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Evaluation database

Evaluation report

2018 Kenya: Evaluation of NICHE in the first 1,000 days of a child’s life in Kitui and Machakos counties, Kenya



Author: Helen Guyatt, PhD; Matthew Klick, PhD; Florence Muiruri; Flavia Della Rosa

Executive summary

With the aim to continuously improve transparency and use of evaluation, UNICEF Evaluation Office manages the "Global Evaluation Reports Oversight System (GEROS)". Within this system, an external independent company reviews and rates all evaluation reports. The quality rating scale for evaluation reports is as follows: “Highly Satisfactory”, “Satisfactory”, “Fair” or “Unsatisfactory”. You will find the link to the quality rating below, labelled as ‘Part 2’ of the report, and the executive feedback summary labelled as ‘Part 3’.

Background:

The Nutritional Improvements through Cash and Health Education (NICHE) programme is a United Nations Children’s Fund (UNICEF)-led initiative in Kitui and Machakos counties with the aim of improving the nutritional status of children during their first 1,000 days of life, beginning in utero through the second year of life outside of the womb. The programme consists of providing intense nutritional counselling through community health volunteers (CHVs) and an additional cash top-up to households that are already recipients of the Government of Kenya’s Cash Transfer for Orphans and Vulnerable Children (CT-OVC) and that have a pregnant woman or a child under the age of two. This report constitutes an evaluation of the NICHE programme.

Previous studies have found that cash transfers can have a positive effect on increasing food consumption, food security, dietary diversity, and infant and young child feeding. However, while some studies of cash transfer programmes have been able to detect a measurable difference in child stunting, many have not been able to detect effects on child anthropometric outcomes. However, studies of interventions entailing both nutritional counselling and cash transfers have shown that combining these can decrease stunting, underweight and wasting among children. These findings support the underlying premise of NICHE: that providing additional cash and health information will facilitate positive behaviour change that will reduce malnutrition, stunting and wasting among children in targeted households.

Purpose/Objective:

1. Assess whether additional cash transfers and/or additional cash transfers with nutritional counselling can increase the number of children in recipient households who are fed in accordance with the World Health Organisation’s Infant and Young Child Feeding guidelines and who participate in using high impact nutrition interventions (HINI);
2. Record whether households with additional cash transfers and / or additional cash transfers and nutrition counselling have an improved awareness and utilisation of community health facilities to support better child growth and development, particularly for the first 1000 days of life;
3. Describe the causal pathways between cash, nutrition counselling and an increased awareness and understanding of practices resulting in improved nutritional uptake including the importance of hand washing and exclusive breast feeding, especially for the first 1000 days of life;
4. Measure whether children in recipient households have an overall improvement in height for age and weight for length Z scores, especially those under 2yrs and whether pregnant and lactating women and women have healthy nutritional status.
5. Identify any specific confounders for the research and monitor them throughout the research period, for example availability of food in the market where two – three commodities could be identified and monitored.
6. Monitor the existing cash transfer accountability feedback mechanisms to identify potential confounders.

Methodology:

The primary research instrument in this study is a panel household survey structured as a randomized control trial, designed to compare between treatment and control groups. The sample population was drawn from existing CT-OVC cash beneficiary households that had a pregnant woman and/or child aged 0-24 months. Several challenges on the ground, including significant loss to follow-up due to migration, falsification of data and delays in the rollout of the interventions, necessitated changes to the initial design of the survey. In the end, two baseline surveys (one in Kitui county and one in Machakos), three midline surveys and an end line survey were conducted between January 2017 and June 2018. Interviews during the end line were conducted in 794 households, 401 in the treatment arm and 394 in the control arm.

The interventions the treatment groups received were an additional 500 to 1000 Ksh per month, depending on the number of children or pregnant women in the household, in addition to the CT-OVC transfer of 2,000 Ksh per month, and nutritional counselling through household visits by CHVs.

