EVALUATION REPORT Mid-Term Performance Evaluation of the Cambodia Integrated Early Childhood Development (IECD) Activity June 20, 2023 Submitted by: 4350 East-West Highway, Suite 210, Bethesda, MD 20814 Contact Person: Teresita Perez, President and CEO Tel: (301) 652-4334 ◆ Fax: (301) 652-3733 ◆ Email: tperez@engl.com Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity MID-TERM PERFORMANCE EVALUATION CAMBODIA INTEGRATED EARLY CHILDHOOD DEVELOPMENT (IECD) ACTIVITY JUNE 2023 This publication was produced at the request of the United States Agency for International Development Developed under Cooperative Agreement Number: 72044220CA00002 It was prepared independently by: Abigail Beeson, Program Cycle Specialist / Team Leader Soksophea Suong, Evaluation Advisor on Nutrition and ECD Bopha Kong, Research Specialist / Logistician Sophea Seng, Research Specialist / Translator Chey Tech, Fieldwork Specialist Contractor: ME&A, Inc. 4350 East-West Highway, Suite 210 Bethesda, MD 20814 Tel: 240-762-6296 www.MEandAHQ.com DISCLAIMER The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity ABSTRACT The five-year (July 2020 to July 2025) USAID/Cambodia Integrated Early Childhood Development (IECD) Activity is led by RTI International, in partnership with Helen Keller International, Safe Haven, Angkor Hospital for Children, Mekhala Radiant Communications, and Dimagi. IECD seeks to improve holistic developmental outcomes for young children by promoting nurturing care, preventing stunting, and increasing early identification and intervention for children living with disability and developmental delays (CLWD). The mid-term performance evaluation of IECD applied a mixed-methods approach, relying primarily on qualitative methods to collect data to answer two overarching evaluation questions: 1) How have caregivers learned from the IECD Activity? What have been the on-going, unresolved challenges the prime and the sub-partners faced, how to overcome those challenges; and 2) How have IECD’s beneficiaries benefitted from IECD’s interventions? There are also 14 subset questions. The Evaluation Team (ET) collected data from 144 women and 89 men through key informant interviews (KIIs) and focus group discussions (FGDs) and conducted observations, mini-surveys, and online surveys. Sampling targeted female and male caregivers, grandparents, caregivers of children living with disability, male and female village health support group (VHSG) members and child development leaders, commune committees for women and children, health centers, national and subnational government stakeholders, international organizations, and implementing partners. The ET analyzed data using Atlas.ti and ArcGIS. Major findings indicate that key interventions have contributed to improvements with caregiver learning and parenting. Mid-upper arm circumference and Cambodia Community-based Development Milestone Assessment Tool screenings have been accepted, while caregivers including men, women, and grandparents are actively working together to ensure optimal childcare practices in households. Caregivers of CLWD have increased access and knowledge of services and care. Translating nutrition and water, sanitation, and hygiene (WASH) knowledge into practice has not always been consistent across the population, particularly in households with malnourished children and old WASH infrastructure and in areas prone to flooding or that lack water. Identifying mechanisms to leverage the learning and efforts from the VHSG engagement is important, while disseminating findings from the cohort evaluation will provide evidence that is missing, particularly for children living with disability. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity ACKNOWLEDGEMENTS The ET wishes to acknowledge helpful guidance from the USAID/Cambodia team, especially Mr. Chansokvibol Mao for being available to answer questions, while organizing timely and effective feedback on the evaluation process. Additionally, from USAID, the ET would like to thank Dr. Sophanearith Sek, Mr. Sam Oeurn Ke, Mr. Serey Rathanak Suon, and Mr. Tonh Mok for being available to answer questions and provide additional feedback on critical deliverables. The IECD team was especially gracious in hosting the ET for two days in their offices in Phnom Penh. The Chief of Party Mr. John Ames, and Deputy Chief of Party, Ms. Chanpheakdey Chhuor, maintained flexibility and extended themselves to ensure the ET met with the correct specialists and partners most familiar with IECD. The technical specialists were most helpful with providing the ET an effective overview of IECD, while the Provincial Coordinators, Mr. Sokhy Chan and Mr. Meanleap Heng, provided contact details and initial introductions to enable data collection in the provinces. We would especially like to thank the caregivers, volunteers, and government officials working to implement the IECD interventions and who found time to meet with the ET to answer important questions about IECD. Lastly, the ET would like to thank ME&A Home Office staff Christopher Coffman and Ricky Perez, who helped with review of evaluation deliverables and data analysis. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity TABLE OF CONTENTS Executive Summary......................................................................................................................... 1 1. Background of the Local Context and the IECD Activity......................................................... 1 2. Purpose and Evaluation Questions......................................................................................... 4 3. Data Collection........................................................................................................................ 5 3.1 Sampling.......................................................................................................................... 7 3.2 Desk Review.................................................................................................................... 7 3.3 Key Informant Interviews ............................................................................................... 8 3.4 Focus Group Discussions................................................................................................. 9 3.5 Observations................................................................................................................. 10 3.6 Mini-Surveys and Online Surveys ................................................................................. 10 3.7 Co-Collection of Locational Data .................................................................................. 11 3.8 Limitations of the Evaluation Methodology ................................................................. 12 4. Data Analysis......................................................................................................................... 13 4.1. Qualitative Analysis....................................................................................................... 13 4.2 Quantitative Analysis.................................................................................................... 13 5. Findings................................................................................................................................. 14 5.1 EQ 1: How have caregivers learned from nurturing care sessions, community dialogue and home visits to improve how they have nurtured their children? From these interventions, what have been the on-going, unresolved challenges the prime and the sub￾partners faced, how to overcome those challenges?............................................................... 14 5.1.1 EQ 1.1. How did nurturing care work for children?.................................................. 23 5.1.2 EQ 1.2. How did nurturing care work for families with children living with disabilities? ........................................................................................................................... 24 5.1.3 EQ 1.3. In what way are different family members particularly men involved in child nurturing care? ..................................................................................................................... 26 5.1.4 EQ 1.4. How are men’s and women’s roles different in the care of boys and girls? 28 5.1.5 EQ 1.5. 1.6, 1.7., 1.8., 1.9. What are the outcomes to date of male engagement with Who tells stories to the child? Who feeds the child? Who teaches the child new things? Who bathes the child or toilet trains them?............................................................ 30 5.1.6 EQ 1.10. Are community members reporting that children are being referred less, the same, more for nutrition? .............................................................................................. 31 5.2 EQ. 2. How have IECD’s beneficiaries benefitted from IECD’s interventions, including home gardening, income generation, child nutrition screening and WASH?.......................... 33 5.2.1 EQ 2.1. Did the interventions contribute toward improving household food security and child nutrition?............................................................................................................... 39 Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 5.2.2 EQ 2.2. What are the differences in women’s (mother) and men’s (father) roles and how can gender power dynamics improve in food security and child nutrition? Home gardening? Income generation? Child nutrition? WASH?.................................................... 43 5.2.3 EQ 2.3. How did home gardening, income generation and child screening help improve nutrition intake for children with disabilities? ....................................................... 44 5.2.4 EQ 2.4. Are there any unintended consequences or results of the activity interventions?....................................................................................................................... 47 6. Conclusions........................................................................................................................... 50 7. Recommendations................................................................................................................ 50 Annex 1. Evaluation Statement of Work ...................................................................................... 55 Annex 2. Description of The Evaluation Design, Methods, and Analysis..................................... 67 Annex 3. Statements regarding Significant Unresolved Differences of Opinion.......................... 80 Annex 4. Data Collection and Analysis Tools................................................................................ 81 Annex 5: Sources of Information ................................................................................................ 165 Annex 6: Conflict of Interest Disclosure Forms .......................................................................... 173 Annex 7: Evaluation Team Member Qualifications.................................................................... 178 Annex 8: Findings, Conclusions, and Recommendations Matrix................................................ 180 Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity LIST OF TABLES Table 1: Planned versus Completed KIIs......................................................................................... 8 Table 2: FGD Participants by Target Group and Gender ................................................................ 9 Table 3: Mini-Survey Participants by Target Group and Gender.................................................. 11 Table 4: Online Survey Participants by Target Group and Gender............................................... 11 Table 5: Summary of Strengths, Areas for Improvement, and Challenges for EQ1 ..................... 22 Table 6: Summary of Strengths, Areas for Improvement, and Challenges for EQ 1.1 ................. 23 Table 7: Summary of Strengths, Areas for Improvement, and Challenges for EQ 1.2 ................. 26 Table 8: Summary of Strengths, Areas for Improvement, and Challenges for EQ 1.3 ................. 28 Table 9: Summary of Strengths, Areas for Improvement, and Challenges for EQ 1.4 ................. 29 Table 10: Summary of Strengths, Areas for Improvement, and Challenges for EQ 1.5, 1.6, 1.7, 1.8, 1.9 .......................................................................................................................................... 31 Table 11: Summary of Strengths, Areas for Improvement, and Challenges for EQ 1.10 ............. 33 Table 12: Summary of Strengths, Areas for Improvement, and Challenges for EQ 2 .................. 38 Table 13: Summary of Strengths, Areas for Improvement, and Challenges for EQ 2.1 ............... 43 Table 14: Summary of Strengths, Areas for Improvement, and Challenges for EQ 2.2 ............... 44 Table 15: Summary of Strengths, Areas for Improvement, and Challenges for EQ 2.3 ............... 47 Table 16: Summary of Strengths, Areas for Improvement, and Challenges for EQ 2.4 ............... 50 LIST OF FIGURES Figure 1: USAID IECD Activity Coverage in Cambodia .................................................................... 2 Figure 2: IECD Activity Theory of Change ....................................................................................... 3 Figure 3: Distribution of Mini-Surveys, Observations, and Online Surveys.................................... 5 Figure 4: Distribution of Survey Respondents by Percentage........................................................ 7 Figure 5: Summary of Findings on Participation in the IECD Activities........................................ 15 Figure 6: Usefulness of IECD Activity Interventions ..................................................................... 16 Figure 7: Confidence of Putting into Practice WASH Actions....................................................... 18 Figure 8: Women’s Responses on Who Helps with Household Activities.................................... 29 Figure 9: Confidence of Respondents from Cohorts to Practice Recommended WASH Practices ....................................................................................................................................................... 36 Figure 10: Household Observations.............................................................................................. 38 Figure 11: Knowledge of Food Groups by Respondent Group..................................................... 42 Figure 12: Female and Male Caregivers’ and Grandparents’ Knowledge of Food Groups for Children 6 to 23 Months............................................................................................................... 42 Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity ACRONYMS Acronym Definition AHC Angkor Hospital for Children BCC Behavior Change Communication CBDMAT Cambodia Community Based Development Milestone Assessment Tool C1 Cohort 1 C1-2 Cohort 1-2 C2 Cohort 2 CARD Council for Agriculture and Rural Development CCWC Commune Committee for Women and Children CDHS Cambodia Demographic Health Survey CDL Child Development Leader CIP Commune Investment Plan CLWD Children Living with a Disability/Developmental Delay CNP Cambodia Nutrition Project CCWC Commune Committee for Women and Children DCWC District Committee for Women and Children ECD Early Childhood Development ECCD Early Childhood Care and Development EQ Evaluation Question ET Evaluation Team FGD Focus Group Discussion GIS Geographic Information Systems GIZ German Agency for International Cooperation GMP Growth Monitoring and Promotion HC Health Center HKI Helen Keller International HMIS Health Management Information System IECD USAID/Cambodia Integrated Early Childhood Development Activity IP Implementing Partner KII Key Informant Interview KT Kampong Thom MAM Moderate Acute Malnutrition ME&A ME&A, Inc. MoEYS Ministry of Education, Youth and Sport MoH Ministry of Health MoSVY Ministry of Social Affairs Veteran and Youth Rehabilitation MRC Mekhala Radiant Communication MUAC Mid-Upper Arm Circumference NGO Non-Government Organization NNP National Nutrition Program NSA Nutrition-sensitive Agriculture ODF Open Defecation-Free Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity Acronym Definition OPHE Office of Public Health and Education PCWC Provincial Committee for Women and Children PHD Provincial Health Department PPH Phnom Penh PRC Provincial Rehabilitation Center PV Preah Vihear RTI Research Triangle Institute SBC Social Behavior Change SRP Siem Reap TOC Theory of Change UNICEF United Nations Children’s Fund USAID United States Agency for International Development VHSG Village Health Support Group WASH Water, Sanitation, and Hygiene WHO World Health Organization Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 1 EXECUTIVE SUMMARY EVALUATION PURPOSE The primary purpose of the mid-term evaluation of the USAID/Cambodia Integrated Early Childhood Development (IECD) Activity is to assess IECD’s performance to date, identify strengths and weaknesses of the components of the Activity that have been implemented and key challenges or bottlenecks, and provide actionable recommendations for improvements to meet the Activity’s intended objectives. The primary audiences for the evaluation are USAID/Cambodia. Including the Office of Public Health and Education and IECD implementing partners (IPs), including RTI International and sub￾partners of IECD. The secondary audiences are the National Nutrition Program (NNP), Council for Agriculture and Rural Development (CARD), the Ministry of Social Affairs, Veterans, and Youth Rehabilitation (MoSVY), and the Ministry of Education, Youth, and Sport (MoEYS). Findings will be used to provide feedback to USAID/Cambodia, IECD IPs, NNP, CARD, representatives from MoSVY and MoEYS, partners, and other relevant stakeholders. PROJECT BACKGROUND Over the last few years, Cambodia has realized success in reducing infant mortality, disease burden, and poverty. Despite these successes, Cambodians continue to face challenges that prevent the holistic growth and development of young children, particularly those in their first 1,000 days of life.1 The COVID-19 pandemic also affected economic and family life in Cambodia. It is anticipated that these circumstances will likely have a far-reaching, deleterious effect on Cambodian families, particularly those with young children.2 When IECD was designed, the most relevant population data from the Cambodia Demographic Health Survey (CDHS) 2014 reported more than 30 percent of children from 36 to 59 months were behind in the domains of language, physical, cognitive, and social emotional development. Stunting was reported at 32.4 percent, which according to World Health Organization (WHO) Criteria demonstrates a very “high level”. The more recent CDHS 2021/2022 demonstrates a reduction in stunting nationally in Cambodia at roughly 22 percent; child development was not assessed in the most recent CDHS. Two of the provinces exceeding this average include Preah Vihear and Kampong Thom, with 26.3 percent and 26.5 percent, respectively.3 Data from the 2014 CDHS suggested further that 3 million Cambodians lack access to safe drinking water and 6.5 million lack access to improved sanitation.4 Global research has demonstrated that limited dietary diversity, food availability, childhood illness (e.g., diarrhea), and poor sanitation 1 USAID Cambodia Integrated Early Childhood Development Activity. 2020. Program Description. 2 Ibid. 3 National Institute of Statistics (NIS) [Cambodia], Ministry of Health (MoH) [Cambodia], and ICF. 2022. Cambodia Demographic and Health Survey 2021–22 Key Indicators Report. Phnom Penh, Cambodia, and Rockville, Maryland, USA: NIS, MoH, and ICF. 4 Ibid. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 2 contribute to high rates of stunting.5 Children’s development is further influenced by psychosocial stimulation and responsive caregiving, which can be negatively affected by traditional gender norms and high rates of domestic violence. Systems of identification, referral, and support for children with developmental delays and/or disabilities is nonexistent in most of Cambodia, resulting in unreliable data. Lack of coordination and integration across sectors that support young children exacerbates the problems.6 IECD is a five-year (July 2020 to July 2025) award led by RTI International, with partners Helen Keller International, Safe Haven, Mekhala Radiant Communication, and Dimagi. The IECD Activity will support the Royal Government of Cambodia (RGC)’s priorities to ensure the best possible outcomes for young children through the following objectives: 1) Improved physical, cognitive, linguistic, socio-emotional development of young children; 2) Decreased stunting rates for children under five among the target population; and 3) Children with developmental delays and disabilities receive appropriate care in target provinces.7 EVALUATION QUESTIONS The IECD mid-term performance evaluation seeks to answer the following two core evaluation questions (EQs) with subsequent follow-up questions: EQ1. How have caregivers learned from nurturing care sessions, community dialogue and home visits to improve how they have nurtured their children? From these interventions, what have been the on-going, unresolved challenges the prime and the sub-partners faced, how to overcome those challenges? a. How did nurturing care work for children with disabilities and their caregivers? b. In what way are different family members particularly men involved in child nurturing care? c. How are men’s and women’s roles different in the care of boys and girls? What are the outcomes to date? (Example: Who tells stories to the child? Who feeds the child? Who teaches the child new things? Who bathes the child or toilet trains them?) EQ2. How have IECD’s beneficiaries benefitted from IECD’s interventions, including home gardening, income generation, child nutrition screening and water, sanitation, and hygiene (WASH)? a. Did the interventions contribute toward improving household food security and child nutrition? b. What are the differences in women’s (mother) and men’s (father) roles and how can gender power dynamics improve in food security and child nutrition (home gardening, income generation, child nutrition and WASH)? 5 Vaivada T, Akseer N, Akseer S, Somaskandan A, Stefopulos M, Bhutta ZA. (2020). Stunting in childhood: an overview of global burden, trends, determinants, and drivers of decline. American Journal of Clinical Nutrition. 112(Suppl 2):777S-791S. 6 USAID Cambodia Integrated Early Childhood Development Activity. 2020. Program Description. 7 Ibid. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 3 c. How did home gardening, income generation and child screening help improve nutrition intake for children with disabilities? Are there any unintended consequences or results of the project interventions? EVALUATION METHODOLOGY The evaluation applied a mixed-methods approach for data collection that relied primarily on qualitative methods. The four main sources of data collection utilized were: 1) available published primary and secondary data from IECD, the CDHS, and other reliable sources (refer to Annex 5); 2) interviews with major stakeholders with a direct or indirect interest in the project from a national to community level, utilizing key information interviews (KIIs) and focus group discussions (FGDs); 3) observations with village health support group (VHSG) volunteers, child development leaders (CDLs), and caregiver households; and 4) mini- and online surveys with targeted complementary questions to the KIIs and FGDs provide a snapshot of current key IECD practices. Mini-surveys targeted respondents at the community level, while online surveys targeted respondents from the national and subnational levels. All surveys were completed by the same ET member who facilitated the corresponding KII or FGD. Interviews included representatives from government at the national and subnational levels, sector experts, affected communities, caregivers, and community volunteers who are delivering activities and performing screenings to children under five years old. Additionally, organizations who are active in nutrition, early childhood development (ECD), nutrition-sensitive agriculture, WASH, and parents and/or caregivers of children living with disability and developmental delays (CLWD). The ET collected data in Cambodia from April 3, 2023, to May 2, 2023. During this phase, the ET collected data on the ground in Phnom Penh, Sandan, Stoung, and Prasad Sambour Districts in Kampong Thom province, Rovieng District in Preah Vihear province, and virtually from partners in Siem Reap. The ET conducted pilot testing of the instruments from April 7 to 8, 2023, and took a break during the Khmer New Year holiday from April 13-16, 2023. The Team Leader handed over in-person leadership of the fieldwork to the Senior Field Research Specialist on April 16, as the Team Leader departed Cambodia on April 17. The IECD Provincial Coordinators provided lists of community contacts for the ET to use in organizing KIIs and FGDs, and supported introductions with government and community leaders, as needed. In total, the ET interviewed 144 women and 89 men through 116 KIIs, 16 FGDs; 52 observations, 92 mini-surveys, and 32 online surveys were added to the KII and FGD interviews. The ET transcribed, cleaned, and uploaded interview notes into Atlas.ti qualitative data analysis software for initial analysis and coding. Once coded, the ET grouped the data by theme against the evaluation questions and data synthesized. When internet connection was not available in the field, the ET collected quantitative data with paper and pen and uploaded the data into Esri ArcGIS Survey123. The ET cleaned and analyzed the quantitative data to identify and provide further context to the qualitative results. The ET used Survey123 to support geolocation of the findings with maps and an interactive feature to track respondents and responses. FINDINGS Major findings indicate that key interventions have contributed to improvements with caregiver learning and parenting, and caregivers appreciated gaining an understanding of and having the Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 4 opportunity to put into practice actions that were linked to holistic growth and development. Additionally, caregivers benefitted from nurturing care sessions and the guidance they offered with how to interact and engage young children through positive methods of talking and listening. Caregivers see the nurturing care curriculum as instrumental in the success of the sessions, and home visits are effective at reaching caregivers with key messages. Mid-upper arm circumference (MUAC) and Cambodia Community-based Development Milestone Assessment Tool (CBDMAT) screenings have been accepted by VHSGs and caregivers. The VHSGs appreciate having the opportunity to complete screenings, while caregivers see the benefits of referrals and follow-up care. A challenge that persists with compliance for treating malnourished children is follow-up at the health center, while considerations should be given to how to effectively continue long-term interventions and investments for CLWD. Men, women, and grandparents are actively working together to ensure optimal childcare practices in households. Time constraints for male and female caregivers include work commitments within the household and externally, which can make it difficult for them to always participate in IECD activities or act as primary caregivers to their children. There is room for grandparents to be proactively engaged in nurturing care by listening and incorporating their caregiver realities into nurturing care sessions, including food preparation and physical ability. Caregivers of CLWD have increased access and knowledge of services and care. There is some confusion at the community level about the duration of time IECD supports caregivers of children living with disability given the cohort design. It should be more explicitly stated that IECD provides support throughout the life of the Activity. Caregivers of CLWD stand to better understand their rights as clients in the health system and solutions to ensure that medical support required for diagnosed disabilities is consistent. Translating nutrition and WASH knowledge into practice is not always consistent and requires some attention, particularly with children who have moderate acute malnutrition (MAM) and where infrastructure needs have not been met to date. Suboptimal breastfeeding and feeding practices continue to be identified as causes of moderate and acute malnutrition in communities. There is variability in access to year-round food due to different factors including adequate consumption of animal sourced proteins. WASH efforts require infrastructure for toilets resistant to flooding, handwashing stations in the community, and clean water that considers the needs of both men and women, in terms of access and use, to be most effective. Identifying mechanisms to sustain the VHSG investment will be important, albeit difficult considering the limitations with financing at the commune level. IECD has demonstrated that VHSGs can deliver a multi-sectoral program that includes MUAC and CBDMAT screening. Disseminating the findings from the cohort evaluations will provide evidence that is missing, particularly for CLWD. Sharing of learning and advocacy is important, particularly as the NNP rolls out efforts to improve screenings of young children and monitoring, and policies and guidelines continue to be rolled out by CARD, MoEYS, and MoSVY. Continued collaboration with the United Nations Children’s Fund (UNICEF), the German Agency for International Cooperation (GIZ), and the World Bank provides another opportunity for knowledge dissemination from IECD, particularly with grandparents, VHSGs, multi-sectoral ECD and nutrition programming, and disability. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 5 CONCLUSIONS IECD is well accepted across Cambodia government ministries. The collaborative process with the design and development of the nurturing care materials is appreciated and the on-going engagement welcomed, particularly with CARD, NNP, MoSVY, and MoEYS. Home visits are effective at reaching caregivers, while screenings have been recognized as an effective way to reach households for nutrition and with CLWD. Progress is being made with reaching and engaging all caregivers including men, women, and grandparents, while attention is needed to make sure they feel represented and reached in IECD activities. A few underlying issues exist in addressing barriers to practice with WASH and nutrition with some parts of the population. IECD is well positioned to address these barriers, considering improvements that have been identified in the final evaluation of IECD Cohort 1. Cambodia structural challenges persist with sustainability of multi-sectoral programs, including with VHSGs. Solutions might be difficult to identify, but continued engagement with the provincial committees for women and children (PCWCs), commune committees for women and children (CCWCs), and communes is recommended, along with generating documentation of efforts with VHSGs. RECOMMENDATIONS HIGH PRIORITY On a national level, the IECD Activity should continue to share its learning and progress specific to training and working with VHSGs on MUAC screening. Additionally, explore how VHSGs in Preah Vihear can be targeted under the Cambodia Nutrition Project (CNP) to be eligible for an allowance. Identify ways to further engage men. Utilize a male-positive deviance or male engagement champion model to increase male caregiver participation. Document the best practices through a quarterly report case study in fiscal year five and share the findings in working groups with CARD, NNP, and MoEYS. WASH infrastructure improvements for latrines, filters, year-round water access, and handwashing stations are required in many communities. Access to enough potable water for year-round growing of food and to meet household sanitation and hygiene demands is an issue. Develop a water safety plan with the private sector and the Ministry of Rural Development and utilize the World Bank WASH analysis on gender to inform thinking on relevant gender issues. 8 Work with local engineers and the private sector to ensure WASH infrastructure meets the needs of women and girls for safety and use, is flood resistant, and provides options for households in different socio-economic situations. 8 World Bank. (2018). Report on Gender Analysis of Water Support for the proposed Bank-supported Water Supply and Sanitation Improvement Project. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 6 MEDIUM PRIORITY Some households are struggling with treatment compliance using BP100. Consider intensive twice-weekly visits during treatment and use the opportunity to support households with responsive feeding and breastfeeding. CBDMAT screenings do not currently fall under the investment of CNP or any Ministry of Health (MoH) funding. Advocate with MoSVY or in the long-term work with MoH under the Provincial Rehabilitation Center (PRC) to add this into disability programming at the PRC. The length of the cohorts presents some challenges. Make modifications if they can be made in Cohort 3. Otherwise, this is a recommendation for future programming. Create a case study to document the design and creation of the nurturing care materials to capture the multi-sectoral process for development and include results from the final evaluation to capture outcomes. Present the case study at working group meetings. Continue to coach and mentor the VHSGs and CDLs to use the nurturing care sessions, with attention to completing the first coaching session within two weeks of the VHSG training or the first time that VHSGs hold community meetings or deliver messages, whichever is sooner. Safe Haven and Angkor Hospital for Children have valuable expertise working with CLWD. Optimize the partnerships to increase capacity of IECD medical staff (e.g., nurses, physical therapists, and interventionists) to ensure appropriate care for CLWD specifically with nutrition and WASH-related interventions. Create and disseminate reminder cards to VHSGs about key overarching needs for caregivers of CLWD. Provide training to the caregivers of CLWD on their rights and support them to increase their confidence to ask questions and remain in touch with the same medical provider. Advocate for longer-term investments for interventions that serve CLWD by utilizing IECD Activity learning on supporting CLWD in an integrated multi-sectoral effort. Grandparents are helping with childcare in IECD Activity target areas. There is literature available in Cambodia and experiences from the Grandmother Project9 to better understand how to effectively leverage grandparents in holistic caregiving. Identify ways to better recognize them and integrate their caregiving needs into IECD.10 LOWER PRIORITY Work with NNP to identify synergies between the CommCARE app and current nutrition monitoring with the Health Management Information System. Identify ways to link the monitoring processes (EQ 1). Caregiving and household tasks are time-intensive, which means that home visits are an effective way to reach target populations with IECD messages. 9 The Grandmother Project website has various resources and experience with programming mainly in Africa but has done some work in Laos. It would be worth checking out their website: https://grandmotherproject.org/programs 10 Schneiders ML, Phou M, Tun V, Kelley M, Parker M, and Turner C. (2021). Grandparent caregiving in Cambodian skip-generation households: Roles and impact on child nutrition. Maternal Child Nutrition. Suppl 1(Suppl 1). Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 7 The Royal Government of Cambodia is supporting private sector investments for WASH. Opportunities should be explored for WASH vocational training. Explore local solutions for childcare. This could include extending community preschools to operate as nurseries or childcare facilities or exploring community childcare models as a local enterprise for caregivers. Work with local restaurants and food vendors to ensure that there are diverse foods available for families to purchase, while working with sellers in the market to sell bundles of fruits and vegetables that meet diversity recommendations. Households are not consuming animal source protein year-round. Focus on what is being consumed or desired for consumption and work to identify strategies for increased consumption within households and particularly for young children. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 1 1. BACKGROUND OF THE LOCAL CONTEXT AND THE IECD ACTIVITY Over the last few years, Cambodia has realized success in reducing infant mortality, disease burden, and poverty. Despite these successes, Cambodians continue to face challenges that prevent the holistic growth and development of young children, particularly those in their first 1,000 days of life.11 The COVID-19 pandemic affected economic and family life in Cambodia through the closure of schools, public venues, limited travel, and the prohibition of large gatherings. It is anticipated that these circumstances will likely have a far-reaching, deleterious effect on Cambodian families, particularly those with young children.12 When IECD was designed, the most relevant population data from the Cambodia Demographic Health Survey (CDHS) 2014 reported more than 30 percent of children from 36 to 59 months were behind in the domains of language, physical, cognitive, and social emotional development. Stunting was reported at 32.4 percent, which according to World Health Organization (WHO) Criteria demonstrates a very “high level”. The more recent CDHS 2021/2022 demonstrates a reduction in stunting nationally in Cambodia at roughly 22 percent; child development was not assessed in the most recent CDHS. Two of the provinces exceeding this average include Preah Vihear and Kampong Thom, with 26.3 percent and 26.5 percent, respectively.13 Data from the 2014 CDHS suggested further that 3 million Cambodians lack access to safe drinking water and 6.5 million lack access to improved sanitation.14 Global research has demonstrated that limited dietary diversity, food availability, childhood illness (e.g., diarrhea), and poor sanitation contribute to high rates of stunting.15 Children’s development is further influenced by psychosocial stimulation and responsive caregiving, which can be negatively affected by traditional gender norms and high rates of domestic violence. Systems of identification, referral, and support for children with developmental delays and/or disabilities is nonexistent in most of Cambodia, resulting in unreliable data. Lack of coordination and integration across sectors that support young children exacerbates the problems.16 IECD is a five-year (July 2020 to July 2025) award led by RTI International, with partners Helen Keller International (HKI), Safe Haven, Mekhala Radiant Communication (MRC), and Dimagi. IECD aims to address stunting through a multi-sectoral approach which aims to a) strengthen the delivery of nutrition services in health facilities and communities; b) support nutrition-sensitive agriculture (NSA) and livelihoods improvements; c) improve water, sanitation, and hygiene 11 USAID Cambodia Integrated Early Childhood Development Activity. 2020. Program Description. 12 Ibid. 13 National Institute of Statistics (NIS) [Cambodia], Ministry of Health (MoH) [Cambodia], and ICF. 2022. Cambodia Demographic and Health Survey 2021–22 Key Indicators Report. Phnom Penh, Cambodia, and Rockville, Maryland, USA: NIS, MoH, and ICF. 14 Ibid. 15 Vaivada T, Akseer N, Akseer S, Somaskandan A, Stefopulos M, Bhutta ZA. (2020). Stunting in childhood: an overview of global burden, trends, determinants, and drivers of decline. American Journal of Clinical Nutrition. 112(Suppl 2):777S-791S. 16 USAID Cambodia Integrated Early Childhood Development Activity. 2020. Program Description. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 2 (WASH) practices among caregivers; and d) promote responsive caregiving to ensure children meet critical cognitive, linguistic, socio-emotional, and physical development milestones.17 Figure 1: USAID IECD Activity Coverage in Cambodia Built by ME&A with the district coverage information of the IECD activity. IECD specifically has targeted the Districts of Sandan, Stoung, Prasad Sambour and Prasad Ballangk in Kampong Thom province and Rovieng, Kulean, and Sangkum Thmei in Preah Vihear province for implementation of all IECD activities through a cohort wave design.18 19 Figure 1 is a map of the intervention districts. Angkor Hospital for Children (AHC) in Siem Reap Province is the primary facility in Cambodia to receive, screen, and treat children with disability, and is included to improve the capacity of identification, referral, and follow-up of children living with 17 Ibid. 18 USAID/Cambodia Integrated Early Childhood Development Activity. FY2023 Quarter 1 Report. October 1, 2022 – December 31, 2022. Phnom Penh. 19 USAID/Cambodia Integrated Early Childhood Development Activity. FY2022 Annual Report October 2021 – September 2022. Revised November 17, 2022. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 3 disabilities/developmental delays (CLWD). Any behavior-change communication (BCC) activities or referral supported by Safe Haven staff under the IECD Activity will be explored.20 IECD has a theory of change (TOC) which posits that if the enabling environment, service providers, and families are all supported to promote holistic, integrated nurturing care for children with and without developmental delays and disabilities, then an increased percentage of Cambodian children will thrive and meet developmental milestones (Figure 2). Figure 2: IECD Activity Theory of Change If the IECD Activity A) Sustainability changes caregivers practice in nurturing care key behaviors, B) Increases access to nutritious food, improve hygiene, and raises incomes, and C) Identifies and support children with delays and disabilities, then Child development outcomes will be measurably improved. To achieve the Activity’s TOC, IECD has identified the following primary objectives: 1. Improve the physical, cognitive, and social development of young children 2. Decrease stunting among children under 5 years of age 3. Provide appropriate care and support for children with developmental delays and disabilities The objectives focus on multiple growth and development domains for children, while working to reduce stunting and providing appropriate care and support for children with delays and disabilities. Below is a more thorough explanation of the objectives with subsequent results. ● Objective 1: Improve the physical, cognitive, and social development of young children. Interventions include providing education, counseling, and support for caregivers of young children, as well as strengthening the providers, policies, and environment for quality early childhood development (ECD) services in Cambodia. o Result 1.1: Increased capacity of caregivers to provide nurturing care for children with and without developmental delays and disabilities. o Result 1.2: Increased capacity and improved attitudes, behaviors, and nurturing practices to better educate and support caregivers with young children. o Result 1.3: Strengthened enabling environment at the national and sub-national levels to promote the institutionalization of ECD activities. ● Objective 2: Decrease stunting among children under 5 years of age. Interventions include increasing families’ ability to grow more nutritious foods, generate more income from agriculture, and use both to provide nutritious foods for women and children. o Result 2.1: Increased community and family crop diversification for home consumption and income generation. 20 Ibid. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 4 o Result 2.2: Increased consumption of nutritional and diverse diets meeting the needs of pregnant mothers, particularly targeting young and first-time mothers and children under five. o Result 2.3: Improved hygiene and sanitation-related behaviors in the household and community. ● Objective 3: Provide appropriate care and support for children with developmental delays and disabilities. Interventions include increasing Cambodia’s capacity for screening and detecting delays and disability in young children, improving specialized care and support services, and strengthening social inclusion for these children. o Result 3.1: Increased developmental monitoring and early identification of children with developmental delays and disabilities. o Result 3.2: Increased referral to quality, sustainable services for children with developmental delays and disabilities. o Result 3.3: Strengthened community-based rehabilitation and support services for children and families with developmental delays and disabilities. 2. PURPOSE AND EVALUATION QUESTIONS The primary purpose of the IECD mid-term evaluation is to assess IECD performance to date, identify strengths and weaknesses of the components of the Activity that have been implemented and key challenges or bottlenecks, and provide actionable recommendations for improvements to meet the Activity’s intended objectives. The IECD Mid-Term Performance Evaluation seeks to answer the following two core evaluation questions (EQs) with subsequent follow-up questions: EQ1. How have caregivers learned from nurturing care sessions, community dialogue and home visits to improve how they have nurtured their children? From these interventions, what have been the on-going, unresolved challenges the prime and the sub-partners faced, how to overcome those challenges? a. How did nurturing care work for children with disabilities and their caregivers? b. In what way are different family members particularly men involved in child nurturing care? c. How are men’s and women’s roles different in the care of boys and girls? What are the outcomes to date? (Example: Who tells stories to the child? Who feeds the child? Who teaches the child new things? Who bathes the child or toilet trains them?) EQ2. How have IECD’s beneficiaries benefitted from IECD’s interventions, including home gardening, income generation, child nutrition screening and WASH? a. Did the interventions contribute toward improving household food security and child nutrition? b. What are the differences in women’s (mother) and men’s (father) roles and how can gender power dynamics improve in food security and child nutrition (home gardening, income generation, child nutrition and WASH)? Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 5 c. How did home gardening, income generation and child screening help improve nutrition intake for children with disabilities? Are there any unintended consequences or results of the project interventions? The primary audiences for the evaluation are USAID/Cambodia and IECD implementing partners (IPs). This includes the Office of Public Health and Education (OPHE), RTI International and sub￾partners of IECD. The secondary audiences are the National Nutrition Program (NNP), Council for Agriculture and Rural Development (CARD), the Ministry of Social Affairs, Veterans, and Youth Rehabilitation (MoSVY), and the Ministry of Education, Youth, and Sport (MoEYS). Findings will be used to provide feedback to USAID/Cambodia, IECD IPs, NNP, CARD, representatives from MoSVY and MoEYS, partners, and other relevant stakeholders. 3. DATA COLLECTION Figure 3: Distribution of Mini-Surveys, Observations, and Online Surveys Built by ME&A with the location of mini-surveys, online surveys, and observations taken during the IECD field data collection. The evaluation team (ET) facilitated an inclusive and participatory mixed-methods data collection approach that combined qualitative and quantitative data from primary and secondary sources Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 6 to address the two EQs and subset questions. The four main sources of data collection utilized were: 1) available published primary and secondary data from IECD, the CDHS, and other reliable sources, including IECD Activity reports and Cambodia peer-reviewed articles (refer to Annex 5); 2) interviews with major stakeholders with a direct or indirect interest in the project from a national to community level, utilizing key information interviews (KIIs) and focus group discussions (FGDs); 3) observations with village health support group (VHSG) volunteers, child development leaders (CDLs), and caregiver households; and 4) mini- and online surveys with targeted complementary questions to provide a snapshot of current key IECD practices. Interviews targeted representatives from government at a national and subnational level, sector experts, affected communities, caregivers, and community volunteers who are delivering activities and performing screenings to children under five years old. Additionally, organizations who are active in nutrition, ECD, NSA, WASH, and parents and/or caregivers of CLWD. Interviews targeted representatives from government at a national and subnational level, sector experts, affected communities, caregivers, and community volunteers who are delivering activities and performing screenings to children under five years old. Additionally, organizations who are active in nutrition, ECD, NSA, WASH, and parents and/or caregivers of CLWD. The ET conducted data collection in Cambodia from April 3 to May 2, 2023. Because of delays around the Khmer New Year holiday, the team did not collect data from April 13-16. The Team Leader handed over in-person leadership of the fieldwork to the Senior Field Research Specialist on April 16, as the Team Leader departed Cambodia on April 17 for their residence, where they continued to complete KIIs virtually with implementing partners (IPs), international organizations and supported quality checks on data collected in the field. In total, the ET completed 116 KIIs and 16 FGDs. KII participants included 62 women and 54 men, while 82 women and 35 men participated in FGDs, for a total of 144 women and 89 men sampled. These respondents also participated in 52 observations, 92 mini-surveys, and 32 online surveys. The ET collected data from three provinces and one municipality. Figure 3 above shows in purple the data collection points for online surveys, green for observations, and orange for mini-surveys from Siem Reap, Kampong Thom, Preah Vihear and Phnom Penh. These data collection points also capture KII and FGD locations. Annex 2 includes a table with the names of the communes and villages in Kampong Thom and Preah Vihear provinces. Interview and survey respondents included female and male caregivers, grandparents, caregivers of CLWD, male and female VHSG members and CDLs, commune committees for women and children (CCWCs), commune representatives, health center staff, national and subnational government representatives, international organizations, and IPs. Figure 4 below presents a summary of the data collected by gender for KIIs and FGDs. All data collection study identifications and gender for each respondent was stored in Survery123, which allowed ME&A to build the figure. