Nutrition Information with the i SAFANSI Nutrition Solutions SeriesPilot Cash Transfer Program Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized

Nutrition Information with the Pilot Cash

Public Disclosure Authorized Transfer Program Nutrition Information with the ii Pilot Cash Transfer Program Nutrition Information with the Pilot Cash Transfer Program

January 2014 Nutrition Information with the 2 Pilot Cash Transfer Program

© The World Bank Group, Afghanistan

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he Afghanistan South Asia Food and relevant sectors. #ese solutions are generated Nutrition Security Initiative (SA- by combining global evidence with in-depth FANSI) Nutrition Solutions Series knowledge of the Afghan context. Each of the is a collaboration with program im- notes in this Series is the result of careful review Tplementers and policymakers in Afghanistan of evidence, additional information gathering to identify and re!ne promising programmatic in Afghanistan, and engagement with a range of platforms for scaling-up e"ective nutrition solu- stakeholders. tions in the country. #e overarching frame- work for the Series is the Government of the #e Series is !nanced by the South Asia Food Islamic Republic of Afghanistan’s Nutrition Ac- and Nutrition Security Initiative, a trust fund tion Framework. #e Nutrition Action Frame- at the World Bank supported by AusAid and work outlines a multisectoral approach for ad- the Department for International Development dressing, in a sustainable way, the alarmingly (DFID)/UKAID. #e South Asia Food and Nu- high rates of child and maternal malnutrition trition Security Initiative seeks to increase the in Afghanistan. #e Series builds on the global commitment of governments and internation- knowledge base to support Afghanistan-specif- al agencies in South Asia to more e"ective and ic analysis, technical assistance, and pilots that integrated food and nutrition security policies generate contextualized nutrition solutions in and programs. Nutrition Information with the 4 Pilot Cash Transfer Program

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About the Afghanistan South Asia Food and Nutrition Security Initiative Nutrition Solutions Series ------3 Acknowledgments ------5 Key Messages ------6

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ith funding from the South Mariam Haidary and Julie-Anne Graitge pro- Asia Food and Nutrition Se- vided much appreciated logistical assistance. curity Initiative, the South #anks also are due to the many colleagues in Asia Human Development the Ministry of Labor, Social A"airs, Martyrs, WDepartment of the World Bank examined the and Disabled-Government of the Islamic Re- nutrition elements of the pilot cash transfer public of Afghanistan, the World Bank o6ce in in Daikundi Province, Afghanistan. #e task Kabul, Afghanistan, and Afghan Management leaders for this project were Abeyah Al-Omair and Marketing Consultants, who supported and Luc Laviolette. Julie McLaughlin and Kees this work and responded to queries with helpful Kostermans provided overall guidance while information. Tawab Hashemi and Oleksiy Sluchynskyy pro- vided valuable inputs as part of the task team. #is work was made possible by the dedicat- Rachel Rosenfeld, consultant, was the main au- ed e"orts of the nutrition community in Af- thor of the report. Appreciated contributions ghanistan and internationally that provided into the planning of this Afghanistan technical excellent support for this endeavor. #ese part- assistance task were made by Johannes Jansen, ners included those at the Ministry of Public Claudia Rokx, and Meera Shekar. #e peer re- Health-Public Nutrition Department; the Min- viewers for this report were Leslie Elder and istry of Labor, Social A"airs, Martyrs, and Dis- Claudia Rokx. abled; and Oxfam International. Nutrition Information with the 6 Pilot Cash Transfer Program

Key Messages

Nutrition interventions in conjunction with sessions were held); hygiene interventions are among the most - Increasingly focus on targeting tools for cost-e"ective interventions to enhance wel- husbands and mothers-in-law; fare and reduce poverty.1 - Scale-up the communications campaign #e Pilot Program to Support Poor Fam- and develop more innovative communi- ilies-Afghanistan Safety Nets Project has cations tools that could stay in the com- been rolled out in 300 villages in Daikundi munity between contact points (e.g., Province, Afghanistan. #e Nutrition and a battery powered mobile phone that Hygiene Awareness Campaign component projects short refresher !lms); was piloted in 20 of the 300 villages. - Focus increasingly on the quality of #e Nutrition and Hygiene Awareness training and supervision for the deliv- Campaign focused on two areas: (1) exclu- ery; sive breastfeeding and breastfeeding with - Based on careful qualitative research at complementary feeding [nutrition]; and (2) the outset, develop a shorter set of mes- hand washing before preparing food and sages (e.g., 2-4 simply worded messages eating and a:er using the toilet or cleaning a on key behaviors, such as “Your baby child’s feces [hygiene]. needs solid food in addition breastmilk For future scale-up, the Ministry of Labor, starting at 6 months old” and “Wash Social A"airs, Martyrs, and Disabled should your hands every time before feeding consider the following key points: your baby”); and - Increase the contact points between the - Consider adding some interventions villagers and the nutrition !eldworkers such as micronutrient supplementation (in the current design two educational for women and children.

