Evaluation of School-based Nutrition Intervention for Adolescents in Bangladesh (SNAP)

Evaluation of a Package of Nutrition Interventions to School-based Nutrition and Health Intervention for Adolescents in Bangladesh

Addressing the nutrition needs of adolescents could be an important initiative for breaking the vicious cycle of intergenerational malnutrition, chronic diseases and poverty. To respond to these diverse needs of adolescents, the Government of Bangladesh (GoB) in 2012, instituted a national policy for adolescent girls' weekly iron and folic acid (WIFA) supplementation in secondary schools to reduce anemia. Efforts are in place to roll out a national WIFA supplementation program for both in-school and out-of-school adolescent girls aged 10-19 years. Responding to the need to demonstrate the feasibility of such a new initiative before it is scaled-up, Nutrition International (NI) with funding support from the Government of Canada committed to providing technical and financial support to demonstrate to the GoB, the feasibility of a school-based delivery of nutrition interventions to improve the nutrition and health status of adolescents in Joypurhat and Sirajganj districts of Bangladesh. The project developed and began roll out of a multi-sectorial holistic and integrated nutrition approach consisting of both a nutrition-specific and nutrition-sensitive program model for improving the general health and nutrition of adolescents in schools. This was delivered in an integrated package for girls and boys including WIFA supplementation (girls only), promotion of improved water, sanitation and hygiene (WASH), behavior change interventions (BCI) on all topics, and support for menstrual hygiene management (MHM) for girls, including sale of menstrual products in schools. To evaluate the program, the GoB (Institute of Public Health and Nutrition, Ministry of Health and Family Welfare (IPHN) and The Directorate of Secondary and Higher Education, Ministry of Education (DSHE) and NI with technical assistance from the CDC Foundation and CDC planned process and outcome evaluations for the first year of the program's implementation.

Study Overview

• Status: Completed
• Conditions: Anemia; Menstrual Hygiene Management; Improved Water, Sanitation and Hygiene (WASH)
• Intervention / Treatment: Dietary supplement: Weekly Iron and Folic Acid Supplementation (WIFA); Combination product: WASH; Combination product: Menstrual Hygiene Management; Behavioral: Nutrition Behavior Change Intervention (BCI); Behavioral: MHM & WASH Behavior Change Intervention (BCI)

Detailed Description

The outcome evaluation was a school (cluster)-based, randomized controlled trial with three equal size intervention arms, sampling adolescents, teachers, and student leaders in 75 selected schools. The study investigated the impact of the school-based program implemented in Joypurhat and aimed to examine the effectiveness and factors influencing scalability of using the secondary school platform to deliver WIFA co-packaged with WASH, MHM, and BCI to improve the nutrition and health status of adolescents in Bangladesh. The process evaluation sampled adolescents, teachers, and student leaders from 12 schools selected through convenience sampling for qualitative interviews, and determined whether the school-based program was implemented as intended, and why and how the intervention components worked to produce an impact - specifically, assessing the level of adherence.

• Study Type: Interventional
• Enrollment (Actual): 3018
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Canada
  • Ontario
    • Ottawa, Ontario, Canada, K2P2K3
      • Nutrition International

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 10 years to 19 years (ADULT, CHILD)
• Accepts Healthy Volunteers: Yes
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Randomly selected adolescent girl or boy
• Present on the day(s) of the survey
• Verbal assent and parental/guardian written consent
• School level headteacher, assigned teacher or student leader in the various grades

Exclusion Criteria:

• Girl or boy enrolled in grades other than grades 8 or 9
• Enrolled after random selection of participants

Study Plan

How is the study designed?

