Action Against Hunger - Teenage Nutrition For Change by ryanhaydon

By: MEL services in Action Against Hunger Author: Nicola Giordano (Head of MEL services at Action Against Hunger UK)

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C) / CONTENTS

TABLE OF CONTENTS 1. EXECUTIVE SUMMARY

2. INTRODUCTION

2.1 OVERVIEW OF THE PROJECTâ&#x20AC;&#x2122;S PATHWAY

2.2. TN4C THEORY OF CHANGE

2.3. LONG-TERM CHANGE

3. OBJECTIVES OF THE BASELINE

3.1. KEY OBJECTIVES 5. BASELINE METHODOLOGY

8 10

5.1. METHODOLOGY

5.2. COMPOSITE INDICATORS FOR THE OUTCOME INDICATORS

5.3. SAMPLE LOGIC FOR THE INDIVIDUAL SURVEY

5.4. SAMPLE STRUCTURE

5.5. LIMITATIONS OF THE STUDY

6. LINK BETWEEN BASELINE, MONITORING AND ASSUMPTIONS

6.1. MONITORING FRAMEWORK

6.2. KEY ASSUMPTIONS

6.3. ASBEF, RAES AND CDEPS

7. BASELINE RESULTS

7.1. BASELINE VALUES FOR IMPACT INDICATORS

7.2. OUTCOME INDICATOR 1 AND 2: KNOWLEDGE

7.3. OUTCOME INDICATOR 1 AND 2: ATTITUDE

7.4. OUTCOME INDICATOR 1 AND 2: PRACTICE

7.5. OUTCOME INDICATOR 3: ACCESS

7.6. OUTCOME INDICATORS 1,2,3 COMPOSITE BASELINE VALUES

7.7. ADDITIONAL ANALYSIS OF THE COMPOSITE SCORES

8. CONCLUSIONS AND MAIN RECOMMENDATIONS

8.1. OUTCOME BASELINE VALUES

8.2. KEY EVALUATION QUESTIONS

ANNEX 1: FOOD CONSUMPTION SCORE MEAN VALUES

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C)

ABBREVIATIONS AND ACRONYMS ASBEF CDEPS DEPT DFID EDS EDU GEE KAP LINK-NCA MEAL MoH NGO RAES SMART SRH TN4C WASH WFP VfM

Association Sénégalaise pour le Bien-Etre Familial Centre Départemental d'Education Sportive et Populaire Senegal Departments Department for International Development Enquête Démographique et de Santé Education Generalized Estimating Equation Knowledge, Attitude and Practice Nutrition Causal Analysis Monitoring, Evaluation, Accountability and Learning Ministry of Health Non-governmental organisation Réseau Africain d’Education pour la Santé Standardized Monitoring and Assessment of Relief and Transition Sexual Reproductive Health Teenage nutrition for change Water, sanitation and hygiene World Food Programme Value for Money

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C) /TABLES & FIGURES

LIST OF TABLES AND FIGURES TABLES TABLE 1 TABLE 2 TABLE 3 TABLE 4 TABLE 5 TABLE 6 TABLE 7 TABLE 8 TABLE 9 TABLE 10 TABLE 11 TABLE 12 TABLE 13 TABLE 14 TABLE 15 TABLE 16 TABLE 17 TABLE 18 TABLE 19 TABLE 20A TABLE 20B TABLE 21 TABLE 22 TABLE 23 TABLE 24 TABLE 25 TABLE 26 TABLE 27 TABLE 28 TABLE 29 TABLE 30 TABLE 31 ANNEX 1

Key evaluation questions per key area Sample distribution across school areas Sample distribution across Departments Sample structure for type of education Sample distribution across marriage status TN4C Context Development Impact Indicator Average number of SRH domains identified by adolescents (out of 8) Domains recognised by adolescents in percentage terms Knowledge about SRH rights and NGO work in this regard Percentages of adolescents recognizing malnutrition Average score for knowledge about breastfeeding and food during pregnancy Frequency in percentage of the most relevant influencers for life decisions Frequency in percentage of the most relevant reference points for SRH Percentage of adolescents perceiving SRH rights entitlement Percentage of adolescents valuing a set of SRH attitudes and practices Percentage of adolescents using protection Percentage of adolescents experiencing abuse Mean and median of food consumption score Mean and median of WASH score for handwashing Frequency of WASH score per key moment Recognition of SRH services from which to get information Naming health facilities from which to get SRH information Naming health facilities from which to get SRH information Channels from which information on SRH comes from Percentage of adolescents participating to SRH promotion Average value of baseline indicators composite scores Median value of baseline indicators composite scores Selected correlation scores Selected correlation scores (2) Livelihood determinants for the food consumption score4 SRH service incidence on the food consumption score Food consumption score mean values

GRAPHS GRAPH 1 GRAPH 2 GRAPH 3 GRAPH 4

Causal drivers to outcome change Results from causal drivers Distribution of outcome indicators scores Distribution of outcome indicators scores

MAPS MAP 1

TN4C Intervention Area

iii

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C)

1. EXECUTIVE SUMMARY Teenage Nutrition for Change (T4NC) is a DFID funded project that is going to be implemented in Matam and seeks to improve the nutritional status and gender norms of teenagers, and their future children. This project is expected to empower them to practice better nutritional care and to access SRH services and knowledge in Northern Senegal. The target group are â&#x20AC;&#x2DC;harder-to-reachâ&#x20AC;&#x2122; teenagers: from remote, rural, nomadic communities, less likely to attend school, more vulnerable to early pregnancies, with less food choice due to droughts/floods and limited access to health services and teenager-focused programmes/ centres. A previous study highlighted that poor nutritional status of breastfeeding adolescent mothers and their low education level act as key determinant for under-nutrition in Matam. Therefore, improving their nutrition practices and SRH before, during and after pregnancy is intended to improve their nutritional status along with their future behaviour and care practices as parents. Another expected results would be the avoidance of early pregnancies to give them more choice to stay in education hence increasing their future potential. Adolescents, female in particular, will benefit from personal and professional development through activities implemented by TN4C that develop their skills, confidence and leadership abilities (e.g. as peersupporters, IT skills, food production). From this rationale, the three key outcomes that were chosen to measure the attributable dimension of change that can impact the overall prevalence of under-nutrition and early pregnancy are: 1) % change in adolescents (girls/boys) not attending school on knowledge, attitude and practice on nutrition and reproductive health choices - prior, during, after pregnancy 2) % change in adolescents (girls/boys) attending school on knowledge, attitude and practice on nutrition and reproductive health choices - prior, during, after pregnancy 3) % change in adolescents accessing reproductive health care services, including family planning (disaggregated by gender) at health centres and health posts In the context of these outcome metrics, the objective of the baseline study is to provide a set of composite indicators that can capture multi-dimensional changes the project seeks to achieve across multiple themes referring to nutritional status, SRH KAPs and services. The structure of the baseline will therefore provide with the following types of content:

1. THE BASELINE OF OUTCOME VALUES CONTAINS: a. A causal pathway that explains the rationale for the outcomes and the contextual assumptions that frame the intervention b. Composite indicators for KAP and access to SRH services are proposed and all of their subcomponents analysed in disaggregated form c. Descriptive and inferential analysis of baseline outcome values with a range of variables related to knowledge, attitudes and practices of teenagers

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C) / EXECUTIVE SUMMARY

2. T HE ANALYSIS WILL BE ENRICHED BY THE EXAMINATION OF THREE KEY EVALUATION QUESTION AREAS: a. A link between nutrition and SRH from a livelihood, nutritional status and knowledge perspectives. The link will entail the analysis of how variables measuring nutrition status and SRH interact with each other and to what extent that relationship can be explained by examining contextual, gender and livelihood dimensions. b. The decision-making determinants of adolescents. The way teenagers make decisions in their lives and how they share SRH-related information in their communities are essential elements to further contextualise the changes in awareness about SRH rights and behaviours to pursue. c. The role, presence and use of SRH services. The extent adolescents recognise a health service on which they can rely on in the community for nutrition and SRH-related issues is one of the central premises to grow access. The evaluation questions at this level examine this expected change along with the roles of school teachers and health service providers in promoting SRH and in the uptaking of related services.

3. THE METHODOLOGICAL APPROACH AND ITS LIMITATIONS: a. The methodology for the baseline was predominantly quantitative and the source of information mostly came from a comprehensive KAP survey that was rolled-out to 1443 teenagers across three Departments in Matam. The KAP survey is supposed to be longitudinal and evaluative in order to provide generalizable findings throughout the whole implementation cycle of the project. b. The lack of qualitative and participatory methodologies represents a limitation to triangulate the direction between variables. In addition, the structure of the sample over-represents particular subgroups (female adolescents, Matam Department etc.) and the results were not adjusted to reflect a more even spread. These limitations lower the accuracy of some of the modelling and the external validity of the study.

4. KEY RESULTS: a. Low knowledge of SRH domains (e.g. food habits during pregnancy) and of SRH services available in the area of respondents. The same is true for awareness about SRH rights. On the contrary, most adolescents see the connection between malnutrition and its consequences for future generations. b. Limited freedom to make independent decisions on SRH issues is complemented by evidence of open exchange between peers of opposite genders in the village and within the same gender at school. The low recognition of the need for consent and perception/use of contraceptives are major area to be addressed by the project. c. The global food consumption score among sampled respondents is above the acceptability threshold but noticeable difference exists across locations. One Department (Kanel) is below the minimum score and this affects both female and male adolescents that are not schooled. Handwashing practices also seem well-diffused across respondents. d. The perception of SRH service coverage is significantly low and a minor fraction of adolescents ever used a facility to access nutritional and SRH-related information. Despite such low uptake, the willingness to participate and to engage others in getting more information on SRH is quite widespread across all locations targeted for this study.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C)

GENERAL RECOMMENDATIONS With the available information at hands, the project team should focus on the following: 1) To track longitudinally KAP respondents to maintain a sufficient degree of statistical rigour when attempting an attribution claim at the outcome level 2) To review the theory of change to make sure the logic of the project is further unpacked, and stakeholders can be analysed more in-depth in their roles with teenagers 3) To focus on gender-norms changes as key drivers to reduce specific behaviours that reinforces inequality and facilitate early pregnancies. The issue of consent seems fundamental along with the need for protection for both genders. 4) To engage adolescents in peer-to-peer modalities to discuss SRH issues, also between opposite genders since it is widespread practice in the communities, while reinforcing the role of educators and health facilities to become source of information 5) To develop an appropriate MEAL framework that can generate output data with regularity and can link financial with results data.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C) / INTRODUCTION

2. INTRODUCTION 2.1. OVERVIEW OF THE PROJECT’S PATHWAY The key outcome states: “At least 70.954 (75%) adolescents in Matam will be reached by the project, of whom 60% are expected to report improved knowledge and attitude and 30% report improved practice with regards to nutrition and SRH care. At least 20% over the baseline value will be expected to benefit from facilitated access to adapted reproductive health and family planning services”. To explain how the program will reach this outcome that is expected to contribute to the reduction in the prevalence of undernutrition across Matam, the following graph outlines the key activities at inception, main stakeholders and expected results. The key hypothesis to be validated when explaining the causal drivers to outcome change during the following evaluation cycle will be on whether a capacity-intensive model through school and health infrastructures led to greater uptake of SRH services and information among adolescents.

