Based on these proposed questions, the following outcome measures will be assessed in the study:

  1. GAM prevalence – this will be measured at each study area or cluster using a two-stage spatial sampling design with a target sample size of 192 per study area or cluster. GAM prevalence will be estimated using a bootstrapped PROBIT estimator1 and will be reported for both under 5 children and for pregnant and lactating women (PLW). This outcome measure will be used to answer the core evaluation question.
  2. GAM incidence – this will be measured using a separate cohort sample nested into the overall study design. This will require at least four study areas from which two separate cohorts of children under 5 years (one control group and one intervention group) will be followed over a one year period and then the number of children under 5 years who develop acute malnutrition will be recorded and counted in order to estimate the number of children-years it takes for acute malnutrition to develop in under 5 children in the control and in the intervention groups. This outcome measure will be used to answer the core evaluation question.
  3. Programme coverage – this will be measured as a nested survey in the GAM prevalence surveys. A two-stage spatial sampling design will be used that incorporates a full enumeration of all eligible beneficiaries for all the different MAM intervention and prevention packages in selected sampling villages within the selected study areas or clusters. Eligibility to each of the various MAM treatment and prevention packages will be determined and then various coverage estimators will be assessed. Given that there are multiple intervention components of the MAM treatment and prevention packages, various coverage estimators will be used. Specifically, we will assess the following coverage indicators:
    • MAM case-finding effectiveness for children – this is defined as children 6-59 months who are
      current MAM cases2 in TSFP out of the total number of children 6-59 months who are current MAM cases.
    • MAM treatment coverage for children – this is defined as the children 6-59 months who are current or recovering MAM cases3 in TSFP out of the total children 6-59 months who are current and recovering MAM cases.
    • MAM case-finding effectiveness for PLW – this is defined as PLW who are current MAM cases4 in TSFP out of the total PLW who are current MAM cases.
    • MAM treatment coverage for PLW – this is defined as PLW who are current and recovering MAM cases in TSFP out of the total PLW who are current and recovering MAM cases.
    • Targeted MAM prevention coverage for children – this is defined as children 6-23 months old who are at risk5 in targeted FBPM programme out of all children 6-23 months old who are at risk.
    • Targeted MAM prevention coverage for PLW – this is defined as PLW who are at risk6 in targeted FBPM programme out of all PLW who are at risk.
    • Blanket MAM prevention coverage for children – this is defined as children 6-23 months old in blanket FBPM out of all children 6-23 months old.
    • Blanket MAM prevention coverage for PLW – this is defined as PLW in blanket FBPM out of all PLW.
    • Home fortification coverage – this is defined as children 6-59 months old not eligible for TSFP or FBPM7 receiving home fortification out of all children 6-59 months old not eligible for TSFP or FBPM.
    • SBCC coverage – this is defined as mothers and/or caregivers of children 6-59 months old and PLW who have received or participated in at least 1 appropriate education session and/or individual counselling session in the past month out of the total of mothers and/or caregivers of children 6-59 months old and PLW.
    • Mothers groups coverage – this is defined as mothers and/or caregivers of children 6-59 months old and PLW enrolled in mothers clubs out of the total of mothers and/or caregivers of children 6-59 months old and PLW.
    • Care groups coverage – this is defined as mothers and/or caregivers of children 6-59 months old and PLW enrolled in care groups out of the total of mothers and/or caregivers of children 6-59 months old and PLW.

    In addition to these coverage indicators, we will assess related barriers to access to the interventions by administering a set of questions to those respondents who are eligible to benefit from the different programmes but are not enrolled or admitted into the appropriate programmes. These responses will then be summarised and then used as a basis for a more in-depth but less structured investigation of the reasons for non-coverage to the various components of the MAM prevention package/s. This investigation will be iterative and will engage as broad a set of respondents as possible in informal group discussions, key informant interviews, semi-structured interviews and other similar methods eliciting more nuanced responses regarding the various mechanisms and conditions that either support or hinder access to the programme. Then using triangulation of information and inductive reasoning, a concept map of the relationships and connections between various barriers and reasons for non-coverage is drawn.

    These programme coverage outcome measures will provide the needed metrics to answer the core question and sub-questions 1, 2, 4, 5 and 7.

  4. Programme performance indicators – this will be measured using data from routine programme monitoring collected using pre-defined programme databases created by WFP for each of the different components of the MAM treatment and MAM prevention programmes. For TSFP, the performance indicators are a) cured; b) defaulted; c) non-responder; d) death; and, e) referred to OTP/SC (only for children and not for PLW). For the targeted FBPM, the performance indicators are a) graduated; b) defaulted; c) death; and d) transferred to OTP/SC/SFP.

    These programme performance indicators will provide information needed to answer the core question and sub-questions 2 and 4.

