International Consultancy -Impact evaluation of Community Based Nutrition Programme (CBNP) for None Afghan Nationals

Consultant Programme & Policy Monitoring & Evaluation

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Afghanistan has achieved notable health improvements in the last 15 years, including in child nutrition with stunting rates in children under 5 years of age decreasing from 60. 5% in 2004 to 40. 9% in 2014. However, these rates are still quite high and infant and child mortality rates are among the highest in South Asia, a situation that is significantly attributable to poor nutritional status of children less than five years of age. 1-3

In October to November 2022, the Afghanistan Nutrition Cluster and its partners conducted an Integrated Phase Classification for Acute Malnutrition (IPC AMN) analysis which was preceded by a National Nutrition SMART Survey with representation for all the 34 provinces in Afghanistan. The results show that the prevalence of acute malnutrition nationally stands at 10.3% with variations across provinces, ranging from serious to critical level of child wasting across the country. The same survey found that 32.7% of children under the age of 5 years are stunted.

The ongoing high stunting and underweight rates likely result from poor infant and child feeding practices. The 2015-2016 Demographic and Health Survey (DHS) found that only approximately 40% of infants were either breastfed within one hour of birth or exclusively breastfed through six months of age, with significant differences by province and wealth quintile.4 Further, harmful practices, such as pre-lacteal feeds and traditional foods served to children with resultant low dietary diversity, appear prevalent in this national survey. 4

Multiple programs have been implemented in Afghanistan to address undernutrition during pregnancy, infancy, and early childhood, but none have been implemented at scale or rigorously evaluated to determine the efficacy or impact of the specific approaches.1 Following a government-led call to action in 2016, there has been substantial investment in nutrition services and interventions to address undernutrition in Afghanistan. As part of that initiative, the Ministry of Public Health (MoPH) has worked with a variety of multisectoral stakeholders to review nutrition interventions implemented to date and design a community-based program specifically targeting infant and young child feeding (IYCF) practice behavior change.

The resultant Community-Based Nutrition Package (CBNP) is a practical, comprehensive minimum service package delivered at the community level as an adjunct to health facility services. The aim of CBNP is to promote high-impact nutrition interventions within the context of the Basic Package of Health Services (BPHS). CBNP comprises both community mobilization and practical demonstrations led by community health workers (CHWs) and other volunteers who provide education to motivate behavior change among pregnant women and caregivers of young children in the community. CHWs are trained and provided with supplies (e. g. printed pictorial tools, mid-upper arm circumference (MUAC) measuring tapes, mapping grids, child monitoring cards) to support the implementation of the community activities. Further, the program is integrated with related sectors like WASH, Agriculture, and Social Protection at the community level. To date, the CBNP program is being implemented in 21 provinces with a mixture of implementation models, including both signing of partnership document with BPHS implementing NGOs and Implementing Partners (those that do not have responsibility for BPHS implementation in the same province). UNICEF is planning to scale up implementation to a further 13 provinces this year. As CBNP is being taken to scale, there are several outstanding questions that need to be addressed to document whether the intervention has achieved its intended goals.

Based on the plan to scale up the CBNP program nationally, an evaluation of CBNP impact was planned from the start to guide further scale-up efforts. The rationale for this evaluation is to determine whether the CBNP intervention, as implemented by BPHS providers in tandem with the government in the selected provinces, can change critical infant and young child feeding (IYCF) practices and examine the various components of the package (e. g. cooking demonstrations) by reported exposure (quantitative) and perceived effect by beneficiaries (mixed methods) as most instrumental in changing child feeding behaviors.

Scope of Work:

The consultant will provide technical input into the design and piloting of data collection instruments for both the household mapping exercise and the selected evaluation sample, training of field data collection teams, conducting complete impact analysis on the cleaned datasets and compiling a comprehensive report detailing findings on key variables plus disaggregation of interest across treatment assignment, geographical location and so on

Study Aim and Objectives

The primary aim of this evaluation is to measure the impact of the Community-Based Nutrition Package (CBNP) intervention on child feeding practices among parents/caregivers to children 6 to 23 months of age in select provinces of Afghanistan. To meet this aim, specific study objectives include:

Primary Objective

To estimate the impact of CBNP in increasing the proportion of children ages 6-23 months who receive the World Health Organization-defined minimum acceptable diet (MAD).

Secondary Objectives

To examine the impact of the CBNP on:

• Initiating breastfeeding within one hour of birth
• Exclusive breastfeeding for the first six months of a baby’s life
• Handwashing knowledge to prevent disease transmission.
• Household food security scores
• Household decision-making collaboration between spouses on food selection, monies allocated for food, foods cultivated or purchased, engagement with health facilities, and household hygiene upgrades.
• Presence of handwashing facilities stocked with soap within households.
• To explore motivators of and barriers to food and related commodity purchase, cultivation, and preparation
• To determine access to community-based nutrition events among men and women
• To assess whether CBNP-introduced behavior changes are sustainable beyond the programme’s lifespan.