GRAPH 1: CAUSAL DRIVERS TO OUTCOME CHANGE

In Schools: strengthing capacity of schools

(through training & resources) to raise awareness & increase access to advise for students

Inception

- Mobilise team - Establish MEAL framework & conduct baseline - Stakeholder engagement - Resource development - Training of trainers

In Communities: raising awareness and

increasing access to advice and services for teenagers delivered through Matams teenage advice centre, Mobile Units, trained Peer Educators, online platform & helpline

Through the health system: strengthening capacity of health service providers (through training & rescources) to support, advise and treat teenagers using an integrated approach to nutrition & SRHR, new teenage-friendly spacdes and improving the supply of modern contraception

Completion Teenagers in Matam have improved: - KAP related to nutrition & SRHR - Access to integrated SRHR services

Referral system: to ensure dedicated teenage pathways between the 3 areas of intervention above so that teenagers are effectively referred between school staff/in-house clinics. Teenage Advice Centre and the health system ro improve access to services

May 2018

Impact

Long-lasting improvements in under-nutrition in Matam (particularly for teenage mothers & their children

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C)

2.2. TN4C THEORY OF CHANGE It is critical to consider TN4C Theory of Change to better address the key evaluation questions and their expected relationships with evidence from the baseline. To begin with, the problem to be addressed refers to the results of a Link-NCA conducted in March 2017, which identified that the poor nutritional status of breastfeeding adolescent mothers is mainly caused by their low education level, and the two together act as a key determinant leading to under-nutrition in Matam. The cause of the problem intended as under-nutrition can therefore be addressed by improving the awareness and use of SRH services and nutrition-sensitive practices among teenagers in Matam. The problematic identified for this project triggered the identification of three output areas that are focused on schools, community’s agents and health services as main contributors to an outcome change that sees adolescents increase their use of SRH services and practices. The second key hypothesis to be validated during the following evaluation cycle is whether the improved KAP of teenagers corresponded to their improved under-nutrition status. The validation of this relationship will largely rely on secondary data from SMART surveys conducted by governmental stakeholders unless additional funding is obtained to run primary triangulation.

GRAPH 2: RESULTS FROM CAUSAL DRIVERS

Outputs

60 schools have increased capacity (knowledge, resources, systems) to deliver adapted and integrated nutrition and reproductive health guidance to adolescents

Problem

Low awareness and use of SRH services and nutritionsensitive practices

Activities in:

Schools, Teenage Advice Center, community and health structures

Matam Teenage Advice Centre and 2 mobile Community Units have increased capacity (knowledge, resources, systems) to provide adapted integrated nutrition and reproductive health services to adolescents At least 100 health service providers have increased capacity (knowledge, resources, systems) to deliver tailored integrated nutrition and reproductive health

Outcome

At least 70,954 (75%) adolescents in Matam (in particular and including at least 36,186 teenage girls) are reached by the project, of whom 60% report improved knowledge and attitude and 30% report improved practice with regards to nutrition and sexual and reproductive health care. At least 20% over the baseline beneﬁt from facilitated access to adapted reproductive health and family planning services.

Impact

Reducing under-nutrition in Matam

To achieve scale, the priorities across all levels are also determined by contextual and external forces. The combined approach included the consideration of the following expectations and assumptions, which are also reported in the Logframe at the outcome level: • Between outcome and impact: There is general stability in the country both politically and environmentally. Senegal is recognised to have one of the most stable governance structures in Western Africa so the likelihood of civil unrest that can damage the nutritional status is considered as low. Similarly, foreseeable natural shocks are hard to predict but the likelihood of drought is quite high so some of the trends in the nutritional status of targeted adolescents may be influenced in larger part by environmental factors. • Between outputs and outcome: At the output level the role of local authorities, community’s leaders and members is the determinant to ensure a sufficient quality of outputs that can increase

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C) / INTRODUCTION

the likelihood of outcome to be attributable to the project. The assumption is mostly fulfilled by Action Against Hunger long-standing relationship with local actors and its partnership with ASBEF that brings thorough understanding about the context and SRH issue. â&#x20AC;˘ Between activities and outputs: At the input level, the main assumption is that the staff from schools, health centres and other community-level stakeholders are professional and willing to be trained on how to implement the content of trainings and sessions organised thanks to this project. The existing relationship with schools and communities should be sufficient to enable an adequate and timely implementation of activities. Provided this assumption, the initial step to measure the key outcome of the project is to define what a knowledge-practice-attitude continuum is all about, which is also the main narrative in TN4Câ&#x20AC;&#x2122;s theory of change.

KNOWLEDGE The baseline provides the initial value of reference for the types of knowledge that are considered in this project: 1) Knowledge of SRH facilities and NGO work in the area 2) Knowledge of SRH-related subjects and legal rights 3) Knowledge of nutrition during pregnancy and during the first 6 months after birth

ATTITUDE The key assumption to explain how these outputs can translate into outcomes can be investigated by tracking how TN4C target group act on the knowledge over a period. By all actors adopting nutrition sensitive and SRH related knowledge, the expectations will be to recognise the importance of protection and legal rights. The dimensions of change in this context are therefore the premises for behavioural change, which can be achieved over a longer time-span. The baseline provides the initial value of reference for the attitudes that are considered in this project: 1) The value attributed to protection by adolescents 2) The right to express consent in a sexual relationship 3) The right for self-determination for adolescent girls

PRACTICE The greater combined effect of knowledge and acquired practices was projected to result in a change of practice by a range of stakeholder in relation to nutrition, WASH and SRH thanks to adequate use of knowledge and a change in attitudes towards SRH services and rights. The baseline provides the initial value of reference for the types of practices that are considered in this project: 1) The identification of key times to wash hands 2) The use of protection by adolescents 3) The role of teachers as referents for information about SRH 4) The diversity of diet measured through the food consumption score

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C)

ACCESS A greater awareness about SRH and nutrition information along with and acquired practices is projected to strengthen the uptake of SRH at health facilities. The baseline provides the initial value of reference for access by considering: 1) The ability to name the types of health centres in the area 2) The use of SRH infrastructures in the area 3) The participation and encouragement to others to attend SRH sensitization sessions

2.3. LONG-TERM CHANGE The project's intended contribution would be composed by a reduction of a) Prevalence of wasting and stunting amongst children under 5 years old from a teenage mother; b) average age of first pregnancy and c) average birth spacing between children of adolescents. These areas of impact change are envisioned to be accelerated in Matam because of T4NC.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C) / OBJECTIVES OF THE BASELINE

3. OBJECTIVES OF THE BASELINE 3.1. KEY OBJECTIVES The objectives for this baseline are to develop and analyse a set of composite indicators to explore what types of knowledge, practices and attitudes compose will allow us to measure the following: 1) 60% report improved knowledge and attitude to nutrition and SRH 2) 30% report improved practice with regards to nutrition and SRH 3) 20% report facilitated access to adapted reproductive health and family planning services.

As outlined before, the articulation of the outcome spans along the knowledge-attitude-practice continuum and access to SRH services. Therefore, to generate composite indicators for the outcome the key metrics will be mapped in the following way: 1.

For outcome indicator 1 and 2, the values of reference for knowledge focus on: a. About SRH domains and services b. About nutrition during and after pregnancy c. About legal entitlements

For outcome indicator 1 and 2, the values of reference for attitude are considered: a. Towards protection b. Towards consent c. Towards self-determination

For outcome indicator 1 and 2, the values of reference for practice are: a. On protection b. On nutrition c. On WASH

4. For outcome indicator 3, the values of reference for access to SRH services look at: a. Participation to sensitization b. Recognition and use of SRH services

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C)

3.1.1. EVALUATION QUESTIONS In addition to the composite indicators for the main outcome of the project, the following question areas proposed for the whole evaluation cycle and relate to key relationships and the roles of stakeholders. Through adequate triangulation of different sets of evidence collected over-time it will possible to learn about and validate the hypothesis underpinning the relationship between activities and expected changes. Hence, the evaluation cycle (from baseline to endline) will focus on the following topics. This initial study provides for an initial ground that will be further probed during the implementation of the project through monitoring and evaluation evidence.

TABLE 1: KEY EVALUATION QUESTIONS PER KEY AREA

AREA 1: LINK BETWEEN NUTRITION AND SRH

1. What is the relationship between expected knowledge about SRH and the nutritional status among targeted adolescents 2. What are the key determinants in the nutritional status of adolescents from a livelihood and household structure perspectives 3. What’s the incidence of use of SRH services and gender on nutritional status of adolescents AREA 2: DECISION-MAKING DETERMINANTS

4. Who are the key referent points for adolescents in relation to SRH and life decisions 5. What are the opinions/values that inform the decision of adolescents with respect to SRH 6. What is the awareness of legal entitlements and adolescents’ act on them AREA 3: THE ROLE, PRESENCE AND USE OF SRH

7. What are the expected changes for school teachers and health service providers in addressing relevant SRH and nutritional practices 8. What is the overall awareness about key topics in SRH and how does it affect access 9. What is the feedback on the content and quality of training and how it affects uptake of services (to be addressed in the monitoring system of future evaluations) In the structure of the result’s section, key highlights related to these evaluation questions will be provided to form an initial understanding of what is relevant to deepen learning on these questions. Some can apply to existing data while others will require some future data collection to extract something useful for the learning of the project (#7 and #9)

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C) / BASELINE METHODOLOGY

5. BASELINE METHODOLOGY 5.1. METHODOLOGY To ensure the baseline reflects the initial values of references for outcome changes, the following approaches were adopted: • Quantitative: The main source of evidence is a comprehensive survey administered across the three Departments of intervention. Therefore, the analysis attempts to propose an approach that explore relationships between variables statistically, both in descriptive and inferential terms through frequency counts, correlations and multi-variate models. For most of the descriptive analysis, binary variables are described in percentages while composite categorial and continuous variables are analysed in their mean and median values. The inferential models are lightly applied to confirm the p-value of correlations and regressions. • Representative: The sample size was randomly selected from a list of schools. It is sufficiently representative for the overall target population. In addition, it partially mirrors the spread of adolescents by geographical area targeted by the project. • Integrated and disaggregated: Key data points form composite indicator but are analysed in a disaggregated way by gender, schooling and geographical department. The size of the sample is large enough to disaggregate for these three layers when producing baseline values for the range of dimensions considered in the project. • Multi-thematic: The relationship between SRH and nutrition is inherently complex and entails many themes and causal drivers in the knowledge, attitudes and practices of adolescents. To address this degree of complexity, a set of relationships are examined by considering causal drivers of different nature (e.g. how knowledge relates to attitudes). • Visually oriented: Visual solutions are included to render data accessible and to explain distribution and correlation of single or multiple variables. Given the absence of a control group in the baseline study, a descriptive approach in statistical analysis is preferred. To explore strategic evaluation questions, correlation and distribution graphs capture initial elements of causality between variables.

