Nepal Sunaula Hazar Din Community Action for Nutrition Project Endline Report April 2018 Development Impact Evaluation (DIME) This material has been funded thanks to the contributions of (1) UK Aid from the UK government, and (2) the European Commission (EC) through the South Asia Food and Nutrition Security Initiative (SAFANSI), which is administered by the World Bank. The views expressed do not necessarily reflect the EC or UK government's official policies or the policies of the World Bank and its Board of Executive Directors. 0 Contents List of Acronyms ............................................................................................................................. 2 Executive Summary ........................................................................................................................ 3 1. Introduction ............................................................................................................................ 4 A. Malnutrition in Nepal ...................................................................................................... 4 B. Program Description ........................................................................................................ 5 C. Impact Evaluation Design ................................................................................................ 6 D. Data and Sampling ........................................................................................................... 8 2. Implementation ...................................................................................................................... 11 A. Goal Selection.................................................................................................................. 11 B. Implementation Challenges ............................................................................................ 13 3. Project Achievement ............................................................................................................... 14 A. Project Development Objectives ..................................................................................... 15 B. Pregnant Women Taking Iron and F0lic Acid (IFA) Supplement .................................. 15 C. Breastfeeding Practices ................................................................................................... 16 D. Complementary Feeding Practice ...................................................................................18 E. Attitudes of Household and Community Members ........................................................ 19 F. Water, Sanitation and Hygiene ...................................................................................... 20 G. Child Malnutrition and Illness ....................................................................................... 23 H. Social Capital .................................................................................................................. 25 4. Conclusion and Policy Recommendations ............................................................................ 30 5. Appendix................................................................................................................................ 33 A. List of Focus Area .................................................................................................................. 33 B. Sample Goal Recommendations by Coaches ........................................................................ 34 C. Sample Goal Recommendations by Coaches ........................................................................ 35 D. SHD IE Timeline ................................................................................................................... 36 E. Weighting of Endline Sample ................................................................................................ 37 F. List of 282 VDCs .................................................................................................................... 38 G. Additional Tables................................................................................................................... 45 1 List of Acronyms DDC District Development Committee DHS Demographic and Health Survey DIME Development Impact Evaluation HH Household IFA Iron and Folic Acid Supplements IYCF Infant and Young Child Feeding KAP Knowledge, Attitudes and Practices PDO Project Development Objective RCT Randomized Controlled Trial RRA Rapid Results Approach RRNI Rapid Results for Nutrition Initiative SHD Sunaula Hazar Din (means golden 1000 days in Nepalese) VDC Village Development Community WHO World Health Organization 2 Executive Summary Sunaula Hazar Din Community Action for Nutrition Project was implemented by the Nepalese government with support from the World Bank from 2014 to 2017 in order to improve child and maternal nutrition in Nepal. “Sunaula Hazar Din” (SHD) translates into English as the “golden 1000 days”. It refers to the period from conception to 24 months of age, when children are most vulnerable to malnutrition. The overall objective of the SHD program is to enable the most vulnerable communities in Nepal to develop better knowledge, attitudes and practices (KAP) to improve nutritional outcomes among children during these first 1000 days. SHD is a particular type of community-driven development program in which communities choose certain goals or focus areas relating to improved nutrition, formulate plans to help achieve the goals, and are granted funds to implement these plans. The focus areas cover a variety of factors affecting nutrition: health practices of pregnant mothers, children’s food intake, sanitation facilities, age of marriage, etc. The impact evaluation team has conducted a rigorous evaluation in order to examine the impact of the SHD program on uptake of nutrition-enhancing practices. Following the impact evaluation study design, 141 Village Development Communities (VDCs) were randomly selected to start the SHD implementation in 2014 (early starter VDCs) and the other 141 VDCs begin project activities only in 2016 (late starter VDCs) comprising of 282 VDCs in total. By the time of the endline survey which took place in April – July 2017, early starter communities had completed up to seven cycles1i, while late starter communities completed up to four cycles. The most common goals selected by communities are using clean and safe water, followed by and increasing consumption of animal protein among pregnant women and young children, and maintaining adequate weight and regular eating among pregnant women and young children. The main results of the report are as follows: • The result related to access to improved toilet is striking since the percentage of households reporting to have access to improved toilet has increased by three-folds from 26% at baseline to 78% at endline. Also, lower percentage of households (10%) reported observing human feces around the house at endline, compared to 30% at baseline. • Overall, the percentage of children under 2 suffer from different types of illness, including coughing, diarrhea and vomiting has decreased after four years of implementation of the SHD project. Also, the project area has lower percentage of children under two who are stunted, wasted and underweight compared to the baseline. 1 A cycle is a period of 100-days during which a goal is meant to be completed. 3 1. Introduction A. Malnutrition in Nepal While Nepal was able to meet the Millennium Development targets relating to the Infant Mortality Rate, Nepal has a very high rate of child malnutrition with 37 per cent of children under five stunted, 11 per cent wasted and 30 per cent underweight (Central Bureau of Statistics 2015).2 The human development and economic costs of malnutrition are very high – an estimated 2-3 per cent of GDP (US$250 to 375 million) is lost every year in Nepal on account of vitamin and mineral deficiencies alone (World Bank 2012).3 Improving nutrition contributes to productivity, economic development, and long-term poverty reduction by improving physical work capacity, cognitive development, school performance, and health through reducing disease and mortality. The 1000 days from the first day of pregnancy through the first two years of life are widely recognized as an important period with potential long-term effects. The damage to physical growth, brain development, and human capital formation that occurs during this period due to inadequate nutrition is extensive and largely irreversible (Grantham-McGregor et al. 2007).4 The main focus in Nepal on improving nutrition therefore is to accelerate the reduction of chronic child malnutrition. Interventions must focus on the risk factors that influence nutritional outcomes during this critical period. These risk factors arise from a combination of individual and community level knowledge, attitudes, and practices (KAP). They include such practices as eating down during pregnancy, smoking during pregnancy, insufficient intake and absorption of nutrients, lack of knowledge about the nutritious value of foods and which foods are required at specific times, including pregnancy and early childhood, poor economic and social access to food and poor feeding practices for children. Community-wide supply-side factors are also important - for instance the availability and cost of appropriate foods is problematic in many districts, and poor access to safe drinking water and poor hygiene and sanitation practices affect the disease burden of communities and nutrition, particularly of young children. Cultural practices also perpetuate the intergenerational problem of malnutrition. In this context, Sunaula Hazar Din Community Action for Nutrition Project was implemented to target these risk factors to improve child and maternal nutrition in Nepal. 2 Central Bureau of Statistics, 2015. Nepal Multiple Indicator Cluster Survey 2014, Final Report. Kathmandu, Nepal: Central Bureau of Statistics and UNICEF Nepal. 3 World Bank, 2012. Nutrition in Nepal: A National Development Priority. 4 Grantham-McGregor, Sally, Yin Bun Cheung, Santiago Cueto, Paul Glewwe, Linda Richter, and Barbara Strupp. 2007. ‘Developmental Potential in the First 5 Years for Children in Developing Countries’. Lancet 369 (9555): 60–70. doi:10.1016/S0140-6736(07)60032-4. 