1 Tracking Progress on Child and Maternal Nutrition. UNICEF. 2009. Accessed from www.unicef.pt/docs/Progress_on_Child_and_ Maternal_Nutrition_EN_110309.pdf. Nutrition Information with the 7 Pilot Cash Transfer Program

Introduction—Genesis of the lot program initially targeted the poorest 10% Project (now the poorest 20%) of rural families with #e Nutrition and Hygiene Awareness Pilot is a children (0-14 years), disabled, widows, and part of the Afghanistan Safety Nets Project, an elderly (65+ years) who are dependents. #e unconditional cash transfer that has been pi- selection, however, was done purely on the ba- loted in various phases over the past two years, sis of a quota of maximum 20% of the families under the leadership of the Ministry of Labor, in each particular village. Each community’s Social A"airs, Martyrs and Disabled with sup- Village Selection Committee and Village Veri!- port from the World Bank. #e Nutrition and cation Committee decided which families were Hygiene Awareness Pilot has been added as a the poorest. #ere was no guarantee that the so: conditionality in twenty select Communi- selected villagers were the 20% poorest, howev- ty Development Councils and their villages in er, because such a !gure only can be measured Miramor and Shahristan Districts in Daikundi by a consumption survey. #e Ministry of La- Province, Afghanistan. #is knowledge brief bor, Social A"airs, Martyrs, and Disabled and discusses the implementation of the Nutrition the World Bank formerly distributed criteria and Hygiene Awareness Campaign, its success- for the selection of the poorest families, but in es and challenges thus far, and suggestions for recent years the villages have decided without the future. #rough the Afghanistan South these criteria. Asia Food and Nutrition Security Initiative Nu- trition Solutions Series, this knowledge brief Community Development Councils, a group of provides background and technical advice for community members elected by the village to similar campaigns throughout Afghanistan. serve as its decision-making body, were respon- sible for program implementation at the village Background of the Afghanistan Safety Nets level including the village surveys, bene!ciary Project selection, collection of detailed information #e Ministry of Labor, Social A"airs, Martyrs, from bene!ciary families, and bene!t distri- and Disabled with !nancing from the World bution. Within the Community Development Bank designed a pilot Safety Nets Project in Councils there was a Village Selection Com- 2009 with a vision of establishing a sustainable mittee and a Village Veri!cation Committee for national Safety Nets Project in Afghanistan, in assisting in bene!ciary selection. Facilitating line with the Social Protection Strategy of the Partners, non-governmental organizations that Afghanistan National Development Strategy. work with the communities for the National #e basic objective of the pilot Safety Nets Proj- Solidarity Programme—o:en Oxfam Inter- ect was to smooth seasonal ;uctuations in food national for this project, were engaged in the consumption to the most needy and vulnerable technical support, capacity development of the by providing support before the winter period Community Development Councils, and the through an unconditional cash transfer. #e pi- implementation of the program. Nutrition Information with the 8 Pilot Cash Transfer Program

#e Pilot Program to Support Poor Fami- children’s health. #us, in consultation with lies-Afghanistan Safety Nets Project has been the literature and colleagues working in devel- rolled out in 300 villages in Daikundi Prov- oping, remote, and con;ict prone areas, hand ince, Afghanistan. #e Nutrition and Hygiene washing and breastfeeding were suggested as Awareness Campaign was piloted in 20 of the the foci for the health pilot campaign. #e Nu- 300 villages—10 in and 10 in trition and Hygiene Awareness Campaign was within Daikundi Province. added as a so: conditionality to the Pilot Pro- As of September 2012, the Nutrition and Hy- gram to Support Poor Families-Afghanistan giene Awareness Campaign was to reach 3508 Safety Nets Project to the increase the e6cacy families, 700 of which would be cash transfer of the Ministry of Labor, Social A"airs, Mar- bene!ciaries. tyrs, and Disabled’s development work from strictly economic to additional social aspects Why a Nutrition Intervention? in villages. Supplementary social and health programs were easier to include in Daikundi Nutrition interventions in conjunction Province, Afghanistan where the Ministry of with hygiene interventions are among Labor, Social A"airs, Martyrs, and Disabled’s the most cost-e6ective interventions to relief work already had a presence. enhance welfare and reduce poverty.2 State of Nutrition in #e World Bank Group invests in nutrition Afghanistan interventions because inadequate nutrition re- sults in the following: Malnutrition – the state of being poorly nourished – is not merely (1) Direct loss in productivity from poor physi- a result of too little food, but of a cal status; combination of factors: insu7cient (2) Indirect loss in productivity from poor cog- protein, energy and micronutrients, nitive development, a"ecting school perfor- frequent infections or disease, poor mance; and care and feeding practices, inadequate (3) Loss in resources from increased health care health services and unsafe water and costs of ill health.3 sanitation.4