5.2. COMPOSITE INDICATORS FOR THE OUTCOME INDICATORS To estimate a baseline value that can be tracked throughout the whole evaluation cycle, the various dimensions of knowledge, attitude and practices were clustered in one comprehensive metric to reflect the multi-dimensional nature of change at the outcome level. The same reasoning was applied to indicator 3 (access), in order to reflect how awareness of SRH services translate into their use and community-wide sensitisation. The only difference between outcome 1 and 2 is on the target group, the first indicator pertains schooled populations while the second relates to adolescents not going to school. The key sub-metrics that were identified for both indicators were: 1) Knowledge- SRH services awareness [0 to 8]: The number of SRH-related domains recognised by respondents that pertain to SRH. The number of domains recognised is 8. 2) Knowledge- Legal entitlements [0 to 1]: If the respondent was aware about the existence of legal entitlements related to SRH.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C)

3) K nowledge- NGO work in SRH [0 to 1]: If the respondent was aware about the existence of NGO interventions in SRH. 4) Knowledge- Contraception Pill [0 to 1]: If girls adolescents ever heard about a contraception pill 5) Knowledge- Malnutrition awareness [0 to 1]: If the respondent ever heard about the issue of undernutrition 6) Knowledge- Food pregnancy awareness score [0 to 6]: A six-dimensional metric summing the scores of respondents when recognising the optimal food habits of a woman when pregnant 7) Knowledge- Breastfeeding awareness score [0 to 5]: A five-dimensional metric summing the correct answers to key considerations on how to feed an infant in terms of frequency and exclusive breastfeeding 8) Attitude- Perception of SRH rights [0 to 3]: A three-dimensional metric summing the scores of respondents when approving the idea of consent and use of protection for both genders 9) Attitude- Self-determination [0 to 1]: A score to reflect if the respondent believed adolescents have the right to decide on their own SRH independently 10) Practice- Protection [0 to 1]: If the respondent ever uses a protection measure during intercourse 11) Practice- Food Consumption Score acceptability [0 to 1]: Whether the adolescent reported a number of food types and frequencies per type that generated a food consumption score above the acceptability threshold (>35%) 12) Practice- Score WASH Handwashing [0 to 7]: A multi-dimensional metric summing up the number of key moments recognised by respondents to wash hands.

Another group of sub-indicators was identified to compose outcome indicator 3, specific to access and use of SRH services. 1) Knowledge of the existence of SRH services [0 to 1]: It reports whether the adolescent knows about the presence of an SRH facility from which receive SRH-related information 2) Know Health Facilities [0 to 3]: This value reflects the number of health facilities that were mentioned by the respondents, three types were identified in the area. 3) Coverage awareness [0 to 9]: In case the adolescent pointed out at health facilities, the number of SRH services that could be mentioned form the basis to measure coverage 4) Access SRH information sources [0 to 8]: Among the services mentioned, this number indicates which ones were recognised as possible to get more information from. 5) Awareness SRH services youth [0 to 8]: In case of a number of SRH and nutrition services were indicated as possible to get information from, which ones pertained to adolescence 6) Use SRH service [0 to 1]: This value shows whether the respondent has used or is using any SRH service in the area 7) Participation SRH sensitization [0 to 1]: If sampled adolescents participated to SRH sensitization sessions in their communities or at health facilities 8) Encourage others SRH [0 to 1]: Whether respondents would encourage peers to participate to SRH sensitization sessions The range of SRH types of knowledge and services identified correspond to the content that the project will disseminate across target areas. For this reason, the scales are defined on the range of SRH services and domains of knowledge that will be established through school teachers and SRH community agents

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C) / BASELINE METHODOLOGY

from health facilities. The aggregation of these scores will be tracked longitudinally throughout the whole evaluation cycle.

5.3. SAMPLE LOGIC FOR THE INDIVIDUAL SURVEY The total population targeted by the project is 70,954 adolescents in Matam, which represents the 75% of the overall population in the area. The sample of 1443 respondents with an average age of 15.9 years were collected over 10 days, 2/3 of the overall collection took place from 25 schools while 1/3 from communities in the proximity of the school across three Departments. The sample was developed to be statistically representative of three layers: gender, geographical spread and schooling ratio. Gender disaggregation has the highest degree of accuracy with respect to the other two characteristics. The key steps that were undertaken to collect data from a sample sized as closely as possible to the structure of the three layers were: 1) Computed a statistically representative sample for each administrative unit (Departments) based on demographic information about adolescent’s population in Matam 2) Estimated number of surveys possible to collect with the amount of available financial resources, recruited and trained a gender-balanced team of enumerators/supervisors 3) Weighted the sample distribution across three Departments in terms of feasibility of data collection, time of transport for collection and geographical spread of communities 4) Determined the sample size to represent schooled adolescents in middle and high school schools. The educational facilities were selected from the list provided by the local authorities and approved for project’s implementation AND if they were above the mean in terms of student’s enrolment size. 5) The remainder of the sample was distributed among communities clustered around the school facilities selected for the survey. Preference was given to villages in the proximity to allow data collectors to gather sufficient number of surveys for schooled and unschooled adolescents socialising in the same location. 6) Over-sampled for adolescent girls since they are the most exposed to SRH issues, especially when becoming pregnant The logic for sampling the respondents for the baseline survey was essentially based on the availability of financial resources, the accessibility of target locations and the requirement for representativeness for the overall population.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C)

5.4. SAMPLE STRUCTURE The following section presents a map and some tables that describe the distribution and structure of the main sample used for the baseline study. The outreach areas for TN4C are in Matam region across 3 Departments. The map below shows where they are located. The overall population that is expected to be reached is at least 70.954 adolescents in Matam (at least 36,186 teenage girls).

MAP 1 TN4C INTERVENTION AREA

The following table 2 initiates the sequence of tables showing the distribution of the sample across various communities and departments in the region of Matam.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C) / BASELINE METHODOLOGY

TABLE 2: SAMPLE DISTRIBUTION ACROSS SCHOOL AREAS TARGET SCHOOL’S COMMUNITY

DEPARTMENT

Agnam civol

Matam

Aoure

Kanel

Bokidiawe

Matam

Bokiladji

Kanel

Dabia

Matam

Nabadji Civol

Matam

Ndendory

Kanel

Ogo

Matam

Orefonde

Matam

Orkadiere

Kanel

Ouro Sidy

Kanel

Ourossogui

Matam

Ranerou

Semme

Kanel

Thilogne

Matam

Velingara Ferlo

Ranerou

Totals

GENDER

NUMBER OF SURVEYS

Female

Male

Female

Male

Female

Male

Female

Male

Female

Male

Female

Male

Female

Male

Female

Male

Female

126

Male

Female

Male

Female

Male

Female

Male

Female

117

Male

Female

Male

Female

Male

Female

Male

Female

Male

Female (60%)

869

Male (40%)

573

Oversampling adolescent girls was an intentional sample design consideration in order to provide stronger accuracy of their voices. Table 3 shows the distribution of the baseline sample by departments and whether adolescents ever received any schooling or received some.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C)

TABLE 3: SAMPLE DISTRIBUTION ACROSS DEPARTMENTS DEPT

Kanel

Matam

Ranerou

GENDER

EDU Y N

RESPONSES

Female

No Edu

Female

Some Edu

136

Male

No Edu

Male

Some Edu

Female

No Edu

175

Female

Some Edu

509

Male

No Edu

101

Male

Some Edu

362

Female

No Edu

Female

Some Edu

Male

No Edu

Male

Some Edu

From Table 3 it appears that most adolescents were sampled from Matam. The project will focus on that area. Ranerou has the lightest weight in the sample structure and it is assumed that a relatively lower project’s outreach is expected for that Department. Table 4 provides more details on the distribution of the sample per type of school. TABLE 4: SAMPLE STRUCTURE FOR TYPE OF EDUCATION EDUCATION

No schooling Arab School/Koranic School Elementary School Middle-Secondary School Pre-college

GENDER

PERCENTAGE

Female

14.63%

Male

8.53%

Female

0.62%

Male

3.33%

Female

4.51%

Male

3.61%

Female

38.56%

Male

22.95%

Female

1.94%

Male

1.32%

It appears the greatest majority of the sample, above 60%, is from middle-secondary school mostly from Matam and Kanel. A significant portion of the sample, almost 25%, also represents adolescents that never received any schooling. This is an important consideration for sample distribution since the schooling ratio in Matam is 52% yet to sample a greater proportion of unschooled adolescents would have required more resources that what available. Table 5 concludes this sequence by outlining the number of adolescent girls who are married, with children or already pregnant.

https://www.epdc.org/sites/default/files/documents/Senegal_OOSC_Profile_2.pdf§

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C) / BASELINE METHODOLOGY

TABLE 5: SAMPLE DISTRIBUTION ACROSS MARRIAGE STATUS DEPT

Kanel

Matam

Ranerou

MARRIAGE

PERCENTAGE

WITH CHILDREN

NOW PREGNANT

Divorced

0.77%

0.39%

Married

5.02%

2.32%

1.54%

Single

94.21%

0.77%

0.00%

Divorced

0.78%

0.44%

0.17%

Married

6.71%

2.53%

2.61%

Single

92.50%

0.78%

0.35%

Married

8.33%

0.00%

Single

91.67%

0.00%

It is worth to note that the whole male population of the sample is single and not married while about 10% of the female population is married, of which 0.5% has children.

5.5. LIMITATIONS OF THE STUDY The sample embed inherent limitations because of financial constraints, which also affected the sample structure: 1) The sample is mostly representative for Matam and Kanel areas. The values derived from Ranerou department should be treated as indicative, especially for unschooled adolescents which only total to 7 individuals in the sample. The values in Ranerou should be tracked with additional oversampling during the next longitudinal study. 2) The methodology adopted is predominantly quantitative, which prevents the evaluation team to form a more accurate idea on causal pathway that can further elaborate on the general relational trends between key variables. The lack of triangulation at this stage can still be accepted since the ability to explain results will be more critical during the next evaluations. 3) The sample structure and composite indicators are unweighted. The lack of adjustments in the sample structure relies on the assumption that the distribution of target respondents per location reflect the number of actual individuals that will benefit from this intervention. For the composite indicator, there is not theory behind how these variables combined can produce a behavioural or longer-term change. Yet, the lack of sample adjustments might create over-biases for sub-groups in the sample structure to infer representativeness beyond the general population. 4) The longitudinal nature of the survey cannot be guaranteed. The sample population might become untraceable or leave/terminate schooling, especially in light of the average number of years of the sample (15.9) which brings it closer right at the end of the school cycle by the end of the project. The sample might need to be reshaped to represent the demographic characteristics of the current one and its geographical spread for it to remain accurate. 5) The distribution of some variables is not normal. Given the binary and categorical nature of most variables, correlation and inferential methods used to explore relationships between dependent and independent variables might be less accurate and ought to be treated as indicative methods. On the other hand, the aggregate scores for the baseline indicators show a normal distribution, which allow for greater accuracy in Gaussian modelling.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C)

6) The theory of change of the project was not designed in a participatory and multi-stakeholder manner, which prevents to defend its external validity. The lack of a focused review process of assumptions, stakeholdersâ&#x20AC;&#x2122; relationships and key triggers of change might prevent the implementing team to establish whether the combination of input is optimal in achieving a set of changes linked to outcome indicators that can be sustained beyond the duration of the project.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C) / LINK BETWEEN BASELINE, MONITORING AND ASSUMPTIONS

6. LINK BETWEEN BASELINE, MONITORING AND ASSUMPTIONS 6.1. MONITORING FRAMEWORK The monitoring framework underpinning the project intends to offer a great wealth of qualitative and quantitative data across various outcome and output indicators. The monitoring approach is set to be evaluative, which means that a series of surveys will help explaining the link between outcomes and outputs by considering the following: • Pre-post testing: The knowledge of SRH and nutrition-related issues imparted through teachers will be tested to ensure retention. The current baseline forms the pre-testing values of reference for a set of questions that represent knowledge about SRH domains, nutrition-sensitive practices and the importance of legal entitlements and consent. During the monitoring cycle, output indicators should be tracked with post-testing that can relate to a similar set of questions proposed in the tool of this baseline. • Longitudinal outcome monitoring: During the duration of this project, three comprehensive surveys are planned. The baseline shaped the tool for future monitoring, which this project will leverage on to monitor population-level changes related to knowledge, attitudes, practices and access to SRH services from the same sample. • Triangulation: The monitoring framework should fill the methodological gaps in the present baseline. A series of qualitative tools are expected to be developed to complement quantitative evidence that will be collected during evaluations. The importance of more participatory and multistakeholder processes is recognised when defining the direction of relationships between variables and the causal factors that prevent or enable change to happen for different sub-groups targeted by the project.

