Improving Nutrition in Nepal: An analysis of food environments, behavioral determinants of consumption, and costs of a multisectoral nutrition program

Thesis (Ph.D.)--University of Washington, 2023Despite significant gains to achieve national nutrition targets in Nepal, infant and young child feeding practices remain sub-optimal. Increased consumption of processed foods high in sugar, salt, and fat in conjunction with low dietary diversity and micronutrient deficiency lead to poor overall diets and nutritional outcomes. Understanding external and personal drivers of infant and young child feeding practices are a key step to design behavior change strategies that improve child nutrition outcomes. Economic evaluations of multi-sectoral nutrition programs aimed to improve child diets can also be used to inform program design and decision making for budgeting and resource allocation. The objective of this dissertation was to identify food environment and behavioral determinants of infant and young child feeding behaviors and costs of a scaled-up program focused on improving child nutrition outcomes.The first study used data collected from households in a cross-sectional survey representative of 42 districts in Nepal. We assessed associations between food environments and child dietary consumption using a novel scale to measure perceived food environments. Vegetable food environments were significantly associated with reaching minimum dietary diversity, while processed snack food environments were associated with unhealthy diets and consumption. Food safety, year-round access, and accessibility of vegetables as well as marketing, availability, convenience, and food safety of processed foods influenced these relationships. Living in a food oasis was protective against unhealthy diets and consumption while living in a food desert or food swamp was associated with unhealthier diets. The second study employed the Theoretical Domains Framework to identify behavioral determinants of key infant and young child feeding practices using data from four years of cross-sectional monitoring surveys in Nepal from the Suaahara II program. We observed that responsive feeding skills, knowledge of timely introduction of complementary foods, and active participation in community health groups were associated with child dietary diversity. Meeting with female community health volunteers modified the relationship between feeding skills and diet diversity. The third study applied a mixed methods approach combining financial and economic costs to estimate total incremental and unit costs of the Suaahara II scaled up multisectoral nutrition program. In addition, we estimated time use of volunteers and participants in community-based nutrition programs. We demonstrate that costs of scaled up programs can be substantial especially when considering contributions made by volunteers and program partners. Community health and agriculture extension volunteers contributed significant time to the program