Strengthening and Evaluating the Preventing Malnutrition in Children under 2 Years of Age Approach Burundi Follow-Up Report: Children Months

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1 Strengthening nd Evluting the Preventing Mlnutrition in Children under 2 Yers of Age Approh Burundi Follow-Up Report: Children 2441 Months Jef L Leroy Celeste Sununtnsuk Jessi Hekert Denn Olney Septemer 2017

2 This report is mde possile y the generous support of the Amerin people through the support of the Offie of Helth, Infetious Diseses, nd Nutrition, Bureu for Glol Helth, U.S. Ageny for Interntionl Development (USAID) nd the Offie of Food for Pee, Bureu for Demory, Conflit nd Humnitrin Assistne, under terms of Coopertive Agreement No. AID OAA A , through the Food nd Nutrition Tehnil Assistne III Projet (FANTA), mnged y FHI 360. The ontents re the responsiility of FHI 360 nd do not neessrily reflet the views of USAID or the United Sttes Government. Septemer 2017 Reommended Cittion Leroy, Jef L.; Sununtnsuk, Celeste; Hekert, Jessi; nd Olney, Denn Strengthening nd Evluting the Preventing Mlnutrition in Children under 2 Approh: Burundi Follow Up Report for Children 2441 Months. Wshington, DC: Food nd Nutrition Tehnil Assistne III Projet (FANTA). Contt Informtion Food nd Nutrition Tehnil Assistne III Projet (FANTA) FHI Connetiut Avenue, NW Wshington, DC T F fntmil@fhi360.org

3 Aknowledgments This pulition would not hve een possile without the work of the Institut de Sttistiques et d Etudes Eonomiques du Burundi (ISTEEBU). In prtiulr, the uthors would like to thnk Niols Ndyishimiye, Noé Nduwike, nd Vénérnd Nizigiyimn of ISTEEBU. We d lso like to thnk Megn Prker, who oversw the seline dt olletion, nd Elyse Iruhiriye, who trined, oordinted, nd supervised fieldworkers t follow-up nd ssisted in trnsltions to filitte dt nlysis. Also instrumentl in the trining proess for the seline survey were the efforts of Leonids Brihut nd Fortunt Ntftiro of Progrmme Ntionl Inte gre d Alimenttion et de l Nutrition (PRONIANUT), Yvette Mpungenge, nd the mny fmilies t Rwgsore medil lini who llowed us to weigh nd mesure their hildren during the nthropometri stndrdiztion proess. For the follow-up survey, we d like to thnk Amp Dogui Ditt nd the ommunity helth workers nd mny fmilies of the Mrmvy zone who llowed us to weigh nd mesure their hildren during trining nd the nthropometri stndrdiztion proess. We d like to thnk the study supervisors, ontrollers, household enumertors, nthropometrists, nd drivers for their hrd work in field onditions tht were often diffiult. The surveys were suessful in lrge prt euse of the tireless efforts of Eliseth Metellus (seline) nd Rémy Lflise (follow-up) in mny tivities, inluding questionnire review, trining, nd fieldwork supervision. Koen Depepe ws instrumentl in writing the Visul Bsi for Applitions ode to rete the sous-olline speifi household listings used y the field tems. Niole Rosenvigue provided invlule lnguge, logistil, nd dministrtive support from the erly plnning stges of the study to the finl steps of dt lening, nlyses, nd write-up. Finlly, we express our grtitude to the ommunity memers, the helth enter stff, nd the fmilies who griously gve their time to nswer our survey questions, without whom this report would not hve een possile. i

4 Contents Contents... ii 1. Introdution Methods Study Setting The Turmure Progrm Turmure Evlution Design nd Study Questions Study Methods Smple Size Smpling Seletion of Index Child Seletion of Colline Leders nd Helth Centers Dt Colletion Field Work Dt Entry nd Clening Dt Anlysis nd Impt Estimtion Results: Colline nd Helth Center Chrteristis Colline Chrteristis Utilities, Infrstruture, nd Aess to Servies Trnsporttion Aess to Shools nd Helth Servies Agriulture Soil Groups, Development Progrms, nd Reent Events Helth Center Chrteristis Infrstruture, Personnel, nd Servies Components of Servies Avilility of Equipment, Medition, nd Supplies Results: Household Chrteristis Household Demogrphy nd Housing Household Assets Results: Mternl Chrteristis Results: Child Chrteristis Results: Turmure Pst Prtiiption Awreness nd Pst Prtiiption in Turmure Pst Prtiiption in Turmure Progrm Ativities Results: Household Post-Progrm Impt Household Hygiene nd Snittion Household Food Seurity, Hunger, nd Dietry Diversity ii

5 9. Results: Mternl Post-Progrm Impt Feeding, Cre, nd Helth Knowledge of Mothers Mternl Diet nd Nutritionl Sttus Results: Child Post-Progrm Impt Child Helth Child Development Child Hemogloin Levels nd Anemi Sttus Child Anthropometry Summry of Findings long the Progrm Impt Pthwys Turmure Progrm Prtiiption The Turmure Food Component The Turmure Helth Component The Turmure Behvior Chnge Communition Component Helth nd Nutrition Knowledge Hygiene nd Snittion Prties Impt on Preventive nd Curtive Cre Seeking nd Child Helth Impt on Mternl Nutrition nd Child Nutrition nd Development Hemogloin Levels nd Anemi Impt on Child Development nd Child Liner growth Referenes Appendix 1. Monthly Rtion Size for the Turmure Benefiiry Popultion Appendix 2. List of Collines ording to Study Tretment Arm Appendix 3. List of Motor Milestones Appendix 4. List of Lnguge Milestones List of Tles Tle 1. omprisons nd reserh questions... 8 Tle 2. Required smple size to mesure impt on height-for-ge z-sore... 9 Tle 3. List of modules inluded in olline questionnire Tle 4. List of modules inluded in helth enter questionnire Tle 5. List of modules inluded in household questionnire Tle 6. List of modules inluded in nthropometry questionnire Tle 7. Ntionl vintion shedule for Burundi Tle 8. Utilities nd infrstruture in eh olline Tle 9. Distne to servies Tle 10. Lol forms of trnsporttion Tle 11. Shool hrteristis Tle 12. Aess to helth servies y olline residents iii