4 B. Program Description “Sunaula Hazar Din” (SHD) translates into English as the “golden 1000 days”. It refers to the period from conception to 24 months of age, when children are most vulnerable to malnutrition. The overall objective of the SHD program is to enable the most vulnerable communities in Nepal to develop better knowledge, attitudes and practices (KAP) in order to improve nutritional outcomes among children during these first 1000 days. Changes in KAP would address the key risk factors for child malnutrition and create demand for nutrition-related services and products. SHD is a particular type of community-driven development program in which communities choose certain goals relating to improved nutrition, formulate plans to help achieve the goals, and are granted money to implement these plans. The SHD program is implemented using the “rapid results” approach, or RRA. The approach encourages communities to achieve a self-selected goal in 100 day cycles. First, communities form a “Rapid Results for Nutrition Initiative” (RRNI) team comprising between 8 and 10 individuals. Second, each team is assigned a “coach”, who helps the team select one nutrition-related “focus area” from a menu of 15 (see Appendix A). The focus areas cover a variety of factors affecting nutrition: health practices of pregnant mothers, food intake of children, sanitation facilities, age of marriage, etc. Third, the community develops a detailed work plan to help achieve the selected goal, and the budget required to execute the work plan. Fourth, the work plan and budgets are approved by the local government5 and released to the communities. Fifth, communities start to execute their plan, aiming to achieve their goal within 100 days. Finally, at the end of the cycle, the coach (and sometimes also an outside monitor) assesses whether or not the goal has been achieved. If the community has been unsuccessful, it can apply for another cycle to try to achieve the same or another goal. If the community has been successful, it can apply for two additional goals at once. The program was implemented in 15 districts out of the total of 75 districts in Nepal. Fifteen districts were selected based on a) stunting levels of children; b) population size; c) poverty levels; and d) the absence of interventions by other partner that focus on social mobilization. These 15 districts were divided into three clusters, each made of five contiguous districts to facilitate knowledge transmission, communication, and lower administrative and operational burdens. Each cluster was designed such that supervision of each cluster was logistically feasible, while still including both hill and terai districts. Cluster 1 Cluster 2 Cluster 36 Udayapur Siraha Rautahat Sunsari Dhanusha Makawanpur Okhaldhunga Mahottari Parsa Khotang Sindhuli Sarlahi Saptari Ramechhap Bara 5 Approval was granted by village level government for projects below $1,000, and by district level government for projects above $1000. 6 Please refer to Appendix Table 1 for the full list of 282 VDCs. 5 There are approximately 1,100 Village Development Committees (VDCs) in these 15 districts. The program targets 25% of the most disadvantaged VDCs -in total approximately 280 VDCs and operates in all wards of the selected VDCs.7 For the sake of evaluation, 141 VDCs were randomly selected to start the SHD implementation in 2014 (early starter VDCs) and the other 141 VDCs begin project activities only in 2016 (late starter VDCs) comprising of 282 VDCs in total. C. Impact Evaluation Design The impact evaluation as a whole addresses whether participation in the SHD program can improve uptake of nutrition-enhancing attitudes practices. We also assess impact on anthropometric indicators and child morbidity as these are some ultimate goals of the program, but with the drawback that changes in these indicators might take longer to realize. The evaluation is a randomized controlled trial (RCT) that uses a randomized phase-in approach. Of 282 VDCs slated for participation in the project, 141 were randomly selected to begin operations at the beginning of the project (“early starter” VDCs), while 141 were selected to begin midway through the project (“late starter” VDCs). The main difficulty in evaluating a project like SHD is that communities choose different sub- projects, and therefore expect to change different outcome variables. For analysis we must choose one of two strategies: either we look at specific outcomes and accept lower effect sizes (as only a subset of early starters chose goals relating to that outcome) or we use aggregate indicators. In this report we do both. The aggregate indicators we look at are anthropometric indicators (stunting/wasting/underweight) as well as an index of key outcome variables. We also look at individual outcome variables for the whole sample, but these need to be interpreted with caution, as some goals were rarely chosen by communities. SHD program implementation variation evaluation Additionally, the evaluation was designed to tests specific variations of the program design to see which are most effective. This was meant to answer the following questions: (i) How does goal choice and outcomes change if the community is encouraged to select particular goals deemed by external experts to be most appropriate to the community based on information obtained from a nutrition profile? (ii) How does goal choice and outcomes change if the Rapid Results for Nutrition Initiative (RRNI) teams have a female leader? 7 Nepal is administratively organized into units of decreasing size: regions, districts, sub-districts (illakas), municipalities (VDCs), and wards. Nepal has 75 districts, each of which is divided into a number of VDCs, the number depending on the population size. There are 3,914 VDCs nationwide and every VDC has 9 wards. Below the ward level are settlements. The project districts are in the central Tera area: Parsa, Bara, Rautahat, Sarlahi, Mahottari and Dhanusa; in the Central Hills: Makwanpur, Sindhuli and Ramechhap; in the Eastern Terai: Siraha, Saptari and Sunsari; in the Eastern Hills: Okhaldunga, Khotang and Udayapur. 6 These questions were addressed using two sub-treatment arms, described below. Figure 1: Impact Evaluation Design 36 VDCs - Female Leadership 71 VDCs - Requirement Standard RRNI Coaching 35 VDCs - No Leadership Requirement 141 VDCs "Early Starters" 35 VDCs - Female 282 Project VDCs Leadership 70 VDCs - Requirement 141 VDCs "Late Coaches suggest Starters" goals 35 VDCs - No Leadership Requirement Treatment 1: Providing Guidance on Goal Choice This treatment is designed to test whether providing advice from experts on community goal choices can shift community choices to more high-impact goals, resulting in larger overall project impact. For each district, three priority focus areas were chosen considering the baseline and input from nutrition experts. All guidance groups were recommended two focus areas - (i) focus area 2 (Increase consumption of animal protein among pregnant women and young children) and (ii) focus area 6 (Regular de-worming and utilization of iron supplements by young women) and an additional focus area of either (i) focus area 3 (Practice proper and consistent breast-feeding) or (ii) focus area 11 (End open defecation).8 In order to test the effectiveness of providing this additional information to RRNI groups, the RRNI coach in half (71) of the “early start” VDCs suggests to the RRNI teams that they implement a goal corresponding to one of these selected focus areas. The half of VDCs that receive the extra guidance on goals are randomly selected from the entire set of the early start VDCs. We then compare these “extra guidance” VDCs to “standard” VDCs that followed the standard procedure of selecting among the set of 15 focus areas. Treatment 2: Requiring Female Leadership 8 Appendix B shows a sample goal selection table provided to coaches on providing guidance. The choice of goals to recommend was based on advice of nutrition experts from the world bank, using baseline values of indicators as an input. Each VDCs was recommended three focus groups. The three recommendations were chosen from proper breastfeeding, IFA supplementation, maintaining weight of infants, and ending open defecation. 7 The second variation is designed to test whether stronger requirements are necessary to ensure adequate female empowerment in goal selection. Standard practice for organization of community groups in Nepal requires that one third of the group is women. In this test, a randomly selected subset of the RRNI teams are required to have a female leader, while other groups could pick a leader of any gender. This requirement would be instituted at the VDC level. Half of the early-start VDCs are randomly selected to have a female leadership for their RRNI groups, while the other half could choose a leader of any gender. Comparison of goal choice between the VDCs with the female leadership requirement and those with standard requirements shows the impact of female leadership. In this report, we will focus simply on the results of the overall impact evaluation of the program. D. Data and Sampling 1. Survey Instrument The baseline, midline, and endline surveys consist of three data collection instruments below: Rapid House Listing: To effectively measure the impact of the SHD project, the sample must include mothers with children under the age of 24 months who are most likely to receive the benefits of the project as well as pregnant women. In order to identify households with our target population, we conducted a rapid house listing to determine household composition in the two most disadvantaged wards within each VDC (roughly 90 households per ward on average). The listing identified households with small children and/or pregnant women for sampling and collected basic information on them. The results from this listing was used to construct a sampling frame. Using this sampling frame, the survey firm randomly selected households with children under the age of 24 months and pregnant women from each VDC for the main household questionnaires. Main Household Questionnaire: The main household questionnaire was applied to randomly selected households through the rapid house listing exercise. In the Main Household Questionnaire, households were asked about questions on labor supply, illness in the past, housing conditions and physical assets, expenditure and food consumption, adverse shocks and transfers, trust and solidarity, collective action and cooperation, social cohesion and inclusion, empowerment and political action, and community opinion. Women & Children Questionnaire: In the Women & Children Questionnaire, questions were asked about the health and nutrition of women and children in the household, including measurement of height and weight of children. From the Rapid House Listing, two groups of households were randomly sampled for the household survey: Baseline: • Group 1: 15 households with at least one child under two