6.2. KEY ASSUMPTIONS One of the aspects that are important to examine from baseline onwards are the contextual determinants that are supposed to hold for the project to be successful. The information is not directly sought from the evaluation tool, but it is expected to emerge from the analysis of monitoring data throughout the implementation of the project. In brief, there is no significant contextual variance to report at this stage; but the following contextual issues represent dimensions of analysis to be taken into account when explaining the key drivers of change.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C)

TABLE 6: TN4C CONTEXT DEVELOPMENT ASSUMPTIONS FROM LOGFRAME

BASELINE CONSIDERATIONS TO BE MONITORED TO EVALUATE THE ASSUMPTIONS

Government programmes/ strategies and stakeholder/ partner initiatives on nutrition and reproductive health for adolescents continue.

A couple of government programmes (Centre Départemental d’Education Sportive et Populaire Senegal (CDEPS) and Association Sénégalaise pour le Bien-Etre Familial (ASBEF)) operate in Senegal in the domain of SRH services/knowledge among young population. The project is expected to interface with both on the assumption their existence will continue.

Political and local authorities and local community leaders support project.

The requirement of every project is the approval of local authorities to work within communities. The existing relationship between Action Against Hunger and these authorities represents an entry point. During the baseline study, it was observed that Action Against Hunger is well-known among school teachers and government representatives because of its association with UNICEF-led interventions in the past.

Presidential elections in 2019 do not impede implementation.

Senegal has been a stable democracy for the past 30 years and the government’s attention in relation to SRH and nutrition has increased since recent years. No major disruption is expected during the election in 2019.

Potential for climate related disaster (flooding, drought) in remote areas of Matam that may adversely affect food security and food availability/prices and travel access are taken into account so as not to prevent project delivery and results.

The risk for climate-related disaster is more likely and this would have implications from a programmatic perspective. According to WFP Country Director in May 2018, more than 357,000 people in six departments, mainly in the north (Matam, Podor, Kanel, Ranerou, Goudiry and Tambacounda) might experience a draught this year with strong likelihood. Climate shocks are an increasing risk in the Sahel region, so it will need to be monitored.

Adolescents willing and able to engage with project.

The reaction of adolescents to baseline survey leads to believe that their engagement in the project is potentially strong. Nonetheless, it is important to consider that some information received in relation to SRH might challenge existing relationships within the household henceforth adolescents’ ability to engage in the project. The relationship between adolescents and their parents will also be monitored through the project’s cycle.

All personnel (schools, health centres, Teenage Advice Centre), engaged and pro-active.

The existing relationships with schools and health centres’ key personnel should ease the roll-out of trainings and sensitization activities across the targeted departments for this project. Key informants’ interview and a close interface between implementing staff and the personnel of public services is expected to strengthen collaborative attitudes.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C) / LINK BETWEEN BASELINE, MONITORING AND ASSUMPTIONS

6.3. ASBEF, RAES AND CDEPS As mentioned in the assumption table, two types of associations work in the SRH space: Association Sénégalaise (CDEPS) pour le Bien-Etre Familial (ASBEF) and Centre Départemental d'Education Sportive et Populaire Senegal (CDPS). These two represent key stakeholders to bring adolescents groups closer to SRH and related nutrition practices. ASBEF is the key partner for this project. It provides family planning, antenatal and post-natal care, prevention and treatment of sexually transmitted infections (STIs) including HIV and AIDS, screening, post-abortion care and infertility diagnosis and counselling. The team consists of full-time staff, volunteers, and peer educators, and the operation works through service points, including static clinics, and outreach programmes. ASBEF represents a platform where to further promote SRH services to adolescents and it will be responsible for training on nutrition and reproductive health, support and supervision to plan and implement new/improved integrated nutrition-reproductive health services for teenagers. RAES (Réseau Africain d’Education pour la Santé) will also work in the project with teenagers at Matam’s Teenage Advice Centre to help them produce local radio emissions on nutrition-reproductive health. RAES will train and support teenagers to produce associated e-content, blogs etc. Both organisations have region-specific knowledge and networks, having worked in Matam with Community Health Workers network already in place, which TN4C will draw on. Even though not directly involved in the project, CDEPS centres also play a central role in SRH. They are established in all regions of Senegal and play a role in the vocational training of young people out of the education system. The CDEPSs promote values of unity, discipline, cohesion and respect of community life. Their activities include thematic areas relevant to: sport education, citizenship and vocational training. The CDEPS can also be involved in the promotion of SRH rights and how to avoid early pregnancy.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C)

7. BASELINE RESULTS 7.1. BASELINE VALUES FOR IMPACT INDICATORS The key impact indicators for the project are the following: • Prevalence of wasting amongst children under 5 years old from a teenage mother • Prevalence of stunting amongst children under 5 years old from a teenage mother These are derived from the SMART Survey conducted on annual basis from the Ministry of Health. The baseline estimates will be tracked after each data collection from the government and will be correlated with trends for the outcome indicators. The current project will not produce any attribution estimate but contribution claims towards this impact indicator based on the longitudinal trends across the outcome indicators and selected impact indicators.

TABLE 7: IMPACT INDICATOR IMPACT INDICATOR #1

BASELINE VALUE

SOURCE

a. WASTING • GAM national rate

• SAM national rate

1.2%

• GAM rate in Matam

16.5% (>15%)

• SAM rate in Matam

3.0% (>2%)

MoH SMART Nutrition survey (2016)

b. STUNTING • Stunted children

21%

• Severely stunted children

• Stunted children in rural areas

24%

• Insufficient weight/age of children in Matam

26.4%

MoH SMART Nutrition survey (2016)

IMPACT INDICATOR #2

a) average age of first pregnancy: b) average birth gap among girls aged 15-19 Child Number Average months 1.0 17.36

21.1 years 17.74 years (sample) 25.5 months 19.39 (sample)

Enquête Démographique et de Santé Continue au. Sénégal (EDS-Continue 2016) and evaluations

2.0 36.75

While impact indicator #1 will solely rely on secondary data collection, the second indicator is also going to consider data collected during each evaluation. The most interesting finding from the baseline collection is the average number of months between children, which is 24% lower than the national average. The spacing between new-borns will be longitudinally monitored since it is considered as a key proxy for early pregnancy. The space between new-borns will also be triangulated from regional trends in TN4C areas of implementation.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C) / BASELINE RESULTS

7.2. OUTCOME INDICATOR 1 AND 2: KNOWLEDGE The following sections relate to each dimension of the outcome indicator 1 and 2. Each sub-section indicates the disaggregated results by location, gender and schooling status for each dimension that form the composite indicator with respect to knowledge about SRH domains, legal entitlements and nutrition during and after pregnancy.

7.2.1. SRH DOMAINS RECOGNITION The awareness of teenagers about the existence of SRH domains was explored in relation to 8 key topics: STDs, HIV / AIDS, family planning, pregnancy tracking, delivery, post-abortion care, sexual violence referral and management of unwanted pregnancies.

TABLE 8: AVERAGE NUMBER OF SRH DOMAINS IDENTIFIED BY ADOLESCENTS (OUT OF 8) GENDER

Female

Male

EDU Y N

AVERAGE OF SRH DOMAINS AWARENESS SCORE** (0 TO 8 SERVICES)

DEPT

No Edu

Kanel

No Edu

Matam

0.126

No Edu

Ranerou

0.667

Some Edu

Kanel

0.507

Some Edu

Matam

0.768

Some Edu

Ranerou

2.154

No Edu

Kanel

0.056

No Edu

Matam

0.158

No Edu

Ranerou

Some Edu

Kanel

0.931

Some Edu

Matam

0.483

Some Edu

Ranerou

1.125

The overall knowledge about key SRH issues and services seem to be pretty low across each area of the intervention, particularly in Kanel area. A significant difference is seen between teenagers going or not going to school, which can lead to the assumption of access to education as an important entry point to share SRH-related information. Tables 9 shows more detailed information to the question exploring what areas are covered by the reproductive health of young people and adolescents according to the respondents.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C)

TABLES 9: DOMAINS RECOGNISED BY ADOLESCENTS IN PERCENTAGE TERMS GENDER

Female

Male

GENDER

Female

Male

EDU Y N

DEPT

STD

HIV

FAMILY PLANNING

PREGNANCY

BIRTH

No Edu

Kanel

0.00%

No Edu

Matam

0.57%

2.29%

2.86%

1.71%

2.29%

No Edu

Ranerou

0.00%

33.33%

0.00%

Some Edu

Kanel

8.09%

11.76%

7.35%

4.41%

Some Edu

Matam

7.07%

19.25%

12.38%

7.47%

9.04%

Some Edu

Ranerou

7.69%

84.62%

30.77%

No Edu

Kanel

5.56%

0.00%

No Edu

Matam

0.99%

7.92%

1.98%

2.97%

0.00%

No Edu

Ranerou

0.00%

Some Edu

Kanel

18.06%

15.28%

12.50%

9.72%

Some Edu

Matam

5.52%

16.02%

9.39%

3.59%

3.87%

Some Edu

Ranerou

6.25%

43.75%

31.25%

6.25%

18.75%

EDU Y N

DEPT

POSTABORTION CARE

SEXUAL VIOLENCE

UNWANTED PREGNANCY

HAVE YOU EVER HEARD ABOUT A CONTRACEPTION PILL*

No Edu

Kanel

0.00%

No Edu

Matam

0.00%

1.14%

1.71%

5.52%

No Edu

Ranerou

0.00%

33.33%

0.00%

66.67%

Some Edu

Kanel

0.74%

5.88%

8.09%

11.38%

Some Edu

Matam

4.13%

8.45%

9.04%

12.66%

Some Edu

Ranerou

0.00%

7.69%

23.08%

No Edu

Kanel

0.00%

No Edu

Matam

0.00%

1.98%

2.15%

No Edu

Ranerou

0.00%

25.00%

Some Edu

Kanel

8.33%

5.56%

5.71%

Some Edu

Matam

2.76%

4.70%

2.49%

14.21%

Some Edu

Ranerou

0.00%

6.25%

0.00%

12.50%

As shown in previous tables, educated adolescent girls in Ranerou seems to know the highest number of SRH services while the unschooled ones in Kanel the least. As expected, schooled female adolescents are more aware about the contraception pill than male adolescents, showing their greater exposure to this contraceptive measure. The value among unschooled boys in Renerou is less accurate since the sample size is too small to be considered representative for such sub-group, yet the trend seems confirmed across the whole Department.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C) / BASELINE RESULTS

7.2.2. SRH LEGAL ENTITLEMENTS Regarding SRH rights, the key questions posed to teenagers where whether they knew about any regulatory/legal frameworks in place to protect their SRH rights and if they were exposed to any NGO activity related to the same. Table 10 shows the

TABLE 10: KNOWLEDGE ABOUT SRH RIGHTS AND NGO WORK IN THIS REGARD

GENDER

Female

Male

Female total Male total

EDUCATION

DEPT

KNOW ABOUT SRH RIGHTS LEGAL PROTECTION*

KNOW ABOUT NGO WORK ON SRH*

No Edu

Kanel

0.00%

No Edu

Matam

3.43%

1.14%

No Edu

Ranerou

0.00%

Some Edu

Kanel

5.15%

3.68%

Some Edu

Matam

11.00%

3.34%

Some Edu

Ranerou

23.08%

0.00%

No Edu

Kanel

5.56%

0.00%

No Edu

Matam

3.96%

0.99%

No Edu

Ranerou

0.00%

Some Edu

Kanel

9.72%

0.00%

Some Edu

Matam

12.71%

4.97%

Some Edu

Ranerou

18.75%

All

8.28%

2.76%

10.64%

3.83%

Schooled teenagers from Ranerou Department seem to be the ones most sensitized on SRH rights, but the general exposure to the concept of SRH-related legal entitlements remain pretty low. Less than 10% of the total sample have heard about SRH rights and projects implemented by NGOs that pursue these themes. The project is definitely addressing a significant gap in the level of SRH rights awareness across the targeted areas and this finding responds to the evaluation question #6 that measures the awareness of legal entitlements among adolescents.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C)

7.2.3. U NDERNUTRITION AND NUTRITION DURING AND AFTER PREGNANCY An additional dimension of knowledge that compose the baseline composite indicator and shown in Table 11 relates to whether the respondents in the baseline have ever heard about malnutrition and its consequences on new-born children.

