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Impact Evaluation of the DFID Programme to Accelerate Improved Nutrition of the Extreme Poor in Bangladesh
Last registered on October 29, 2015

Pre-Trial

Trial Information
General Information
Title
Impact Evaluation of the DFID Programme to Accelerate Improved Nutrition of the Extreme Poor in Bangladesh
RCT ID
AEARCTR-0000927
Initial registration date
October 29, 2015
Last updated
October 29, 2015 1:46 PM EDT
Location(s)
Primary Investigator
Affiliation
International Food Policy Research Institute
Other Primary Investigator(s)
PI Affiliation
Institute for Development Studies, University of Sussex
PI Affiliation
Cornell University
PI Affiliation
International Food Policy Research Institute
PI Affiliation
University of Dhaka
PI Affiliation
Institute for Development Studies, University of Sussex
Additional Trial Information
Status
On going
Start date
2013-09-01
End date
2015-12-31
Secondary IDs
Abstract
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 (e.g., Smith et al. 2002; Ramalingaswami, Jonsson, and Rohde 1996; Deaton and Dreze 2009). 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 (e.g., Bhutta et al. 2013; Hoddinott et al. 2013), 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 we 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)?
Research questions 2 and 3 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. Baseline data were collected on potential control groups for all three programmes. Exploratory matching analysis showed that the control group for only UPPR was sufficiently comparable to serve as a potentially valid counterfactual. Therefore questions regarding absolute benefits will be addressed only for UPPR, not for CLP or Shiree.

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
Registration Citation
Citation
Hoddinott, John et al. 2015. "Impact Evaluation of the DFID Programme to Accelerate Improved Nutrition of the Extreme Poor in Bangladesh." AEA RCT Registry. October 29. https://doi.org/10.1257/rct.927-1.0.
Former Citation
Hoddinott, John et al. 2015. "Impact Evaluation of the DFID Programme to Accelerate Improved Nutrition of the Extreme Poor in Bangladesh." AEA RCT Registry. October 29. https://www.socialscienceregistry.org/trials/927/history/5821.
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Experimental Details
Interventions
Intervention(s)
CLP Livelihoods Only (CLP, L): Capital for purchase of income generating asset, physical infrastructure (plinths, latrines, tubewells), livelihood maintenance stipend, monthly asset maintenance cost stipend, agricultural livelihood training, non-agricultural livelihood training, financial training, health and nutrition training.

CLP Livelihoods plus Nutrition (CLP, L+N): Livelihoods intervention described above, plus nutrition intervention as follows. Counseling on breastfeeding and complementary feeding; five components micronutrients (iron 12.5 mg, folic acid 0.16 mg, zinc 5 mg, vitamin A 0.3 mg, vitamin C 30 mg) for children 7-23 months dosage of 120 sachets per year; 180 iron and folic acid tablets (60 mg iron and 400 mg folic acid) tablets to each pregnant woman after first trimester and up to 180 for each breastfeeding woman per year, as well as 104 tablets to each adolescent girl; deworming treatment for children aged 1-5 years, adolescent girls, pregnant women after first trimester; identification and referral of acute malnutrition; facilitation of government campaigns on nutrition.

Shiree Livelihoods Only (Shiree, L): Financial training; input support for livelihoods (cropping, livestock, poultry, fishing, bamboo working, small businesses, tailoring etc.); capacity building (mobilising Self Help Groups, facilitating community based organizations (CBOs), skills transfer); innovation support (market linkage and access to value chains); credit and savings groups; support in mobilizing communities to advocate for their needs.

Shiree Livelihoods plus Nutrition (Shiree, L+N): Livelihoods intervention described above, plus nutrition intervention as follows. Counseling on breastfeeding, complementary feeding, and sanitation; community discussions including adolescent girls on early and forced marriage; five components micronutrients (iron 12.5 mg, folic acid 0.16 mg, zinc 5 mg, vitamin A 0.3 mg, vitamin C 30 mg) for children aged 7-23 months; 180 iron and folic acid tablets (60 mg iron and 400 mg folic acid) tablets to each pregnant woman after first trimester and up to 180 for each breastfeeding woman per year, as well as 104 tablets to each adolescent girl; deworming treatment for children aged 1-5 years, adolescent girls, pregnant women after first trimester.

UPPR Livelihoods Only (UPPR, L): Monetary support for communities to improve infrastructure (drains, footpaths, latrines and water dwells, access to roads and markets); financing for apprenticeships; grants for small businesses; education grants for girls; grants for urban food production activities; financial training; establishment of savings and credit groups; support for communities in advocating for their needs; microcredit; improving access to health facilities; improving housing conditions; provision of plinths.