6 Tle 13. Most ommon rops nd vegetles Tle 14. Ten most ommon fruit trees Tle 15. Presene of ssoitions, oopertives, nd other groups Tle 16. Reent historil events experiened y the ollines Tle 17. Most ommon negtive events experiened y ollines during preeding 2 yers...33 Tle 18. Helth enter infrstruture nd personnel Tle 19. Avilility nd frequeny of servies Tle 20. Components of servies for sik hildren Tle 21. Components of servies for pregnnt nd ltting women Tle 22. Lortory servies Tle 23. Mlri-relted servies Tle 24. Avilility of equipment Tle 25. Avilility of meditions nd supplies Tle 26. Chrteristis of households Tle 27. Housing hrteristis Tle 28. Wter nd energy ess Tle 29. Asset ownership Tle 30. Mternl hrteristis nd tivities Tle 31. Child hrteristis Tle 32. Turmure progrm wreness nd pst prtiiption Tle 33. Turmure progrm experienes (mong pst enefiiries) Tle 34. Hygiene nd snittion Tle 35. Hygiene nd snittion: post-progrm impt Tle 36. Sop use Tle 37. Sop use: post-progrm impt Tle 38. Spot hek oservtions Tle 39. Spot hek oservtions: post-progrm impt Tle 40. Household hunger nd dietry diversity Tle 41. Household hunger nd dietry diversity: post-progrm impt Tle 42. Knowledge mong mothers of hildhood illness dnger signs Tle 43. Knowledge mong mothers of hildhood illness dnger signs: post-progrm impt...60 Tle 44. Knowledge mong mothers of feeding prties for sik hildren...61 Tle 45. Knowledge mong mothers of feeding prties for sik hildren: post-progrm impt...62 Tle 46. Brestfeeding knowledge mong mothers Tle 47. Brestfeeding knowledge mong mothers: post-progrm impt Tle 48. Mlnutrition knowledge mong mothers Tle 49. Mlnutrition knowledge mong mothers: post-progrm impt Tle 50. Complementry feeding knowledge mong mothers iv

7 Tle 51. Complementry feeding knowledge mong mothers: post-progrm impt...70 Tle 52. Hygiene knowledge mong mothers Tle 53. Hygiene knowledge mong mothers: post-progrm impt Tle 54. Mternl onsumption nd dietry diversity Tle 55. Mternl onsumption nd dietry diversity: post-progrm impt...75 Tle 56. Anthropometri sttus of mothers Tle 57. Anthropometri sttus of mothers: post-progrm impt Tle 58. Preventive helth re prties Tle 59. Preventive helth re prties: post-progrm impt Tle 60. Child helth nd prevlene of moridity symptoms Tle 61. Child helth nd prevlene of moridity symptoms: post-progrm impt...81 Tle 63. Tretment of illness nd urtive re seeking prties: post-progrm impt...83 Tle 64. Motor nd lnguge milestones ttined Tle 65. Motor nd lnguge milestones ttined: post-progrm impt Tle 66. Child hemogloin levels nd nemi sttus Tle 67. Child hemogloin levels nd nemi sttus: post-progrm impt...88 Tle 68. Child stunting nd wsting Tle 69. Child stunting nd wsting: post-progrm impt List of Figures Figure 1. Allotion of ollines to study rms in Ruyigi nd Cnkuzo v

8 Arevitions nd Aronyms BCC BCG BMI m CRS CSB DHS dl DPT DRC EICV FANTA FFP g HAZ H HDDS HFIAS HepB HHS HiB HIV IFPRI IMC INSP ISTEEBU IU kg km km 2 m mm NGO ehvior hnge ommunition Bille Clmette-Guérin (tuerulosis vine) ody mss index entimeter(s) Ctholi Relief Servies orn-soy lend Demogrphi nd Helth Survey deiliter(s) diphtheri, pertussis, nd tetnus (vine) Demorti Repuli of the Congo Enquête Intégrle sur les Conditions de Vie des Ménges Food nd Nutrition Tehnil Assistne III Projet Offie of Food for Pee grm(s) height-for-ge z-sore hemogloin Household Dietry Diversity Sle Household Food Inseurity Aess Sle heptitis B virus (vine) Household Hunger Sle hemophilus influenz B (vine) humn immunodefiieny virus Interntionl Food Poliy Reserh Institute Interntionl Medil Corps Institut Ntionl de Snté Pulique Institut de Sttistiques et d Etudes Eonomiques du Burundi interntionl unit(s) kilogrm(s) kilometer(s) squre kilometer(s) meter(s) millimeter(s) nongovernmentl orgniztion vi

9 ORS orl rehydrtion slts PM2A Preventing Mlnutrition in Children under 2 Approh SD stndrd devition SE stndrd error SRQ-20 self-report questionnire T18 Turmure 18 T24 Turmure 24 THP Turmure helth promoter TNFP Turmure no food during pregnny U.S. United Sttes USAID U.S. Ageny for Interntionl Development WHO World Helth Orgniztion vii