years of age 8 • Group 2: 10 households with a married woman aged 15-25 Midline: • Group 1: 15 households with at least one child under two years of age • Group 2: 5 households with a pregnant woman9 Endline: • Group 1: In 100 VDCs, 25 households with children under 48 months. In 30 VDCs, 15 households with children under 24 months. • Group 2: 5 households with a pregnant woman Households in Group 1 were asked both the Main Household Questionnaire and modules on maternal and child health practices in the Women and Children Questionnaire. Households in Group 2 were asked the Main Household Questionnaire and specific modules on pregnant women’s health and nutrition and family planning. Therefore, indicators in this report pertaining to the general household outcomes come from both households in Group 1 and Group 2. Indicators on maternal and child health practices come from Group 1, and are therefore representative of households with children under two in our included wards. Indicators on pregnant women’s dietary diversity and IFA tablet consumption come from Group 2, and are therefore representative of pregnant women. Respondents in all the households interviewed in any VDC were also invited to participate in the Behavior Game exercise which measured social cohesion and cooperation. Of all eligible people who accepted this invitation, 8 were randomly selected to participate. The behavior games were played in the same 100 VDCs at baseline, midline, and endline, though the participating households were not necessarily the same. 2. Survey Activities The report draws on data from three rounds of household surveys and administrative data on RRNI project implementation. The timeline of the three rounds of household surveys is as follows: 1. Baseline: August 2013 – January 2014 The baseline survey was implemented in 282 VDCs in all 15 SHD participating districts, 141 early starter VDCs and 141 late starter VDCs. In each ward, a census was conducted to understand basic demographics characteristics of each household. From this census, two groups of households were randomly sampled for the household survey: 4965 households with at least one child under the age of 24 months and 337 households with pregnant 9Since only a few teams had selected family planning focus area by the time of the mid-term review, the project decided to drop the PDO indicator for family planning. Hence, for the midline and endline survey, pregnant women were sampled instead of married woman aged 15-25. 9 woman10. The behavioral games were conducted to measure social capital in the 100 VDCs selected from the 282 VDCs. For each VDC, one ward is selected to conduct the game which consists of randomly selected eight adults from the household roster. 2. Midline: September – December 2015 The midline household survey was conducted in the same 282 VDCs from the baseline between September and December 2015. It was used to assess the effect of SHD after approximately 2 years of project implementation. At this point, only the 141 early starter VDCs implemented the project and therefore, 141 late starter VDCs form a counterfactual. The survey covered 5539 households of which 4215 households with at least one child under the age of 24 months and 1409 households with pregnant woman. The behavioral games were conducted in the same 100 VDCs from the baseline. 3. Endline: April – July 2017 The endline survey was administered across 130 sample VDCs between April and July 2017. The survey covered 3659 households of which 1923 households with at least one child under the age of 24 months. The endline sample includes 3052 households from the 100 VDCs, 50 early starter VDCs and 50 late starter VDCs and 607 households from the 30-additional early starter VDCs to have a representative sample. We also collected data from 649 households with pregnant woman across 130 VDCs. The behavioral games were conducted in the same 100 VDCs from the baseline and midline. Table 1 shows the detailed sample size by survey round: Table 1: Sample (number of households) by survey round Baseline Midline Endline VDC 282 282 130 number of HH 7049 5539 3659 pregnant woman11 337 1409 649 HH with child under 24 months 4965 4215 1923 HH with child 24-48 months 2545 1313 152812 number of child under 24 months 5526 4429 2053 number of child under 48 months 8294 5790 3511 10 For the baseline, we targeted married women as opposed to pregnant women since the family planning practice was one of the PDO indicator. Not sure how to explain it here, but it’s good to mention. 11 As explained in the sampling design section, we specifically sampled 5 households with pregnant women per VDC during the midline and endline survey. 12 As explained in the sampling design section, we sampled 25 households for 100 VDCs during the endline survey. This was decided to try to get a sample of children who most benefitted from the project which means they were born one year before the program started. 10 2. Implementation A. Goal Selection The goal selection and implementation was monitored by the SHD project team. Based on the monitoring data, we compiled the goal selection information between February 2014 and December 2017. There were 9,073 goals selected and approved during this period in 2,321 wards of 258 VDCs in total. The project implementation started in February 2014 for the early starter VDCs, while implementation started in April 2015 for early starter VDCs in Cluster 2 due to the implementation delays. In total, early starter communities have completed up to 7 cycles. Implementation for the late starter VDCs started in January 2016 and communities have completed up to 4 cycles. Table 2: Number of Cycles Completed by Wards Number of cycles Early Starter Late Starter Total 1 63 19 82 2 38 487 516 3 178 70 248 4 109 521 630 5 550 0 550 6 56 0 56 7 230 0 230 Total 1,224 1,097 2,321 Average number of cycles completed 4.74 3.01 3.91 Table 3 shows the number and percentage of wards selecting each goal by treatment status. The most commonly selected goal is using clean and safe water (70%) where 1,616 out of 2,321 wards selected this goal at least once. Also, almost half of the wards selected goals related to (i) maintaining adequate weight and regular eating among pregnant women and young children (42%); increasing consumption of animal protein among pregnant women and young children (43%); and 38% of total wards selected a goal related to ending open defecation. Table 4 shows the implementation status of each goal at the VDC level. This is the number and percentage of VDCs with at least one ward from the VDC selecting the goal in any cycle. For example, the goal of use clean and safe water, 91% of the SHD VDCs had at least one ward selecting the goal at any point, meaning that roughly 10% of the VDCs implemented SHD, which is about 28 VDCs and 252 wards, did not implement the interventions targeting at improving access to clean and safe water at all. 11 Table 3: Number and Percentage of Wards Selecting Each Focus Area Before After Midline midline Total Early Starter Early Starter Late Starter N % N % N % N % Maintain adequate weight and regular eating among pregnant women 196 16% 346 33% 462 42% 965 42% and young children Increase consumption of animal protein among pregnant women and 330 27% 327 31% 393 36% 1005 43% young children Practice proper and consistent breast-feeding 26 2% 58 5% 48 4% 130 6% Use clean and safe water 569 46% 548 52% 697 64% 1616 70% Delay marriage and pregnancy for young girls 19 2% 88 8% 85 8% 190 8% Regular de-worming and utilization of iron supplements by young 65 5% 25 2% 4 0% 93 4% women Extend education of young girls 92 8% 265 25% 171 16% 502 22% Utilize family planning methods to avoid unwanted pregnancies 8 1% 28 3% 12 1% 48 2% Practice proper and consistent handwashing 323 26% 317 30% 266 24% 857 37% Ensure immunization of all children 4 0% 34 3% 7 1% 45 2% End open defecation 654 53% 78 7% 202 18% 878 38% Ensure prompt medical treatment of chest infection, fever, and 17 1% 106 10% 96 9% 214 9% diarrhea in young children Reduce workload of pregnant women 39 3% 50 5% 61 6% 144 6% Improve school sanitation 69 6% 126 12% 67 6% 241 10% Reduce exposure to indoor smoke for pregnant women and young 190 16% 257 24% 247 23% 660 28% children Total number of wards 1224 1062 1097 2321 12 Table 4: SHD Goal Selection by Treatment Status at VDC-level Early Starter Late Starter Total Number of VDCs selecting each goal N % N % N % Maintain adequate weight and regular eating 98 72% 86 70% 184 71% among pregnant women and young children Increase consumption of animal protein among 103 76% 80 66% 183 71% pregnant women and young children Practice proper and consistent breast-feeding 33 24% 18 15% 51 20% Use clean and safe water 128 94% 108 89% 236 91% Delay marriage and pregnancy for young girls 39 29% 22 18% 61 24% Regular de-worming and utilization of iron 28 21% 4 3% 32 12% supplements by young women Extend education of young girls 83 61% 56 46% 139 54% Utilize family planning methods to avoid 11 8% 6 5% 17 7% unwanted pregnancies Practice proper and consistent handwashing 96 71% 61 50% 157 61% Ensure immunization of all children 11 8% 4 3% 15 6% End open defecation 102 75% 34 28% 136 53% Ensure prompt medical treatment of chest 43 32% 40 33% 83 32% infection, fever, and diarrhea in young children Reduce workload of pregnant women 36 26% 27 22% 63 24% Improve school sanitation 65 48% 33 27% 98 38% Reduce exposure to indoor smoke for pregnant 83 61% 53 43% 136 53% women and young children Total number of VDCs 136 122 258 B. Implementation Challenges We also interviewed each coach assigned to treatment wards to understand the challenges at implementation. Local elite capture was the most common challenge faced by many of the coaches. Many of the coaches mentioned that cash was not disbursed in time and that District Development Committee tried to get commission from the budget. In addition, impact of the 2015 earthquake in Nepal, illiteracy of community members, mistrust towards women leaders were also cited as one of the challenges in implementing the SHD project. Implementation challenges were also examined by the SHD qualitative team by conducting focus group interviews with the SHD project’s key stakeholders, including DDC officials, VDC officials, RRNI coaches, Ward Citizen Forum chairpersons, RRNI team members, and beneficiaries. Implementation challenges raised during the qualitative study are consistent with the comments made by coaches during the midline survey. Key implementation challenges cited in the qualitative report are listed in box 1. 