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 7 Figure 4: Distribution of Survey Respondents by Percentage Built by ME&A with mini- and online survey data. May 2023. 3.1 SAMPLING Data collection relied primarily on qualitative methods. The ET used purposive sampling to ensure respondents had participated in IECD activities. The ET identified for data collection districts with the greatest number of villages per cohort, with representation of villages from both cohorts 1 (C1) and 2 (C2), and targeted villages that are easier to travel to from the district capital. Selection criteria for KII and FGD respondents included participation in implemented activities in either Cohort 1 (C1) or Cohort 2 (C2) and, if they did not identify as a VHSG or CDL, residence in a village where VHSGs and CDLs received some training. Online surveys targeted KII participants representing IPs, national and subnational government ministries and departments, and health centers, while the ET facilitated observations and mini-surveys with community-level KII and FGD participants. Interview guides can be found in Annex 4. 3.2 DESK REVIEW The ET completed a review of all the Activity-related documents provided by USAID/Cambodia and IPs. A list of the reviewed documents is in Annex 5. The review included activity documents, reports, and other documents with secondary data produced by organizations that are working on IECD. The ET used information on IECD Activity volunteers, stakeholders, and beneficiaries to guide the sample selection, including trained VHSGs and CDLs and parents with children who had been identified for nutrition referral and developmental delays, using the MUAC and CBDMAT tools. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 8 3.3 KEY INFORMANT INTERVIEWS The ET completed a total of 116 KIIs representing 62 women and 54 men, with participants from USAID, IPs, international organizations, national government ministries and provincial government departments, governors’ offices, operational districts, female and male caregivers, grandparents, caregivers of CLWD, female and male VHSG members, CDLs, CCWCs, and health center staff. Interviews took place at respondents’ offices or homes. A majority were in-person. The ET also held virtual interviews with USAID, some IPs, and international organizations. The ET met, if not exceeded, planned targets in most instances. Early in the field work, the ET struggled to identify male caregivers for interviews. However, as data collection progressed the ET was able to locate men and ultimately exceeded male caregiver targets. Nonetheless, the ET attempted more interviews with female caregivers and VHSGs to ensure representation in a district and cohort if the target for men could not be reached. Below in Table 1 is a summary of the planned versus actual KIIs completed, by respondent category. Table 1: Planned versus Completed KIIs Respondent Categories Locations Total Planned Total Completed USAID Cambodia Phnom Penh 2 2 IPs: RTI 9, HKI 2, Dimagi1, and MRC 1 Phnom Penh 13 13 IPs: AHC 3 and Safe Haven 2 Siem Reap 5 4 International Development Organizations, Donors, and Donor￾Funded Projects UNICEF 2, World Bank 1, GIZ 1 Phnom Penh 4 5 National State Organizations NNP 1, CARD 1, MoEYS 1, MoSVY 1 Phnom Penh 4 4 Provincial Level Health 2, Education 2, MoSVY 2, Provincial Rehabilitation Center (PRC) 2 Province 7 7 Deputy District Governor’s Office/District Committee for Women and Children (DCWC) District 4 5 Operational District 2 Operational District 2 2 Female Caregivers Two villages in each of the four IECD target Districts 8 9 Male Caregivers Two villages in each of the four IECD target Districts 8 10 Grandparents / Alternate Caregivers Two villages in each of the four IECD target Districts 8 8 Parents of CLWD Two villages in each of the four IECD target Districts 8 9 Female VHSGs Two villages in each of the four IECD target Districts 8 10 Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 9 Respondent Categories Locations Total Planned Total Completed Male VHSGs Two villages in each of the four IECD target Districts 8 8 CDLs Two villages in each of the four IECD target Districts 8 7 CCWCs Two villages in each of the four IECD target Districts 8 8 Health Center Staff One per district 4 5 Total 109 116 3.4 FOCUS GROUP DISCUSSIONS The ET completed 16 FGDs with female and male caregivers, grandparents, caregivers of CLWD, VHSGs and CDLs, and CCWC/commune council/community leaders. A total of 82 women and 35 men participated. On average, the ET held one FGD in each province with target respondents representing both Cohorts 1 and 2 (C1-2), and the ET held FGDs at commune offices or in pagodas. FGD participants, particularly caregivers of CLWD, grandparents, and VHSGs were primarily females. Additionally, 15 female caregivers came for one discussion, which the ET split into two FGDs. As noted above, the ET initially had difficulty identifying male caregivers to participate but similarly to the KIIs, male participation ultimately exceeded targets. Regardless, the ET organized two additional FGDs in case enough men were not able to be identified for participation in an FGD. In Kampong Thom, the ET was not able to organize a separate FGD for grandparents/alternative caregivers. Grandmothers were represented in all the female caregiver FGDs in Kampong Thom. Table 2 provides specific information on the number of FGDs completed for each target group. Table 2: FGD Participants by Target Group and Gender Numbers of FGD Participants by Target Group and Gender Target Total FGDs Female Participants Male Participants Total Participants Kampong Thom Female Caregivers 4 28 0 28 Male Caregivers 2 0 17 17 Grandparents/ Alternate Caregivers 0 0 0 0 Parents with Children Living with Disability / Developmental Delay 1 3 0 3 CCWC / Commune Council / Community Leaders 1 1 6 7 VHSGs / CDLs 1 8 4 12 Preah Vihear Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 10 Numbers of FGD Participants by Target Group and Gender Target Total FGDs Female Participants Male Participants Total Participants Female Caregivers 1 15 0 15 Male Caregivers 2 0 7 7 Grandparents / Alternate Caregivers 1 10 0 10 Parents with Children Living with Disability / Developmental Delay 1 4 0 4 CCWC / Commune Council/ Community Leaders 1 6 0 6 VHSGs / CDLs 1 7 1 8 Grand Total 16 82 35 117 3.5 OBSERVATIONS The ET conducted observations of VHSGs and CDLs completing MUAC and CBDMAT screening to gauge confidence and understanding of the expectations. The observations followed the key steps in the CommCare app.21 The ET completed household observations with random KII and FGD respondents to determine if home gardens and WASH infrastructure were in place to enable putting into practice recommended key messages and to triangulate responses from interviews. These were the only two items observed (refer to Annex 4). The ET completed 52 observations, including 19 with VHSGs and CDLs and 33 that represented households. 3.6 MINI-SURVEYS AND ONLINE SURVEYS The ET asked interviewees a brief series of close-ended (e.g., multiple choice, Likert scale, ranked preference) questions integrated into the KII and FGD guides. The ET also administered an online survey of closed-ended questions to all identified KII respondents at the national, provincial, and district levels with access to reliable internet, for whom the ET has a working email address, and who represent a key IECD stakeholder group. All questionnaires can be found in Annex 4. The mini-surveys focused more on community participation and engagement with the IECD Activity, while the online surveys focused on the strengths, areas for improvement, opportunities, and sustainability. Respondents from KIIs and FGDs completed 92 mini-surveys and 32 online surveys. Tables 3 and 4 below provide mini-survey and online survey participant information specific to target and gender. Mini-surveys represented respondents located in Kampong Thom and Preah Vihear, while the online surveys targeted respondents with more reliable internet access in Siem Reap and Phnom Penh. The ET did not meet its planned online survey response number due to 21 USAID, RTI International, & Helen Keller International. (NA). Community Based- Developmental Milestone Assessment Tool (CB-DMAT) P99. Cambodia Integrated Early Childhood Development Activity. Phnom Penh. USAID, RTI International, & Helen Keller International. (NA). Community Based- Developmental Milestone Assessment Tool (CB-DMAT) P75. Cambodia Integrated Early Childhood Development Activity. Phnom Penh. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 11 one refusal and seven non-responses. The ET collected the survey data with paper and pen and uploaded the data into Survey123 when internet connections were unreliable in the field. The ET randomly selected FGD participants to complete mini-surveys. The ET completed observations with the VHSGs and CDLs in lieu of the mini-survey. ET members observed VHSGs and CDLs completing MUAC and CBDMAT screenings. Ahead of the interviews, the ET requested VHSGs and CDLs to bring their tablets, MUAC tapes, and nurturing care materials. Table 3: Mini-Survey Participants by Target Group and Gender Target Female Male Total Kampong Thom Female Caregivers 13 0 13 Male Caregivers 0 9 9 Grandparents / Alternate Caregivers 4 0 4 Parents with Children Living with Disability / Developmental Delay 8 0 8 CCWC / Commune Council / Community Leaders 3 3 6 VHSGs/ CDLs 7 9 16 Preah Vihear Female Caregivers 5 0 5 Male Caregivers 0 9 9 Grandparents / Alternate Caregivers 5 1 6 Parents with Children Living with Disability / Developmental Delay 3 0 3 CCWCs / Commune Council / Community Leaders 5 1 6 VHSGs / CDLs 4 3 7 Grand Total 57 35 92 Table 4: Online Survey Participants by Target Group and Gender Target Female Male Total USAID Cambodia 0 1 1 Implementing Partners Phnom Penh 3 6 9 Implementing Partners Siem Reap 3 1 4 National Government 1 3 4 Subnational Government 6 4 10 Health Centers 0 4 4 International Organizations 0 0 0 Grand Total 13 19 32 3.7 CO-COLLECTION OF LOCATIONAL DATA The ET used Esri’s ArcGIS Survey123 to collect data from the observations and mini- and online surveys and store data from all interviews. Figures presented in this report were generated Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 12 through this tool and can also be used to compare respondents and their responses in various geographic locations. 3.8 LIMITATIONS OF THE EVALUATION METHODOLOGY The ET realized several limitations during the evaluation process as summarized below. More details on the limitations are found in Annex 2. 1. The timeline to complete data collection overlapped with Khmer New Year. This resulted in limited time to complete proper introductions in the field, which resulted in some initial hesitation from communities when the ET arrived in villages. It also resulted in the ET experiencing seven days of a very reduced interview schedule. 2. The ET faced inconsistent internet access in the field. To ensure the integrity of the data collected, the ET used paper and pen with the mini-surveys and transferred data to Survey123 once a secure internet connection was established. There is an offline function in Survey123, but some ET members’ phones were not reliable with the offline function. 3. Appointments often had to be made on short notice and contact numbers were sometimes not correct. This was particularly evident in Preah Vihear, where many of the interviews were set the night before or in the morning once the ET arrived in the villages. 4. Initially the ET found it difficult to identify men to participate in interviews. This changed around Khmer New Year when more men returned to the villages. In the end, the ET found fewer grandparents and caregivers of CLWD than planned. 5. Due to implementation of IECD ending more than six months before the time of the interviews for C1 respondents, some respondents demonstrated recall bias. The ET used techniques such as a timeline to attempt to reduce recall bias and tried to link engagement with certain activities taking place, like COVID-19 or holidays. The ET held all interviews in as private of locations as possible to reduce input from other family members or neighbors listening to the interviews. 6. The ET observed children in communities eating packaged snacks and junk food, but few caregiver respondents spoke about this, which demonstrated some halo bias. Respondents from health centers confirmed that this consumption is common. 7. Due to the timeline for data collection, the ET only collected data from districts and villages that were within a one hour to two-hour drive of the provincial capital of each province. This demonstrates a limitation with selection criteria, as it prevented the ET from sampling from populations that live further away. 8. The evaluation applied purposive sampling to ensure reach of stakeholders and participants who know the IECD Activity. Selection bias was therefore inherent in the design process to ensure respondents reflect engagement. 9. Interviews were facilitated in Khmer, except with the IP and international organizations in Phnom Penh. This required all data collection instruments to be translated into Khmer from English and for all interview notes to be transcribed from Khmer to English. As a Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 13 result, some nuances, and details from the interview guides or from the participants themselves might have been lost. 10. ADRA and World Vision have actively implemented similar WASH and nutrition interventions to the IECD Activity in Kampong Thom. At times it was difficult for interview participants to distinguish between an IECD Activity intervention and non-IECD Activity intervention. 11. The ET does not have access to the most recent IECD evaluation of C1. Therefore, some areas lack updated data from secondary sources. 12. The baseline data was collected between June and July, compared to the mid-term evaluation in April. April is considered the hottest and driest month ahead of the rainy season. Household incomes and food consumption might be different due to it being the pre-planting season. 4. DATA ANALYSIS The ET conducted analysis of the quantitative and qualitative data gathered to answer the two EQs and 14 subset questions. 4.1. QUALITATIVE ANALYSIS To prepare for qualitative data analysis, the ET translated from Khmer to English all interviews that had not been completed in English or simultaneously translated from English to Khmer. The ET then transcribed the interview notes in English and shared completed transcriptions with the Team Leader, who reviewed the responses for thoroughness and checked data against the interview guides. The ET completed all cleaned transcriptions by May 5 and uploaded them into Atlas.ti. The ET coded the data against various themes, which resulted in 1,516 unique entries linked to the following overarching primary codes: community development, family and caregiving responsibilities, personal and professional development (e.g., caregivers and VHSGs learning about and putting into practice motor skill development, trainings for VHSGs, etc.), and program implementation. The ET extracted and matched quotations to the relevant evaluation matrix questions. From this, the ET reviewed data to determine how it contributed to the evaluation questions in terms of its relevance for identifying the various strengths, areas for improvement, opportunities, and overall recommendations for the IECD Activity. The ET used secondary data to provide further explanation of the findings. 4.2 QUANTITATIVE ANALYSIS The ET cleaned and analyzed the quantitative data to identify and provide further context to the qualitative results. Data from mini and online surveys was either collected with paper and pen or directly uploaded into Survey123. Surveys submitted through Survey123 were checked for completeness and the data cleaned with attention to redundancies. Outliers were removed from the data sets where necessary. Data was then used to determine the results of various respondents’ engagement with the IECD activity, male and female dynamics, and respondents’ recall of certain WASH and nutrition practices. Findings have been used to triangulate the qualitative outcomes to enable a more complete understanding of IECD interventions to answer Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 14 the evaluation questions. The ET used ArcGIS to create maps, graphs, and figures. Overall, the data collected is sufficient to answer the evaluation questions, while also being able to provide evidence of engagement with community volunteers. 5. FINDINGS This section presents the findings of the IECD mid-term performance evaluation. In each subsection, the findings are summarized followed by a matrix which highlights the strengths, areas of improvements, challenges for each EQ and subset of questions. Following this section is the conclusion and then the recommendations per EQ. Quotes from participants in the data collection are cited using a format that reflects the province, target, whether they represent C1, C2, or C1-2, and the study ID number. Acronyms are used in the quotes to enable ease when reading but are not applied throughout the document. The report focuses on findings that most accurately respond to the EQs and should not be considered a comprehensive list of all IECD activities in the project Results Framework. These can be found in detail in the IECD quarterly and annual reports submitted to USAID. 5.1 EQ 1: HOW HAVE CAREGIVERS LEARNED FROM NURTURING CARE SESSIONS, COMMUNITY DIALOGUE AND HOME VISITS TO IMPROVE HOW THEY HAVE NURTURED THEIR CHILDREN? FROM THESE INTERVENTIONS, WHAT HAVE BEEN THE ON-GOING, UNRESOLVED CHALLENGES THE PRIME AND THE SUB-PARTNERS FACED, HOW TO OVERCOME THOSE CHALLENGES? IECD has been implementing various interventions since its inception in 2020 to enable learning for caregivers. Nurturing care sessions are the primary mode of learning. The nurturing care sessions include 10 modules with key messages delivered at a community level on roughly a bi￾weekly basis by a trained VHSG. Modules include topics on ECD, health, and nutrition requirements for pregnant women and children under five years old, NSA, WASH, and male and female engagement with responsive parenting. Nurturing care sessions are also called caregiver group sessions and trainings by respondents. In this report, they are called nurturing care sessions. Complementary activities to the nurturing care sessions include nutrition and disability screenings and referrals, cooking demonstrations, model farmer activities, male caregiver groups, and peer support groups for caregivers of CLWD. Early intervention services were not specifically mentioned by respondents. Home visits take place between nurturing care sessions with families who are identified as at risk due to, for example, a pregnancy, a child who has been identified as malnourished or living with a disability or developmental delay, local authority reports of domestic violence, or ID Poor designation. The home visits provide time for VHSGs to reflect with the household on how the caregivers have been able to put into practice what they have learned during the nurturing care sessions and specifically work with the family to put the recommended messages into practice. Community dialogue sessions take place with families whose children have been identified as living with disability and developmental delay. These dialogues bring forward the messages from nurturing care by specifically focusing on families with CLWD. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 15 Overall, respondents reflected on the ease of use and specific messages included in the IECD materials. A provincial health representative shared: “The IECD Activity has a great approach. They provide training to VHSGs and CDLs, who train caregivers to have a better understanding of how to care for children” (KT, C1-2, 111). Respondents from those engaged in the development process of the materials spoke highly of the collaborative process, while VHSG and CDL members were pleased with the materials (Government, PPH, C1-2, 090 & CDL, KT, C2). Receiving the “10 session nurturing care, tent, 10 session tabs, poster of IECD Activity, children’s toys, story books, table, and some money for doing enriched porridge was very useful” (Female VHSG, KT, C2, 035). Nurturing care session content was well accepted. Caregivers reported learning most about the importance of play, reading, nutrition for pregnant women and young children, the importance of preventing neglect and abuse, and WASH. One female caregiver in Preah Vihear shared: “I get to learn and become more aware about child development. I can observe my child. I play with her and make her laugh. IECD is very useful. They teach us how to take care of children” (C2, 010). One respondent remarked on the social benefits of the nurturing care sessions by stating: “My daughter is five and a half years old, but she is scared to meet outside people. So, when I facilitated a caregiver group, I always took my child along with me to let her meet different people. I observe that she speaks more and plays with her friends” (Female VHSG, KT, C1, 033). Caregivers reported most on being aware of nurturing care sessions, followed by cooking demonstrations, child nutrition screenings, trainings, and home visits. Figure 5 below was created using the results of data collected from mini-surveys and online surveys and stored using Survey123. It demonstrates community awareness of IECD activities. Figure 5: Summary of Findings on Participation in the IECD Activities Built by ME&A with mini and online survey data. May 2023. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 16 Figure 6 below presents more findings from the mini-surveys. The results indicate that most of the respondents to mini-surveys, regardless of target population, found that the nutrition screenings were the most useful at nearly 79 percent, followed by disability screenings and cooking demonstrations at 78 percent each, then home visits at 76 percent and nurturing care sessions at 75 percent of respondents. Figure 6: Usefulness of IECD Activity Interventions Built by ME&A with mini and online survey data. May 2023. Many respondents found the nurturing care sessions time intensive, partly due to competing priorities at the household level or for income generation purposes. Households reported taking turns to participate in the sessions between female and male caregivers, and grandparents, but few if any reported sharing the information they learned in the sessions at home. One VHSG member shared that “we tried to inform them in advance, and on the day of meeting we still follow up and call them again, but less people attend” (Female VHSG, KT, C2). Another stated: “Even if they can’t participate, VHSGs do follow-up or home visits” (Female VHSG, KT, C2, 036). Home visits are found to be quite useful. Households are busy with work and asking them to participate in meetings can be time intensive. One female VHSG member shared: “At the household is a good way to approach and easy to provide sessions directly to caregivers” (KT, C2, 035), while a CCWC representative stated: “families that are migrating for work usually do not attend caregiver groups, so we reach them during home visits” (CCWC, KT, C2, 059). The usefulness of home visits was felt particularly when discussing childcare, MUAC screening, and following up with families who could not attend nurturing care sessions (Male Caregiver FGD, PV, C2, 008 and Female VHSG, PV, C2, 038). Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 17 Distinguishing between nurturing care sessions and community dialogues was often difficult for households during interviews, which is likely why only 24 percent of respondents found them useful. Community dialogues are targeted for caregivers with CLWD but are open to all community members. However, caregivers of CLWD are also invited to participate in nurturing care sessions. Therefore, some cited that they were participating in “meetings once a month” (Parent of CLWD, Preah Vihear, C1, 030), while others spoke about “not participating fully” (Parent of CLWD, Preah Vihear, C2, 032). Those caregivers who could distinguish between the two cited the community dialogues as useful in supporting them to overcome their own stigma with disability, while enabling them to realize that they are not the only caregivers who have CLWD (Male Caregiver, KT, C1, 009). CAREGIVER LEARNING Caregivers who participated in IECD activities learned about various components of nurturing care. Respondents from a female caregiver FGD in Kampong Thom indicated, “in the past before IECD there were many sick children with diarrhea and vomiting. We did not take good care of our children. We were too busy with our work and forgot about our children” (C1, 018). Other respondents identified learning that they need to “speak good words with children and read books to them” (Female Caregiver, KT, C2, 005), “teach the children how to play, know their colors, read books since pregnancy, and demonstrate good behaviors” (CCWC, PV, C1, 063), and that they should “let children play with their friends. We {caregivers} just guide them not to take others’ belongings and share toys. We also tell the children what they did wrong, and we answer what they ask” (Female Caregiver, KT, C1, 003). One respondent summarized their engagement with IECD as follows: The good points I have learned are how to be a responsive parent by playing with children, being close to the children, and having a happy family. The way IECD has taught us to play with children allows parents the opportunity to observe the progress of children’s physical, mental, and linguistic growth (Female VHSG, KT, CI, 034). Many respondents spoke about learning how to make enriched porridge through cooking demonstrations. Also, respondents often commented on how the nutrition screenings have allowed them to be more aware of their children’s growth. A male caregiver stated: “I know my son’s weight and height now. He is three years old and weighs 15 kilograms” (KT, Cohort 2, 011). Others stated how the IECD Activity taught them how to plant a home garden (Female Caregiver, KT, C1, 018; CCWC, KT, Cohort 1, 058). Handwashing was the most mentioned WASH practice learned by KII and FGD respondents, along with the benefits of community clean-up days. One respondent stated: “WASH is easy to put into practice and it is the most interesting session in the nurturing care session” (Female VHSG, KT, C1, 033). Mini-survey data demonstrates that 70 percent of respondents are very confident with being able to have regular access to a handwashing station and 70 percent feel confident that they can maintain a clean and safe environment at home, as shown in Figure 7 below. The IECD cohort baseline reported 68.7 percent of respondents practicing positive key behaviors towards Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 18 the health and WASH component of nurturing care22. Despite learning about a practice, it does not always result in behavior change. For some individuals, behavior change is not dependent solely upon knowledge, but underlying factors linked to self-efficacy or additional external resources such as food, water, latrines, or time.23 24 Figure 7: Confidence of Putting into Practice WASH Actions Built by ME&A with mini-survey data. May 2023. Respondents often reported learning that reflected a holistic approach to caregiving. A male caregiver from Kampong Thom stated: “Children grow healthy when we {caregivers} provide sufficient and nutritious food along with clean clothing, often bathe children, and ensure they get enough sleep” (Male Caregiver, KT, C2, 011). Another male respondent shared that he found “almost all families are not violent to their child, they practice better hygiene, and use clean water” (Male VHSG, PV, C1, 047). A key learning for many respondents was linked to care of children, as it relates to abuse, neglect, and violence. A CDL stated that now, when VHSGs and CDLs meet with caregivers, they can “speak to the family about not neglecting their child or forgetting children who are disabled” and that there is “better care of children with more positive parenting including less swear words when the parents get frustrated” (KT, C1, 049). One female caregiver FGD participant shared: “If 22 USAID and RTI International. (2022). IECD Cohort Evaluation Baseline Report. 23 Arlinghaus K.R., & Johnston C.A. (2017). Advocating for Behavior Change with Education. American Journal of Lifestyle Medicine.12(2):113- 116. 24 WHO. (2018). WASH and Health working together: a ‘how-to’ guide for neglected tropical disease programs. Geneva. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 19 we verbally abuse children, they will not grow up smart. If the children see us beating children, they will copy us” (KT, C1, 018). Some respondents reflected on how they had experienced first-hand or witnessed changes in behavior. One grandmother stated: “My daughter joined the IECD session. She used to be mean with her child, but since she has joined nurturing care, she is less mean” (Preah Vihear, C1, 023). A female caregiver shared that she learned how to nurture her child. “Before, when my child cried, I yelled and shouted at him and that made my child scared. After going to the training {nurturing care session}, I do not shout at my child anymore” (KT, C2, 004). A health center nurse in Kampong Thom shared that “clothes are getting washed, families are more attentive and responding to the various needs of the children” (C1, 065), while a CDL stated “families are taking good care and they are paying close attention to their children” (KT, C1, 049). ONGOING AND UNRESOLVED CHALLENGES Some of the ongoing, unresolved challenges that have been identified include misinformation and recall of messages, time constraints of caregivers, misinformation of messages, integration of nutrition, agriculture and WASH with disability efforts, grandparents as predominant caregivers, length of the cohorts, and devices. Misinformation and Recall. Misinformation and recall occur in the IECD Activity. While IECD cannot manage all information flow to and from the target population, there were instances of misinformation and recall from those directly engaged with the Activity. Who participates in trainings from government and health centers, which is beyond the scope of the IECD Activity, has a trickle-down effect. A representative from the provincial health department (PHD) in Kampong Thom stated: “The modules and trainings are good, but there can be too much information in each session and the VHSGs often forget. It would be good if the supervision could happen straight after the trainings” (Government, C1-2, 111). Some individuals involved in implementation shared that “the community does not know the interventions the same way that they are described to us by the technical specialists. It has been hard to understand which interventions community members have been participating in specifically and to specifically understand or pinpoint which ones might be having the greatest impact” (IP, PPH, C1-2, 077 and 078). At the community level, a female VHSG stated specifically that “it is difficult to apply the MUAC and child disability screening” (KT, C2, 035). Participants in a VHSG FGD from Kampong Thom representing C1 further acknowledge that they “recognize that the master trainers are good and well trained, but the screenings get more watered down with the trainings” (004). Male and female caregivers alike shared that it is not always easy to remember the messages or be clear on how to put messages into action (Male Caregiver, PV, C1, 120 and Female Caregiver, KT, C1, 002). The IECD Annual Report stated that events like the planting season and flooding can limit the participation of VHSGs and CDLs in coaching sessions, particularly with the CommCare App, Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 20 while also noting that “some parents hesitated to bring their children who were detected as having MAM to health centers because parents perceived their child to be healthy”.25 Disability. For CLWD, many respondents felt that the work is just beginning as the cohorts are ending (Caregiver CLWD FGD, KT, C1, 006; Caregiver CLWD, KT, C2, 027 and 028). One challenge linked to nurturing care is that there should be more effective integration between nutrition and WASH to better represent CLWD in the nurturing care materials (IP, PPH and SRP, C1-2, 076, 084, 085). VHSGs should also be able to identify caregivers who might require specific follow-on support from the IECD nurse, physical therapist and/or interventionists to modify key messages to effectively respond to the needs of a CLWD. Other challenges identified include caregivers’ ability to follow up or receive follow up treatment and care. ET members observed that caregivers and families do not always follow through on doing the physical therapy and medical treatment. Some of the caregivers are convinced that receiving services once will be enough to “fix” the children (Caregiver of CLWD, KT, C1, 026 and PV, C1, 031). While many caregivers reported improvements on how others in the community responded to and accepted their children, caregivers still face challenges with getting the community and medical support they require. Caregivers lack the confidence to ask questions or seek answers about medical care, treatment, and services. A health center nurse from Kampong Thom stated: “Many families do not see an instant improvement, so they do not come back” (C1, 065). To ensure that children receive the long-term care and treatment they might require, it is important that caregivers are clear on their rights as clients, while IECD continues to advocate with government parents to improve the services available to CLWD for the long term. Community Constraints. Community constraints specific to time and financial resources were mentioned by many respondents. One Female VHSG indicated: “The most difficult one is to call caregivers to meet for training or awareness raising” (KT, C2, 037), while a CDL from Kampong Thom indicated there is “limited participation from the community. We should conduct more home visits to those who are absent during the training/meeting” (C2, 053). However, others shared that despite the overall noted success of the home visits that sometimes caregivers have no time to meet at home either (Female VHSG, KT, C1, 033). Some respondents noted that it was harder to do home visits during the “busy season”, while some felt it was more due to labor activities, as “they leave from home in early morning, return late in the evening, and sometimes stay over where they are working” (CDL, KT, C2, 053 & Female VHSG, KT, C1, 115). Male caregiver respondents in an FGD in Preah Vihear shared that they are working. “A main problem is villagers are not interested in meeting/training especially men because they are busy with farming activities” (Male Caregivers, PV, C1-2, 016), while a grandmother from Preah Vihear shared that she thinks part of the challenge is that “many caregivers do not attend the meetings because they do not understand the importance of the ECD session” (C1, 022). A female caregiver in Kampong Thom noted that she “finds it hard to commit to join all IECD sessions since she has one baby plus two older children” (C1, 002). Male caregivers from a FGD in Preah Vihear shared 25 USAID. (2022). Cambodia Integrated Early Childhood Development Activity. FY2022 Annual Report October 2021 to September 2022. Phnom Penh. Revised November 17, 2022. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 21 that “IECD will have more participation in the meeting/training if IECD provides some travel allowance for gasoline” (C2, 008). Strategies that the community has attempted to mitigate include the “VHSGs using their motorbikes to take them to the meeting” (Male VHSG, Preah Vihear, C1, 047). Some VHSGs and CDLs are trying to work “closely with the village chief to invite villagers to participate in the meeting/training” (CDL, KT, C2, 053). The IECD Activity itself has also tried to mitigate this challenge by allowing and encouraging reasonable flexibility with the schedules for meetings and home visits (CCWC, PV, C1, 062). In the next year, it will be important for IECD to review these strategies against participation to determine if they have worked. Grandparents. A study from Cambodia found that grandmothers do play “a central role in their grandchildren’s health and nutrition” and as a result interventions should be designed to enable grandparents to take care of their grandchildren, while not neglecting their own health and nutrition needs.26 Female and male caregivers are busy. Male caregivers remain primarily responsible for income generation, but more women are either having to do day labor or are busy at home with other household tasks. Changes are being realized with male caregivers supporting female caregivers as they can, but there is a fundamental reality that grandparents are very much involved in the caregiving of children. “I stay at home and take care of my grandson. His parents go to work in the plantation every day. They leave home in the morning and come back in the evening,” stated a grandparent in Preah Vihear (C1, 023). Overall, it is felt that “grandparents play a very important role in taking care of young children” (CDL, KT, C2, 053). Grandparents are aware of the IECD activities. “I know about IECD because they invited my daughter a few times,” shared a grandparent (Preah Vihear, C1, 023), but they are not necessarily joining or practicing the key messages. One grandparent shared that they cannot join because the location is too far away (Preah Vihear, C1, 022), while another grandparent stated: “I feed white porridge with salt to my grandchild” (Kampong Thom, C2, 020). This is due in part to caregivers not making or having time to share information at home, but also grandparents not feeling the messages link to their realities, or they can effectively participate, which was a similar finding to the Schneiders, et al. article.27 “I cannot do agricultural activities anymore and I do not like soft food like vegetables. I like hard, salty food. I give this to my grandchild, not vegetables,” stated a grandparent from Kampong Thom (C2, 021). Length of the Cohort. Respondents for the most part indicated that they would like the implementation period for each cohort to be longer than 15 months. Most respondents felt that a few more months or a minimum of two years would have been more effective given the number of different messages in the nurturing care sessions and various activities, particularly for those caregivers with CLWD. A female caregiver in Preah Vihear shared: “Sometimes I don’t get it because there are so many things to learn. I don’t think I can remember it all. I wish they could teach me some more. I am a young mother and I do not know much about this” (C2, 010). Another female caregiver from Preah Vihear (but from C1) stated: “This activity finished a long time ago; that’s why I did not attend any activities recently” (Female Caregiver, PV, C1, 006). One CDL reflected on how change 26 Schneiders ML, Phou M, Tun V, Kelley M, Parker M, and Turner C. (2021). Grandparent caregiving in Cambodian skip-generation households: Roles and impact on child nutrition. Maternal Child Nutrition. Suppl 1(Suppl 1). 27 Ibid. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 22 takes time. “The difficulty of nurturing care is that the people could not change their behavior because they still practice the old ways of child nurturing care” (CDL, KT, C2, 051) Language Development of Young Children. In the IECD Activity baseline report it was reported that 57 percent of women and 53 percent of men in the target areas are literate. This means that roughly one-third of the target population is illiterate.28 This was evident in the data collection process as respondents indicated that they cannot read (Male Caregiver, KT, C1, 009; Female Caregiver, KT, C1, 002; Grandparent, PV, C1, 023). Others shared that they “do not let my son see the book, which was provided by the Activity, because he gets tired of the book” (Female Caregiver, KT, C2, 005). As a result of caregivers not being able to read, caregivers are using phones either to entertain while they are working, busy or use them to support language development. Female caregivers in an FGD shared that “parents play, shower, feed, and put children to bed, but they do not tell stories because children are watching on phone” (KT, C1, 018). One CDL shared that children’s access to phones is becoming so prevalent that “phones are interfering with language development.” The CDL is working to “encourage caregivers to engage more with speaking and playing with their children, but more needs to be done” (KT, C1, 049). One caregiver of a CLWD identified a benefit with devices being an opportunity to work on fine motor skills. “We use our phones to entertain our son and help him build his understanding of letters and numbers in Khmer, while working on muscle tone in his fingers” (Caregiver of CLWD, KT, C1, 025). Regardless, it is important to recognize that while reading stories is being promoted under the IECD Activity, caregivers’ literacy level is preventing stories from being read. Caregivers default to using devices for language development. Table 5: Summary of Strengths, Areas for Improvement, and Challenges for EQ1 Summary of Findings for EQ 1 Caregivers learned from nurturing care sessions, community dialogue and home visits to improve how they have nurtured their children Strengths Areas for Improvement Challenges ● Collaborative in the design process ● Nurturing care materials are user-friendly, integrated and reflect current national recommendations, policies, and processes across all ministries and departments ● Home visits are considered very useful in reaching caregivers ● Screenings for MUAC and CBDMAT ● Engaging grandparents with messages that matter to them ● Community time constraints and frequency of meetings for nurturing care sessions ● Turnover of staff and busy communities can result in misinformation and recall of messages ● Language development of young children ● Length of the IECD Activity cohort ● Migration is an unresolved challenge for IECD IPs. ● Literacy and devices 28 USAID and RTI International. (2022). IECD Cohort Evaluation Baseline Report. Phnom Penh. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 23 5.1.1 EQ 1.1. How did nurturing care work for children? Overall, respondents indicated that caregivers were more aware of child development, confident with making enriched porridge, and more aware of how to prevent maltreatment, abuse, and neglect. Respondents recognized that children are benefiting from more responsive caregiving. One CDL stated that there is “less use of swear words when the parents get frustrated” (Kampong Thom, C1, 049), while a male VHSG from Preah Vihear stated that he finds “almost all of the families now are not violent to their child, they practice better hygiene and use clean water” (CI, 047). A female caregiver in Preah Vihear shared the following: I participated in IECD activities like cooking demonstrations of enriched porridge, teaching my child to know the colors (e.g., yellow, red, and blue) and words like grandmother and grandfather. The VHSG came to do MUAC at my house to measure all my children’s weight and growth. From this activity, I learned that my child is underweight. I was introduced to healthy food by mixing meat, fish, and vegetables. As a result, my child’s weight has increased” (C1, 006). However, there is a fundamental reality that caregivers are busy. Caregivers, communes, VHSG members, and other respondents stated this frequently in interviews. “Messages are difficult to put into practice. It is difficult to invite villagers or caregivers to attend the meeting or training because they are busy and not willing to participate” (CCWC, KT, C2, 060), while others stated that “I don’t get it because there are so many things to learn. I don’t think I can remember it all” (Female Caregiver, PV, C2, 010). The time constraints that households face can perpetuate misinformation, particularly as information may not get shared (Grandparent, PV, C1, 023) or is forgotten entirely or there is too much time between the caregiver learning and putting the key message into practice (Government, KT, C1-2, 111). These limitations can result in some “caregivers not attending meetings because they do not understand the importance of the ECD sessions,” as stated by a grandmother in Preah Vihear (C1, 022). Table 6: Summary of Strengths, Areas for Improvement, and Challenges for EQ 1.1 Summary of Findings for EQ 1.1 Nurturing Care for Children Strengths Areas for Improvement Challenges ● Communities understand the importance of child development ● Responsive caregiving practices ● Safety and security for children ● Caregivers who participate in IECD activities are not consistently sharing information with other household members ● Caregiver time constraints Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 24 5.1.2 EQ 1.2. How did nurturing care work for families with children living with disabilities? The integration of CLWD with early childhood development and nutrition is a new programming approach for USAID in Cambodia (USAID, PPH, C1-2, 083). It was stated across many of the government, international organization, IP, and community member respondents that the IECD Activity has been a great opportunity to explore the integration of ECD, nutrition, WASH, and inclusion of CLWD. Two families of CLWD expressed appreciation about being recognized, while also having the “opportunity to meet with other families in similar situations” and “learn that you can have a CLWD who you can nurture” (Male Caregiver, KT, C1, 009 and Caregiver of CLWD, KT, C1, 025). A caregiver of a CLWD from Kampong Thom stated: “I now try my best to teach my child to play, read and speak to them, and to know colors. I also try to provide more nutritious food” (C2, 027). Another caregiver from Preah Vihear shared how the IECD Activity “called for a meeting once a month with participants, who have children with disabilities from two to three villages at the RTI office. We discussed our children’s situation. I have attended two to three times” (C1, 030). Female caregivers in an FGD in Preah Vihear reflected on how families with CLWD are appreciating that they are being “invited to meetings once a month to discuss how to take care of children with disability” (C1-2, 007). Caregivers of a CLWD further stated that “I teach my son to call names, speak, stand up, or walk every day. Currently, he can laugh louder than before and can stand for a few minutes” (PV, C2, 032). Other respondents commented on the services being offered by AHC and support that they are receiving from Safe Haven and AHC for nutrition, care, and therapy. “Parents of children with disabilities have support for a separate meeting at RTI. RTI supports referral to Angkor Children’s Hospital” (Female VHSG, PV C2, 040). Respondents also appreciated knowledge that they were gaining from home visits as part of nurturing care or Safe Haven. They said that “home visits provide more information on the importance of IECD activities” (Caregiver CLWD, KT, C2, 027) and “I have received monthly home visits from activity staff.29 When the staff visited, he taught me how to do my son’s face therapy to reduce saliva, and how to teach my son to recognize the color yellow, green, blue…as well as how to teach my son to stand up and try to walk. Moreover, he gave me some toys for teaching and playing with my son” (Caregiver CLWD, PV, C1, 030). Respondents spoke a bit about the relationship between male and female caregivers of CLWD. Many female caregivers spoke about how, as they become more responsive and positive about their child’s realities and needs, the male caregivers become more supportive. “When the child looks cleaner and more engaged, the father enjoys this and wants to be around more and has more respect for the family,” stated a CCWC member (KT, C2, 059). While male caregivers may not be participating in many nurturing care sessions, they make themselves available as needed 29 Respondents for the most part cannot differentiate between RTI and Safe Haven interventions. “Le Cru” is the word used to distinguish Safe Haven for other IECD staff. This was confirmed with a CDL representative. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 25 when the family needs to travel to AHC in Siem Reap. “My husband could not attend the male caregiver session. We had to travel for training to AHC”30 (Caregiver CLWD, KT, C1, 025). While the IECD Activity has successfully initiated disability inclusion into a multi-sectoral holistic approach for caregiving with nurturing care, some areas of improvement have been identified and challenges realized. Integration of nutrition and WASH could be better mainstreamed into the interventions supporting CLWD by directly linking nutrition and WASH with disability, either through early interventions or more directly with the nutrition and WASH activities Providing standard guidance on nutrition and WASH is not possible given the various needs of CLWD. However, overarching messages should be considered that speak to the fact that modifications might need to be made for a CLWD and that caregivers of CLWD should discuss options with a specialist. This can include guidance to caregivers on consulting with medical staff who specialize in pediatric disability to discuss feeding support for children who might require it or seek referrals for private sector contractors who can support modifications to WASH infrastructure for households (IPs, PPH and SRP, C1-2, 074, 075, 076, 084, 085). Part of the challenge with achieving this is the lack of evidence in Cambodia about the needs of CLWD. IP respondents have indicated that “without evidence to inform the key messages, materials more specific for CLWD could not be created for nurturing care” (PPH, C1-2, 080). While this may be true, the IECD Activity presents a great opportunity to inform the evidence for CLWD in Cambodia for future programs with the cohort study and by leveraging the expertise of Safe Haven. Caregivers with CLWD face time constraints to participate in IECD activities. Most caregivers of CLWD are busy working, similarly to other families in communities in IECD target areas. They said that “many villagers do not participate in the meetings due to being busy with farming activities” (Caregiver of CLWD, KT, C2, 027) and “I used to take my son for a walk but not regularly because I am busy at the farm now” (Caregiver of CLWD, PV, C2, 032). The socio-economic realities of caregivers of CLWD came through in a couple of interviews as it related to putting into practice nurturing care messages. A CDL discussed how they have seen families refuse any follow-up care as “they are poor” (PV, C1, 055). Other caregivers of CLWD seem concerned that while everything is there, delays persist, quality of local health services is not consistent, support varies from cohort to cohort, and financial resources from government social protection mechanisms are not meeting family needs or are not on time. One area where some challenges seem to be more common is specific with families being able to access quality care and medical resources from local public health centers, particularly if a child is sick but not requiring the need to go to Siem Reap. As the Deputy Director of Kampong Thom Provincial Health Department stated: “We can only guide them to where the services are available. The issue is that we do not have budget for this.” (C1-2, 112). One caregiver shared that due to her son’s disability, he has a weakened immune system, which makes him vulnerable 30 Respondents often use the word “training” to refer to any activity where they might learn something. This could be a physical therapy session where the caregivers learn new therapies, or it could be the nurturing care sessions. Attempts were made to understand what exactly “training” might entail across the IECD interventions, but realized it is a catch phrase for most of the interventions. Implementing partners at Safe Haven and AHC confirmed that the participants are likely using the term as a “catch all phrase” for any activity that has a learning component. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 26 to illness. As a result, the family spends more money seeking health services and purchasing medicines (Caregiver of CLWD, KT, C1, 025). Many of the CLWD being identified, referred, and followed up with under IECD are children that require extended care. A 15-month cohort timeline only enables an initial identification, referral, and initial follow-up for services – services that many families lack the confidence to understand or continue to seek once the IECD Activity ends (IPs, C1-2, 076, 084, 085, 086). IECD has extended its support to CLWD beyond the timeframe of the cohorts, but resources are limited to about three visits to Siem Reap and follow-up of CLWD currently enrolled. It has been noticed by caregivers. “I attended the meetings two or three times and now there are none,” stated a caregiver from a cohort 1 village in Preah Vihear. Table 7: Summary of Strengths, Areas for Improvement, and Challenges for EQ 1.2 Summary of Findings for EQ 1.2 Nurturing Care for Children Living with Disability Strengths Areas for Improvement Challenges ● CLWD are being identified, referred, and followed up with ● Partnership with Safe Haven and AHC in Siem Reap ● Male and female caregiver engagement ● Integration of CLWD needs across nurturing care messages ● Share learning about CLWD activities ● Caregiver time constraints ● Length of the cohort/ implementation ● Lack of evidence for CLWD and nurturing care ● Accessing primary health care services for CLWD 5.1.3 EQ 1.3. In what way are different family members particularly men involved in child nurturing care? Men and grandparents, when they are available, are engaged with nurturing care. The ET for the IECD mid-term evaluation discovered that men are often not available, similarly to the IECD Gender Analysis,. 31 Men are away in the fields working or in some instances have migrated to other provinces and Thailand for work. A female VHSG from Preah Vihear stated: “Men are busy with income generation activities” (C2, 040), while a representative from the Kampong Thom PHD stated: “During most of our visits we meet only mothers and we have always promoted men to participate in the session. Most of the men always go to work at the farm or migrate” (C1-2, 099). Mitigation techniques tried by the IECD Activity to engage men have been to include them in nurturing care sessions and in some instances allow for the mixing of female and male 31 USAID, RTI, and Helen Keller International. (2021). Gender Analysis for the Integrated Early Childhood Development Activity. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 27 participation in male caregiver group sessions32 (Female VHSG, PV, C1, 038). Even when mixing participants there are only an average of three or four men per male caregiver group (VHSG and CDL FGD, KT, C1, 004). A CDL shared that “VHSG do home visits, but men are still not available” (KT, C1, 049). Another CDL from a cohort 2 village in Kampong Thom indicated that “we need to select the suitable time to meet men, but even then, it can be a challenge” (051). One or two men, as noted in the results of data from the mini-survey and shared in a male FGD, are not finding the male caregiver groups useful, asthey do not have time to participate. However, nearly 65 percent of those who participated in the mini-survey find the groups very useful (refer to Figure 6). Therefore, working to find ways to engage men is worth IECD investigating. IECD is primarily focusing on working with men to support women at home with household tasks and child caregiving responsibilities. Additionally, the Activity is focusing on providing opportunities to discuss machoism, male social gender norms around alcohol consumption, device use, and preventing domestic violence and abuse (IP, PPH, C1-2, 073). The intention of IECD is to be gender transformative. When interviewed, most men reported trying to support their wife when they are at home and available. Many other respondents agreed. A female VHSG member in Preah Vihear stated that “men take care of children day and night, the same as women. We together feed the child and shower them. We support each other in the family” (C1, 039). A female caregiver stated that when her husband is home “he can take care of children with their baths and feeding them while the mother cooks or does other house chores” (KT, C1, 003). Female caregivers in an FGD agreed that “fathers now hug and cuddle the kids. They play with children. When the father sees that the children are clean and well looked after, the father is happy and loves his kids more. The fathers appreciate the mother and help her more” (KT, C1, 018). Grandparents are helping with caregiving of young children and, when motivated are also participating in IECD activities such as nurturing care sessions and home visits.33 “Grandparents play a very important role in taking care of young children because parents are busy with income generation activities,” stated a CDL from Kampong Thom (C2, 053). Grandparents themselves stated that “grandmothers take care of grandchildren because the men are busy farming” (Grandparent, PV, CI, 022), “I stay at home and take care of my grandson. His parents go to work at the plantation every day. They leave home in the morning and come back in the evening” (Grandparent, PV, C1, 023), and “I take care of everything for my grandchildren. Sometimes the mother also takes care of the children, but the father does not take care of children because he is busy” (Grandparent, KT, CI, 018). Overall, grandparents have stepped up to help families. However, messages and resources that are contextual for grandparents and caregivers are not available at the community level. The dietary needs and tastes of grandparents have changed. They prefer dried meat and fewer veggies, which could be beneficial because, given grandparents’ preference for meat, they might have strategies about how to ensure young children consume meat. The time it takes to prepare 32 The IECD Activity Male Caregiver Group session guidelines explicitly state that the groups are for men only, to enable honest discussion among participants and candid conversations about issues more relevant to men. 33 It is common in Asian families to practice intergenerational cohabitation. This article specifically focuses on this reality in Asia: https://www.un.org/development/desa/family/wp-content/uploads/sites/23/2020/06/EGM2020.Grandparenting-in-Asia.SK_.pdf Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 28 food for young children is not something that the grandparents are convinced is worth their time, nor is investing in the right foods for young children. An area that requires attention by IECD is understanding how to enable families to share what they are learning. All caregivers are busy. Caregivers and the IECD Activity have taken the initiative to work together to ensure a representative from each target household participates in key activities. Next is to determine how participants can share the information learned. Table 8: Summary of Strengths, Areas for Improvement, and Challenges for EQ 1.3 Summary of Findings for EQ 1.3 Role of Different Family Members Strengths Areas for Improvement Challenges ● Men are supporting women when they are at home ● Domestic violence and alcohol abuse are not as common ● Grandparents are helping families ● Target messages to meaningfully engage grandparents ● Migration ● Income generation activities 5.1.4 EQ 1.4. How are men’s and women’s roles different in the care of boys and girls? The IECD mid-term ET did not identify any “gendered differences in how boys and girls are cared for by their parents”, 34 similarly to the IECD Gender Analysis report. A representative from the CCWC in Preah Vihear specifically stated that “boys and girls get the same treatment of being taken care of by parents” (C2, 064). Additionally, there do not seem to be any distinct differences between men or women’s roles in the care of boys and girls. A female VHSG stated: “Men take care of children day and night, the same as women. Men and women feed children, shower them and we support each other in the family” (PV, C1, 039). A female VHSG further reinforced this by sharing that “there Is no difference between male and female caregiver tasks in the household. The primary male caregiver can feed, bathe, and wash clothes, and female caregivers do house chores, cooking, send children to school, and some farming” (Female VHSG, KT, C1, 034). Another respondent, a female caregiver, stated that female caregivers “cook food, breastfeed, and wash clothes. The primary male caregiver takes children for a walk, feeds, and plays with children” (KT, C2, 004). These results demonstrate that there are not gendered roles in taking on household and childcare tasks between male and female caregivers or with their children. According to mini-survey data in Figure 8, men are more inclined to help with household tasks that are physical, like carrying water and chopping wood, but they do support other household 34 USAID, RTI, and Helen Keller International. (2021). Gender Analysis for the Integrated Early Childhood Development Activity. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 29 tasks like food preparation, childcare, cleaning, cooking, and laundry. Regardless of there being increased male engagement, there is a reality that the household is still considered the domain of women (CCWC, PV, C2, 064). Figure 8: Women’s Responses on Who Helps with Household Activities Built by ME&A with mini-survey data. May 2023. Table 9: Summary of Strengths, Areas for Improvement, and Challenges for EQ 1.4 Summary of Findings for EQ 1.4 Male and Female Roles Strengths Areas for Improvement Challenges ● Male and female caregivers are sharing responsibilities at home ● Underlying norms around women’s and men’s domains of influence ● Men are viewed as the primary ones to earn an income Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 30 5.1.5 EQ 1.5. 1.6, 1.7., 1.8., 1.9. What are the outcomes to date of Male engagement with Who tells stories to the child? Who feeds the child? Who teaches the child new things? Who bathes the child or toilet trains them? As demonstrated in the previous section, men are engaging in caregiving at home. Regardless, respondents did indicate that male caregivers can still do more. “IECD should get the husbands to come to learn more so that they can improve. For me, when I know there is an invitation for the learning, I tell my husband in advance to make sure he would quit work on that day, so he can go to join,” stated a female caregiver in an FGD in Kampong Thom (C1, 018). Respondents indicated that at home men are contributing to various tasks, but no caregivers stated that men are engaging in all caregiving tasks. The reason for this is that “men play less of a role as caregivers because they are busy with their farming, which is far away from home, or sometimes leave home in the early morning and return back home in the evening” (Male VHSG, PV, CI, 047). As a result, female caregivers are still considered the primary caregivers, which is not a change from the IECD Gender Analysis from 2021.35 What has changed is that few respondents spoke about any of the caregiving tasks solely as women’s work. A female caregiver from Kampong Thom stated that “the husbands have become very different. They help take care of the children, feed them, and shower them. Before, when we asked them to do it, they said it was a woman’s job not a man’s job. This has changed” (C2, 018). Another female caregiver stated that a “majority of the tasks of taking care of children is shared between men and women. They are the same, except men must go out to earn income and I must spend my time to take care of my children” (PV, C1, 030). Overall, most respondents stated that men are engaged with caregiving tasks when they are home. A male caregiver stated: I do feed my son and often bathe him and sometimes my wife does it. I always provide free time for her, for example, before going out to drink with my friend, I prepare food and cook for them. My neighbor asked me why I do clothes washing, which is female work, and I respond to them that it is my own family, and it is good that husbands and wives help each other on house chores (Kampong Thom, C2, 011). Husbands are changing, but some still report that men might just take children for a walk (Female Caregiver, KT, C1, 001) or that male caregivers lack the confidence or knowledge about what are cues for feeding, as stated in an FGD (Female Caregivers, PV, C1-2, 007). 35 USAID, RTI, and Helen Keller International. (2021). Gender Analysis for the Integrated Early Childhood Development Activity. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 31 Table 10: Summary of Strengths, Areas for Improvement, and Challenges for EQ 1.5, 1.6, 1.7, 1.8, 1.9 Summary of Findings for EQ 1.5, 1.6, 1.7, 1.8 and 1.9 Male Engagement with Caregiving Strengths Areas for Improvement Challenges ● Male caregivers are engaged with caregiving tasks at the household ● Identify ways to further engage men in all household tasks and encourage them to lead on caregiving to learn cues ● Men are busy with income generation activities 5.1.6 EQ 1.10. Are community members reporting that children are being referred less, the same, more for nutrition? The IECD Activity has been training VHSGs and CDLs to facilitate MUAC screenings in target villages. Cambodia recommends the use of MUAC to identify moderate and severe acute malnutrition at a community level or for outreach services.36, 37 Interviews indicated that the CDLs and VHSGs are familiar with MUAC screenings across all IECD target areas. CDLs and VHSGs interviewed stated that “MUAC is a tool to screen the child physical development” (CDL, C2, 051) and “I did the MUAC screening for child nutrition” (Female VHSG, Cohort 1, 033) in Kampong Thom while, similarly in Preah Vihear, a female VHSG member stated: “We also screen the children by using MUAC tools” (C1, 038). In addition to completing MUAC screenings, community volunteers and caregivers shared their experiences. “I took my son to get MUAC to follow up his progress which was conducted by VHSG two times per month. I also got the advice to nurture my son, feed him regularly with tasty food and fruit. I also learned how to wash hands properly and bathe my son” (Female Caregiver, KT, C2, 005). A CDL from Kampong Thom stated that “the MUAC activities made parents interested in their children’s progress by knowing that their children are healthy or have malnutrition. When they know that their children are under the line of nutrition, they need to provide more supplemental food” (C1, 050), while a female VHSG spoke about how there is an increased understanding of why it is important to do a MUAC screening. “Malnutrition can lead to children having many problems when they grow-up” (KT, C2, 035). While health center respondents from Sandan and Stoung Districts indicated that they felt referrals were up given the increased screening, cases of severe acute malnutrition were roughly the same. (KT, C1, 065; KT, C2, 066). A female caregiver from Kampong Thom stated: 36 Royal Government of Cambodia. (2022). Interim Guidelines on Growth Monitoring and Promotion for Children under Five Years Old in Cambodia. 37 Laillou A, Prak S, de Groot R, Whitney S, Conkle J, et al. (2014). Optimal Screening of Children with Acute Malnutrition Requires a Change in Current WHO Guidelines as MUAC and WHZ Identify Different Patient Groups. PLoS ONE 9(7): e101159. doi:10.1371/journal.pone.0101159 Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 32 Through child screening some children were referred to a health center to get BP100. The recommended treatment schedule was to take BP100 three times per day for four weeks. However, some other children are just encouraged to get more breastmilk and the caregivers were encouraged to be more responsive with the child’s feeding. These recommendations made the children better (C2, 005). The health center in Stoung district reinforced this caregiver’s statement by sharing that “breastfeeding and responsive feeding practices are often the underlying factors contributing to malnutrition” in their health center (C2, 066). A health center in Rovieng district stated: “Most of the children we see are in yellow. The children like to eat package snacks” (C2, 068). At a population level in IECD target areas, minimum acceptable diet has increased from 27 percent to 54 percent.38 Given this success, children who are identified as being moderately or severely malnourished should be followed up with more frequently. Support to the families, specifically on responsive feeding, breastfeeding, and alternatives to packaged snack foods, should be considered. One CCWC member stated that “the MUAC screening is just helping to reduce the child development delay but cannot eliminate it. This is because mothers do not pay much attention to the new way of nurturing care. They still believe in the traditional way to raise their children” (KT, C1, 058). Other respondents shared concern about the capacity of VHSG to complete the screenings and/or a misunderstanding of recommendations for a well-nourished child. A CDL stated that they “would suggest health center staff participate in screening activities to ensure that the result is trustworthy. For example, some children are healthy but from MUAC screening results, they are low weight and do not meet the standards.” (KT, C2, 051). This also reinforces the idea that there is some misinformation in the communities around critical IECD topics, specifically with households where a child has been identified as malnourished. Lastly, respondents shared that there are some issues with treatment compliance for malnutrition in IECD target areas. The health center in Sandan shared that “families might come once, but unless they see a quick result they will not come again” (KT, C1, 065). In Rovieng, a CCWC member shared a similar experience. “In a case where a child was identified as malnourished, we sent them to a health center to access BP100. The caregivers did not go to meet the health center. The health center called us to push or motivate them to visit the health center according to the appointment, but they never went” (PV, C2, 064). 38 USAID. (2023). IECD Cohort 1 Endline Report. Revisions still ongoing. Phnom Penh. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 33 Table 11: Summary of Strengths, Areas for Improvement, and Challenges for EQ 1.10 Summary of Findings for EQ 1.10 Nutrition Screening Strengths Areas for Improvement Challenges ● VHSGs have been trained to use the tool ● More children are being screened and referred ● Confidence to complete a MUAC screening ● Treatment compliance ● Improve breastfeeding and responsive feeding practices in the household where a child has been identified as malnourished ● Sustainability 5.2 EQ. 2. HOW HAVE IECD’S BENEFICIARIES BENEFITTED FROM IECD’S INTERVENTIONS, INCLUDING HOME GARDENING, INCOME GENERATION, CHILD NUTRITION SCREENING AND WASH? Respondents benefited from various IECD interventions, including home gardening and child nutrition screening. Figure 6, earlier in this section, demonstrates that respondents believe child nutrition screening is the most useful IECD intervention, followed by disability/developmental delay screening, village model farmer activities, and cooking demonstration. Income generation was something respondents spoke about, but usually in the broader sense of work and not necessarily specific to the activities of IECD. Much of the data on WASH reinforces the need for the increased investment that IECD initiated in early 2023. Community members appreciated learning about home gardening, particularly about natural pesticides and compost (Male Caregivers FGD, PV, C2, 008). Cooking demonstrations were also useful, with their focus on making enriched porridge and screenings widely accepted and appreciated by respondents. Areas recommended for improvement include identifying more local solutions for home gardening and local food production. At times it was also difficult to differentiate the efforts of home gardening and village model farmer activities with other agriculture activities not supported by IECD. Communities shared concerns about having the income to build handwashing stations and toilets and having access to the right foods to feed children, particularly enriched porridge, while time to participate remains a challenge. A unique challenge for enriched porridge is that some children do not initially like the taste and texture and caregivers are concerned that it is triggering diarrhea. HOME GARDENS Many respondents shared that their villages have home gardens. “Yes, in my village nearly all the households have home gardening except during the flooding period. They grow cabbage, Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 34 lemongrass, and morning glory” (CDL, KT, C1, 050). Morning glory is one of the most produced vegetables in home gardens (Female Caregiver FGD, KT, C2, 014; Female VHSG, KT, CI, 033; and Female Caregiver, PV, C1, 006). Home gardens primarily are used for family consumption (Male Caregiver FGD, PV, C1-2, 016 and CCW, KT, C2, 060). A grandparent stated: “I have a home garden. I grow some vegetables for family use. The vegetables in the market have chemicals that affect our health, but my vegetables do not have chemicals” (KT, C2, 020). Being taught organic methods for growing vegetables was stated by others as a benefit: “Training on home garden, natural pesticides, and fertilizer is good” (Male Caregiver FGD, PV, C1-2, 016). Another benefit identified by respondents is that home gardens can help “reduce household expenses,” saving families money in the long term (CCWC, KT, C1, 058; Caregiver of CLWD, PV, C1, 030). Respondents also often shared that home gardens are opportunities for households to work together for planting and maintenance and any income generated is for women (Female Caregiver FGD, PV, C1-2, 007). Most often it was stated that home gardens were for family consumption, with only surpluses being sold at the market (Female Caregiver, PV, C1, 006; Female Caregiver, KT, C2, 027). Men’s participation in home gardens generally does not seem common. Access to water is a challenge for some households with being able to keep a home garden. It was stated in a few interviews that “households do not grow vegetables because of water shortages or lack of access to water” (CCWC, PV, C1, 063), while some cannot keep a home garden year-round due to flooding (Female VHSG, KT, C1, 033; Grandparent, PV, C1, 022). A similar challenge was reported in the IECD annual report from September 2022 where it stated that “In the dry season, some households have limited water available to grow vegetables”39 The IECD cohort baseline report demonstrated that 66.8% of households were currently planting vegetables. Lack of water and flooding could be reasons why more households are not able to keep a home garden. INCOME GENERATION Income generation linked to IECD interventions is primarily linked to home gardens and the surplus of vegetables grown by households (Male Caregiver FGD, PV, C1-2, 016). Communities have tried to increase their growing yields, but market prices have not responded favorably (Male Caregivers FGD, PV, C1-2, 016). This has resulted in communities not being motivated to grow vegetables for income. The data from IECD demonstrates an increase in vegetable production because of IECD interventions. It is not clear if this is from home gardens or model farmer activities. Overall, many respondents indicated that “men play more of a role in income generation activities, while women manage the money. Big purchase items are discussed between men and women and agreed upon between them” (Female Caregiver, PV, C1-2, 007). A female VHSG in Kampong Thom added that “it is not common for men to hold onto the family finances. Women are the ones to manage the household money” (C1, 033). The IECD Gender Analysis had a similar 39 USAID/Cambodia Integrated Early Childhood Development Activity. FY2022 Annual Report October 2021 - September 2022. Revised November 17, 2022. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 35 finding that “men are expected to be breadwinners, commonly working as construction workers or laborers on plantations” (p. 34, 2021). CHILD NUTRITION SCREENING Respondents consider child nutrition screening the most useful IECD activity. One respondent stated that “I took my son to get MUAC to follow up on his progress. The MUAC was conducted by the VHSG two times per month. I also received advice on how to nurture my son and to feed him regularly with tasty food and fruit” (female caregiver, KT, C2, 005). A CDL stated that “the MUAC activities made parents interested in their children’s growth progress by knowing whether their children are healthy or not” (KT, CI, 050). The screenings also benefited communities by ensuring referral to health centers for those who required treatment. As one CCWC shared, “in cases where children were identified as malnourished, we would send them to the health center to access BP100” (PV, C2, 064), while a female caregiver added that “some children were referred to the health center to BP100 for three times a day for four weeks” (KT, C2, 005). All health center staff interviewed shared that caregivers complain that children do not like the taste of BP100 (HC, KT and PV, C1 and C2, 065, 066, 067, 068, 115) Some challenges presented themselves with the screenings. One is that some families struggled to adhere to the BP100 treatment while addressing the underlying causes of malnutrition, including but not limited to suboptimal breastfeeding, responsive feeding, and package snack food consumption. The health centers would often reach out to community volunteers including the CCWC, CDLs, and VHSGs to motivate families to continue with their follow-up and treatment, but this was not always successful (CCWC, PV, C2, 064). Further work needs to be done to address adherence to BP100 treatment and ensure families can overcome underlying causes of malnutrition in their households. WASH According to the CDHS roughly 21 percent40 of children under five years old are stunted, while almost half of the population in rural areas lacks access to safe drinking water and sanitation.41 The quality of water specifically impacts women and girls in their ability to clean, cook, and perform other household tasks, while also having a direct link to illness in children and women.42 The National Action Plan for Early Childhood Care and Development (ECCD) 2022 to 2026 also prioritizes the need for clean water and sanitation in its links to reducing malnutrition. 43 All respondents reported some knowledge of WASH. Many spoke about handwashing and the benefits of hand washing and some reported on toilet use, community clean ups, hygiene with young children, and sanitation of households. Respondents stated that “caregivers wash their hands before cooking and after leaving from toilet” (Grandparent, KT, C2, 020), while a female 40 National Institute of Statistics (NIS) [Cambodia], Ministry of Health (MoH) [Cambodia], and ICF. 2022. Cambodia Demographic and Health Survey 2021–22 Key Indicators Report. Phnom Penh, Cambodia, and Rockville, Maryland, USA: NIS, MoH, and ICF. 41 CARD (2019). The second national strategy for food security and nutrition 2019 – 2023. RGC, Phnom Penh. 42 World Bank. (2018). Report on gender analysis water supply for the proposed Bank-supported Water Supply and Sanitation Improvement Project. Phnom Penh. 43 Royal Government of Cambodia. (2022). National Action Plan on Early Childhood Care and Development 2022 – 2026. Phnom Penh. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 36 caregiver indicated that “handwashing is done before eating, after doing anything” (KT, C2, 005). Overall, a female VHSG shared that she has seen “improvements on hygiene and sanitation at household with more people washing their hands before eating” (KT, C1, 034). One respondent indicated that their community is almost open defecation-free (ODF) (CC, PV, C1, 063), while another stated that “most of the families in their village have a toilet. Families that do not have toilets do not have money to make payments towards a contribution to build one” (Female VHSG, PV, C1, 039). A CDL shared that their community “used to let children use the world as the toilet, but now they help even young children to use the toilet” (KT, C1, 049). Community clean-ups were identified by a few respondents as being a success of the IECD Activity. A female VHSG member shared that they do a “village cleaning event every three months where caregivers and VHSGs collect trash/waste in the village” (PV, C2, 040). Communities in Kampong Thom did the same by “mobilizing villagers to clean the environment in the village and complete rubbish collection along the road, at the school, and at the pagoda” (Female VHSG, C1, 033). One female VHSG stated that the “IECD is very useful. Our children don’t get sick as often” (PV, C1, 039). While IECD was identified as a driver to motivate communities to practice recommended WASH practices, respondents often also mentioned the efforts of ADRA and World Vision. This made it difficult at times to determine if respondents were speaking about IECD activities or other investments. One CCWC member stated that “it is good IECD came after World Vision. It helps to keep us motivated” (KT, C2, 059). Figure 9 below demonstrates the confidence of cohort respondents in their ability to have regular access to safe drinking water, maintain a clean and safe environment at home, and have regular access to a handwashing station and latrine. C1 respondents demonstrate the least amount of confidence. This could be due to flooding that took place since the end of the cohort, lack of access to water, old and broken infrastructure, and/or respondents not having access to handwashing stations and latrines when they are away from home. Figure 9: Confidence of Respondents from Cohorts to Practice Recommended WASH Practices Built by ME&A with mini-survey data. May 2023. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 37 Barriers that communities still face with access to toilets are primarily linked to infrastructure. “When we go to the plantation, there is no toilet,” stated one grandparent (PV, C1, 023), while young couples and families with fewer financial resources were reported to have less access to toilets (Female VHSG, PV, C1, 039 and Female Caregiver, PV, C2, 010). Households with fewer financial resources were also observed not being able to support any modifications to handwashing because they cannot afford soap or other supplies. Handwashing faces similar challenges to toilets. Knowledge is high, but practice is not always consistent with knowledge. According to the IECD baseline report, handwashing is highest after using a latrine, at 83.8 percent, and lowest before eating, at 64.3 percent. Respondents indicated that when they are away from home it is harder for them to access handwashing stations. Female caregivers in a FGD in Kampong Thom, summarized that “handwashing is practiced by all participants, but there is no soap. The soap was provided by other agencies and there are no proper water containers” (C2, 014). Another FGD with VHSGs and CDLs stated that “handwashing is still an issue. There is room for improvement particularly after working in the fields, but more common than before” (KT, C1, 004). Misconceptions about clean water exist in the IECD Activity target villages. Some communities are receiving piped water and others are still relying on wells, ponds, and streams. One CCWC member spoke about the cleanliness of her water at home. During the household observation, the water was found to be green. There was no safety ring around it or lid (KT, C2, 059). Other clean water misconceptions abounded with respondents believing that purchased water was clean even though it was observed to have visible bits of dirt in it. A female caregiver also shared that in her household they “use a water filter, but do not boil the water” (KT, C 2, 004). The ET was also not able to confirm from the commune councils whether water had been tested for arsenic. Considering how low some of the water tables are in IECD target villages, it would be worth the Activity exploring this. A household observation of a grandparent in Preah Vihear produced the following data: The chicken run around in the yard and poop. The sewage water is not properly managed, resulting in a muddy and smelly shower station. Water for use is stored in a small and shallow basin and debris is in the water. The dirty dishes are placed in a water bucket near the water basin, where the puppy was licking water and chickens were walking nearby. The toilet has been out of order for a couple days already (C 1, 023). Overall, WASH knowledge is high, but does not always translate into practice at the household level. The IECD cohort baseline survey demonstrated that 93.7 percent of households have soap and water, and while 83.8 percent of respondents wash their hands with soap and water after using the toilet, only 64.3 percent do so before eating.44 Random observations in 52 households (see Figure 10) from the ET also demonstrate that some more work needs to be done with WASH. 44 USAID and RTI International. (2022). IECD Cohort Evaluation Baseline Report. Phnom Penh. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 38 Figure 10: Household Observations Built by ME&A with household observation data. May 2023. Table 12: Summary of Strengths, Areas for Improvement, and Challenges for EQ 2 Summary of Findings for EQ 2 Home Gardens Strengths Areas for Improvement Challenges ● Easy access to vegetables ● Organic gardening techniques ● Income for women ● Access to water year￾round ● Flooding ● Low water tables Income Generation Activity Strengths Areas for Improvement Challenges ● Income for women ● Primarily from home gardens ● Challenging cultural norms about women’s financial contributions ● Market fluctuations ● Timeline of the cohort Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 39 Summary of Findings for EQ 2 Child Nutrition Screening Strengths Areas for Improvement Challenges ● More children were identified for malnutrition ● Improve treatment adherence ● Address children’s aversion to BP100 ● Sustainability WASH Strengths Areas for Improvement Challenges ● Knowledge is present for handwashing, toilet use, and clean environments ● Access to WASH infrastructure ● Misconceptions about clean water ● Flooding ● Lack of subsidies for poor households for WASH 5.2.1 EQ 2.1. Did the interventions contribute toward improving household food security and child nutrition? As indicated in Figure 6, respondents find that many of the IECD activities linked to food security and child nutrition are quite useful. One CCWC member stated that she “got the training on how to make enriched porridge, then I conducted the enriched porridge cooking demonstration to caregivers” (KT, C1, 058). A female caregiver also stated that “I eat better after learning from the IECD Activity, so breastfeeding is better and easier” (KT, C1, 002). Male caregivers in an FGD stated that they observe “women and children eating more nutritious food like green vegetables, they know now that breastfeeding is important for children aged below six months and above six months children can also have complementary foods” (PV, C2, 008). The next section focuses on IECD interventions that contributed to improvements in food security and child nutrition. FOOD SECURITY Food security and nutrition are complex issues for Cambodia. While the CDHS demonstrates most recently that stunting is at 21 percent for children under five years old, recent data published by the National Institute of Public Health demonstrates that the prevalence of overweight and obesity among women of reproductive age has increased from 18 percent in 2014 to 33 percent in 2021-2022.45 46This demonstrates that Cambodia is now at the age of experiencing a double burden for malnutrition. The IECD baseline report also demonstrated that 63.6 percent of 45 National Institute of Statistics, Directorate General for Health, and ICF International. (2015). Cambodia Demographic and Health Survey 2014. Phnom Penh, Cambodia, and Rockville, Maryland, USA: National Institute of Statistics, Directorate General for Health, and ICF International. 46 National Institute of Statistics (NIS) [Cambodia], Ministry of Health (MoH) [Cambodia], and ICF. 2022. Cambodia Demographic and Health Survey 2021–22 Key Indicators Report. Phnom Penh, Cambodia, and Rockville, Maryland, USA: NIS, MoH, and ICF. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 40 children are fed a diet that meets the minimum for diversity, 37 percent for meal frequency, and 40 percent for minimum acceptable diet.47 Most respondents shared that they are consuming more diverse diets at home. Knowledge of the various food groups for children 6 to 23 months in Figure 14 demonstrates that caregivers and community volunteers generally are aware of the various food groups that should be consumed in a 24-hour period. This would align with the IECD cohort baseline survey data which reported that 97.1 percent of respondents felt confident that there was year-round access to nutritious food.48 Many of the caregivers indicated that the primary source of animal protein in households is fish. A CDL from Preah Vihear stated that “most of the villagers eat fish that they have caught, or they buy some pork from the market. Beef is too expensive, so people do not eat it often” (C1, 055). Similarly, a female caregiver from Kampong Thom stated: “The majority of the time, I eat fish and sometimes we have pork that we buy from a house-to-house vendor. If we want beef, we buy it from the local market, but it is more expensive” (C2, 005). While respondents mentioned animal source proteins, some felt that barely more than half of households in their respective areas are consuming animal source proteins daily. A CCWC member stated: “A bit more than half of families will regularly prepare animal source proteins for their children to eat and apply what they learn” (KT, C2, 059). A female caregiver also stated that pork and fish are more common to eat and that “the chickens are for livelihoods and not for eating” (KT, C1, 002). Another said that chickens and other animals are there, but more sources of animal protein need to be available (C1, 049). In the IECD cohort baseline report, 81.4 percent of households reported raising chickens, ducks, or fish, while 96.4 percent of households reported that on a monthly and yearly basis, they felt confident that they have access to nutritious food including vegetables, fruit, meat, fish, and eggs.49 It would be worth exploring whether the households are raising chickens and other animals solely for income or consumption. Additionally, it would better to understand bi-weekly or seasonal access, including the percentage of food bought. Access to green vegetables does not seem to be consistent for the reasons mentioned in the home garden section. Households face challenges in keeping home gardens when water is either scarce or too abundant, like during floods (Caregiver for CLWD, KT, C1, 025). Households that farm fish face similar challenges due to water access. A female VHSG shared: “I used to farm some fish, but during the dry season we are in shortage of water, so I cannot raise fish anymore” (PV, C1, 039). Figure 10 above demonstrates that, during the ET’s household observations, only 41 percent of households had vegetables growing. This could be linked to data being collected in April and it being the peak dry season. In addition to ensuring diverse food consumption, respondents indicated that messages about overall health and well-being specifically for pregnant women are common. “Pregnant women need to have check-ups and use iron medicine50, eat diverse food, deliver the baby in the health 47 USAID and RTI International. (2022). IECD Cohort Evaluation Baseline Report. 48 USAID and RTI International. (2022). IECD Cohort Evaluation Baseline Report. 49 Ibid. 50 Iron folic acid was not mentioned by any respondents. Only iron is referenced in the data set. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 41 center, and then they need to have a postnatal check-up and breastfeed,” as was stated by a CCWC member from Kampong Thom (C2, 060). Based on responses in interviews, many individuals spoke about purchasing food. It was not clear how many are net buyers, producers, or a combination, but it was clear that many households do at least a combination of purchasing and producing. A female caregiver in Preah Vihear stated that “we do not plant vegetables. We have a rice paddy, cassava, and cashew nut plantation”, while a CCWC mentioned that “it is dependent on different villages. Some villages go fishing, grow vegetables, or do small chicken raising or fish farming. But most families buy food from the market” (KT, C2, 060). While respondents spoke about access to animal source proteins, vegetables, and rice, some also spoke about lean seasons. A few commune respondents and VHSGs shared that there are families in their communities who face food shortages. These families often do not have access to land and daily focus on “earning and eating” (CDL, PV, C1, 055). A grandparent also shared that the family runs out of food about two or three times per year (PV, C1, 023). In summary knowledge about food diversity is high, but practices need to be better understood with attention to purchasing and/or producing food to enable consumption of a diverse diet. Pregnant women overall seem to be receiving information on health services in addition to food consumption, which is important for healthy pregnancy outcomes. Water access for agricultural activities is a challenge as it is for WASH interventions. CHILD NUTRITION Cooking demonstrations and enriched porridge are considered very useful IECD activities. Respondents participated in cooking demonstrations and many caregivers have tried to prepare enriched porridge for their children. Some challenges persist regarding preparation time and young children’s acceptance of the diverse foods used to prepare the porridge. A CCWC member shared that “most of the children I have observed do not like enriched porridge because it is not tasty” (KT, C1, 058). One challenge that was raised by some respondents is the accessibility of healthy snacks for children in communities. Junk food is becoming more prevalent, and respondents indicated that it is not easy to find IECD-recommended snack foods like potato and banana (Female VHSG, PV, C1, 039)51. The IECD cohort baseline report demonstrated that 59.1 percent of children often eat packaged snacks. The ET also collected data to try to establish caregiver knowledge of categories of diverse foods. Overall, most of the respondents demonstrated some knowledge of diverse food groups for children from six to 23 months, as seen in Figure 11. Grandparents responded most when identifying flesh foods. There could be an opportunity to work with grandparents to determine how they sustain regular access to flesh foods and how this practice could be put forward with young children. Figure 12 further demonstrates that across female and male caregivers and grandparents that knowledge is similar for food group recommendations for children from 6 to 23 months. 51 USAID, RTI International and Helen Keller International. (2021). Facilitators Guide for Caregiving Sessions. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 42 Figure 11: Knowledge of Food Groups by Respondent Group Built by ME&A with mini-survey data. May 2023. Figure 12: Female and Male Caregivers’ and Grandparents’ Knowledge of Food Groups for Children 6 to 23 Months Built by ME&A with mini-survey data. May 2023. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 43 Table 13: Summary of Strengths, Areas for Improvement, and Challenges for EQ 2.1 Summary of Findings for EQ 2.1 Improving Household Food Security and Child Nutrition Strengths Areas for Improvement Challenges ● Cooking demonstrations ● Animal source protein consumption for young children ● Net food buyers ● Lean seasons ● Water availability 5.2.2 EQ 2.2. What are the differences in women’s (mother) and men’s (father) roles and how can gender power dynamics improve in food security and child nutrition? Home gardening? Income generation? Child nutrition? WASH? Men and women are working together in many areas to ensure food security and good child nutrition with income generation and WASH interventions. One female caregiver shared that her husband “takes our child when I am busy cooking. My husband washes our child, plays with our child, and helps with cooking when I need it” (KT, C2, 005). Home gardens are primarily organized and run by women with any excess vegetables being sold for income. Income generated from home gardens belongs to women (Female Caregiver FGD, KT, C1, 018 and Female Caregiver FGD, KT, C2, 015). Food security and child nutrition is dependent upon what the household can produce but is also dependent on income generation activities. Men are still largely considered to be the breadwinners, while women are the primary caregivers.52 As food security and income generation are linked, a female caregivers reflected in an FGD: “we help each other, but sometimes men do more to earn money” (KT, C2, 014). With child nutrition, the ET often observed male caregivers feeding children while it interviewed female caregivers. It was often mentioned by female caregivers that if the men are home they will help. Data from the mini￾survey further demonstrates that men are helping women with food preparation and cooking. Knowledge of WASH across all target populations is high. Putting knowledge into practice is always not consistent. Men, particularly, shared that they help with bathing children and do wash their hands at home, “they often cannot wash their hands when they are away from home” (Male Caregiver, KT, C2, 011 and Male Caregiver, KT, C1, 009). Underlying many of these WASH practices is access to water. A report from the World Bank demonstrates that, while women are the major water users in a household, few feel confident raising concerns in public forms like communes about water access and ultimately men in the household make the decision about establishing a household water connection.53 52 USAID, RTI, and Helen Keller International. (2021). Gender Analysis for the Integrated Early Childhood Development Activity. 53 World Bank. (2018). Report on gender analysis water supply for the proposed Bank-supported Water Supply and Sanitation Improvement Project. Phnom Penh. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 44 Overall, improvements are being realized with gender dynamics between men and women with food security, child nutrition, and income generation practices. Men are demonstrating less engagement with WASH and are self-reporting that they could do more with maintaining recommended WASH practices when they are away from home. This is important to prioritize as men and communes play a role in decision-making about water access at the household level. Table 14: Summary of Strengths, Areas for Improvement, and Challenges for EQ 2.2 Summary of Findings for EQ 2.2 Gender Power Dynamics in Improving Household Food Security, Child Nutrition, Home Gardening, Income Generation and WASH Strengths Areas for Improvement Challenges ● Men are more engaged in household activities ● Putting knowledge into practice with WASH ● Understanding water usage demands for men and women ● Volatility of incomes for households ● Climate change and access to water for growing food and household consumption 5.2.3 EQ 2.3. How did home gardening, income generation and child screening help improve nutrition intake for children with disabilities? Like other components of the IECD Activity, effort was given at the start of the Activity to engage as much as possible with disability organizations across Cambodia and with the various ministries to ensure IECD interventions effectively engaged caregivers and CLWD. This was largely in response to the gap identified with disability screening services and capacity of stakeholders in the situational analysis.54 The IECD Activity, in addition to nurturing care sessions, home visits, community dialogues, peer support, and other activities, prioritizes identification, referral, and follow-up of CLWD through the CBDMAT screenings. Additionally, IECD supports families with their costs of travel to Siem Reap and for receiving care at AHC. Resources do not exist to provide ongoing financial support to families with a CLWD. Caregivers of CLWD reported participating in various IECD activities. Various caregivers of CLWD shared that they had participated in sessions on enriched porridge, while another started using water filters because of the IECD Activity (PV, C2, 032 and KT, C2, 027). One caregiver of CLWD stated that “now our child is never sick after we attended IECD activities” (KT, C, 027). Female caregivers in Preah Vihear reflected on how IECD is an activity for all families. “It’s not only for families who have children with disability or developmental delay, but for community groups in general” (C1-2, 007). Another caregiver of a CLWD stated: “IECD teaches us how to teach our child to know and call objects properly, and how to teach my child to walk with some assistant tools” (PV, C1, 030), while a CDL reflected on how “in the past, neighbors would say bad things such as what a burden your child is or you should kill the child, and ask why the family is keeping the child. This is not common now” (KT, C1, 049). 