10 Exeutive Summry Turmure, U.S. Ageny for Interntionl Development (USAID) multi-yer development food ssistne projet, ws implemented y onsortium of nongovernmentl orgniztions in estern Burundi from 2010 to The projet s im ws to improve the helth nd nutritionl sttus of pregnnt nd ltting women nd hildren under 2 yers of ge through three ore omponents: distriution of food rtions, prtiiption in ehvior hnge ommunition (BCC) sessions delivered vi re groups, nd ttendne t preventive helth servies. A omprehensive reserh progrm onduted y the Interntionl Food Poliy Reserh Institute in ollortion with the onsortium of nongovernmentl orgniztions implementing Turmure, nd with funding from the Offie of Food for Pee t USAID through the Food nd Nutrition Tehnil Assistne III Projet (FANTA), ws integrted into the Turmure projet. The impt of Turmure ws evluted vi luster-rndomized ontrolled tril with three tretment rms. Benefiiries in the three tretment rms reeived food rtions for vrying durtions to test the optiml length of provisions: from 4 months gesttionl ge until the hild is 24 months old (referred to s the T24 rm), from 4 months gesttionl ge until the hild is 18 months old (T18), nd from irth until the hild is 24 months old (TNFP). The progrm s impt ws ssessed using three ross-setionl surveys (onduted in 2010, 2012, nd 2014). The first ross-setionl study provided seline referene. The 2012 follow-up survey ssessed the impt of Turmure following pproximtely 2 yers of progrm implementtion on hildren 023 months of ge. The orresponding report foused on outomes suh s mternl knowledge regrding helth nd nutrition-relted prties, inluding infnt nd young hild feeding prties (Leroy et l. 2014). The urrent report summrizes the findings of the 2014 survey. None of the households in the 2014 follow-up were urrent enefiiries, s the progrm ended 1 month efore the follow-up survey strted. The ojetive of the survey ws thus to ssess the lsting impt of the progrm fter the progrm ended. We refer to this impt s the post-progrm impt. The 2014 survey foused on (households with) hildren 2441 months of ge the group of hildren exposed to Turmure onsistently from erly pregnny to 24 months of ge. The lrgest progrm impt on hild liner growth (the min mesure of nutritionl sttus) ws expeted to e oserved in this ge group. The impt on hild liner growth in this report thus reflets the full, umultive effet of the progrm s impt. The food omponent of the Turmure (rtions of orn-soy lend 1 nd fortified vegetle oil) ws expeted to inrese household vilility of mironutrient-rih food nd, in turn, onsumption of suh foods nd to improve diet diversity. The 2012 survey found tht prtiiption in food distriution ws high mong those eligile. Turmure s BCC strtegy ws designed to inrese helth, hygiene, nd nutrition knowledge nd to promote the doption of est prties. The BCC omponent ws implemented through prtiiption in re groups tht were direted y leder mothers who were lso progrm enefiiries. Cre group prtiiption, s ssessed in the 2012 survey, ws low (Leroy et l. 2014). A proess evlution onduted in Deemer 2011 nd Jnury 2012 reveled tht leder mothers hd limited tehnil expertise nd tehing skill nd tht lrge proportion of progrm enefiiries were not exposed to the module on omplementry feeding sine it ws rolled out lte (Olney et l. 2013). The progrm s third omponent foused on helth nd ws designed to improve the provision of preventive nd urtive helth servies y helth stff (y providing trining for helth stff nd some key 1 While most FFP development ssistne projets swithed to CSB+ (whih hs n upgrded mro- nd mironutrient formultion) y 2012, the Turmure projet ontinued to use the older formultion of CSB to preserve the study s integrity. 1

11 supplies) nd to inrese utiliztion of these servies y pregnnt nd ltting women nd hildren under 24 months of ge. The 2014 survey found tht Turmure hd lrge positive post-progrm effet on household ess to food. Smll, ut signifint, positive post-progrm effets were lso found for household nd mothers onsumption of more diverse diet. The post-progrm impt on mothers knowledge ws mixed. The progrm hd positive post-progrm impt on mothers knowledge in the re of optiml hild feeding prties. Turmure hd smll positive post-progrm effet on limited numer of household hygiene nd snittion prties. No postprogrm effet ws found on preventive helth re utiliztion. Even fter the progrm hd ended, protetive effet on hild moridity ws oserved from seline to follow-up, ut no post-progrm effet on urtive re-seeking ehviors ws oserved. Beuse of the smll numer of helth enters, no forml impt evlution of the vilility of servies nd supplies ws onduted. Helth enters were found to e etter equipped nd etter stffed to re for expeting mothers nd young hildren t follow-up (s ompred with seline). Helth edution nd servies ville for sik hildren nd hildren with dirrhe improved drmtilly. However, shortges of selet immuniztions nd meditions were not unommon. 2 An lrming finding ws the steep inrese in the prevlene of nemi in mothers (y out 12 perentge points) nd hildren (y out 9 perentge points) from 2010 to The intervention did not hve post-progrm effet on men levels of hemogloin or nemi. The progrm hd positive post-progrm effet on hild development: Turmure ws found to hve n overll positive post-progrm effet on the highest lnguge milestone hieved mong hildren 2429 months; the post-progrm impt on the highest motor milestone hieved ws limited to hildren 2429 months in the T24 group. The seond follow-up survey found steep inrese in the lredy high prevlene of stunting in the ontrol group from 2010 to 2014 (from 68.2 perent to 74.8 perent). Turmure hd lrge postprogrm protetive effet on stunting of 5.5 perentge points (ll tretment groups omined). The lrgest effet ws found in the T24 group (7.1 perentge points). The effets in the other tretment groups were smller nd did not reh sttistil signifine. The entrl reserh question of the Burundi study ws to determine the optiml progrm durtion to improve liner growth. Our findings thus suggest tht progrm exposure from pregnny to 24 months ws neessry for impt on liner growth in the enefiiry popultion in Burundi. It seems plusile tht Turmure s effet on improving infnt nd young hild feeding prties (i.e., minimum reommended numer of mels, perentge of hildren reeiving the minimum dietry diversity, perentge of hildren onsuming minimlly eptle diet) nd on reduing hild moridity (whih we doumented in the first follow-up report) (Leroy et l. 2014) ontriuted to this liner growth impt. 2 Note tht Turmure, under the USAID Offie of Food for Pee guidelines, ws not le to purhse immuniztions or meditions. 2

