Strategies to Increase Milk Consumption by Young Nepali Children

The study will be conducted in close collaboration with Heifer International Nepal, a well‐established branch of Heifer International, an international non‐government organization based in Little Rock, Arkansas. Heifer specializes in community development activities and livestock management training; as part of Heifer's activities, participating households receive 1 or more dairy animals. The proposed study will take place in 3 districts in western Nepal (Bardiya, Surkhet, and Dang) where Heifer has been active and dairy animals have been distributed. Households (n=400) will be eligible for participation if there is at least one child between the ages of 6‐66 months and at least one dairy animal. Household clusters (separated geographically) will be randomly assigned to receive either nutrition education or to control status (no education). Households assigned to control status will be offered the nutrition education after completion of data collection for the proposed project (12 months later). The participants will be one adult in each household (usually the child's mother), and any children in the household between the ages of 6‐66 months. The study design involves 3 household visits, spaced over 12 months (thus: baseline, 6 months, and endline). In addition, information about household dairy animal milk production will be collected on a monthly basis. At the baseline and endline household visits, the mother (or other caretaker) of the target child will be asked to respond to a questionnaire. The questionnaire will be based on standardized tools developed by "Measure Demographic and Health survey (DHS)", specifically the version used in the "2016 Nepal Demographic and Health Survey" conducted by the Government of Nepal (Ministry of Health et al. 2017) (Ministry of Health and Population Nepal et al. 2012). The questionnaire will address (A) household attributes, (B) child diet, (C) child growth, and (D) child development. (A) Household attributes: basic demographics, possessions (used to determine wealth score by standard principal components analysis), hygiene practices, animal ownership, mother's knowledge/attitudes/practices related to child nutrition. (C) Child growth will also be assessed by standard anthropometric techniques (see (Miller et al. 2017) for details) using Seca scales and stadiometers and paper measuring tapes (for head and mid‐upper arm circumferences). The midline visit will include only child anthropometry and child diet record. (B) Child diet: Consumption of animal source foods (ASFs: meat, fish, offal, eggs, or dairy) in the past 24 hours by all children in the household (ages 12‐60 months) will be recorded (Ruel 2003, Steyn et al. 2007), along with the frequency of intake. The quantity of milk and other dairy foods ingested will also be determined. In addition, 16 specific foods/food groups will be documented (Kennedy et al. 2013). Milk and "other dairy products" (yogurt, paneer, cheese, etc.) will be recorded separately. In addition, the number of times in the previous week that the child consumed each of the 16 individual food items will be recorded. A diet diversity score (DDS) will be constructed by aggregating the food groups into 8 categories: starchy staples (grains and white potatoes); vitamin‐A rich fruits and vegetables; other fruits and vegetables; offal, meat, and fish; eggs; legumes, nuts, and seeds; milk and dairy products; oils (Swindale et al. 2006). (D) Child development: relevant sections of the Multiple Indicator Cluster Survey (UNICEF 2015), a standardized questionnaire developed by UNICEF (and validated in Nepal (Government of Nepal 2014)) to assess early child development, will be administered by the enumerator. The child's parent (usually the mother), will respond to questions related to child literacy/numeracy, gross and fine motor skills, social‐emotional development, and learning skills. In addition, the age‐appropriate version of the Ages and Stages Questionnaire will be administered. This simple assessment serves as a screen test for developmental issues by asking the child (or if the child is unable or unwilling to participate) to engage in developmentally appropriate activities such as completing a puzzle, jumping, scribbling with a crayon, or answering simple questions ("How old are you").