Improving Nutritional Status through Behavioral Change: Lessons from

Madagascar

January 11, 2008, Emanuela Galasso & Nithin Umapathi

A recent impact evaluation study of a community based nutrition program in Madagascar shows that malnutrition
can be improved over the short- and long-term when mothers participate in community health programs that
promote behavioral change in nutrition, feeding, and hygiene practices. The study highlights important
complementarities between maternal education, knowledge, and community infrastructure to achieve improvements
in children’s nutritional status.

Nearly one-third of children in the developing world are either underweight or stunted. Child nutrition has direct, short-
term impacts on health outcomes and important long-term cognitive functions, school performance, and productivity
1
consequences later in life. Research has shown that economic growth alone (by reducing poverty over the long run)
2
is not sufficient to achieve desired reductions in malnutrition rates.

Understanding direct nutrition interventions and how they work best under different conditions has great policy
3
relevance for improving immediate health outcomes and stemming the intergenerational transmission of poverty.

Direct nutrition interventions are generally based on a heuristic model of the production of nutrition based on three
pillars: nutrients (through food or supplementation), health and sanitation services (to protect from diseases), and the
role of child care.

Evidence from programs that focus on child care and promoting behavioral change in child care practices is
relatively scant

Policy research working paper 4424 (December 2007) provides one of the few rigorous ex post evaluations on the
4
effectiveness of community based nutrition programs. The program in Madagascar (SEECALINE) targets children
from birth to three years of age and pregnant/lactating women.

The preventive approach involves a monthly growth-monitoring and promotion activity facilitated by a local nutrition
worker. Adoption of improved hygiene, child care, and nutrition practices is promoted through a community based
approach of communication with locally adapted messages.

To identify the causal effect of the program, the study design addresses the non-random selection of
communities into the program

The selection process takes into account the purposive targeting of the program to the most malnourished districts of
the country, as well as the potential differences in unobserved characteristics (such as motivation) arising from the
decision of the communities to participate in the program.

The evaluation design builds on two nationally representative surveys administered before and after the program over
seven years, which are longitudinal at the community level and done in close collaboration with the Madagascar
National Statistical Institute.

The longitudinal community level design allows the authors to difference out any time-invariant component of the
selection bias and use propensity-score weighted regressions to balance the observable characteristics between
sampled program and nonprogram villages.
 The program targeted the most
malnourished and vulnerable districts
of the country

The figure to the right shows that

communities participating in the program
bridged the weight gap with respect to
non-participating communities in terms of
short-term nutritional outcomes (weight
for age z-scores reduced by 0.15-0.22
standard deviations and the incidence of
underweight children reduced by 5.2-7.5
percentage points).

The overall share of observed

improvements in nutrition nationwide
(reduced malnutrition rates) between
1997/98 and 2004 attributable to the
program (using the estimates above)
ranges between ¼ and ⅓.

The figure on height shows the protective

effect of the program on longer-term
nutritional outcomes (reversing the trend
in stunting). This result is particularly
important in light of the fact that program
communities had a higher incidence of
shocks and experienced higher food
insecurity.

The observed program effects were

obtained through significant
improvements in feeding practices
(exclusive breastfeeding, timing of
weaning, and proactive and responsive feeding) and hygiene practices (appropriate disposal of garbage and toilet
use, and improved methods of water purification).

More educated mothers and households living in better-off areas gain more from the program

The results reveal important socioeconomic gradients—characteristics of the household as well as conditions of the
living environment—that affect the uptake of improvements in practices and nutritional outcomes.

Worse-off households are more likely to have gained from adopting beneficial child care practices, but have greater
difficulty translating new practices into improved nutritional outcomes.

Nutritional gains are larger for households in relatively less poor and remote areas with relatively better infrastructure
(access to electricity, secondary schools, and hospitals).

Knowledge is a necessary but not sufficient condition for improving nutritional outcomes for households
with limited access to complementary resources

The results highlight important policy trade-offs between targeting areas with higher needs—where the initial stock of
malnutrition is higher—and targeting areas with the highest expected impact.

Direct nutrition intervention bundled with complementary interventions in other sectors (health, infrastructure, and
water and sanitation) is the best way to maximize effectiveness in the neediest areas.
Notes

1. Alderman Harold, John Hoddinott, and Bill Kinsey. 2006. “Long Term Consequences Of Early Childhood
Malnutrition.” Oxford Economic Papers 58: 450–74.

2. Alderman Harold, Jere Behrman, and John Hoddinott. 2004. "Malnutrition and Hunger." In Global Crises, Global
Solutions, ed. Bjorn Lomborg. Cambridge (UK): Cambridge University Press.

3. World Bank. 2006. Repositioning Nutrition as Central for Development. A Strategy for Large-Scale Action.
Washington, DC: World Bank. Download book| Order book

4. Galasso, Emanuela, and Nithin Umapathi. 2007. “Improving Nutritional Status through Behavioral Change:
Lessons from Madagascar.” Policy Research Working Paper 4424, World Bank, Washington, DC.

Related Resources

• Development Impact Evaluation Initiative (website)

• Research on Poverty (website)
• Bank Conference “Making Smart Policy: Using Impact Evaluation for Policy Making,” January 15-16, 2008
(website)

Researchers

EMANUELA GALASSO is an economist in the Development Research Group. She serves as the evaluation
coordinator for the Poverty Research Team. Her ongoing work focuses on the medium term and dynamic effects of
anti-poverty programs using multi-year longitudinal surveys in Madagascar and Chile, with particular emphasis on
their distributional impacts. Email: Egalasso@worldbank.org.

NITHIN UMAPATHI is a scholar at the Centre for Microdata Methods and Practice at University College of London.
His research interests include development economics and the econometrics of program evaluation. Email:
n.umapathi@ucl.ac.uk