12 1. Introdution This report presents the findings from the seond follow-up survey for the impt evlution of Turmure, Preventing Mlnutrition in Children under 2 Approh (PM2A) progrm, whih ws implemented in estern Burundi. 3 This report ssesses the impt of the progrm on hildren 2441 months of ge hildren whose first 1,000 dys of life (from oneption to 24 months of ge, during whih they were eligile to prtiipte in the progrm) fell entirely within the progrm implementtion period. Turmure ws U.S. Ageny for Interntionl Development (USAID) development food ssistne progrm (formerly lled Multi-Yer Assistne Progrm, or MYAP) funded y the Offie of Food for Pee (FFP) with Title II resoures. The ojetives were to improve the helth nd nutritionl sttus of pregnnt nd ltting women nd hildren under 2 yers of ge nd to strengthen the qulity nd delivery of helth re servies. The progrm hd three ore omponents: distriution of fmily nd individul food rtions; ehvior hnge ommunition (BCC) sessions foused on improving helth nd nutritionrelted ehviors; nd promotion of preventive nd urtive helth servies for pregnnt nd ltting women nd hildren under 2 yers of ge. A onsortium of nongovernmentl orgniztions (NGOs) led y Ctholi Relief Servies (CRS) nd omposed of the Interntionl Medil Corps (IMC), Food for the Hungry, nd CARITAS Burundi implemented the progrm. A omprehensive reserh progrm onduted y the Interntionl Food Poliy Reserh Institute (IFPRI) in ollortion with the onsortium of NGOs nd with funding from the USAID FFP through the Food nd Nutrition Tehnil Assistne Projet (FANTA) ws integrted into the Turmure progrm. The overll ojetive of the reserh ws to ssess the impt nd ost-effetiveness of Turmure on hild nutritionl sttus, s well s to evlute the differentil nd solute impt of vrying the durtion of reeiving food rtions. The study lso sought to evlute the impt of the progrm on numer of other household, mternl, nd hild outomes, suh s household hunger, infnt nd young hild feeding prties, helth-seeking prties, mternl levels of hemogloin (H) nd nemi, hildren s moridity symptoms, hildren s levels of H nd nemi, nd hildren s lnguge nd motor development. Extensive proess evlution reserh ws lso onduted to understnd progrm delivery nd utiliztion (Olney et l. 2013). In totl, three ross-setionl surveys onduted from Otoer to Deemer in 2010, 2012, nd 2014 were used to ssess the progrm s impt. The first ross-setionl study provided seline referene nd is summrized in prior report (Prker et l. 2012). The seond ross-setionl study evluted the progrmmti impt on hildren 023 months 4 (Leroy et l. 2014). The urrent report uses the results of the third ross-setionl study, whih evluted the impt in hildren 2441 months nd their mothers. 3 A study onduted in Hiti nd funded y USAID through the Food nd Nutrition Tehnil Assistne Projet (FANTA) ws the first rigorous evlution onduted under rel progrmmti onditions tht showed tht the lnket trgeting of foodssisted mternl nd hild helth nd nutrition progrm to ll hildren 624 months of ge (preventive pproh) ws more effetive t reduing the ommunity prevlene of stunting, wsting, nd eing underweight thn the trditionl pproh sed on trgeting underweight hildren (weight-for-ge z-sore < 2) (reupertive pproh). Bsed on the evidene from Hiti, the USAID Offie of Food for Pee (FFP) invited proposls to replite the preventive pproh (PM2A) in two other ountries: Guteml nd Burundi. The two ountries were seleted euse of their exessively high levels of hild stunting. FANTA onsidered tht it would e importnt to inorporte strong tion-oriented reserh nd development progrm linked to the implementtion of PM2A in the two ountries, to llow lerning nd refinement of the pproh nd to generte lessons lerned for future PM2A progrmming. 4 For ese of referene, we use 023 months for hildren months of ge nd 2441 months for hildren months of ge in the reminder of the text. 3

13 The reminder of this report is strutured s follows. Setion 2 presents the study methods. Helth enter nd olline 5 hrteristis re presented in Setion 3. The household, mternl, nd hild hrteristis re presented in Setions 4, 5, nd 6, respetively. Setion 7 presents informtion on pst Turmure prtiiption. Setions 8, 9, nd 10 follow with results on progrmmti impt t the household, mother, nd hild levels, respetively. Setion 11 onludes with disussion of the results. 5 Colline is the smllest dministrtive sudivision in Burundi. 4

14 2. Methods 2.1 Study Setting Burundi is one of the 10 poorest ountries in the world (United Ntions Development Progrmme 2015). The ountry is loted in the Gret Lkes region of Est Afri, ordered y the Demorti Repuli of the Congo (DRC), Rwnd, nd Tnzni. With pproximtely 10.8 million people living on 25,680 km 2 of lnd, Burundi is one of the most densely populted Afrin ountries (World Bnk 2016). Approximtely 84 perent of the popultion lives elow the interntionl poverty line of US$1.90 per dy (World Bnk 2016). Eighty-eight perent of the popultion lives in rurl res nd more thn 90 perent of the lor fore is employed in griulture (Centrl Intelligene Ageny 2016). The mjority of rurl households depend lmost entirely on smll-sle susistene frming (Interntionl Fund for Agriulturl Development 2012). Rpid popultion growth (estimted t 3.3 perent in 2014) hs ontinued to frgment household frming res, resulting in deline in verge household holdings from 0.7 hetres in 1989 to 0.5 hetres in 2009 (Interntionl Monetry Fund 2012; World Bnk 2016). The most ommonly produed food rops re nns, sweet pottoes, ssv, ens, nd mize. Reurrent droughts, delining soil fertility, nd insuffiient investment in the griulturl setor hve ontriuted to delines in griulturl produtivity nd inresed food inseurity for rurl popultions (Interntionl Monetry Fund 2012). The Turmure progrm ws implemented in the estern provines of Cnkuzo nd Ruyigi, loted long the order with Tnzni. These provines re mong the poorest of Burundi s 17 provines nd re predominntly rurl. Aording to the 2010 Demogrphi nd Helth Survey (DHS), 6 the entrl-estern provines hve the gretest prevlene of stunting (62 perent) nd eing underweight (33 perent) (Institut de Sttistiques et d Etudes Eonomiques du Burundi [ISTEEBU] nd l Institut Ntionl de Snté Pulique [INSP] 2011). Mironutrient defiienies re ommon: nemi prevlene in these provines is pproximtely 44 perent mong hildren 659 months nd 18 perent mong pregnnt women; in 2005, more thn one-qurter of hildren 659 months nd 12 perent of pregnnt women were vitmin A defiient (serum retinol <0.7 µmol/l) despite lrge-sle distriutions of vitmin A supplements y the Expnded Progrm of Vintion (World Helth Orgniztion [WHO] 2009; ISTEEBU nd INSP 2011). 2.2 The Turmure Progrm Women were invited to enroll in the Turmure progrm when they were pregnnt (usully t or fter the fourth month of gesttion 7 ). Turmure inluded three ore omponents 8 : reeipt of food rtions, ttendne t preventive helth servies, nd prtiiption in BCC strtegy. The progrm omponents re desried in more detil elow. Food omponent. 9 The food omponent of the Turmure progrm ws expeted to inrese household vilility of mironutrient-rih food nd, in turn, onsumption of suh foods nd improved dietry diversity. To hieve these gols, ll Turmure enefiiries reeived monthly household food rtion 6 Results for the more reent 2015 DHS re not yet pulilly ville. 7 At the eginning of the progrm, women ould enroll in the progrm s soon s they found out they were pregnnt (if they hd proof from pregnny test from helth enter). However, urine shring eme ommon. The stndrd ws hnged to enroll women into the progrm if they hd proof from pregnny test from helth enter nd if they were showing, whih ws usully round the fourth month of pregnny. 8 FFP limited the fous of the projet to the three min res nd did not fund suh interventions s griulturl prodution, livelihoods/inome genertion, home grdens, nd svings/lending groups. 9 Using privte funds, CRS lter dded home grdening nd niml-rising omponent. Sine these tivities were not prt of the Turmure progrm t the time of the seline survey, dt on these outomes were not olleted. 5