UPPR Livelihoods plus Nutrition (UPPR, L+N): Livelihoods intervention described above, plus nutrition intervention as follows. Counseling on breastfeeding, complementary feeding, and sanitation; community discussions including adolescent girls on early and forced marriage; five components micronutrients (iron 12.5 mg, folic acid 0.16 mg, zinc 5 mg, vitamin A 0.3 mg, vitamin C 30 mg) for children aged 7-23 months; 180 iron and folic acid tablets (60 mg iron and 400 mg folic acid) tablets to each pregnant woman after first trimester and up to 180 for each breastfeeding woman per year, as well as 104 tablets to each adolescent girl; deworming treatment for children aged 1-5 years, adolescent girls, pregnant women after first trimester.

UPPR Control group (UPPR, C): no livelihoods or nutrition interventions.
Intervention Start Date
2013-12-01
Intervention End Date
2015-12-31
Primary Outcomes
Primary Outcomes (end points)
Primary Outcome Measures:

1.Child anthropometry
[Time Frame: Baseline. Up to 24 months.] [Safety Issue: No]
Height for age z scores, weight for age z scores, stunting, wasting. Outcomes specified in terms of levels two years after intervention started, as well as in changes (2013-2015).

2.Child food intake
[Time Frame: Baseline. Up to 24 months.] [Safety Issue: No]
Number of unique foods consumed in previous 24 hours, number of food groups consumed in previous 24 hours, consumption of specific food groups (animal source foods, dairy, vitamin A rich foods, etc.), caloric consumption in previous 24 hours. Outcomes specified in terms of levels two years after intervention started, and as changes (2013-2015).

3.Dietary diversity of index child's mother, father, and of adolescent girl
[Time Frame: Baseline. Up to 24 months.] [Safety Issue: No]
Number of unique foods consumed in previous 24 hours, number of food groups consumed in previous 24 hours. Outcomes specified in terms of levels two years after intervention started, and as changes (2013-2015).

4.Index child mother's nutrition knowledge
[Time Frame: Baseline. Up to 24 months.] [Safety Issue: No]
Knowledge of index child's mother regarding breastfeeding, complementary feeding, nutrition, and sanitation practices (29 questions). Outcomes specified as a total score (out of 29). Outcomes specified in terms of levels two years after intervention started, and as changes (2013-2015).

5.Household food security
[Time Frame: Baseline. Up to 24 months.] [Safety Issue: No]
Food groups consumed by household in previous seven days, number of unique foods consumed in previous seven days, number of food groups consumed in previous seven days weighted by nutritional value and frequency of consumption, value of food consumption in previous seven days, household caloric availability in previous seven days, whether and how often a household member has gone to sleep hungry because of lack of food. Outcomes specified in terms of levels two years after intervention started, and as changes (2013-2015).

6.Infant and young child feeding practices
[Time Frame: Baseline. Up to 24 months.] [Safety Issue: No]
Length of breastfeeding of index child, age complementary feeding initiated. Outcomes specified in terms of levels two years after intervention started, and as changes (2013-2015).

7.Exposure to nutrition from health workers and media
[Time Frame: Baseline. Up to 24 months.] [Safety Issue: No]
Visits from health care workers, activities carried out by health care workers during visits, counseling received by health care workers during visits, attendance at group meetings on health or nutrition, exposure to breastfeeding or complementary feeding from radio and television. For mother of index child and adolescent girl. Outcomes specified in terms of levels two years after intervention started, and as changes (2013-2015).

8.Receipt of and participation in livelihoods and nutrition interventions (take up)
[Time Frame: Baseline. Up to 24 months.] [Safety Issue: No]
Take up of livelihoods and nutrition interventions by CLP/Shiree/UPPR programmes. Outcomes specified in terms of levels two years after intervention started, and as changes (2013-2015).

9.Community nutrition worker knowledge and activities.
[Time Frame: Endline.] [Safety Issue: No]
Misconceptions regarding nutrition knowledge and attitudes; breastfeeding, complementary feeding, and sanitation knowledge; number of home visits and group training sessions. Outcomes specified in terms of levels two years after intervention started.

Secondary Outcome Measures:

Nutrition knowledge of adolescent girl
[Time Frame: Baseline. Up to 24 months.] [Safety Issue: No]
Knowledge of adolescent girl regarding breastfeeding, complementary feeding, nutrition, and sanitation practices (29 questions). Outcomes specified as a total score (out of 29). Outcomes specified in terms of levels two years after intervention started, and as changes (2013-2015).