Study Setting

This study covers Herat, Ghazni and Parwan provinces of Afghanistan where the CBNP was implemented by the BPHS organization contracted to provide public sector health services and are geographically and ethnically distinct from each other. Within these provinces, health facilities (HFs), typically a basic health center (BHC) or comprehensive health center (CHC), coordinates delivery of the intervention through Nutrition Mobilization teams (NMTs), which are made up of individuals drawn from the communities served by the HF. Each HF has approximately 6-10 HPs attached to it. A HP is staffed by one or more CHWs and serves a community of 100 to 150 households. These communities are rural, predominantly agrarian, and generally ethnically homogeneous.

Study Population

The target population for the CBNP intervention includes women who are pregnant or who have children under two years of age, their husbands, and other key household influencers. For the purposes of this evaluation, to be able to measure the impacts of the intervention on child nutrition practices, the study population includes women with infants and young children ages 6 to 23 months for both quantitative and qualitative components. The qualitative component also includes husbands and key informants regarding household food and related commodity (e. g. micronutrient supplements and fortified foods) supply, such as mothers-in-law, and possibly other key informants, like CHWs, volunteers and Public Nutrition Officers.

Sampling Design & Sample Size

The study sampling design is a three-stage sample. The primary sampling unit is the HF cluster. For each HF cluster, a list of affiliated HPs in its catchment area was created, each assessed for eligibility and for contamination potential. HP catchment areas that were too close to another HP catchment area affiliated with another HF in the sample were dropped. Among the final list of HPs, up to four eligible HPs were randomly selected for study inclusion. Within the catchment areas of each of the selected HPs, the corresponding community were mapped, a sample of eligible households was selected at random for the baseline and, within them, participants for data collection selected prior to randomization. For the endline, a new mapping exercise will be conducted to generate the sampling frame of eligible households from which the evaluation sample of households will be selected for data collection. Within households, one woman meeting eligibility criteria will be selected to participate in the study. In households with more than one eligible woman, a Kish grid is used to select the female participant for that household.

The sample size below will be adjusted to account for up to 10% of non-response (unavailability at the time of interview or refusal).

Table 1. Proportion of children 6-23 months old who meet the 3 IYCF criteria that make up MAD, DHS data 2015.

Province

MAD %

Parwan

18. 5

Ghazni

9. 2

Herat

16. 4

Assuming that the percentage of children receiving MAD may have improved since 2015 and to be conservative in our sample size calculations, we used a base MAD estimate of 25%, so If we randomize 34 HF population clusters (selected HP catchment areas), 17 in each study arm and recruit 45 eligible women per cluster across catchment areas of up to four health posts, we would have at least 80% power to detect a 12% difference, from 25% to 37% in children between 6-23 months receiving MAD between control and treatment groups using a 5% significance level for a two-sided comparison. The calculation also assumed an intraclass correlation (ICC) of 5% to account for clustering effects and was adjusted to account for up to 10% non-response. ICC of 5% is reasonable because the health post catchment communities did not differ substantially from each other across a given district and more particularly within a given cluster around a designated HF.

For the qualitative components, a convenience sample of between 12-15 men and women with children aged 6-23 months and community leaders from each province will be selected according to the eligibility criteria and availability to meet with the qualitative interviewer (36-45 men and women per province only in intervention site). This number provided approximately what’s needed to achieve thematic saturation.7 HFs with a nutrition counselor on staff were listed and six each selected randomly from HFs allocated to the intervention arm.

Analysis

Structured questionnaires

All data will be analyzed using STATA, SAS, or similar software programs.

A detailed data analysis plan for quantitative data will be agreed prior to data analysis. The plan will define key variables, standardized tables, and describe the statistical methods to address each study objective. It will also include data cleaning decisions made for analysis purposes. Analyses will be performed using Stata version 15, or a similar software. Descriptive analysis will be employed to get simple summaries about the sample and the measures. These will be presented as proportions with 95% confidence intervals or as means and standard errors. Confidence intervals will account for clustering effects as appropriate. A final evaluation report will be developed by the consultant to determine whether there are critical differences in treatment and control clusters by socioeconomic or outcome measures and to gauge proportion of children receiving MAD.

The evaluation analysis of the cluster RCT to be done at endline will focus on comparing the effect of CBNP exposure on the study outcomes. It is anticipated an analysis of covariance (ANCOVA) approach will be used for a post-only comparison of study arms with possible adjustment for baseline levels in an aggregate manner (note: aggregation for baseline adjustment will be needed given the independent samples selected at each time point). We plan to use generalized mixed models to compare the study groups and adjust for clustering at the HF level. A logit link will be used

for the primary outcome (i.e., MAD) as it is a dichotomous outcome, while other link functions will be used for other outcomes as appropriate. We hypothesize that the treatment arm implementing the CBNP intervention will be superior to standard practice.