15 omposed of 12 kg of orn-soy lend (CSB) nd 1,200 g of fortified vegetle oil (see Appendix 1). This rtion ws distriuted to the enefiiry, ut intended for household onsumption. In ddition to the household rtion, n individul rtion ws distriuted for the enefiiry: pregnnt or ltting womn (05 months postprtum) reeived 6 kg of CSB nd 600 g of oil, nd hild 623 months reeived 3 kg of CSB nd 300 g of oil. From the time of enrollment up to the moment the hild rehed 6 months of ge, the enefiiry mother reeived the monthly individul rtion. When the hild ws 6 months (the ge t whih it is reommended to introdue omplementry foods), the mother s individul rtion ws disontinued nd the hild egn reeiving monthly individul rtion until she or he grduted from the progrm (t 24 months of ge). Helth omponent. 10 The helth omponent ws designed to improve the provision of preventive nd urtive helth servies t lol helth enters nd to inrese utiliztion of these servies y pregnnt nd ltting women nd y hildren 023 months of ge. The improved provision nd inresed utiliztion of these servies were expeted to ontriute to improvements in mternl nd hild helth outomes. The Turmure progrm strengthened existing helth servies through trining helth stff 11, s well s y providing key supplies for implementing helth servies. Helth supplies inluded equipment for prentl re (e.g., vginl speulum, Pinrd ostetri stethosope), lor nd delivery (e.g., delivery tle), growth monitoring (e.g., slter sle, infnt sle), nd urtive re (e.g., thermometer, sterile equipment). In ddition, the Turmure progrm through the BCC strtegy sri the utiliztion of preventive nd urtive helth servies y pregnnt nd ltting women (pre- nd postntl servies, respetively) nd hildren 023 months (growth monitoring nd promotion). Benefiiry mothers nd hildren were expeted to ttend nd use reommended preventive helth servies t the lol helth enter. These inluded pre- nd postntl hek-ups for women nd growth monitoring nd vintions for hildren. Behvior hnge ommunition omponent. Turmure s BCC strtegy enourged the doption of est prties in helth, hygiene, nd nutrition nd ws designed speifilly to ddress mny of the underlying uses of undernutrition in Burundi. The BCC strtegy ws implemented y CRS nd Food for the Hungry stff memers nd lolly hired Turmure helth promoters (THPs). Groups of leder mothers, who were progrm enefiiries seleted y fellow enefiiry mothers, were first trined y THP during leder mother re groups. The leder mother re groups were held every 2 weeks. The leder mother in turn tught her fellow enefiiry mothers on the helth, hygiene, nd nutrition topis tht she hd most reently lerned from the THP; she did this during enefiiry mother re groups, whih lso met every 2 weeks. The urriulum ontined five modules, eh with etween 6 nd 12 lessons. 10 The progrm followed USAID s FFP guidelines regrding dmissile helth expenses s per FFP Responses to PM2A Guidelines Questions nd Comments Jnury 22, 2009 whih stted Admissile expenses re the sme s those listed in the Food for Pee At Title II Guidne. FFP expets progrms to leverge resoures from third prties to omplement the resoures provided for the PM2A tht nnot e purhsed using Title II resoures y linking with existing helth servies. Plese review the new FFPIB 08-03: Eligile Uses of Setion 202e nd ITSH funding udget mtrix found t 11 IMC provinil tehnil ssistnts provided medil trining for two nurses nd two nurses ssistnts working within eh distrit helth enter nd two dotors working within eh distrit hospitl. IMC lrgely foused its efforts on trining nurses nd prmedis working in the helth enters euse they were the frontline stff for eh ommunity. They reeived nnul trining on prentl re, postntl re, growth monitoring nd promotion, integrted mngement of hildhood illness, nd ommunity mngement of ute mlnutrition. IMC lso trined the provinil nd distrit helth offiers to monitor helth re tivities within the helth enters nd hospitls to ensure tht servies were implemented ording to the omponents of the IMC trining. 6