#e overall objective of the nutrition and hy- Levels of child undernutrition in Afghanistan are giene components was to raise awareness very high. #e 2004 National Nutrition Survey, among the families, particularly among wom- using World Health Organization references, !nds en of childbearing age about their and their that 60.5% of children under the age of !ve are

2 Tracking Progress on Child and Maternal Nutrition. UNICEF. 2009. Accessed from www.unicef.pt/docs/Progress_on_Child_and_ Maternal_Nutrition_EN_110309.pdf. 3 Shekar, Meera, et. al. Repositioning Nutrition as Central Development: A Strategy for Large Scale Action. The World Bank Group. 2006. 4 Nutrition-The Big Picture. UNICEF. Accessed from http://www.unicef.org/nutrition/index_bigpicture.html. Updated 25 May 2012. Nutrition Information with the 9 Pilot Cash Transfer Program

stunted, and 33.7% are underweight (Islamic Re- Another area that requires the international public of Afghanistan’s Ministry of Public Health community’s attention is teaching proper hy- and others 2009). #e stunting levels are among gienic practices. In Afghanistan, 1 in 3 child the highest in the world. Acute undernutrition deaths is due to pneumonia; close to 1 in 4 (wasting) in children under !ve is 8.7%, lower child deaths is due to diarrhea.8 Additionally, than would be expected for a country experienc- only 22% of the population has access to clean ing protracted con;ict, but these wasting levels re- water.9 Parasitic infestation diverts nutrients main very high in the !rst few years of life (18.1% from the body and causes blood loss, anemia, in children 1–2 years old).5 Afghanistan has one of and diarrhea, especially in young children. the highest infant mortality rates in the world;6 the Many children in Afghanistan die each year 2010 Afghan Mortality Survey reported an infant of easily preventable diseases; nearly 25% of mortality rate of 77 deaths of children under 1 year those deaths are from diarrhea.10 One of the old per 1000 live births.7 #e purpose of the child most e"ective ways of preventing diarrhea is to nutrition awareness aspect of the campaign was to improve hygiene in the home through regular teach women, speci!cally at childbearing age and hand washing with soap before preparing and those lactating, about the nutrition needs of chil- eating food, a:er using the toilet, or handling dren under age 2. a child’s feces.11 Additionally, undernourished children who fall sick are signi!cantly more Why focus on birth to age 2: In likely to die from illness than well-nourished the period of conception up to the children.12 #erefore, the other primary pur- age of 24 months (i.e., 2 years old) pose of the awareness campaign was to instruct damage to physical growth, stunted about proper hygienic practices and to link brain development, and inhibited these practices to child nutrition awareness. human capital formation all due to inadequate nutrition are extensive and #e Nutrition and Hygiene Awareness Cam- largely irreversible. An increase in the paign focused on communities in Daikundi prevalence of chronic malnutrition is Province, Afghanistan because of its high ma- especially pronounced in the period ternal mortality ratio.13 #e maternal mortality from birth up to the age of 24 months. ratio in Daikundi Province is 6000 maternal

5 Levitt, Emily, Kees Kostermans, Luc Laviolette, and Nkosinathi Mbuya. Malnutrition in Afghanistan: Scale, Scope, Causes, and Potential Response. The World Bank Group. 2011. Accessed from www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2010/11/15/000356161_201011 15233235/Rendered/PDF/578720PUB0Maln11public10BOX353782B0.pdf. 6 Hazara People International Network. Accessed from www.hazarapeople.com/2011/02/16/the-tribalist-karzai-government-is-the-killer-of-21- hazaras-in-daikundi-not-snowfall/. 7 Afghanistan Mortality Survey 2010. APHI/MoPH, CSO, ICF Macro, IIHMR and WHO/EMRO. Calverton, Maryland, USA. 2011. 8 Tracking Progress on Child and Maternal Nutrition. UNICEF. 2009. Accessed from www.unicef.pt/docs/Progress_on_Child_and_Maternal_Nutrition_ EN_110309.pdf. 9 State of the World’s Children. UNICEF. 2009. From Nutrition at a Glance: Afghanistan. The World Bank Group. 10 Newbrander, Bill. Preventing Diarrhea that Kills Children in Rural Afghanistan. Management Sciences for Health: Global Health Impact. 2010. Accessed from http://blog.msh.org/2010/12/14/preventing-diarrhea-that-kills-children-in-rural-afghanistan/. 11 Water Aid International. Accessed from www.wateraid.org/. 12 Nutrition at a Glance Afghanistan. 2013. Washington, DC: The World Bank Group. 13 All infant and child mortality rates are national or regional; no provincial rates exist, which is why the maternal mortality ratio was a determining factor rather than infant mortality rate. Nutrition Information with the 10 Pilot Cash Transfer Program

