Attachment J.4 Suaahara II Annual Household Survey Report.pdf

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SUAAHARA II

GOOD NUTRITION PROGRAM

YEAR 6 ANNUAL SURVEY REPORT (2022)

March 2023

This publication was produced for review by the United States Agency for International Development.

It was prepared by Helen Keller International under the terms of cooperative agreement number

AID-367-A-16-00006.

SUAAHARA II

GOOD NUTRITION PROGRAM

Year 6 Annual Survey Report (2022)

DISCLAIMER:

This report is made possible by the generous support of the American people through the United States Agency for International Development (USAID). The content of this report is produced by Helen Keller International, Suaahara II Program and does not necessarily reflect the views of USAID or the United States Government.

The Suaahara II Good Nutrition Program is supported by the United States Agency for International Development (USAID) under Cooperative Agreement No. AID-367-A-16-00006.

Suaahara II is managed by:

Helen Keller International

In partnership with:

Cooperative for Assistance and Relief Everywhere, Inc.

(CARE)

Family Health International 360

(FHI 360)

Digital Broadcast Initiative Equal Access

(DBI EA)

Environmental and Public Health Organization

(ENPHO)

Nepali Technical Assistance Group

(NTAG)

Vijaya Development Resource Center

(VDRC)

Contents List of Tables

List of Figures

Executive Summary

Acronyms

1. Background

1.1 Health and nutrition status in Nepal

1.2 An overview of the Suaahara II project in Nepal

1.3 Structure of the report

2. Annual Monitoring Survey Design

2.1 An overview of survey objectives

2.2 Survey design

2.2.1 Sample size and power calculations

2.2.2 Sampling methodology

2.3 Survey instruments

2.3.1 Mothers’ questionnaires

2.4 Training, fieldwork, and logistics

2.4.1 Training of personnel and testing of survey tools

2.4.2 Administration of survey questionnaires

2.4.3 Fieldwork challenges

2.5 Data management

2.5.1 Data entry and cleaning

2.5.2 Statistical Analysis

3. Results: Background characteristics

4. Results: Intermediate Result 1 - Improved household nutrition and health behaviors

5. Results: Intermediate Result 1: Improved household WASH behaviors

6. Results: Intermediate Result 2: Increased use of quality nutrition and health services by women and children

7. Results: Intermediate Result 3: Improved access to diverse and nutrient-rich foods by women and children

8. Results: Social and Behavior Change Communication (SBCC)

9. Results: Gender and Social Inclusion (GESI)

9.1 Disaggregated analysis of key behaviors promoted by Suaahara II

9.2 Suaahara II coverage - Disaggregated

10. Discussion and Program Implications

10.1 Background characteristics

10.2 Nutrition outcomes

10.3 Maternal and Child Nutrition

10.4 Water, Sanitation, and Hygiene (WASH)

10.5 Health and Family Planning (FP) Services

10.6 Homestead Food Production (HFP)

10.7 Social and Behavior Change Communication (SBCC)

10.8 Gender Equality and Social Inclusion (GESI)

Annexes

List of Tables Table 1: Key indicators from 2017, 2018, 2019, and 2022 surveys Table 2.1 Sample sizes needed for each indicator, by population type Table 3.1 Households’ socio-economic and demographic characteristics Table 3.2 Household heads’ demographic characteristics Table 3.3 Mothers’ demographic characteristics Table 3.4 Children’s demographic characteristics Table 4.1 Breastfeeding knowledge among mothers Table 4.2 Breastfeeding children <2 years Table 4.3 Complementary feeding knowledge among mothers Table 4.4 Complementary feeding practices for children <2 years Table 4.5 Mothers’ knowledge regarding sick child feeding and care practices Table 4.6 Practice of child feeding during illness, among children ill in the last 2 weeks Table 4.7 Dietary practices among children aged 6-23 months Table 4.8 Maternal nutrition knowledge among mothers Table 4.9 Dietary practices during pregnancy and lactation among mothers of children <2 years Table 4.10 Dietary practices among mothers Table 4.11 Child anthropometric indicators of nutritional status by age group Table 4.12 Child anthropometric indicators of nutritional status by sex Table 4.13 Nutritional status of children by age group Table 4.14 Nutritional status of children by sex Table 4.15 Nutritional status of children by equity status Table 4.16 Distribution of hemoglobin levels and prevalence of anemia among children aged 6-59 months, by age group Table 4.17 Distribution of hemoglobin levels and prevalence of anemia among children aged 6-59 months, by sex Table 4.18 Prevalence of anemia among children aged 6-59 months, by equity status Table 4.19 Anthropometric indicators of mothers, by pregnancy status Table 4.20 Chronic energy deficiency (BMI <18.5 kg/m²) of mothers, by equity status Table 4.21 Distribution of hemoglobin levels and prevalence of anemia among mothers, by pregnancy status Table 4.22 Anemia of mothers, by equity status Table 5.1 Drinking water treatment knowledge among mothers Table 5.2 Drinking water treatment practices in households Table 5.3 Drinking water treatment practices Table 5.4 Handwashing (with soap and water) knowledge among mothers Table 5.5 Practice of handwashing with soap and water among mothers Table 5.6 Household sanitation and hygiene facilities and practices Table 5.7 Menstrual hygiene practices among mothers Table 6.1 Child health: Diarrhea and treatment among children aged 0-5 years Table 6.2 Child health: Diarrhea and treatment among children aged 0-2 years Table 6.3 Child health: Acute respiratory infection (ARI) and fever Table 6.4 Growth monitoring practices among children aged 0-2 years Table 6.5 Knowledge on maternal health among mothers Table 6.6 ANC, delivery, and PNC practices among mothers with children <2 years Table 6.7 Age at marriage, pregnancy and childbirth Table 6.8 Family planning/healthy timing and spacing of pregnancy (HTSP) knowledge among mothers 50 Table 6.9 Family planning practices among non-pregnant mothers Table 7.1 Household food security status Table 7.2 Interactions between VMFs and homestead food production participant (HFPP) Table 7.3 Homestead gardening practices Table 7.4 Poultry ownership and management Table 7.5 Income, sales, and use of revenue from the sale of surplus vegetables in the last 12 months . 57