Health of index child <36 months
[Time Frame: Baseline. Up to 24 months.] [Safety Issue: No]
Did mother report child was ill in previous 2 weeks. Whether care was sought and where care was received. Outcomes specified in terms of levels two years after intervention started, and as changes (2013-2015).

Antenatal care
[Time Frame: Baseline. Up to 24 months.] [Safety Issue: No]
Attendance at antenatal care sessions, care received at antenatal sessions, receipt of food, receipt of iron folic acid and vitamin A, location of delivery of index child, weighing of index child after birth. Outcomes specified in terms of levels two years after intervention started, and as changes (2013-2015).

Sanitation practices for index child
[Time Frame: Baseline. Up to 24 months.] [Safety Issue: No]
Disposal of stool of index child. Outcomes specified in terms of levels two years after intervention started, and as changes (2013-2015).

Women's status
[Time Frame: Baseline. Up to 24 months.] [Safety Issue: No]
Ability to work, decision making power in spending earnings, decision making power in household expenditures, mobility outside the household, participation in group meetings, voting, respect and domestic violence, control and agency, time preferences. Outcomes specified in terms of levels two years after intervention started, and as changes (2013-2015).

Ownership of assets
[Time Frame: Baseline. Up to 24 months.] [Safety Issue: No]
Ownership of assets (total), ownership of assets provided by CLP/Shiree/UPPR, value of assets. Outcomes specified in terms of levels two years after intervention started, and as changes (2013-2015).

Housing quality
[Time Frame: Baseline. Up to 24 months.] [Safety Issue: No]
Ownership status of house, quality of materials of house, electricity and fuel sources, acquisition of plinths, water and sanitation quality. Outcomes specified in terms of levels two years after intervention started, and as changes (2013-2015).

Household consumption
[Time Frame: Baseline. Up to 24 months.] [Safety Issue: No]
Value of food consumption in previous seven days, value of monthly non-food consumption, value of monthly non-food consumption by specified sub-groups (clothing, medical expenses, education expenses, transport, consumables, semi-durables), value of monthly household consumption (food and non-food). Outcomes specified in terms of levels two years after intervention started, and as changes (2013-2015).

Household income
[Time Frame: Baseline. Up to 24 months.] [Safety Issue: No]
Value of annual income derived from agriculture, value of annual income derived from nonagricultural sources, value of annual total income derived from all sources. Outcomes specified in terms of levels two years after intervention started, and as changes (2013-2015).
Primary Outcomes (explanation)
Secondary Outcomes
Secondary Outcomes (end points)
Secondary Outcomes (explanation)
Experimental Design
Experimental Design
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)?

Research questions 2 and 3 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. Baseline data were collected on potential control groups for all three programmes. Exploratory matching analysis showed that the control group for only UPPR was sufficiently comparable to serve as a potentially valid counterfactual. Therefore questions regarding absolute benefits will be addressed only for UPPR, not for CLP or Shiree.
Experimental Design Details
Randomization Method
Randomization conducted in office by a computer.
Randomization Unit
Unit of randomization is at the level of the ward in rural areas (for CLP and Shiree programs) and at the level of clusters of slums for urban areas (for UPPR program).
Was the treatment clustered?
Yes
Experiment Characteristics
Sample size: planned number of clusters
70 clusters per program (3 programs) for a total of 210 clusters.
Sample size: planned number of observations
11,060 households.
Sample size (or number of clusters) by treatment arms
CLP, L: 980 households in cross-section sample, 600 households in panel sample (total 1,580 households)
CLP, L+N: 980 households in cross-section sample, 600 households in panel sample (total 1,580 households)
Shiree, L: 980 households in cross-section sample, 600 households in panel sample (total 1,580 households)
Shiree, L+N: 980 households in cross-section sample, 600 households in panel sample (total 1,580 households)
UPPR, L: 980 households in cross-section sample, 600 households in panel sample (total 1,580 households)
UPPR, L+N: 980 households in cross-section sample, 600 households in panel sample (total 1,580 households)
UPPR, C: 980 households in cross-section sample, 600 households in panel sample (total 1,580 households)
Minimum detectable effect size for main outcomes (accounting for sample design and clustering)
IRB
INSTITUTIONAL REVIEW BOARDS (IRBs)
IRB Name
International Food Policy Research Institute IRB
IRB Approval Date
2013-08-28
IRB Approval Number
2015-46-PHND-C
Post-Trial
Post Trial Information
Study Withdrawal
Intervention
Is the intervention completed?
No
Is data collection complete?
Data Publication
Data Publication
Is public data available?
No
Program Files
Program Files
Reports and Papers
Preliminary Reports
Relevant Papers