16 Module 1 Cre Group Orienttion six lessons on the progrm s ojetives, tehing tehniques, leder mother responsiilities, wthing for hnge nd monitoring groups, the vlue of hildren, nd the ility to hnge. Module 2 Essentil Nutrition, Hygiene, nd Cre Prties during Pregnny nine lessons on ntentl re servies nd developing irthing pln, mternl nutrition, mironutrients (iron nd iodine), hndwshing with sop (or sh), retion of household hndwshing sttions, mlri prevention, prepring for delivery nd irth, immedite restfeeding nd the use of olostrum, nd neworn re prties. Module 3 Essentil Nutrition, Hygiene, nd Cre Prties during Infny (first prt) 12 lessons on the importne of postprtum re, vrious spets of exlusive restfeeding, hildhood illness dnger signs, overoming restfeeding prolems, growth monitoring nd promotion, men s involvement in restfeeding nd hild re, hild sping, point-of-use wter tretment nd sfe wter soures, proper disposl of fees, mlri trnsmission nd prevention, mlril dnger signs nd tretment, nd home re. Module 4 Essentil Nutrition, Hygiene, nd Cre Prties during Infny (seond prt) seven lessons lrgely foused on nutrition, inluding omplementry feeding for hildren 68 months of ge, 911 months of ge, nd 1223 months ge; prepring CSB with lol foods; the importne of vitmin A nd good food soures of vitmin A; worms nd deworming medition; nd prepring, ooking, nd storing foods. Module 5 Mngement of Childhood Infetions six lessons relted to the signs nd dngers of hild dehydrtion, dehydrtion prevention using orl rehydrtion slts (ORS), proper feeding of sik hildren, dysentery nd persistent dirrhe, pneumoni prevention, nd developing kithen grden. In ddition to the ollines prtiipting in the evlution study (see next setion), the Turmure progrm ws implemented ross ll ollines in Cnkuzo nd Ruyigi. Enrollment in the Turmure progrm in the non-study ollines strted in June The enrollment of new enefiiries ended in Otoer Progrm enrollment in the study ollines did not strt until Jnury 2011 (i.e., fter the seline survey, see elow) nd ontinued until Otoer The provision of progrm enefits ontinued in the non-study ollines until April 2014 nd in the study ollines until Septemer Turmure Evlution Design nd Study Questions For the purposes of the IFPRI-led reserh on Turmure, 60 study ollines were rndomly ssigned to one of four study rms, whih differed primrily y timing nd durtion of food rtions, to test the optiml length of provisions provided y the PM2A progrm: Turmure 24 (T24): the full Turmure progrm, inluding BCC, preventive nd urtive helth servies, nd food rtions (individul nd fmily) during pregnny nd lttion for the mother nd for her hild up to ge 24 months. Turmure 18 (T18): the full Turmure progrm, inluding BCC, preventive nd urtive helth servies, nd food rtions (individul nd fmily) during pregnny nd lttion for the mother nd for her hild up to ge 18 months. Turmure no food during pregnny (TNFP): the full Turmure progrm, inluding BCC, preventive nd urtive helth servies, nd food rtions (individul nd fmily) strting fter the irth of the hild, for the mother nd for her hild up to ge 24 months. Control: the Turmure progrm not provided to these households; however, households ould still ess preventive nd urtive servies. 7

17 The Turmure helth strengthening tivities (trining for helth stff nd the provision of key supplies for preventive nd urtive helth servies) were implemented in ll helth enters throughout Cnkuzo nd Ruyigi, regrdless of whether they were loted in one of the tretment or ontrol ollines. 12 These tivities my thus hve hd positive impt on helth-relted outomes in ll study rms, inluding the ontrol group. The proposed omprison groups nd how they relte to the speifi reserh questions re shown in Tle 1. Tle 1. omprisons nd reserh questions Compred to Reserh question T24 TNFP T18 TNFP T18 Control Control Control T24 T24 Wht is the impt of Turmure (ompred to ontrol group) on hild nutritionl sttus? Wht is the impt of Turmure without food rtions during pregnny (individul + fmily) on hild nutritionl sttus? Wht is the impt of reeiving Turmure food rtions only up to the ge of 18 months on hild nutritionl sttus? Wht is the differentil impt of Turmure without food rtions during pregnny (individul + fmily) vs. Turmure? Wht is the differentil impt of reeiving Turmure up to the ge of 18 months vs. reeiving it up to the ge of 24 months? All reserh proedures involving humn sujets were pproved y IFPRI s institutionl review ord, nd the study ws pproved y the Ministry of Helth in Burundi. Verl informed onsent ws otined from the primry household respondent efore the strt of eh interview t seline nd follow-up. 2.4 Study Methods The min outome of the study ws hild nutritionl sttus. The lrgest progrm impt on hild liner growth (the min mesure of nutritionl sttus) ws expeted to e oserved in hildren exposed to Turmure onsistently from erly in-utero to 23 months of ge. The first group of hildren to meet this ondition were 2441 months of ge in Otoer to Deemer 2014 (i.e., 4 yers fter the seline survey, rried out from Otoer to Deemer 2010), when the survey for this report ws onduted. None of the households in this survey were urrent enefiiries, s the progrm hd ended 1 month efore the strt of the survey. The impt on hild liner growth in this report thus reflets the full, umultive effet of the progrm s impt. The impt on other outomes (suh s knowledge, helth prties, nd dietry diversity) reflet the lsting impt of the progrm fter the progrm ended. We refer to this impt in this report s the post-progrm impt. For the short-term or immedite impt on these outomes, we refer reders to the report of the 2012 follow-up survey (Leroy et l. 2014). To redue rell is, these outomes were ssessed mong mothers of hildren 023 months of ge in 2012, when the progrm ws still eing implemented Smple Size Smple size lultions for hildren 2441 months of ge were sed on the estimted progrm impt on height-for-ge z-sore (HAZ) nd stunting using the differenes expeted to e found t follow-up etween the three intervention groups nd the ontrol (first three study questions in Tle 1), etween 12 Not every olline hs helth enter. (Of the 60 ollines in the study smple, only 13 hd helth enter.) As onsequene, the helth strengthening tivities ould not e rndomized. 8