Table 7.6 Total income, sales, and use of revenue from the sale of poultry outputs in the last 12 months Table 7.7 Total income, sales, and use of revenue from the sale of HFP outputs (vegetables and chickens) in the last 12 months Table 8.1 Interactions with Suaahara II Front Line Workers (FLWs) among mothers Table 8.2 Interactions with FCHVs among mothers Table 8.3 Exposure to Bhanchhin Aama (BA) radio program Table 8.4 Mobile Phone access and use among mothers Table 8.5 Mobile Phone ownership and SMS exposure among mothers of children aged 0-2 years Table 9.1 Maternal minimum dietary diversity among mothers of children aged 0-23 months Table 9.2 Egg consumption among mothers of children aged 0-23 months Table 9.3 Meat consumption among mothers of children aged 0-23 months Table 9.4 Attended ANC at least four times Table 9.5 Intake of at least 180 IFA tablets during pregnancy Table 9.6 Use of modern method of family planning among mothers of children <2 years Table 9.7 Minimum dietary diversity among children aged 6-23 months Table 9.8 Egg consumption among children aged 6-23 months Table 9.9 Meat consumption among children aged 6-23 months Table 9.10 Consumption of iron-rich foods among children aged 6-23 months Table 9.11 Feeding more to sick children <2 years Table 9.12 Practice of exclusive breastfeeding Table 9.13 Appropriate drinking water treatment among households with a child <2 years Table 9.14 Handwashing practice at six critical times among mothers with a child less than 2 years Table 9.15 Minimum acceptable diet (MAD) for children among children aged 6-23 months Table 9.16 Newborns receiving postnatal health check within 24 hours of birth Table 9.17 Intake of at least 45 IFA tablets during postnatal period (among those who take any) Table 9.18 Soap and water at handwashing station among households with children <2 years Table 9.19 Ever met Suaahara II FLWs (among mothers with children <2 years) Table 9.20 Ever participated in Suaahara II community activities, other than group meetings (among mothers with children <2 years) Table 9.21 Ever heard of Bhanchhin Aama (among mothers with children <2 years) Table 9.22 Ever listened to Bhanchhin Aama (among mothers with children <2 years) Table 9.23 Received health/nutrition SMS on personal mobile phone in the last month (among mothers with children <2 years)

List of Figures Figure 1 Annual Survey Districts Figure 2 Sampling methodology Figure 3 Questionnaire modules 2022 Figure 4 Suaahara II Implementation timeline and major disruptions

Executive Summary Over the first two decades of the 21st century, Nepal has made remarkable progress towards reducing the burden of maternal and child undernutrition. However, Nepal remains behind the Sustainable Development Goal targets on undernutrition to be achieved by 2025. According to the Nepal Demographic and Health Survey (NDHS) 2022, 25% of children under five years of age are stunted, 8% are wasted, and 19% are underweight (NDHS, 2022).

Suaahara II is a USAID-funded multi-sectoral nutrition program, aligned with Nepal’s Multi-Sector Nutrition Plan (MSNP). The program has been implemented in 42 out of Nepal’s 77 districts since 2016. Suaahara II aims at reducing the prevalence of stunting, wasting, and underweight among children under five years of age, and anemia among women of reproductive age (WRA) and children aged 6-59 months. The Suaahara II’s community-based interventions strive to achieve this by reaching and mobilizing disadvantaged households and communities particularly those in the first 1,000 days of life (between a woman’s pregnancy and her child’s second birthday).

Suaahara II activities cover multiple thematic areas including nutrition, health and family planning (FP), water, sanitation and hygiene (WASH), homestead food production (HFP), and governance.

Furthermore, cross-cutting approaches and themes such as social and behavior change communication (SBCC) and gender equality and social inclusion (GESI) are also integrated into all Suaahara II activities.

Suaahara II has a comprehensive and rigorous monitoring, evaluation, and research (MER) system. Annual monitoring surveys, a key component of Suaahara II’s monitoring system, primarily serve to monitor progress in key Suaahara II inputs, outputs, and outcomes over time.

The first Suaahara II annual monitoring survey was conducted by New ERA (a local survey firm) in Year 2017 (between June and September) on a representative sample of households with children under five years of age. At the household level, mothers were the primary survey respondents. A primary male household decision maker (or female, in the absence of male household head), the youngest child’s grandmother, and an adolescent girl (10-19 years), residing in the same household, were also interviewed. Data was also collected from Female Community Health Volunteers (FCHVs) and one key informant from each health facility (HF) in the sampled areas. The household surveys included questions related to exposure, knowledge, and practices for each of the thematic areas mentioned above. Anthropometry and anemia status were assessed for all available women aged 15-49 years, adolescent girls aged 10-19 years and children under 5 years of age. FCHV and health facility (HF) questionnaires were used to collect information on exposure to training, motivation, supervision, and work-related activities. In 2017, the final survey sample included 3,642 households.

New ERA also carried out the second, third, and fourth surveys between July and September 2018, 2019, and 2022, respectively, again on a representative sample of households with children under five years of age in the same sample clusters. In the 2018 and 2019 surveys, only mothers and a primary male household decision maker (or female, in the absence of male household head) were interviewed. In the 2022 survey, only mothers were interviewed but data on anthropometry and anemia status were collected for all available women aged 15-49 years and children under 5 years of age.