13 Box 1: Key Implementation Challenges from SHD Qualitative Report 1. Slow implementation: As opposed to the rapid results design, there were delays in project approval and grant disbursement which created frustration among project implementers and beneficiaries. 2. Capture by small group: When there was low participation in the beginning of the cycle, a small group of individuals dominated the decision-making step and other community members were not included until the end. 3. Unequal gender norm: Even when women were included in the RRNI team, their voices were unheard, and they were not given decision-making power. Inclusion of women were difficult due to cultural norms, time constraint with household chores, and resistance by men. 4. Forming RRNI members: It was challenging to find the nine members required for each project-based RRNI team, and oftentimes, members were “selected” without being informed, resulting in confusion and inefficiency. 3. Project Achievement In this section, we present the project achievement by comparing the baseline, midline and endline values for the main outcomes of interest. We use both the early and late starter VDCs for the baseline dataset since neither group had benefitted from the project at the time of the baseline interview. For the midline, we use data for only early starter VDCs to show the progress two-year after implementation. For the endline, we use only the early starter VDCs to show progress four- year after implementation. For this reason, sample size is not comparable across three rounds of the survey. Table 5 shows the sample size for each round of survey. Within this section, we report the evolution of key indicators over time, so the reported changes (or lack of) cannot be attributed to the program, and could instead be due to pre-existing time trends, and aggregate shocks. Table 5: Sample Size for Each Round Baseline Midline Endline VDC 282 141 80 number of HH 7049 2767 2140 pregnant woman 337 704 399 HH with child under 24 months 4965 2107 1171 HH with child 24-48 months 2545 657 811 number of child under 24 months 5526 2226 1236 number of child under 48 months 8294 2904 1976 14 A. Project Development Objectives Table 6 presents the change in project development indicators over the course of project implementation. Each indicator is discussed in detail throughout this section of the report. Note that these numbers are calculated using all VDCs, regardless of the chosen goal. The PDO targets were determined under the assumption that the PDO indicators would be measured using all VDCs. In line with the observation that safe water and sanitation were the most popular goals chosen, the project met (and exceed by a large margin) the target in these areas. The targets related to pregnant women were either met or missed by a narrow margin. The targets related to child nutrition (diet and exclusive breastfeeding) were missed by a larger margin. Table 6: Project Development Objectives Project Development Indicators Baseline Midline Endline Target Percentage of pregnant women taking IFA 21% 24% 27% 30% supplements for 180 days Percentage of children 0-6 months age who are 69% 69% 58% 80% exclusively breastfed Percentage of children 6-24 months age who 9% 13% 15% 25% consume a minimum acceptable diet Percentage of households reporting no smoke in 35% 43% 39% 45% the room while cooking Percentage of pregnant women reporting consuming animal-sourced protein in the previous 60% 72% 76% 75% day Percentage of households reporting using improved toilet facilities (flush toilet, covered pit 25% 52% 80% 35% within household, community latrine) After defecation 71% 77% 85% 80% Percentage of mothers (of After cleaning a 53% 56% 62% 70% children aged 0-2) child’s bottom reporting always washing Before eating 17% 24% 38% 25% hands at critical times Before feeding 10% 14% 22% 20% children B. Pregnant Women Taking Iron and F0lic Acid (IFA) Supplement Anemia (lack of sufficient iron) increases risk of perinatal and maternal mortality. Adequate micronutrient intake can prevent anemia during pregnancy. According to the nationally representative Nepal DHS (2011), the percentage of women age 15-49 who took the recommended 15 dose of IFA during pregnancy rose from 7% in 2006 to 38% in 2011.13 Using iron supplements for young women is one of the focus areas of the SHD project but only 4% of total wards selected this focus area. Our survey posed a question to mothers of children under two in the sample if they took the recommended dose of IFA during their most recent pregnancy. At the endline, 27% of mothers in the sample reported taking IFA supplements for the recommended duration of 180 days during their last pregnancy, compared to 21% at baseline and 24% at midline. Figure 2: Pregnant Women Taking IFA Supplements Percentage of pregnant women taking IFA supplements for 180 days 27% 24% 21% baseline midline endline C. Breastfeeding Practices The WHO recommends exclusive breastfeeding (no other liquid, solid food or plain water) for children under 6 months of age, followed by introduction of solid or semi-solid foods at 6 months along with continued breastfeeding until 2 years of age. While practicing a proper and consistent breastfeeding was one of the focus areas of the SHD project, only 6% of the total wards selected this focus area at least once during the project cycles. Figure 3 shows the proportion of children put to the breast within one hour of birth. It is recommended that children be fed with the first liquid to come from the breast, known as colostrum, within this first hour. 39% of children from the baseline sample were put to the breast within one hour of birth, and the percentage increased to 46% after two-year of project implementation, and 75% after four-year of project implementation. 13Ministry of Health and Population (MOHP) [Nepal], New ERA, and ICF International Inc. 2012. Nepal Demographic and Health Survey 2011. Kathmandu, Nepal: Ministry of Health and Population, New ERA, and ICF International, Calverton, Maryland. 16 Figure 3: Early Initiation of Breastfeeding Early Initiation of Breastfeeding 75% 46% 39% Baseline Midline Endline Figure 4 shows the percentage of children under six months who are exclusively breastfed. 58% of children under 6 months were exclusively breastfed at endline compared to 69% for both baseline and endline. Many of the children under six months who were not exclusively breastfed were fed with plain water at the endline. 80% of children under 6 months were fed with only breastmilk and plain water, and the percentage is comparable to the baseline and midline values. It is unclear what could explain the increase of water intake in children under 6 months. One possibility is that mothers fed their children under 6 months with plain water due to increased access to clean water from project implementation. However, other explanations are also possible. For instance, Table 5 shows an increase in the number of households with children 24 to 48 months. It could also be that mothers find it more challenging to have the time to breastfeed when they have other small children in the household. Figure 4: Percentage of children under 6 months exclusively breastfed Exclusive Breastfeeding Baseline Midline Endline 69% 69% 58% Baseline Midline Endline 17 D. Complementary Feeding Practice The third project development indicator tracks the improvement of child feeding practices in households with children 6 to 24 months of age. This section analyzes the sample according to the IYCF guideline on minimum acceptable diet for children in this age group. Guidelines stipulate that complementary foods (solid, semisolid or soft) be fed to children along with breast milk starting at 6 months of age. Minimum acceptable diet is the proportion of children who meet the minimum dietary diversity and minimum meal frequency. Minimum dietary diversity indicates the proportion of children 6- 24 months of age who receive foods from at least 4 different food groups. According to the WHO (2008) Report,14 dietary diversity is a proxy for adequate micronutrient-density of foods, since consumption of foods from at least 4 food groups implies that the child had a high likelihood of consuming at least one animal-source food and one fruit or vegetable per day. Minimum meal frequency measures the proportion of breastfed and non-breastfed children 6-24 months of age who receive solid, semi-solid, or soft foods (including milk for non-breastfed children) the minimum number of times or more in the previous day. Minimum is defined as 2 times for breastfed infants 6-8 months, 3 times for breastfed children 9-24 months and 4 times for non- breastfed children 6-24 months. While higher percentage of children 6-24 months of age at endline met the standard for minimum acceptable diet compared to the baseline, this number is still low at 15%. This indicator relates to two focus areas. The first is “Maintain adequate weight and regular eating among pregnant women and young children”, and 42 percent of wards chose this goal at least once during the project cycle. The second is “Increase consumption of animal protein among pregnant women and young children”, and 43% of wards chose this focus area at least once. Figure 5: Complementary Feeding Practices Minimum Acceptable Diet 15% 13% 9% Baseline Midline Endline 14WHO (2008) Indicators for assessing infant and young child feeding practices: conclusions of a consensus meeting held 6–8 November 2007 in Washington D.C., USA. http://www.who.int/nutrition/publications/infantfeeding/9789241596664/en/ 18 E. Attitudes of Household and Community Members Community-wide characteristics also hold implications for malnutrition, and the project aims to improve community attitudes towards practices known to improve nutritional outcomes of women of reproductive age and children under age 2. This project mainly focuses on improving (i) community attitude towards the importance of keeping girls at school until age 20, (ii) community attitude towards the importance of reducing indoor air pollution, and (iii) attitude of community towards dietary needs of pregnant women. 