Enhancing the evaluation of integrated, nutrition-sensitive strategies to improve maternal and child nutrition and health Open Access
Self, Julie Lynn (2015)
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
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