deaths per 100,000 live births.14 15 #is number In the Nutrition and Hygiene Awareness is extraordinarily high considering that Af- Campaign through the Afghanistan Safety ghanistan has one of the highest maternal mor- NetsProject,19 the Ministry of Labor, Social Af- tality ratios in the world at 374 maternal deaths fairs, Martyrs, and Disabled with World Bank per 100,000 live births.16 17 Furthermore, in Dai- support focused on points one and two. kundi Province, only 18% of households have access to clean drinking water, which is 4 per- centage points lower than the Afghan national Pilot Details for the Nutrition average.18 Finally, the Pilot Program to Support and Hygiene Awareness Poor Families-Afghanistan Safety Nets Project Campaign—Methods already was occurring in Daikundi Province, which allowed for a logical access point for the The 3 Stages and the Process Nutrition and Hygiene Pilot Program. Unlike the cash transfer program, which target- ed the poorest 20% of villagers, the Nutrition #e following are necessary to overcome mal- and Hygiene Awareness Pilot Program targeted nutrition: all villagers, i.e. bene!ciaries and non-bene!- ciaries of the cash transfer. #e Nutrition and (1) An adequate diet, including immediate Hygiene Awareness Pilot Program consisted of and exclusive breastfeeding for the !rst six three stages over about 3 months. Two educa- months a:er a baby is born and continued tional nutrition and hygiene awareness sessions breastfeeding with age-appropriate comple- occurred in each village—one at the beginning mentary foods. A balanced diet includes a and one at the end of the rollout—with a small range of micronutrients, and where that is evaluation in the middle. #e evaluation helped not possible supplements or food forti!ca- to improve delivery between the !rst and sec- tion should be provided. ond educational sessions. (2) Prevention of disease with proper hygiene practices. (1) During the !rst stage, most of the village (3) Treatment of disease with proper healthcare. gathered in a central location in the village

14 Bartlett, Linda A., et. al. “Where Giving Birth is a Forecast of Death: Maternal Mortality in Four Districts in Afghanistan, 1999-2002.” The Lancet. 365: 9462. 865-870. 15 2010 data on the maternal mortality ratio in Daikundi Province Afghanistan are not available. 16 Afghanistan Mortality Survey 2010. APHI/MoPH, CSO, ICF Macro, IIHMR and WHO/EMRO. Calverton, Maryland, USA. 2011. 17 From 2000-2010, the maternal mortality ratio in Afghanistan declined from 1600 maternal deaths per 100,000 live births to 374 maternal deaths per 100,000 live births, but much progress has yet to be made in further reducing this number. Also, signi!cant variation in the maternal mortality ratio occurs across provinces. 18 Figures are approximate. Levitt, Emily, Kees Kostermans, Luc Laviolette, and Nkosinathi Mbuya. Malnutrition in Afghanistan: Scale, Scope, Causes, and Potential Response. The World Bank Group. 2011. Accessed from www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/201 0/11/15/000356161_20101115233235/Rendered/PDF/578720PUB0Maln11public10BOX353782B0.pdf. 19 Pensions Administration and Safety Nets Project is the formal name for the World Bank’s involvement in this pilot. The Islamic Republic of Afghanistan’s Government proposed the Afghanistan Social Protection Program as the scale-up to Pensions Administration and Safety Nets Project, but the Afghanistan Social Protection Program has yet to be fully formalized. Nutrition Information with the 11 Pilot Cash Transfer Program