22% of wards selected a focus area to extend education for young girls, 28% of wards selected a focus area to reduce exposure to indoor smoke for pregnant women and young children, and 42% of wards selected a focus area to maintain adequate weight and regular eating among pregnant women and young children. The project decided to measure success on each of these focus areas through improving community attitudes. According to the 2011 Nepal DHS, women who are more educated are more likely to be knowledgeable about the use of health facilities, contraceptives and health of their children. Even though female education in Nepal has improved, the level of educational attainment is still a significant factor for malnutrition in Nepal. As shown in Figure 6, only one third of household heads (33%) in the endline sample believe girls should be sent to school until at least 20 years of age. Figure 6: Community attitude towards the importance of keeping girls at school until age 20 Percentage of households believing girls should be sent to school until at least 20 years of age 37% 33% 26% baseline midline endline Households were asked if they knew what should be done to avoid smoke inside the house, if they employed methods to avoid smoke, and if they have plans to avoid smoke inside the house. As shown in Figure 7, 77% of surveyed households at endline, compared to 39% at baseline and 55% at midline, responded that they know how to avoid smoke in the house. At the same time, only 27% reported to have taken action to avoid smoke in the house. This shows that the improved knowledge didn’t necessarily translated into improved practice. 79% of the surveyed households at endline answered that they have plans to avoid smoke in the house compared to 38% at baseline and 68% at midline. 19 Figure 7: Community Attitudes on Reducing Indoor Air Pollution baseline midline endline 77% 79% 68% 55% 39% 38% 27% 23% 14% Percentage of households Percentage of households that Percentage of households knowing how to avoid smoke have taken action to avoid having plans to avoid smoke in the house smoke in the house in the house Household heads were asked about the food that should be consumed by pregnant women. They were asked about both the frequency and the types of foods they should consume, and the response is coded as an adequate diet if they indicated eating three or more meals per day, including one animal-sourced food. As shown in Figure 8, most of the household heads in the endline sample (93%) are aware about an adequate diet of pregnant women, compared to 75% at baseline. Figure 8: Attitudes toward Pregnant Women's Dietary Needs Percentage of households aware about an adequate diet of pregnant women 94% 93% 75% baseline midline endline F. Water, Sanitation and Hygiene Water and sanitation are directly linked to children’s health, and inadequate access to water or sanitation facilities can cause illness, such as diarrhea, which increases risk of malnutrition. 70% 20 of wards selected a goal related to improving access to improved source of water, and 38% of wards selected a goal related to eradicating open defecation. This section focuses on access to water and sanitation for households in the sample as well as hygiene behaviors such as hand- washing. Access to Improved Water Source As shown in Figure 9, majority of households in the sample (99%) have access to an improved water source.15 Since many of the wards selected a goal related to improving access to clean water, we expect higher percentage of households with access to clean water at endline. However, there is little difference in access to water throughout the project. In fact, the communities selecting this focus area did not actually construct water sources, but rather received filters, buckets, and storage tanks. For this reason, this particular question on access to improved water source does not reflect the impact of the project for communities selecting this focus area. Figure 9: Access to Improved Water Source baseline midline endline 98% 98% 99% Improved water source Access to Improved Toilet Figure 10 shows the change in access to improved toilet over the course of project implementation. As shown in Figure 10, 80% of households reported to have access to improved toilet after four years of project implementation, compared to 25% at baseline and 52% at midline. This finding is striking since the percentage of households with access to improved toilet have increased by three- folds over four years and is consistent since more than a third of wards implemented a goal related to building toilet. 15Access to clean water is defined as having the main source of drinking water from one of the followings: (i) piped water directly to the household/ compound, (ii) piped water from a public water tap, (iii) private hand-pump (shallow), (iv) private hand-pump (deep), (v) public hand-pump (shallow), (vi) public hand-pump (deep), (vii) private well, or (viii) public well. 21 Figure 10: Access to Improved Toilet Percentage of households with access to improved toilet 80% 52% 25% baseline midline endline Household Sanitation As reported in Figure 11, 10% of households at endline reported observing human feces in or around their house compared to 30% at baseline and 16% at midline. We conjecture that increased access to improved toilet is the main reason for lower percentage of households observing human feces at endline. At the same time, there is no change in the percentage of households observing animal feces around the household. Figure 11: Household Sanitation by Treatment Status baseline midline endline 76% 72% 62% 30% 16% 10% Human feces Animal feces Mother’s Handwashing Behavior 37% of wards selected a focus area related to practicing proper and consistent handwashing. Mothers of children under age 2 in the sample were asked about hand-washing behavior using soap and Figure 12 shows the percentage of mothers washing hands in relation to the following six activities: (i) after defecation, (ii) after cleaning a young child’s bottom, (iii) before eating; (iv) 22 before feeding children, (v) after cleaning the house or compound, and (v) after disposing of garbage. As shown in Figure 12, most mothers in the sample at endline responded that they wash hands with soap after defecation (85%), and 62% report that they wash hand after cleaning a child’s bottom. Overall, higher percentage of mothers at endline reported always washing hands after different activities compared to the baseline. Figure 12: Percentage of Handwashing after Activities baseline midline endline 85% 77% 71% 62% 53% 56% 45% 38% 37% 39% 39% 33% 24% 22% 25% 17% 10% 14% after defecation after cleaning a before eating before feeding after cleaning the after disposing child's bottom children house/compound garbage G. Child Malnutrition and Illness One of the ultimate goals of the SHD project is to improve nutrition for children under 2. Standard anthropometric measurements of childhood nutrition include stunting, wasting, and being underweight. We also assess changes in self-reported disease incidence, as proper diet can help children ward off disease. Child Illness The main caregiver of children under age 2 in our sample were asked if the child had an illness in the 15 days prior to the interview. As shown in Figure 13, less children at endline suffered from coughing, diarrhea, and vomiting compared to the baseline and midline. At endline, 20% of children under age 2 had a cough in the 15 days prior to the interview, compared to 36% at baseline. Also, 5% of children under age 2 in our sample suffered from diarrhea for more than 3 days compared to 10% at baseline, and 3% of children suffered from vomiting compared to 6% at baseline. 23 Figure 13: Child's Illness in the Past 15 Days baseline midline endline 36% 31% 20% 10% 8% 5% 6% 5% 3% Coughing Diarrhea Vomiting Child Malnutrition The rate of stunting, or chronic malnutrition, is the percentage of children whose height is more than two standard deviations less than the median height of children of the same age and gender, as per the WHO Child Growth Standards16. Stunting suggests that a child was not provided with adequate nutrition and/or has suffered from illness over a long period of time. The rate of wasting, or acute malnutrition rate, is the percentage of children whose weight is more than two standard deviations below the median weight of children of the same height and gender as per the Child Growth Standards. Finally, children whose weight is more than two standard deviations below the median weight of children of the same age and gender as per the WHO Child Growth Standards are classified as underweight. As shown in Table 7, the overall anthropometric indicators have improved over the course of the project. The rate of wasting has decreased from 21% at baseline, to 16% at both midline and endline. While almost one-third of the children under 2 were underweight at baseline (32%), this percentage decreased to 21% at midline, and 15% at endline. Stunting rate has also decreased from 38% to 27% at midline, but increased to 33% at endline. Table 7: Anthropometric Measures for Children under 2 Baseline Midline Endline Child malnutrition Stunting 38% 27% 33% Wasting 21% 16% 16% Underweight 32% 21% 15% Child Growth Z-Scores Weight for age -1.38 -0.91 -0.77 Height for age -1.41 -0.99 -1.27 Weight for height -0.75 -0.46 -0.17 16 http://www.who.int/childgrowth/en/ 24 H. Social Capital Since the SHD project takes a Rapid Results Approach where communities are encouraged to select goals and formulate plans to achieve the goals, social cohesion is an important factor that may affect the outcome of the project. Additionally, it has been hypothesized that this project could help build social capital. In order to measure the social capital in the sample, the impact evaluation uses two mechanisms: (i) respondents were asked questions about trust, collective action, empowerment and political action during each round of survey; and (2) several behavioral games were conducted to indirectly assess and quantify these same social capital factors. The behavioral games were conducted in a subsample of 100 VDCs, and were constrained to VDCs with less than 100 households. Trust As shown in Figure 14, it seems that trust level has moderately increased throughout four years of project implementation – 89% of respondents stated that most people in their village can be trusted during the baseline, while 94% of respondents stated that most people in their village can be trusted during the midline and endline. Also, 87% of respondents stated that most people in their village try to be helpful during the baseline, and this percentage increased to 90% for both midline and endline. Figure 14: Trust Level Baseline Midline Endline 94% 94% 90% 90% 89% 87% Most people in this village can be trusted Most people in this village try to be helpful According to Figure 15, 93% of respondents during the midline and 95% of respondents during the endline stated that they trust people from their ethnic group, compared to 80% during the baseline. Similarly, 84% of respondents during the midline and 88% of respondents during the endline stated that they trust people from other ethnic group, compared to 78% during the baseline. 