There is some variation in survey modules and questions between the 2017, 2018, and 2019 tools, mostly due to the addition of questions for program monitoring and removal of questions that did not require measurement due to the change in activity implementation timelines.

Additionally, given the simultaneous execution of the Suaahara II endline survey and the Year Six Annual Survey, the 2022 questionnaire was slightly shortened, to eliminate redundancies and avoid unnecessarily long interviews. However, the modules and questions needed for calculation of key Suaahara II indicators remained unchanged in all versions of the survey instruments, allowing trends over time to be compared for all intervention areas across all years. To assess these changes, a comparison of results between 2017 and 2019, 2019 and 2022, and 2017 and 2022 were done. The test of statistical significance was conducted for all comparison years.

However, more significant p-values were observed between years 2017 and 2022 due to a longer period of exposure of the target population to program interventions.

The purpose of the annual survey report is to document and disseminate key results from the Suaahara II annual monitoring surveys related to the four key intermediate results (IRs) themes, i.e., (i) household nutrition and WASH behaviors, (ii) use of nutrition and health services by women and children, (iii) access to nutrient rich foods by women and children, and (iv) improved roll-out of the multi-sector nutrition plan (MSNP) through strengthened local governance. Each annual survey provides data on the outcome variables for each of the IRs and is used to assess progress from the previous year and establish “baseline” levels for the following year. In addition to providing the results from the sixth annual monitoring survey, this year’s report analyzes and discusses trends over time by comparing results of the four annual surveys – 2017, 2018, 2019, and 2022. The report also discusses the implications of these trends for overall program effectiveness.

Changes in key performance indicators over the six-year period are provided in Table 1.

Table 1: Key indicators from 2017, 2018, 2019, and 2022 surveys

Indicators 2017 2018 2019 2022 P-value P-value P-value

Mean/% Mean/% Mean/% Mean/% 2017/

2019/

2017/

Child and maternal Health and Nutrition Stunted children under 5 years of age (N=4585, 4368)

28.1% NA NA 21.9% NA NA <0.001

Underweight children under 5 years of age (N=4594, 4374)

22.6% NA NA 20.1% NA NA 0.013

Wasted children under 5 years of age (N=4579, 4367)

9.9% NA NA 9.8% NA NA 0.928

Anemia among children 6-59 months of age (N=4098, 3946)

32.3% NA NA 24.5% NA NA <0.001

Underweight among women of reproductive age (N=4998, 4800)

17.7% NA NA 15.1% NA NA <0.001

Anemia among women of reproductive age (N=4982, 4793)

29.3% NA NA 24.0% NA NA <0.001

Mean number of food groups consumed by women of reproductive age (N=3640, 3648, 3648, 3648)

4.1 4.3 4.4 4.4 <0.001 0.577 <0.001

2017 2018 2019 2022 P-value P-value P-value

Mean/% Mean/% Mean/% Mean/% 2017/

2019/

2017/

Minimum dietary diversity among WRA (consuming foods from at least 5 out of 10 food groups in the previous 24 hours)

(N=3640, 3648, 3648, 3648)

35.6% 41.6% 45.2% 46.1% <0.001 0.549 <0.001

Women consuming all 180 tablets of iron and folic acid (IFA) during pregnancy (N=1835, 1899, 1820, 1806)

52.4%

59.1%

53.9% 65.3% 0.391 <0.001 <0.001

Pregnant women weighed during most recent ANC visit, among those who received ANC (N=1772, 1855, 1775, 1764)

86.7% 93.4% 94.7% 89.3% <0.001 <0.001 0.048

Births receiving at least 4 ANC visits during pregnancy (N=1848, 1910, 1825, 1814)

79.5% 85.5% 88.8% 87.1% <0.001 <0.001 <0.001

Births attended by a skilled birth attendant (N=1848, 1910, 1825, 1814)

73.2% 77.2% 82.3% 85.6% <0.001 0.007 <0.001

Women of reproductive age currently using a modern method of contraception (N=3642, 3648, 3648, 3648)

34.2% 33.2% 35.7% 37.7% 0.194 0.120 0.003

Child Health and Nutrition Low birth weight (N=621, 702, 896, 923)

11.1% 8.3% 9.5% 9.0% 0.296 0.714 0.194

Newborns receiving postnatal health check within 24 hours of birth (N=1820, 1896, 1784, 1730)

73.5% 79.1% 83.0% 86.5% <0.001 0.348 <0.001

Children 0-2 years of age weighed in the past month (N=1850, 1910, 1827, 1815)

17.8% 22.2% 26.3% 49.8 <0.001 <0.001 <0.001

Children 0-2 years of age who were put to the breast within one hour of birth (N=1843, 1902, 1820, 1807)

67.5% 69.2% 74.8% 66.9% <0.001 0.010 0.031

Children under 6 months of age who are exclusively breastfed (N=455, 450, 431, 412)

62.9% 65.8% 68.9% 56.5% 0.060 0.054 <0.001

Children 12–15 months of age who are breastfed (N=201, 265, 222, 201)

98.5% 99.6% 98.2% 99.5% 0.821 0.271 0.343

Children 6-23 months of age meeting a minimum acceptable diet (N=1385, 1460, 1396, 1403)

37.5% 45.7% 47.2% 47.8% <0.001 0.753 <0.001

Minimum dietary diversity among children 6-23 months of age (eating food from 4 or more of 7 food groups) (N=1385, 1460, 1396, 1403)

46.7% 53.5% 57.5% 60.0% <0.001 0.178 <0.001

Infants 6-8 months of age who received solid, semi-solid or soft foods (N=214, 210, 204, 218)

91.6% 88.1% 92.2% 87.2% 0.848 0.122 0.122

2017 2018 2019 2022 P-value P-value P-value

Mean/% Mean/% Mean/% Mean/% 2017/

2019/

2017/

Breastfed and non-breastfed children 6-23 months of age, who received solid, semi-solid, or soft foods (N=1385, 1460, 1396, 1403)