54 USAID, RTI International and Helen Keller International. (2021). Situational Analysis Report: The Integrated early Childhood Development Activity. Phnom Penh. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 45 HOME GARDENS Caregivers of CLWD did not share much on their engagement in home gardening. Most stated they do what they can and if time or resources are there, they will grow a home garden. A caregiver of CLDW in Kampong Thom shared that during the rainy season they will keep a garden, but they cannot in the dry season as there is no water (C1, 025). A female caregiver of CLWD stated that she manages all the money in the household (KT, C2, 027). Other families with CLWD shared that they have attended sessions on enriched porridge and know to also provide family foods (PV, C2, 023) CBDMAT SCREENINGS: IDENTIFICATION, REFERRAL, AND FOLLOW-UP Many respondents spoke about the benefits of the identification, referral, and follow-up with the CBDMAT despite some initial skepticism about what the IECD Activity was going to do (Caregiver CLWD, KT, C1, 026 and Caregiver CLWD, PV, C2, 114). Many VHSG, CDL, and health center staff spoke about recent identification efforts. “During the screening, we identified two cases” (Female VHSG, KT, C1, 033). One child had issues with his kidneys, while the other child’s brain had not increased in size, and he could not stand alone. This child received a wheelchair because of the IECD referral activities. Commune council representatives spoke about increased identification and referral in their communes and how they had been “sent to AHC to get treatment and medical support” (PV, C1, 063). The commune council also supported one family in getting their ID Poor status updated so that the family could receive their health services for free and be eligible for a monthly cash transfer (CC, PV, C1, 063). Respondents often reflected on the process that took place after identification of the disability or developmental delay. “My son has cerebral palsy. My son has been identified by the Activity and is in the process of referral to AHC. Next month will be the first time we visit, and we will receive financial support from the IECD Activity,” stated a caregiver of a CLWD (PV, C 2, 032). A male caregiver in an FGD specifically shared that his daughter, who has liquid on the brain, had been identified by the IECD Activity, referred to AHC for a check, and received medical support. “My daughter stayed one night, and we returned after receiving the medical care from the hospital” (PV, C 2, 008). Others spoke about how community support increased once their child had been identified with the disability or developmental delay. In addition to support received from hospitals and consultations with doctors, a caregiver of CLWD stated that “we need support from our neighbors and our relatives for their advice on how to raise our children in a healthy way” (PV, C1, 030). Another stated: “During the meeting (community dialogue), I get some advice from the organization and other participants. I have organized to get help for my son, who cannot walk or sit,” shared another caregiver of a CLWD from Preah Vihear (C2, 032). Some caregivers of CLWD have noticed improvements since seeking medical services and receiving follow-up medical care. One female caregiver in Kampong Thom spoke about how she has “noticed physical improvement in my child after I do the physical therapy and movement exercises with him” (C1, 025), while another shared that they “do see improvements also with gross motor skills, speaking, and the hand and feet are becoming more responsive” (Caregiver CLWD, KT, C2, 027). Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 46 WASH Caregivers of CLWD spoke mainly about how they were using current WASH facilities with their child and making modifications as needed. One caregiver of a CLWD spoke about using a water jar, bowl and soap and bringing it to their child (KT, C2, 029), while another spoke about using a toddler training toilet, as it is easier to hold their child over this toilet (Caregiver CLWD, KT, C1, 025). The main reason for using the toddler training toilet is that their “son’s wheelchair cannot reach the family toilet because the ground is not straight. It will not fit in the door and there is no space for the wheelchair inside” (Caregiver CLWD, KT, C1, 025). INCOME GENERATION Various caregivers who have CLWD spoke about their financial realities. Research of childhood disability and socioeconomic circumstances shows an association between learning disability and behavior problems in children living in low to middle income countries.55 This demonstrates that it is important to take into consideration social protection options and costs for caregivers. One caregiver stated that the family spends “more money with our son. He gets sick more often as his immune system is not strong and it costs more to access the health services” (PV, C2, 032). “Comparing to the normal child” one caregiver of a CLWD stated, “I really spend more on medicine and food to cure him and ensure that he grows healthy” (PV, C1, 030). When asked if social protection funds cover the costs of services sought, one respondent stated: “No, we do not get the money” (Caregiver CLWD, KT, C2, 029). Costs to seek and use medical services can be higher for caregivers who have a CLWD. It can be confusing how to access social protection funds that do exist. One CCWC member reiterated that “in order to access the public services like health center or hospital by using social protection, the family needs a supporting letter from the commune” (PV, C2, 064). IECD is inclusive in including all households in nurturing care sessions, but some areas of improvement were observed. One recommendation made was to create and disseminate reminder cards to VHSGs about key overarching needs of caregivers of CLWD. Images used in the nurturing care sessions should reflect CLWD, while WASH infrastructure should consider modification for those requiring support with mobility. Disabilities are not easy to narrow down or compartmentalize, as even two different children with a similar diagnosis can have vastly different symptoms (IP, SRP, C1-2, 084, 085). However, it would be useful for IECD to ensure physical therapists, nurses, and other specialists prioritized for referral have appropriate backgrounds in the needs of CLWD. Some challenges were identified during the data collection process. One is that there could be more effective integration between nutrition and WASH. Improving collaboration between disability and other sectors is not unique to the IECD Activity.56 The USAID Advancing Nutrition project recently supported a review of CLWD and nutrition. Findings demonstrate that there is a 55 Pov, S. (2021), "Education of Children with Disabilities in Cambodia: Trends, Collaborations, and Challenges", Semon, S.R., Lane, D. and Jones, P. (Ed.) Instructional Collaboration in International Inclusive Education Contexts (International Perspectives on Inclusive Education, Vol. 17), Emerald Publishing Limited, Bingley, pp. 139 - 150. 56 Simkiss, D.E., Blackburn, C.M., Mukoro, F.O. et al. (2011). Childhood disability and socio-economic circumstances in low- and middle-income countries: systematic review. BMC Pediatr 11, 119. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 47 combination of challenges in identifying feeding difficulties and disability. There is a lack of understanding of the link between disabilities and feeding, coupled with weak or nonexistent referral or specialized services results in CLWD being at risk of malnutrition.57 This is similarly what the ET found in the data with nutrition and CLWD. Overall, most respondents spoke about the positive benefits of targeting caregivers and CLWD in the IECD Activity. Many caregivers of CLWD have attempted to participate in activities and practice recommended messages at home. Community members are accepting more CLWD, but more attention needs to be considered for more of the specific needs of CLWD and their caregivers when it comes to nutrition, WASH, client and provider rights, and social protection. Table 15: Summary of Strengths, Areas for Improvement, and Challenges for EQ 2.3 Summary of Findings for EQ 2.3 Improvements for CLWD Strengths Areas for Improvement Challenges ● Identification, referral and follow up of CLWD is a priority ● Integration with IECD across all sectors ● Client and Provider Rights ● Missed screenings ● Reliability of social protection funds with payments and ensuring enough cash flow 5.2.4 EQ 2.4. Are there any unintended consequences or results of the activity interventions? COVID-19 presented some challenges in the start-up of the IECD Activity. As a result, meetings and trainings took longer to start and communities were not able to meet as consistently. Also, opportunities to share about the IECD Activity were limited as technical working groups did not meet as frequently. However, it presented an opportunity. Men were not migrating for work or traveling quite as far. They were available in the early days of IECD. Many of the men have returned to the income generation activities that require them to travel further each day. Regardless, male engagement is improving with more men participating in household tasks. Another result of the Activity is the learning from the home visits and curriculum development. While home visits can be more time intensive for VHSGs, both caregivers and VHSGs indicated that they are more effective in supporting uptake of the key messages. The curriculum and messages were a great tool for stakeholders, such as government department and health center staff who were trained as master trainers, and for the VHSGs. The VHSGs can use the curriculum to review the key messages and review what they need to do ahead of activities. Concerns that were raised include staff numbers and IECD commitments, the capacity of the VHSGs, and sustainability. STAFF NUMBERS AND IECD COMMITMENTS The various skills and levels of expertise that are required mean that there is not always an expert readily available to support a VHSG or respond to the needs of a caregiver with a CLWD. Technical 57 Klein A, Uyehara M, Cunningham A, Olomi M, Cashin K, Kirk CM. (2023). Nutritional care for children with feeding difficulties and disabilities: A scoping review. PLOS Global Public Health. 17;3(3). Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 48 expectations of the front-line workers are high given the multi-sectoral approaches of the IECD Activity. VHSGs require more mentoring, and coaching and more learning should take place around how to enable actual translation of knowledge into practice (Female VHSG, KT, C1, 033 and CC, PV, C1, 062). Additionally, recently hired nurses, physical therapists, and interventionists will need to feel they have support as they begin their work with CLWD. The IECD Activity should also continue key discussions with provincial governments and other stakeholders around learning and possible sustainability of the Activity. More staff are required to ensure learning from IECD is shared and used for advocacy, while VHSGs require more support to enable confidence once the cohort closes. With a third cohort beginning and the project starting its fourth year, it makes sense to do this in the next fiscal year. VHSG CAPACITY The only notable differences between cohorts 1 and 2 are the commitment and capacity of the VHSGs. Cohort 1 focused on recruiting existing VHSGs who represent older community members. These VHSGs are well recognized by the community but lack the capacity and skills to utilize the screening apps for MUAC and CBDMAT effectively. In cohort 2, there is a mix of young and old VHSGs. There are complementary skill sets, with the older VHSGs supporting mobilization of community members, while the younger VHSGs facilitate screenings. According to one health center respondent, “screenings are more accurate” (KT, C2, 066). NNP and CARD both spoke to the fact that VHSGs are expected to do a lot. As a result, they can lack confidence. A representative from the PHD in Kampong Thom noticed that VHSGs should get support on mentoring and coaching in the field closer to the trainings (C1-2, 111). The time between trainings and supervision is too long and many VHSGs require a lot more support as a result, or in some cases lose motivation. VHSG confidence with screening can wane and those supervising VHSGs notice that the trainings and nurturing care sessions are not as detailed after the trainings. One health center stated: “The VHSGs still do not get enough” (PV, C2, 068). Overall, the VHSGs are an instrumental part of the IECD Activity. While some capacity gaps have been addressed, there is a need for more targeted mentoring and coaching. Some VHSGs from C1 indicated that they are committed, while others lacked motivation due to the lack of follow up, payment, and support from RTI on screenings and through the telegram app (VHSG FGD, KT, C1, 004; CC FGD, KT, C1, 005; and VHSG and CDL FGD, PV, C1-2, 010). MIGRATION AND INCOME GENERATION ACTIVITIES Cambodia is one of the fastest growing economies in Southeast Asia with a projected forecast to grow at 5.5 percent in 2023 and 6 percent in 2024 as it realizes recovery to the tourism and service sectors58. Migration for work in Cambodia takes place primarily in rural areas, with 58 Asia Development Bank. (2023). Cambodia’s Economy to Accelerate on Tourism. Asia Development Bank. https://www.adb.org/news/cambodia-economy-accelerate-tourism-recovery￾adb#:~:text=“Cambodia%27s%20economic%20outlook%20is%20positive,easing%20to%206.8%25%20in%202024. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 49 various studies attributing it to push factors such as poverty, lack of employment, landlessness, debt, and natural disasters.59 Migration is a fact that impacts community-level investments like the IECD Activity. Caregivers are not able to participate when they are not present in the community. Their lack of presence also results in caregivers who remain, often having an increased workload at home and increased caregiving responsibilities. Even if male and female caregivers are not migrating, many are working long days and not available to participate in IECD activities. While this finding is beyond the scope of the IECD Activity, it has been found to be an underlying issue in caregiver engagement. SUSTAINABILITY Sustainability of IECD is dependent upon the capacity of the VHSG and financing to pay, mentor, coach, and train the VHSGs. Currently, the Government of Cambodia does not invest in VHSGs in any capacity. VHSGs have a volunteer structure largely dependent upon funding from development partners and capacity strengthening from non-government organizations (NGOs). Meetings with national-level government stakeholders at CARD, NNP, and MoEYS were happy to discuss ideas about how to sustain the VHSG model. CARD spoke about the need to further strengthen the capacity of commune/Sangkats to more effectively monitor their projects so that it is clear what commune priorities are and how the money is being spent. However, this is not the focus of IECD. CARD also recommends linking as much as possible to the national food security strategy and mainstream with the CARD and national and subnational ECD working groups as a means to share learning and advocate for VHSGs (Government, PPH, C1-2, 090). This was echoed by His Excellency from MoEYS, who specifically stated to work as much as possible with the PCWCs, as “they are the budget decision-makers for ECD in the provinces” (Government, PPH, C1-2, 092). He also reiterated that MoEYS is advocating a lot with PCWCs to strengthen their engagement on ECD and would welcome IECD also advocating with PCWCs to invest in ECD. CARD also recommended sharing more with GIZ and the World Bank on IECD learning. The World Bank, through the Cambodia Nutrition Project (CNP), provides some funding to the commune/Sangkats for VHSG allowances. NNP is in the process of rolling out and scaling up trainings for growth monitoring and promotion (GMP) across Cambodia. UNICEF and CNP are supporting this activity as needed. IECD has a lot of learning from working with VHSGs and MUAC screening, and NNP would welcome opportunities to discuss learning to integrate into the process of roll-out with monitoring and screenings, as feasible. 59 OECD/CDRI. (2017). Interrelations between Public Policies, Migration and Development in Cambodia. OECD Development Pathways. OECD Publishing, Paris, https://doi.org/10.1787/9789264273634-en. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 50 Table 16: Summary of Strengths, Areas for Improvement, and Challenges for EQ 2.4 Summary of Findings for EQ 2.4 Unintended Consequences or Results Strengths Areas for Improvement Challenges ● Men participated more readily during COVID-19 ● Correctly aligned with current government policies and frameworks ● Staff time and commitments ● VHSG engagement ● VHSGs and sustainability ● Commune Investment Plan (CIP) budgets ● Community vulnerability to debt 6. CONCLUSIONS IECD is well accepted across Cambodia government ministries. The collaborative process with the design and development of the nurturing care materials is appreciated and the ongoing engagement, particularly with CARD, NNP, MoSVY, and MoEYS welcomed. Home visits are effective at reaching caregivers, while screenings have been recognized as an effective way to reach households for nutrition and with CLWD. Progress is being made with reaching and engaging all caregivers including men, women, and grandparents, while attention still needs to make sure they feel represented and reached in the IECD activities. Many underlying issues exist in enabling communities to translate their knowledge into practice with child nutrition and WASH. IECD is well positioned to take on a few of these barriers, particularly with identifying local solutions to ensure food diversity for pregnant women and young children, as well as with WASH infrastructure with toilets, handwashing, and clean water supply. Cambodia structural challenges persist with sustainability of multi-sectoral programs, including with VHSGs. Solutions might be difficult to identify, but continued engagement with the PCWCs, CCWCs, and communes is recommended along with generating documentation of efforts with VHSG. 7. RECOMMENDATIONS Some of the recommendations being made for the IECD Activity are relevant to multiple EQs. Recommendations are therefore presented from highest to lowest priority. Those identified with the highest priority are linked to more than two EQs. Medium priority recommendations are relevant for two EQs, while the lowest priority recommendations are linked to one EQ. The EQs they support are indicated in the parenthesis. HIGH PRIORITY On a national level, the IECD Activity should continue to share its learning and progress specific to training and working with VHSGs on MUAC screening. The IECD Activity should explore with NNP, UNICEF, and CNP ways to ensure investments in capacity strengthening are sustained and Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 51 can be leveraged with the roll out of the GMP trainings. Additionally, explore how VHSGs in Preah Vihear can be targeted under CNP to be eligible for an allowance (EQ1, EQ1.10, EQ2, EQ2.4). Identify ways to further engage men. Utilize a male-positive deviance or male engagement champion model to increase male caregiver participation. Consider meeting in rice paddies, near plantations, and in other locations where men might be working or passing to and from work. Meet with men on Saturday or Sunday. The IECD Activity should consider using social media, TV and radio, or other media that men can access when they are away from home working in fields and forests and on plantations. Document the best practices through a quarterly report case study in fiscal year five and share the findings in working groups with CARD, NNP, and MoEYS (EQ1.3, 1.5, 1.6, 1.7, 1.8, 1.9, 2.2) WASH infrastructure improvements for latrines, filters, year-round water access, and handwashing stations are required in many communities, particularly as some of the IECD communities are not ODF. All infrastructure improvements should meet the needs of women and men and absolutely require both in the decision-making process. Consider public toilets near farms and plantations to enable ODF and test for arsenic as part of the infrastructure plan for improvement (EQ1, EQ2, EQ2.2). Access to enough potable water for year-round growing of food and to meet household sanitation and hygiene demands is an issue. Respondents regularly mentioned links between lack of water and the availability of food, including fish. The ET’s observations at households demonstrated that while infrastructure for WASH might be in place, the same water might be used over and over, particularly for handwashing, to reduce the demand for collecting. Develop a water safety plan with the private sector and the Ministry of Rural Development and utilize the World Bank WASH analysis on gender to inform thinking on relevant gender issues60 (EQ1, EQ1.3, EQ2, EQ2.2). Work with local engineers and the private sector to ensure WASH infrastructure meets the needs of women and girls for safety and use (e.g., locks for nighttime), is flood resistant, and provides options for households in different socio-economic situations (EQ1, EQ1.3, EQ2, EQ2.2). MEDIUM PRIORITY Some households are struggling with treatment compliance using BP100. IECD should track households and ensure VHSGs are following up with households to check on households’ treatment compliance. Use the opportunity to follow up on breastfeeding and responsive feeding, particularly to understand if there are any barriers or misinformation about either feeding practice. Consider intensive twice-weekly visits during treatment (EQ1.10, EQ2). CBDMAT screenings do not currently fall under the investment of CNP or any MoH funding. Advocate with MoSVY or, in the long-term, work with MoH under the PRC to add this into disability programming at the PRC (EQ1, EQ 1.10). The length of the cohorts presents some challenges with reinforcing messages, ensuring capacity and confidence with delivering nurturing care sessions, and missed opportunities for continued 60 World Bank. (2018). Report on Gender Analysis of Water Support for the proposed Bank-supported Water Supply and Sanitation Improvement Project. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 52 home visits to support the various needs of households in achieving the recommended messages. In the future, there should be a consideration of a two- to two-and-a-half-year implementation cycle for the cohorts (EQ1.1, EQ2). Create a case study to document the design and creation of the nurturing care materials to capture the multi-sectoral process for development and include results from the final evaluation to capture outcomes. Present the case study at CARD, the National Committee for ECD working group, SUN, and national and provincial nutrition and food security technical workings group meetings to enable other projects to learn about the successful collaboration and how to create and deliver integrated materials for ECD, nutrition, NSA, WASH, and CLWD (EQ 1, EQ2.4). Continue to coach and mentor the VHSGs and CDLs to use the nurturing care sessions, with attention to completing the first coaching session within two weeks of the VHSG training or the first time that VHSGs hold community meetings or deliver messages, whichever is sooner. Consider more coaching and mentoring within the first six months, with the plan that VHSGs and CDLs would graduate from more intensive coaching. Encourage VHSGs to use the nurturing care materials to practice between coaching sessions, meetings, and message delivery and meet to support one another (EQ1, EQ 2.4). Safe Haven and AHC have valuable expertise working with CLWD. Optimize the partnerships to increase capacity of IECD medical staff (e.g., nurse, physical therapist, and interventionists) to ensure appropriate care for CLWD, specifically with nutrition- and WASH-related interventions. This might include more specific training for the IECD interventionists or nurses on nutrition and food security. Also, connect local WASH suppliers in Kampong Thom and Preah Vihear with those in Siem Reap to learn about modifications for people with mobility devices (EQ1.2, EQ2.3). Create and disseminate reminder cards to VHSGs about key overarching needs for caregivers of CLWD. These cards should focus on reminding caregivers of their client and provider rights to medical care. Provide training to the caregivers of CLWD on their rights and support them to increase their confidence to ask questions and remain in touch with the same medical provider. (EQ1.2, EQ2.3) Advocate for longer-term investments for interventions that serve CLWD by utilizing IECD Activity learning on supporting CLWD in an integrated multi-sectoral effort (EQ1.2, EQ2.3). Grandparents are helping with childcare in IECD Activity target areas. There is literature available in Cambodia and experiences from the Grandmother Project61 to better understand how to effectively leverage grandparents in holistic caregiving. Identify ways to better recognize them and their caregiving needs into IECD (EQ1, EQ1.3).62 61 The Grandmother Project website has various resources and experience with programming mainly in Africa but has done some work in Laos. It would be worth checking out their website: https://grandmotherproject.org/programs 62 Schneiders ML, Phou M, Tun V, Kelley M, Parker M, and Turner C. (2021). Grandparent caregiving in Cambodian skip-generation households: Roles and impact on child nutrition. Maternal Child Nutrition. Suppl 1(Suppl 1). Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 53 LOWER PRIORITY Work with NNP to identify synergies between the CommCARE app and current nutrition monitoring with the Health Monitoring Information System. Identify ways to link the monitoring processes (EQ 1). Caregiving and household tasks are time-intensive, which means that home visits are an effective way to reach target populations with IECD messages. Share learning and advocate with government, international donors, and other implementing agencies to include them as part of the model of IECD care (EQ 1, EQ1.1). The Royal Government of Cambodia is supporting private sector investments for WASH. Opportunities should be explored for WASH vocational training to increase access to local expertise for fixing and constructing toilets, hand washing facilities, and water access points (EQ1.3). Explore local solutions for childcare. This could include extending community preschools to operate as nurseries or childcare facilities or exploring community childcare models as a local enterprise for caregivers. UNICEF and the World Bank are considering options, but very little work has been done to date in Cambodia to invest in alternative childcare options (EQ1.3). Work with local restaurants and food vendors to ensure that there are diverse foods available for families to purchase, while working with sellers in the market to sell bundles of fruits and vegetables that meet diversity recommendations. Identify local solutions with neighbors and family members to prepare enriched porridge regularly (EQ2). Households are not consuming animal source protein year-round. Some community volunteers suggested introducing more animal source proteins. The IECD Activity needs to focus on what is being consumed or desired for consumption and work to identify strategies for increased consumption within households, particularly for young children. Consider liaising with Danish Care Foods to get the results of relevant ongoing pilots (EQ2.1). Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 54 ANNEXES Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 55 ANNEX 1. EVALUATION STATEMENT OF WORK SECTION C – STATEMENT OF WORK C.1 SUMMARY OF ACTIVITY UNDER EVALUATION Cooperative Agreement No. 72044220CA00002 Agreement Officer’s Representative (AOR) and Alternate AOR Sopheanarith Sek, AOR Sam Oeurn Ke, Alternate AOR Activity Start Date July 17, 2020 Activity End Date July 16, 2025 Locations of Activity (Provinces/Districts) Kampong Thom, Preah Vihear and Siem Reap Implementing Partner RTI International C.2 PURPOSE OF THE MID-TERM PERFORMANCE EVALUATION The primary purpose of this mid-term performance evaluation is to assess IECD activity performance to date, identify strengths and weaknesses of the implemented components, key bottlenecks/challenges, and actionable recommendations for improvements to meet the activity’s intended objectives. C.3 BACKGROUND The United States Agency for International Development (USAID)’s IECD activity in Cambodia seeks to improve holistic developmental outcomes for young children by promoting nurturing care, preventing stunting and increasing early identification and intervention for children with developmental delays and disabilities. C.4 PROJECT OBJECTIVES The purpose of the IECD activity is to support children to thrive and reach their full developmental potential by promoting nurturing care for the most vulnerable newborns and young children, starting before birth. Nurturing care interventions aim to optimize early childhood development (ECD). The IECD activity specifically addresses stunting through a multi-sectoral approach that strengthens nutrition service delivery at health facilities and in communities; supports nutrition￾sensitive agriculture and improved livelihoods; improves water,sanitation, and hygiene practices among caregivers; and promotes responsive caregiving to help children meet critical cognitive, linguistic, socio-emotional, and physical developmental milestones. Activity focus is on the early childhood years, with an emphasis on the first 1,000 days, for more intensive nutritional, psychosocial, and physical stimulation interventions. IECD supports developmental milestone screening to enable the early identification of and interventions for children with developmental delays or who are at risk for impairments and 1 “Activity” here is used interchangeably with “Project” by USAID and this term describes project components that are being implemented by USAID implementing partners. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 56 disabilities. It addresses the limited access to programs and services available to these individuals because they may require more support. IECD has used integrated approaches to address social behavior change across the three objectives (below). With this regard, IECD has developed the nurturing care modules and trained village health support groups (VHSGs) and child development leaders (CDLs) to use those modules to promote behavior change among caregivers/parents to improve their practices by organizing nurturing care sessions and home visits. Objective 1: Improved physical, cognitive, linguistic, socio-emotional development of children. Objective 1 is formulated in IECD’s approach to address changing behavior at three critical levels of the ecosystem surrounding young children: (1) caregivers, including parents and grandparents; (2) service providers interacting with families; and (3) the policy and governance structures of the enabling environment, including public and private actors. The results that follow each focus on one of these levels. IECD trained VHSGs to use the Ministry of Health’s mid-upper arm circumference (MUAC) tools to screen children for malnutrition and referred children who had nutrition issues to receive appropriate services at the nearest health center. IECD also conducted agriculture technique training to caregivers of pregnant women and children under five. This helped them to grow vegetables and raise chickens for household consumption and income generation. Expected results: Result 1.1: Increased capacity of caregivers to provide nurturing care for children with and without developmental delays and disabilities. Result 1.2: Increased capacity and improved attitudes, behaviors, and nurturing practices to better educate and support caregivers with young children . Result 1.3: Strengthened enabling environment at the national and sub-national levels to promote the institutionalization of ECD activities. Objective 2: Decreased stunting rates for children under five among the target population. IECD’s intensive, multi-channel social and behavior change (SBC) discussed across the three Objectives. To contribute to decreased stunting rates over time, IECD focuses on changing the behavior of actors throughout the ecosystem. In Objective 2, in collaboration with the CNP, SBC interventions will focus on topics such as optimal maternal nutrition, breastfeeding, complementary feeding, food preparation, optimal feeding of children during and after illness, and good hygiene and sanitation practices. Through implementing nutrition-sensitive agricultural practices, IECD will promote home consumption of a diverse diet of nutritious foods and the generation of additional income through market engagement. To improve WASH practices, IECD will address the demand side through the SBC approach and the supply side by linking targeted villages to water and sanitation service providers, producers, and retailers. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 57 Expected results: Result 2.1: Increased community and family crop diversification for home consumption and income generation. Result 2.2: Increased consumption of nutritional and diverse diets meeting the needs of pregnant mothers, particularly targeting young and first-time mothers and children under five. Result 2.3: Improved hygiene and sanitation-related behaviors in the household and community. Objective 3: Children with developmental delays and disabilities receive appropriate care in target provinces. As in Objectives 1 and 2, achievement of Objective 3 depends on changes in behavior of key actors regarding increased awareness of and reduced stigma associated with disability, improved capacity and consistency of screening, and improved quality and reach of special services. In collaboration with partners, IECD will seek to extend the reach of existing high-quality care and services so that children with developmental delays and disabilities in the target provinces can access them. IECD increases developmental monitoring and early identification of children with developmental delays and disabilities, increases referrals to higher quality and sustainable services, and strengthens community based rehabilitation and support services for children and their families. The IECD used Community-Based Development Milestone Assessment tools (CB￾DMAT) which was endorsed by Cambodian Ministry of Social Affairs to assess the developmental delays for children under 5 years old. IECD integrated activities and services support children with developmental delays and disabilities and their families across the three tiers of IECD support. IECD has developed the nurturing care modules and trained VHSGs and CDLs to use those modules to promote behavior change among caregivers/parents to improve their practices by organizing nurturing care sessions and home visits. Expected results: Result 3.1: Increased developmental monitoring and early identification of children with developmental delays and disabilities. Result 3.2: Increased referral to quality, sustainable services for children with developmental delays and disabilities. Result 3.3: Strengthened community-based rehabilitation and support services for children and families with developmental delays and disabilities. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 58 C.5 PROGRAM SITES, TARGETING, AND SUSTAINABILITY IECD has been implementing the activities in Sandan, Stoung and Prasad Balang districts of Kampong Thom province, and Rovieng district of Preah Vihear province. Kampong Thom and Preah Vihear provinces have high poverty, rurality, and stunting rates. IECD has referred children with disabilities to Angkor Hospital for Children in Siem Reap province. C.6 AUDIENCE AND APPLICATION The primary audience of this mid-term evaluation is USAID/Cambodia Office of Public Health and Education and USAID/Cambodia and implementing partners including prime and subpartner of IECD, in general. The secondary audiences will be the National Nutrition Program, Ministry of Social Affairs, Council for Agriculture and Rural Development. C.7 MID-TERM EVALUATION QUESTIONS 1. How have caregivers learned from nurturing care sessions, community dialogue and home visits to improve how they have nurtured their children? From these interventions, what have been the on-going, unresolved challenges the prime and the sub-partners faced, how to overcome those challenges? a. How did nurturing care work for children with disabilities and their caregivers? b. In what way are different family members particularly men involved in child nurturing care? c. How are men’s and women’s roles different in the care of boys and girls? What are the outcomes to date? (Example: Who tells stories to the child? Who feeds the child, Who teaches the child new things? Who bathes the child or toilet trains them?) 2. How have IECD’s beneficiaries benefitted from IECD’s interventions, including home gardening, income generation, child nutrition screening and WASH? a. Did the interventions contribute toward improving household food security and child nutrition? b. What are the differences in women’s (mother) and men’s (father) roles and how can gender power dynamics improve in food security and child nutrition (home gardening, income generation, child nutrition and WASH)? c. How did home gardening, income generation and child screening help improve nutrition intake for children with disabilities? Are there any unintended consequences or results of the project interventions? C.8 MID-TERM EVALUATION APPROACH AND METHODOLOGY This study is the mid-term performance evaluation. The evaluation will utilize mixed methods. The methodology should be collaborative and participatory, including implementing partners, key and vulnerable populations benefitting from the Project/Activity interventions/services, and key stakeholders, as much as possible in evaluation planning and implementation. USAID suggests qualitative as primary data collection methods for this study. It is anticipated that the Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 59 field data collection will be conducted in Khmer language. The evaluation team must provide the rationale behind the methods selected, why they are appropriate, any known methodological/data limitations, and how they provide rigor to answering the evaluation questions. The evaluation Mid-term Performance Evaluation of USAID Cambodia Integrated team is expected to engage with a range of stakeholders, including but not limited to relevant Royal Government of Cambodia, USAID/Cambodia, development partners, and implementing partner counterparts. The approach and methods proposed by the evaluation team are subject to USAID’s approval as part of the evaluation work plan. The evaluation team must consider gender issues when designing the evaluation and collect and analyze appropriate data to identify any potential gender inequality pertaining to each evaluation question as appropriate. The “Do No Harm” principle is recommended to apply in the evaluation methodology. The principle is to promote inclusive and provide safe space with respect and confidential information for women, vulnerable community, and children with disabilities. The team must be aware of gender sensitivity in evaluation design like questionnaires, interview, focus group discussion or one-on-one meetings because it is to understand and give consideration to community context, community norms, discrimination in order to acknowledge the different rights, roles and responsibilities of women and men in the community and relations between them3. Communication with women and children with disabilities is recommended to use inclusive language which promotes gender equality and the equal and fair visibility of women, men and children with disabilities4. C.8.1 DATA AND INFORMATION SOURCE The Evaluation Team is expected to conduct a short review of the relevant literature and USAID guidance. In addition, USAID/Cambodia will share the following documents for a desk review: ● Cooperative Agreement ● Quarterly reports ● Research reports conducted or commissioned by the implementing partner ● Baseline evaluation report, conducted by the implementing partner ● Activity Monitoring, Evaluation, and Learning Plan ● IECD Cohort Evaluation ● Recall Survey SBCC evaluation ● Disability screening evaluation ● IECD Situational Analysis ● Monitoring data (i.e. monitoring tracker, Nurturing care session tracker, etc.) ● Gender analysis for IECD While the Evaluation Design will likely rely on some primary data, the Evaluation Team is also encouraged to take advantage of existing (secondary) datasets for its analyses. USAID/Cambodia and implementing partners will provide initial contact to the following possible data sources: ● USAID Mission Staff ● Prime Implementing Partners, Sub Partners Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 60 ● Other development partners working in the areas ● Key staff from relevant ministries C.8.2 EVALUATION DESIGN The evaluation design should clearly articulate the link between each evaluation question, the proposed data to address it and the analysis planned for these data. For qualitative approaches, the design may detail each planned analytical step (eg. coding frame, how it was developed). The evaluation design should demonstrate that the proposed approaches are best practice (based on evaluation and research literature), that they are intended to provide robust answers to each evaluation question, and that they are suitable to the Cambodian context. The proposed methods should be specific and name each method used, the reason to use it and the motivation for data sources for each method. For example, what is meant by “focus group discussion”, what is the motivation for the selection of its participants and why would the focus group discussion be more appropriate than a group discussion, key informant interviews, or indepth interviews for a particular data source and a particular evaluation question? Each evaluation question should also examine subsets of relevant populations such as poorer households, women, and children with disability. While a detailed analysis for each subset might not be relevant for each question, the evaluation should address each and explain who is relevant. For the relevant groups, the analysis may require more than simple disaggregation of quantitative data. For example, analysis of gender dynamics is more than statistics by gender. The Evaluation Team should refer to relevant USAID guidance on gender and inclusion and propose specific evaluation designs, as appropriate. During evaluation design, the evaluation team must identify all evaluation questions, where applicable, for sex-disaggregated data like sex, age, gender identity, ethnicity, children with disability to examine gender gap and see improvement of project outcome. It strives to ensure that evaluation designs, methodologies, data collection, analyses and reports adequately capture the situations and experiences of both males and females and children with disabilities5. In addition to proposing a strong theoretical evaluation design, the evaluation team should plan on using software for qualitative analysis (for example: Atlas.ti, Dedoose or NVIVO). C.8.3 PRIMARY DATA COLLECTION INSTRUMENTS The Evaluation Team may propose to design qualitative protocols and quantitative data collection instruments and to gather data as appropriate. Though such instruments and protocols may be based on existing tools, they will need to be adapted and tested so that they address the specific evaluation questions and the Cambodian context. Therefore, the evaluation team should include a detailed plan for relevant tests of such instruments. The data collection instruments shall be accompanied by an informed-consent appropriate for each type of informants/respondents. Either written or verbal consent to participate and/or to be audio recorded must be obtained prior to any data collection. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 61 All quantitative data should be collected digitally and the proposal should demonstrate that proper data quality assurance systems will be put in place and that personally identifiable information (PII) of respondents are protected. The evaluators will record all qualitative interviews, transcription and translation for analysis and delivery to USAID. C.8.4 METHODOLOGICAL STRENGTHS AND LIMITATIONS The Evaluation Team must explain the strengths and the weaknesses for the evaluation methodology proposed under this SOW. In explaining the limitations, the Evaluation Team shall further explain factors contributing to the selection of the proposed methodology despite its limitation and the means to be employed by the evaluation team to mitigate the potential effect of the limitation. C.8.5 DATA COLLECTION AND ANALYSIS USAID/Cambodia requests that the evaluator complete the following table as part of its detailed design and evaluation plan. Please note that another format may be used if the table is not preferred, but any chosen format should contain all the information specified for each question, and will need to be pre-approved by USAID/Cambodia. Evaluation questions including sub-set Data source Data collection method (including sampling methodology, where applicable, date, location) Data analysis method C.9 EVALUATION SCHEDULE The evaluation period is expected to be completed within 16 weeks after the effective award date. The evaluation team will submit the detailed activity timeline to USAID for review including the final report due date. C.10 MID-TERM EVALUATION TEAM COMPOSITION The mid-term evaluation team should be composed of one Program Cycle Specialist/Evaluation Team Leader, one National Evaluation Advisor on health system strengthening and/or infectious diseases, preferably in nutrition, Logistics/Program Assistant, and Translator/Interpreter. A mix of gender is strongly encouraged for the team composition. 1. Program Cycle Specialist/Evaluation Team Leader Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 62 The program cycle specialist (level III) will be responsible for (1) providing team leadership; (2) managing the team’s activities, (3) ensuring that all deliverables are met in a timely manner, (4) serving as a liaison between USAID and the evaluation/analytic team, and (5) leading briefings and presentations. Cambodia-based is preferred. Qualifications ● The education and experience requirements must be in line with the appropriate Labor Category Level set forth in the IDIQ. ● Minimum of 15 years of experience of field experience managing childhood development, nutrition projects, programs and evaluations. ● Demonstrated extensive experience in gender integration or gender analysis and experience in leading nutrition and child care project/program evaluation/analytics, utilizing both quantitative and qualitative methods. ● Advanced knowledge and skills of program performance evaluation design, methodology and processes. ● Excellent skills in planning, facilitation, and consensus building. ● Demonstrated experience in conducting high quality evaluations to USAID standards. ● Excellent communication (written, presentation, and spoken) and interpersonal skills. ● Fluency in written and spoken English. ● Experience working in the region, and/or in Cambodia is desirable. 2. National Evaluation Advisor on Nutrition and/or Childhood Development The National Evaluation Advisor will support the Program Cycle Specialist/Evaluation Team Leader in designing, planning and implementing the evaluation, including qualitative data collection and analysis. In addition to that, s/he will ensure contextual relevance of the design and implementation of the evaluation. As a member of this evaluation, s/he must demonstrate strong contextual knowledge of nutrition and/or childhood development in Cambodia. Qualifications ● At least a Master’s Degree in Public Health, Statistics, Epidemiology, Social Studies, or another related field. ● At least 5-10 years of experience in the field of nutrition and/or childhood development, particularly in the project focus regions is desirable. ● At least 5 years of experience in designing and conducting evaluations and/or research of similar projects. ● Demonstrated experience using qualitative evaluation methodologies and analysis, and triangulating with quantitative data. ● Able to review, interpret and reanalyze as needed existing data pertinent to the evaluation. ● Excellent analytical and writing skills and command of written and spoken English and Khmer. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 63 3. Logistics Assistant Logistics Assistant will be responsible for providing logistical support to the assessment team members including, but not limited to, scheduling appointments and arranging transportation. 