25 Figure 15: Trust Level II Baseline Midline Endline 93% 95% 84% 88% 80% 78% People from your ethnic group can be People from other ethnic group can be trusted. trusted. Trust and trustworthiness were also measured by a trust game played between two people from the same communities during each round of the survey.17 In the trust game, one of the players becomes a “sender” and the other a “receiver,” but neither of them knows who the other player is. Both the sender and the receiver get 32 rupees to start, and the sender decides how much of his 32 rupees to send to the receiver.18 The amount sent by the sender will be given to the receiver, and the receiver will decide how much to send back to the sender. The amount sent by the sender serves as a proxy for the trust level towards community members and amount sent back by the receiver indicates the trustworthiness level. As shown in Figure 16, among those who participated in the behavioral game during each round of survey, senders sent on average 53% out of 12 rupees during the baseline, 40% out of the 32 rupees during the midline and 33% out of the 32 rupees during the endline. Receivers sent back 34% of the money they received during baseline, 69% during midline, and 61% during the endline. 19 However, the results should be interpreted with caution since the game structure changed from the baseline to midline (explained in footnote 16.) Also, it is very important to understand that we are reporting time trends rather than changes that can solely be attributed to the program. The time trends that we observe could well be due to aggregate shocks unrelated to the program, such as the earthquake or political elections. Another explanation is that, as more times the games are played in the wards, players understand better the incentives embedded in the game and they behave more strategically. 17 The behavioral games are based on those found in: Cardenas, J. C., & Carpenter, J. (2008). Behavioural development economics: Lessons from field labs in the developing world. The Journal of Development Studies, 44(3), 311-338. http://www.tandfonline.com/doi/abs/10.1080/00220380701848327 18 This is equal to around .30 USD, and is equivalent to around 12% of the daily minimum wage. 19 There are two major differences in the game structure between baseline and midline/endline. During the baseline behavioral game, the amount sent back was tripled, while this part of the game was removed for the midline and endline games. The second difference is that during the baseline, each player played either the sender or receiver role, while the game was played twice in order to have both measures per individual during the midline and endline. 26 Figure 16: Trust and Trustworthiness from Behavioral Game Baseline Midline Endline 69% 61% 53% 40% 33% 34% Trust Trustworthiness Collective Action As shown in Figure 17, higher percentage of households reported that they have worked with others in the village for benefits of the community during the endline (18%), compared to the baseline (11%) or midline (9%). Also, higher percentage of households during the midline (80%) and endline (84%) reported that people who do not participate in community activities will be criticized or sanctioned, compared to the baseline (61%). Figure 17: Collective Action I Baseline Midline Endline 80% 84% 61% 18% 11% 9% Household has worked with others People who do not participate in in the village for benefits of the community activities will be community criticized At the same time, lower percentage of respondents during the endline (52%) believe more than half of people in their village contribute time or money towards common development goals, compared to 67% during the baseline and 63% during the midline. As shown in Figure 18, 80% of 27 respondents during the endline believe that people will cooperate to solve a water supply problem, compared to 85% during the baseline and 83% during the midline. Figure 18: Collective Action II Baseline Midline Endline 85% 83% 80% 67% 63% 52% More than half of people in the If there was a water supply problem, community contribute time or money people in this village will cooperate to toward common development goals solve the problem. In order to measure the altruism level in each community a dictator game was conducted. In the game, each player is given 40 rupees and decides how much of the amount they will donate to a needy family in the community. As shown in Figure 19, players contributed on average 40% during the baseline, 42% during the midline, and 34% during the endline. In another game, cooperation level was measured by how much each player was willing to contribute to public goods of the community. Each player receives 5 cards (representing public goods), and can (secretly) contribute as many cards as they want to a public pot, and the rest will go to a private pot. For each card that is turned in every person in the group receives three rupees. For each card in the private pot, however, they receive 12 rupees in addition to the amount determined by the number of cards turned in to the public pot.20 In other words, everyone benefits if more cards are contributed to the public pot, but an individual player is better off by not contributing to the public pot. However, the game structure during the baseline differs from that during the midline or endline, so the measures of cooperation is not comparable between baseline and midline/endline. As shown in Figure 18, players contributed to the public goods 56% during the baseline, 55% during the midline and 46% during the endline. 20During the baseline, individuals faced a binary decision: they either cooperate or not to a common pool. During the midline and endline, individuals can choose among cooperation levels (6 possibilities). Thus, the measures of cooperation cannot be directly compared between baseline and midline/endline. 28 Figure 19: Altruism and Cooperation from Behavioral Game Baseline Midline Endline 56% 55% 42% 46% 40% 34% Altruism Cooperation Empowerment During each round of the survey, respondents were also asked how they feel about life in general. Higher percentage of households during the endline (98%) respond that they consider themselves to be happy, compared to the baseline (69%) and midline (91%). At the same time, lower percentage of households during the endline (17%) believe that they have control over decisions that affect everyday activities, compared to 38% at baseline and 27% at midline. Also, the majority of households believe that they have impact in making the village a better place across three rounds of the survey (87% at baseline; 76% at midline; 86% at endline.) Figure 20: Empowerment Level Baseline Midline Endline 98% 91% 87% 86% 76% 69% 38% 27% 17% Consider themselves to Have control over Have impact in making be happy decisions that affect the village a better place everyday activities 29 4. Conclusion and Policy Recommendations This report summarizes the SHD project implementation, achievement and results over the course of 2013 – 2017. During this period, there were 9,073 goals selected and approved in 2,321 wards of 258 VDCs in total.21 The most common goals selected by communities are using clean and safe water (70%), followed by increasing consumption of animal protein among pregnant women and young children (43%), and maintaining adequate weight and regular eating among pregnant women and young children (42%). Overall, the project achieved original and revised Development Objectives. Especially, it is worth noting that access to improved toilet increased from 26% at baseline to 78% at endline. We also observe modest improvement on anthropometric indicators over the course of the project. The rate of wasting has decreased from 21% at baseline, to 16% at endline. While almost one-third of the children under 2 were underweight at baseline (32%), this percentage decreased to 15% at endline. Stunting rate has also decreased from 38% to 33%. Despite the implementation challenges due to the novelty of the project design and geographic coverage, in addition to the external factors such as the 2015 earthquake and political blockade, the project recorded substantial achievements overall. Based on the lesson learned from a CDD intervention and evaluation, we would like to point out several operational and research implications: Operational implications • Target focus area: the project offered 15 focus areas (see Appendix A) to choose from to the communities, covering multiple sectors and area of interests (Health, Nutrition, Water and Sanitation, Handwashing, Education, etc.) As summarized above, some of the focus area were selected by many communities such as using clean and safe water (70%) and increase in consumption of animal protein among pregnant women and young children (43%). On the other hand, some of the other focus areas were hardly selected by the communities – for example, utilizing family planning methods to avoid unwanted pregnancies (2%), ensuring immunization of all children (2%) and regular de-worming and utilization of iron supplements by young women (4%). In order to provide a list of focus area that are most relevant to the needs of the communities, project teams should work with the government and communities from the design stage and clearly identify the demands from the communities. • Define PDO indicators carefully: due to the nature of CDD projects, project teams do not know which focus area beneficiary communities will be choosing ex-ante. Therefore, it is risky to set PDO indicators which are focus area specific. For example, only 6% of communities selected “practicing proper and consistent breast-feeding” and as a result the project was not able to achieve the target related to exclusive breastfeeding at the endline. However, it is misleading to conclude that the project failed to achieve the target since the relevant focus area was not selected by communities. • Monitor the progress of implementation: The impact evaluation included in this study measured the overall impact of the project after 2 years of project implementation. As highlighted by other study (Wong 2012), evaluating impact of intervention poses conflicting dilemma: a) project teams need to obtain results and impacts quickly in order to make course correction or to inform future projects, and b) sometimes it takes longer to materialize the 21 The project was implemented in 282 VDCs, but we were able to collect goal selection information for only 258 VDCs. 30 impacts of intervention by its nature. It is important to study the long term impact of interventions to facilitate better decision making. At the same time, it is also important to monitor the progress of interventions during the project cycle. To do so, project team needs to invest in capacity building of project staffs and develop relevant information system to manage the project, and monitor its progress. Research Implications Sustainability of intervention effectiveness on outcomes: The project adopted Rapid Results Approach, which has a 100-day project cycle to create motivation and confidence within a short period of time among community members. Since the communities received consumable goods (e.g. eggs and water filter) rather than long-lasting facilities (e.g. sanitation facilities) for some of the focus areas, the exact time of the implementation of a specific focus area relative to the time of the data collection can be an important factor in observing the impact of the intervention on specific outcomes. In this regard, we would like to study how the intensity of interventions has a short-term as well as long-term impact in achieving the project objectives. Social cohesion: Recent study published by 3ie (White et al. 2018) suggested to abandon building social cohesion from CDD type project objectives. However, social cohesion is an important factor that may affect the outcome of the project for community-based projects and need to be analyzed with more attention. Therefore, we propose to continue our research on measuring the social capital to answer if CDD projects build social cohesion. 