81.2% 87.8% 85.5% 82.9% 0.004 0.078 0.263

Children 6-23 months of age who received an iron-rich food or iron-fortified food (N=1385, 1460, 1396, 1403)

84.2% 88.6% 89.8% 90.6% <0.001 0.532 <0.001

Children 6-23 months of age who were fed more during illness (N=593, 541, 597, 675)

38.5% 38.8% 35.9% 31.0% 0.342 0.109 0.018

Children younger than 5 years who had diarrhea in the prior two weeks (N=3642, 3648, 3648, 3648)

11.1% 9.1% 9.5% 10.8% 0.062 0.083 0.661

Children 6-23 months of age given oral rehydration solution (ORS) and zinc when sick with diarrhea (N=190, 165, 176, 205)

20.0% 14.6% 19.3% 7.8% 0.859 0.001 <0.001

Households with a child 0-2 years of age who had contact with the FCHV in the previous month (N=1848, 1909, 1826, 1815)

52.5% 58.5% 60.9% 34.5 <0.001 <0.001 <0.001

Water, Sanitation and Hygiene Households using an improved sanitation facility (N=3641, 3647, 3648, 3648

86.7% 88.3% 84.1% 86.4% 0.100 0.213 0.868

Households practicing correct use of household water treatment technologies (N=3629, 3646, 3647, 3648)

14.3% 19.0% 18.4% 28.6% <0.001 <0.001 <0.001

Households with soap and water at a handwashing station commonly used by family members (N=3629, 3646, 3647, 3647)

37.0% 48.5% 61.2% 72.5% <0.001 <0.001 <0.001

Women practicing handwashing at six critical times (N=3640, 3648, 3648, 3648)

7.8% 19.0% 9.8% 16.8% 0.161 <0.001 <0.001

Agriculture/Enhanced Homestead Food Production Households with homestead gardens meeting minimum criteria (N=986, 988, 988, 988)

7.7% 22.3% 22.1% 30.0% <0.001 0.010 <0.001

Households owning chickens (N=986, 988, 988, 988)

42.9% 47.4% 43.4% 44.0% 0.782 0.738 0.645

Number of chickens vaccinated against Newcastle disease (N=423, 468, 429, 435)

1.0 0.1 3.2 20.2 0.215 0.359 0.297

Mean number of nutrient-dense vegetable cultivated by households in previous year (N=986, 988, 988, 988)

8.2 9.9 11.6 14.3 <0.001 <0.001 <0.001

2017 2018 2019 2022 P-value P-value P-value

Mean/% Mean/% Mean/% Mean/% 2017/

2019/

2017/

Households with a child aged 0-2 years who received HFP inputs from village model farmers (VMFs) and/or graduated HFP beneficiaries (N=519, 552, 510, 520)

16.8% 27.2% 21.0% 22.5% 0.127 0.675 0.047

Households who sold surplus vegetable production in the past year (N=986, 988, 988, 988)

20.9% 17.9% 19.9% 18.6% 0.737 0.545 0.485

Mean number of eggs produced in the past month (N=423, 468, 429, 435)

11.3 8.9 12.3 15.8 0.568 0.171 0.108

Households who sold surplus eggs produced in the past month (N=423, 543, 513, 489)

4.3% 2.0% 3.1% 2.9% 0.257 0.767 0.182

Households that used revenue earned by selling HFP surplus for nutrition, in the previous years (N=220, 180, 211, 202)

17.3% 31.1% 21.3% 22.3% 0.373 0.857 0.243

Acronyms ANC Antenatal Care ANM Auxiliary Nurse Midwifery BA Bhanchhin Aama BMI Body Mass Index CBO Community-Based Organization COVID-19 Coronavirus Disease-2019 DAG Disadvantaged Groups DBI EA Digital Broadcast Initiative Equal Access DHS Demographic and Health Surveys EBF Exclusive Breastfeeding EDP External Development Partner EHFP Enhanced Homestead Food Production HFP Homestead Food Production FCHV Female Community Health Volunteer FG Food Group FLW Frontline worker FP Family Planning GESI Gender Equality and Social Inclusion GMP Growth Monitoring and Promotion GoN Government of Nepal GPS Global Positioning System HF Health Facility HFP Homestead Food Production HFPB Homestead Food Production Beneficiaries HH Household HMG Health Mothers’ Group HTSP Healthy Timing and Spacing of Pregnancy IFA Iron and folic acid IR Intermediate Result IYCF Infant and Young Child Feeding MAD Minimum Acceptable Diet MDD Minimum Dietary Diversity MER Monitoring Evaluation and Research MSNP Multi-sector Nutrition Plan NDHS Nepal Demographic and Health Survey NHRC Nepal Health Research Council NPC National Planning Commission ODK Open Data Kit ORS Oral Rehydration Solution PNC postnatal care SBA Skilled Birth Attendance SBCC Social and Behavior Change Communication SMS Short Message Service ToT Training of Trainers USAID United States Agency for International Development VMF Village Model Farmers WASH Water, Sanitation and Hygiene WRA Women of Reproductive Age

1. Background

1.1 Health and nutrition status in Nepal

Nepal has witnessed substantial political, economic, and demographic changes over the last three decades. Years of armed conflict and political instability culminated in the formation of a democratic republic government in 2008. A new constitution was signed in 2015, replacing the interim constitution created in 2007, officially establishing federalism in Nepal. Subsequently, the existing administrative units were restructured to form 77 districts and 7 provinces. Within the districts, rural and urban municipalities were allocated to replace and, in most instances, amalgamate with the former village development committees and municipalities as the first sub-district unit, with wards now being the smallest formal administrative unit. At present, there are a total of 753 local government units (6 metropolitans, 11 sub-metropolitans, 276 urban municipalities, and 460 rural municipalities) and 6743 wards operating in Nepal.