TABLE 11: PERCENTAGES OF ADOLESCENTS RECOGNIZING MALNUTRITION

GENDER

Female

Male

DEPT

AWARENESS ABOUT WHAT MALNUTRITION IS*

EDU Y N

IF SO, AWARENESS ABOUT ITS CONSEQUENCES

Kanel

No Edu

48.50%

93.80%

Kanel

Some Edu

81.60%

91.90%

Matam

No Edu

42.30%

86.50%

Matam

Some Edu

78.70%

92.70%

Ranerou

No Edu

66.70%

100.00%

Ranerou

Some Edu

100.00%

Kanel

No Edu

38.90%

100.00%

Kanel

Some Edu

76.40%

92.70%

Matam

No Edu

29.70%

93.30%

Matam

Some Edu

77.60%

93.20%

Ranerou

No Edu

100.00%

75.00%

Ranerou

Some Edu

100.00%

87.50%

Unschooled adolescents in Matam are the ones showing the least awareness about malnutrition and its consequences while 100% schooled adolescents in Ranerou recognize both. Schooled teenagers consistently score higher than their unschooled counterparts. The exposure to education seems like a key driver in the overall percentage of adolescents that can see the connection between malnutrition and their inter-generational implications. Table 12 shows the results of two composite sub-indicators that investigate how much knowledge adolescents hold in regard to the optimal food habits during pregnancy and breastfeeding practices after birth. The Food pregnancy score assigns a value of 1 to each of the following option that the respondents managed to identify during data collection: â&#x20AC;˘ Do you know the eating habits that a woman in pregnancy or breastfeeding should have?

o Eat more (absorb more energy) o Eat more at each meal (eat more each day) o Eat more frequently (eat more times a day) o Eat more protein-rich foods o Eat more iron-rich foods o Have a varied diet o Use iodized salt in meal preparation

Similarly, the Breastfeeding awareness score assigns a value of 1 to each of the correct answers provided by the adolescents to the following questions:

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C) / BASELINE RESULTS

• What is the first food that a new-born should consume at birth? o Only breast milk o Mentioned breast milk but also other foods or do not know • Have you heard of exclusive breastfeeding? • If yes, what does exclusive breastfeeding mean? o Exclusive breastfeeding means that the infant only drinks breast milk and no other liquid or food o The teenager said something else or does not know • Between the two following options, which one do you think is right in the first six months? •

How often should a baby under 6 months be breastfed? o At the request of the baby o According to the availability of the mother o The respondent gave another number of times

TABLE 12: AVERAGE SCORE FOR KNOWLEDGE ABOUT BREASTFEEDING AND FOOD DURING PREGNANCY

GENDER

Female

Male

Total average female Total average male

DEPT

EDU Y N

FOOD PREGNANCY AWARENESS SCORE* (OUT OF 7)

BREASTFEEDING AWARENESS SCORE* (OUT OF 5)

Kanel

No Edu

0.42

3.18

Kanel

Some Edu

0.99

3.26

Matam

No Edu

0.61

2.28

Matam

Some Edu

1.32

2.85

Ranerou

No Edu

2.67

3.33

Ranerou

Some Edu

1.69

3.46

Kanel

No Edu

0.17

1.28

Kanel

Some Edu

1.24

1.96

Matam

No Edu

0.55

1.69

Matam

Some Edu

1.19

2.35

Ranerou

No Edu

3.5

Ranerou

Some Edu

2.19

2.69

1.10

2.82

1.08

2.17

All

Unschooled male adolescents in Kanel are the least aware about the required food habits and breastfeeding practices to minimise the risk of malnutrition in pregnant women and new infants. Overall, the scores seem higher for adolescents’ girls more than boys, which is to be expected because of their direct role in prevalence reduction. Yet, both highest values are relatively low compared to totals, less than 40% for food during pregnancy and 70% for knowledge about exclusive breastfeeding possible scores.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C)

7.3. OUTCOME INDICATOR 1 AND 2: ATTITUDE The following section indicates the disaggregated results by location, gender and schooling status for each sub-dimension that form the composite indicator and focused on attitude of adolescents with respect to SRH rights and consent.

7.3.1. REFERENCE POINTS FOR LIFE-DECISIONS AND SRH The following findings address the evaluation question #4 and #7, which explores who the key referent points are for adolescents in relation to life decisions and SRH issues and how they will change over the duration of the project. To begin with, table 13 lists for each gender the key focal points in respondentsâ&#x20AC;&#x2122; lives.

TABLE 13: FREQUENCY IN PERCENTAGE OF THE MOST RELEVANT INFLUENCERS FOR LIFE DECISIONS GENDER ADOLESCENT

Female

Male

LIFE DECISIONS DETERMINED BY

FREQUENCY

Aunt Grandmother

16.00%

Both Parents

36.94%

Father

7.94%

Husband

7.48%

Mother

28.88%

Others

0.92%

Uncle Grandfather

1.84%

Aunt Grandmother

5.06%

Both Parents

52.88%

Father

17.63%

Mother

17.98%

Others

0.87%

Uncle Grandfather

5.59%

Although adolescent females and males indicated both parents acting together as their greatest influencers, an even higher percentage for girls can be derived by combining their mothers and grandmothers. Adolescent girls are more likely to entrust their key decisions to female role-models while the role of both parents play a more balanced role in the lives of adolescent boys. Table 14 provides an additional perspective of referent groups anent SRH issues with very different results from Table 13.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C) / BASELINE RESULTS

TABLE 14: FREQUENCY IN PERCENTAGE OF THE MOST RELEVANT REFERENCE POINTS FOR SRH REFERRING TO WHOM WHEN IN NEED TO UNDERSTAND SRH ISSUES

FEMALE

MALE

Father

1.16%

3.02%

Mother

33.86%

4.64%

Brothers Cousins M

2.17%

8.35%

Sisters Cousins F

14.33%

1.39%

Aunts Grandmothers

5.79%

0.7%

Uncles Grandfathers

0.43%

1.16%

School Friends Girls

17.51%

5.57%

School Friends Boys

0.87%

22.51%

Friends Boys Village

20.12%

12.06%

Friends Girls Village

1.16%

39.44%

Women Village

1.45%

0.23%

Men Village

0.0%

0.93%

Pair Educators

0.29%

0.0%

Teachers Women

0.87%

0.0%

Even though female adolescents are more likely to rely on mothers when to understand SRH issues, male adolescents in the village are also considered as referent points. For adolescent boys the finding is even more striking since the greatest majority in the sample chose the option of a female adolescent friend in the village as the most important person of reference in regard to SRH issues. The peer-to-peer exchange at school is within the same gender group while in the village between different genders is a preferred modality to discuss about SRH. Fathers and men in the village are not considered as focal points neither for adolescent boys and girls.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C)

7.3.2. CONSENT AND SELF-DETERMINATION Another dimension on how attitudes are measured consider the perception about and the entitlement attributed to SRH rights. This series of findings inform the evaluation questions #5 which seeks to measure the opinions/values that inform the decision of teenagers with respect to SRH. Table 15 starts the analysis off by showing the average % of adolescents recognising SRH rights to apply to their lives.

TABLE 15: PERCENTAGE OF ADOLESCENTS PERCEIVING SRH RIGHTS ENTITLEMENT GENDER

Female

Male

Total female Total male

EDUCATION

DEPT

CAN YOU DECIDE ON SRH*

No Edu

Kanel

3.03%

No Edu

Matam

7.43%

No Edu

Ranerou

33.33%

Some Edu

Kanel

5.15%

Some Edu

Matam

8.64%

Some Edu

Ranerou

30.77%

No Edu

Kanel

11.11%

No Edu

Matam

6.93%

No Edu

Ranerou

50.00%

Some Edu

Kanel

20.83%

Some Edu

Matam

25.69%

Some Edu

Ranerou

43.75%

All

8.05% 21.98%

Schooled female and male adolescents in Ranerou are more likely to perceive SRH rights entitlements while unschooled adolescents in Matam and Kanel are the least likely to experience so. Generally, boys perceive them more than girls, but the overall frequency does not follow a specific pattern, with the exception of Ranerou where the values are higher. Table 16 takes the analysis further by presenting a set of frequency values on the perceptions of adolescents about consent and protection.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C) / BASELINE RESULTS

TABLE 16: PERCENTAGE OF ADOLESCENTS VALUING A SET OF SRH ATTITUDES AND PRACTICES COMPOSITE SCORE DEPT

Kanel

Matam

Ranerou

Total Means

GENDER

EDU Y N

CAN GIRLS REFUSE SEX*

SHOULD BOY USE PROTECTION*

SHOULD GIRLS USE PROTECTION*

Female

No Edu

27.27%

3.33%

3.45%

Female

Some Edu

57.58%

22.31%

17.65%

Male

No Edu

11.11%

5.56%

Male

Some Edu

50.00%

52.38%

Female

No Edu

43.87%

16.54%

18.46%

Female

Some Edu

60.37%

33.48%

31.05%

Male

No Edu

30.00%

20.22%

20.00%

Male

Some Edu

49.02%

51.28%

47.99%

Female

No Edu

50.00%

0.00%

Female

Some Edu

66.67%

Male

No Edu

25.00%

33.33%

25.00%

Male

Some Edu

68.75%

93.75%

55.56%

27.78%

25.99%

45.19%

45.92%

43.59%

Male Female

All

The distribution of the percentages in Table 16 consistently confirm that schooled adolescents are more likely to recognise the value in protection and consent. Almost half of the overall adolescent population in the sample recognizes the importance of consent but adolescent males are less likely to value the use of contraceptive than adolescent females with the exception of Ranerou.

7.4. OUTCOME INDICATOR 1 AND 2: PRACTICE The following section indicates the disaggregated results by location, gender and schooling status for each sub-dimension of the composite outcome indicator 1 & 2 that represent practice of adolescents with respect to protection, their own nutrition and hand-washing habits.

