attitudes, and practices of nutrition (including dietary diversity), IFA, deworming<br>Behavioral: MHM & WASH Behavior Change Intervention (BCI)<br>* Changing the knowledge, attitudes, and practices of WASH and menstrual hygiene management<br>|
| Experimental: Limited package intervention arm<br>Dietary Supplement of Weekly Iron and Folic Acid (WIFA) Supplementation (containing 60 mg of elemental iron and 2800 µg of folic acid; weekly school provision of WIFA tablets) and; Associated behavior change intervention (BCI) to change the knowledge, attitudes, and practices of nutrition (including dietary diversity), IFA, deworming | Dietary Supplement: Weekly Iron and Folic Acid Supplementation (WIFA)<br>* Weekly school provision of WIFA tablets to adolescent girls<br>* Other names: Behavior Change Intervention;Behavioral: Nutrition Behavior Change Intervention (BCI)<br>* Changing the knowledge, attitudes, and practices of nutrition (including dietary diversity), IFA, deworming<br>|
| No Intervention: Control<br>No intervention. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Hemoglobin concentration and anemia prevalence among adolescent girls | Assessment of hemoglobin concentration and anemia prevalence among adolescent girls, using HemoCue® Hb-301 photometer | Up to 12 months | 
| Iron and folate status, iron deficiency and folate insufficiency among adolescent girls | a) Iron status and inflammation was assessed using a sandwich ELISA method, including 2 indicators of iron status (ferritin, sTfR) and 2 indicators of inflammation (C-reactive protein (CRP) and alpha 1-acid glycoprotein (AGP)); b) Folate status was assessed using a microbiological assay to test for red blood cell (RBC) folate and serum folate | Up to 12 months | 
| Decrease morbidity among adolescents due to improved water, sanitation and hygiene (WASH) behaviour. | Recall of morbidity symptoms over the past 3 days | Up to 12 months | 
| Decrease barriers to menstrual hygiene management (MHM) for adolescent girls and thereby improve their school attendance | In-school subsidized purchase of sanitary pads for menstruating girls | Up to 12 months |