Suaahara Impact Evaluation: End-line Survey

Study Overview
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Brief Summary
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Suaahara's primary aim is to reduce the prevalence of stunting, wasting, and underweight among children under 5 years of age and to reduce the prevalence of anemia among women of reproductive age and children 6-59 months of age. For this, the program uses a multi-sectoral approach to achieve four key intermediate results: 1) improved household nutrition, sanitation, and health behaviors; 2) increased use of quality nutrition and health services by women and children; 3) improved access to diverse and nutrient-rich foods by women and children; and 4) accelerated roll-out of the Multi-Sectoral Nutrition Plan (MSNP) through strengthened local governance

Detailed Description
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The Government of Nepal and development partners have prioritized multi-sectoral (integrated) nutrition as a key development agenda. The Suaahara program funded by the United States Agency for International Development is one of the programs that support the Government of Nepal's multi-sectoral nutrition plan. It aims to reduce maternal and child under-nutrition over a period of ten years, spanning two phases: Suaahara I (2011-2016) and Suaahara II (2016-2021). Initially launched in 20 of 75 districts, the program has scaled-up to 42 of 77 districts that span across Nepal's three agroecological zones of mountains, hills, and terai. Suaahara I was led by Save the Children International in partnership with Helen Keller International, Johns Hopkins University Center for Communications Programs, Jhpiego, Nepal Water for Health (NEWAH), the National Promotion and Consultancy Service, and the Nepali Technical Assistance Group (NTAG). Suaahara II was led by Helen Keller International in partnership with Cooperative for Assistance and Relief Everywhere, Inc., Family Health International 360), he Nepali Technical Assistance Group, Digital Broadcast Initiative Equal Access, Environmental and Public Health Organization, and Vijaya Development Resource Center. Suaahara's primary aim is to reduce the prevalence of stunting, wasting, and underweight among children under 5 years of age and to reduce the prevalence of anemia among women of reproductive age and children 6-59 months of age. For this, the program uses a multi-sectoral approach to achieve four key intermediate results (IRs): 1) improved household nutrition, sanitation, and health behaviors; 2) increased use of quality nutrition and health services by women and children; 3) improved access to diverse and nutrient-rich foods by women and children; and 4) accelerated roll-out of the MSNP through strengthened local governance. Suaahara interventions span health and family planning (FP), nutrition, agriculture/homestead food production (HFP), and water, sanitation and hygiene (WASH). Diverse social and behavior change communication interventions are used, primarily to generate demand for access to improved services and to motivate households to adopt optimal health, nutrition, and WASH practices. All Suaahara interventions are supported by a crosscutting theme of gender equality and social inclusion (GESI), in part by targeting women and disadvantaged groups and conducting activities that address GESI-related barriers to optimal health, nutrition, and WASH behaviors. Suaahara's conceptual framework illustrates the paths by which the program activities linked to desired outcomes achieve Suaahara II objectives.

Official Title
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Suaahara Impact Evaluation: End-line Survey

Conditions
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Nutritional Stunting, Feeding Behavior

Intervention / Treatment
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* Behavioral: Health and family planning
* Behavioral: Nutrition
* Behavioral: Agriculture and homestead food production
* Behavioral: Water, sanitation, and hygiene


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: At the household level, the primary respondents are mothers of children under 5 years of age from the selected households. Other survey respondents include a primary male (or female, if male unavailable) household decision-maker, and a grandmother of children under 5 years of age residing in the household. The Female Community Health Volunteer and health workers are also Suaahara beneficiaries, as the program explicitly aims to improve their knowledge and skills. Exclusion Criteria: None.

Ages Eligible for Study
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Minimum Age: 0 Months
Maximum Age: 60 Months

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Prevention
Allocation: Non-Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Two-arm quasi-experimental design with baseline and end-line. The baseline and end-line were collected on different households but in the same clusters.
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Intervention<br>Suaahara interventions span health and family planning; nutrition; agriculture/homestead food production; and water, sanitation and hygiene (WASH). Diverse social and behavior change communication interventions are used, primarily to generate demand for access to improved services and to motivate households to adopt optimal health, nutrition, and WASH practices. All Suaahara interventions are supported by a crosscutting theme of gender equality and social inclusion (GESI), in part by targeting women and disadvantaged groups and conducting activities that address GESI-related barriers to optimal health, nutrition, and WASH behaviors. | Behavioral: Health and family planning<br>* Promotion of health and family planning behaviors<br>Behavioral: Nutrition<br>* Promotion of maternal, infant, and young child feeding behaviors and nutrition<br>Behavioral: Agriculture and homestead food production<br>* Promotion of knowledge and practices about homestead food production<br>Behavioral: Water, sanitation, and hygiene<br>* Promotion of behaviors to improve water, sanitation, and hygiene<br>|
| No Intervention: Comparison<br>Usual care. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Child dietary diversity (Indicators for Assessing Infant and Young Child Feeding Practices) | Mean score, range 0 to 8, higher is better | Over the 24 hours of the day before data collection | 
| Maternal dietary diversity (Minimum Dietary Diversity for Women) | Mean score, range 0 to 10, higher is better | Over the 24 hours of the day before data collection | 
| Stunting | Prevalence of height or length for age zscore < -2 | Over the 24 hours of the day of data collection | 
| Underweight prevalence | Prevalence of weight for age zscore < -2 | Over the 24 hours of the day of data collection | 
| Wasting | Prevalence of weight for length for height zscore < -2 | Over the 24 hours of the day of data collection | 
| Maternal underweight | Prevalence of body mass index < 18.5 | Over the 24 hours of the day of data collection | 
| Maternal anemia | Prevalence < 12 g/dl | Over the 24 hours of the day of data collection | 
| Anemia among children aged 6-59 months | Prevalence < 11 g/dl | Over the 24 hours of the day of data collection | 
| Accurate health, nutrition, and water, sanitation, and hygiene knowledge and skills among Female Community Health Volunteers and health workers from 52 items | Prevalence > 80% correct from 52 items | Over the 24 hours of the day of data collection | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Child minimum dietary diversity (Indicators for Assessing Infant and Young Child Feeding Practices) | Prevalence > 4 food groups of 8 | Over the 24 hours of the day before data collection | 
| Maternal minimum dietary diversity (Minimum Dietary Diversity for Women) | Prevalence > 4 food groups of 10 | Over the 24 hours of the day before data collection | 
| Height for age | Mean z-score | Over the 24 hours of the day of data collection | 
| Weight for age | Mean z-score | Over the 24 hours of the day of data collection | 
| Weight for height | Mean z-score | Over the 24 hours of the day of data collection | 
| Maternal body mass index | Mean | Over the 24 hours of the day of data collection | 
| Maternal hemoglobin | Mean in g/dl | Over the 24 hours of the day of data collection | 
| Child hemoglobin | Mean in g/dl | Over the 24 hours of the day of data collection | 
| Knowledge score on core infant and young child feeding practices among mothers from 15 items | Mean score, range 0 to 15, higher is better | Over the 24 hours of the day of data collection | 
| Knowledge score on health and water, sanitation, and hygiene practices among mothers from 37 items | Mean score, range 0 to 37, higher is better | Over the 24 hours of the day of data collection | 
| Female Community Health Volunteers and health workers with ideal practices related to health, nutrition, and water, sanitation, and health from 52 items | Prevalence > 80% correct from 52 items | Over the 24 hours of the day of data collection |