18 T24 nd T18 (fourth reserh question), nd etween T24 nd TNFP (fifth reserh question). One-sided test ssumptions were used when ler priori ssumptions out the diretion of the effet were justified. The required smple size in eh study rm is shown elow (Tle 2). The smple size ws lulted with the following prmeters: 0.05 proility of type I error, power of 0.90, nd intrluster orreltions of for stunting nd for HAZ. Tle 2. Required smple size to mesure impt on height for ge z sore T24 T18 TNFP Control 13 Age (months) Minimum smple size required (y ge) 1,000 1,000 1, Smpling To systemtilly selet the reserh ollines, the 210 ollines meeting ertin popultion nd primry helth re provision riteri were rnked ording to popultion size nd divided into five strt (sed on popultion size) in Cnkuzo (13 or 14 ollines per strtum) nd 10 strt in Ruyigi (14 or 15 ollines per strtum). The numer of strt per provine ws sed on the reltive popultion size. Within eh strtum, four ollines were seleted using rndom numers with fixed rndom numer seed in Stt version 11 (SttCorp 2009). The four ollines in eh strtum were then eh ssigned rndomly to one of the four study rms in puli event orgnized for oth study provines in the dministrtive enter of Ruyigi on Jnury 25, The list of seleted ollines nd how they were ssigned to the study rms is shown in Appendix 2. The rndom llotion of study ollines is shown in Figure 1. A household ensus ws onduted in the 60 reserh ollines to generte omplete list of households (with hildren under 60 months of ge t seline nd 1260 months of ge t follow-up) efore the strt of oth the seline nd follow-up surveys (Otoer of 2010 nd 2014, respetively). An enumertor visited eh household in the 60 reserh ollines to inquire if there ws hild meeting the ge requirement. The following informtion ws reorded on pre-numered ensus sheet if the household met the requirement: the sous-olline 14 where the household lived, the first nd lst nmes of the hed of household, nd the household size. The hed of the household ws given pre-printed slip with unique numer orresponding to the numer on the ensus sheet. After ll households were identified nd reorded, the dt were entered nd trnsferred to IFPRI. Using the household ensus dt, the trget smple sizes for hildren 2441 months of ge (seline nd 2014 follow-up) were lulted for eh sous-olline. At seline, the trget smple size for eh sousolline ws lulted y first dividing the totl numer of households with hild under 5 yers in eh sous-olline y the totl numer of households with hild under 5 yers ross the 15 ollines of the respetive study rm. The trget smple size ws then lulted for the 2441 month ge group in eh sous-olline y multiplying the sous-olline-speifi proportion y the rm- nd ge group-speifi smple size needed. The sme proedure ws used t follow-up to lulte the numer of hildren 2441 months to e smpled. A list of the potentil households to e surveyed ws generted for the field tem in eh of the sousollines. Eh sous-olline-speifi list showed the lotion identifiers nd the totl numer of households 13 The smller smple size requirement in the ontrol group ws onsequene of the ft tht the expeted differene etween the tretment rms nd the ontrol ws lrger thn tht etween the different tretment rms. 14 Eh olline is divided into numer of sous-ollines. 9

19 to e visited. Eh list further showed the (rndomly ordered) households with hild potentilly meeting the ge riteri. The supervisor of eh field tem ws instruted to visit households in the order tht they were listed until the required smple size ws rehed. Households were revisited when the respondent ws not ville. Figure 1. Allotion of ollines to study rms in Ruyigi nd Cnkuzo T24 Tretment 1 T18 Tretment 2 TNFP Tretment 3 Control Regulr progrm Seletion of Index Child At seline, if there ws only one hild under 42 months of ge in the household, tht hild ws designted s the index hild. If there ws more thn one hild under 42 months of ge, the hildren s first nmes were lphetized, nd the first hild on the list ws seleted s the index hild. 15 At the 2014 follow-up, households were inluded in the smple sed on hving hild 2441 months of ge. If there ws more thn one hild 2441 months of ge, the hildren s first nmes were lphetized, nd the first hild on the list ws seleted s the index hild Seletion of Colline Leders nd Helth Centers Dt were olleted from group of leders in eh olline nd from ll puli helth enters loted in reserh olline. Severl ommunity leders in eh olline were invited to meet to omplete the ollinelevel questionnire. A survey tem memer helped the group ollortively omplete the olline-level questionnire. The olline-level interviews were onduted t oth seline nd the 2014 follow-up. After 15 At seline, it ws determined tht mothers with two hildren 041 months of ge would e interviewed only out one hild, for two resons. First, we wnted to redue the respondent urden to the extent possile. Seond, lengthy surveys n led to poorer dt qulity (United Ntions Deprtment of Eonomi nd Soil Affirs Sttistis Division 2005). 16 The prevlene of multiple hildren 2441 months of ge ws low (2 perent). No weights were used in the nlyses. 10

20 the ompletion of olline-level interviews t the 2014 follow-up, questionnires for six ollines were stolen in the field. Thus, dt for only 54 ollines re presented t follow-up. All puli helth enters loted within eh of the 60 reserh ollines were invited to e interviewed. At seline, the study tem identified 13 puli helth enters in the reserh ollines. A memer of the nthropometry tem interviewed memer (or multiple memers) of the stff ple of ompleting the survey t eh enter. It ws lter determined tht one of the puttive helth enters ws tully hospitl, nd it ws therefore not revisited t follow-up. Additionlly, personnel from one enter did not gree to n interview t follow-up. Thus, the desription of helth enters is sed on the 11 helth enters for whih we hve oth seline nd follow-up dt. The smple sizes for the evlution were lulted to detet meningful hnges in hild HAZ mesured t the individul level. The study ws not powered to detet meningful hnges t the helth enter or olline level. Therefore, these dt re minly intended to e desriptive Dt Colletion Dt were olleted t the olline, helth enter, nd household levels, using pretested questionnires. The list of modules inluded within eh of the questionnires, s well s rief module desriptions, re presented in Tles 3, 4, 5, nd 6. Colline Questionnire The olline questionnire olleted informtion on the vilility of nd ess to shools nd helth servies, food rops, nd fruit trees; the presene of ssoitions or oopertives; forms of trnsporttion; infrstruture; reent immigrtion/emigrtion ptterns; wether onditions; development projets; nd positive nd negtive events tht ffeted the olline residents. Tle 3. List of modules inluded in olline questionnire Module Topi Desription Respondent 1 Shools Identified shools ttended y hildren living in the olline, inluding Group of ommunity lotion, type, osts, nd pereived qulity memers 2 Helth servies Identified helth servies used y fmilies living in the olline, inluding Group of ommunity lotion, trvel time, vintion mpigns, nd epidemis memers 3 Food rops Identified the min rops in the olline nd timing of hrvest Group of ommunity memers 4 Fruit trees Identified the min fruit trees in the olline nd timing of hrvest Group of ommunity memers 5 Community Group of ommunity Identified existing orgniztions, ojetives, nd memership orgniztions memers 6 Trnsporttion Investigted the distne from nd the vilility nd ost of puli Group of ommunity trnsporttion to vrious puli servies memers 7 Infrstruture Investigted the vilility of eletriity, wter, nd telephone servies Group of ommunity memers 8 History Investigted migrtion, limti onditions, nd living onditions over Group of ommunity the pst 5 yers memers 9 Development Identified the presene nd outomes of lol development progrms Group of ommunity progrms over the pst 5 yers memers 10 Events Investigted lol events (positive, negtive) tht ffeted the olline Group of ommunity over the pst 5 yers memers Helth Center Questionnire The helth enter questionnire gthered informtion on the helth enter s shedule, personnel, servies provided, vintions provided, servies for hildren nd mothers provided, equipment, nd medil supplies. Differenes etween the seline nd follow-up questionnires re identified in Tle 4. 11