Design Details

• Primary Purpose: PREVENTION
• Allocation: RANDOMIZED
• Interventional Model: PARALLEL
• Masking: NONE

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
NO_INTERVENTION: Control; No intervention.
EXPERIMENTAL: Full package intervention arm; Dietary Supplement of Weekly Iron and Folic Acid (WIFA) Supplementation (containing 60 mg of elemental iron and 2800 µg of folic acid) and;; Associated behavior change intervention (BCI) to change the knowledge, attitudes, and practices of nutrition (including dietary diversity), IFA, deworming; Water, sanitation and hygiene (WASH) intervention: ensure availability (or provision) of water, sanitation, and hygiene supplies; Menstrual hygiene management (MHM) intervention: support for menstrual hygiene, including sale of menstrual products in schools; Associated behavior change intervention (BCI) to change the knowledge, attitudes, and practices (KAP) of WASH and menstrual hygiene management (MHM)	Dietary supplement: Weekly Iron and Folic Acid Supplementation (WIFA); Weekly school provision of WIFA tablets to adolescent girls; Other Names: Behavior Change Intervention; Combination product: WASH; Ensure availability (or provision) of water, sanitation, and hygiene supplies for adolescent girls and boys; Combination product: Menstrual Hygiene Management; Support for adolescent girls' menstrual hygiene; Behavioral: Nutrition Behavior Change Intervention (BCI); Changing the knowledge, attitudes, and practices of nutrition (including dietary diversity), IFA, deworming; Behavioral: MHM & WASH Behavior Change Intervention (BCI); Changing the knowledge, attitudes, and practices of WASH and menstrual hygiene management
EXPERIMENTAL: Limited package intervention arm; Dietary Supplement of Weekly Iron and Folic Acid (WIFA) Supplementation (containing 60 mg of elemental iron and 2800 µg of folic acid; weekly school provision of WIFA tablets) and;; Associated behavior change intervention (BCI) to change the knowledge, attitudes, and practices of nutrition (including dietary diversity), IFA, deworming	Dietary supplement: Weekly Iron and Folic Acid Supplementation (WIFA); Weekly school provision of WIFA tablets to adolescent girls; Other Names: Behavior Change Intervention; Behavioral: Nutrition Behavior Change Intervention (BCI); Changing the knowledge, attitudes, and practices of nutrition (including dietary diversity), IFA, deworming

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Hemoglobin concentration and anemia prevalence among adolescent girls	Assessment of hemoglobin concentration and anemia prevalence among adolescent girls, using HemoCue® Hb-301 photometer	Up to 12 months
Iron and folate status, iron deficiency and folate insufficiency among adolescent girls	a) Iron status and inflammation was assessed using a sandwich ELISA method, including 2 indicators of iron status (ferritin, sTfR) and 2 indicators of inflammation (C-reactive protein (CRP) and alpha 1-acid glycoprotein (AGP)); b) Folate status was assessed using a microbiological assay to test for red blood cell (RBC) folate and serum folate	Up to 12 months
Decrease morbidity among adolescents due to improved water, sanitation and hygiene (WASH) behaviour.	Recall of morbidity symptoms over the past 3 days	Up to 12 months
Decrease barriers to menstrual hygiene management (MHM) for adolescent girls and thereby improve their school attendance	In-school subsidized purchase of sanitary pads for menstruating girls	Up to 12 months

Collaborators and Investigators

• Sponsor: Nutrition International
• Collaborators: Centers for Disease Control and Prevention; CDC Foundation; Institute of Public Health and Nutrition, Ministry of Health and Family Welfare, Bangladesh; Directorate of Secondary and Higher Education, Ministry of Education, Bangladesh

Study record dates

Study Major Dates

• Study Start (ACTUAL): July 31, 2019
• Primary Completion (ACTUAL): March 22, 2021
• Study Completion (ACTUAL): February 28, 2022

Study Registration Dates

• First Submitted: April 6, 2022
• First Submitted That Met QC Criteria: July 8, 2022
• First Posted (ACTUAL): July 13, 2022

Study Record Updates

• Last Update Posted (ACTUAL): July 13, 2022
• Last Update Submitted That Met QC Criteria: July 8, 2022
• Last Verified: April 1, 2022

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Physiological Effects of Drugs; Micronutrients; Vitamins; Vitamin B Complex; Hematinics; Folic Acid
• Other Study ID Numbers: NI-02-2019-SNAP

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No