A Multisectoral Nutrition Program in Nepal Improves Knowledge of Dietary Diversity, Sick Child Feeding, and Handwashing, but Not All Practices: a Program Impact Pathways Mediation Analysis

BACKGROUND: Few intervention studies have focused on how inputs link with outcomes. OBJECTIVES: This study tested whether Suaahara I program inputs translated into intended outcomes and identified gaps along the theorized program impact pathway to improved nutrition, care, and water, sanitation, and hygiene behaviors. METHODS: We used household-level, cross-sectional survey data from a process evaluation of Suaahara I conducted in 2014. A total of 480 households with a pregnant woman or child aged <2 y were selected with an equal split between intervention and comparison arms. We used regression models to test associations between exposure to Suaahara I and 3 primary outcomes and 3 parallel knowledge mediators: child minimum dietary diversity, child feeding during illness, and proper handwashing during child care. We used generalized structural equation modeling using full information maximum likelihood to test whether knowledge mediated associations between exposure and outcomes. RESULTS: In the adjusted regression models between maternal exposure to Suaahara I and 3 behavioral outcomes, we found a small positive association for handwashing (β: 0.21; 95% CI: 0.10, 0.31), but no association with the other 2 outcomes. In the mediation analysis, maternal exposure to Suaahara I, however, was associated with the mediator (knowledge) for all 3 outcomes: handwashing with soap and water (β: 0.05 ± 0.02), child minimum dietary diversity (logit = 0.06; P = 0.03), and child feeding during illness (logit = 0.09 ± 0.02). We found a positive, significant association for the full indirect pathway of program input to output via knowledge for child feeding during illness (logit = 0.07 ± 0.03) only. CONCLUSIONS: Exposure to Suaahara I behavior change interventions improved knowledge, but this did not always translate into improved practices. It is important to address barriers to optimal practices beyond knowledge in future nutrition programs in Nepal.