The 2022 NDHS key indicators report indicated that 25% of children under five years of age are stunted, 8% are wasted, and 19% are underweight down from 36% stunting, 10% wasting, and 27% underweight in 2016 NDHS. These impressive results suggest that the collective efforts of the Government of Nepal (GoN) and its partners have paid off. However, despite these achievements, anemia rates remain high with 43% of children under five years of age and 33% of pregnant women being anemic.

The GoN, with support from external development partners (EDPs), is now developing the third phase of its multi-sector nutrition plan (MSNP). EDPs invest heavily in supporting the GoN to address persistent health and nutrition burdens and achieve goals outlined in Nepal’s MSNP, the World Health Assembly and Sustainable Development Goals (SDG) targets. Suaahara II is one such USAID-funded program, with an overall objective to reduce undernutrition among women and children, particularly those in the 1,000-day period between conception and a child’s second birthday, and those belonging to the disadvantaged communities.

1.2 An overview of the Suaahara II project in Nepal

Suaahara II is a USAID-funded multi-sectoral nutrition program implemented in 42 out of Nepal’s 77 districts, in 6 out of the 7 provinces from 2016 to 2023. Suaahara II builds and follows on the first Suaahara project (i.e., Phase 1) implemented from 2011 to 2015. Helen Keller International serves as the prime and lead organization for Suaahara II. It has partnered with six consortium organizations, namely Cooperative for Assistance and Relief Everywhere, Inc. (CARE), Family Health International 360 (FHI360), Digital Broadcast Initiative Equal Access (DBI EA), Environment and Public Health Organization (ENPHO), Nepali Technical Assistance Group (NTAG) and Vijaya Development Resource Center (VDRC) to oversee program implementation.

It has also partnered with a Community-Based Organization (CBO) in each district to implement activities within communities of the 42 districts until December 2022. From January 2023, Helen Keller Intl, together with DBI EA and 14 CBOs, is continuing implementation of Suaahara II -focusing on reducing the negative impact of the hike in food prices and increased inflation caused by the Ukraine-Russian war. Suaahara II covers a total of 389 municipalities (including 262 rural municipalities and 127 urban municipalities) and 3353 wards in Nepal.

The Suaahara II project primarily aims at reducing the prevalence of stunting, wasting, and underweight among children under five years of age, and anemia among WRA and children aged 6-59 months. The program uses a multi-sectoral approach across four key intermediate result (IR) themes: (1) improved household nutrition, sanitation and health behaviors; (2) increased use of quality nutrition and health services by women and children; (3) improved access to diverse and nutrient rich foods by women and children; and (4) improved roll-out of the MSNP through strengthened local governance. Suaahara II activities cover diverse health areas including family planning (FP), nutrition, agriculture/homestead food production (HFP), and water, sanitation and hygiene (WASH). Diverse social and behavior change communication (SBCC) approaches are used, primarily to generate demand for access to improved services. Additional cross-cutting themes for Suaahara II implementation include gender equality and social inclusion (GESI) -targeting women and disadvantaged groups (DAGs); public private partnership (PPP) -encouraging private sector investments to increase access to services and commodities; and monitoring, evaluation, and research (MER) for learning.

1.3 Structure of the report

The first section of the report outlines an overview of the Suaahara II project in Nepal with a contextual background. Section 2 outlines Suaahara II’s 2022 annual survey methods including survey design, sampling and data collection, management and analysis. The results sections include the survey sample (Section 3) and presentation of key findings based on IR themes: IR1

– Nutrition (Section 4); IR1 – WASH (Section 5); IR2 – Health and Family Planning (Section 6);

and IR3 – Agriculture/Homestead Food Production (Section 7). As cross-cutting themes (CCTs), SBCC and GESI activities and outcomes have been discussed in Section 8 and 9 respectively.

The last section of the report includes an assessment of program implications for the third phase of Suaahara project.

2. Annual Monitoring Survey Design

2.1 An overview of survey objectives

As part of Suaahara II’s monitoring, evaluation and research (MER) system, the Suaahara II annual survey tracks key process and outcome indicators, at the individual, household, and health system levels. Such monitoring enables the project to identify implementation gaps and assess program performance in terms of intervention coverage and quality, with a focus on those indicators listed in the key indicator table (pages 6-8). The 2017 annual survey, the first in Suaahara II, had an additional objective of establishing baseline levels and targets for key indicators (including the nutritional status of WRA and children under five years of age) for a representative population of Suaahara II target beneficiaries. The objective of the 2018, 2019 and 2022 annual surveys were to track the progress, or a lack thereof in key indicators.

Each of the Suaahara II annual surveys uses a repeat cross-sectional design involving multi-stage cluster sampling and returning to the same clusters each year. In 2017, 16 districts were randomly selected as survey sites (Figure 1). Surveys were repeated each year in the same districts and clusters, but household sampling was based on a random selection of annually refreshed lists of eligible households in each cluster.

Figure 1 Annual Survey Districts

The Suaahara II annual surveys were approved by the Nepal Health Research Council (NHRC).

A written informed consent was obtained from each respondent included in the survey prior to conducting any interview. Besides, a verbal informed consent to continue the survey was also obtained after the completion of each module in the questionnaire.

2.2 Survey design

2.2.1 Sample size and power calculations

Before the 2017 survey, sample size calculations were done in Stata13 SE, for each of the six-key anthropometric and hemoglobin outcomes: stunting, underweight, and wasting among children under five years of age, anemia in children 6 to 59 months of age, and body mass index (BMI) and anemia in WRA. The Suaahara II team used Suaahara I impact evaluation baseline data (2012) to establish the intra-cluster correlation for each outcome and assumed a desired power of 0.80 in a two-arm cluster-designed study. Using these factors, along with the prevalence from NDHS 2016 and expected change over time, the team calculated the sample sizes needed for each indicator (Table 2.1).