4. Translator/Interpreter Translator/Interpreter will be responsible for conducting interpretation support to the evaluation team leader during field visit. C.11 FINAL REPORT FORMAT The final evaluation report must include: ● Title page ● Table of contents, tables and charts ● List of acronyms ● Acknowledgements (optional) ● Evaluation abstract not more than 250 words briefly describing what was evaluated, evaluation questions, methods, and key findings or conclusions. The abstract should appear on its own page immediately after the evaluation report cover. ● Executive summary (must be 2–5 pages) in length and summarize the purpose, background of the project being evaluated, main evaluation questions, methods, findings, conclusions and recommendations. ● Background of the local context and the activity being evaluated o Map showing the location of program activities ● Evaluation purpose and final evaluation questions o State the purpose of, audience for, and anticipated use(s) of the evaluation. ● Evaluation methodology and limitations o State the evaluation questions o Describe the evaluation method(s) for data collection and analysis. o Describe limitations of the evaluation methodology. ● Summary of data analysis, including methods and other relevant observations. ● Findings (explicit response to the evaluation question), conclusions, and recommendations Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 64 ● Annexes The annexes to the report must include: ● Mid-term evaluation SOW ● Detailed description of the evaluation design and methods and the analysis performed ● Statements regarding significant unresolved differences of opinion by funders, implementers, and/or members of the evaluation team, if any ● All data collection and analysis tools used in conducting the evaluation, such as surveys, interview questions, checklists, and discussion guides ● All sources of information, properly listed and PII data redacted (including documents reviewed, sites visited, and key informants); All qualitative interviews are recorded, transcription and translation for analysis and delivery to USAID ● Signed disclosure of any conflict of interest forms for all evaluation team members, by including a statement by evaluation team members that attest to a lack of conflict of interest or describes existing conflicts of interest relative to the project being evaluated; and ● Summary information about evaluation team members, including qualifications, experience, and role on the team ● A matrix that summarizes the themes/key topics, findings, conclusions, and recommendations The evaluation methodology must be explained in detail in the report. Limitations to the evaluation must be disclosed in the report, with particular attention to the limitations associated with the evaluation methodology. In accordance with ADS 201, the Contractor will make the final evaluation report publicly available through the Development Experience Clearinghouse (DEC) within 90 days of the approval by USAID and before the final invoice is submitted to USAID. For more details, please see the following links: ● “How-To Note: Preparing Evaluation Reports” (https://usaidlearninglab.org/resources/how-note-preparing-evaluation-reports) ● A Mandatory Reference for ADS Chapter 201 (https://www.usaid.gov/ads/policy/200/201mah) ● An optional evaluation report template is available in the Evaluation Toolkit (https://usaidlearninglab.org/library/evaluation-report-template). Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 65 C.12 CRITERIA TO ACCESS EVALUATION QUALITY This evaluation will adhere to relevant quality standards as provided in the USAID Evaluation Policy, as well as international standards for conducting social sciences research, especially the “Do No Harm” principles such as the principles for treatment of human subjects and collection and safeguard of personally identifiable information. The Contractor is required to follow USAID and/or host-country government protocols for research activity as guided by the Contracting Officer’s Representative. While the Mission and the host-government do not specifically require an official ethical review of the evaluation design and protocols, the Contractor must ensure that the design and protocols are appropriately reviewed to ensure ethical standards such as obtaining an approval from the Contractor’s own Institutional Review Board (IRB). The Contractor will start the evaluation by reviewing documentation provided by USAID and the IP and any relevant secondary research they collect. The Contractor is expected to construct the overall theory of change for this evaluation during the desk review period, as well as to present initial findings from the document review against the evaluation questions at the beginning of the evaluation. Evaluation tools/instruments will be developed to codify and organize data from the document review for analysis according to the research questions. Where possible and appropriate, USAID encourages the Contractor to consider low-cost methods such as online survey and phone-based services available on the local market. Should the Contractor deem it necessary to collect data using a sample survey, the Contractor will need to include a clear description on how the survey will be conducted, e.g., the sampling frame and sampling method, sample size and its calculation, quality assurance, and data analysis plan. The Contractor will be accountable for ensuring data analysis methods are in line with best practices. Data analysis methods must correspond to the kind of data collected. For both quantitative and qualitative data, the team will need to articulate methodologies for analyzing collected data, including any software programs to be used. For qualitative data specifically, the Contractor will need to ensure recording and transcribing of the data collected to the extent possible. Qualitative data should be coded, either by hand or using a software, systematically analyzed, and used interpretively and not just descriptively. C.13 OTHER REQUIREMENTS AND GUIDANCE All deliverables that are in written format must be in plain6, grammatically correct English language; be submitted in appropriate electronic format (i.e. Microsoft Word, Excel, PowerPoint Presentation, and PDF); and meet all the requirements. All raw data, quantitative and qualitative, collected by the evaluation team must be provided in machine-readable, non-proprietary formats. All raw dataset produced for this evaluation, accompanied by a codebook, must be submitted to USAID/CAMBODIA. If the contractor collected any quantitative data, those dataset must be also submitted to USAID’s Development Data Library (DDL) at https://data.usaid.gov/ as required by USAID’s Open Data policy (see ADS 579). Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 66 The data shall be organized and fully documented for use by those not fully familiar with this study. USAID will retain ownership of all datasets developed and deliverables produced under this contract. The Contractor shall not use any data or information obtained through this contract, in full or in part, for purposes other than to develop the Report for USAID. The Contractor is responsible for making all travel, transportation and lodging arrangements as per the work plan. Logistical support in-country will be the responsibility of the Contractor. Government travel restrictions and corresponding approvals must be considered when planning for the field data collection. A representative(s) of USAID may participate in the meetings with government officials and/or field data collections provided that USAID participation does not affect the quality of data to be collected or be misinterpreted by partners/stakeholder. [END OF SECTION C] Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 67 ANNEX 2. DESCRIPTION OF THE EVALUATION DESIGN, METHODS, AND ANALYSIS 2.1 OVERVIEW The evaluation was guided by the USAID Evaluation Policy63 and the Organization for Economic Cooperation and Development’s Development Assistance Committee (OECD-DAC) Evaluation Quality Standards for Development Evaluation.64 It utilized a predominantly qualitative approach with some quantitative methods to assess the performance of the IECD activity. Four main sources were utilized for data collection: 1) available published primary and secondary data from IECD, the CDHS, and other reliable sources; 2) interviews with major stakeholders with a direct or indirect interest in the project from a national to community level; 3) random observations of VHSG and CDL completing MUAC and CBDMAT screening and households observations of home gardens and WASH infrastructure; and, 4) mini and online surveys with targeted complementary questions to provide a snapshot of current key IECD practices. Data was collected through qualitative methods including a desk review, KIIs, and FGDs. Complementary quantitative data collected included random household and community observations for actions linked to objectives two and three, as well as subset questions for EQ 2, a mini-survey targeting KII participants with FGD participants, an online survey to be completed by KII participants, and co-collection of locational data. Interviews target representatives from government at a national and subnational level, sector experts, as well as affected communities specifically, caregivers and community volunteers who deliver activities and perform screenings to children under five years old. Additionally, other donor organizations who are active in nutrition, ECD, nutrition-sensitive agriculture (NSA), water, sanitation and hygiene (WASH), and parents and/or caregivers of children living with disability and developmental delays (CLWD). To ensure inclusion in the data collection process, a plan was in place to accommodate individuals identifying as LGBTQI+, indigenous, and/or living with a disability to enable participation that would have mitigated any harm or risk to them and their families. This plan included but was not limited to holding the interview in a secure location, translating interview questions into a third language as possible with the ET, accommodating physical, emotional, and developmental realities of the respondents, and listening to young children if they are present with parents or caregivers and offer ideas knowing that all protocols for data protection and consent are in place. None of the respondents identified as LGBTQI+, indigenous or living with a disability. It is important that respondents can express their views openly and without prejudice, as is the case with all evaluations. The tone and openness of the discussions will be established from the outset by the ET members. The purpose of evaluation and the potential for learning and improvement will be emphasized. The ET members made it clear through the interview process that they were independent consultants (and not employees of any donor organization), and that the final opinions and findings are theirs. All participants, prior to the beginning of interview 63 https://www.usaid.gov/sites/default/files/2022-05/Evaluation_Policy_Update_OCT2020_Final.pdf 64 https://www.oecd.org/development/evaluation/qualitystandards.pdf. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 68 activities, completed an informed consent form and the ET reminded interviewees that they can stop participation in the interview at any time as well as choose not to answer a question. Data collection tools were designed by the ET to answer each EQ as well as integrate gender, children’s disability, and cultural sensitivities in the design of the protocols, and used inclusive language to facilitate discussion. Central to the ET approach was to generate a detailed and nuanced understanding of the effectiveness of IECD’s integrated approach to ECD in facilitating social behavior change and improved child development outcomes. The tools have enabled the ET to identify strengths, weaknesses, key challenges or bottlenecks, and actionable recommendations for the IECD Activity. The Team Leader led the ET on the development of the evaluation work plan including the creation of all data collection tools. They were in Cambodia supporting the evaluation process from the In-Brief meeting through to the pilot and initial data collection for roughly two weeks before returning to their country of residence. For the final two weeks of data collection a Cambodian Senior Field Research Specialist supported the team with on-the-ground data collection and quality checks, while the Team Lead began initial data analysis and monitored data collection through daily quality checks of field operations using WhatsApp. A handover process took place between all members of the ET on April 13th and 17th. The handover focused on providing a real time update on data collection, review of the data collection instruments to ensure the Senior Field Researcher was clear on how to use them, and discussion of the next steps, including times for daily check-ins. The National Evaluation Advisor supported the Team Leader in all parts of the evaluation process including being on the ground supporting all of the data collection, review and contributing key documents throughout the evaluation process. A Program/Logistics Assistant and Interpreter￾Translator also joined the ET. The Program/Logistics Assistant supported the ET in scheduling interviews and helping the ET to complete interviews, while the Interpreter-Translator joined the Team Leader in the field with data collection supporting simultaneous translation of all data collection with the Team Leader and continued on as a data collector. The IECD Activity is the first time that USAID Cambodia has supported a sector-integrated program for young children’s growth and development with the goal to reduce stunting. It focuses on key interventions that enable children in their first 1,000 days of life to thrive. As a result, there is an emphasis on learning with this Activity. A longitudinal cohort evaluation study was developed to test the IECD TOC and allows the IECD team to monitor key program implementation indicators throughout the activity while providing useful information about the strengths of families targeted in the communities and areas where they need support. Overall, its aim is to document change over time that may be attributed to the IECD intervention in three areas: 1) caregiver practice of key Nurturing Care behaviors; 2) nutritional status of women of childbearing age, pregnant women and children under five years old; and 3) children’s developmental status. It is designed along with the implementation of IECD to focus on three cohorts. Every 15 months a new cohort becomes operational with an evaluation completed that collects data from the target villages of each of the cohorts. By the end of Year 2 of the IECD Activity, implementation of all activities in Cohort 1 had ended. Cohort 1 reached 75 villages Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 69 across Kampong Thom and Preah Vihear Provinces, 56 and 19, respectively. At the time of the submission of the Year 2 report to USAID65, IECD had begun to expand the implementation of activities into the 135 Cohort 2 villages – 112 in Kampong Thom and 23 in Preah Vihear. When this evaluation began, implementation had not begun in the remaining 135 Cohort 3 villages. KII and FGD interviews represented individuals from randomly selected villages in cohorts 1 and 2. The location of the respondents was identified with inputs from the IP often the day before. Criteria for selection included accessibility to the district capital, the village having completed some IECD specific trainings, and the village representing either cohort 1 or 2. Additionally, a core component of the IECD Activity is identifying, referring, and following up with CLWD. IECD is working with Angkor Children’s Hospital in Siem Reap and Safe Haven to enable the referral and follow-up process. The ET completed virtual KII with IP in Siem Reap. 2.2 EVALUATION PHASES The ET worked closely with USAID/Cambodia and IPs to plan and implement the evaluation through three evaluation phases: Work Plan Phase, Data Collection Phase, and Data Analysis and Reporting Phase, as described below. Phase 1: Work Plan Phase (Duration: March 10 until March 31) During this phase, the ET conducted a detailed review of the activity documentation and undertake further research of their own to gain a more complete understanding of the activity and its context. An evaluation kickoff meeting between the ME&A team and USAID/Cambodia was held on March 16th Eastern Standard Time (EST) with participation from USAID, ME&A home office personnel, and ET members. The purpose of the call was to introduce the USAID team and the ET members, discuss the current work plan, gain clarification on who the ET should be communicating with regarding documents and identified stakeholders, and confirm the ET members. During this phase of the evaluation, the focus was on getting all ET members on board and drafting the work plan and data collection tools, while working with all stakeholders to continue to gather documents for the desk review and planning for data collection in the field. During this time, the ET also be submitted the Work Plan to USAID Cambodia for their review and approval. This phase ended with an approved Work Pan and the ET finalizing the data collection plan. The main deliverable for this phase was the Draft Evaluation Work Plan and a revised Work Plan incorporating USAID comments for final approval. The work plan was approved on March 2 Phase 2: Data Collection Phase (Duration: April 3 until May 1) This phase focused on the collection of data by the ET in Cambodia. It commenced with an In￾Brief held with USAID/Cambodia, ME&A, and the ET to present the Work Plan and evaluation design by March 24th. The In-Brief provided stakeholders an opportunity to comment on the Work Plan and evaluation design, and allowed the ET to answer questions prior to commencing fieldwork. After the In-Brief, the ET worked to finalize the work plan, familiarize themselves with 65 USAID/Cambodia Integrated Early Childhood Development Activity. FY2022 Annual Report October 2021 - September 2022. Revised November 17, 2022. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 70 the data collection instruments, conduct pre-testing, and translate and finalize the tools as part of quality assurance and control. The data collection officially commenced on April 9th. All members of the ET traveled together to the designated data collection sites to initiate the data collection process based on the final data collection plan. Two data collection teams were formed at the district level to gather data. The Team Leader and Translator worked together to gather data, while the National Evaluation Advisor and Program/Logistics Assistant worked independently to collect. Khmer New Year was from April 15 to 17, 2023. As many target respondents for the evaluation participated in the Khmer New Year (KNY) holiday events, the Team Leader used this time to hand over the fieldwork to the Cambodian Senior Field Research Specialist. Additionally, a communication protocol for quality assurance and control was put in place. During the data collection phase, the Project Manager provided regular briefs on the field work to USAID. At the end of the data collection phase, the ET presented preliminary findings at a validation workshop on May 23rd with USAID/Cambodia. Phase 3: Data Analysis and Reporting Phase (Duration: May 2 until June 9) This phase commenced at the completion of data collection; however, data analysis was ongoing as data were collected, discussed, tested, and triangulated. The analysis resulted in findings, conclusions, and lessons learned. A findings validation and recommendation workshop took place with USAID/Cambodia on May 23rd. Based on the analysis of the desk review and data collected, the ET will also submit a draft Evaluation Report to USAID Cambodia for review on May 24th, 2023. Comments will be received from USAID Cambodia by June 7th, 2023 and the ET will submit a final Evaluation Report including the response to each of the comments made by USAID Cambodia by June 14th, 2023. Table 1 shows the deliverables and timelines, and the illustrative evaluation schedule provides detailed information on each step of the evaluation. Table 1: Summary of Deliverables and Timeline for the IECD Mid-Term Performance Evaluation DELIVERABLE/PRODUCT TIMELINE Phase 1: Inception Phase Kick-Off Meeting March 17, 2023 Draft Evaluation Work Plan Submission March 20, 2023 Mission’s Feedback on Draft Evaluation Work Plan March 24, 2023 Submission of Revised Evaluation Work Plan March 27, 2023 Mission’s Review and Approval of the Evaluation Work Plan March 29, 2023 Phase 2: Data Collection Phase In-Brief Meeting with USAID March 27, 2023 Draft Data Collection Tools and Testing Protocol April 3, 2023 Regular Updates on Fieldwork and Data Analysis April 3 to May 19, 2023 USAID Feedback April 7, 2023 Resubmission after pre-testing April 10, 2023 Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 71 DELIVERABLE/PRODUCT TIMELINE Data Collection April 10 to May 1, 2023 Phase 3: Data Analysis and Reporting Phase Data Analysis and Preliminary Findings May 10, 2023 USAID Feedback May 17, 2023 Findings Validation and Recommendation Workshop May 23, 2023 Draft Evaluation Report May 24, 2023 USAID Comments June 7, 2023 Final Evaluation Report June 14, 2023 2.3 SAMPLING Data collection relied primarily on qualitative methods, so a purposive sample was used to ensure respondents had participated in IECD activities. Districts were identified based on the greatest number of villages per cohort with representation of villages from both cohort 1 and 2 and being a reasonable distance from the district capital. A list of the districts, communes and villages where data was collected is in Table 2. Selection criteria for KII and FGD respondents included participation in implemented activities in either cohort 1 or 2 and living in a village where a VHSG and CDL had received some training, if they did not identify as a VHSG or CDL. Observations, mini and online survey were added to KII and FGD interviews given the criteria for participation. Online surveys targeted IP, national and subnational government ministries and departments, and health centers, while observations and mini-surveys were facilitated with the remaining respondents. All interview guides used can be found in Annex 4. Table 2: District, Commune and Village Locations for Kampong Thom and Preah Vihear Provinces Province District Commune Village Kampong Thom Sandan Sandan Prasat Andaet Svay Klaeng Klaeng Kampout Chhouk Toek Vil Prey Chor Chheu Teal Veal Pring Kraom Boeng Pra Samreth Kae Rang Mean Chey Choan Leaeng Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 72 Province District Commune Village Stoung Chamna Leu Khmak Chamna Kraom - Kampong Chen Cheung Tnaot Kampong Chen Tboung Leab Tong Kampong Kdei Trea Totea Msa Krang Ou Doung Pralay Srae Ta Maen Prasat Sambour Sambour Pralay Poh Tret Kaun Ka’Ek Kampong Chheu Teal Stueng Saen Municipality - - Preah Vihear Rovieng Robieb Tang Trak Bak Kdaong Ou Rovieng Cheung Tnaot M’lou Romdaoh Dei Kraham Thnal Kaong Ov Loek Kork Ampil Rohas Kak Poun Thkaeng Kampot Sangkae Rung Rung Roeung Srae Thum Boh Pey Rovieng Tboung Ros Roan Ruessei Srok Tonloab Chhnuon Romoneiy Rumchek Reaksa Daun Ma Preah Vihear Municipality Kampong Pranaak Andaung Poh Kandal Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 73 2.4 EVALUATION MATRIX Following an in-depth review of the materials provided by USAID/Cambodia, IPs, NNP, and CARD, the ET developed an evaluation matrix. The matrix highlights the methodology the ET employed to satisfactorily answer each of the two key EQs and 14 related sub-questions. 2.5 DATA COLLECTION The ET implemented an inclusive and participatory mixed-methods data collection approach, combining qualitative and quantitative data from primary and secondary sources to address the two EQs and 14 subset questions. Given the methodology of the evaluation, purposive sampling was applied to identify respondents. National ET members contributed to the design of data collection tools. “Do No Harm” principles were followed in the design and implementation of data collection by providing a safe and confidential space for women, parents of CLWD, and vulnerable groups to feel comfortable sharing insights about their experiences with the IECD activities. Findings were triangulated to reach a more complete understanding of whether and how IECD interventions have contributed to activity outcomes. The ET worked closely with USAID/Cambodia and the activity IPs to select a representative sample of KII and FGD participants in each of the activity provinces and districts, and from each of the implementation cohorts. Attention was given to ensuring the inclusion of a diverse group of beneficiaries and stakeholders, including male and female caregivers, grandparents, child development leaders (CDLs), village health support groups (VHSGs), IPs, and other stakeholders. Data collection included the following methods: Desk Review The ET completed a thorough review of all the project-related documents provided by USAID/Cambodia and relevant IPs. This included a review of activity documents and performance data, in addition to other documents and secondary data produced by organizations that are working on IECD. The document review focused on secondary data that has been used to triangulate the primary data that has been collected during the data collection phase. Below is an illustrative list of the documents identified for the review. ● IECD Reports o Cooperative Agreement o Quarterly reports o Research reports conducted or commissioned by the implementing partner o Baseline evaluation report, conducted by the IP o Activity Monitoring, Evaluation, and Learning Plan o IECD Cohort Evaluation o Recall Survey SBCC evaluation o Disability screening evaluation o IECD Situational Analysis o Monitoring data (i.e. monitoring tracker, Nurturing care session tracker, etc.) o Gender analysis for IECD Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 74 ● National Policies o Cambodia Roadmap for Food Systems for Sustainable Development 2030 o Accelerating Progress towards SDG2 o Second National Strategy for Food Security and Nutrition 2019 to 2023 o National Policy on Early Childhood Care and Development o Inter-Ministerial Joint Prakas for the Marketing and Promotion of Breastmilk Substitutes ● Others o Cambodia Demographic Health Survey 2014 and 2021/22 o CBDMAT Key Informant Interviews A total of 116 KII were completed with respondents representing USAID, IP, International Organizations, National State Organizations, Provincial Government Departments, Governor’s office, Operational Districts, female and male caregivers, grandparents, caregivers of CLWD, female and male VHSG, CDL, CCWC, and health center staff. Interviews took place at respondent’s offices or homes. A majority were in person. Virtual interviews were held with USAID, some IP, and international organizations. Planned targets in most instances were met. Early in the field work, the ET struggled to identify male caregivers for interviews. The ET attempted various strategies, including interviewing more female caregivers and VHSG, to ensure representation in a district and cohort if the target itself could not be reached for interviews. Therefore, targets for female targets were exceeded. Below in Table 3 is a summary of the planned versus actual KIIs completed. More information on KII respondents can be found in Annex 5. Table 3: Planned versus Completed KII Respondent Categories Locations Total Planned Total Completed USAID Cambodia Phnom Penh 2 2 IPs: RTI 9, HKI 2, Dimagi1, and MRC 1 Phnom Penh 13 13 IPs: AHC 3 and Safe Haven 2 Siem Reap 5 4 International Development Organizations, Donors, and Donor-Funded Projects UNICEF 2, World Bank 1, GIZ 1 Phnom Penh 4 5 National State Organizations NNP 1, CARD 1, MoEYS 1, MoSVY 1 Phnom Penh 4 4 Provincial Level Health 2, Education 2, SVY 2, PRC 2 Province 7 7 Deputy District Governor’s Office/DCWC District 4 5 Operational District 2 OD 2 2 Female Caregivers Two villages in each of the four IECD target Districts 8 9 Male Caregivers Two villages in each of the four IECD target Districts 8 10 Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 75 Respondent Categories Locations Total Planned Total Completed Grandparents/Alternate Caregivers Two villages in each of the four IECD target Districts 8 8 Parents of CLWD Two villages in each of the four IECD target Districts 8 9 Female VHSG Two villages in each of the four IECD target Districts 8 10 Male VHSG Two villages in each of the four IECD target Districts 8 8 CDL Two villages in each of the four IECD target Districts 8 7 Commune Committees for Women and Children (CCWC) Two villages in each of the four IECD target Districts 8 8 Health Center Staff One per district 4 5 Total 109 116 All KII’s were no more than 90 minutes in duration from the national to community level. The ET used purposive sampling for selection of key informants, based on their knowledge and involvement in IECD activities. The ET used a semi-structured questionnaire, shaped by the key EQs, to gather data and information from KIIs, as appropriate (see Annex 4). The ET administerd a mini-survey to key informants at the end of each interview. Key informants with internet access and a working email address were also asked to complete an online survey, which took no more than 15 minutes to complete. KII respondents at the community level represented villages from two implementation cohorts. The ET conducted a combination of in-person and remote KIIs with RTI and subs (Helen Keller International, Safe Haven), USAID/Cambodia staff, Angkor Hospital staff, national and local government authorities, and donor/development organizations who have first-hand knowledge of IECD interventions. Additionally, those with knowledge of cross-cutting projects focused on child nutrition, ECD, and related social behavior change interventions were identified. Challenges experienced by the IPs at various levels of activity management were investigated as a means of identifying how activity interventions have (or have not) contributed to observed outcomes. Geospatial data has been used to analyze and illustrate with maps and other visualization graphics how location-specific attributes of the target populations explain activity context and results. Focus Group Discussions A total of 16 FGDs were completed with an average of seven participants. More FGDs were held with female caregivers than planned, as 15 female caregivers came for one discussion. Given the numbers, two groups were held. Identifying male caregivers to participate in data collection was Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 76 difficult in some locations. Therefore, the ET organized two additional FGDs in case enough men were not able to be identified. Each of the four male caregiver FGDs only had three participants each. In Kampong Thom, the ET was not able to organize a separate FGD for grandparents/ alternative caregivers. Grandparents were represented in all of the female caregiver FGD in Kampong Thom. Table 4 provides more specific information on the number of FGDs completed for each target group. FGDs were held at Commune offices or pagodas and lasted on average 60 minutes for the discussion. As ET members were waiting for the FGD participants to arrive, the mini-survey was administered to those consenting to participate. It took no more than 15 minutes of the participants’ time. VHSG and CDL FGD participants were not asked to take the mini-survey as they demonstrated a child disability and MUAC screening. The interview guides for both the FGDs and mini-survey can be found in Annex 4. Through FGDs, the ET identified aspects of IECD that worked well and those that did not and why. The information has been triangulated with the review of quantitative data to understand how integrated approaches like handwashing, breastfeeding, and dietary diversity scores were effective in facilitating behavior change. The FGDs also assessed how the provision of nurturing care sessions, community dialogues, and home visits through VHSGs and CDLs have contributed to increasing the capacity of all caregivers (men, women, grandparents) to provide nurturing care for their children. A timeline approach was used to initiate and continue discussion among the participants. Prompts were also be made to get participants to reflect on the children who have been in their care. The ET took great care to incorporate gender and community-level sensitivities in the data collection tools and protocols. This included holding separate FGDs for male and female caregivers. Female facilitators were used when interviewing female targets as a means of fostering open dialogue and sharing. FGDs with caregivers examined more in-depth gender roles within households and investigated the ways in which household gender dynamics affect activity outcomes. Table 4 below provides a summary of the FGD groups. Table 4: Focus Group Discussions by Province Targets Kampong Thom Preah Vihear Total Female Caregivers Planned 1 1 2 Completed 4 1 5 Male Caregivers Planned 1 1 2 Completed 2 2 4 Grandparents/ Alternate Caregivers Planned 1 1 2 Completed 0 1 1 Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 77 Targets Kampong Thom Preah Vihear Total Parents with Children Living with Disability/ Developmental Delay Planned 1 1 2 Completed 1 1 2 CCWC/ Commune Council/ Community Leaders Planned 1 1 2 Completed 1 1 2 VHSG/ CDL Planned 1 1 2 Completed 1 1 2 Observations Observations were made of VHSG and CDL completing MUAC and CBDMAT screening to gauge confidence and understanding of the expectations. The observations followed the key steps in the CommCare app. Households observations were completed with random KII and FGD respondents to determine if home gardens and WASH infrastructure were in place to enable putting into practice recommended key messages. 52 observations were completed. Mini and Online Survey The ET asked a brief series of closed-ended (e.g. multiple choice, Likert scale, ranked preference) questions integrated into the KII and FGD guides. An online survey of closed-ended questions and limited open-ended questions was also administered to all identified KIIs at national, provincial and district level with access to reliable internet, for whom the ET has a working email address, and who represent a key IECD stakeholder. Respondents from KIIs and FGDs completed 92 mini￾surveys and 32 online surveys. Mini-surveys represented respondents located in Kampong Thom and Preah Vihear, while the online surveys targeted respondents with more reliable internet access in Siem Reap and Phnom Penh. Online survey target responses were not met due to one refusal and seven non-responses. Mini-survey’s were administered after KII and before and after FGD at the community level. Data was collected using the Esri ArcGIS’s Survey123. Paper survey’s were available for back-up data collection if connectivity to the platform was limited or restricted. An online survey link was shared with KII stakeholders including government and IP. However, the Translator followed up with most respondents who received the link to complete the survey for them online. Co-Collection of Locational Data Esri ArcGIS’s Survey123 was used by the ET to collect data from the mini and online survey. It was also used to store data from all interviews. Figures presented in this report were generated through this tool and can also be used to compare respondents and their responses in various geographic locations. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 78 2.6 DATA ANALYSIS QUALITATIVE ANALYSIS The ET took the following initial steps to prepare for data analysis. All interviews that had not been completed in English or simultaneously translated from English to Khmer were translated from Khmer to English. Notes were than transcribed in English. Completed transcriptions were shared with the Team Leader who reviewed the responses for thoroughness and checked data against the interview guides. All cleaned transcriptions were completed on May 5th and uploaded into Atlas.ti. Atlas.ti was used to code data against various themes which resulted in 1516 unique entries linked to the following overarching codes: community development, family and caregiving responsibilities, personal and professional development, and program implementation. Quotations from the codes were extracted and matched to the relevant evaluation matrix questions. From this, data was reviewed to determine how it contributed to the evaluation questions in terms of its relevance for identifying the various strengths, areas for improvement, opportunities, and overall recommendations for the IECD activity. Secondary data has been used to provide further explanation of the findings. QUANTITATIVE ANALYSIS Data from mini and online surveys was either collected with paper and pen or directly uploaded into Survery123. Surveys submitted through Survey123 were checked for completeness and the data cleaned with attention to redundancies. Outliers were removed from the data sets where necessary. Data was then used to determine the results of various respondents’ engagement with the IECD activity, male and female dynamics, and respondents recall of certain WASH and nutrition practices. Findings have been used to triangulate the qualitative outcomes to enable a more complete understanding of IECD interventions in order to answer the evaluation questions. Overall, the data collected is sufficient to answer the evaluation questions, while also being able to provide evidence of engagement with community volunteers. 2.7 EVALUATION LIMITATIONS 1. The timeline to complete data collection overlapped with Khmer New Year. This resulted in limited time to complete proper introductions in the field, which resulted in some initial hesitation from communities when the ET arrived in villages. It also resulted in the ET experiencing seven days of a very reduced interview schedule. 2. The ET faced inconsistent internet access in the field. To ensure the integrity of the data collected, the ET used paper and pen with the mini-surveys and transferred data to Survey123 once a secure internet connection was established. There is an offline function in Survey123, but some ET members’ phones were not reliable with the offline function. 3. Appointments often had to be made on short notice and contact numbers were sometimes not correct. This was particularly evident in Preah Vihear, where many of the interviews were set the night before or in the morning once the ET arrived in the villages. 4. Initially the ET found it difficult to identify men to participate in interviews. This changed around Khmer New Year when more men returned to the villages. In the end, the ET found fewer grandparents and caregivers of CLWD than planned. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 79 5. Due to implementation of IECD ending more than six months before the time of the interviews for cohort 1 respondents, some respondents demonstrated recall bias. The ET used techniques such as a timeline to attempt to reduce recall bias and tried to link engagement with certain activities taking place, like COVID-19 or holidays. The ET held all interviews in as private of locations as possible to reduce input from other family members or neighbors listening to the interviews. 6. The ET observed children in communities eating packaged snacks and junk food, but few respondents spoke about this, which demonstrated some halo bias. Evaluation methods need to be explored to ensure proper measurement of this in villages, including using more deliberate language to track consumption. 7. Due to the timeline for data collection, the ET only collected data from districts and villages that were within an hour to two hour drive of the provincial capitol of each province. This demonstrates a limitation with selection criteria as it prevented the ET from sampling from populations that live further away. 8. The evaluation applied purposive sampling as a means to ensure reach of stakeholders and participants who know the IECD Activity. Selection bias was therefore inherent in the design process as a means to ensure respondents reflect engagement with the IECD activity. 9. Interviews were facilitated in Khmer except with the IP and international organizations in Phnom Penh. This required all data collection instruments to be translated into Khmer from English and for all interview notes to be transcribed from Khmer to English. As a result, some nuances and details from the interview guides or from the participants themselves might have been lost in translation. 10. ADRA and World Vision has actively implemented similar WASH and nutrition interventions to the IECD activity in Kampong Thom. At times it was difficult for interview participants to distinguish between an IECD Activity intervention. 11. The ET does not have access to the most recent IECD evaluation of cohort 1. Therefore, some areas lack updated data from secondary sources 12. The baseline data was collected between June and July compared to the mid-term evaluation in April. April is considered to be the hottest and driest month ahead of the rain season. Household incomes and food consumption might be different due to it being the pre-planting season. However, previous experience in conducting similar evaluations provides us the knowledge to know that none of these potentialities will negatively impact the ET’s research, investigations or its ability to produce the required deliverables including the final Evaluation Report. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 80 ANNEX 3. STATEMENTS REGARDING SIGNIFICANT UNRESOLVED DIFFERENCES OF OPINION Nothing has been brought to the attention of the ET at the time of submission of the draft report on May 24, 2023. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 81 ANNEX 4. DATA COLLECTION AND ANALYSIS TOOLS 4.1 INTERVIEW GUIDES KEY INFORMANT INTERVIEWS KII INTERVIEW GUIDE - IECD Implementing Partners Introduction: Hello, My name is _______. I am an independent consultant working with ME&A. USAID Cambodia has contracted with ME&A to conduct a mid-term performance evaluation of the IECD project’s first three years 2022 to 2023, as part of the USAID evaluation procedures. This is a routine process for all USAID￾funded project and information we collect will help USAID to plan their investments. We circulated an information card about this evaluation in anticipation of this interview. The interview will likely take about 90 minutes. If we are unable to finish today, I will be happy to call you again to complete the questions. Your participation is voluntary and you have the right to stop your participation at any time but we hope you will agree to answer the questions since your views are important. If I ask you any question you do not want to answer, just let me know and I will go on to the next question or you can stop the interview at any time. In case you need more information about the evaluation, you may contact the person listed on this card. The responses you provide will be kept confidential and we will list all respondents’ names, titles, and affiliations as part of the final report. The information will be disseminated in a final report and final presentation for USAID and partners. Do you have any questions? 1. Yes 2. No May I begin the interview now? 1. Yes 2. No May I have your name and title/role, please? (Interview begins here.) Study ID No. …………………… Location: ……………………………………… Participant’s name: ………………………………………………………………………………………………….. Position/Role: ……………………………………………………………………………………………………….. Organization: ………………………………………………………………………………………………………… Contact (in case additional info is needed): ………………………………………………………………………… Gender: Male Female Non-binary/other 1. Can you please share with what is the IECD Activity? 2. Can you please share with us where specifically is it being implemented and how? 3. Who are the partners and what is their role? PROMPTS: -Location? -Time of engagement? One off or throughout the life of the activity? 4. Can you share with us what is taking place with _____ ? A. Overall implementation with the Senior Management Team (John Ames and Chhuor Chanpheakdey) B. Early childhood development with Rany Koy Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 82 C. Health/nutrition with Hun Vannary D. Food security and agriculture with Chim Chon E. MEL with Veng Seng F. Gender with Say Sreignep G. Disability and inclusion with Chhany Chek 3. Could you please share with us what specifically you are doing? 4. What is your thinking with the implementation model with waves and the accompanying cohort evaluation? 4.a. Are there any strengths, weaknesses, challenges or recommendations that you would like to make With this model? 5. Fostering an environment of equity with and amongst primary and alternate caregivers is a key focus of the IECD activity. The IECD activity is working with women, men, families that identify as parents of children living with disability and developmental delays and grandparents. 5.1. Do you think there are differences in the roles of men and women with their children particularly if their child/ren is a boy or girl? 5.2. Do you think families who have children living with a disability or developmental delay face the same or different successes and challenges then families who do not have children with these abilities? 6. Improving nutrition practice is one the goals of the IECD project. What are some of the activities that you feel are having the most impact with reaching this goal? What are some of the activities you feel could improve? 7. The IECD activity approaches improving nutrition through a lens of integration with early childhood development, disability/developmental delays, agriculture and WASH. PROMPTS: -What do see are strengths to this approach? -What are weaknesses? -What could improve? -What would you like to see scaled up? 8. Specifically with the identification, referral and follow up of children living with disability and developmental delays from the communities to Angkor Children’s Hospital in Siem Reap. PROMPTS: -What do see are strengths to this approach? -What are weaknesses? -What could improve? -What would you like to see scaled up? 9. Various development domains have been identified in the IECD activity such as social/personal, language/cognition, fine motor skill and gross motor skills. PROMPTS: -What do see are strengths to this approach with the various development domains? -What are weaknesses? -What could improve? -What would you like to see scaled up? 10. Many projects like to consider sustainability. What do you think is the most sustainable activity that IECD activity is implementing? FOLLOW UP: Are there other activities that you would also consider for sustainability? -Are there recommendations you would have for how to go about fostering sustainability of the activities you have mentioned? Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 83 11. Could you please share with us any remaining ideas overall of what you think some of the strengths and weaknesses are of the IECD activity project overall? 12. Are there key challenges that you feel are having an impact on the implementation of the IECD activity that you have not shared with us yet today? 13. Do you have any suggestions or know of any opportunities for how the challenges could be overcome? 14. Are there any final recommendations that you would like to share with us? Please ask the person if they have any questions for the ET. Before the end of the interview, thank the person for the time and inputs in the evaluation and provide a copy of the evaluation postcard with additional information and contact details. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 84 KII INTERVIEW GUIDE: SIEM REAP: HOSPITAL AND IMPLEMENTING PARTNER Introduction: Hello, My name is _______. I am an independent consultant working with ME&A. USAID Cambodia has contracted with ME&A to conduct a mid-term performance evaluation of the IECD project’s first three years 2022 to 2023, as part of the USAID evaluation procedures. This is a routine process for all USAID￾funded project and information we collect will help USAID to plan their investments. We circulated an information card about this evaluation in anticipation of this interview. The interview will likely take about 90 minutes. If we are unable to finish today, I will be happy to call you again to complete the questions. Your participation is voluntary and you have the right to stop your participation at any time but we hope you will agree to answer the questions since your views are important. If I ask you any question you do not want to answer, just let me know and I will go on to the next question or you can stop the interview at any time. In case you need more information about the evaluation, you may contact the person listed on this card. The responses you provide will be kept confidential and we will list all respondents’ names, titles, and affiliations as part of the final report. The information will be disseminated in a final report and final presentation for USAID and partners. Do you have any questions? 1. Yes 2. No May I begin the interview now? 1. Yes 2. No May I have your name and title/role, please? (Interview begins here.) ID No. …………………… Location: ……………………………………… Participant’s name: ………………………………………………………………………………………………….. Position/Role: ……………………………………………………………………………………………………….. Organization: ………………………………………………………………………………………………………… Contact (in case additional info is needed): ………………………………………………………………………… Gender: Male Female Non-binary/other 1. Can you please share with us what you know about the IECD Activity? 2. Specifically, what area is Angkor Children’s Hospital/Safe Haven supporting? Could you please share with us what specifically you are doing? 3. Could you provide us an overview of the behavior change communication activities being implemented in Siem Reap as it links to the IECD activity? 4. How does the identification, referral and follow up system work for children living with disability and developmental delay works between your organizations here in Siem Reap and the two implementation provinces? 5. Are families who are identified as having a child living with disability/ developmental delay gaining access to the necessary social protection schemes? Social Protection Fund? Health Equity Fund? NSSF? PROMPT: What is preventing them from gaining access? What more needs to be done? 6. From what you observe, do you find parents are willing to come for services for their children who live with disability and development delays? Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 85 PROMPT: Are they reluctant? Are there specific challenges that they face? 7. When children are here how are the caregivers engaging with them? PROMPTS: Do you ever see men here taking care of the children? What is the role of caregivers here? Who feeds them? Who bathes or toilets them? Does someone play, read and/or attentively respond to them? Are grandparents ever with the children? 