The primary outcome measures of the study are the prevalence of stunting, wasting and underweight. Changes in these were to be identified by detecting differences in z-scores over time between treatment and control groups. Secondary outcomes include infant and young child feeding practises, pregnant woman and mother feeding practises, WASH practises, use of health services, general health of the child, stress levels, food intake, and household coping strategies. Data for primary and secondary outcomes were examined using Difference-in-Differences (DiD) models.
In addition to the panel survey, the evaluation also includes qualitative data gleaned from seven focus group discussions (FGDs) and seven in-depth interviews with beneficiaries to understand the experience of NICHE participants, and programme strengths and weaknesses.

Findings and Conclusions:

Data and findings suggest that NICHE has had, over the course of a relatively short time span and with complications in its implementation, a direct effect on the health and well-being of children under 24 months, pregnant women and caregivers, though effects are small and variegated. NICHE was unable, over the course of the study, to measurably impact stunting, wasting and underweight among young children, though z-score coefficients were positive. Similarly, global models testing for the relationship between a broad scope of intermediate outcomes and variables reflecting caregiver health, household nutrition and household sanitary practices, were not statistically significant.

However, individual variables within those models were routinely significant, and the incremental effect of cash and counselling combined, in DiD logistic regressions, revealed near-universally positive outcomes among the treatment group. While some improvements were smaller, such as an increased probability of exclusive breastfeeding (7 percent) and initiating breastfeeding early (8 percent), others were much larger, including the probability of obtaining a minimum acceptable diet (44 percent), having a household handwashing facility (29 percent) and treating drinking water (40 percent).

The FGDs revealed that beneficiaries found nutritional counselling to be relevant. Beneficiaries reported making behaviour changes, such as feeding their children a balanced diet, exclusively breastfeeding for six months, and unexpectedly, planting kitchen gardens and noting subsequent health benefits.

This evaluation found that counselling and cash transfers, coupled as they are in NICHE, improved well-being for participating households.

Recommendations:

Based on the lessons learned from this evaluation, we propose the following main recommendations for the cash transfer and nutritional counselling components of the NICHE programme:
• Improve communication to beneficiaries, particularly about how to access cash, to ensure better uptake of activities.
• Consider alternative cash distribution methods, such as sending cash through mobile phones, to avoid the time and travel costs for beneficiaries to collect cash.
• Consider providing cash on a monthly rather than bi-monthly basis.
• Increase the number of beneficiary learning forums and conduct them closer to targeted households to increase attendance and uptake of nutritional messages.
• Improve communication to beneficiaries about the timing of CHV visits.
• Provide support to households in dry areas to grow kitchen gardens, such as lessons on safe water storage and appropriate garden site locations through CHV visits.
• Encourage participation of male household members in nutritional counselling sessions as they are often key decision-makers in how money is spent.

Lessons Learned:

FOR THE EVALUATION
●It is thus crucial that interventions are properly timed and implemented consistently to obtain the maximum benefits from the NICHE intervention.
●While verification exercises were conducted both before the January and October baselines, several households were later determined to be ineligible, nevertheless. This therefore highlights the importance of in-depth probing, especially considering the high mobility of caregivers and children of the target population, which was also used during subsequent surveys to verify household eligibility.
●The involvement of the County Government representatives during all surveys was crucial to ensuring that fieldwork was carried out smoothly.
●NICHE households were sometimes unable to comment on the nutritional counselling received under the programme, and the Kimetrica team had to probe extensively, given that CHVs did not always wear easily recognizable items (such as their uniforms). Wearing these items during all household visits would have enabled a swifter recognition of the CHVs and their role in NICHE.
■FOR NICHE AND IMPLEMENTATION
●The decision to use an existing government system (the CT-OVC cash transfer programme) was important as it allowed for implementation to be mostly smooth (despite some delays in the cash transfers), given that the system was pre-existing.
●Collaboration between the NICHE partners and the Government’s involvement and ownership of the programme were both instrumental in facilitating its rollout.
●Cash transfer programs need to put into consideration of cost of diet and cost of living in the context of the intervention.
●It is important in future contexts to communicate effectively to beneficiaries on the functioning of the cash transfer system.



Full report in PDF

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Report information

Year: 2018

Office/Country: Kenya

Region: ESAR

Type: Evaluation

Theme: Nutrition

Language: English

Sequence #: 2018/006

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