Table 2.1 Sample sizes needed for each indicator, by population type Indicator Population Sample Size Needed Stunting Children <5 years 1728

Underweight Children <5 years 980 Wasting Children <5 years 980 Anemia Children aged 6-59 months 3460

BMI Women aged 15-49 years 2304 Anemia Women aged 15-49 years 3072

Given the need for 3460 children (between 6-59 months of age) for measuring changes in anemia over time, and to allow for refusals, the Suaahara II team decided to include at least 3600 households in the survey, estimating that some households would have a child 0-6 months of age, while others would also have two children.

2.2.2 Sampling methodology

The annual surveys were designed using the new administrative units (e.g., urban and rural municipalities and wards), based on government request given that the transition happened during survey firm training for the first Suaahara II annual survey. The Suaahara II team employed a multi-stage cluster sampling design (Figure 2) with districts as the first-stage sampling unit (n = 16), municipalities as the second-stage sampling unit (1 urban and 1 rural per district, excluding the district headquarter municipality; n = 32), wards as the third-stage sampling unit (3 per municipality, n = 96), “old” wards as the fourth-stage sampling unit (2 per ward, n = 192) as the new wards are too big to be a survey cluster, and households with at least one child under five years of age as the final-stage sampling unit (19 per cluster, n = 3648). The first four stages were conducted using probability proportional to size techniques, based on total population sizes according to the 2011 national census data. For the fifth stage, households with a child under five years of age and his/her mother in residence were selected randomly from a full listing done at the start of the survey field work.

Figure 2 Sampling methodology

Using the list of the districts and number of households per district, sampling interval (k) was obtained by dividing the total number of households in the district. A random number (x) between one and the sampling interval (k) was chosen as the starting point, and the sampling interval (k) was added cumulatively and repeatedly (x+k)th, (x+2k)th, and so on, until the 8 districts were selected in each arm. The same process of listing, sampling interval, and selection was replicated for the municipalities (1 urban and 1 rural per district), wards (3 per municipality) and clusters (2 per ward).

In the selected wards, a list of households was created which contained detailed information about those households having children under five years of age. The detailed information also included the names of the household head and the child’s mother. From the list of all households, a narrowed-down list of households, with a child under five years of age living with his/her mother, was prepared and 19 households were randomly selected for inclusion in the survey, by drawing names out of a hat. In case there was and insufficient number of eligible householdsin a survey cluster, the same procedures were followed in the adjoining (defined as shortest distance from working cluster) cluster (i.e., old “pre-federalism” ward) to select the remaining required households. In 2017, this happened in 17 clusters. Because of it, the same adjoining wards were selected in 2018, 2019 and 2022. Sampled households were also replaced if they were found to have a mother with any kind of disability (e.g., inability to speak), no children within the age range eligible for the survey, or if the mother/child were not available during data collection.

From each selected household, one child under five years of age was further selected as the unit of analysis for the survey. If more than two children under five years of age resided in the same household, the youngest child was selected. The mother of the selected child was the respondent for the mothers’ questionnaire. A primary male household decision maker (or female, in the absence of male household head) was selected for the household questionnaire, with first preference given to the child’s father. In some cases (e.g., if the mother lived alone with the child, or, the mother was the primary household decision maker), the child’s mother answered a shortened version of the household questionnaire. The shortened version of the household questionnaire was prepared to avoid repetition of module questions already included in the mothers’ questionnaire.

1 District (n = 16)

2 Municipalities (n = 16 x 2 = 32)

3 Wards (n = 32 x 3 = 96)

2 Old (Pre-federalism) Wards (n = 96 x 2 = 192)

19 Households (n = 192 x 19 = 3648)

2.3 Survey instruments

2.3.1 Mothers’ questionnaires

The primary respondents of the 2022 survey were mothers with children under five years of age.

Global Positioning System (GPS) coordinates - including altitude, latitude, and longitude of all sampled households - were measured using Garmin eTrex 30x devices.

Figure 3 Questionnaire modules 2022 Women

1. Child health and nutrition practices

a. Child health and childcare

b. Child dietary recall

c. Infant and Young Child Feeding (IYCF) practices

2. Maternal health and nutrition

a. General health seeking practices

b. Antenatal Care (ANC)

c. Delivery and postnatal care (PNC)

3. Maternal dietary recall

a. Food environment

4. Agriculture/homestead food production (HFP)

5. Water, sanitation, and hygiene (WASH)

6. Integrated nutrition knowledge and exposure

7. Suaahara exposure

8. Adolescent mother-specific questions

2.4 Training, fieldwork, and logistics

2.4.1 Training of personnel and testing of survey tools

New ERA recruited a team of 71 field staff, including three quality controllers, 17 supervisors, and 51 enumerators, to make up 17 teams – each team constituting one male supervisor and three female enumerators. The criteria for the selection of field staff included prior work experience in similar kind of surveys (Suaahara Annual Survey 2017, 2018, 2019 or similar), work experience in rural communities, a bachelors’ degree as the minimum qualification requirement, fluency in a local language required for the survey and rapport building skills, and gender, caste/ethnicity and cultural sensitivity. An additional 10% field staff were trained as “backup staff” to ensure continuation of work in the absence or shortage of regular staff. Each field staff’s performance was evaluated during the training and further screened to ensure the selection of qualified and capable field staff for data collection. Further information regarding hired field staff is shown in annex A.