  5. Morbidity – we will assess period prevalence of most common childhood illnesses (i.e., fever, ARI, diarrhoea) based on a two-week recall of the mother or carer of the child. This component will be nested along with the GAM prevalence survey. This measure will help answer the core question and sub-question 7.
  6. Cost-effectiveness – cost measures will be determined and quantified for each of the MAM intervention packages and appropriate cost-effectiveness metrics will be calculated based on these cost calculations. This measure will support in answering the core question and sub-question 6.
  7. Mortality – this will most likely require a specific mortality survey approach that should be designed to be nested within the main prevalence surveys. However, it should be noted that mortality surveys in the context of Sudan involves a lot of political sensitivities which should first be considered before deciding whether to add mortality as an outcome measure. We highly recommend that this measure not be included.
  8. Knowledge, attitude and practices – this will be measured using specifically designed set of questions to be asked of mothers / caregivers of children 6-59 months old and PLW on topics covered by the SBCC component of the programme (i.e., healthy pregnancy, child health and healthcare, breastfeeding, complimentary feeding, dietary diversity, food supplementation, use of micronutrient powder (MNP) and WASH. Wherever possible, standard question sets that have been developed and tested for KAP assessment will be used. Following are some of the standard question sets that we will consider using for this purpose:
    • Healthy pregnancy – assess women of reproductive age (15-49 years old) of their knowledge of pregnancy danger signs. There are 10 pregnancy danger signs. Women of reproductive age (15-49 years old) can be asked to identify pregnancy danger signs that they know of. The number of danger signs they’ve identified correctly are recorded and the mean number of pregnancy danger signs can be used as the summary indicator / measure.
    • Child health and healthcare – mother / caregiver of children 6-59 months will be asked whether their children have had and illness in the past 2 weeks to assess morbidity (#5 above). For those who report as having had an illness, a series of questions on what the mother did in response to the illness will be asked to assess whether or not appropriate healthcare / treatment-seeking behaviour was exhibited by the mother/caregiver.
    • IYCF – standard IYCF question set can be used to assess breastfeeding, complementary feeding and diet diversity8.
    • Women’s dietary diversity – standard diet diversity questionnaire9 will be used to assess the dietary diversity of mothers with children 6-59 months old and PLW.
    • Food supplementation and MNP – we will build upon a set of questions we’ve developed and used for assessment of coverage of, knowledge and practices on the use of complementary food supplements in Eastern Ghana10.
    • WASH – we will use some components of the standard WASH indicator set11 that focus on WASH-related behaviours such as safe disposal of child’s faeces, water treatment practices and hand washing practices and other variations made in relation to WASH behaviours12.

    The abovementioned indicators will measure at the individual level the effects of the SBCC interventions quantitatively (i.e., proportions and means). In addition to this, we will conduct key informant interviews, focused group discussions, semi-structured interviews and case studies of specific target person/s or groups that have been identified as target audiences of the SBCC interventions. These include influential leaders, staff of health services and the community-at-large. The information from these respondents using this method will provide qualitative context to the quantitative information gathered.

    These measures will support in answering the core question and sub-question 4 and 7.

 
 
 

Endnotes

1 Method developed by Brixton Health and Valid International that allows for GAM prevalence estimation at much smaller sample sizes. Documentation available on request.

2 WFP Sudan’s Community-based Nutrition Integrated Programme (CNIP) Field Guide defines MAM cases as children 6-59 months with MUAC ≥ 115mm and < 125mm and no oedema or children 6–59 months discharged from OTP

3 Recovering cases are children whose MUAC is > 125mm but has not met minimum two consecutive visits discharge verification criteria

4 WFP Sudan’s Community-based Nutrition Integrated Programme (CNIP) Field Guide defines acute malnourished PLW as women in their second or third trimester or with a child < 6 months old who have a MUAC < 210mm

5 WFP Sudan’s Community-based Nutrition Integrated Programme (CNIP) Field Guide defines at risk children as children 6-23 months with MUAC ≥ 125mm and < 135mm

6 WFP Sudan’s Community-based Nutrition Integrated Programme (CNIP) Field Guide defines at risk PLW as PLW with MUAC ≥ 210mm < 230mm

7 This includes children discharged from FBPM and children discharged from TSFP where no FBPM exists

8 See World Health Organization. Indicators for Assessing Infant and Young Child Feeding Practices: Conclusions of a Consensus Meeting Held 6–8 November 2007, Washington, DC, 2008; World Health Organization. Indicators for Assessing Infant and Young Child Feeding Practices Part 2: Measurement, Geneva: World Health Organization, 2010; World Health Organization. Indicators for Assessing Infant and Young Child Feeding Practices Part 3: Country Profiles, Geneva: World Health Organization, 2010; and KPC Module 2: Breastfeeding and Infant and Young Child Feeding. 2006 ed., June 29, 2006.

9 Women’s dietary diversity is assessed using a similar questionnaire as the one use for the household dietary diversity. Main difference is that there are questions on certain foods / food groups that are of particular importance to women particularly those of reproductive age. For more information, see Arimond, Mary, Liv Elin Torheim, Maria Joseph Wiesmann, and Alicia Carriquiry. “Dietary Diversity as a Measure of the Micronutrient Adequacy of Women’s Diets: Results From Rural Bangladesh Site,” Food and Nutrition Technical Assistance, Academy for Educational Development, December 2009; Kennedy, Gina, Terri Ballard, and Marie Claude Dop. Guidelines for Measuring Household and Individual Dietary Diversity, Rome: Food and Agricultural Organization, 2011.

10 See Aaron, Grant, Daniel Sarpong, Nicholas Strutt, Katja Siling, Allie Norris, Ernest Ryan Guevarra, and Mark Myatt. “Coverage of a Market-Based Approach to Deliver a Complementary Food Supplement to Infants and Children in Three Districts in Eastern Ghana: Use of the Simple Spatial Survey Method (S3M).” Faseb J 28, no. 1 (April 1, 2014): 255.5.

11 See World Health Organization. Core Questions on Drinking-Water and Sanitation for Household Surveys, Geneva: World Health Organization, 2006

12 See Hernandez, Orlando. Access and Behavioral Outcome Indicators for Water, Sanitation, and Hygiene, Washington, DC: USAID, February 2010.