7.4.1. PROTECTION AND ABUSE The first dimension of practice considers if teenagers protect themselves during intercourse and whether they are subject to abuse. Table 17 outlines to what extent adolescents rely on contraceptive methods, which is considered as a critical SRH issue.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C)

TABLE 17: PERCENTAGE OF ADOLESCENTS USING PROTECTION GENDER

EDU Y N

No Edu Female Some Edu

No Edu Male Some Edu

Total Means

Male Female

DEPT

HAVE YOU EVER HAD A SEXUAL RELATION

IF SO, HAVE YOU USED PROTECTION*

Kanel

24.24%

0.00%

Matam

29.71%

0.57%

Ranerou

0.00%

Kanel

8.09%

0.74%

Matam

14.34%

1.57%

Ranerou

15.38%

0.00%

Kanel

33.33%

0.00%

Matam

33.66%

3.96%

Ranerou

0.00%

Kanel

29.17%

9.72%

Matam

30.00%

13.26%

Ranerou

37.50%

31.25%

30.64%

41.55%

16.80%

11.16%

All

From the findings, it can be seen that around a third of male adolescents had a relationship that led to a sexual relation while the figure is half for female adolescents. While the use of contraceptive methods variate across Departments, a consistent finding seems to indicate that male adolescents are more likely to use protection than female adolescents. Another result that emerges from the analysis is unschooled female adolescents are less likely to use protection but the same does not apply for unschooled male adolescents. Both relevant findings underline an interpretation of decision making power on the use of protection held by males. To corroborate the findings showing unequal gender relations, Table 18 considers forms of abuses experienced by teenagers in frequency terms by schooling status and gender.

TABLE 18: PERCENTAGE OF ADOLESCENTS EXPERIENCING ABUSE DEPT

All

GENDER

WAS HARASSED

WAS APPROACHED

WAS ABUSED

Schooled Female

10.56%

19.14%

2.75%

Unschooled Female

10.39%

14.92%

3.50%

Schooled Male

7.81%

11.83%

4.00%

Unschooled Male

9.91%

13.11%

3.27%

The table indicates that female adolescents are more likely to be approached and harassed while it is a mixed figure for actual abuse. These values have important implications because they are defining traumas that can shape the perception of SRH issues and rights. Often, these SRH right abuses can lead to the reinforcement of problematic relationships and of fear to share information at health facilities, with the relevant authorities or at the household level.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C) / BASELINE RESULTS

7.4.2. FOOD CONSUMPTION AND WASH Other two dimensions to consider when measuring practice in this project refer to the food consumption score and handwashing habits score. Table 19 shows the food consumption score, which represents a benchmark composite index calculated by summing the weighted frequency of the following food types: 1) food made from grains; 2) food from roots or tubers, 3) vegetables, 4ยง) fruits, 5) meat, 6) eggs, 7) fish, 8) dried nuts, 9) dairy products, 10) oil-based foods, 11) sugar/honey, 12) coffee/the. The acceptability threshold is set at 35, so any value below is to be considered as undernutrition.

TABLE 19: MEAN AND MEDIAN OF FOOD CONSUMPTION SCORE GENDER

Female

Male

Total Male Total Female

DEPT

EDU Y N

FOOD CONSUMPTION SCORE (MEAN)

FOOD CONSUMPTION SCORE (MEDIAN)

ABOVE ACCEPTABILITY THRESHOLD*

Kanel

No Edu

39.94

31.83

45%

Kanel

Some Edu 50.85

53.42

63%

Matam

No Edu

48.69

45.67

69%

Matam

Some Edu 55.31

55.83

79%

Ranerou

No Edu

58.11

100%

Ranerou

Some Edu 59.28

92%

Kanel

No Edu

41.06

34.33

44%

Kanel

Some Edu 56.19

54.58

89%

Matam

No Edu

53.33

78%

Matam

Some Edu 59.96

61.5

91%

Ranerou

No Edu

68.29

70.08

100%

Ranerou

Some Edu 71.14

73.17

100%

57.82

59.33

87.08%

52.76

52.66

73.64%

All

51.77

The area is generally well-above the acceptability threshold for both genders. The sub-group in the sample which seems to be at most risk of undernutrition is unschooled female and male adolescents in Kanel. There is a difference of 15% between male and female adolescents below the acceptability threshold, which leads to believe male adolescents are better nourished. The score included in the composite outcome indicator which captures the WASH dimension of nutrition-sensitive practices mainly relates to hand-washing. The score is composed by a scale 0 to 6, which corresponds to key moments of handwashing that are practiced by the respondents of the sampled teenagers. Table 20.a and 20.b provides the overview of the mean and median values for the total and individual scores on the following key moments for handwashing:

1. 2. 3. 4. 5. 6. 7.

After going to the toilet / latrine After cleaning the back of a baby / changed a diaper Before cooking / handling food Before feeding a child / eating After touching raw foods After handling garbage Others

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C)

TABLE 20.A: MEAN AND MEDIAN OF WASH SCORE FOR HANDWASHING GENDER

Female

Male

Total Male Total Female

DEPT

EDU Y N

SCORE WASH HANDWASHING* MEAN (OUT OF 7)

SCORE WASH HANDWASHING MEDIAN (OUT OF 7)

Kanel

No Edu

5.42

Kanel

Some Edu

4.91

Matam

No Edu

4.78

Matam

Some Edu

4.16

Ranerou

No Edu

Ranerou

Some Edu

2.85

Kanel

No Edu

5.78

Kanel

Some Edu

5.25

Matam

No Edu

3.98

Matam

Some Edu

4.18

Ranerou

No Edu

2.5

Ranerou

Some Edu

3.31

All

4.29

4.00

4.42

4.00

TABLE 20.B: FREQUENCY OF WASH SCORE PER KEY MOMENT

GENDER

DEPT

AFTER TOILET

AFTER CHANGE A BABY

BEFORE BEFORE FEEDING COOKING A CHILD

AFTER HANDLING FOOD

AFTER HANDLING GARBAGE

OTHERS

Female

Kanel

90.62%

70.07%

75.17%

88.76%

67.81%

74.17%

76.36%

Female

Matam

89.40%

53.65%

64.52%

79.61%

51.76%

65.20%

63.61%

Female

Ranerou

100.00% 25.00%

18.75%

75.00%

18.75%

37.50%

13.33%

Male

Kanel

96.67%

67.78%

70.00%

80.00%

83.33%

Male

Matam

91.87%

41.46%

48.05%

58.28%

57.73%

71.78%

58.37%

Male

Ranerou

100.00% 30.00%

30.00%

35.00%

45.00%

65.00%

10.00%

91.09%

59.40%

72.60%

56.30%

69.08%

63.37%

Total

51.67%

The average median number of key moments enumerated by both male and female adolescents is 4, which corresponds to 57% of the total number of possible options. Some variations are noticeable, for example unschooled male adolescents and schooled adolescent girls are less likely to be aware about handwashing practices. Education does not seem to be a driver determinant while by looking at the geographical spread of the score, Ranerou seems to be the area with the lowest awareness about handwashing. In more detail, the key moment that is most cited is washing hands after using the toilet whereas the one cited the least is washing hands after changing a diaper.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C) / BASELINE RESULTS

7.5. OUTCOME INDICATOR 3: ACCESS The following sections relate to each dimension of the outcome indicator 3. Each sub-section indicates the disaggregated results by location, gender and schooling status for each dimension that form the composite indicator with reference to awareness and use of SRH services along with engagement in their promotion.

7.5.1. AWARENESS AND USE OF SRH SERVICES A dimension of access, as shown in Table 21, considers number of services that SRH facilities can provide to adolescents in their communities and from which they can get informed and learn.

TABLES 21: RECOGNITION OF SRH SERVICES FROM WHICH TO GET INFORMATION GENDER

DEPT

COVERAGE AWARENESS FROM 0 TO 9

STD SERVICE

HIV SERVICE

FAMILY PLANNING SERVICE

PREGNANCY SERVICE

Kanel

0.04

0.60%

0.00%

Matam

0.25

1.90%

5.60%

2.80%

2.00%

Ranerou

0.13

0.00%

6.20%

Kanel

0.70

5.60%

12.20%

11.10%

Matam

0.46

3.00%

14.70%

10.20%

5.40%

Ranerou

1.00

0.00%

50.00%

25.00%

0.00%

Totals

All

0.32

2.28%

8.80%

5.68%

3.46%

GENDER

DEPT

Female

Male

Female

Male Totals

BIRTH SERVICE

POSTABORTION CARE

SEXUAL ABUSE REFERRAL

UN-WANTED PREGNANCY SUPPORT

KNOWLEDGE ON THE MENSTRUAL CYCLE

Kanel

0.60%

0.00%

1.20%

0.00%

1.20%

Matam

2.20%

0.90%

3.10%

3.70%

0.90%

1.60%

Ranerou

0.00%

6.20%

0.00%

Kanel

8.90%

6.70%

0.00%

Matam

5.40%

2.40%

1.30%

0.90%

0.20%

Ranerou

20.00%

0.00%

5.00%

0.00%

All

3.67%

1.59%

2.77%

2.70%

0.69%

0.97%

OTHERS

By looking at the table visually, it can be seen that the presence of reds (0%) greatly outweighs the green values (highest values), which entails that the lack of knowledge about SRH services provided in across Department is very significant all across. Another important variation is between genders, male adolescents recalled a higher number of SRH services than female adolescents. The indication of greater exposure of male adolescents to SRH facilities is further corroborated in Table 22 when respondents named the health facilities from which relevant information can be collected.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C)

TABLE 22: NAMING HEALTH FACILITIES FROM WHICH TO GET SRH INFORMATION

GENDER

Female

Male

DEPT

KNOW HEALTH FACILITIES TO GET SRH INFORMATION FROM**

HOSPITAL/ HEALTH POST

DEPARTMENT OF SPORT EDUCATION (CDEPS)

OTHERS

Kanel

4.10%

3.60%

0.00%

0.60%

Matam

10.70%

8.80%

1.30%

1.90%

Ranerou

6.20%

0.00%

Kanel

11.10%

0.00%

Matam

13.20%

12.10%

1.30%

0.90%

Ranerou

25.00%

0.00%

The facilities that were most-recurrently indicated as the ones from which SRH information can be collected are health posts at the community-level. Very few mentions of other associative-types of platforms in which SRH issues can be discussed among peers. To have an overview of how teenagers are linking the health facilities to types and relevance of information, additional nuances were given to understand how adolescents interface with SRH services by asking the following three sub-questions: 1. In these structures, what are the SRH domains [ref. to Table 9] for which information and advice may be available to you? 2. In terms of clinical management for SRH issues, what services are offered in these structures dedicated to adolescents and young people? 3. Have you ever used any SRH service from a health facility? Table 23 shows the results from the analysis of findings referring to the questions above, which values are expressed in integers to reflect how many options out of a possible total were selected. The value in percentage is measuring the actual degree of access to SRH domains of knowledge.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C) / BASELINE RESULTS

TABLE 23: NAMING HEALTH FACILITIES FROM WHICH TO GET SRH INFORMATION

DEPT

Kanel

Matam

Ranerou

GENDER

EDU Y N

COVERAGE AWARENESS** (OUT OF 9)

ACCESS SRH INFORMATION SOURCES** (OUT OF 8)

AWARENESS SRH SERVICES YOUTH** (OUT OF 8)