(typically a mosque) to receive food packets is among the largest and most intensive hand and soap cakes from the Facilitating Partner, washing, hygiene/sanitation, and water qual- because they hoped they would be eligible for ity improvement programs ever attempted in the cash transfer and genuinely wished to learn a low-income country. Additionally, for the about proper nutrition and hygiene practices. breastfeeding campaign, UNICEF’s Global #e session was held for several hours in the Strategy on Infant and Young Child Feeding morning, a:ernoon, or evening.20 In the !rst helped guide the pilot framework. stage, a health care !eld worker presented the messages with pictorial representations to the (2) During the second stage (which occurred females and males in separate groups. Messag- several weeks a:er the !rst stage), the villagers es were altered for the male or female audi- were interviewed in a door-to-door survey to ences in order to adhere to culturally sensitive assess how well they retained the information practices. It was an interactive presentation in from stage one. #is was a Ministry of Labor, which all participants could ask the facilitators Social A"airs, Martyrs, and Disabled/World questions. #e healthcare ! eldworkers pro- Bank designed survey, carried out by the Af- vided relevant examples about children who ghan Management and Marketing Consultants died from diarrhea because of a lack of hand and Facilitating Partner !eldworkers. washing, so participants could relate to the messages. (3) During the third stage, with the help of the Facilitating Partner, the villagers as- #e below !gure (Figure 1) is the document sembled with the health care !eldworkers for that was used to illustrate proper hand wash- another hygiene and nutrition awareness pre- ing and breastfeeding techniques. Much time sentation. #is third stage but second educa- was spent to create a document that would be tional presentation took place about one to two culturally sensitive and logical for illiterate months a:er the door-to-door survey. Prior populations. #e document focuses on hand to this presentation, Afghan Management washing before eating or preparing food and and Marketing Consultants, the Ministry of a:er using the toilet or cleaning a child’s fe- Labor, Social A"airs, Martyrs, and Disabled, ces; and exclusive breastfeeding and breast- and members from the World Bank o6ces in feeding along with proper complementary Kabul and Washington, DC analyzed the pre- feeding. #e World Bank and the Ministry of liminary data from stage two to improve the Labor, Social A"airs, Martyrs, and Disabled delivery of the second and !nal nutrition and narrowed the nutrition and hygiene themes hygiene awareness session. #is time special down to these two topics because of their ef- attention was given to questions that were mis- !cacy in low-income countries. Speci!cally, interpreted from stage one. Each presentation those researching these topics drew heavily on was tailored to the needs of the individual vil- the work done with Sanitation, Hygiene Ed- lages as discovered from the survey data anal- ucation and Water Supply-Bangladesh—that ysis. Once each of the newly tailored presen-

20 Part of the operational evaluation entails determining the best time of day for the sessions. Nutrition Information with the 12 Pilot Cash Transfer Program

Figure 1: Handout for Nutrition and Hygiene Awareness Presentation tations was !nished, a hygiene and nutrition awareness presentation was conducted in each of the original 20 villages in Daikundi Prov- ince, Afghanistan.

#e Facilitating Partner, typically Oxfam Inter- national, formed clusters of 4-10 neighboring villages for easy and e"ective implementation of the Safety Nets Project, including the Nutrition and Hygiene Awareness Campaign. If villages could not be grouped into clusters due to dis- tance, security, or other considerations, the Fa- cilitating Partner would interact with the villages independently. In the initial preparations and training, the Facilitating Partner arranged meet- ings with the Community Development Council representatives for Safety Nets Project introduc- tions. #ey discussed selection criteria for ben- e!ciary families, cash transfer bene!t amounts, bene!t distribution mechanisms, various com- mittees necessary to handle the administration of the program (Village Selection Committee and Village Veri!cation Committee), as well as the awareness generation for nutrition and hygiene. Once the list of eligible families was !nalized, the Community Development Councils informed the Facilitating Partner, and the Facilitating Partner planned a trip to the villages to further discuss bene!ciary information and collect ben- e!ciary data to ensure that appropriate bene!- ciaries were selected. As part of this visit to the select villages, Facilitating Partner !eldworkers conducted the Nutrition and Hygiene Awareness Campaign for the entire community described in stage one above.

For the evaluation of the Nutrition and Hygiene Awareness Campaign, the health care !eld- workers were trained and supervised by Afghan Management and Marketing Consultants. #is consultation !rm was heavily evaluated by the Ministry of Labor, Social A"airs, Martyrs, and Nutrition Information with the 13 Pilot Cash Transfer Program

Disabled and the World Bank team to ensure di Province, Afghanistan). #e data show that appropriate training for the data collection most of the female bene!ciaries and non-ben- !eldworkers. #e !rm employed the “Training e!ciaries attended the !rst meeting for the of Trainers” method to train for the evaluation Nutrition and Hygiene Awareness Program, stage, in which information was passed on us- with the exception of a few villages with lower ing a cascade approach from Master Trainers rates of participation.23 24 Data for male partic- to Social Mobilizers and onward to additional ipation rates are not available. Importantly, all !eld sta". For the evaluation process, a two-day bene!ciaries, male and female, expressed high training session was held for newly recruited fa- levels of satisfaction with the Nutrition and cilitators including a mock exercise. Hygiene Awareness Campaign, and almost all male and female non-bene!ciaries expressed Results high levels of satisfaction with the campaign; Some of the surveyors collected general data the remaining simply expressed indi"erence to from all 20 villages in which the pilot project the program’s importance and e6cacy. occurred; these surveyors interviewed 576 fe- males (both bene!ciaries and non-bene!cia- Analysis ries). Other surveyors collected more detailed On hand washing, the messages on the occa- data from 6 of the 20 pilot villages;21 these sur- sions before which it is crucial to wash hands veyors interviewed 204 male and female bene- appear to have reached the population more !ciaries and non-bene!ciaries.22 #e data pri- clearly than the messages on the occasions a:er marily were collected in the form of multiple which to wash hands. Nevertheless, villagers choice answers, but the surveys included a few overall did not appear to grasp the importance open-ended discussion questions that provid- of washing hands before feeding infants and ed useful suggestions for future campaigns and children, which was of crucial importance as a scale-up. message for this campaign since children are a primary target. Additionally, the responses to In general, villagers exhibited high levels of the questions about hand washing only showed participation in the Nutrition and Hygiene that respondents were aware of one reason (or Awareness Campaign, with slightly higher what they viewed as the most important/pre- participation for villagers in Miramor District ferred situation) for washing hands. For repeat- than in Shahristan District (both in Daikun- ed awareness sessions, the community health