Qualitative Analysis

For the qualitative component, semi-structured in-depth interviews will be conducted with purposively selected male and female key informants and household members to explore food supply practices. Additionally, interviews and Focus group Discussions (FGDs) will be conducted with Community Health Workers (CHWs)/volunteers, Nutrition Management Team members and CBNP facilitators to provide insights into the causal mechanisms through which programme impacts are attained and to inform their sustainability beyond the programme’s lifespan

Deliverables:

Tasks/Milestone:

Deliverables/Outputs:

Timeline

Inception Phase

• Supervise mapping exercise and sample selection.
• Revise data collection instruments
• Develop training manuals and supervise field team training.
• Review and make revisions to complete evaluation protocol.
• Prepare data analysis plan

Deliverables:

• Clean dataset of all eligible households from mapping exercise

Inception report containing:

• Finalized quantitative and qualitative data collection instruments.
• Fieldwork training manual
• Complete evaluation protocol
• Final evaluation sample
• Concrete data analysis plan

30 August 2023

Data Collection and Analysis Phase:

• Supervise data collection and share weekly updates.
• Clean data and conduct high frequency checks to ensure quality and adherence to protocols
• Conduct data analysis according to analysis plan
• Submit preliminary draft evaluation report

Deliverables:

• Weekly fieldwork progress reports
• Final fieldwork report at conclusion of data collection
• Clean, well scrutinized datasets and interview scripts
• Complete analysis do-files
• Draft evaluation report in-line with analysis plan

30 October 2023

Report Finalization and Presentation Phase:

• Incorporate feedback from evaluation reference group to draft report and finalize report
• Prepare evaluation brief PowerPoint presentation and infographic-focused evaluation brief (5 pages Max)
• Present the findings to the stakeholders

Deliverables:

• Final evaluation report
• PowerPoint Presentation
• Evaluation brief

30 November 2023

To qualify as an advocate for every child you will have…

• An advanced degree (PhD preferred) in nutrition, public health, health economics, biostatistics or other health or social science related field.
• At least ten years’ experience in conducting evaluations/ research of programmes focusing on public health or nutrition and ideally experience in fragile countries.
• Experience conducting research or evaluations in the nutrition/health sector programmes, preferably in Afghanistan.
• Special skills: Experience leading RCT studies of health and/or nutrition programmes
• Developing country work experience and/or familiarity with emergency is considered an asset.
• Fluency in English is required. Knowledge of another official UN language (Arabic, Chinese, French, Russian or Spanish) or a local language is an asset.

For every Child, you demonstrate…

UNICEF's values of Care, Respect, Integrity, Trust, Accountability, and Sustainability (CRITAS).

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UNICEF is here to serve the world’s most disadvantaged children and our global workforce must reflect the diversity of those children. The UNICEF family is committed to include everyone, irrespective of their race/ethnicity, age, disability, gender identity, sexual orientation, religion, nationality, socio-economic background, or any other personal characteristic.

UNICEF offers reasonable accommodation for consultants/individual contractors with disabilities. This may include, for example, accessible software, travel assistance for missions or personal attendants. We encourage you to disclose your disability during your application in case you need reasonable accommodation during the selection process and afterwards in your assignment.

UNICEF has a zero-tolerance policy on conduct that is incompatible with the aims and objectives of the United Nations and UNICEF, including sexual exploitation and abuse, sexual harassment, abuse of authority and discrimination. UNICEF also adheres to strict child safeguarding principles. All selected candidates will be expected to adhere to these standards and principles and will therefore undergo rigorous reference and background checks. Background checks will include the verification of academic credential(s) and employment history. Selected candidates may be required to provide additional information to conduct a background check.

Remarks:

Interested consultants are required to apply online, indicating availability and all-inclusive lump sum fee to undertake the terms of reference.

Only shortlisted candidates will be contacted and advance to the next stage of the selection process.

Individuals engaged under a consultancy or individual contract will not be considered “staff members” under the Staff Regulations and Rules of the United Nations and UNICEF’s policies and procedures and will not be entitled to benefits provided therein (such as leave entitlements and medical insurance coverage). Their conditions of service will be governed by their contract and the General Conditions of Contracts for the Services of Consultants and Individual Contractors. Consultants and individual contractors are responsible for determining their tax liabilities and for the payment of any taxes and/or duties, in accordance with local or other applicable laws.

The selected candidate is solely responsible to ensure that the visa (applicable) and health insurance required to perform the duties of the contract are valid for the entire period of the contract. Selected candidates are subject to confirmation of fully vaccinated status against SARS-CoV-2 (Covid-19) with a World Health Organization (WHO)-endorsed vaccine, which must be met prior to taking up the assignment. It does not apply to consultants who will work remotely and are not expected to work on or visit UNICEF premises, programme delivery locations or directly interact with communities UNICEF works with, nor to travel to perform functions for UNICEF for the duration of their consultancy contracts.

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Added 11 months ago - Updated 10 months ago - Source: unicef.org