USE SRH SERVICE**

Female

No Edu

0.18

0.12

Female

Some Edu

0.04

0.38

0.12

Male

No Edu

0.11

0.56

0.67

Male

Some Edu

0.85

1.56

1.22

Female

No Edu

0.14

0.42

0.22

Female

Some Edu

0.28

0.63

0.47

Male

No Edu

0.12

0.4

0.54

Male

Some Edu

0.55

0.87

0.99

Female

No Edu

0.67

1 out of 3

Female

Some Edu

0.62

1.15

Male

No Edu

0.25

0.5

Male

Some Edu

1.19

1.56

1.62

0.51

0.88

0.94

5.65%

0.20

0.53

0.36

2.07%

Total Male Total Female

All

The results of the multiple awareness scores are on average very low and the use of SRH is also on the single digits. Such low knowledge of SRH domains and related services from which to collect relevant information that speaks to the reality of adolescents is a great barrier to use of existing services. This finding also responds to evaluation question #8 that seeks to establish a relationship between the awareness of adolescents about key topics in SRH and how does it affect access to services. The project is expected to become a strong driver in affecting both. Table 24 provides a more in-depth understanding of other sources of SRH information recognised by adolescents.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C)

TABLE 24: CHANNELS FROM WHICH INFORMATION ON SRH COMES FROM NAME OF CHANNEL FROM WHERE SRH INFO

FEMALE

MALE

Kanel

Matam

Ranerou

Kanel

Matam

Ranerou

Radio

24.00%

14.49%

0.00%

25.81%

16.92%

0.00%

Television

36.00%

22.22%

11.11%

35.48%

19.23%

16.67%

Newspaper

0.00%

1.45%

0.00%

3.08%

0.00%

Internet

8.00%

8.70%

0.00%

16.13%

10.77%

16.67%

Community

12.00%

23.19%

44.44%

6.45%

29.23%

66.67%

Friends

4.00%

11.59%

22.22%

12.90%

10.00%

0.00%

Family

16.00%

18.36%

22.22%

3.23%

10.77%

0.00%

The main channel in Kanel to receive SRH is the television for both female and male adolescents whereas the community seems to be main platforms for teenagers to exchange SRH information in both Matam and Ranerou. It is worth to underline that Kanel has consistently scored low in many other dimensions of SRH awareness, so it can be assumed that face-to-face exchange of information is a more effective means to facilitate the up-take of SRH and nutrition-related knowledge and practices.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C) / BASELINE RESULTS

7.5.2. PARTICIPATION IN AND PROMOTION OF SRH SENSITIZATION The last dimension to be analysed for outcome indicator 3 measuring access to SRH is shown in Table 25 and focused on participation in SRH sensitization through the following key questions: o Did you participate to information sessions or sensitization campaign in relation to SRH of adolescents in your community? [Yes/No] o Would you encourage your peers to get more information about SRH? [Yes/No]

TABLE 25: PERCENTAGE OF ADOLESCENTS PARTICIPATING TO SRH PROMOTION GENDER

Female

Male

Total Male Total Female

DEPT

EDU Y N

PARTICIPATION IN SRH SENSITIZATION**

ENCOURAGE OTHERS SRH**

Kanel

No Edu

3.00%

42.40%

Kanel

Some Edu

2.90%

66.90%

Matam

No Edu

3.40%

53.70%

Matam

Some Edu

6.70%

74.50%

Ranerou

No Edu

33.30%

Ranerou

Some Edu

7.70%

61.50%

Kanel

No Edu

0.00%

33.30%

Kanel

Some Edu

8.30%

77.80%

Matam

No Edu

8.90%

50.50%

Matam

Some Edu

25.40%

79.30%

Ranerou

No Edu

0.00%

50.00%

Ranerou

Some Edu

37.50%

56.20%

All

19.72%

71.72%

5.40%

67.54%

The table above shows a significant difference between genders in the number of adolescents that are participating to SRH sensitization. Because of the same reason, the highest reported values to participate and to encourage others in doing the same were expressed by male adolescents in Ranerou and Matam. The majority of adolescents wish to encourage others get more information about SRH, which demonstrates the overall openness to SRH knowledge.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C)

7.6. OUTCOME INDICATORS 1,2,3 COMPOSITE BASELINE VALUES This last section is dedicated to the analysis of the composite score for baseline indicator 1,2, 3 and the food consumption score, which remains an important proxy for the overall nutritional status of adolescents. Table 26 shows the mean values for the composite scores while Table 27 presents the median value to appreciate the distribution of data for each indicator more in-depth.

TABLE 26: AVERAGE VALUE OF BASELINE INDICATORS COMPOSITE SCORES

GENDER

DEPT

BASELINE OUTCOME INDICATORS 1&2

BASELINE OUTCOME INDICATOR 3

FOOD CONSUMPTION SCORE

MEAN

EDU Y N

Kanel

No Edu

11.55

0.76

39.94

Kanel

Some Edu

13.49

1.35

50.85

Matam

No Edu

10.78

1.39

48.69

Matam

Some Edu

13.26

2.51

55.31

Ranerou

No Edu

3.33

58.11

Ranerou

Some Edu

15.15

2.62

59.28

Kanel

No Edu

9.5

1.67

41.06

Kanel

Some Edu

13.51

4.82

56.19

Matam

No Edu

9.23

1.69

51.77

Matam

Some Edu

12.73

3.88

59.96

Ranerou

No Edu

12.25

2.25

68.29

Ranerou

Some Edu

15.19

5.94

71.14

Schooled females

13.34

2.27

54.47

Unschooled females

10.94

1.32

47.45

Schooled males

12.94

4.10

59.75

Unschooled males

9.36

4.19

50.74

Female

Male

The composite scores are higher for schooled teenagers for both genders, especially in Ranerou. Slight variations are noticeable between genders, with the exception of indicator for outcome 3. Male adolescents are more likely to know the existence of SRH facilities in the community and to use them, or to participate more actively in SRH sensitization activities. The exposure to SRH services is a probable result of gender norms.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C) / BASELINE RESULTS

TABLE 27: MEDIAN VALUE OF BASELINE INDICATORS COMPOSITE SCORES

GENDER

DEPT

BASELINE OUTCOME INDICATORS 1&2

BASELINE OUTCOME INDICATOR 3

FOOD CONSUMPTION SCORE

MEDIAN

EDU Y N

Kanel

No Edu

31.83

Kanel

Some Edu

53.42

Matam

No Edu

45.67

Matam

Some Edu

55.83

Ranerou

No Edu

Ranerou

Some Edu

Kanel

No Edu

34.33

Kanel

Some Edu

54.58

Matam

No Edu

53.33

Matam

Some Edu

61.5

Ranerou

No Edu

12.5

1.5

70.08

Ranerou

Some Edu

73.17

Schooled females

55.83

Unschooled females

44.33

Schooled males

61.33

Unschooled males

52.50

Female

Male

The median values further confirm the findings from the average scores. Schooled adolescents have a greater likelihood to improved KAP on SRH while access and use of SRH services is still gender-defined in favour of male adolescents.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C)

7.7. ADDITIONAL ANALYSIS OF THE COMPOSITE SCORES In this section a series of additional graphs can further help the analysis of the large amount of descriptive data provided so far in tabular form. The initial area of interest is to explore the distribution of outcome indicators values in Graph 3 to assess whether the scores are normally distributed and can be further explored through Gaussian inferential modelling.

GRAPH 3: DISTRIBUTION OF OUTCOME INDICATORS SCORES

From Graph 3, it seems all outcome indicators follow a normal distribution. The only difference is in the distribution for outcome indicator 3 which seems a little skewed to the right while the one for outcome indicators 1 and 2 is optimally bell shaped and can be considered as normally distributed. Since outcome values are normally distributed, they can be put in relationship with other composite scores, mostly related to SRH awareness. Through the Pearson method a set of correlations (which square value denotes coefficients of determination) are included in Graph 4. These figures which explain a measure of linear correlation between the list of variables along the x and y axis.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C) / BASELINE RESULTS

GRAPH 4: DISTRIBUTION OF OUTCOME INDICATORS SCORES

The graph above shows that the strongest correlation (0.82) exists between the baseline outcome indicator 3 and awareness about the existence of SRH services for youth and their use. As expected, metrics on awareness, use and relevancy of SRH services for adolescentsâ&#x20AC;&#x2122; needs also influence each other. In terms of unexpected correlations, knowledge of breastfeeding seems to be moderately correlated with handwashing habits by a factor of 0.28 and knowledge of food habits during pregnancy also positively correlate with baseline indicators 3 by a factor of 0.3. Importantly, there is a relatively strong correlation between baseline indicators 1,2 and 3 by a factor of 0.41 which can be interpreted as a mutually reinforcing relation between access/use of SRH services and KAP trends.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C)

TABLE 28: SELECTED CORRELATION SCORES

Table 28 describes correlations highlighted above and other ones in visual and numerical forms. The values with 3 asterisks indicate 95% confidence. The value of this graph is to appreciate how the distribution of different scores follow certain patterns that can be understood from a visual perspective. The left side of the graph is meant to provide visual inputs on the relationships between all selected variables while the right one shows the correlation values using the Pearson method. The visualisation of the relationship between baseline indicators 1&2 and indicator 3 is particularly compelling since there seems to be an acceleration between the use and access of SRH services and KAP of adolescents. The same trend can be inferred, although to a lower extent, between handwashing and the composite indicator for KAP. Although causation cannot be inferred from these linear correlations, it is possible to assume that greater access/use of SRH services and higher practice-related scores (such as food consumption and handwashing) reinforce each other.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C) / BASELINE RESULTS

TABLE 29: SELECTED CORRELATION SCORES (2)

Table 29 represents a deep dive on exploring relationships between different types of SRH and nutrition knowledge, which can also address evaluation question #1 meant to discuss the relationship between expected knowledge about SRH and nutritional status of targeted teenagers. The correlation table does not show strong correlation but some indicative relationship, all below a factor of 0.3. The food consumption score seems to have a relatively moderate relationship with knowledge about food types during pregnancy and of SRH services in the community. One of the possible reasons why correlations are quite weak when relating types of knowledge with each other is low awareness of SRH across all Departments in Matam, which also explains the lack of normally distributed categorical variables (values tend to be clustered around 0).

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C)

To appraise possible explanatory variables for the food consumption score table 30 below shows a set of key determinants that affect the nutritional status of adolescents from a livelihood and household structure perspective. The table also provides initial ground to respond to the evaluation question #2.

TABLE 30: LIVELIHOOD DETERMINANTS FOR THE FOOD CONSUMPTION SCORE4

Most independent variables with exception of location and household assets are significant in explaining the drivers for the food consumption score, but the analysis of the coefficients give additional insights on the most important determinants. Even though there are variations between locations in the descriptive tables presented so far, the geographical distribution has no-influence in this regression model probably because the spread of the respondents in not evenly balanced and the outliers cannot explain the other patterns of evidence. On the contrary, gender, schooling status and whether other siblings have children are all influential factors. The direction of each relationship follows what was expected but the amount of assets at the household does not feature as such a relevant dimension to explain the nutritional status of adolescents, which entails that access to education and gender are the most relevant coefficients in this context. Table 31 provides with additional insights on the incidence of awareness/use of SRH services and knowledge of food habits during pregnancy on nutritional status, which relates to evaluation questions #1 and #3.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C) / BASELINE RESULTS

TABLE 31: SRH SERVICE INCIDENCE ON THE FOOD CONSUMPTION SCORE

The results of the multi-variate regression indicate that the food consumption score is determined in a statistically significant way by knowledge of SRH domains, awareness about their availability and use of SRH services. Albeit access is a positive driver, the results from the proposed model indicates gender to be the strongest explanatory factor in the food consumption score. From both inferential models, the gender dimension increases in its relevance when including access or livelihood-related considerations as explanatory factors. The project will need to tackle gender norms and relations if an improved nutritional status of teenangers is expected to be achieved.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C)

8. CONCLUSIONS AND MAIN RECOMMENDATIONS 8.1. OUTCOME BASELINE VALUES OUTCOME DIMENSIONS OF CHANGE

KEY FINDINGS

Knowledge of SRH domains

The recognition of SRH domains is very low across the three Departments, especially among unschooled adolescents. The global average value of services indicated by adolescents sampled for the baseline is 0.58 out of 8. Access to education seems like an important entry point to accelerate the uptake of knowledge related to SRH domains.