21 The operational evaluation for the Pilot Program to Support Poor Families-Afghanistan Safety Nets Project was conducted in 18 of the 300 villages in which the Safety Nets Project occurred. Of the 18 villages in which the operational evaluation surveys were conducted, 6 of the villages were villages that included the Nutrition and Hygiene Awareness Campaign (one small, one medium, and one large in Miramor District and one small, one medium, and one large in Shahristan District). 22 51 male cash transfer bene!ciaries were interviewed from both districts—25 from Shahristan District and 26 from Miramor District. 50 female cash transfer bene!ciaries were interviewed from both districts—25 each from Shahristan District and Miramor District. 51 male non-bene!ciaries were interviewed from both districts—25 from Shahristan District and 26 from Miramor District. 52 female non-bene!ciaries were interviewed from both districts—28 from Shahristan District and 24 from Miramor District. 23 Evaluation Surveys: Surveys designed by the Ministry of Labor, Social A"airs, Martyrs, and Disabled and the World Bank/Rachel Rosenfeld. Data collected by Afghan Management and Marketing Consultants. Survey data analysis by the World Bank/Rachel Rosenfeld. 24 From the surveys, of those interviewed, 529 out of 576 female bene!ciaries and non-bene!ciaries participated in the nutrition and hygiene awareness sessions. This number accounts for female interviewees in all 20 villages. Furthermore, in 13 of the 20 villages, all those interviewed were present at the nutrition and hygiene awareness sessions. Nutrition Information with the 14 Pilot Cash Transfer Program

workers and volunteers conducting the aware- most all of the sessions in all villages. Evaluation ness campaign need to be sure that the recip- data show that in most villages almost 100% of ients understand the necessity to wash hands female and male bene!ciaries and non-bene!- before and a:er multiple situations (such as be- ciaries attended the sessions. #e attendees at fore preparing food, eating, and feeding a child/ the sessions expressed favorable perceptions infant & a:er touching anything in a latrine, about the Government of the Islamic Republic cleaning a baby’s bottom, touching or working of Afghanistan’s role in managing the initiative. with animals, and cleaning or working in a yard which may be contaminated with feces). Addi- When the Ministry of Labor, Social A"airs, tionally, the questions asked by the surveyors Martyrs, and Disabled introduced the Nutrition must ensure that respondents have the option and Hygiene Initiative into the Pilot Program to reply with their full range of knowledge for to Support Poor Families, the concepts that all times to wash hands. were to be addressed were quite varied. With technical assistance from the World Bank, the In terms of breastfeeding, villagers appeared to public health topics to be discussed were nar- understand the importance of breastfeeding, rowed to hand washing for hygiene training and but they did not clearly grasp when and how breastfeeding for nutrition training. Based on food other than a mother’s milk should be in- UNICEF and the United Kingdom Government troduced. #e concept of when it is appropriate Department for International Development to proceed with complementary feeding was supported Sanitation, Hygiene Education and the most frequently misunderstood question of Water Supply-Bangladesh and on the UNICEF the nutrition questions. Most villages showed a supported Global Strategy on Infant and Young lack of understanding for these three questions Child Feeding, the Ministry of Labor, Social Af- about breastfeeding: (i) When do you think a fairs, Martyrs, and Disabled with World Bank newly delivered baby should be breastfed?; (ii) technical assistance uni!ed the varied nutrition Do you think bottle-feeding is good for your and hygiene messages into speci!c hand wash- baby or not?; and (iii) At what age should liquid ing and breastfeeding points. Sanitation, Hy- food be introduced in small quantities?25 Fu- giene Education and Water Supply-Bangladesh ture nutrition and hygiene awareness sessions is among the largest and most intensive hand should concentrate on these issues. washing, hygiene and sanitation, and water quality improvement programs ever attempt- Successes ed in a low-income country. Sanitation, Hy- #e Nutrition and Hygiene Awareness Cam- giene Education and Water Supply-Bangladesh, paign experienced very favorable opinions from which had high success rates, suggested nar- both male and female community members in rowing the hand washing messages, which cor- all villages qualitatively and quantitatively. Ex- respond to hygiene practices, to hand washing tremely high attendance rates occurred at al- before eating or feeding and a:er coming into