31 References Central Bureau of Statistics. 2015. Nepal Multiple Indicator Cluster Survey 2014, Final Report. Kathmandu, Nepal: Central Bureau of Statistics and UNICEF Nepal. Gilligan, Michael J., Pasquale, Benjamin J. and Samii, Cyrus. 2011. Civil War and Social Capital: Behavioral-Game Evidence from Nepal. Grantham-McGregor S, Cheung YB, Cueto S, Glewwe P, Richter L, Strupp B. 2007. International Child Development Steering Group. Developmental Potential in the First 5 Years for Children in Developing Countries. Lancet. 2007; 369: 60-70. Nepal Demographic and Health Survey. 2011. http://dhsprogram.com/publications/publication- FR257-DHS-Final-Reports.cfm. Stallings, Rebecca. 2004. DHS Comparative Reports No. 8: Child Morbidity and Treatment Patterns. http://dhsprogram.com/pubs/pdf/CR8/CR8.pdf White, H, Menon, R and Waddington, H, 2018. Community-driven development: does it build social cohesion or infrastructure? A mixed-method evidence synthesis, 3ie Working Paper 30. New Delhi: International Initiative for Impact Evaluation (3ie) Wong, Susan. 2012. What have been the impacts of World Bank Community-Driven Development Programs? CDD impact evaluation review and operational and research implications. Washington, DC: World Bank. World Bank. 2012. Nutrition in Nepal: a national development priority (English). Washington, DC: World Bank. World Bank. 2017. Qualitative Study of “Sunaula Hazar Din” Community Action for Nutrition Project Nepal. World Health Organization. 2010. Indicators for Assessing Infant and Young Child Feeding Practices – Part II: Measurement. 32 5. Appendix A. List of Focus Area Focus Area 1 Maintain adequate weight and regular eating among pregnant women and young children 2 Increase consumption of animal protein among pregnant women and young children 3 Practice proper and consistent breastfeeding 4 Use clean and safe water 5 Delay marriage and pregnancy for young girls 6 Regular de-worming and utilization of iron supplements by young women 7 Extend education of young girls 8 Utilize family planning methods to avoid unwanted pregnancies 9 Practice proper and consistent handwashing 10 Ensure immunization of all children 11 End open defecation 12 Ensure prompt medical treatment of chest infection, fever, and diarrhea in young children 13 Reduce workload of pregnant women 14 Improve school sanitation 15 Reduce exposure to indoor smoke for pregnant women and young children 33 B. Sample Goal Recommendations by Coaches District VDCs selected for the IE Impact Group 1 Group 2 Group 3 Group 4 Evaluation Profile • Barahachhetra • Gautampur • Ramnagar- • Bokhraha • Madhuban bhutaha SUNSARI • Mahendranagar Recommendation for selection of focus area No. Focus Area Reason for recommendation Adequate १ Weight and • The baseline survey data indicate that among the nutrition indicators, “Percentage of children 6-24 months of age who consume a minimum Regular acceptable diet” is only 11%. In addition, the indicator “Percentage of Eating children 6-24 months who consumed animal protein” is also very weak. • Pregnant mothers need to eat regular meals and maintain adequate weight to support her growing baby and to maintain good health during pregnancy. Young children need to eat regularly to grow well, to develop strong bodies and smart minds, and to protect them from illnesses. • Therefore, to improve the nutritional status of your district, it is important for pregnant women and young children to maintain adequate weight and develop regular and proper eating habits. Deworming ६ and Iron • The baseline survey data indicate that among the nutrition indicators, “Percentage of pregnant women who took iron folic acid for 180 days” Supplements is only 22%. In addition, the indicator “Percentage of women who for Young took deworming drugs” is only 75%. Women • Pregnant women or those women who want to get pregnant must take iron folic acid (IFA) and deworming drugs. Especially it helps to reduce anemia levels, the risk of low birth weight, early delivery, and perinatal deaths. • Therefore, to improve the nutritional status of your district, it is important for pregnant women and women who want to get pregnant to take iron folic acid supplements and deworming drugs. End Open • ११ The baseline survey data indicate that only 42% use latrines. Defecation • Open defecation increases the chances of illness, such as diarrhea, cholera, and worm infestation among everyone in the community. When germs that are in excreta make it into our water that we use for washing, cooking and drinking, or through the medium of flies into our food, then the germs enter our body and make us ill. Illnesses such as diarrhea cause young children to lose important nutrients and it greatly inhibits child growth and development. 34 • Therefore, to improve the nutritional status of your district, it is important for your community to end open defecation and promote hygienic practices. C. Sample Goal Recommendations by Coaches 35 VDCs - Female Leadership 70 VDCs - Requirement Standard RRNI Coaching 35 VDCs - No Leadership Requirement 136 VDCs "Early Starters" 32 VDCs - Female 273 Project VDCs Leadership 66 VDCs - Requirement 137 VDCs "Late Coaches suggest Starters" goals 34 VDCs - Coaches suggest goals Actual implementation differed from planned implementation in a handful of VDCs. The main reason for this deviation was due to VDCs either splitting or combining as administrative divisions in the region tend to change over time. 35 D. SHD IE Timeline 36 E. Weighting of Endline Sample In the endline, data was collected in 100 VDCs for which network and behavioral games had been collected at midline. This was a random sample of 50 treated and 50 control VDCs that included wards that had between 60 and 120 households. To be able to obtain estimates representative of the universe of Early Starters VDCs that entered into the program, data from additional 30 VDCs was also collected in a boost sample of smaller and larger Early Starters wards. This was a sample stratified wards by zone (terai and mountain), cluster (1-3 and 2) and size (largest ward in the VDC below 60 individuals, and above 120) to make sure that all environments were represented. The table below provides the correspondence between wards in the original sample of Early Starters and in the endline sample, by strata 1. Clearly, the VDCs with wards between 60 and 120 are overrepresented in the endline sample, and it is necessary to re-weight it to get estimates that are representative of the original sample of Early Starters. Baseline Endline Region Cluster Size VDCs % VDCs % - - Medium 84 59.6% 53 66.3% Terai 1 or 3 Small 2 1.4% 1 1.3% Terai 1 or 3 Large 20 14.2% 9 11.3% Terai 2 Large 15 10.6% 7 8.8% Hill 1 or 3 Small 8 5.7% 4 5.0% Hill 2 Small 6 4.3% 3 3.8% Hill 1 or 3 Large 1 0.7% 1 1.3% Hill 2 Large 5 3.5% 2 2.5% Size categories: Small: 1-59, Medium: 60-120, Large: 121 or more The weights are calculated as the inverse of the probability of selecting a unit (child, mother or pregnant woman) in the sample. Such probability is the product of: • the number of VDCs in the original sample of Early Starters in the strata divided by the total number of VDCs in the original sample of Early Starters (141) • the number of VDCs in the endline sample of Early Starters in the strata divided by the total number of VDCs in the original sample of Early Starters in the strata • the number of units of interest (children, mothers, or pregnant women) sampled in the VDC divided by the total number of units of interest that exist in that VDC 37 F. List of 282 VDCs Appendix Table 1: List of 282 VDCs District Name VDC Name Treatment Status Bara Balirampur Treatment Bara Basantapur (Bhaganpur) Control Bara Bharatgunj sigaul Treatment Bara Bisunpur Control Bara Bisunpurwa Control Bara Vediya Control Bara Devapur Control Bara Hariharpur Treatment Bara Inarwa sira Treatment Bara U. bhitkaiya Treatment Bara Kawahi gotha Treatment Bara Kawahi jabdi Control Bara Madhuri jabdi Treatment Bara Manarwa Treatment Bara Matiarwa Control Bara Prasaunna Treatment Bara Parsurampur Control Bara Raghunathpur Treatment Bara Sihorwa Control Bara Sishaniya Control Bara Tedhakatti Treatment Bara Telkuwa Control Bara Tetariya Control Bara Uchidiha Treatment Dhanusha Ahurahi Treatment Dhanusha Baheda bela Control Dhanusha Bahuawa Treatment Dhanusha baswitti Treatment Dhanusha Bateshowar (Bateswor) Treatment Dhanusha bharatpur Control Dhanusha bhuchakrapur Treatment Dhanusha Bhutahi patewa Treatment Dhanusha Winhi Control Dhanusha Dhawauli Control Dhanusha Dubarkot hathaletawa Control Dhanusha Ekrahi Treatment Dhanusha Tallo godar Control 38 Dhanusha kajara ramaul Control Dhanusha Kanakpatti Treatment Dhanusha kharihani Control Dhanusha pra.khe.mahuwa Control Dhanusha makhnaha Control Dhanusha Machijhitkaiya Control Dhanusha Mithileshwar nikas Treatment Dhanusha Mukhiya patti musaharniya Treatment Dhanusha Nagarain Control Dhanusha Singhyahi madan Control Dhanusha sinurjoda Treatment Dhanusha Umaprempur Treatment Khotang Bahunidanda Treatment Khotang Baspani Control Khotang Chasmitar Control Khotang Dhitung Treatment Khotang Dikuwa Control Khotang Dipsung Treatment Khotang Faktang Control Khotang Jyamire Treatment Khotang Khartanchha Treatment Khotang Mauwabote Control Khotang pauwasera