New ERA conducted a training of trainers (ToT) of the quality controllers and supervisors from June 15-20, 2022. This training provided supervisors and quality controllers with a brief overview of the revised tools of 2022 Annual Survey. The ToT helped in detecting inconsistencies and anomalies in the paper-based questionnaires and in the Open Data Kit (ODK) programming.

Supervisors beta-tested the ODK programming for all survey tools in Kageswori Manahara-1, Kathmandu from June 21-22, 2022. Feedback was presented on June 23, 2022, and informed revisions to the surveys in preparation for the main training.

New ERA and Suaahara II staff trained the entire field survey team for 7 days from June 27-July 05, 2022, in order to familiarize the trainees with the survey objectives and tools. Role play and mock interviews with peers were used and the questionnaires were further checked for content, consistency, flow, validity, and reliability. The training included detailed explanations of the survey objectives and design, including multi-stage sampling and selection of households, process of obtaining informed consent and the methods of interviewing. Questions from each module were discussed and skip patterns, filtering, and probing techniques were explained in the training. The field survey team was also trained in how to collect data using Android phones. Roles and responsibilities of the field team members were clearly outlined. Use of quality control techniques by the interviewers, supervisors and the quality control professionals were highlighted. The training also addressed important ethical considerations, including referral of severely malnourished or ill persons; significance of maintaining confidentiality and privacy during the survey; and the importance of obtaining written or verbal informed consent before an interview.

All questionnaires were pre-tested multiple times during the training before the finalization. The 17 teams were sent to 3 different municipalities of Dolakha – Bhimeswor Municipality, Jiri Municipality and Baiteswor Rural Municipality – from June 06-09, 2022, for a pilot test. This pilot test provided data collectors with an opportunity to use the survey tools and equipment in real field settings. The teams tested all the tools including the questionnaires and GPS measurements.

In two days of pre-testing, each male supervisor was assigned to do anthropometry measurement and anemia test; and, each female interviewer was assigned to interview mothers. A review of the pre-test took place on July 10, 2022, with an additional one day of training on July 11, 2022, to address any issues encountered during the pre-test. After pre-testing, the survey tools were again revised and Suaahara II MER team and New ERA re-checked and finalized the revised questionnaire.

2.4.2 Administration of survey questionnaires

After completion of trainings, ethical approvals, and other logistics, data collection was undertaken during the rainy season (July 13-September 10, 2022), adhering with the same timing as previous Suaahara II annual surveys. During the training period, one supervisor and three enumerators left the study team due to personal reasons. Hence, on July 13, 2022, only 16 field teams (of four members) departed for data collection. While supervisors were responsible for collecting biomarker and GPS data, enumerators were responsible for collecting information from mothers of the child younger than five years of age selected for the survey. Only female enumerators were assigned to interview mothers – allowing informants to open up and comfortably discuss potentially sensitive topics.

Each field team was provided with a field schedule before departing to the assigned clusters. As the teams reached each district, they contacted the Suaahara II district office. After consultation with district level authorities (e.g., district health office) and the Suaahara district team, the field teams then moved to the assigned clusters, where they met official municipality authorities again before collecting field information. New ERA core team and Suaahara II MER team members conducted periodic field monitoring and supervision. They also provided feedback on the interviews and verified the consistency and accuracy of the completed questionnaires. The New ERA team conducted their first round of field monitoring visits from July 21 to 25, 2022 in Dhading, Gorkha and Palpa. The second round of visits were conducted in Bajhang, Dadeldhura, Kailali, Bardiya, Salyan, Dang, Rupandehi and Nawalparasi from July 27 to August 02, 2022. The third round of visits were conducted in Dailekh, Salyan, Dang, Sindhupalchowk, Arghakhanchi, Rupandehi and Myagdi. Likewise, the Suaahara II MER team’s field monitoring visit took place from July 25th to 29th, 2022 in Gorkha and Dhading. Fieldwork was completed on September 10, 2022.

2.4.3 Fieldwork challenges

Given how data collection took place annually during the rainy season, conducting Suaahara II annual surveys was always challenging, particularly for the enumerators. Besides being a busy time of year for the farmers, monsoon is also associated with heavy rainfall, floods and landslides, water borne illnesses, etc. Likewise, Nepal’s complex geographical terrain and difficult roads make traveling even more lengthy and arduous during the wet season. For the sixth annual survey, 55 actual days were needed for the conduction of fieldwork because of the harsh weather.

Fieldworkers took longer routes to avoid dangerous conditions, subsequently, causing delays in reaching some clusters. Furthermore, due to difficult geographical terrain and unavailability of mobile network in Sirsha, Dadeldhura, data couldn’t be received on central server every day. Also, two enumerators in Kailali were infected with COVID-19; therefore, they were advised to self-isolate for a certain period.

2.5 Data management

2.5.1 Data entry and cleaning

For the household questionnaires, data was collected on Android phones by the field staff, using Ona, an offline data collection application. Once the data was collected and reviewed by the supervisor, the enumerator synced the data to the Ona server. New ERA and Suaahara II MER staff in Kathmandu had access to the uploaded data. New ERA staff was responsible for downloading the data from the Ona server weekly, checking the quality and consistency of the data, and providing feedback to enumerators, as needed. The New ERA staff recorded all data corrections and subsequently, updated the database and informed the Suaahara II MER team.

Immediately after mobilizing the field teams, a software package for data entry was developed by the data supervisor in New ERA’s central office, for paper-based survey modules (e.g., 24-hour dietary recalls, anthropometric information of children under five years of age and women of reproductive age - 15-49 years). Quality check mechanisms, such as range checks and skip instructions, were developed to help detect errors in data entry. Before data entry, each questionnaire was thoroughly checked by the coders and open-ended questions were coded.

There was some overlap between field work and data management. Paper forms (each labeled by location and cluster number) were transferred from each completed cluster to Kathmandu.