25 For future nutrition and hygiene awareness sessions, question (iii) should be phrased in the following way, “At what age do children need to be given solid food in addition to breastmilk?” The term liquid food can be confusing, and “liquid foods” often do not provide the necessary nutrient density required for successful complementary feeding. To be more speci!c, a critical failing of some traditional complementary foods in some regions is the low dietary energy/nutrient density of watery foods. Feeding practices with thin gruels and other similar foods need to be altered in order for children to eat and absorb enough energy and nutrients, especially given the small size of their stomachs. Furthermore, liquid foods sometimes harm children because they include contaminated water. Thus, future nutrition and hygiene awareness campaigns also should address the problems of contaminated water, speci!cally for children, and the need to use puri!ed or boiled water for food preparation and consumption. Nutrition Information with the 15 Pilot Cash Transfer Program

contact with feces to minimize confusion from ages, such as contracting artists, ensuring multiple messages. #e Global Strategy on In- the images were accurate portrayals of the fant and Young Child Feeding greatly helped to messages for largely illiterate communities, suggest basic, proper breastfeeding techniques, ensuring that the images were culturally the amounts one should breastfeed, and com- sensitive representations of the messages, plementary food feeding practices. and printing speed (or lack thereof). Participation in the Nutrition and Hygiene Additionally, all villagers felt the pilot program Awareness Campaign did not appear to be the was important for their families and for their problem (in fact, it was quite high except for a communities, especially because this was the few villages). #e challenge was ensuring vil- !rst of this type of campaign for the majori- lagers understood and retained the messages. ty of respondents. For the villagers who were Unfortunately at this time we do not have re- familiar with a similar nutrition and hygiene sults on the behavior change that has occurred initiative, they a6rmatively responded that the as a result of this pilot intervention.26 Nutrition and Hygiene Awareness Campaign To continue, ensuring that villagers under- in the Pilot Program to Support Poor Families stood and retained the messages was di6- was more useful than previous campaigns. #e cult, especially with the lack of frequency of visual images used in the demonstrations were messages. #ere most likely were too few well received as pictorial teaching tools; they points of contact with villagers. Only two were easily interpreted and culturally sensitive. educational sessions were conducted as part #e majority of attendees, especially women, of the awareness campaign, one during stage at the sessions also expressed that they gen- 1 and one during stage 3. uinely attended the sessions to learn about More focus should have been incorporated nutrition and hygiene rather than in hopes of to include targeting tools for husbands and receiving the cash transfer or a one-time food mothers-in-law because of their in;uential supplement or soap cake. roles. While the current data show positive impressions from both men and women at- Obstacles and Gaps tendees, women felt more positively about In terms of project generation, the time- the campaign. In a country experiencing frame for producing the Nutrition and Hy- gender and cultural constraints, the cam- giene Awareness Campaign implementation paign was targeted at women and children, framework was too brief. Approximately but both genders needed to be involved. It four months were spent from developing the was and is especially important to incor- concept note to the start of the nutrition pi- porate men, speci!cally husbands, into the lot role-out. Ideally, more collaboration with campaign because of the in;uential role that experts who work in similar demographics they play in women’s lives in Afghanistan. would have been useful. Importantly, all bene!ciaries, male and fe- During the production of materials, there male, expressed high levels of satisfaction were numerous issues with the pictorial im- with the campaign. And 80% of the male

26 An impact evaluation assessment has not yet been conducted, so data on behavior change are not available at this time. An impact evaluation will show how knowledge acquired from the messages translates into behavior change. Nutrition Information with the 16 Pilot Cash Transfer Program

