Enhancing the evaluation of integrated, nutrition-sensitive strategies to improve maternal and child nutrition and health Open Access

Self, Julie Lynn (2015)

Permanent URL: https://etd.library.emory.edu/concern/etds/08612p07q?locale=en
Published

Abstract

There is a critical gap in the evidence base for the estimated impact of nutrition-sensitive strategies. The objective of this dissertation is to demonstrate how path analysis and economic evaluation of integrated, nutrition-sensitive programs can enhance understanding about their role in improving maternal and child nutrition and health. We use path analysis to assess the mechanisms of effect for the Action Against Malnutrition through Agriculture (AAMA) Project in Nepal and assesses the cost-effectiveness of the Mama-SASHA Project in Kenya. The AAMA Project combined a nutrition-sensitive agriculture intervention with behavior change communication. Cross-sectional endline survey data were used to measure variables along the hypothesized Program Impact Pathway, from inputs through outcomes of interest, including child nutritional status, maternal underweight, child diarrhea, maternal night blindness, and maternal and child hemoglobin. Survey respondents included mothers with children aged 12-48 months. We used path analysis to assess the relative contribution of specific mechanisms of effect on nutrition and health. The hypothesized model for height-for-age z-score fit the data well (RMSEA=0.027; CFI=0.945), while the model for child hemoglobin (RMSEA=0.073, CFI=0.913) was a moderate fit, and some models did not achieve adequate fit. Areas of weak association and poor model fit may be attributed to weaknesses in measurement, intervention fidelity, and contextual factors unaccounted for in the models. The Mama-SASHA project aims to improve the health and nutrition of pregnant/lactating women and children <2 years through an integrated orange-fleshed sweetpotato (OFSP) and health service strategy in Western Kenya. We estimated the incremental cost-effectiveness ratio (ICER) of the intervention, which includes OFSP vouchers provided at antenatal care (ANC) visits, nutrition education, and pregnant women's clubs, compared to status quo ANC services. Effectiveness data from a quasi-experimental study and estimates from the literature were used to estimate DALYs for a range of benefits. We used ingredients-based micro-costing to estimate economic costs of agriculture, health and community interventions, including opportunity costs of labor. Annual net economic cost was USD $145,589. 72 DALYs were averted per year, mostly attributable to improvements in stunting and anemia. The ICER was USD $2,015 per DALY averted, which meets cost-effectiveness criteria set by WHO.

Table of Contents

CHAPTER 1: INTRODUCTION. 1

RESEARCH AIM 1. 2

RESEARCH AIM 2. 2

REFERENCES. 3

CHAPTER 2: BACKGROUND. 4

THE BURDEN OF MALNUTRITION. 4

Global trends and consequences of malnutrition. 4

Micronutrient malnutrition. 5

Causes of malnutrition and conditions for optimal nutrition. 7

STRATEGIES FOR IMPROVING NUTRITION AND FOOD SECURITY. 9

Nutrition-specific strategies. 9

Nutrition-sensitive strategies. 11

Impact pathways of nutrition-sensitive strategies. 12

Evidence for the effectiveness of household food production programs. 14

Factors influencing the effect of household food production interventions. 16

EVALUATION OF NUTRITION-SENSITIVE PROGRAMS. 17

Theory-driven evaluation of complex programs. 17

Path analysis of nutrition-sensitive programs. 18

Economic evaluation of nutrition-sensitive programs. 20

Nutrition-sensitive interventions included in this research. 25

REFERENCES. 29

CHAPTER 3: ASSESSING PATHWAYS OF EFFECT FOR HOUSEHOLD FOOD PRODUCTION INTERVENTIONS TO IMPROVE MATERNAL AND CHILD NUTRITION AND HEALTH: APPLYING

PATH ANALYSIS TO THE PROGRAM IMPACT PATHWAY FOR THE HOMESTEAD FOOD PRODUCTION PROGRAM IN NEPAL. 40

INTRODUCTION. 40

METHODS. 44

Intervention design and implementation. 44

Evaluation design and implementation. 45

Measurement and indicators. 46

Theoretical models, simple mediation and path analyses. 49

RESULTS. 51

Refining the path model and variable selection. 52

Simple mediation analyses. 53

Path analyses. 53

DISCUSSION. 54

CHAPTER 3 TABLES AND FIGURES. 61

REFERENCES. 67

CHAPTER 4: HOW DOES HOMESTEAD FOOD PRODUCTION IMPROVE MATERNAL AND CHILD NUTRITION? PATH ANALYSIS OF THE AAMA PROJECT IN NEPAL. 71

INTRODUCTION. 71

METHODS. 74

AAMA Project description. 74

Evaluation design and data collection. 75

Measurement. 76

Model specification and testing. 78

RESULTS. 80

Child nutrition and health status. 80

Maternal nutrition and health status. 82

DISCUSSION. 83

CHAPTER 4 TABLES AND FIGURES. 91

REFERENCES. 101

CHAPTER 5: COST-EFFECTIVENESS OF MAMA-SASHA: A PROJECT TO IMPROVE HEALTH AND NUTRITION THROUGH AN INTEGRATED ORANGE-FLESH SWEET POTATO PRODUCTION AND HEALTH SERVICE DELIVERY MODEL. 104

INTRODUCTION. 104

Description of the intervention. 106

METHODS. 107

Costs. 107

Health outcomes. 110

Economic benefits. 112

DALYs averted and incremental cost-effectiveness ratio. 112

Sensitivity analysis. 114

RESULTS. 115

Economic costs and benefits. 115

DALYs averted and ICER. 116

Multiple variable sensitivity and scenario analyses. 116

DISCUSSION. 117

CHAPTER 5 TABLES AND FIGURES. 121

REFERENCES. 129

CHAPTER 6: SUMMARY AND CONCLUSIONS. 135

SUMMARY OF FINDINGS. 135

LIMITATIONS. 137

STRENGTHS AND INNOVATIONS. 138

CONCLUSIONS AND FUTURE RESEARCH. 139

REFERENCES. 142

About this Dissertation

Rights statement
  • Permission granted by the author to include this thesis or dissertation in this repository. All rights reserved by the author. Please contact the author for information regarding the reproduction and use of this thesis or dissertation.
School
Department
Degree
Submission
Language
  • English
Research Field
Keyword
Committee Chair / Thesis Advisor
Committee Members
Last modified

Primary PDF

Supplemental Files