New ERA completed the first round of data cleaning and verification and translated the data into English, where necessary, before sharing the cleaned raw data files in Stata with the Suaahara II MER team on November 30th, 2022, for further data cleaning. The Suaahara II MER team followed standard data cleaning procedures such as range checks and skip patterns, before starting the process of variable generation and tabulations. All data cleaning and variable generation activities were done using StataSE 14 from the first week of October to December 2022. The early findings were shared with thematic program teams in mid-December 2022. The thematic program teams provided feedback regarding additional checks that were needed.

2.5.2 Statistical Analysis

The Suaahara II MER team, supported by an intern from Yale University, conducted the statistical analyses using StataSE 14. The team generated results on means and proportions for the entire survey sample (or sub-sample, where appropriate - for example, by age or geographic area) to examine descriptive trends.

To find out if differences between 2017, 2019, and 2022 were meaningful, the Suaahara II MER team conducted tests of statistical significance for key indicators. Two additional statistical significance comparisons were conducted – between 2019 and 2022 and between 2017 and 2022

– adding to the comparison conducted previously between 2017 and 2019. For these tests of statistical significance, binary logistic regression was used for dichotomous variables, linear regression was used for continuous variables, and ANOVA for variables with multiple categories.

Standard errors were adjusted for sample clustering in all binary logistic or linear regression tests.

Other factors which may influence the differences found (e.g., socio-economic status, age, education) were not adjusted for in this descriptive analysis. Each test of statistical significance provided a p-value. The Suaahara II MER team interpreted p-values greater than or equal to 0.05 to present no significant change. This means that the change between years, whether an increase or a decrease, is not significant and should instead be interpreted as “no change” since it is likely due to chance. Accordingly, p-values less than 0.05 indicated a significant change between years.

Statistical testing was only done on single indicator changes over time and not on disaggregated analyses. For example, the p-value presented for equity quintiles only presents change over time in each quintile. It does not compare the disaggregated categories against each other (i.e., highest quintile vs. lowest quintile).

It is important to note that the Suaahara II annual monitoring survey is designed to collect information on core health and nutrition package to track progress of IR1 and IR2 (and not IR3 and IR4). The questionnaire heavily focuses on tracking and monitoring how the core health and nutrition indicators are performing and responding to Suaahara II interventions corresponding to the two IR-domains (IR1 and IR2). These surveys were not powered to conduct sub-population level analyses and thus, the smaller the sample size, the more challenging it is to confirm statistical significance. Moreover, this is a monitoring survey and not a counter factual. Therefore, attribution of changes to Suaahara II interventions may be plausible but cannot be assumed.

3. Results: Background characteristics The annual survey included 3,642 households in 2017 and 3,648 households in 2018, 2019, and 2022. The survey response rate was 99.8% in the first year and 100% in the following three years.

This section presents survey results of socio-economic and demographic characteristics of the sampled households (Table 3.1) followed by demographic characteristics of the household heads (Table 3.2), mothers (Table 3.3), and the children (Table 3.4).

By using the 2016 Demographic and Health Survey (DHS) data as a reference point, equity quintiles were calculated to understand the socio-economic status of the study population vis-a-vis Nepal’s overall population. To calculate the equity quintile, the household’s ownership of assets and housing characteristics (e.g., roof/wall/floor materials) were used (for further details please see www.equitytool.org). The distribution of households across equity quintiles indicated that the sample mostly represented households belonging to the middle quintile or lower.

However, the distribution has shifted over the years. In 2017, 21.7% of the sample was in the poorest quintile compared to only 9.8% in 2022. Similarly, 26.9% of the sample was in the top two quintiles in 2017 compared to 42.7% in 2022. These shifts indicate improvements in socio-economic well-being in the survey areas. Many more houses have floors, walls, and roofs made of cement in 2022 compared to the first survey (2017). As of 2022, 39.2% of houses had cement floors, 38.3% had cement walls, and 20.3% had cement roofs. Across all four surveys, the primary source of energy for cooking was firewood. However, use of liquefied propane gas increased from 17.1% to 24.4% (Table 3.1).

The two most represented castes in the sample were Brahmin/Chhetri and disadvantaged Janajati in all four surveys. The prevalence of household heads without any formal education declined from 34% in 2017 to 30% in 2022 (P:<0.001) (Table 3.2).

The demographic characteristics of mothers and children showed little variation among the three survey rounds. On average, the mothers were 26 years (Table 3.3) and their youngest child was 26 months in 2022 (Table 3.4).

Agriculture was reported to be the primary occupation for most mothers. However, the proportion declined from 62.6% in 2017 to 49.7% in 2022. Meanwhile, fewer mothers reported having never attended school in 2022 (9.0%) compared with 2017 (21.0%) (P:<0.001); and more mothers reported having completed secondary school (36.2% in 2022 compared with 23.7% in 2017, P:<0.001) (Table 3.3).

Table 3.1 Households’ socio-economic and demographic characteristics

2017 2018 2019 2022 All HH Heads

N=3642 Mean (SD)%

All HH Heads N=3648

Mean (SD)%

All HH Heads N=3648

Mean (SD)%

All HH Heads N=3648

Mean (SD)%

P-value 2017/

P-value 2019/

P-value 2017/

Equity quintile1 Poorest 21.7% 17.1% 16.2% 9.8% <0.001 <0.001 <0.001 2nd Poorest 28.6% 24.8% 22.6% 22.6% <0.001 <0.001 <0.001 Middle 23.2% 24.9% 22.0% 24.9% 0.235 0.007 0.168 2nd Wealthiest 20.3% 24.9% 29.5% 31.3% <0.001 0.082 <0.001 Wealthiest 6.2% 8.3% 9.8% 11.4% <0.001 0.017 <0.001

Housing characteristics:

cement as main material

Floor 18.7% 26.0% 28.5% 39.2% - - -…