Child Nutritional Status Clinical Trial
Official title:
Impact Evaluation of the DFID Programme to Accelerate Improved Nutrition of the Extreme Poor in Bangladesh
This is a randomized study in three areas of Bangladesh (Chars region where CLP operates,
Haor region where Shiree operates, and urban slums where UPPR operates). Treatment is
assigned at the community level, where treatments are:
- Livelihoods intervention only (L only)
- Livelihoods intervention plus nutrition intervention (L+N)
In UPPR only, the study also includes a non-randomly selected comparison group (C).
Within treatment localities, targeted beneficiaries include women, adolescent girls, and
children under 24 months. Benefits are received for two years.
Undernutrition is widespread in Bangladesh. In 2011, according to the Bangladesh Demographic
and Health Survey, 41.3 per cent of children under age five were stunted, 36.4 per cent were
underweight, 15.6 per cent were wasted, and more than 50 per cent were anaemic. Prevalences
were even higher among extremely poor households. Meanwhile, evidence from South Asia shows
that high rates of economic growth and reduction in poverty have not led to similarly large
reductions in undernutrition (see 1, 2, 3). These findings have suggested that improvements
in income alone may not be sufficient to improve nutritional status. Extensive research has
also shown that the critical window for nutritional interventions is during the "first
thousand days" of life (see 4, 5), from the time when a child is in utero until about two
years of age. Based on this accumulated evidence, growing attention has come to introducing
nutrition interventions that target children's "first thousand days" alongside household
poverty reduction programmes. In particular, there has been growing emphasis on nutrition
interventions that aim to improve infant and young child feeding practices—through
increasing nutritional knowledge of women who are pregnant, lactating, or likely to be
pregnant in the future—as well as to improve the nutritional status of these women
themselves.
Although there exists considerable evidence assessing the effectiveness of various
livelihoods interventions and other social protection programmes, as well as some evidence
on the effectiveness of various direct nutritional interventions, little research directly
assesses how an integrated livelihoods and nutrition programme might compare with
livelihoods support alone. There are several reasons why the combination of nutrition and
livelihoods support may have nutritional benefits over and above livelihoods support only.
First, a key constraint to improved nutritional status may be insufficient knowledge of
appropriate infant and young child feeding practices (for example, the appropriate duration
of exclusive breastfeeding, the appropriate frequency and diversity of child feeding
thereafter, etc.). If this is the case, then improving income alone will not necessarily
lead to improved feeding practices. Second, there may be synergies between the two types of
support. For example, even if a mother's knowledge of infant and young child feeding
practices improves, she may still need access to sufficient resources for undertaking those
practices (such as income to purchase the recommended types of food), which can be
facilitated through a livelihoods intervention. Third, there may be other dynamics shifted
through the direct nutrition intervention that mediate how the livelihoods intervention
affects nutritional status. For example, if a direct nutrition intervention targeting women
improves women's bargaining power within the household, and if women tend to prefer devoting
more resources to young children's nutrition (e.g., Quisumbing and Maluccio 2003), the
result may also be larger impacts on nutritional status than livelihoods support alone.
The DFID Programme to Accelerate Improved Nutrition for the Extreme Poor in Bangladesh aims
to improve nutrition outcomes for young children, pregnant and lactating mothers, and
adolescent girls. Its approach is to integrate direct nutrition interventions into the
livelihood support currently provided to extremely poor households in Bangladesh through
three existing programmes: the Chars Livelihoods Programme (CLP), the Shiree Economic
Empowerment of the Poorest Programme (Shiree or EEP, within which the investigators focus on
the Concern subproject), and the Urban Partnership for Poverty Reduction Programme (UPPR).
In order to rigorously and independently assess the impacts of these integrated nutrition
and livelihoods programmes, DFID has collaborated with research partners and implementation
partners to undertake a mixed methods impact evaluation, entitled "Impact Evaluation of the
DFID Programme to Accelerate Improved Nutrition for the Extreme Poor in Bangladesh." The
evaluation team includes IDS (the lead organisation), IFPRI, ITAD, CNRS, and BRAC
University. The evaluation uses mixed quantitative and qualitative methods within a strong
theory-based design to assess the impacts of the integrated programmes on nutritional
status.
The quantitative impact component involves a baseline survey (conducted in
September-November 2013) and an endline survey (to be conducted in November-December 2015).
The exploratory/explanatory component includes a qualitative subcomponent (for which the
first phase of fieldwork has been ongoing since February 2014), as well as a process
evaluation subcomponent (ongoing since July 2014, final results not yet available). The cost
effectiveness component began in August 2014 and will be completed in early 2016 following
the quantitative endline survey completion.
The three key research questions regarding programme impact that will be addressed are:
1. What is the impact on nutrition outcomes of receiving a combination of livelihoods and
direct nutrition interventions (denoting this scenario (L+N)), relative to receiving a
livelihoods intervention only (denoting this scenario (L))?
2. What is the impact on nutrition outcomes of receiving a combination of livelihoods and
direct nutrition interventions (L+N), relative to receiving no intervention (denoting
this scenario (C) for control)?
3. What is the impact on nutrition outcomes of receiving a livelihoods intervention only
(L), relative to receiving no intervention (C)? This will pertain only to the urban
group served by UPPR.
In order to construct a proxy for the (L+N) households in the counterfactual (L) scenario,
randomisation is used. Among the households that already receive the livelihoods
intervention at baseline, half are randomly assigned to additionally receive the nutrition
intervention after the baseline (denoted the (L+N) group). The remaining half continue to
receive only the livelihoods intervention (denoting the (L) group). Randomisation is
conducted at the level of primary sampling units (PSUs) that cover an entire locality,
rather than at the level of individual households. The randomisation makes it very likely
that characteristics of the (L) and (L+N) groups will on average be similar at baseline. (L)
is then a valid proxy for (L+N), and average differences between the groups at endline can
be interpreted as impacts caused only by the addition of the nutrition component rather than
pre-existing differences.
In order to construct a proxy for the (L+N) households in the counterfactual (C) scenario of
no intervention, non-randomised approaches are used. Since none of the original livelihoods
interventions was rolled out following a randomised control trial design, there is no
obvious set of comparable non-beneficiaries to serve as the counterfactual. Because a
control group is nonetheless required to assess the absolute benefits of either (L) or (L +
N) interventions, attempts were made to construct the best possible control group out of
non-randomly selected non-beneficiaries. It is important to emphasise that a non-random
control group is not expected to be on average identical to beneficiary households. In the
baseline survey, the objective was simply to sample a group of non-beneficiaries as similar
as possible to the beneficiaries except for receipt of the intervention.
Major topics areas covered by the qualitative data collection tools include the following:
1. Social, economic, institutional and political context of the community
2. Local practices, resources, customs in regards to health, hygiene, nutrition and care
of children, pregnant and lactation mothers, adolescent girls
3. For (L) and (L+N) sites: Perceived impact of the livelihood intervention
4. For (L+N) sites: Perceived synergies and disconnects between the nutrition and
livelihood interventions in the communities
5. For (L+N) sites: Micro-dynamics of the nutrition intervention at the community level
and how beneficiaries perceive/experience the intervention
;
Allocation: Randomized, Intervention Model: Factorial Assignment, Masking: Open Label, Primary Purpose: Basic Science