Treatment Khotang Phedi Treatment Khotang Maheshwori Control Khotang Rakha wangdel Control Khotang Sapteshwori Treatment Khotang Sungdel Treatment Khotang Suntale Control Khotang Bopung Control Mahottari Balawa Control Mahottari Banouli Danouli Control Mahottari Bardibas Treatment Mahottari Basbitti Control Mahottari Bathnaha Treatment Mahottari Dhirapur Control Mahottari Phulhatta Control Mahottari Goushala Control Mahottari Gonarpura Treatment Mahottari Hariharpur Harinmara Treatment Mahottari Hatisarwa Treatment Mahottari Khopi Control Mahottari Loharpatti Treatment 39 Mahottari Matihani Control Mahottari Nigoul Treatment Mahottari Pigouna Treatment Mahottari Ramgopalpur Treatment Mahottari Sitapur Bhaganha Control Makawanpur Beteni Control Makawanpur Bharta Pundyadevi Treatment Makawanpur Dandakharka Treatment Makawanpur Dhiyal Treatment Makawanpur Faparbari Control Makawanpur Kalikatar Control Makawanpur Kankada Treatment Makawanpur Khairang Control Makawanpur Manthali Treatment Makawanpur Raigaun Control Makawanpur Raksirang Control Okhaldhunga Balakhu Treatment Okhaldhunga Bhadaure Control Okhaldhunga Bilandu Control Okhaldhunga Diyale Control Okhaldhunga Jantarkhani Treatment Okhaldhunga Khijikati Treatment Okhaldhunga Mamkha Control Okhaldhunga Mulkharka Control Okhaldhunga Palapu Treatment Okhaldhunga Patle Control Okhaldhunga pokali Treatment Okhaldhunga Ranagdeep Treatment Okhaldhunga Shreechaur Treatment Okhaldhunga Unbu Control Parsa Amarpatti Treatment Parsa Bagahi Treatment Parsa Bagwana Control Parsa Bahuari Pidari Control Parsa Basdilwa Control Parsa Belwa Treatment Parsa Bairiyabirta da.pu. Control Parsa Gamhariya Treatment Parsa Ghoddauda pipara Treatment Parsa Harpur Treatment Parsa jhauwaguthi Treatment Parsa Lalparsa Control Parsa lipanibirta Treatment 40 Parsa Madhuwan Mathwal Control Parsa Vikhampur Control Parsa Mirjapur Control Parsa Pancharukhi Control Parsa samjhauta Treatment Parsa Udayapur ghurmi Treatment Parsa Vauratar Control Ramechhap Bhatauli Control Ramechhap Daduwa Treatment Ramechhap Dimipokhari Control Ramechhap Pharpu Treatment Ramechhap Goswara Treatment Ramechhap Gumdel Treatment Ramechhap Gupteshor Treatment Ramechhap Himganga Control Ramechhap Khandadevi Treatment Ramechhap Kubukasthali Control Ramechhap Naghdaha Control Ramechhap Namadi Control Ramechhap Rakathum Control Ramechhap Tokarpur Treatment Rautahat Badharwa Control Rautahat Banjaraha Treatment Rautahat Bishrampur Treatment Rautahat Brahmapuri Treatment Rautahat Dumariya (Matiauna) Control Rautahat Fatuha Maheshpur Treatment Rautahat Gamhariya Parsa Treatment Rautahat Hadirya Paltuwa Control Rautahat Inarbari Jyutahi Treatment Rautahat Inaruwa Control Rautahat Jowaha(Jokaha) Control Rautahat Kakanpur Control Rautahat Laxmipur Belbichawa Treatment Rautahat Madhopur Treatment Rautahat Maryadpur Control Rautahat Mudwalawa Control Rautahat Pipara Pokhariya Control Rautahat Pipariya(Paroha) Treatment Rautahat Pipra Bhagwanpur Treatment Rautahat Pipra Rajbara Treatment Rautahat Santpur(Matiaun) Control Rautahat Shitalpur Bairgania Control 41 Rautahat Simara Bhawanipur Control Saptari Ko.Barshain Treatment Saptari Basbitti Control Saptari Bhardaha Control Saptari Bramhapur Control Saptari Dadha Control Saptari Deuribharuwa Control Saptari Dhangadhi Treatment Saptari Farseth Treatment Saptari Gamhariya Parwaha Control Saptari Hanumannagar Treatment Saptari Haripur Control Saptari Inarwa Fulbariya Control Saptari Joginiya-1 Treatment Saptari Launiya Control Saptari Madhawapur Control Saptari Mahadeva Treatment Saptari Mainakaderi Treatment Saptari Malhanma Treatment Saptari Malhaniya Treatment Saptari Pakari Control Saptari Paterwa Control Saptari Portaha Control Saptari Rampurmalhaniya Control Saptari Simraha singyaun Treatment Saptari Siswa Belhi Treatment Saptari Tikuliya Treatment Saptari Tilathi Treatment Saptari Trikaula Treatment Sarlahi Barahathawa Control Sarlahi batraul Control Sarlahi Belwajabdi Control Sarlahi Bhadsar Treatment Sarlahi Bhawanipur Treatment Sarlahi Chatauna Treatment Sarlahi Dhankaul Paschim Treatment Sarlahi Dhangada Treatment Sarlahi Pharhadawa Treatment Sarlahi Phullparasi Treatment Sarlahi Gadhiya Treatment Sarlahi hathiaual Control Sarlahi Kabilasi Control Sarlahi khairwa Treatment 42 Sarlahi Khutauna Control Sarlahi kisanpur Control Sarlahi Laxmipur Sukhachaina Treatment Sarlahi Madhuwangoth Treatment Sarlahi madhuwani Control Sarlahi Manpur Treatment Sarlahi Mirjapur Control Sarlahi Pidari Control Sarlahi Pipariya Control Sarlahi Simara Treatment Sarlahi Sundarpur chuhariya Control Sindhuli Amale Control Sindhuli Bastipur Control Sindhuli Bitijor Treatment Sindhuli Kalpa brishykha Control Sindhuli Khangasang Treatment Sindhuli Kuseswar Dumja Control Sindhuli Kyaneshwor Treatment Sindhuli Mahadevsthan Treatment Sindhuli Nipane Control Sindhuli Pipalmadi Treatment Sindhuli Ranichuri Treatment Sindhuli Ratanchura Treatment Sindhuli Santeshwori Control Siraha Ashopur balkawa Treatment Siraha Aurahi Control Siraha Belhi Control Siraha Bhawanipur Treatment Siraha Chandra ayodhyapur Control Siraha Chandra udayapur Treatment Siraha Chikana Control Siraha Devipur Control Siraha Dumri Treatment Siraha Durgapur Treatment Siraha Gadha Treatment Siraha Harkatti Treatment Siraha Itatar Treatment Siraha Kabilasi Control Siraha KachAnari Control Siraha Laxmipur patari Treatment Siraha Maheshpur Gamharia Control Siraha Maheshpur Patari Treatment Siraha Bhadaiya Control 43 Siraha Pokharbhinda Treatment Siraha Sanhaitha Treatment Siraha Sikron Control Siraha Sitapur Pra. Da. Control Siraha Sitapur Pra. Ra. Treatment Siraha Sukhipur Control Siraha Tulsipur Control Sunsari Barahachetra Treatment Sunsari Bharoul Control Sunsari Bhokraha Treatment Sunsari Dewangunj Control Sunsari Ghuski Control Sunsari Gautampur Treatment Sunsari Madhuban Treatment Sunsari Madhyaharsahi Control Sunsari Mahendranagar Treatment Sunsari Rajgunj Sinwari Control (Ramganjsenuwari) Sunsari Ramnagar Bhutaha Treatment Sunsari Saterjhora Control Udayapur Baraha Control Udayapur Bashbote Treatment Udayapur Chaudandi Control Udayapur hardeni Treatment Udayapur Katunjebabala Treatment Udayapur mainamaini Control Udayapur Nametar Control Udayapur Sorungchabise Control Udayapur Tamlicha Treatment Udayapur Thanagaun Treatment Udayapur Mayankhu Treatment 44 G. Additional Tables Appendix Table 2: Nutritional Status by Age Group Baseline Endline Stunting Wasting Underweight Stunting Wasting Underweight Age in Months 0-2 23% 23% 24% 29% 49% 20% 3-4 26% 19% 32% 23% 16% 26% 5-6 20% 28% 29% 37% 29% 34% 7-8 23% 17% 25% 11% 18% 19% 9-10 26% 24% 29% 22% 6% 8% 11-12 34% 22% 34% 25% 22% 18% 13-14 38% 27% 37% 25% 20% 6% 15-16 46% 22% 35% 49% 12% 22% 17-18 44% 23% 38% 51% 9% 14% 19-20 54% 19% 35% 39% 3% 3% 21-22 57% 21% 36% 33% 1% 3% 23-24 51% 16% 34% 51% 5% 6% Appendix Table 3: Child Health Baseline Endline Coughing 36% 20% Child illness Diarrhea 10% 5% Vomiting 6% 3% Stunting 38% 33% Child malnutrition Wasting 21% 16% Underweight 32% 15% Weight for age -1.38 -0.77 Child Growth Z-Scores Height for age -1.41 -1.27 Weight for height -0.75 -0.17 Mothers of children up to 2 years old were asked about the foods consumed the day before the survey. Based on the answer, Appendix Table 4 shows the proportion of mothers who consumed any foods in the food group, and the dietary diversity score by summing the number of food groups consumed. Compared to the 9 food groups used in the FAO guideline on Individual Dietary Diversity, the score ranges from 0 to 8 since our survey did not differentiate consumption of organ meat from meat in general. 45 Appendix Table 4: Maternal Nutrition Baseline Endline Mean SD N Mean SD N Starchy staples 1 0.05 4250 1 0.03 1908 Dark green leafy vegetables 0.47 0.5 4250 0.49 0.5 1908 Vitamin A rich fruits and vegetables 0.16 0.37 4250 0.1 0.3 1908 Other fruits and vegetables 0.48 0.5 4250 0.56 0.5 1908 Meat and fish 0.3 0.46 4250 0.49 0.5 1908 Eggs 0.06 0.23 4250 0.09 0.29 1908 Legumes, nuts and seeds 0.47 0.5 4250 0.68 0.47 1908 Milk and milk products 0.42 0.49 4250 0.35 0.48 1908 Dietary Diversity Score (0-8) 3.36 1.44 4250 3.75 1.2 1908 Appendix Table 5: IYCF Indicators Baseline Endline IYCF Indicators Mean SD N Mean SD N Early Initiation of Breastfeeding 0.39 0.49 4557 0.75 0.44 1220 Exclusive Breastfeeding under 6 Months 0.69 0.46 1021 0.57 0.5 329 Continued Breastfeeding at 1 Year 0.92 0.28 779 1 0 180 Introduction of Solid, Semi-solid, or Soft Foods 0.66 0.47 511 0.8 0.4 176 Minimum Dietary Diversity 0.14 0.34 3536 0.19 0.39 892 Minimum Meal Frequency 0.6 0.49 3536 0.77 0.42 892 Minimum Acceptable Diet 0.09 0.29 3379 0.15 0.35 892 Appendix Table 6: Household Characteristics Baseline Endline Household Characteristics Mean SD N Mean SD N Number of children age 0-17 1.16 1.25 7038 2.32 1.52 2140 Number of HH members 5.98 2.01 7038 5.44 2.35 2140 Household head attended school 0.41 0.49 7037 0.50 0.50 1927 Household head's literacy 0.42 0.49 7037 0.51 0.50 1927 Distance to road head 6.73 10.79 6227 5.32 7.88 1483 Distance to health institutions 8.2 10.57 6521 6.44 6.00 1483 Distance to government hospital 22.58 21.58 6811 23.42 17.12 1483 Ownership of house 1.00 0.07 7038 1.00 0.05 1480 Access to clean water 0.98 0.15 7038 0.99 0.10 1480 Usage of toilet 0.26 0.44 7035 0.86 0.34 1930 Separate Kitchen 0.46 0.5 7038 0.51 0.50 1930 Stove Channel 0.31 0.46 7038 0.52 0.50 1930 Open window for cooking room 0.3 0.46 7038 0.65 0.48 1930 Smoke inside when cooking 0.66 0.47 7038 0.61 0.49 1930 46 Anyone smoking inside the house 0.38 0.49 7038 0.28 0.45 1930 Human Feces in/near the house 0.31 0.46 7037 0.08 0.27 1930 Animal Feces in/near the house 0.72 0.45 7038 0.76 0.43 1930 Land Owner 0.69 0.46 7038 0.80 0.40 1480 Land Size (Hectare) 0.58 0.77 4863 0.58 0.70 1006 Livestock Owner 0.76 0.43 7035 0.82 0.38 1480 Cow, Bull, Buffalo 0.83 0.374 5349 0.84 0.37 1137 Goat, Sheep 0.68 0.47 5346 0.70 0.46 1137 Pig 0.15 0.36 5342 0.23 0.42 1137 Chicken 0.38 0.49 5344 0.62 0.49 1137 Appendix Table 7: Type of Toilet Type of Toilet (%) Baseline Endline Use toilet Flush to municipal sewer system 0.01 0 Flush to septic tank 17.35 71.20 Covered pit 8.09 15.04 Community latrine 0.04 0 Other type of latrine 0.19 0 No toilet Open pit 1.12 1.15 Forest, farm 63.24 12.11 Riverbank 9.95 0.46 Total 100 100 Number of Observations 6883 1930 Appendix Table 8: Source of Drinking Water Water (%) Baseline Endline Source of drinking water Direct piped water 3.86 4.73 Piped water from public tap 20.2 38.42 Shallow/private pump 34.93 32.45 Deep/private pump 18.17 5.35 Shallow/public pump 9.18 12.16 Deep/public pump 7.09 0.97 Private well 0.52 3.09 Public well 3.78 1.75 Open water 1.48 0.76 Other 0.8 0.28 47 48