Knowledge of SRH legal entitlements

Only 9.23% of the total sample recognised legal entitlements related to SRH and 3.19% identified NGO work in reference to SRH rights. This value is especially low for unschooled population, which is a recurrent trend across all Departments. Moreover, the limited engagement of NGOs and local authorities in the SRH space in Matam drives down the perception of SRH as a right instead of just a health issue.

Knowledge about malnutrition and pregnancy

Almost 70% of adolescents are aware about the issue of malnutrition and among them 92.33% can recognise its consequences. Therefore, the awareness of the fact that malnutrition translates to new-borns is widespread and represents a leverage for the project to reinforce the link with SRH issues and services. Yet, when measuring awareness about optimal food habits during pregnancy and breastfeeding practices, the average scores remain pretty low: 1.09 on a scale to 7 and 2.56 on a scale to 5 respectively.

RECOMMENDATION

The overall low level of knowledge about basic SRH information, nutrition practices during and after pregnancy and legal entitlements gives the project the opportunity to potentially fill an important gap in the way teenagersâ&#x20AC;&#x2122; interface with SRH and its nutrition-related implications. The importance to invest resources in creating awareness about SRH rights has wider consequences on gender norms and on the ability of female adolescents to postpone their first pregnancy.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C) / CONCLUSIONS AND MAIN RECOMMENDATIONS

OUTCOME DIMENSIONS OF CHANGE

KEY FINDINGS

Attitude towards life-decisions

Life decisions are mainly determined by both parents for male and female adolescents. Yet, it is quite common to discuss about SRH issues with the opposite gender in the village and with the same gender at school. Both pair educators and male figures play a limited role and indicates that teenagers already seek for a more gender-balanced approach in accessing SRH knowledge than what provided within the households and the community.

Attitude towards selfdetermination

Only 13.59% of the total number of sampled adolescents can decide for themselves on SRH rights and practices, which confirms their limited ability to act independently in this sphere of their lives. In a collectivist society this is to be expected, especially when considering the role of family members and the community in the decisions of teenagers.

Attitude towards consent

More than half of sampled teenagers (51.41%) recognise the issue of female adolescentsâ&#x20AC;&#x2122; consent and the trend is the same for both genders. On the contrary, male adolescents are less likely to value protection than female counterparts. This can be interpreted in many ways, for example as an attempt at minimising the risk of pregnancy.

RECOMMENDATION

The attitudes of teenagers in regard to SRH seems problematic. Less than half of adolescents value the use of contraceptives and just about half believes in the value of consent. Yet, a silver lining appears when analysing the relative openness of adolescents to exchange with the opposite gender on SRH issues. Yet, the project will need to look at SRH from a gender norm and consent perspective other than just from a bio-medical one. The importance to create dignifying relationships between adolescents can have wider and more long-lasting effects if tackled as early as possible in collaboration with communityâ&#x20AC;&#x2122;s stakeholders and households.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C)

OUTCOME DIMENSIONS OF CHANGE

KEY FINDINGS

Practice of protection

Among the adolescents that already had an intercourse, only 28.68% used protection. The difference between gender is very significant, in fact it was twice more likely for adolescent males to use protection, which further highlights the risk of early pregnancy. The use of contraceptive remains a key SRH issue with such low level of their use.

Practice of nutrition

The overall nutritional status of adolescents measured through the food consumption score is above the acceptability threshold, its average value is 54.73 for the whole sample. Yet, there are important variations and for some sub-groups (unschooled adolescents in Kanel) the value is below the threshold.

Practice of handwashing

The practice of handwashing seems to be more mainstreamed among teenagers and an average of 4.37 practices were recognised as key moments. The variation between gender is minimal while there is a difference in the frequency of different key moments. For instance, washing hands after changing a diaper is less frequently recognised (51.67%) than washing hands after using the toilet (91.09%).

RECOMMENDATION

The nutritional status of adolescents and practice of handwashing seem to be above acceptability for both genders, with the notable exception analysed in the report. Yet, protection is reported from less than a third of teenagers that are sexually active. As noted before the low value given to protection translate in its limited adoption, especially from male adolescents. The role of the project should be to empower female adolescents to make their own decision with reference to protection, which seems limited also from a practice perspective.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C) / CONCLUSIONS AND MAIN RECOMMENDATIONS

OUTCOME DIMENSIONS OF CHANGE

KEY RELATIONSHIPS TO MONITOR

Coverage of SRH services

An average of 0.32 SRH services in a scale up to 9 were recognised by teenagers, which is a very low value overall. The SRH service that was recognised the most relates to HIV while the one that was recognised the least as a service provided by SRH facilities is education on the menstrual cycle.

Use of SRH services

As expected by the low number of SRH services identified by adolescents, an equally low proportion uses them. Just 3.56% of respondents indicated the use of one SRH service in their area. To confirm limited knowledge and use of relevant SRH services, only 0.59 of such services were considered as applicable to the needs of teenagers.

Participation in SRH sensitization

Despite such low recognition and use of SRH services, a relatively higher proportion (11.09%) of adolescents participated to an SRH sensitization campaign or session. The percentage of adolescents exposed to SRH sensitization is still low but the willingness to engage peers in promoting SRH is surprisingly high (69.20%). This clearly shows a great interest in engaging with SRH issues among teenagers.

RECOMMENDATION

The awareness about the existence of SRH services and their use is generally low across all Departments. The most direct reason seems to be low knowledge about SRH domains and the key considerations for nutrition during and after pregnancy. Despite the limited use of SRH services and participation in SRH sensitization, there is great willingness to engage more peers in the discussion and in getting additional information on this subject. The project can leverage on that to ensure peer-topeer conversation takes place also between opposite genders, which is already happening. Steering these horizontal exchanges could generate a greater return from the project, especially when the role of adults is weak and might reinforces existing gender and social norms that are necessary to change in order for the project to produce lasting effects.

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C)

8.2. KEY EVALUATION QUESTIONS AREAS

KEY FINDINGS AND RECOMMENDATIONS

1. Relationship between knowledge about SRH domains and the nutritional status of adolescents

The relationship between knowledge of SRH and the nutritional status of adolescents is characterized by a moderate correlation between the food consumption score and knowledge related to food habits during pregnancy, which is further confirmed inferentially. In addition, the overall KAP score in baseline indicator 1&2 also seems to have a moderate correlation with the nutritional status of teenagers. Yet, these values are relatively low and there are additional factors to be explored that could further explain this relationship.

2. The key determinants in the nutritional status of adolescents from a livelihood and household structure perspectives

Additional determinants to explain the nutritional status of teenagers were considered through a multi-variate model which generated strong coefficients for gender, educational status and location as explanatory factors for the food consumption score. The role of assets and size of the household are less significant and influence the nutritional status in a more limited way.

3. The incidence of use of SRH services and gender with nutritional status

In another multi-variate model, the food consumption score was explored through a set of variables related to SRH service use and the results pointed out that gender is the strongest coefficient along with use of SRH services. In light of these results, the role of access to SRH can be stated as a determinant while gender remains a crosscutting explanatory variable that also drives the nutritional status of teenagers in Matam.

4. The key referent points for adolescents in relation to SRH and life-decisions

The key referent points for life decisions among adolescents who participated to the survey are both parents. Yet, the exchange on SRH issues takes place among peers. Interestingly, male adolescents are more likely to rely on peers of the opposite gender for these discussions outside of school and on peers of the same gender when at school. The same is true for female adolescents. This trend outlines a certain degree of openness among teenagers which could be leveraged upon to improve SRH.

5. The opinions/values that inform the decision of adolescents with respect to SRH

The way adolescent perceive consent is a worrying factor. Only half of the respondents recognise the right of female adolescents to express consent. In addition, less than a third of male adolescents value the use of protection while female adolescents are more likely to value contraceptive methods. These low values indicate the important issue to tackle about gender norms and SRH rights among teenagers.

6. The awareness of legal entitlements and adolescentsâ&#x20AC;&#x2122; act on them

Legal entitlements associated to SRH are known by less than 10% of the overall sample, which indicates a limited ability to recall the legal implications of SRH abuses. In addition, the ability to take independent decisions on SRH is limited for both genders but especially for female adolescents (8%) w.r.t male (22%). Such difference further reinforces the differential from a normative perspective, which the project seeks to address.

7. The expected changes for school teachers and health service providers in addressing relevant SRH and nutritional practices

The low knowledge about SRH services in the community brings teenagers to interact with peers when attempting to understand SRH issues. Therefore, the role of educators or health practitioners is extremely limited. If the project is successful, a steep increase in their role as focal points for SRH should emerge from KAP evidence.

8. The overall awareness about key topics in SRH and how does it affect access

The relationship between perceived coverage of SRH services and their use is very weak at the moment since most adolescents are not aware about their existence. As SRH sensitization increases, the assumption to be validates is whether use of SRH services at health facilities also increases.

9. What is the feedback on the content and quality of training and how it affects uptake of services

To be addressed in the monitoring system of future evaluations

Male

Female

GENDER

No Edu

Matam

Some Edu

No Edu

Kanel

Matam

Ranerou Some Edu

6.57

6.36

Ranerou No Edu

Some Edu

5.28

No Edu

Kanel

Matam

6.85

Ranerou Some Edu

6.22

6.49

6.08

5.87

4.88

FOOD MADE FROM GRAINS

Ranerou No Edu

Some Edu

Kanel

Matam

No Edu

Kanel

DEPT

EDU YN

2.56

3.75

2.93

1.88

2.97

2.17

3.77

3.67

2.4

2.06

2.58

FOOD FROM ROOTS OR TUBERS

6.19

3.75

5.98

5.34

5.11

4.61

5.33

5.56

5.06

5.18

4.42

VEGETABLES

1.31

1.5

1.95

2.01

1.83

0.72

1.67

2.29

1.81

2.17

1.33

FRUITS

3.19

1.94

1.85

1.89

1.72

2.69

3.33

2.12

1.8

1.74

1.94

MEAT

0.75

1.1

1.19

1.28

0.56

0.62

0.56

1.01

EGGS

6.31

5.63

5.35

4.5

2.33

4.92

5.94

5.34

4.89

4.06

FISH

1.93

1.6

1.93

0.89

2.46

1.33

1.71

2.13

1.55

1.7

DRIED NUTS

5.12

4.51

3.44

4.36

3.56

3.92

3.7

2.74

3.53

2.12

DAIRY PRODUCTS

6.81

6.25

5.67

4.58

4.4

2.5

6.54

5.07

4.35

4.79

2.79

OILBASED FOODS

6.72

6.59

6.78

6.33

5.93

5.57

SUGAR/ HONEY

6.56

6.26

5.9

5.65

6.46

4.33

4.46

4.73

3.11

3.33

COFFEE/ THE

BASELINE TEENAGE NUTRITION FOR CHANGE (TN4C) / ANNEX 1

ANNEX 1: FOOD CONSUMPTION SCORE MEAN VALUES

Action Against Hunger 6 Mitre Passage London, SE10 0ER Tel. : +44 (0)20 8293 6190 Registered Charity: 1047501 Cover photo © Action Against Hunger Designed by Ryan Haydon