non-bene!ciaries and 96% of the female #e villages were small, so word of mouth non-bene!ciaries expressed high levels of was used to disseminate the occurrence of the satisfaction with the campaign; the remain- sessions. #at is, the Community Develop- ing 20% of male non-bene!ciaries and 4% of ment Councils in each village advertised the female non-bene!ciaries simply expressed Nutrition and Hygiene Awareness Campaign indi"erence to the program’s e6cacy. #ese as well as the greater Safety Nets Project. No evaluation data show that men, while incor- media campaigns were used. Additionally, as porated in the campaign, need to be further the project stands, there were few to no ways involved in future scale-up. of communicating with the villagers between #e !eldworkers trained by Afghan Manage- contact points. Mobile phone communication ment and Marketing Consultants to conduct between the Community Development Coun- the evaluation survey as part of stage 2 did not cils and national sta" should be enhanced, correctly ask and/or did not correctly record and if fully utilized, battery powered mobile the set of responses for the “When do you phones that project video refreshers of the think you should wash your hands?” ques- nutrition and hygiene messages could be used tions—assessing how well villagers under- as well. An innovative communication tool stood and retained the messages. Based on the that evolves along with citizen participation available data, recorded responses for when to will be essential for the development of future wash hands did not give people the full range Nutrition and Hygiene Awareness Campaign of options for all times to wash hands that they scale-up, which in turn will help demand should have learned. #e !eldworkers were greater accountability, capacity building, and supposed to allow for an “all of the above” op- higher quality for monitoring service deliv- tion OR “Option D: Before preparing food, ery. Increased communication does, indeed, eating, and feeding a child/infant” (an option seem feasible without disrupting the Nutri- including everything listed out) rather than tion and Hygiene Awareness Campaign and requiring the respondents to select one option the greater Safety Nets Project, and in fact, over the others. #us, the villagers’ responses rather strategic communication tools have were not reliable for how the villagers inter- the potential to increase program e6cacy. preted the messages, assuming the messages were delivered correctly in the stage 1 educa- Scale-Up tional session. #e same situation occurred Respondents in all surveys felt very strongly about for the a:er what situations does one wash recommending this campaign to their friends and hands questions as well. #us, the data pro- other villages, which demonstrated great village ap- vide no true gauge as to how well the villagers proval for the future of scale-up beyond this pilot. understood and retained the hand washing messages in their entirety. #e Ministry of Labor, Social A"airs, Martyrs, and Disabled and the World Bank have dis- Finally, the communication tool used in the cussed scale-up to more villages and their village sessions was a conventional tool. Fieldwork- Community Development Councils in Daikundi ers presented the messages orally and with Province, Afghanistan and to a few other prov- pictorial images in standard presentations. inces in Afghanistan pending the success rate. Nutrition Information with the 17 Pilot Cash Transfer Program

#e Ministry of Labor, Social A"airs, Martyrs, since the villages are far from cities and for- and Disabled in consultation with the Ministry of mal health facilities. Secondly, the same male Finance and the World Bank selected Samangan, respondents from Rook Ushto recommended Laghman, and Paktika Provinces as additional that the program should include detailed in- provinces for scale-up. #e scale-up of the Nu- formation on how to deal with waste materi- trition and Hygiene Awareness Generation Cam- als. #is suggestion is important from health, paign would occur in conjunction with scale-up social, and environmental standpoints. #e of the Afghanistan Safety Nets Project. #ese female respondents were less vocal in provid- three provinces were selected because they have ing suggestions than their male counterparts, very high poverty rates and are located in regions most likely because of cultural constraints. with relatively low security concerns.27 #e selec- Ideally, these community suggestions will be tion was primarily based o" of the National Risk addressed in future scale-up projects. and Vulnerability Assessment (2007/08) and Ministry of Finance security lists. #e rollout and For future scale-up, the Ministry of Labor, So- impact evaluation will begin in Samangan Prov- cial A"airs, Martyrs, and Disabled should con- ince during the 2013 !scal year and subsequently sider the following key points: will continue in Laghman and Paktika Provinces (1) Increase the educational sessions/contact during the 2014 !scal year. #e impact evalua- points between the villagers and the nutri- tion will allow the World Bank and the Ministry tion !eldworkers; of Labor, Social A"airs, Martyrs, and Disabled to (2) Scale-up the communications campaign and monitor the results in terms of actual behavior develop more innovative communications change rather than verbal con!rmation of un- tools that could stay in the community between derstanding. #is evaluation will help to assess contact points (e.g., a battery powered mobile the e6cacy of the awareness campaign because phone that projects short refresher !lms); knowledge may or may not translate into behav- (3) Focus increasingly on the quality of training ior change. and supervision for the delivery; (4) Based on careful qualitative research at the #e two most useful and detailed suggestions outset, develop a shorter set of messages that came from the series of open discussion (e.g., 2-4 simply worded messages on key questions were from the male respondents behaviors, such as “Your baby needs sol- in the village Rook Ushto in Miramor Dis- id food in addition breastmilk starting at 6 trict, Daikundi Province, Afghanistan. #e months old” and “Wash your hands every- !rst suggestion proposed the inclusion of fe- time before feeding your baby”); 28 and male doctors for the presentation to provide (5) Consider adding some interventions, such more detailed information regarding mater- as micronutrient supplementation for wom- nal health and hygiene. #e male respondents en and children, but the feasibility of adding also inquired about the possibility of having micronutrient supplementation should be a female doctor reside in the local villages tested prior to scale-up.

27 The percentage of the population below the poverty line in is 55%, in is 67%, and in is 76%. 28 When conceptualizing the campaign, project team members from the Ministry of Labor, Social A"airs, Martyrs, and Disabled and the World Bank thought extensively about the simplicity of hygiene and nutrition themes, and thus, only two themes were selected—hand washing and breastfeeding. However, additional thought should be taken to simplify the word choice for the messages, also accounting for the need to translate from English to when designing the messages. Nutrition Information with the 18 Pilot Cash Transfer Program

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