8. How are families coping once they return to their homes? PROMPT: Are they finding more acceptance? Do they still struggle with services or participating in daily livelihoods activities? 9. Could you please share with us any remaining ideas overall you have specific to the strengths or areas that require more attention under the IECD activity? 10. Are there any final recommendations that you would like to share with us? Please ask the person if they have any questions for the ET. Before the end of the interview, thank the person for the time and inputs in the evaluation and provide a copy of the evaluation postcard with additional information and contact details. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 86 KII INTERVIEW GUIDE: USAID/Cambodia Introduction: Hello, My name is _______. I am an independent consultant working with ME&A. USAID Cambodia has contracted with ME&A to conduct a mid-term performance evaluation of the IECD project’s first three years 2022 to 2023, as part of the USAID evaluation procedures. This is a routine process for all USAID￾funded project and information we collect will help USAID to plan their investments. We circulated an information card about this evaluation in anticipation of this interview. The interview will likely take about 90 minutes. If we are unable to finish today, I will be happy to call you again to complete the questions. Your participation is voluntary and you have the right to stop your participation at any time but we hope you will agree to answer the questions since your views are important. If I ask you any question you do not want to answer, just let me know and I will go on to the next question or you can stop the interview at any time. In case you need more information about the evaluation, you may contact the person listed on this card. The responses you provide will be kept confidential and we will list all respondents’ names, titles, and affiliations as part of the final report. The information will be disseminated in a final report and final presentation for USAID and partners. Do you have any questions? 1. Yes 2. No May I begin the interview now? 1. Yes 2. No May I have your name and title/role, please? (Interview begins here.) ID No. …………………… Location: ……………………………………… Participant’s name: ………………………………………………………………………………………………….. Position/Role: ……………………………………………………………………………………………………….. Organization: ………………………………………………………………………………………………………… Contact (in case additional info is needed): ………………………………………………………………………… Gender: Male Female Non-binary/other 1. Can you please share with us what you know about the IECD Activity? 2. Specifically, can you speak about the collaboration and coordination around the IECD Activity to ensure its multi￾sectoral approach for nurturing care? 3. How is coordination occurring with agriculture/health/other sectors with gender to ensure engagement of all caregivers? 4. Migration is an issue in the provinces with many men leaving the villages for work. What are current mitigation efforts taking place to attract more men to work locally or in Cambodia? 5. What are your thoughts on the disability integration? What is working? What requires more attention? 6. Collaboration and coordination takes place with the health centers and commune councils in varying degrees. Could you speak to things that you think are working well in the project with regards to these relationships? What more could take place particularly with links to the Commune Investment Plans (CIP)? Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 87 7. WASH will be a bigger focus on cohort 2 and 3 going forward. Are there any particular areas that you feel require attention? 8. Could you please share with us any remaining ideas overall of what you think some of the best practices are with IECD and what could use more attention? 9. Are there any final recommendations that you would like to share with us? Please ask the person if they have any questions for the ET. Before the end of the interview, thank the person for the time and inputs in the evaluation and provide a copy of the evaluation postcard with additional information and contact details. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 88 KII INTERVIEW GUIDE: INTERNATIONAL ORGANIZATIONS (E.G. UNICEF, GIZ, AND WORLD BANK) Introduction: Hello, My name is _______. I am an independent consultant working with ME&A. USAID Cambodia has contracted with ME&A to conduct a mid-term performance evaluation of the IECD project’s first three years 2022 to 2023, as part of the USAID evaluation procedures. This is a routine process for all USAID￾funded project and information we collect will help USAID to plan their investments. We circulated an information card about this evaluation in anticipation of this interview. The interview will likely take about 90 minutes. If we are unable to finish today, I will be happy to call you again to complete the questions. Your participation is voluntary and you have the right to stop your participation at any time but we hope you will agree to answer the questions since your views are important. If I ask you any question you do not want to answer, just let me know and I will go on to the next question or you can stop the interview at any time. In case you need more information about the evaluation, you may contact the person listed on this card. The responses you provide will be kept confidential and we will list all respondents’ names, titles, and affiliations as part of the final report. The information will be disseminated in a final report and final presentation for USAID and partners. Do you have any questions? 1. Yes 2. No May I begin the interview now? 1. Yes 2. No May I have your name and title/role, please? (Interview begins here.) Study ID No. …………………… Location: ……………………………………… Participant’s name: ………………………………………………………………………………………………….. Position/Role: ……………………………………………………………………………………………………….. Organization: ………………………………………………………………………………………………………… Contact (in case additional info is needed): ………………………………………………………………………… Gender: Male Female Non-binary/other 1. Could you please share with us what specifically your organization is doing with nutrition, early childhood development, WASH, disability, and/or gender? 2. Can you please share with us what you know about the IECD Activity? PROMPT: locations, activities? 3. Specifically, is your organizing currently coordinating any activities with the IECD Activity? 4. Either through the lens of coordination with IECD or what your organization is doing generally, what are some of things you are currently doing in nutrition for women of reproductive age, pregnant women and children under five years old? PROBE: Community groups? MUAC screenings? Working with the health facilities? Community agriculture efforts? 5. What about with early childhood development. Is there anything you are coordinating with IECD on or doing directly? Specifically, can you speak to current progress towards efforts linked to the social/personal, linguistic/cognitive, fine and gross motor skill development of children under five years old? Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 89 6. Cambodia has made progress on increasing the capacity of the private sector to improve water and sanitation services in urban areas. However, seems to be struggling some at the subnational level. Getting the private sector out and investing seems to be the most sustainable way forward particularly as there might be a need for some investment in technologies that are resilient to flooding, drought, etc. Is there anything that you are aware of in terms of mobilizing the private sector for WASH? Are there locally appropriate interventions that should be considered that might not be scaled up at the moment (e.g. toilets and filters are there)? 7. Gender is a cross cutting theme for IECD in terms of increasing equity in the household with caregiving. What are some effective strategies that you see in place for enabling equity among caregivers in the household? Particularly, have you seen any community models that support mitigating the reality that men do migrate for work? Are there models for identifying alternate caregivers to support women at home? 8. Disability is another priority for the IECD. Specifically, identifying, referring and following up with children living with disability/ developmental delay. What are your thoughts or ideas on ways to improve this or enable sustainability around the effort? 9. Everyone is vying to work with the Commune Councils and advocate with them for commitments from the commune investment plan (CIP). Is there any coordination taking place at the Commune Council level to mitigate this possible competition for funds? Are there other mechanisms in place that you think can support sustainability? 10. Are there any final recommendations that you would like to share with us? Please ask the person if they have any questions for the ET. Before the end of the interview, thank the person for the time and inputs in the evaluation and provide a copy of the evaluation postcard with additional information and contact details. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 90 NATIONAL, PROVINCIAL AND DISTRICT GOVERNMENTS Introduction: Hello, My name is _______. I am an independent consultant working with ME&A. USAID Cambodia has contracted with ME&A to conduct a mid-term performance evaluation of the IECD project’s first three years 2022 to 2023, as part of the USAID evaluation procedures. This is a routine process for all USAID￾funded project and information we collect will help USAID to plan their investments. We circulated an information card about this evaluation in anticipation of this interview. The interview will likely take about 90 minutes. If we are unable to finish today, I will be happy to call you again to complete the questions. Your participation is voluntary and you have the right to stop your participation at any time but we hope you will agree to answer the questions since your views are important. If I ask you any question you do not want to answer, just let me know and I will go on to the next question or you can stop the interview at any time. In case you need more information about the evaluation, you may contact the person listed on this card. The responses you provide will be kept confidential and we will list all respondents’ names, titles, and affiliations as part of the final report. The information will be disseminated in a final report and final presentation for USAID and partners. Do you have any questions? 1. Yes 2. No May I begin the interview now? 1. Yes 2. No May I have your name and title/role, please? (Interview begins here.) Study ID No. …………………… Village:…………………….. District: ……………………………………… Commune:……………………………. Province:…………………………. Participant’s name: ………………………………………………………………………………………………….. Position/Role: ……………………………………………………………………………………………………….. Organization: ………………………………………………………………………………………………………… Contact (in case additional info is needed): ………………………………………………………………………… Gender: Male Female Non-binary/other Question 1 to 5 and the last question are the same for all of the Provincial and District Offices National, Provincial and Operational District for Health *H indicates the question is for health and nutrition stakeholders 1. Can you please share with us what you know about the IECD Activity? PROMPT: Locations? Activities? 2. Specifically, how is your Ministry/Department working/coordinating/collaborating with the RTI IECD Activity? PROMPT: Trainings for Nurturing Care? MUAC trainings? Referral for MUAC? AHC CBDMAT Master Trainer? Supervision for CBDMAT screenings? Organizing? Coordinating? 3. Are you familiar with the implementation of the project through cohorts? 3.a. What are your thoughts about this type of implementation (skip to 3b if they cannot respond or already explained)? 3.b. Are there any strengths, weaknesses, challenges or recommendations that you would like to make about this model? Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 91 4. The IECD activity is working with women, men, families that identify as parents of children living with disability and developmental delays. What is your Ministry/Department doing for children living disability/developmental delay? 5. What is your Ministry/Department focusing on with gender? Is there anything specifically being done to address the roles of men and women as caregivers of young children? 6H. The Royal Government of Cambodia has identified improving nutrition as a priority in the National Nutrition and Food Security Strategy. What are some of the actions linked to health that you see working well Nationally or in this Province/District? 7H. Improving nutrition practices for women of reproductive age, pregnant women and children from 6 to 23 months is a priority for the IECD activity. What are some of the activities that you think are having the most impact with reaching this goal? What do you think could improve? 8H. The IECD activity approaches improving nutrition practices through a lens of integration with early childhood development, disability/developmental delays, agriculture and with WASH. What are the strengths? What are weaknesses? What could improve? 9H. What do you think is the most sustainable activity that IECD activity is implementing to improve nutrition? FOLLOW UP: Are there recommendations you have for how to best sustain the activities? 10. Are there any final recommendations that you would like to share with us? PLEASE LET THE RESPONDENT KNOW THAT MS. SOPHEA SENG WILL BE FOLLOWING UP WITH THEM TO COMPLETE AN ONLINE SURVEY. Please ask the person if they have any questions for the ET. Before the end of the interview, thank the person for the time and inputs in the evaluation and provide a copy of the evaluation postcard with additional information and contact details. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 92 National, Provincial and District Education Offices *E indicates the question is for education and early childhood development stakeholders 1. Can you please share with us what you know about the IECD Activity? PROMPT: Locations? Activities? 2. Specifically, how is your Ministry/Department working/coordinating/collaborating with the RTI IECD Activity? PROMPT: Trainings for Nurturing Care? MUAC trainings? Referral for MUAC? AHC CBDMAT Master Trainer? Supervision for CBDMAT screenings? Organizing? Coordinating? 3. Are you familiar with the implementation of the project through cohorts? 3.a. What are your thoughts about this type of implementation (skip to 3b if they cannot respond or already explained)? 3.b. Are there any strengths, weaknesses, challenges or recommendations that you would like to make about this model? 4. The IECD activity is working with women, men, families that identify as parents of children living with disability and developmental delays. What is your Ministry/Department doing for children living disability/developmental delay? 5. What is your Ministry/Department focusing on with gender? Is there anything specifically being done to address the roles of men and women as caregivers of young children? 6E. Linkages have been made to achieve the National Early Childhood Development strategy. What are some of the actions linked to early childhood development that are working well in Nationally or in your Province/District? What is working well? What could be improved? 7E. The IECD activity is designed to integrate early childhood development with health, agriculture and WASH to improve the growth and development outcomes in children under five years of age. There are multiple domains of growth and development in the IECD nurturing care sessions. They include social/personal, language/cognition, fine motor skill, and gross motor skill development. What do you think are the strengths, weaknesses, challenges and opportunities for IECD with this approach? Specifically, with: -Social/personal development? Language and cognition? Fine motor skill? -Gross motor skill? 8E. What do you think is the most sustainable activity that IECD activity is implementing linked to early childhood development? FOLLOW UP: Are there recommendations you have for how to best sustain the activities? 9. Are there any final recommendations that you would like to share with us? PLEASE LET THE RESPONDENT KNOW THAT MS. SOPHEA SENG WILL BE FOLLOWING UP WITH THEM TO COMPLETE AN ONLINE SURVEY. Please ask the person if they have any questions for the ET. Before the end of the interview, thank the person for the time and inputs in the evaluation and provide a copy of the evaluation postcard with additional information and contact details. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 93 National, Provincial and District Social, Veterans and Youth Affairs Offices *DDD indicates the question is for disability and developmental delay stakeholders. 1. Can you please share with us what you know about the IECD Activity? PROMPT: Locations? Activities? 2. Specifically, how is your Ministry/Department working/coordinating/collaborating with the RTI IECD Activity? PROMPT: Trainings for Nurturing Care? MUAC trainings? Referral for MUAC? AHC CBDMAT Master Trainer? Supervision for CBDMAT screenings? Organizing? Coordinating? 3. Are you familiar with the implementation of the project through cohorts? 3.a. What are your thoughts about this type of implementation (skip to 3b if they cannot respond or already explained)? 3.b. Are there any strengths, weaknesses, challenges or recommendations that you would like to make about this model? 4. The IECD activity is working with women, men, families that identify as parents of children living with disability and developmental delays. What is your Ministry/Department doing for children living disability/developmental delay? 5. What is your Ministry/Department focusing on with gender? Is there anything specifically being done to address the roles of men and women as caregivers of young children? 6DDD. The Royal Government of Cambodia has identified improving the identification, referral and follow up of children living with disability and developmental delay as a priority. Overall, what is taking place in Nationally or in your province/district? PROMPT: Social protection fund? Service identification? Links to HEF and/or NSSF? 7DDD. Improving the capacity of frontline workers such as village health support groups (VHSG) and commune development leaders (CDL) to screen, refer, and follow up with children living with disability and developmental delay is a priority of the IECD Activity. What do you think are the strengths, weaknesses, challenges and opportunities for IECD with this approach? Specifically, with: -Identification? -Referral? -Follow up? 8DDD. Can you speak about the identification, referral and follow up of children living with disability and developmental delays from the communities to Angkor Hospital for Children in Siem Reap? What works? What is not working? What are opportunities? 9DDD. What do you think is the most sustainable activity that IECD activity is implementing linked to identification, referral and follow for children living with disability/ developmental delay? FOLLOW UP: Some of the children in the IECD activity have not received all services, but have been identified. What could be options for them with the continuum of care? Are there recommendations you have for how to best sustain the activities? 10. Are there any final recommendations that you would like to share with us? PLEASE LET THE RESPONDENT KNOW THAT MS. SOPHEA SENG WILL BE FOLLOWING UP WITH THEM TO COMPLETE AN ONLINE SURVEY. Please ask the person if they have any questions for the ET. Before the end of the interview, thank the person for the time and inputs in the evaluation and provide a copy of the evaluation postcard with additional information and contact details. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 94 KII INTERVIEW GUIDE: HEALTH FACILITY STAFF Introduction: Hello, My name is _______. I am an independent consultant working with ME&A. USAID Cambodia has contracted with ME&A to conduct a mid-term performance evaluation of the IECD project’s first three years 2022 to 2023, as part of the USAID evaluation procedures. This is a routine process for all USAID￾funded project and information we collect will help USAID to plan their investments. We circulated an information card about this evaluation in anticipation of this interview. The interview will likely take about 90 minutes. If we are unable to finish today, I will be happy to call you again to complete the questions. Your participation is voluntary and you have the right to stop your participation at any time but we hope you will agree to answer the questions since your views are important. If I ask you any question you do not want to answer, just let me know and I will go on to the next question or you can stop the interview at any time. In case you need more information about the evaluation, you may contact the person listed on this card. The responses you provide will be kept confidential and we will list all respondents’ names, titles, and affiliations as part of the final report. The information will be disseminated in a final report and final presentation for USAID and partners. Do you have any questions? 1. Yes 2. No May I begin the interview now? 1. Yes 2. No May I have your name and title/role, please? (Interview begins here.) Study ID No:……………… Health Center: …….…….. Commune:…………… District:………………. Cohort 1 or 2 Participant’s name: ………………………………………………………………………………………………….. Position/Role: ……………………………………………………………………………………………………….. Name of Health Center: …………………………………………………………………………………………… Contact (in case additional info is needed): ………………………………………………………………………… Gender: Male Female Non-binary/other 1. Can you please share with us what you know about the IECD activity? 2. How have you been engaged with the RTI IECD activity? 3. What are the most important activities IECD has been doing? PROMPT: Are you aware of the home visits? Nurturing care sessions/ Caregiver groups? Cooking demonstrations? Village model farmer activities? Male support group? Child screenings for disability, developmental delay, and MUAC? Peer support? Community dialogues? 4. What kind of changes have you seen in your health facility or community due to IECD? 5. Has IECD affected your work? How and why? 6. What, if any, challenges have you experienced around implementing the IECD activities? Why? PROMPT: screening and reporting of child disability, development delay or nutrition. How do you think those challenges can be addressed? Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 95 7. Do you know about any IECD trainings? Specifically, have you been trained as a master training? 8. What are your thoughts on the referral that VHSG are doing? PROMPT: What works? What requires attention? What would you change? 9. In your opinion, what do think worked well with IECD activity? 10. What do you think the challenges are for IECD? 11. What do you think can be improved with the IECD activity? 12. Do you have any questions or anything to add for the evaluation team? Please ask the person if they have any questions for the ET. Before the end of the interview, thank the person for the time and inputs in the evaluation and provide a copy of the evaluation postcard with additional information and contact details. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 96 KII INTERVIEW GUIDE: WOMEN Introduction: Hello, My name is _______. I am an independent consultant working with ME&A. USAID Cambodia has contracted with ME&A to conduct a mid-term performance evaluation of the IECD project’s first three years 2022 to 2023, as part of the USAID evaluation procedures. This is a routine process for all USAID￾funded project and information we collect will help USAID to plan their investments. We circulated an information card about this evaluation in anticipation of this interview. The interview will likely take about 90 minutes. If we are unable to finish today, I will be happy to call you again to complete the questions. Your participation is voluntary and you have the right to stop your participation at any time but we hope you will agree to answer the questions since your views are important. If I ask you any question you do not want to answer, just let me know and I will go on to the next question or you can stop the interview at any time. In case you need more information about the evaluation, you may contact the person listed on this card. The responses you provide will be kept confidential and we will list all respondents’ names, titles, and affiliations as part of the final report. The information will be disseminated in a final report and final presentation for USAID and partners. Do you have any questions? 1. Yes 2. No May I begin the interview now? 1. Yes 2. No May I have your name and title/role, please? (Interview begins here.) Study ID No. …………………… Village: ………………………………… Commune:………………………….. District:………………………………….. Cohort 1 or 2 Age of youngest child: …………. Participant’s name: ………………………………………………………………………………………………….. Contact (in case additional info is needed): ………………………………………………………………………… 1. Can you please share with us what you know about: 1.a. Child nutrition? (DO NOT PROMPT ONLY LISTEN SPECIFICALLY FOR: Breastfeeding /Poultry, fish, meat consumption/Vegetable and fruit consumption/Women eating while pregnant and breastfeeding) 1.b. Early childhood development? (DO NOT PROMPT ONLY LISTEN SPECIFICALLY FOR: Play, reading, singing, positive parenting) 1.c. Home gardening? (DO NOT PROMPT ONLY LISTEN SPECIFICALLY FOR: small animal raising, vegetables, fruit) 1.d. Water, sanitation and hygiene activities? (LISTEN SPECIFICALLY F DO NOT PROMPT ONLY LISTEN SPECIFICALLY FOR OR: handwashing, toilet use, food hygiene, and clean house) 2. Have you heard of the IECD (NEED KHMER WORD – how introduce the program to them?) activity? IF ANSWER NO THEN SKIP TO QUESTION 6 3. Could you please share with us what you know about the activities being implemented by the IECD activity? PROMPT: Community Dialogues? Peer Support? Caregiver Groups/Nurturing care sessions? Home Visits? Cooking demonstrations? Village Model Farmer Activities? Child Screenings for Disability, Development Delays and Nutrition? Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 97 4. Have you participated in an IECD activity? PROMPTS: -What was the most recent activity? -How frequently would you say that you engage in an activity? -How often would you say that you see a VHSG? 5. Is there anything that you have learned from the IECD activity that you find: PROMPTS: -Easy to put into practice? -Difficult to put into practice? -Do you think it will be easy to keep up the practice over time? 6. In your household or village, what is the role of the primary female caregiver and primary male caregiver in the household (e.g. parents/caregivers and/or grandparents/alternate caregivers)? PROMPTS: who tells stories to children? Feed children? Teach children new things? Bathe and toilet the children? Do both men and women engage with boy and girl children in the same way? 7. Is there a home garden at your home? PROMPTS: -If yes, what are some of the things that you grow? -What do you do with the food that is grown in your home? Prompt: consume and/or sell at the market -If no, how do you get food? -What types of food? -Does your family experience time’s of the year when you do not have food? -If yes, What do you do? -Is it more common for women to go without a meal than men when there is not enough food? 8. How do you access animal source proteins (e.g. eggs, fish, meat)? PROMPTS: -What are the most common types of animal source protein you consume? 9. Have you received support for agriculture inputs? -If yes, what? -If no, proceed to question 9. 10. What is your main source of income generation? 11. Who manages the household finances and makes decisions about what is purchased? PROMPTS: - Do men and women talk about finances? -Share money that is earned? 12. What are the practices are in your household for handwashing and use of the toilet (this will be checked with the household observation)? PROMPT: Do you have regular access to clean water? Do you buy it? 13. In your village, do you know of any children who have been identified as having a disability or developmental delay? In no, skip to question 14. IF YES: Who do they seek out for support and services? - Do their families have access to the Health Center? Home gardens? Income generation activities? Referral and follow up for care for their children? Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 98 14. What do you see community volunteers (e.g. VHSG and CDL) doing in your village that are linked to the IECD activity? 15. Who completes screenings for disability/development delay and MUAC in your village? 16. What is the role of grandparents and young children in your home or village? 17. Does the support you receive from your husband/partner or other family members impact upon your ability to be a good parent and provide the things that your children require to thrive? 18. Is there anything else that you would like to share with us today? NOW I HAVE A FEW MORE QUESTIONS TO ASK YOU THAT WILL REQUIRE SHORT AND QUICK ANSWERS. PROCEED TO THE MINI-SURVEY. ONCE THE MINI-SURVEY IS COMPLETE, FOLLOWING THE SKIP PATTERN, ASK THE RESPONDENT IF IT WOULD BE OKAY TO OBSERVE THEIR HAND WASHING STATION AND TOILET. PROCEED TO THE OBSERVATION CHECKLIST FOR HOUSEHOLDS. Please ask the person if they have any questions for the ET. Before the end of the interview, thank the person for the time and inputs in the evaluation and provide a copy of the evaluation postcard with additional information and contact details. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 99 KII INTERVIEW GUIDE: MEN66 Introduction: Hello, My name is _______. I am an independent consultant working with ME&A. USAID Cambodia has contracted with ME&A to conduct a mid-term performance evaluation of the IECD project’s first three years 2022 to 2023, as part of the USAID evaluation procedures. This is a routine process for all USAID￾funded project and information we collect will help USAID to plan their investments. We circulated an information card about this evaluation in anticipation of this interview. The interview will likely take about 90 minutes. If we are unable to finish today, I will be happy to call you again to complete the questions. Your participation is voluntary and you have the right to stop your participation at any time but we hope you will agree to answer the questions since your views are important. If I ask you any question you do not want to answer, just let me know and I will go on to the next question or you can stop the interview at any time. In case you need more information about the evaluation, you may contact the person listed on this card. The responses you provide will be kept confidential and we will list all respondents’ names, titles, and affiliations as part of the final report. The information will be disseminated in a final report and final presentation for USAID and partners. Do you have any questions? 1. Yes 2. No May I begin the interview now? 1. Yes 2. No May I have your name and title/role, please? (Interview begins here.) Study ID No. …………………… Village: ………………………………… Commune:………………………….. District:………………………………….. Cohort 1 or 2 Age of youngest child: …………. Participant’s name: ………………………………………………………………………………………………….. Contact (in case additional info is needed): ………………………………………………………………………… 1. Can you please share with us what you know about: 1.a. Child nutrition? (DO NOT PROMPT ONLY LISTEN SPECIFICALLY FOR: Breastfeeding /Poultry, fish, meat consumption/Vegetable and fruit consumption/Women eating while pregnant and breastfeeding) 1.b. Early childhood development? (DO NOT PROMPT ONLY LISTEN SPECIFICALLY FOR: Play, reading, singing, positive parenting) 1.c. Home gardening? (DO NOT PROMPT ONLY LISTEN SPECIFICALLY FOR: small animal raising, vegetables, fruit) 1.d. Water, sanitation and hygiene activities? (LISTEN SPECIFICALLY F DO NOT PROMPT ONLY LISTEN SPECIFICALLY FOR OR: handwashing, toilet use, food hygiene, and clean house) 2. Have you heard of the IECD (NEED KHMER WORD – how introduce the program to them?) activity? IF ANSWER NO THEN SKIP TO QUESTION 6 66 IECD. Findings of IECD Men Involvement. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 100 3. Could you please share with us what you know about the activities being implemented by the IECD activity? PROMPT: Community Dialogues? Peer Support? Caregiver Groups/Nurturing care sessions? Home Visits? Cooking demonstrations? Village Model Farmer Activities? Child Screenings for Disability, Development Delays and Nutrition? 4. Have you participated in an IECD activity? PROMPTS: -What was the most recent activity? -How frequently would you say that you engage in an activity? -How often would you say that you see a VHSG? 5. Is there anything that you have learned from the IECD activity that you find: PROMPTS: -Easy to put into practice? -Difficult to put into practice? -Do you think it will be easy to keep up the practice over time? 6. In your household or village, what is the role of the primary female caregiver and primary male caregiver in the household (e.g. parents/caregivers and/or grandparents/alternate caregivers)? PROMPTS: who tells stories to children? Feed children? Teach children new things? Bathe and toilet the children? Do both men and women engage with boy and girl children in the same way? 7. Is there a home garden at your home? PROMPTS: -If yes, what are some of the things that you grow? -What do you do with the food that is grown in your home? Prompt: consume and/or sell at the market -If no, how do you get food? -What types of food? -Does your family experience time’s of the year when you do not have food? -If yes, What do you do? -Is it more common for women to go without a meal than men when there is not enough food? 8. How do you access animal source proteins (e.g. eggs, fish, meat)? PROMPTS: -What are the most common types of animal source protein you consume? 9. Have you received support for agriculture inputs? -If yes, what? -If no, proceed to question 9. 10. What is your main source of income generation? 11. Who manages the household finances and makes decisions about what is purchased? PROMPTS: - Do men and women talk about finances? -Share money that is earned? 12. What are the practices are in your household for handwashing and use of the toilet (this will be checked with the household observation)? PROMPT: Do you have regular access to clean water? Do you buy it? Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 101 13. In your village, do you know of any children who have been identified as having a disability or developmental delay? In no, skip to question 14. IF YES: Who do they seek out for support and services? - Do their families have access to the Health Center? Home gardens? Income generation activities? Referral and follow up for care for their children? 14. What do you see community volunteers (e.g. VHSG and CDL) doing in your village that are linked to the IECD activity? 15. Who completes screenings for disability/development delay and MUAC in your village? 16. What is the role of grandparents and young children in your home or village? 17. How do you specifically take care of children at home? 18. How do you feel when you help to take care of children at home? PROMPT Would you like to do more? Are there things you think you could help out with that you currently do not? 19. Is there more that you think you could do with your children to help out at home and ensure the children grow to the best of their ability? PROMPT: Less time on devices? Play more games with children? Less alcohol consumption at home? 20. Is there anything else that you would like to share with us today? NOW I HAVE A FEW MORE QUESTIONS TO ASK YOU THAT WILL REQUIRE SHORT AND QUICK ANSWERS. PROCEED TO THE MINI-SURVEY. ONCE THE MINI-SURVEY IS COMPLETE, FOLLOWING THE SKIP PATTERN, ASK THE RESPONDENT IF IT WOULD BE OKAY TO OBSERVE THEIR HAND WASHING STATION AND TOILET. PROCEED TO THE OBSERVATION CHECKLIST FOR HOUSEHOLDS. Please ask the person if they have any questions for the ET. Before the end of the interview, thank the person for the time and inputs in the evaluation and provide a copy of the evaluation Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 102 KII INTERVIEW GUIDE: PARENTS OF CLDDD Introduction: Hello, My name is _______. I am an independent consultant working with ME&A. USAID Cambodia has contracted with ME&A to conduct a mid-term performance evaluation of the IECD project’s first three years 2022 to 2023, as part of the USAID evaluation procedures. This is a routine process for all USAID￾funded project and information we collect will help USAID to plan their investments. We circulated an information card about this evaluation in anticipation of this interview. The interview will likely take about 90 minutes. If we are unable to finish today, I will be happy to call you again to complete the questions. Your participation is voluntary and you have the right to stop your participation at any time but we hope you will agree to answer the questions since your views are important. If I ask you any question you do not want to answer, just let me know and I will go on to the next question or you can stop the interview at any time. In case you need more information about the evaluation, you may contact the person listed on this card. The responses you provide will be kept confidential and we will list all respondents’ names, titles, and affiliations as part of the final report. The information will be disseminated in a final report and final presentation for USAID and partners. Do you have any questions? 1. Yes 2. No May I begin the interview now? 1. Yes 2. No May I have your name and title/role, please? (Interview begins here.) Study ID No. …………………… Village: ……………………………… Commune:…………………………… District:…………………………. Cohort 1 or 2. Age of child with disability: …………. Participant’s name: ………………………………………………………………………………………………….. Contact (in case additional info is needed): ………………………………………………………………………… Gender: Male Female Non-binary/other 1. Can you please share with us what you know about: 1.a. Child nutrition? (DO NOT PROMPT ONLY LISTEN SPECIFICALLY FOR: Breastfeeding /Poultry, fish, meat consumption/Vegetable and fruit consumption/Women eating while pregnant and breastfeeding) 1.b. Early childhood development? (DO NOT PROMPT ONLY LISTEN SPECIFICALLY FOR: Play, reading, singing, positive parenting) 1.c. Home gardening? (DO NOT PROMPT ONLY LISTEN SPECIFICALLY FOR: small animal raising, vegetables, fruit) 1.d. Water, sanitation and hygiene activities? (LISTEN SPECIFICALLY F DO NOT PROMPT ONLY LISTEN SPECIFICALLY FOR OR: handwashing, toilet use, food hygiene, and clean house) 2. Have you heard of the IECD (NEED KHMER WORD – how introduce the program to them?) activity? IF ANSWER NO THEN SKIP TO QUESTION 6 3. Could you please share with us what you know about the activities being implemented by the IECD activity? PROMPT: -Community Dialogues? -Peer Support? Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 103 -Caregiver Groups/Nurturing care sessions? -Home Visits? -Cooking demonstrations? -Village Model Farmer Activities? -Child Screenings for Disability, Development Delays and Nutrition? -Male support groups? 4. Have you participated in an IECD activity? PROMPT: -What was the most recent activity? -How frequently would you say that you engage in an activity? -How often would you say that you see a VHSG? 5. Is there anything that you have learned from the IECD activity that you find: PROMPT: -Easy to put into practice? -Difficult to put into practice? -Do you think it will be easy to keep up the practice over time? 6. When you think about the needs of young children particularly those living with disability and developmental delays, what are things that support your community most in being able to respond to the growth and development needs of these young children? 7. When it comes to home gardening, income generation, child nutrition, and water, sanitation and hygiene in the home, does the role of women and men differ when there is a CLDDD? PROMPT: -Is it the same? -Can you please explain how it may differ or be the same? -If you see differences in households with CLDDD, are they positive or negative differences? 8. What are ways that families who have CLDDD earn an income? PROMPT: -From their gardens? -Other? -Who might manage the money? Is it the same person if the money comes from the sale of food? 9. How do you access food? Vegetables/fruit? Animal source proteins (e.g. eggs, fish, meat)? PROMPT: -Home gardens? -Markets? -Other (e.g. cash transfer, social protection fund, etc.)? 10. Have you received support for agriculture inputs? -If yes, what? -If no, proceed to question 11 11. Who manages the household finances and makes decisions about what is purchased? PROMPT: - Overall do you feel like you have to spend more money due to your child’s disability/ developmental delay? 12. What are the practices in your household for handwashing and use of the toilet (this will be checked with the household observation)? PROMPT: -Are modifications required and being made to ensure CLDDD can access handwashing stations Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 104 and toilets? -Do you have regular access to clean water? -What about hygiene and sanitation? -Access to waste disposal? 13. For families whose children are identified as having a disability or developmental delay, could you share with us overall what you know about their: PROMPT: - Access to IECD activities particularly home gardens? -Income generating activities? -Referral? -Follow up and support at home? -Health services? -Social protection fund? 14. Do you know of families that have been referred to Angkor Children’s Hospital? PROMPT: -Was the referral successful, if not why? -Did anyone support them in the process? Who? 15. Has anyone followed up with you and your family regarding your child’s disability and developmental needs? 16. Are families who identify as ID Poor, are they receiving any reimbursements through the social protection fund? PROMPT: -What are the reimbursements covering? -Transportation? 17. Could you share with us how you identify as eligible for social protection funds? PROMPT: -What is the process to access the funds? -Do the funds cover the services that you are seeking? 18. What do you think is the best thing being done at the moment for families who have children living with a disability, developmental delay? PROMPT: -What more can be done for these families? 19. Overall, could you share with us what you think is working with the IECD activity or with any of the topics discussed today if you are not familiar with the IECD activity? What is not working? What could change? 20. Is there anything else that you would like to share with us today? NOW I HAVE A FEW MORE QUESTIONS TO ASK YOU THAT WILL REQUIRE SHORT AND QUICK ANSWERS. PROCEED TO THE MINI-SURVEY. ONCE THE MINI-SURVEY IS COMPLETE, FOLLOWING THE SKIP PATTERN, ASK THE RESPONDENT IF IT WOULD BE OKAY TO OBSERVE THEIR HAND WASHING STATION AND TOILET. PROCEED TO THE OBSERVATION CHECKLIST FOR HOUSEHOLDS. Please ask the person if they have any questions for the ET. Before the end of the interview, thank the person for the time and inputs in the evaluation and provide a copy of the evaluation postcard with additional information and contact details Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 105 KII INTERVIEW GUIDE: GRANDPARENTS/ALTERNATE CAREGIVERS Introduction: Hello, My name is _______. I am an independent consultant working with ME&A. USAID Cambodia has contracted with ME&A to conduct a mid-term performance evaluation of the IECD project’s first three years 2022 to 2023, as part of the USAID evaluation procedures. This is a routine process for all USAID￾funded project and information we collect will help USAID to plan their investments. We circulated an information card about this evaluation in anticipation of this interview. The interview will likely take about 90 minutes. If we are unable to finish today, I will be happy to call you again to complete the questions. Your participation is voluntary and you have the right to stop your participation at any time but we hope you will agree to answer the questions since your views are important. If I ask you any question you do not want to answer, just let me know and I will go on to the next question or you can stop the interview at any time. In case you need more information about the evaluation, you may contact the person listed on this card. The responses you provide will be kept confidential and we will list all respondents’ names, titles, and affiliations as part of the final report. The information will be disseminated in a final report and final presentation for USAID and partners. Do you have any questions? 1. Yes 2. No May I begin the interview now? 1. Yes 2. No May I have your name and title/role, please? (Interview begins here.) Study ID No. …………………… Village: ……………………………… Commune:…………………………… District:…………………………. Cohort 1 or 2 Age of youngest grandchild: …………. Participant’s name: ………………………………………………………………………………………………….. Contact (in case additional info is needed): ………………………………………………………………………… Gender: Male Female Non-binary/other 1. Can you please share with us what you know about: 1.a. Child nutrition? (DO NOT PROMPT ONLY LISTEN SPECIFICALLY FOR: Breastfeeding /Poultry, fish, meat consumption/Vegetable and fruit consumption/Women eating while pregnant and breastfeeding) 1.b. Early childhood development? (DO NOT PROMPT ONLY LISTEN SPECIFICALLY FOR: Play, reading, singing, positive parenting) 1.c. Home gardening? (DO NOT PROMPT ONLY LISTEN SPECIFICALLY FOR: small animal raising, vegetables, fruit) 1.d. Water, sanitation and hygiene activities? (LISTEN SPECIFICALLY F DO NOT PROMPT ONLY LISTEN SPECIFICALLY FOR OR: handwashing, toilet use, food hygiene, and clean house) 2. Have you heard of the IECD (NEED KHMER WORD – how introduce the program to them?) activity? IF ANSWER NO THEN SKIP TO QUESTION 6 3. Could you please share with us what you know about the activities being implemented by the IECD activity? PROMPT: -Community Dialogues? -Peer Support? Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 106 -Caregiver Groups/Nurturing care sessions? -Home Visits? -Cooking demonstrations? -Village Model Farmer Activities? -Child Screenings for Disability, Development Delays and Nutrition? -Male Support Group? 4. Have you participated in an IECD activity? PROMPT: -What was the most recent activity? -How frequently would you say that you engage in an activity? -How often would you say that you see a VHSG? 5. Is there anything that you have learned from the IECD activity that you find: PROMPT: -Easy to put into practice? -Difficult to put into practice? -Do you think it will be easy to keep up the practice over time? 6. In your household or village, what is the role of the primary female caregiver and primary male caregiver in the household (e.g. parents/caregivers and/or grandparents/alternate caregivers)? PROMPTS: who tells stories to children? Feed children? Teach children new things? Bathe and toilet the children? Do both men and women engage with boy and girl children in the same way? 7. Is there a home garden at your grandchildren’s house? PROMPTS: -If yes, what are some of the things that are grown? -What is done with the food that is grown? Prompt: consume and/or sell at the market -If no, how do your grandchildren, women of reproductive age and pregnant women get food? -What types of food? -Does your family experience time’s of the year when you do not have food? -If yes, what do you do? -Is it more common for women to go without a meal than men when there is not enough food? 8. How do families with young children or with women of reproductive age and pregnant women access animal source proteins (e.g. eggs, fish, meat)? PROMPTS: -What are the most common types of animal source protein they consume? 9. Have they or you received support for agriculture inputs? -If yes, what? -If no, proceed to question 9. 10. What are families with young children or with women of reproductive age and pregnant women main source of income generation? 11. Who manages the household finances and makes decisions about what is purchased? PROMPTS: - Do men and women talk about finances? -Share money that is earned? Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 107 12. What are the practices in households with young children or with women of reproductive age and pregnant women for handwashing and use of the toilet (this will be checked with the household observation)? PROMPT: -Do you have regular access to clean water? -Do you buy it? -What are your thoughts about hygiene in the community and waste disposal? 13. In your village, do you know of any children who have been identified as having a disability or developmental delay? In no, skip to question 14. IF YES: Who do they seek out for support and services? - Do their families have access to the Health Center? Home gardens? Income generation activities? Referral and follow up for care for their children? 14. What do you see community volunteers (e.g. VHSG and CDL) doing in your village that are linked to the IECD activity? 15. Do the parents of your grandchildren work here or do they migrate for work? 16. What is your role in taking care of grandchildren? PROMPT: Tell stories to children? Feed Children? Teach children new things? Bathe and toilet the children? Do both men and women engage with boy and girl children in the same way? Caretaking? 17. Overall, could you share with us what you think is working with the IECD activity? -What is not working? -What could change? 18. Is there anything else that you would like to share with us today? NOW I HAVE A FEW MORE QUESTIONS TO ASK YOU THAT WILL REQUIRE SHORT AND QUICK ANSWERS. PROCEED TO THE MINI-SURVEY. ONCE THE MINI-SURVEY IS COMPLETE, FOLLOWING THE SKIP PATTERN, ASK THE RESPONDENT IF IT WOULD BE OKAY TO OBSERVE THEIR HAND WASHING STATION AND TOILET. PROCEED TO THE OBSERVATION CHECKLIST FOR HOUSEHOLDS. Please ask the person if they have any questions for the ET. Before the end of the interview, thank the person for the time and inputs in the evaluation and provide a copy of the evaluation postcard with additional information and contact details. