Download StudyGeneral

Study Overview

The Sustainable Undernutrition Reduction in Ethiopia (SURE) study: a protocol to evaluate impact and process of an integrated health and agriculture programme to improve child feeding practices
Study is 3ie funded:
Study ID:
Initial Registration Date:
Last Update Date:
Study Status:

The Sustainable Undernutrition Reduction in Ethiopia (SURE) programme is the first Government-led multi-sectoral intervention to deliver improved complementary feeding and dietary diversity among young children in Ethiopia. This mixed methods observational study aims to evaluate the impact and process of the SURE integrated health and agriculture programme. We hypothesise that the package of SURE interventions including integrated health and agriculture behaviour change communication for nutrition, systems strengthening, and multi-sectoral coordination will result in detectable differences in the minimum acceptable diet (MAD) in children 6-23 months of age and stunting among children 24-47 months of age between intervention and comparison groups. To inform interpretation of outcomes and to enable beneficial adaptation of the intervention, we will investigate the fidelity, dose and reach of implementation; mechanisms of impact; and contextual factors interacting with the intervention.

Registration Citation:

Eshetu, S. and Dangour, A., 2017. The Sustainable Undernutrition Reduction in Ethiopia (SURE) study: a protocol to evaluate impact and process of an integrated health and agriculture programme to improve child feeding practices. Registry for International Development for Impact Evaluations (RIDIE). Available at: 10.23846/ridie118

Agriculture and Rural Development
Health, Nutrition, and Population
Additional Keywords:
Complex intervention, impact pathways, process evaluation, growth, behaviour change, frontline workers
Secondary ID Number(s):

Principal Investigator(s)

Name of First PI:
Solomon Eshetu
Ethiopian Public Health Institute (EPHI)
Name of Second PI:
Alan Dangour
London School of Hygiene and Tropical Medicine (LSHTM)

Study Sponsor

Children’s Investment Fund Foundation (CIFF)
Study Sponsor Location:
United Kingdom

Research Partner

Name of Partner Institution:
Ethiopian Federal Ministry of Health
Type of Organization:
Government agency (eg., statistics office, Ministry of Health)

Intervention Overview


The SURE programme is a complex intervention that aims to develop and integrate activities of the health and agriculture sectors to deliver services for nutrition outcomes, namely improved child complementary feeding and dietary diversity. The programme will deliver an enhanced Community-Based Nutrition (CBN) intervention with the following components: 1) infant and young child (IYCF) counselling and agriculture advising [mothers and fathers of children under two years of age (CU2)]; 2) nutrition services including growth monitoring and promotion, vitamin A supplementation and deworming, and acute malnutrition screening [mothers of CU2]; 3) agriculture inputs including improved seeds or poultry [low-income mothers of CU2]; 4) men’s and women’s group dialogues and 5) cooking demonstrations on foods for CU2 [community]; 6) media messages on IYCF and dietary diversity [community]; 7) systems strengthening including nutrition training for health and agriculture extension workers [sub-district]; and 8) nutrition multi-sectoral coordination mechanisms at local levels [district and sub-district]. The programme objectives are to improve IYCF and dietary diversity and to decrease stunting.

Theory of Change:
Multiple Treatment Arms Evaluated?

Implementing Agency

Name of Organization:
Government of Ethiopia: Federal Ministry of Health, Federal Ministry of Agriculture and Natural Resources
Type of Organization:
Public Sector, e.g. Government Agency or Ministry

Program Funder

Name of Organization:
Children’s Investment Fund Foundation (CIFF)
Type of Organization:
NGO (International)

Intervention Timing

Intervention or Program Started at time of Registration?
Start Date:
End Date:
Evaluation Method

Evaluation Method Overview

Primary (or First) Evaluation Method:
Difference in difference/fixed effects
Other (not Listed) Method:
Additional Evaluation Method (If Any):
Other (not Listed) Method:

Method Details

Details of Evaluation Approach:

The SURE study is a mixed method, theory-based evaluation with impact and process evaluation components. Impact will be estimated through baseline and endline surveys to detect differences in stunting and minimum acceptable diet (MAD) between children in intervention and comparison groups. Impact on stunting and MAD will be estimated through mixed effects models with a random effect for cluster (kebele, a sub-district administrative area) to account for correlations among women and children in the same cluster. Fixed effects will be area (intervention vs comparison), time (follow up versus baseline) and the interaction between area and time, which estimates the change from baseline to follow up in the intervention area relative to change in the control area (analogous to a difference in differences approach). Process evaluation will use mixed methods and will include qualitative studies examining 1) the fidelity and dose of the programme delivered, 2) barriers and facilitators of behaviour change along the programme impact pathway, and 3) context. Quantitative data will estimate reach and casual mediation analyses will be explored to identify pathways of impact.

Outcomes (Endpoints):

The primary outcomes of interest are linear growth failure or stunting in children 24-47 months, as measured by height-for-age z (HAZ) score, and minimum acceptable diet in children 6-23 months of age. Secondary outcomes are minimum dietary diversity among children 6-23 months (MDD), minimum dietary diversity score for women (MDD-W), household food insecurity access score (HFIAS), number of food groups produced and consumed at household level, father’s contribution to child care, and multi-sectoral coordination.

Unit of Analysis:
Stunting, MAD, MDD and MDD-W-- Individual (child/mother); Food security, food production, father’s contribution to child care-- Household; Multi-sectoral coordination -- District and Sub-district

We hypothesise that exposure to the SURE intervention will decrease stunting and increase child minimum acceptable diet in the intervention areas compared to comparison areas. We further hypothesise that effects of SURE will be mediated by variables along the impact pathways including: multi-sectoral coordination, household dietary diversity, number of food groups produced and consumed at household level, and father’s support of child care practices at household level.

Unit of Intervention or Assignment:
Number of Clusters in Sample:
Baseline – 288 kebeles in 72 districts; Endline – 432 kebeles in 72 districts. A kebele is a defined sub-district administrative area in Ethiopia.
Number of Individuals in Sample:
Baseline – 4,980 children 0-47 months; Endline – 7,456 children 0-47 months
Size of Treatment, Control, or Comparison Subsamples:
Treatment – 3,728 children 0-47 months in 216 kebeles in 36 districts; Control – 3,728 children 0-47 months in 216 kebeles in 36 districts

Supplementary Files

Analysis Plan:
Other Documents:

Outcomes Data

Household surveys will be used to assess impact and process including coverage.
Data Already Collected?
Data Previously Used?
Data Access:
Data Obtained by the Study Researchers?
Data Approval Process:
Approval Status:

Treatment Assignment Data

Participation or Assignment Information:
Data Obtained by the Study Researchers?
Data Previously Used?
Data Access:
Data Obtained by the Study Researchers?
Data Approval Process:
Approval Status:

Data Analysis

Data Analysis Status:

Study Materials

Upload Study Materials:

Registration Category

Registration Category:
Prospective, Category 1: Data for measuring impacts have not been collected

Completion Overview

Intervention Completion Date:
Data Collection Completion Date:
Unit of Analysis:
Clusters in Final Sample:
Total Observations in Final Sample:
Size of Treatment, Control, or Comparison Subsamples:


Preliminary Report:
Preliminary Report URL:
Summary of Findings:
Paper Summary:
Paper Citation:

Data Availability

Data Availability (Primary Data):
Date of Data Availability:
Data URL or Contact:
Access procedure:

Other Materials

Survey Instrument Links or Contact:
Program Files:
Program Files Links or Contact:
External Link:
External Link Description:
Description of Changes:

Study Stopped