To confirm validity of probability outcome of RCT evidence is also needed along the causal pathways (plausibility) to show that each step of the intervention is delivered and contributing to ultimate objectives. Also must document adequacy of observed changes on causal pathway to lead to these objectives.We used a stratified, probability survey design. Eight Illakas were selected from the total twelve Illakas of Baitadi district based on the size of the population of children 12-48 months. From the selected 8 Illakas (41 VDCS), four Illakas (21 VDCs) were randomly assigned for intervention, and the remaining four Illakas (20 VDCs) were assigned to the control group. A total of 28 VDCs were randomly selected for the baseline survey (14 from intervention and 14 from control areas) with probability of selection proportionate to size of the population aged 12-48 months. The survey covered 2106 households, and the questionnaire was administered to the mother of the eligible child. In addition to the questionnaire-based data collection, anthropometric (Weight, height/length) and hemoglobin measurements were collected from the mother and eligible children in each household. In addition data on exclusive BF were collected on n=209 infants <6 months in sampled households.
In addition to documenting progress in establishing garden production, increased knowledge of key messages
IncludesMinistry of Health and Population (MoHP), Ministry of Agriculture and Cooperatives (MoAC), Ministry of Local Development (MoLD), Ministry of Education (MoE) in prioritizing the integration of food and nutritional security objectives and nutrition programming in existing systems from national to district level. Joint planning and budgeting at community level byDistrict Development Committee (DDC) and VDC helps to mobilize local resources around locally identified needs.
Aama operations research case study hki nepal - j. nielsen presentation
Background HKI has implemented Homestead Food Production (HFP) programs linked with nutrition education for >20 years to improve simultaneously food access, quality and utilization Evidence of impact on production, consumption, income, inconclusive on nutritional status Lack of highly rigorous studies to evaluate both impact and quality of delivery (process)
Background AAMA child survival project began Sept 2008 Project strategy combines HFP to improve access to nutrient dense plant and animal- source foods with Essential Nutrition Actions to promote optimal nutrition practices (“EHFP”) Targets mothers with children in nutritional “window of opportunity” Baitadi and Kailali [and Bajura] districts of Far Western Region Research to answer long-standing challenge
Operations ResearchObjectives Community randomized control trial to determine impact of EHFP on nutritional status (growth) of children < 2yrs and use program impact pathways to demonstrate plausibility Hypothesis: Exposure to EHFP will reduce stunting by 10% underweight by 10% wasting by 5% In children 12-48 months of age exposed to program during critical window Randomization by Illaka (4/4 of total 12), resulting in n=21 intervention and n=20 control VDCs. Cross- sectional design; baseline survey n=2,106 HH
AAMA Program Impact Pathways schema HKI, NTAG, SMJK, District Health, Agriculture and Livestock Offices, District Development Committee Input Process Outputs Outcomes Impact Improved Agriculture inputs and including developed seeds, saplings and Supportive gardens Increased Increased Process/Output indicators poultry supervision establishe production Income d of nutrient- rich fruits & Outcome indicators vegetables Impact indicators Village Improved Model Farms Small animal maternal (VMF) productionHKI partners Agriculture- and child established established Increased with local related health and NGOs and training household nutritional Increasedgovernment consumption animal status HFPB groups Beneficiaries source food established understand production agriculture Nutrition training & BCC- related Linkages to education VMF, FCHVs Improved and health Beneficiaries child care services understand and feeding nutrition practices education Project Monitoring and Evaluation
Support for Research MCHIP staff was generous with technical support on research design, sample size challenges, spillover risks IFPRI collaboration also contributed to PIP, research design Strong project team including SMJK; input from Asia/Pacific Regional Nutrition Advisor and HQ Nutrition Program Manager Additional funding from WB, Alive & Thrive, USAID/Nepal
Research Challenges Defining age range for survey sample to capture maximum exposure to intervention during critical window of a “moving target” Lengthy preparation before project fully operational (baseline survey; formative research; establish and supply VMFs; HFP training of trainers, VMFs, mothers; ENA training for FCHVs/VMFs, mothers; seasonal lag until production) vs. 4 year project life Logistical difficulties of FW hill region Increasing equity of model
Operations Research Have used LQAS following program pathways (targeting children <2 years - non-comparable with baseline). Findings informed steps to: Strengthen formative supervision of VMFs to improve support to mothers; simplify reference materials Strengthen poultry input supply systems in partnership with district livestock office Address water constraints in partnership with district agriculture office Add facilitation skills training to strengthen training impact Address knowledge gaps of FCHV on ENA and HFP
Operations Research-successes Garden diversity increasing Dietary diversity increasing Reported EBF rates increasing Intake of Fe and VA rich foods, eggs increasing Poultry cultivation accepted despite cultural taboos “Superflour” use growing “Lactation management” major impact
Sharing Operations Researchfindings Process monitoring results are shared on monthly basis with the project team, on a quarterly basis with FCHVs and health workers to improve performance, and regularly with other implementation partners Strong and weak pathways on impact schema identified through data reviewed annually Four HKI internal bulletins on “program implementation lessons learned” with government and development partners have been developed and disseminated
Additional Publications Analyses of baseline data on HH food insecurity in Kailali and Baitadi (one published; one under review) Manuscript on formative research process nearly complete but stalled due to time constraints Additional nested sub-study (A&T) examining impact of EHFP vs. EHFP + micronutrient powders Eventually findings of impact evaluation (end line survey August 2012)
Governance Impact Additional support from USAID/Nepal has allowed HKI to reinforce GON strategy for multisectoral planning and collaboration to reduce malnutrition, including multisectoral nutrition plan National, FWR and district planning workshops to define joint objectives and areas for integration VMFs integrated into extension system District-level nutrition & food security working groups Recognition of synergies and potential between Agriculture, Health, Local Government Final results will ideally provide additional momentum
Multisectoral governance fornutrition and food security at all levels