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 108 KII INTERVIEW GUIDE: FEMALE AND MALE VHSG AND CDL Introduction: Hello, My name is _______. I am an independent consultant working with ME&A. USAID Cambodia has contracted with ME&A to conduct a mid-term performance evaluation of the IECD project’s first three years 2022 to 2023, as part of the USAID evaluation procedures. This is a routine process for all USAID￾funded project and information we collect will help USAID to plan their investments. We circulated an information card about this evaluation in anticipation of this interview. The interview will likely take about 90 minutes. If we are unable to finish today, I will be happy to call you again to complete the questions. Your participation is voluntary and you have the right to stop your participation at any time but we hope you will agree to answer the questions since your views are important. If I ask you any question you do not want to answer, just let me know and I will go on to the next question or you can stop the interview at any time. In case you need more information about the evaluation, you may contact the person listed on this card. The responses you provide will be kept confidential and we will list all respondents’ names, titles, and affiliations as part of the final report. The information will be disseminated in a final report and final presentation for USAID and partners. Do you have any questions? 1. Yes 2. No May I begin the interview now? 1. Yes 2. No May I have your name and title/role, please? (Interview begins here.) Study ID No. …………………… Village: ……………………………… Commune:…………………………… District:…………………………. Cohort 1 or 2 Participant’s name: ………………………………………………………………………………………………….. Position/Role: ……………………………………………………………………………………………………….. Organization: ………………………………………………………………………………………………………… Contact (in case additional info is needed): ………………………………………………………………………… Gender: Male Female Non-binary/other 1. Can you please share with us what you know about: 1.a. Child nutrition? (DO NOT PROMPT ONLY LISTEN SPECIFICALLY FOR: Breastfeeding /Poultry, fish, meat consumption/Vegetable and fruit consumption/Women eating while pregnant and breastfeeding) 1.b. Early childhood development? (DO NOT PROMPT ONLY LISTEN SPECIFICALLY FOR: Play, reading, singing, positive parenting) 1.c. Home gardening? (DO NOT PROMPT ONLY LISTEN SPECIFICALLY FOR: small animal raising, vegetables, fruit) 1.d. Water, sanitation and hygiene activities? (LISTEN SPECIFICALLY F DO NOT PROMPT ONLY LISTEN SPECIFICALLY FOR OR: handwashing, toilet use, food hygiene, and clean house) 2. Have you heard of the IECD (NEED KHMER WORD – how introduce the program to them?) activity? IF ANSWER NO THEN SKIP TO QUESTION 6 Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 109 3. Could you please share with us what you know about the activities being implemented by the IECD activity? PROMPT: Community Dialogues? Peer Support? Caregiver Groups/Nurturing care sessions? Home Visits? Cooking demonstrations? Village Model Farmer Activities? Child Screenings for Disability, Development Delays and Nutrition? Male Support Groups? 4. Have you participated in an IECD activity? PROMPTS: -What was the most recent activity? -How frequently would you say that you engage in an activity? -How often would you say that you see a VHSG? 5. Is there anything that you have learned from the IECD activity that you find: PROMPTS: -Easy to put into practice? -Difficult to put into practice? -Do you think it will be easy to keep up the practice over time? 6. How do you find the trainings and follow up activities for VHSG and CDL? 7. What support exists for VHSG and CDL to implement the IECD activities? PROMPT: : Community Dialogues? Peer Support? Caregiver Groups/Nurturing care sessions? Home Visits? Cooking demonstrations? Village Model Farmer Activities? Child Screenings for Disability, Development Delays and Nutrition? Male Support Group? 8. What works well with these activities? What challenges exist? What would you do the same? Differently? 9. Under the IECD activity, VHSG and CDL have been trained to complete MUAC and child disability and development delays screenings: -What is working for this? -What needs improvement? -What should change? 10. In your village, what is the role of the primary female caregiver and primary male caregiver in the household (e.g. parents/caregivers and/or grandparents/alternate caregivers)? PROMPTS: who tells stories to children? Feed children? Teach children new things? Bathe and toilet the children? Do both men and women engage with boy and girl children in the same way? 11. Are there home gardens in your village? PROMPTS: -If yes, what are some of the things that are grown? -What does the village do with the food that is grown in the home gardens? Prompt: consume and/or sell at the market -If no, how does the village get food? -What types of food? -Do family’s experience time’s of the year when they do not have food? -If yes, What do they do? -Is it more common for women to go without a meal than men when there is not enough food? 12. How does the village access animal source proteins (e.g. eggs, fish, meat)? PROMPTS: -What are the most common types of animal source protein you consume? 13. What is the main source of income generation for the village? Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 110 14. Who manages the household finances and makes decisions about what is purchased? PROMPTS: - Do men and women talk about finances? -Share money that is earned? 15. What are the practices in the village for handwashing and use of the toilet (this will be checked with the household observation)? PROMPT: Do you have regular access to clean water? Do you buy it? 16. In your village, do you know of any children who have been identified as having a disability or developmental delay? In no, skip to question 16 IF YES: Who do they seek out for support and services? - Do their families have access to the Health Center? Home gardens? Income generation activities? Referral and follow up for care for their children? 17. What is the role of grandparents with young children in your village? PROMPTS: Caregiving? Feeding? Taking them to school? Playing? Reading? Helping with bathing and bedtime? Toileting? 18. Overall, could you share with us what you think is working with the IECD activity? What is not working? What could change? 19. Is there anything else that you would like to share with us today? NOW I HAVE A FEW MORE QUESTIONS TO ASK YOU THAT WILL REQUIRE SHORT AND QUICK ANSWERS. PROCEED TO THE MINI-SURVEY. ONCE THE MINI-SURVEY IS COMPLETE, FOLLOWING THE SKIP PATTERN, ASK THE RESPONDENT IF IT WOULD BE OKAY TO OBSERVE THEIR HAND WASHING STATION AND TOILET. PROCEED TO THE OBSERVATION CHECKLIST FOR HOUSEHOLDS. Please ask the person if they have any questions for the ET. Before the end of the interview, thank the person for the time and inputs in the evaluation and provide a copy of the evaluation postcard with additional information and contact details. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 111 KII INTERVIEW GUIDE: CCWC/COMMUNE COUNCIL/COMMUNITY LEADERS Introduction: Hello, My name is _______. I am an independent consultant working with ME&A. USAID Cambodia has contracted with ME&A to conduct a mid-term performance evaluation of the IECD project’s first three years 2022 to 2023, as part of the USAID evaluation procedures. This is a routine process for all USAID￾funded project and information we collect will help USAID to plan their investments. We circulated an information card about this evaluation in anticipation of this interview. The interview will likely take about 90 minutes. If we are unable to finish today, I will be happy to call you again to complete the questions. Your participation is voluntary and you have the right to stop your participation at any time but we hope you will agree to answer the questions since your views are important. If I ask you any question you do not want to answer, just let me know and I will go on to the next question or you can stop the interview at any time. In case you need more information about the evaluation, you may contact the person listed on this card. The responses you provide will be kept confidential and we will list all respondents’ names, titles, and affiliations as part of the final report. The information will be disseminated in a final report and final presentation for USAID and partners. Do you have any questions? 1. Yes 2. No May I begin the interview now? 1. Yes 2. No May I have your name and title/role, please? (Interview begins here.) Study ID No. …………………… Village: ……………………………… Commune:…………………………… District:…………………………. Cohort 1 or 2 Participant’s name: ………………………………………………………………………………………………….. Position/Role: ……………………………………………………………………………………………………….. Contact (in case additional info is needed): ………………………………………………………………………… Gender: Male Female Non-binary/other 1. Can you please share with us what you know about: 1.a. Child nutrition? (DO NOT PROMPT ONLY LISTEN SPECIFICALLY FOR: Breastfeeding /Poultry, fish, meat consumption/Vegetable and fruit consumption/Women eating while pregnant and breastfeeding) 1.b. Early childhood development? (DO NOT PROMPT ONLY LISTEN SPECIFICALLY FOR: Play, reading, singing, positive parenting) 1.c. Home gardening? (DO NOT PROMPT ONLY LISTEN SPECIFICALLY FOR: small animal raising, vegetables, fruit) 1.d. Water, sanitation and hygiene activities? (LISTEN SPECIFICALLY F DO NOT PROMPT ONLY LISTEN SPECIFICALLY FOR OR: handwashing, toilet use, food hygiene, and clean house) 2. Have you heard of the IECD (NEED KHMER WORD – how introduce the program to them?) activity? IF ANSWER NO THEN SKIP TO QUESTION 6 Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 112 3. Could you please share with us what you know about the activities being implemented by the IECD activity? PROMPT: Community Dialogues? Peer Support? Caregiver Groups/Nurturing care sessions? Home Visits? Cooking demonstrations? Village Model Farmer Activities? Child Screenings for Disability, Development Delays and Nutrition? Male Support Groups? 4. Have you participated in an IECD activity? PROMPTS: -What was the most recent activity? -How frequently would you say that you engage in an activity? -How often would you say that you see a VHSG? 5. Is there anything that you have learned from the IECD activity that you find: PROMPTS: -Easy to put into practice? -Difficult to put into practice? -Do you think it will be easy to keep up the practice over time? 6. In your commune or village, what is the role of the primary female caregiver and primary male caregiver in the household (e.g. parents/caregivers and/or grandparents/alternate caregivers)? PROMPTS: who tells stories to children? Feed children? Teach children new things? Bathe and toilet the children? Do both men and women engage with boy and girl children in the same way? 7. In your Commune/Community, where do households get food? 8. Are households in this Commune/Community growing gardens at home? IF YES, what are some of the things that the households grow? 9. In your Commune/Community, how are household finances managed and decisions about what is purchased? PROMPT: Do men and women talk about finances? Share money that is earned? 10. In your Commune/Community, what do communities do to ensure adequate access to handwashing facilities and toilets? Hygiene and sanitation facilities? 11. In your Commune/Community, do you know of any children who have been identified as having a disability or developmental delay? IF YES: Do their families have access to the Health Center? Home gardens? Income generation activities? Referral and follow up for care for their children? Social protection funds? 12. The IECD activity has been supporting VHSG and CDL to complete screenings of children for disability, development delays and nutrition. Could you share with us what you see taking place with these activities? PROMPT: -What can improve? -What should be scaled up? 13. What is the role of grandparents and young children in your Commune/Community? 14. Has there been any discussions in your Commune or Community about how the Commune Investment Plan (CIP) can support any of the activities that have been discussed today? IF YES: what specifically has been discussed? -What challenges exist in preventing the CIP from absorbing the costs and facilitating more of the IECD activities? -Are there other activities that you wish IECD could have you supported you with in the handover of activities? Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 113 15. Overall, could you share with us what you think is working with the IECD activity? -What is not working? -What could change? 16. Is there anything else that you would like to share with us today? NOW I HAVE A FEW MORE QUESTIONS TO ASK YOU THAT WILL REQUIRE SHORT AND QUICK ANSWERS. PROCEED TO THE MINI-SURVEY. ONCE THE MINI-SURVEY IS COMPLETE, FOLLOWING THE SKIP PATTERN, ASK THE RESPONDENT IF IT WOULD BE OKAY TO OBSERVE THEIR HAND WASHING STATION AND TOILET. PROCEED TO THE OBSERVATION CHECKLIST FOR HOUSEHOLDS. Please ask the person if they have any questions for the ET. Before the end of the interview, thank the person for the time and inputs in the evaluation and provide a copy of the evaluation postcard with additional information and contact details Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 114 FOCUS GROUP DISCUSSIONS FGD INTERVIEW GUIDE: WOMEN Introduction: Hello, My name is _______. I am an independent consultant working with ME&A. USAID Cambodia has contracted with ME&A to conduct a mid-term performance evaluation of the IECD project’s first three years 2022 to 2023, as part of the USAID evaluation procedures. This is a routine process for all USAID￾funded projects and information we collect will help USAID to plan their investments. We circulated an information card about this evaluation in anticipation of this interview. The interview will likely take about 90 minutes. If we are unable to finish today, I will be happy to call you again to complete the questions. Your participation is voluntary and you have the right to stop your participation at any time but we hope you will agree to answer the questions since your views are important. If I ask you any question you do not want to answer, just let me know and I will go on to the next question or you can stop the interview at any time. In case you need more information about the evaluation, you may contact the person listed on this card. The responses you provide will be kept confidential and we will list all respondents’ names, titles, and affiliations as part of the final report. The information will be disseminated in a final report and final presentation for USAID and partners. Do you have any questions? 1. Yes 2. No May I begin the interview now? 1. Yes 2. No May I have your name and title/role, please? (Interview begins here.) Study ID No. ………………………… Village: ……………………………… Commune:…………………………… District:…………………………. Cohort 1 or 2 Participant’s name: ………………………………………………………………………………………………….. Contact (in case additional info is needed): ………………………………………………………………………… Assign the following numbers to each participant for note taking: 1 2 3 4 5 6 7 8 9 10 BEGIN TO COMPLETE THE MINI-SURVEY WITH PARTICIPANTS WHO HAVE ARRIVED BEFORE THE START OF THE FGD The following questions will be used to begin the activity of the timeline approach: 1. Can you please share with us what you know about the IECD Activity? -Start with COVID, had the activity begun when there was COVID-19? -What was it like when COVID restrictions eased? -Last Khmer New Year? -Last Pchum Ben? -Does your village currently participate in IECD activities? 2. What are things being done in your community to support the growth and development needs of young child? 3. If your village is or has implemented IECD activities could you please share with us what some of the activities are that you see/saw being implemented? If your village has not implemented IECD activities, please share with us what you know about child nutrition, early childhood development, home gardening and/or water, sanitation and hygiene activities? Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 115 4. Thinking specifically about some of the IECD activities or any experience you have had with similar activities, could you please share with us what you know about: PROMPTS: o Caregiver groups, community dialogues and home visits? o Nurturing care sessions? o Cooking demonstrations? o Village Model Farmer Activities? o Child Screenings for Disability, Development Delays and Nutrition? Peer Support? Community Dialogues? 5. In your village, who is responsible for the following: PROMPTS: Telling stories to children? Feeding children? Teaching children new things? Bathing and toileting children? IF MEN ARE NOT MENTIONED FOLLOW UP WITH: How are men engaged with caregiving or helping at home? 6. If there are home gardens in your village, how do households use the gardens to enable access to food for the family, particularly young children? PROMPT: Who is responsible for the gardens? 7. Could you share how families earn an income and who might manage the money from the sale of food grown by the family? PROMPT: Do families rely on the sale of items from their home gardens for an income? 8. When it comes to home gardening, income generation, child nutrition, and water, sanitation and hygiene in the home, does the role of women and men differ? PROMPTS: Is it the same? Can you please explain how it may differ or be the same? 9. Could you share with us what the practices are in your village for handwashing and use of the toilet? 10. In your communities, children who might have a disability or developmental delay, do their families have access to home gardens? Income generation activities? 11. VHSG and CDL have been trained in some villages to complete screenings of children for disability, developmental delays and nutrition. Could you share with us what you see taking place with these activities? 12. For families whose children are identified as having a disability or developmental delay, could you share with us what you know about their access to IECD activities particularly home gardens? Income generating activities? Referral? Follow up and support at home? 13. Overall, could you share with us what you think is working with the IECD activity or with any of the topics discussed today if you are not familiar with the IECD activity? What is not working? What could change? 14. Is there anything else that you would like to share with us today? DO NOT FORGET TO THANK EVERYONE FOR THERE TIME BEFORE YOU PROCEED TO FINISH COMPLETING THE MINI-SURVEY WHO RESPONDENTS WHO HAVE NOT BEEN INTERVIEWED. Please ask the person if they have any questions for the ET. Before the end of the interview, thank the person for the time and inputs in the evaluation and provide a copy of the evaluation postcard with additional information and contact details Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 116 FGD INTERVIEW GUIDE: MEN Introduction: Hello, My name is _______. I am an independent consultant working with ME&A. USAID Cambodia has contracted with ME&A to conduct a mid-term performance evaluation of the IECD project’s first three years 2022 to 2023, as part of the USAID evaluation procedures. This is a routine process for all USAID￾funded project and information we collect will help USAID to plan their investments. We circulated an information card about this evaluation in anticipation of this interview. The interview will likely take about 90 minutes. If we are unable to finish today, I will be happy to call you again to complete the questions. Your participation is voluntary and you have the right to stop your participation at any time but we hope you will agree to answer the questions since your views are important. If I ask you any question you do not want to answer, just let me know and I will go on to the next question or you can stop the interview at any time. In case you need more information about the evaluation, you may contact the person listed on this card. The responses you provide will be kept confidential and we will list all respondents’ names, titles, and affiliations as part of the final report. The information will be disseminated in a final report and final presentation for USAID and partners. Do you have any questions? 1. Yes 2. No May I begin the interview now? 1. Yes 2. No May I have your name and title/role, please? (Interview begins here.) Study ID No. …………………… Village: ……………………………… Commune:…………………………… District:…………………………. Cohort 1 or 2 Participant’s name: ………………………………………………………………………………………………….. Age of their youngest child: ………….. Contact (in case additional info is needed): ………………………………………………………………………… Assign the following numbers to each participant for note taking: 1 2 3 4 5 6 7 8 9 10 BEGIN TO COMPLETE THE MINI-SURVEY WITH PARTICIPANTS WHO HAVE ARRIVED BEFORE THE START OF THE FGD The following questions will be used to begin the activity of the timeline approach: 1. Can you please share with us what you know about the IECD Activity? -Start with COVID, had the activity begun when there was COVID-19? -What was it like when COVID restrictions eased? -Last Khmer New Year? -Last Pchum Ben? -Does your village currently participate in IECD activities? 2. What are things being done in your community to support the growth and development needs of young child? 3. For how much of the year, do men reside in your village and with their family’s? PROMPT: Do they migrate for work? Where? In Cambodia or out? Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 117 4. If your village is or has implemented IECD activities could you please share with us what some of the activities are that you see/saw being implemented? If your village has not implemented IECD activities, please share with us what you know about: -Child nutrition? Early childhood development? Home gardening? WASH? 5. Thinking specifically about some of the IECD activities or any experience you have had with similar activities, could you please share with us what you know about: o Caregiver groups and home visits? o Nurturing care sessions? o Cooking demonstrations? o Village Model Farmer Activities? o Child Screenings for Disability, Development Delays and Nutrition? Peer Support? Community Dialogues? 6. In your village, how are men involved in activities in the home? PROMPT: Cleaning? Cooking? Reading to children? Playing with Children? Feeding children? Bathing and toileting children? 7. If there are home gardens in your village, how do households use the gardens to enable access to food for the family, particularly young children, women of reproductive age and pregnant women? 8. Could you share how families earn an income from their gardens and who might manage the money from the sale of food grown by the family? PROMPT: Who manages money overall? 9. When it comes to home gardening, income generation, child nutrition, and water, sanitation and hygiene in the home, does the role of women and men differ? PROMPT: Is it the same? Can you please explain how it may differ or be the same? 11. Could you share with us what the practices are in your village for handwashing and use of the toilet? Hygiene and waste disposal? 12. In your communities, children who might have a disability or developmental delay, do their families have access to home gardens? Income generation activities? 13. VHSG and CDL have been trained in some villages to complete screenings of children for disability, developmental delays and nutrition. Could you share with us what you see taking place with these activities? 14. For families whose children are identified as having a disability or developmental delay, could you share with us what you know about their access to IECD activities particularly home gardens? Income generating activities? Referral? Follow up and support at home? 15. Are there other ways that men support the growth and development of children in your households and villages? 16. Overall, could you share with us what you think is working with the IECD activity or with any of the topics discussed today if you are not familiar with the IECD activity? What is not working? What could change? 17. Is there anything else that you would like to share with us today? DO NOT FORGET TO THANK EVERYONE FOR THERE TIME BEFORE YOU PROCEED TO FINISH COMPLETING THE MINI-SURVEY WHO RESPONDENTS WHO HAVE NOT BEEN INTERVIEWED. Please ask the person if they have any question for the ET. Before the end of the interview, thank the person for the time and inputs in the evaluation and provide a copy of the evaluation postcard with additional information and contact details. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 118 FGD INTERVIEW GUIDE: PARENTS OF CLDDD Introduction: Hello, My name is _______. I am an independent consultant working with ME&A. USAID Cambodia has contracted with ME&A to conduct a mid-term performance evaluation of the IECD project’s first three years 2022 to 2023, as part of the USAID evaluation procedures. This is a routine process for all USAID￾funded project and information we collect will help USAID to plan their investments. We circulated an information card about this evaluation in anticipation of this interview. The interview will likely take about 90 minutes. If we are unable to finish today, I will be happy to call you again to complete the questions. Your participation is voluntary and you have the right to stop your participation at any time but we hope you will agree to answer the questions since your views are important. If I ask you any question you do not want to answer, just let me know and I will go on to the next question or you can stop the interview at any time. In case you need more information about the evaluation, you may contact the person listed on this card. The responses you provide will be kept confidential and we will list all respondents’ names, titles, and affiliations as part of the final report. The information will be disseminated in a final report and final presentation for USAID and partners. Do you have any questions? 1. Yes 2. No May I begin the interview now? 1. Yes 2. No May I have your name and title/role, please? (Interview begins here.) Study ID No. …………………… Village: ……………………………… Commune:…………………………… District:…………………………. Cohort 1 or 2 Participant’s name: ………………………………………………………………………………………………….. Age of their child living with disability/ developmental delay: ………….. Contact (in case additional info is needed): ………………………………………………………………………… Gender: Male Female Non-binary/other Assign the following numbers to each participant for note taking: 1 2 3 4 5 6 7 8 9 10 BEGIN TO COMPLETE THE MINI-SURVEY WITH PARTICIPANTS WHO HAVE ARRIVED BEFORE THE START OF THE FGD The following questions will be used to begin the activity of the timeline approach: 1. Can you please share with us what you know about the IECD Activity? -Start with COVID, had the activity begun when there was COVID-19? -What was it like when COVID restrictions eased? -Last Khmer New Year? -Last Pchum Ben? -Does your village currently participate in IECD activities? 2. If your village is or has implemented IECD activities could you please share with us what some of the activities are that you saw/see being implemented? If your village has not implemented IECD activities, please share with us what you know about: -Child nutrition? Early childhood development? Home gardening? WASH? Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 119 3. Thinking specifically about some of the IECD activities or any experience you have had with similar activities, could you please share with us what you know about: o Home visits? o Nurturing care sessions/ Caregiver groups? o Cooking demonstrations? o Village Model Farmer Activities? o Child Screenings for Disability, Development Delays and Nutrition? o Peer support? o Community dialogues? o Male support groups? 4. When you think about the needs of young children particularly those living with disability and developmental delays, what are things that support your community most in being able to respond to the growth and development needs of these young children? 5. In your village, how are men involved in activities at home when there is a child living with a disability/developmental delay (CLDDD)? PROMPT: Cleaning? Cooking? Reading to children? Playing with Children? Feeding children? Bathing and toileting children? 6. If there are home gardens in your village, are they accessible for parents of CLDDD as a means to enable access to food for the family particularly young children? PROMPT: If they are not accessible, why? 7. What are ways that families who have CLDDD earn an income? PROMPTS: From their gardens? Other? Who might manage the money? Is it the same person if the money comes from the sale of food? 8. When it comes to home gardening, income generation, child nutrition, and water, sanitation and hygiene in the home, does the role of women and men differ when there is a CLDDD? PROMPTS: Is it the same? Can you please explain how it may differ or be the same If you see differences in households with CLDDD, are they positive or negative differences? 9. Could you share with us what are the practices in your village for handwashing and use of the toilet particularly with CLDDD? PROMPT: Are modifications required and being made to ensure CLDDD can access handwashing stations and toilets? 10. VHSG and CDL have been supported to complete screenings of children for disability, development delays and nutrition. Could you share with us what you see taking place with these activities? PROMPT: Are children being screened by a VHSG or CDL? If yes, what happens next to the family and children? What happens to families who do not qualify for an intervention under the IECD project? And, why do they not qualify? 11. Could you share with us how the identification and screening processes are going in your village or community? 12. For families whose children are identified as having a disability or developmental delay, could you share with us overall what you know about their: PROMPT: Access to IECD activities particularly home gardens? Income generating activities? Referral? Follow up and support at home? 13. Do you know of families that have been referred to Angkor Children’s Hospital? PROMPTS: Was the referral successful, if not why? Who supported them in the process Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 120 14. Has anyone followed up with you and your family regarding your child’s disability and developmental needs? 15. Are families who identify as ID Poor, are they receiving any reimbursements through the social protection fund? PROMPT: What are the reimbursements covering? Transportation? 16. Could you share with us how you identify as eligible for social protection funds? PROMPT: What is the process to access the funds? Do the funds cover the services that you are seeking? 17. What do you think is the best thing being done at the moment for families who have children living with a disability, developmental delay? PROMPT: What more can be done for these families? 18. Overall, could you share with us what you think is working with the IECD activity or with any of the topics discussed today if you are not familiar with the IECD activity? What is not working? What could change? 19. Is there anything else that you would like to share with us today? DO NOT FORGET TO THANK EVERYONE FOR THERE TIME BEFORE YOU PROCEED TO FINISH COMPLETING THE MINI-SURVEY WHO RESPONDENTS WHO HAVE NOT BEEN INTERVIEWED. Please ask the person if they have any questions for the ET. Before the end of the interview, thank the person for the time and inputs in the evaluation and provide a copy of the evaluation postcard with additional information and contact details. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 121 FGD INTERVIEW GUIDE: GRANDPARENTS/ ALTERNATE CAREGIVERS Introduction: Hello, My name is _______. I am an independent consultant working with ME&A. USAID Cambodia has contracted with ME&A to conduct a mid-term performance evaluation of the IECD project’s first three years 2022 to 2023, as part of the USAID evaluation procedures. This is a routine process for all USAID￾funded project and information we collect will help USAID to plan their investments. We circulated an information card about this evaluation in anticipation of this interview. The interview will likely take about 90 minutes. If we are unable to finish today, I will be happy to call you again to complete the questions. Your participation is voluntary and you have the right to stop your participation at any time but we hope you will agree to answer the questions since your views are important. If I ask you any question you do not want to answer, just let me know and I will go on to the next question or you can stop the interview at any time. In case you need more information about the evaluation, you may contact the person listed on this card. The responses you provide will be kept confidential and we will list all respondents’ names, titles, and affiliations as part of the final report. The information will be disseminated in a final report and final presentation for USAID and partners. Do you have any questions? 1. Yes 2. No May I begin the interview now? 1. Yes 2. No May I have your name and title/role, please? (Interview begins here.) Study ID No. …………………… Village: ……………………………… Commune: …………………………… District: …………………………. Cohort 1 or 2 Participant’s name: ………………………………………………………………………………………………….. Age of their youngest grandchild: ………….. Contact (in case additional info is needed): ………………………………………………………………………… Gender: Male Female Non-binary/other Assign the following numbers to each participant for note taking: 1 2 3 4 5 6 7 8 9 10 BEGIN TO COMPLETE THE MINI-SURVEY WITH PARTICIPANTS WHO HAVE ARRIVED BEFORE THE START OF THE FGD The following questions will be used to begin the activity of the timeline approach: 1. Can you please share with us what you know about the IECD Activity? -Start with COVID, had the activity begun when there was COVID-19? -What was it like when COVID restrictions eased? -Last Khmer New Year? -Last Pchum Ben? -Does your village currently participate in IECD activities? 2. What are things being done in your community to support the growth and development needs of young child? 3. If your village is or has implemented IECD activities could you please share with us what some of the activities that you saw/see being implemented? If your village has not implemented IECD activities, please share with us what you know about: -Child nutrition? Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 122 -Early childhood development? -Home gardening? -Water, sanitation and hygiene activities? 4. Thinking specifically about some of the IECD activities or any experience you have had with similar activities. Could you please share with us what you know about?: o Home visits? o Nurturing care sessions/ caregiver groups? o Cooking demonstrations? o Village Model Farmer Activities? o Child Screenings for Disability, Development Delays and Nutrition? o Peer support? o Community dialogues? o Male support groups? 4. When you think about the needs of young children, what are things that support your community most in being able to respond to the growth and development needs of young child? 5. In your village, how are grandparents/ alternate caregivers involved in: PROMPTS: Telling stories to children? Feeding children? Teaching children new things? Bathing and toileting children? Does it differ with how they engage boys and girls? 6. As a grandparent/alternate caregiver, how does your role differ or remain the same from a primary caregiver or parent? 7. If there are home gardens in your village, how do households use the gardens to enable access to food for the family, particularly young children, women of reproductive age and pregnant women? PROMPT: Do any of you have a role in home gardening? 8. Could you share how families earn an income from their gardens and who might manage the money from the sale of food grown by the family? 9. When it comes to home gardening, income generation, child nutrition, and water, sanitation and hygiene in the home, what are the roles of adults in the household including yourself? PROMPT: -Do they differ particularly between men and women? -If a grandparent or alternate caregiver does not live with the family, what are their roles if any in the household of their grandchildren/ young children they help to take of? 10. Could you share with us what the practices are in households where young children, women of reproductive age and pregnant women live for handwashing and use of the toilet? PROMPT: Have you seen them change over time? What are your thoughts about hygiene in the community and waste disposal? 11. In your communities, children who might have a disability or developmental delay, do their families have access to home gardens? PROMPT: Income generation activities? Does a grandparent or alternative caregivers role differ? Remain the same from a household where children have special abilities? 12. The IECD activity has been supporting VHSG and CDL to complete screenings of children for disability, development delays and nutrition. Could you share with us what you see taking place with these activities? 13. For families whose children are identified as having a disability or development delay, could you share with us what you know about their access to IECD activities particularly home gardens? Income generating activities? Referral? Follow up and support at home? Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 123 14. Could you share with us how you see the role of parenting changing or remaining the same? PROMPT: Are you helping more with the care of young children or less? 15. Do you think mothers are receiving the support they need to effectively parent? PROMPT: Are men helping or is it more that grandparents or other people in the community are helping? 16. What more do you think needs to be done to ensure children are: PROMPT: -Well fed? -Taught to read, play, etc? -Can take forward important knowledge from your community? 17. Overall, could you share with us what you think is working with the IECD activity or with any of the topics discussed today if you are not familiar with the IECD activity? What is not working? What could change? 18. Is there anything else that you would like to share with us today? DO NOT FORGET TO THANK EVERYONE FOR THERE TIME BEFORE YOU PROCEED TO FINISH COMPLETING THE MINI-SURVEY WHO RESPONDENTS WHO HAVE NOT BEEN INTERVIEWED. Please ask the person if they have any questions for the ET. Before the end of the interview, thank the person for the time and inputs in the evaluation and provide a copy of the evaluation postcard with additional information and contact details. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 124 FGD INTERVIEW GUIDE: VHSG AND CDL Introduction: Hello, My name is _______. I am an independent consultant working with ME&A. USAID Cambodia has contracted with ME&A to conduct a mid-term performance evaluation of the IECD project’s first three years 2022 to 2023, as part of the USAID evaluation procedures. This is a routine process for all USAID￾funded project and information we collect will help USAID to plan their investments. We circulated an information card about this evaluation in anticipation of this interview. The interview will likely take about 90 minutes. If we are unable to finish today, I will be happy to call you again to complete the questions. Your participation is voluntary and you have the right to stop your participation at any time but we hope you will agree to answer the questions since your views are important. If I ask you any question you do not want to answer, just let me know and I will go on to the next question or you can stop the interview at any time. In case you need more information about the evaluation, you may contact the person listed on this card. The responses you provide will be kept confidential and we will list all respondents’ names, titles, and affiliations as part of the final report. The information will be disseminated in a final report and final presentation for USAID and partners. Do you have any questions? 1. Yes 2. No May I begin the interview now? 1. Yes 2. No May I have your name and title/role, please? (Interview begins here.) Study ID No. ………………………….. Village: ……………………………… Commune:…………………………… District:…………………………. Cohort 1 or 2 Participant’s name: ………………………………………………………………………………………………….. Position/Role: ……………………………………………………………………………………………………….. Organization: ………………………………………………………………………………………………………… Contact (in case additional info is needed): ………………………………………………………………………… Gender: Male Female Non-binary/other Assign the following numbers to each participant for note taking: 1 2 3 4 5 6 7 8 9 10 The following questions will be used to begin the activity of the timeline approach: 1. Can you please share with us what you know about the IECD Activity? -Start with COVID, had the activity begun when there was COVID-19? -What was it like when COVID restrictions eased? -Last Khmer New Year? -Last Pchum Ben? -Does your village currently participate in IECD activities? 2. If your village is or has implemented IECD activities could you please share with us what some of the activities are that you see being implemented? If your village has not implemented IECD activities, please share with us what you know about: -Child nutrition? -Early childhood development? -Home gardening? -Water, sanitation and hygiene activities? Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 125 3. Thinking specifically about some of the IECD activities or any experience you have had with similar activities, could you please share with us what you know about: o Caregiver groups, community dialogues and home visits? o Nurturing care sessions? o Cooking demonstrations? o Village Model Farmer Activities? o Child Screenings for Disability, Development Delays and Nutrition? Peer Support? Community Dialogues? o Male Support Groups? 4. When you think about the needs of young children, what are things specifically that you do in your community to respond to the growth and development needs of young children? 5. In the villages where you work, what are the roles of men and women? PROMPT: Do they differ? How? Are they the same? How? 6. If there are home gardens in your village, how do households use the gardens to enable access to food for the family particularly young children? 7. Could you share how families earn an income from their gardens and who might manage the money from the sale of food grown by the family? 8. Could you share with us what the practices are in your village for handwashing and use of the toilet? 9. In your communities, children who might have a disability or developmental delay, do their families have access to home gardens? Income generation activities? 11. The IECD activity has been supporting VHSG and CDL to complete screenings of children for disability, development delays and nutrition. Could you share with us what your experience has been like participating in these activities? PROMPTS: Where the trainings useful or not? How? Could you discuss the supervision and mentoring you receive? What works? What does not? What could be improved? 12. Overall, could you share with us what you think is: -Working with the IECD activity? -What is not working? -What could change? 13. Is there anything else that you would like to share with us today? 14. Now we would like to observe you completing a disability and MUAC screening. You will work with the person next to you. Our evaluation team (ET) will walk around the room observing you and making notes. ET: Refer to observation checklists. PROCEED TO THE OBSERVATION Please ask the person if they have any questions for the ET. Before the end of the interview, thank the person for the time and inputs in the evaluation and provide a copy of the evaluation postcard with additional information and contact details Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 126 FGD INTERVIEW GUIDE: CCWC, COMMUNE, COMMUNITY LEADERS Introduction: Hello, My name is _______. I am an independent consultant working with ME&A. USAID Cambodia has contracted with ME&A to conduct a mid-term performance evaluation of the IECD project’s first three years 2022 to 2023, as part of the USAID evaluation procedures. This is a routine process for all USAID￾funded projects and information we collect will help USAID to plan their investments. We circulated an information card about this evaluation in anticipation of this interview. The interview will likely take about 90 minutes. If we are unable to finish today, I will be happy to call you again to complete the questions. Your participation is voluntary and you have the right to stop your participation at any time but we hope you will agree to answer the questions since your views are important. If I ask you any question you do not want to answer, just let me know and I will go on to the next question or you can stop the interview at any time. In case you need more information about the evaluation, you may contact the person listed on this card. The responses you provide will be kept confidential and we will list all respondents’ names, titles, and affiliations as part of the final report. The information will be disseminated in a final report and final presentation for USAID and partners. Do you have any questions? 1. Yes 2. No May I begin the interview now? 1. Yes 2. No May I have your name and title/role, please? (Interview begins here.) Study ID No. …………………… Village: ……………………………… Commune:…………………………… District:…………………………. Cohort 1 or 2 Participant’s name: ………………………………………………………………………………………………….. Position/Role: ……………………………………………………………………………………………………….. Organization: ………………………………………………………………………………………………………… Contact (in case additional info is needed): ………………………………………………………………………… Gender: Male Female Non-binary/other Assign the following numbers to each participant for note taking: 1 2 3 4 5 6 7 8 9 10 BEGIN TO COMPLETE THE MINI-SURVEY WITH PARTICIPANTS WHO HAVE ARRIVED BEFORE THE START OF THE FGD The following questions will be used to begin the activity of the timeline approach: 1. Can you please share with us what you know about the IECD Activity? -Start with COVID, had the activity begun when there was COVID-19? -What was it like when COVID restrictions eased? -Last Khmer New Year? -Last Pchum Ben? -Does your village currently participate in IECD activities? Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 127 2. If your commune or community is or has implemented IECD activities could you please share with us what some of the activities are that you saw/see being implemented? If your commune or community has not implemented IECD activities, please share with us what you know about child nutrition, early childhood development, home gardening and/or water, sanitation and hygiene activities? 3. Thinking specifically about some of the IECD activities or any experience you have had with similar activities, could you please share with us what you know about: PROMPTS: o Trainings? o Home visits? o Nurturing care sessions/ Caregiver groups? o Cooking demonstrations? o Village Model Farmer Activities? o Child Screenings for Disability, Development Delays and Nutrition? Peer Support? Community Dialogues? o Male Support Groups? o Monitoring and Evaluation? 4. When you think about the needs of young children, what are things that support your commune or community most in being able to respond to the growth and development needs of young children? 5. In your commune or community, who is responsible for the following:: PROMPTS: Telling stories to children? Feeding children? Teaching children new things? Bathing and toileting children? IF MEN ARE NOT MENTIONED FOLLOW UP WITH: How are men engaged with caregiving or helping at home? 8. . In your Commune/Community, where do households get food? 9. Are households in this Commune/Community growing gardens at home? IF YES, what are some of the things that you grow? 10. In your Commune/Community, how are household finances managed and decisions about what is purchased? PROMPT: Do men and women talk about finances? Share money that is earned? 11. In your Commune/Community, what do communities do to ensure adequate access to handwashing facilities and toilets? 12. In your Commune/Community, do you know of any children who have been identified as having a disability or developmental delay? IF YES: Do their families have access to the Health Center? Home gardens? Income generation activities? Referral and follow up for care for their children? 11. VHSG and CDL have been trained in some villages to complete screenings of children for disability, developmental delays and nutrition. Could you share with us what you see taking place with these activities? 12. For families whose children are identified as having a disability or developmental delay, could you share with us what you know about their access to IECD activities particularly home gardens? Income generating activities? Referral? Follow up and support at home? Social Protection Fund? 13. Has there been any discussions in your Commune or Community about how the Commune Investment Plan (CIP) can support any of the activities that have been discussed today? IF YES: what specifically has been discussed? Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 128 -What challenges exist in preventing the CIP from absorbing the costs and facilitating more of the IECD activities? -Are there other activities that you wish IECD could have you supported you with in the handover of activities? 14. Overall, could you share with us what you think is working with the IECD activity or with any of the topics discussed today if you are not familiar with the IECD activity? What is not working? What could change? 15. Is there anything else that you would like to share with us today? DO NOT FORGET TO THANK EVERYONE FOR THERE TIME BEFORE YOU PROCEED TO FINISH COMPLETING THE MINI-SURVEY WHO RESPONDENTS WHO HAVE NOT BEEN INTERVIEWED. Please ask the person if they have any questions for the ET. Before the end of the interview, thank the person for the time and inputs in the evaluation and provide a copy of the evaluation postcard with additional information and contact details. