2. 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)
3. 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
4. Operations Research
Objectives
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
5. 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) production
HKI partners Agriculture- and child
established established Increased
with local related health and
NGOs and training household nutritional
Increased
government 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
6. 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
7. 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
8. 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
9. 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
10. Sharing Operations Research
findings
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
11. 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)
12. 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
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.
Baitadi OR
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.