21 Tle 4. List of modules inluded in helth enter questionnire Module Topi Desription Respondent 1 Shedule Identified the hours of opertion for emergeny servies, prevention servies, prevention servies for pregnnt women, nd prevention servies for postprtum women 2 Personnel Identified the numer of personnel per estlishment, personnel qulifitions, nd the servies to whih the personnel ttend 3 Servies Identified the helth servies provided y eh estlishment for women nd hildren Differenes etween seline nd follow up survey modules: The follow up survey lso inluded monitoring growth of hildren under 5 yers vi moile servies (i.e., fility stff trvel to nother ple to provide servies) 4 Vintions Evluted the vilility of vines nd vitmin A 5 Servies for hildren 6 Servies for women Differenes etween seline nd follow up survey modules: The follow up survey lso inluded the PCV 13 (pneumool onjugte), VAROTA (rotvirus), nd RR (mesles nd ruell) vines Investigted the provision of growth monitoring servies, exmintions for sik hildren, nd tretment for severely mlnourished hildren Investigted the provision of prentl re, delivery ssistne, nd postntl re Differenes etween seline nd follow up survey modules: The follow up survey lso inluded prziquntel (for teni deworming) nd tests for mlri under prentl servies provided to women 7 Equipment Evluted the presene of equipment nd mteril ville for preventive nd urtive re for hildren nd pregnnt women Differenes etween seline nd follow up survey modules: At follow up, types of registries (sked only s registries t seline) were sudivided into urtive onsulttions, growth monitoring, vintions, nd prentl re Immuniztion rds (t seline) were further speified s mternl helth rds, hild helth rds, nd hild helth pssports t follow up Disposle needles nd syringes were single tegory t seline nd listed seprtely t follow up Additionl items t follow up inluded wheelhir, trsh n, sterile dressings, sink, sop, towels/npkins, metl tongue depressor, flshlight, soure of sution, nd pket of urine smple dipstiks 8 Meditions Evluted the presene of meditions nd ruptures in their supply Differenes etween seline nd follow up survey modules: Helth enter personnel Helth enter personnel Helth enter personnel Helth enter personnel Helth enter personnel Helth enter personnel Helth enter personnel Helth enter personnel Co trimoxzole nd erythromyin, s well s enzylpeniillin nd gentmyin, were listed together t seline nd seprtely t follow up. Additionl items t follow up inluded tetryline ophthlmi ointment (for mesles tretment), nysttin, prziquntel (for shistosom nd teni tretment), dilofen sodium, spirin, iuprofen, nilosmide, orl ontreptives, multivitmin pills, drinkle multivitmins, vitmin B omplex, nd ntiretrovirl meditions (inluding emtriitine, lmivudine, zidovudine, tenofovir, nd nevirpine) Household Questionnire The household questionnire gthered informtion on household, mternl, 17 nd hild hrteristis. The household questionnire ws sed on the questions used in the Rwnd DHS 17 Dt were olleted on the mother or regiver of the index hild. Where the index hild did not live with his/her iologil mother, dt were olleted from the regiver of tht index hild. 12

22 ( the Rwnd Enquête Intégrle sur les Conditions de Vie des Ménges (EICV 1998); nd other instruments from vriety of soures, inluding the FANTA Household Hunger Sle (HHS), the FANTA Household Food Inseurity Aess Sle (HFIAS), nd the FANTA Household Dietry Diversity Sle (HDDS) (Cotes et l. 2007; Deithler et l. 2010; Swindle nd Bilinsky 2006). All modules were dpted to the speifi needs of this study. Tle 5 presents the modules inluded in the questionnire, the questionnire or instrument the module ws sed on, nd short desription of eh module. We lso indite where the seline nd follow-up questionnires differed. Tle 5. List of modules inluded in household questionnire Module Topi Soure Desription Respondent 1 Household IFPRI Colleted informtion on the omposition of the Hed of household, spouse, roster nd household, inluding designtion of the hed of or household memer over edution household, list of ll household memers, their ges* 18 yers of ge nd sex, nd their reltionship to the hed of household, (iologil) prents of the hildren under 5 yers of ge, nd the highest edutionl level ttined nd tivity/employment in the pst month of ll household memers t lest 3 yers of ge * Eh hild s irth dte ws otined from the irth ertifite, from the hild s vintion rd, or from rell if neither doument ws ville 2 Eligile hild IFPRI Identified ll hildren 2441 months of ge nd rndomly Hed of household, spouse, seleted the index hild or household memer over 18 yers of ge 3 Dwelling EICV Identified onstrution mterils used for floor, wlls, nd Mother or household roof; vilility of wter nd eletriity; fuel/energy used memer over 18 yers of ge for ooking, lighting, et. 4 Assets EICV, Identified ownership of durle household goods (in Mother or household IFPRI working ondition), inluding tools for griulturl memer over 18 yers of ge prodution 5 Household FANTA Evluted the diversity of the household diet in the pst Individul in hrge of food dietry HDDS 24 hours preprtion, or household diversity memer over 18 yers of ge 6 Prtiiption IFPRI Identified ll soil progrms tht household memers Hed of household, spouse, in soil progrms prtiipte in nd the enefits reeived from those progrms or household memer over 18 yers of ge Differenes etween seline nd follow up survey modules: A setion on pst prtiiption in Turmure ws dded t follow up 7 Shoks IFPRI Identified ll shoks (eonomil, griulturl, nd fmilil) Hed of household, spouse, fed y the household in the pst 12 months or household memer over 18 yers of ge 8 Food seurity FANTA HHS, HFIAS Investigted the prevlene of household hunger using the FANTA HHS Differenes etween seline nd follow up survey modules: At follow up, HFIAS ws used to mesure the ess omponent of household food inseurity; the HHS ws lulted from the HFIAS olleted t follow up Individul in hrge of food preprtion or household memer over 18 yers of ge 13