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 129 OBSERVATIONS OBSERVATION: VHSG AND CDL *INFORMED CONSENT WILL HAVE BEEN OBTAINED AT THE START OF THE FGD. Study Identification Number: FGD – XXX – XXX – CX – XXX Assign a number of 1 to 10 for each FGD participant. Please circle the number of the participant(s) observed: 1 2 3 4 5 6 7 8 9 10 Guidance for completing the observations: As you set up the interviews with VHSG and CDL please ask them to bring their tablet and MUAC tapes with them to the interview Below are observation checklists for the VHSG and CDL screening tools CBDMAT and MUAC. Also for the household observations for home gardens and WASH. Please observe the indicator in the first column and mark your observations as: Yes - I observed the VHSG or CDL complete this step of the screening No - I did not observe the VHSG or CDL complete this step of the screening I don’t know - I don’t know if the VHSG or CDL completed this step of the screening Not available - Reporting is not relevant for this indicator Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 130 VHSG AND CDL 1. Child Disability and Development Screening: INDICATOR RESPONSE YES NO DON’T KNOW NOT AVAILABLE 1. Obtain verbal consent 2. Indicate the following: -Screening date -Child’s name -Child’s date of birth 3. Can name the four categories on the cDMAT 3.1. Social/personal 3.2. Fine motor 3.3. Language/cognition 3.4. Gross motor 4. Can identify where to start the survey based on the age of the child 5. Understands and follows the prompts in the CommCare App 6. The assessor indicates the child’s performance – refer or not Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 131 2. MUAC Screening67, 68: INDICATOR RESPONSE YES NO DON’T KNOW NOT AVAILABLE 1. CONSENT TAKEN Check the following: -Screening date -Child’s name -Child’s sex -Child’s date of birth 2. EXPLAIN THE OPTIONS IN THE REPORTING APP 1. Band is right side up 2. Arm of the person to be screened is properly measured for placement of the band (the band should be fitted at the mid way point between the shoulder joint bone and elbow bone) 3. Strap is inserted correctly to make a cuff around the arm and so the screener can read the mark correctly 4. The cuff should be snug against the skin and not tight 5. The mark is aligned 6. Score is reported correctly:If the score is less than 120 mm or 125 mm for children 6 to 59 months, then the child is referred Yellow, Red or Green 67 Laillou A, Prak S, de Groot R, Whitney S, Conkle J, et al. (2014) Optimal Screening of Children with Acute Malnutrition Requires a Change in Current WHO Guidelines as MUAC and WHZ Identify Different Patient Groups. PLoS ONE 9(7): e101159. doi:10.1371/journal.pone.0101159 68 UNICEF. (2020). Guidance Note: New Design for the Mid-Upper Arm Circumference (MUAC) Tape Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 132 HOUSEHOLDS 1. Household Observation: INDICATOR RESPONSE YES NO DON’T KNOW NOT AVAILABLE 1. Home garden is in place within a reasonable distance of the home 2. Vegetables are being grown in the home grown 3. Fruit is grown in the home garden or on the property 4. A handwashing station exists 5. There is soap at the hand washing station 6. Person observed can name at least three key times to wash hands 7. There is an improved toilet for common use of the household 8. Water for consumption is treated (e.g. filter, boiled, clean container) 9. Water for consumption is properly stored 10. Waste has been properly disposed 11. No animal feces or other dirt is present on the floor where children are playing 12. Raw food is stored properly in a location away from animals, the floor or other contaminants Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 133 MINI-SURVEYS MINI-SURVEY: WOMEN Study Identification Number: KII – XXX – XXX – CX – XXX Age of youngest child: …………. *INFORMED CONSENT WILL HAVE BEEN OBTAINED AT THE START OF THE KII OR FGD 1. Do you qualify for ID Poor? Yes ߀ No ߀ ߀ Do not know 2. Have you heard about the IECD Activity? (IF NO SKIP TO QUESTION 9) Yes ߀ No ߀ ߀ Do not know 3. What are some of the activities that the IECD Activity has been doing (wait for them to respond then follow up by reading off each activity. Check all that apply)? Training ߀ ߀ Home visits ߀ Nurturing Care Session/Caregiver Groups ߀ Cooking Demonstrations ߀ Village Model Farmer Activities ߀ Community Dialogue ߀ Male Caregiver Group ߀ Peer Support for PLDDD ߀ Community Dialogue Group ߀ Child Disability and Developmental Screenings ߀ Child Nutrition Screening ߀ Identified for Referral for Disability, Development Delay or Malnutrition ߀ Other (Please Specify): _____________ 4. Have you participated in an IECD activity in the community? Yes ߀ No ߀ ߀ Do not know ߀ If yes, which one: ____________________ 5. Have you participated in an IECD activity at home? Yes ߀ No ߀ ߀ Do not know ߀ If yes, which one: ____________________ 6. When was the last time that you engaged in an IECD activity? ߀ Last week Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 134 ߀ Last two weeks ߀ Last month ߀ Six months ago ߀ One year ago ߀ Other: specify_______________ ߀ I do not know 7. On average how often do you engage with an IECD activity? ߀ Every week ߀ Every two weeks ߀ Every month ߀ Every six months ߀ Other: specify_______________ ߀ I do not know 8. Can you name for me a topic from an IECD activity (the interviewer from the ET will check all that apply)? Language ߀ Play ߀ Reading ߀ ߀ Early stimulation ߀ Stunting/Nutrition Handwashing ߀ ߀ Toilet use ߀ Hygiene at home ߀ Home gardens ߀ Access to Markets Cooking ߀ ߀ Safe food preparation ߀ Responsive feeding ߀ Early initiation of breastfeeding Breastfeeding߀ ߀Dietary diversity for pregnant women ߀Minimum acceptable diet for children 6 to 23 months ߀Child disability screening ߀Child development screening ߀MUAC/ Child nutrition screening ߀Other (Please Specify): _____________ 9. If you are not familiar with the IECD Activity, what types of children nutrition, health, education or protection activities have been taking place in your community (check all that apply)? ߀ Caregiver Groups ߀ Nurturing Care Session ߀ Cooking Demonstrations ߀ Village Model Farmer Activities ߀ Child Disability and Developmental Screenings ߀ Child Nutrition Screening (MUAC) ߀ Identified for Referral for Disability, Development Delay or Malnutrition Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 135 ߀ Monitoring and reporting ߀ Other (Please Specify): _____________ 10. Can you please tell me if the following statements are true, false or don’t know for positive key behaviors toward nutrition (check all that apply)? No. Statement True False Don’t Know 10.1 . Pregnant and breastfeeding mothers should eat 4 healthy meals per day of diverse foods 10.2 . Pregnant mother and postpartum women must take iron and folic acid minerals 10.3 . Breastmilk only should be given to a child until 6 months of age 10.4 . Breastmilk is important because it can protect a child against illness 10.5 . Solid foods should be introduced at 6 months (e.g. chopped boiled egg, mashed meat/potato, porridge) 10.6 . Family foods can be introduced at 24 months 10.7 . Responsive feeding is what a caregiver pays attention and responds consistently to a child’s hunger and satiation cues 11. Can you please tell me if the following statements are true, false or don’t know for positive key behaviors toward safety and security (check all that apply)? No. Statement True False Don’t Know 11.1. Reduce stress 11.2. Avoid abusing your child, neglect, violently punishing your child 11.3. Keep your environment at home safe 11.4. Avoid domestic violence 11.5. Listen before you react to your child 11.6. Model, teach and remind children of good behavior 11.7. Provide clear rules and expectations 11.8. Reward positive behavior 11.9. Provide adequate supervision and monitoring 12. In the last 24 hours from what food groups did you (WRA and PW) consume/eat (check all that apply)? ߀ Grains, roots, tubers and plantains (e.g. rice, cassava) ߀ Pulses (beans, peas, lentils), nuts and seeds ߀ Dairy products (milk, infant formula, yogurt, cheese) ߀ Flesh foods (meat, fish, poultry, organ meats) Eggs ߀ ߀ Vitamin-A rich fruits and vegetables ߀ Other fruits and vegetables 13. In the last 24 hours, from what food groups did your child under five eat (check all that apply)? ߀ Breast milk ߀ Grains, roots, tubers and plantains (e.g. rice, cassava) Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 136 ߀ Pulses (beans, peas, lentils), nuts and seeds ߀ Dairy products (milk, infant formula, yogurt, cheese) ߀ Flesh foods (meat, fish, poultry, organ meats) Eggs ߀ ߀ Vitamin-A rich fruits and vegetables ߀ Other fruits and vegetables 14. Can you please name for me the food groups that you know for a child from 6 to 23 months (check all that apply)? ߀ Breast milk ߀ Grains, roots, tubers and plantains (e.g. rice, cassava) ߀ Pulses (beans, peas, lentils), nuts and seeds ߀ Dairy products (milk, infant formula, yogurt, cheese) ߀ Flesh foods (meat, fish, poultry, organ meats) Eggs ߀ ߀ Vitamin-A rich fruits and vegetables ߀ Other fruits and vegetables 15. On a scale of 1 to 5, how confident are you with being able to access and practice the following water, sanitation and hygiene practices in your home: 1.Not at all confident 2. A little bit confident 3. Very confident 4. Not applicable 5. I do not know 15.1. Regularly access a handwashing station 15.2. Have regular access to safe drinking water 15.3. Use a latrine 15.4. Maintain a clean and safe environment at home 16. On a scale of 1 to 3, how would you rate the main activities of IECD in terms of impact on your life? Please rate only those activities you know and/or participate in 1. Not at all useful 2. A little bit useful 3. Very useful 4. Not applicable 5. I do not know 16.1. Trainings 16.2. Home Visits 16.3. Nurturing Care/ Caregiver Groups 16.4. Cooking Demonstrations 16.5. Village Model Farmer Activities 16.6. Community Dialogue 16.7. Male Caregiver Group 16.8. Peer Support for PLDDD 16.9. Community Dialogue Group 16.10. Child Disability and Development Screening 16.11. Child Nutrition Screening Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 137 1. Not at all useful 2. A little bit useful 3. Very useful 4. Not applicable 5. I do not know 16.12. Monitoring and Reporting 16.12. Other If you use the “other” row, please specify what is shared 17. In the last year, where was the location of your main livelihood (check all that apply)? ߀ Village of residence ߀ Commune of residence, but not your village of residence ߀ District of residence ߀ Province of residence ߀ Outside their province of residence ߀ Outside of Cambodia 18. For the following questions, determine who supports the respondent with the following household tasks. 1. Husband 2. Grandparent 3. Friend 4. Child 4. Other, Specify 4. No one 5. I do not know 18.1. Childcare 18.2. Cooking 18.3. Cleaning the house 18.4. Food preparation 18.5. Laundry 18.6. Home garden 18.7. Collecting water 18.8. Preparing wood for cooking 18.9. Other 19. On a scale of 1 to 3, how often do you get help with household tasks? 1. Never 2. Sometime 3. Always 4. Not applicable 5. I do not know 19.1. Childcare 19.2. Cooking 19.3. Cleaning the house 19.4. Food preparation 19.5. Laundry 19.6. Home garden 19.7. Collecting water 19.8. Preparing wood for cooking 19.9. Other 20. On a scale of 1 to 3, how often do you have access to the following? 1. Never 2. Sometime 3. Always 4. Not applicable 5. I do not know 20.1. Enough nutritious food to eat 20.2. Money Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 138 1. Never 2. Sometime 3. Always 4. Not applicable 5. I do not know 20.3. Clean and safe water 20.4. Electricity 20.5. Nutrition Support 20.6. Health Services 20.7. Other Please ask the person if they have any questions for the ET. Before the end of the interview, thank the person for the time and inputs in the evaluation and provide a copy of the evaluation postcard with additional information and contact details. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 139 MINI-SURVEY: MEN Study Identification Number: KII – XXX – XXX – CX – XXX Age of youngest child: …………. *INFORMED CONSENT WILL HAVE BEEN OBTAINED AT THE START OF THE KII OR FGD 1. Do you qualify for ID Poor? Yes ߀ No ߀ ߀ Do not know 2. Have you heard about the IECD Activity? (IF NO SKIP TO QUESTION 9) Yes ߀ No ߀ ߀ Do not know 3. What are some of the activities that the IECD Activity has been doing (wait for them to respond then follow up by reading off each activity. Check all that apply)? Training ߀ ߀ Home visits ߀ Nurturing Care Session/Caregiver Groups ߀ Cooking Demonstrations ߀ Village Model Farmer Activities ߀ Community Dialogue ߀ Male Caregiver Group ߀ Peer Support for PLDDD ߀ Community Dialogue Group ߀ Child Disability and Developmental Screenings ߀ Child Nutrition Screening ߀ Identified for Referral for Disability, Development Delay or Malnutrition ߀ Monitoring and reporting ߀ Other (Please Specify): _____________ 4. Have you participated in an IECD activity in the community? Yes ߀ No ߀ ߀ Do not know ߀ If yes, which one: ____________________ 5. Have you participated in an IECD activity at home? Yes ߀ No ߀ ߀ Do not know ߀ If yes, which one: ____________________ 6. When was the last time that you engaged in an IECD activity? ߀ Last week ߀ Last two weeks ߀ Last month Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 140 ߀ Six months ago ߀ One year ago ߀ Other: specify_______________ ߀ I do not know 7. On average how often do you engage with an IECD activity? ߀ Every week ߀ Every two weeks ߀ Every month ߀ Every six months ߀ Other: specify_______________ ߀ I do not know 8. Can you name for me a topic from an IECD activity (the interviewer from the ET will check all that apply)? Language ߀ Play ߀ Reading ߀ ߀ Early stimulation ߀ Stunting/Nutrition Handwashing ߀ ߀ Toilet use ߀ Hygiene at home ߀ Home gardens ߀ Access to Markets Cooking ߀ ߀ Safe food preparation ߀ Responsive feeding ߀ Early initiation of breastfeeding Breastfeeding߀ ߀Dietary diversity for pregnant women ߀Minimum acceptable diet for children 6 to 23 months Masculinity߀ ߀Chronic Disease Prevention ߀Alcohol Consumption ߀ Device Use ߀Child disability screening ߀Child development screening ߀MUAC/ Child nutrition screening ߀Other (Please Specify): _____________ 9. If you are not familiar with the IECD Activity, what types of children nutrition, health, education or protection activities have been taking place in your community (check all that apply)? ߀ Caregiver Groups ߀ Nurturing Care Session ߀ Cooking Demonstrations ߀ Village Model Farmer Activities ߀ Child Disability and Developmental Screenings ߀ Child Nutrition Screening (MUAC) Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 141 ߀ Identified for Referral for Disability, Development Delay or Malnutrition ߀ Monitoring and reporting ߀ Other (Please Specify): _____________ 10. Can you please tell me if the following statements are true, false or don’t know for positive key behaviors toward nutrition (check all that apply)? No. Statement True False Don’t Know 10.1 . Pregnant and breastfeeding mothers should eat 4 healthy meals per day of diverse foods 10.2 . Pregnant mother and postpartum women must take iron and folic acid minerals 10.3 . Breastmilk only should be given to a child until 6 months of age 10.4 . Breastmilk is important because it can protect a child against illness 10.5 . Solid foods should be introduced at 6 months (e.g. chopped boiled egg, mashed meat/potato, porridge) 10.6 . Family foods can be introduced at 24 months 10.7 . Responsive feeding is what a caregiver pays attention and responds consistently to a child’s hunger and satiation cues 11. Can you please tell me if the following statements are true, false or don’t know for positive key behaviors toward safety and security (check all that apply)? No. Statement True False Don’t Know 11.1. Reduce stress 11.2. Avoid abusing your child, neglect, violently punishing your child 11.3. Keep your environment at home safe 11.4. Avoid domestic violence 11.5. Listen before you react to your child 11.6. Model, teach and remind children of good behavior 11.7. Provide clear rules and expectations 11.8. Reward positive behavior 11.9. Provide adequate supervision and monitoring 12. Name for us the key food groups that pregnant women should be eating: ߀ Grains, roots, tubers and plantains (e.g. rice, cassava) ߀ Pulses (beans, peas, lentils), nuts and seeds ߀ Dairy products (milk, infant formula, yogurt, cheese) ߀ Flesh foods (meat, fish, poultry, organ meats) Eggs ߀ ߀ Vitamin-A rich fruits and vegetables ߀ Other fruits and vegetables 13. In the last 24 hours, from what food groups did your child under five eat (check all that apply)? ߀ Breast milk ߀ Grains, roots, tubers and plantains (e.g. rice, cassava) Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 142 ߀ Pulses (beans, peas, lentils), nuts and seeds ߀ Dairy products (milk, infant formula, yogurt, cheese) ߀ Flesh foods (meat, fish, poultry, organ meats) Eggs ߀ ߀ Vitamin-A rich fruits and vegetables ߀ Other fruits and vegetables 14. Can you please name for me the food groups that you know for a child from 6 to 23 months (check all that apply)? ߀ Breast milk ߀ Grains, roots, tubers and plantains (e.g. rice, cassava) ߀ Pulses (beans, peas, lentils), nuts and seeds ߀ Dairy products (milk, infant formula, yogurt, cheese) ߀ Flesh foods (meat, fish, poultry, organ meats) Eggs ߀ ߀ Vitamin-A rich fruits and vegetables ߀ Other fruits and vegetables 15. On a scale of 1 to 5, how confident are you with being able to access and practice the following water, sanitation and hygiene practices in your home: 1.Not at all confident 2. A little bit confident 3. Very confident 4. Not applicable 5. I do not know 15.1. Regularly access a handwashing station 15.2. Have regular access to safe drinking water 15.3. Use a latrine 15.4. Maintain a clean and safe environment at home 16. On a scale of 1 to 3, how would you rate the main activities of IECD in terms of impact on your life? Please rate only those activities you know and/or participate in 1. Not at all useful 2. A little bit useful 3. Very useful 4. Not applicable 5. I do not know 16.1. Trainings 16.2. Home Visits 16.3. Nurturing Care/ Caregiver Groups 16.4. Cooking Demonstrations 16.5. Village Model Farmer Activities 16.6. Community Dialogue 16.7. Male Caregiver Group 16.8. Peer Support for PLDDD 16.9. Community Dialogue Group 16.10. Child Disability and Development Screening 16.11. Child Nutrition Screening Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 143 1. Not at all useful 2. A little bit useful 3. Very useful 4. Not applicable 5. I do not know 15.12. Monitoring and Reporting 16.13. Other If you use the “other” row, please specify what is shared 17. In the last year, where was the location of your main livelihood (check all that apply)? ߀ Village of residence ߀ Commune of residence, but not your village of residence ߀ District of residence ߀ Province of residence ߀ Outside their province of residence ߀ Outside of Cambodia 18. on a scale of 1 to 3, how often do you help with the following? 1. Never 2. Sometime 3. Always 4. Not applicable 5. I do not know 18.1. General Childcare 18.2. Read to a child 18.3. Feed a child 18.4. Bathe and toilet a child 18.5 Teach a child new things 18.6. Cooking 18.7. Cleaning the house 18.8. Food preparation 18.9. Laundry 18.10. Home garden 18.11. Collecting water 18.12. Enable access to money to another family member 18.13. Manage household money 18.14. Help collect firewood 18.15. Other Please ask the person if they have any questions for the ET. Before the end of the interview, thank the person for the time and inputs in the evaluation and provide a copy of the evaluation postcard with additional information and contact details. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 144 MINI-SURVEY: PLDDD Study Identification Number: KII – XXX – XXX – CX – XXX Age of child with disability: …………. *INFORMED CONSENT WILL HAVE BEEN OBTAINED AT THE START OF THE KII OR FGD 1. Do you qualify for ID Poor? Yes ߀ No ߀ ߀ Do not know 2. Have you heard about the IECD Activity? (IF NO SKIP TO QUESTION 9) Yes ߀ No ߀ ߀ Do not know 3. What are some of the activities that the IECD Activity has been doing (wait for them to respond then follow up by reading off each activity. Check all that apply)? Training ߀ ߀ Home visits ߀ Nurturing Care Session/Caregiver Groups ߀ Cooking Demonstrations ߀ Village Model Farmer Activities ߀ Community Dialogue ߀ Male Caregiver Group ߀ Peer Support for PLDDD ߀ Community Dialogue Group ߀ Child Disability and Developmental Screenings ߀ Child Nutrition Screening ߀ Identified for Referral for Disability, Development Delay or Malnutrition ߀ Other (Please Specify): _____________ 4. Have you participated in an IECD activity in the community? Yes ߀ No ߀ ߀ Do not know ߀ If yes, which one: ____________________ 5. Have you participated in an IECD activity at home? Yes ߀ No ߀ ߀ Do not know ߀ If yes, which one: ____________________ 6. When was the last time that you engaged in an IECD activity? ߀ Last week ߀ Last two weeks ߀ Last month Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 145 ߀ Six months ago ߀ One year ago ߀ Other: specify_______________ ߀ I do not know 7. On average how often do you engage with an IECD activity? ߀ Every week ߀ Every two weeks ߀ Every month ߀ Every six months ߀ Other: specify_______________ ߀ I do not know 8. Can you name for me a topic from an IECD activity (the interviewer from the ET will check all that apply)? Language ߀ Play ߀ Reading ߀ ߀ Early stimulation ߀ Stunting/Nutrition Handwashing ߀ ߀ Toilet use ߀ Hygiene at home ߀ Home gardens ߀ Access to Markets Cooking ߀ ߀ Safe food preparation ߀ Responsive feeding ߀ Early initiation of breastfeeding Breastfeeding߀ ߀Dietary diversity for pregnant women ߀Minimum acceptable diet for children 6 to 23 months ߀Child disability screening ߀Child development screening ߀MUAC/ Child nutrition screening ߀Other (Please Specify): _____________ 9. If you are not familiar with the IECD Activity, what types of children nutrition, health, education or protection activities have been taking place in your community (check all that apply)? ߀ Caregiver Groups ߀ Nurturing Care Session ߀ Cooking Demonstrations ߀ Village Model Farmer Activities ߀ Child Disability and Developmental Screenings ߀ Child Nutrition Screening (MUAC) ߀ Identified for Referral for Disability, Development Delay or Malnutrition ߀ Monitoring and reporting ߀ Other (Please Specify): _____________ Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 146 10. In the last 24 hours from what food groups did you (WRA and PW) consume/eat (check all that apply)? ߀ Grains, roots, tubers and plantains (e.g. rice, cassava) ߀ Pulses (beans, peas, lentils), nuts and seeds ߀ Dairy products (milk, infant formula, yogurt, cheese) ߀ Flesh foods (meat, fish, poultry, organ meats) Eggs ߀ ߀ Vitamin-A rich fruits and vegetables ߀ Other fruits and vegetables 11. In the last 24 hours, from what food groups did your child under five eat (check all that apply)? ߀ Breast milk ߀ Grains, roots, tubers and plantains (e.g. rice, cassava) ߀ Pulses (beans, peas, lentils), nuts and seeds ߀ Dairy products (milk, infant formula, yogurt, cheese) ߀ Flesh foods (meat, fish, poultry, organ meats) Eggs ߀ ߀ Vitamin-A rich fruits and vegetables ߀ Other fruits and vegetables 12. Can you please name for me the food groups that you know for a child from 6 to 23 months (check all that apply)? ߀ Breast milk ߀ Grains, roots, tubers and plantains (e.g. rice, cassava) ߀ Pulses (beans, peas, lentils), nuts and seeds ߀ Dairy products (milk, infant formula, yogurt, cheese) ߀ Flesh foods (meat, fish, poultry, organ meats) Eggs ߀ ߀ Vitamin-A rich fruits and vegetables ߀ Other fruits and vegetables 13. On a scale of 1 to 5, how confident are you with being able to access and practice the following water, sanitation and hygiene practices in your home: 1.Not at all confident 2. A little bit confident 3. Very confident 4. Not applicable 5. I do not know 13.1. Regularly access a handwashing station 13.2. Have regular access to safe drinking water 13.3. Use a latrine 13.4. Maintain a clean and safe environment at home 14. Was your child identified with a disability or developmental delay by the IECD activity? Yes ߀ No ߀ ߀ I Do not know Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 147 15. Has your child ever been referred for further services to Angkor Hospital for Children (If no, skip to question 17)? Yes ߀ No ߀ ߀ I Do not know 16. If yes, how did you reach Angkor Hospital for Children? ߀ Private vehicle Taxi ߀ Ambulance ߀ ߀ Public Transportation ߀ Other (please specify):___________ 17. Has anyone from the IECD project followed up with you regarding your child’s disability or developmental delay? Yes ߀ No ߀ ߀ Do not know ߀ If yes, who?:____________________ 18. On a scale of 1 to 3, how easy or not is it for you to access the following activities or services in your community?: 1. Not easy 2. A little bit easy 3. Very easy 4. Not applicable 5. I do not know 18.1. Home Visits 18.2. Peer Support Groups 18.3. Nurturing Care/Caregiver Groups 18.4. Community Dialogues 18.5. Cooking Demonstrations 18.6. Village Model Farmer Activities 18.7. Child Disability and Development Screening 18.8. Child Nutrition Screening 18.9. Health Center 18.10. Social Protection Fund 18.11. Angkor Hospital for Children 18.12. Support with referral from a Nurse 18.13. Physical Therapy Sessions 18.14. Provincial Rehabilitation Center (PRC) 18.15. Other 19. On a scale from 1 to 3, how useful are the following activities for you considering the needs of your child? 1. Not at all useful 2. A little bit useful 3. Very useful 4. Not applicable 5. I do not know 19.1. Home Visits 19.2. Peer Support Groups Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 148 1. Not at all useful 2. A little bit useful 3. Very useful 4. Not applicable 5. I do not know 19.3. Nurturing Care/Caregiver Groups 19.4. Community Dialogues 19.5. Cooking Demonstrations 19.6. Village Model Farmer Activities 19.7. Child Disability and Development Screening 19.8. Child Nutrition Screening 19.9. Health Center 19.10. Social Protection Fund 19.11. Angkor Hospital for Children 19.12. Support with referral from a Nurse 19.13. Physical Therapy Sessions 19.14. Provincial Rehabilitation Center (PRC) 19.15. Other 20. What more do you need to meet the caregiving needs of your child? 21. What are your hopes and dreams for your child? Please ask the person if they have any questions for the ET. Before the end of the interview, thank the person for the time and inputs in the evaluation and provide a copy of the evaluation postcard with additional information and contact details. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 149 MINI-SURVEY: GRANDPARENT/ ALTERNATE CAREGIVER: Study Identification Number: KII – XXX – XXX – CX – XXX Age of youngest grandchild: …………. *INFORMED CONSENT WILL HAVE BEEN OBTAINED AT THE START OF THE KII OR FGD 1. Do you qualify for ID Poor? Yes ߀ No ߀ ߀ Do not know 2. Have you heard about the IECD Activity? (IF NO SKIP TO QUESTION 9) Yes ߀ No ߀ ߀ Do not know 3. What are some of the activities that the IECD Activity has been doing (wait for them to respond then follow up by reading off each activity. Check all that apply)? Training ߀ ߀ Home visits ߀ Nurturing Care Session/Caregiver Groups ߀ Cooking Demonstrations ߀ Village Model Farmer Activities ߀ Community Dialogue ߀ Male Caregiver Group ߀ Peer Support for PLDDD ߀ Community Dialogue Group ߀ Child Disability and Developmental Screenings ߀ Child Nutrition Screening ߀ Identified for Referral for Disability, Development Delay or Malnutrition ߀ Other (Please Specify): _____________ 4. Have you participated in an IECD activity in the community? Yes ߀ No ߀ ߀ Do not know ߀ If yes, which one: ____________________ 5. Have you participated in an IECD activity at home? Yes ߀ No ߀ ߀ Do not know ߀ If yes, which one: ____________________ 6. When was the last time that you engaged in an IECD activity? ߀ Last week ߀ Last two weeks ߀ Last month ߀ Six months ago Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 150 ߀ One year ago ߀ Other: specify_______________ ߀ I do not know 7. On average how often do you engage with an IECD activity? ߀ Every week ߀ Every two weeks ߀ Every month ߀ Every six months ߀ Other: specify_______________ ߀ I do not know 8. Can you name for me a topic from an IECD activity (the interviewer from the ET will check all that apply)? Language ߀ Play ߀ Reading ߀ ߀ Early stimulation ߀ Stunting/Nutrition Handwashing ߀ ߀ Toilet use ߀ Hygiene at home ߀ Home gardens ߀ Access to Markets Cooking ߀ ߀ Safe food preparation ߀ Responsive feeding ߀ Early initiation of breastfeeding Breastfeeding߀ ߀Dietary diversity for pregnant women ߀Minimum acceptable diet for children 6 to 23 months Masculinity߀ ߀Chronic Disease Prevention ߀Alcohol Consumption ߀ Device Use ߀Child disability screening ߀Child development screening ߀MUAC/ Child nutrition screening ߀Other (Please Specify): _____________ 9. If you are not familiar with the IECD Activity, what types of child nutrition, health, education or protection activities have been taking place in your community (check all that apply)? ߀ Caregiver Groups ߀ Nurturing Care Session ߀ Cooking Demonstrations ߀ Village Model Farmer Activities ߀ Child Disability and Developmental Screenings ߀ Child Nutrition Screening (MUAC) ߀ Identified for Referral for Disability, Development Delay or Malnutrition Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 151 ߀ Other (Please Specify): _____________ 10. Can you please tell me if the following statements are true, false or don’t know for positive key behaviors toward nutrition (check all that apply)? No. Statement True False Don’t Know 10.1 . Pregnant and breastfeeding mothers should eat 4 healthy meals per day of diverse foods 10.2 . Pregnant mother and postpartum women must take iron and folic acid minerals 10.3 . Breastmilk only should be given to a child until 6 months of age 10.4 . Breastmilk is important because it can protect a child against illness 10.5 . Solid foods should be introduced at 6 months (e.g. chopped boiled egg, mashed meat/potato, porridge) 10.6 . Family foods can be introduced at 24 months 10.7 . Responsive feeding is what a caregiver pays attention and responds consistently to a child’s hunger and satiation cues 11. Can you please tell me if the following statements are true, false or don’t know for positive key behaviors toward safety and security (check all that apply)? No. Statement True False Don’t Know 11.1. Reduce stress 11.2. Avoid abusing your child, neglect, violently punishing your child 11.3. Keep your environment at home safe 11.4. Avoid domestic violence 11.5. Listen before you react to your child 11.6. Model, teach and remind children of good behavior 11.7. Provide clear rules and expectations 11.8. Reward positive behavior 11.9. Provide adequate supervision and monitoring 12. Name for us the key food groups that pregnant women should be eating: ߀ Grains, roots, tubers and plantains (e.g. rice, cassava) ߀ Pulses (beans, peas, lentils), nuts and seeds ߀ Dairy products (milk, infant formula, yogurt, cheese) ߀ Flesh foods (meat, fish, poultry, organ meats) Eggs ߀ ߀ Vitamin-A rich fruits and vegetables ߀ Other fruits and vegetables 13. In the last 24 hours, from what food groups did your grandchild under five eat (check all that apply)? ߀ Breast milk ߀ Grains, roots, tubers and plantains (e.g. rice, cassava) ߀ Pulses (beans, peas, lentils), nuts and seeds ߀ Dairy products (milk, infant formula, yogurt, cheese) Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 152 ߀ Flesh foods (meat, fish, poultry, organ meats) Eggs ߀ ߀ Vitamin-A rich fruits and vegetables ߀ Other fruits and vegetables 14. Can you please name for me the food groups that you know for a child from 6 to 23 months (check all that apply)? ߀ Breast milk ߀ Grains, roots, tubers and plantains (e.g. rice, cassava) ߀ Pulses (beans, peas, lentils), nuts and seeds ߀ Dairy products (milk, infant formula, yogurt, cheese) ߀ Flesh foods (meat, fish, poultry, organ meats) Eggs ߀ ߀ Vitamin-A rich fruits and vegetables ߀ Other fruits and vegetables 15. On a scale of 1 to 5, how confident are you with being able to access and practice the following water, sanitation and hygiene practices in your home: 1.Not at all confident 2. A little bit confident 3. Very confident 4. Not applicable 5. I do not know 15.1. Regularly access a handwashing station 15.2. Have regular access to safe drinking water 15.3. Use a latrine 15.4. Maintain a clean and safe environment at home 16. On a scale of 1 to 3, how would you rate the main activities of IECD in terms of impact on your life? Please rate only those activities you know and/or participate in 1. Not at all useful 2. A little bit useful 3. Very useful 4. Not applicable 5. I do not know 16.1. Trainings 16.2. Home Visits 16.3. Nurturing Care/ Caregiver Groups 16.4. Cooking Demonstrations 16.5. Village Model Farmer Activities 16.6. Community Dialogue 16.7. Male Caregiver Group 16.8. Peer Support for PLDDD 16.9. Community Dialogue Group 16.10. Child Disability and Development Screening 16.11. Child Nutrition Screening 16.13. Other If you use the “other” row, please specify what is shared Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 153 17. on a scale of 1 to 3, how often do you help with the following? 1. Never 2. Sometime 3. Always 4. Not applicable 5. I do not know 17.1. General Childcare 17.2. Read to a child 17.3. Feed a child 17.4. Bathe and toilet a child 17.5 Teach a child new things 17.6. Cooking 17.7. Cleaning the house 17.8. Food preparation 17.9. Laundry 17.10. Home garden 17.11. Collecting water 17.12. Enable access to money t another family member 17.13. Manage household money 17.14. Help collect firewood 17.15. Other Please ask the person if they have any questions for the ET. Before the end of the interview, thank the person for the time and inputs in the evaluation and provide a copy of the evaluation postcard with additional information and contact details Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 154 MINI-SURVEY: VHSG AND CDL Study Identification Number: KII – XXX – XXX – CX - XXX *INFORMED CONSENT WILL HAVE BEEN OBTAINED AT THE START OF THE KII. VHSG AND CDL FGD PARTICIPANTS WILL NOT PARTICIPATE IN THE MINI-SURVEY AS THEY WILL BE OBSERVED. ONLY FROM THE KII. 1. Have you heard about the USAID IECD Activity? (IF NO SKIP TO QUESTION X) Yes ߀ No ߀ ߀ Do not know 2. What are some of the activities that you are volunteering to implement under the IECD Activity has been doing (check all that apply)? Training ߀ ߀ Home visits ߀ Nurturing Care Session/Caregiver Groups ߀ Cooking Demonstrations ߀ Village Model Farmer Activities ߀ Community Dialogue ߀ Male Caregiver Group ߀ Peer Support for PLDDD ߀ Community Dialogue Group ߀ Child Disability and Developmental Screenings ߀ Child Nutrition Screening ߀ Identified for Referral for Disability, Development Delay or Malnutrition ߀ Monitoring and reporting ߀ Other (Please Specify): _____________ 3. Have you participated in an IECD training? Yes ߀ ߀ No (skip to question 5) ߀ Do not know 4. If yes, mark all that apply: ߀ Nurturing Care/ Caregiver Group ߀ Home Visits ߀ Male Support Group ߀ Village Model Farmer ߀ Cooking Demonstration ߀ AHC Child Disability/Developmental Delay Screening with CBDMAT ߀ MUAC Screening ߀ Commcare App (monitoring and reporting) ߀ Peer Support Group ߀ Community Dialogue 5. Have you facilitated an IECD activity in the community? Yes ߀ Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 155 No ߀ ߀ Do not know ߀ If yes, which one: ____________________ 6. Have you facilitated an IECD activity at home? Yes ߀ No ߀ ߀ Do not know ߀ If yes, which one: ____________________ 7. Can you name for me a topic from an IECD activity (the interview from the ET will check all that apply)? Language ߀ Play ߀ Reading ߀ ߀ Early stimulation ߀ Stunting/Nutrition Handwashing ߀ ߀ Toilet use ߀ Hygiene at home ߀ Home gardens ߀ Access to Markets Cooking ߀ ߀ Safe food preparation ߀ Responsive feeding ߀ Early initiation of breastfeeding Breastfeeding߀ ߀Dietary diversity for pregnant women ߀Minimum acceptable diet for children 6 to 23 months Masculinity߀ ߀Chronic Disease Prevention ߀Alcohol Consumption ߀ Device Use ߀Child disability screening ߀Child development screening ߀MUAC/ Child nutrition screening ߀Other (Please Specify): _____________ 8. Can you please tell me if the following statements are true, false or don’t know for positive key behaviors toward nutrition (check all that apply)? No. Statement True False Don’t Know 8.1. Pregnant and breastfeeding mothers should eat 4 healthy meals per day of diverse foods 8.2. Pregnant mother and postpartum women must take iron and folic acid minerals 8.3. Breastmilk only should be given to a child until 6 months of age 8.4. Breastmilk is important because it can protect a child against illness Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 156 No. Statement True False Don’t Know 8.5. Solid foods should be introduced at 6 months (e.g. chopped boiled egg, mashed meat/potato, porridge) 8.6. Family foods can be introduced at 24 months 8.7. Responsive feeding is what a caregiver pays attention and responds consistently to a child’s hunger and satiation cues 9. Can you please tell me if the following statements are true, false or don’t know for positive key behaviors toward safety and security (check all that apply)? No. Statement True False Don’t Know 9.1. Reduce stress 9.2. Avoid abusing your child, neglect, violently punishing your child 9.3. Keep your environment at home safe 9.4. Avoid domestic violence 9.5. Listen before you react to your child 9.6. Model, teach and remind children of good behavior 9.7. Provide clear rules and expectations 9.8. Reward positive behavior 9.9. Provide adequate supervision and monitoring 10. Can you please name for me the recommended food groups for a pregnant women (check all that apply)? ߀ Grains, roots, tubers and plantains (e.g. rice, cassava) ߀ Pulses (beans, peas, lentils), nuts and seeds ߀ Dairy products (milk, infant formula, yogurt, cheese) ߀ Flesh foods (meat, fish, poultry, organ meats) Eggs ߀ ߀ Vitamin-A rich fruits and vegetables ߀ Other fruits and vegetables 11. Can you please name for me the food groups that you know for a child from 6 to 23 months (check all that apply)? ߀ Breast milk ߀ Grains, roots, tubers and plantains (e.g. rice, cassava) ߀ Pulses (beans, peas, lentils), nuts and seeds ߀ Dairy products (milk, infant formula, yogurt, cheese) ߀ Flesh foods (meat, fish, poultry, organ meats) Eggs ߀ ߀ Vitamin-A rich fruits and vegetables ߀ Other fruits and vegetables 12. On a scale of 1 to 5, how confident are you with being able to access and practice the following water, sanitation and hygiene practices in your home: 1.Not at all confident 2. A little bit confident 3. Very confident 4. Not applicable 5. I do not know 12.1. Regularly access a handwashing station Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 157 1.Not at all confident 2. A little bit confident 3. Very confident 4. Not applicable 5. I do not know 12.2. Have regular access to safe drinking water 12.3. Use a latrine 12.4. Maintain a clean and safe environment at home 13. On a scale of 1 to 3, how useful to do you think the following IECD Activity is for the community? Please rate only those activities you know and/or participate in 1. Not at all useful 2. A little bit useful 3. Very useful 4. Not applicable 5. I do not know 13.1. Trainings 13.2. Home Visits 13.3. Nurturing Care/ Caregiver Groups 13.4. Cooking Demonstrations 13.5. Village Model Farmer Activities 13.6. Community Dialogue 13.7. Male Caregiver Group 13.8. Peer Support for PLDDD 13.9. Community Dialogue Group 13.10. Child Disability and Development Screening 13.11. Child Nutrition Screening 13.12. Other If you use the “other” row, please specify what is shared 14. On a scale of 1 to 3, how would you rate your training, coaching and supervision experiences? 1. Not at all useful 2. A little bit useful 3. Very useful 4. Not applicable 5. I do not know 14.1. Trainings 14.2. Content of trainings 14.3. Experience with the training 14.4. Supervision 15. When was your last supervision visit for the IECD activity? ߀ Within the past 3 months ߀ Within the past 6 months ߀ Within the past 12 months ߀ One or more years ago ߀ Other: specify_______________ ߀ I do not know Please ask the person if they have any questions for the ET. Before the end of the interview, thank the person for the time and inputs in the evaluation and provide a copy of the evaluation postcard with additional information and contact details. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 158 MINI-SURVEY: CCWC, COMMUNE, COMMUNITY LEADERS Study Identification Number: KII – XXX – XXX – CX - XXX *INFORMED CONSENT WILL HAVE BEEN OBTAINED AT THE START OF THE KII OR FGD 1. Have you heard about the USAID IECD Activity? (IF NO SKIP TO QUESTION 9) Yes ߀ No ߀ ߀ Do not know 2. What are some of the activities that you are support to implement under the IECD Activity has been doing (check all that apply)? Training ߀ ߀ Home visits ߀ Nurturing Care Session/Caregiver Groups ߀ Cooking Demonstrations ߀ Village Model Farmer Activities ߀ Community Dialogue ߀ Male Caregiver Group ߀ Peer Support for PLDDD ߀ Community Dialogue Group ߀ Child Disability and Developmental Screenings ߀ Child Nutrition Screening ߀ Identified for Referral for Disability, Development Delay or Malnutrition ߀ Monitoring and reporting ߀ Other (Please Specify): _____________ 3. Have you participated in an IECD training? Yes ߀ ߀ No (skip to question 5) ߀ Do not know 4. If yes, mark all that apply: ߀ Nurturing Care/ Caregiver Group ߀ Home Visits ߀ Male Support Group ߀ Village Model Farmer ߀ Cooking Demonstration ߀ AHC Child Disability/Developmental Delay Screening with CBDMAT ߀ MUAC Screening ߀ Commcare App (monitoring and reporting) ߀ Peer Support Group ߀ Community Dialogue 5. Have you facilitated an IECD activity in the community? Yes ߀ No ߀ ߀ Do not know ߀ If yes, which one: ____________________ Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 159 6. Have you facilitated an IECD activity at home? Yes ߀ No ߀ ߀ Do not know ߀ If yes, which one: ____________________ 7. Can you name for me a topic from an IECD activity (the interview from the ET will check all that apply)? Language ߀ Play ߀ Reading ߀ ߀ Early stimulation ߀ Stunting/Nutrition Handwashing ߀ ߀ Toilet use ߀ Hygiene at home ߀ Home gardens ߀ Access to Markets Cooking ߀ ߀ Safe food preparation ߀ Responsive feeding ߀ Early initiation of breastfeeding Breastfeeding߀ ߀Dietary diversity for pregnant women ߀Minimum acceptable diet for children 6 to 23 months Masculinity߀ ߀Chronic Disease Prevention ߀Alcohol Consumption ߀ Device Use ߀Child disability screening ߀Child development screening ߀MUAC/ Child nutrition screening ߀Other (Please Specify): _____________ 8. Can you please tell me if the following statements are true, false or don’t know for positive key behaviors toward nutrition (check all that apply)? No. Statement True False Don’t Know 8.1. Pregnant and breastfeeding mothers should eat 4 healthy meals per day of diverse foods 8.2. Pregnant mother and postpartum women must take iron and folic acid minerals 8.3. Breastmilk only should be given to a child until 6 months of age 8.4. Breastmilk is important because it can protect a child against illness 8.5. Solid foods should be introduced at 6 months (e.g. chopped boiled egg, mashed meat/potato, porridge) 8.6. Family foods can be introduced at 24 months 8.7. Responsive feeding is what a caregiver pays attention and responds consistently to a child’s hunger and satiation cues Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 160 9. Can you please tell me if the following statements are true, false or don’t know for positive key behaviors toward safety and security (check all that apply)? No. Statement True False Don’t Know 9.1. Reduce stress 9.2. Avoid abusing your child, neglect, violently punishing your child 9.3. Keep your environment at home safe 9.4. Avoid domestic violence 9.5. Listen before you react to your child 9.6. Model, teach and remind children of good behavior 9.7. Provide clear rules and expectations 9.8. Reward positive behavior 9.9. Provide adequate supervision and monitoring 10. Can you please name for me the recommended food groups for a pregnant women (check all that apply)? ߀ Grains, roots, tubers and plantains (e.g. rice, cassava) ߀ Pulses (beans, peas, lentils), nuts and seeds ߀ Dairy products (milk, infant formula, yogurt, cheese) ߀ Flesh foods (meat, fish, poultry, organ meats) Eggs ߀ ߀ Vitamin-A rich fruits and vegetables ߀ Other fruits and vegetables 11. Can you please name for me the food groups that you know for a child from 6 to 23 months (check all that apply)? ߀ Breast milk ߀ Grains, roots, tubers and plantains (e.g. rice, cassava) ߀ Pulses (beans, peas, lentils), nuts and seeds ߀ Dairy products (milk, infant formula, yogurt, cheese) ߀ Flesh foods (meat, fish, poultry, organ meats) Eggs ߀ ߀ Vitamin-A rich fruits and vegetables ߀ Other fruits and vegetables 12. On a scale of 1 to 5, how confident are you with being able to access and practice the following water, sanitation and hygiene practices in your home: 1.Not at all confident 2. A little bit confident 3. Very confident 4. Not applicable 5. I do not know 12.1. Regularly access a handwashing station 12.2. Have regular access to safe drinking water 12.3. Use a latrine 12.4. Maintain a clean and safe environment at home Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 161 13. On a scale of 1 to 3, how useful to do you think the following IECD Activity is for the community? Please rate only those activities you know and/or participate in 1. Not at all useful 2. A little bit useful 3. Very useful 4. Not applicable 5. I do not know 13.1. Trainings 13.2. Home Visits 13.3. Nurturing Care/ Caregiver Groups 13.4. Cooking Demonstrations 13.5. Village Model Farmer Activities 13.6. Community Dialogue 13.7. Male Caregiver Group 13.8. Peer Support for PLDDD 13.9. Community Dialogue Group 13.10. Child Disability and Development Screening 13.11. Child Nutrition Screening 13.12. Monitoring and Reporting 13.13. Other If you use the “other” row, please specify what is shared 14. On a scale of 1 to 3, how would you rate your training, coaching and supervision experiences? 1. Not at all useful 2. A little bit useful 3. Very useful 4. Not applicable 5. I do not know 14.1. Trainings 14.2. Content of trainings 14.3. Experience with the training 14.4. Supervision 15. When was your last supervision visit for the IECD activity? ߀ Within the past 3 months ߀ Within the past 6 months ߀ Within the past 12 months ߀ One or more years ago ߀ Other: specify_______________ ߀ I do not know 16. What are ways to best integrate IECD activities into the Commune Investment Plan (CIP)? Please ask the person if they have any questions for the ET. Before the end of the interview, thank the person for the time and inputs in the evaluation and provide a copy of the evaluation postcard with additional information and contact details. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 162 ONLINE SURVEY: NATIONAL GOVERNMENT, PARTNERS AND STAKEHOLDERS, PROVINCIAL AND DISTRICT GOVERNMENT, AND HEALTH CENTER STAFF *INFORMED CONSENT WILL HAVE BEEN OBTAINED AT THE START OF THE KII Study Identification Number: KII – XXX – XXX – C1-2 - XXX 1. How do you identify? ߀ National Government ߀ IECD Implementing Partner ߀ IECD Stakeholder ߀ Provincial Government ߀ District Government ߀ Health Center ߀ Other (please specify): ________________ 2. Have you heard about the USAID IECD Activity (If no, skip to the end)? Yes ߀ No ߀ ߀ Do not know 3. What are some of the activities that the IECD Activity has been implementing (check all that apply)? Training ߀ ߀ Home visits ߀ Nurturing Care Session/Caregiver Groups ߀ Cooking Demonstrations ߀ Village Model Farmer Activities ߀ Community Dialogue ߀ Male Caregiver Group ߀ Peer Support for PLDDD ߀ Community Dialogue Group ߀ Child Disability and Developmental Screenings ߀ Child Nutrition Screening ߀ Identified for Referral for Disability, Development Delay or Malnutrition ߀ Monitoring and reporting ߀ Other (Please Specify): _____________ 4. On a scale of 1 to 5, how effective useful have the main activities of IECD been up for communities up until March 2023? 1. Not at all useful 2. A little bit useful 3. Very useful 4. Not applicable 5. I do not know 4.1. Trainings 4.2. Home Visits 4.3. Nurturing Care/ Caregiver Groups 4.4. Cooking Demonstrations 4.5. Village Model Farmer Activities 4.6. Community Dialogue 4.7. Male Caregiver Group 4.8. Peer Support for PLDDD Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 163 1. Not at all useful 2. A little bit useful 3. Very useful 4. Not applicable 5. I do not know 4.9. Community Dialogue Group 4.10. Child Disability and Development Screening 4.11. Child Nutrition Screening 4.12. Identified for referral for disability, developmental delay or malnutrition 4.13. Monitoring and Reporting 4.14. Other 5. On a scale of 1 to 5, how sustainable are the following IECD activities? 1. Not sustainable 2. A little bit sustainable 3. Very sustainable 4. Not applicable 5. I do not know 5.1. Trainings 5.2. Home Visits 5.3. Nurturing Care/ Caregiver Groups 5.4. Cooking Demonstrations 5.5. Village Model Farmer Activities 5.6. Community Dialogue 5.7. Male Caregiver Group 5.8. Peer Support for PLDDD 5.9. Community Dialogue Group 5.10. Child Disability and Development Screening 5.11. Child Nutrition Screening 5.12. Monitoring and Reporting 5.13. Other 6. If you answered sustainable to any of the activities above, can you please provide a short answer as to why you think they are not sustainable? 7. If you answered not or a little bit sustainable to any of the activities above, can you please provide a short answer as to why you think they are not sustainable? Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 164 8. If you answered not or a little bit sustainable to any of the activities above, can you please provide a short answer as to how you think the activities can be sustained? 9. What are the strengths of the IECD activity? 10. What are the challenges for the IECD activity? 11. What opportunities exist for the IECD activity in Cambodia? Please ask the person if they have any questions for the ET. Before the end of the interview, thank the person for the time and inputs in the evaluation and provide a copy of the evaluation postcard with additional information and contact details. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 165 ANNEX 5: SOURCES OF INFORMATION Documents Reviewed Royal Government of Cambodia. (2022). Interim Guidelines on Growth Monitoring and Promotion for Children under Five Years Old in Cambodia. Phnom Penh. Laillou A, Prak S, de Groot R, Whitney S, Conkle J, et al. (2014). Optimal Screening of Children with Acute Malnutrition Requires a Change in Current WHO Guidelines as MUAC and WHZ Identify Different Patient Groups. PLoS ONE 9(7) USAID, RTI, and Helen Keller International. (2021). Gender Analysis for the Integrated Early Childhood Development Activity. Phnom Penh. USAID and RTI International. (2022). IECD Cohort Evaluation Baseline Report. Phnom Penh. US Center for Disease Control and Prevention. (2023). Picky eaters and what to do. https://www.cdc.gov/nutrition/infantandtoddlernutrition/foods-and-drinks/picky-eaters.html National Institute of Statistics (NIS) [Cambodia], Ministry of Health (MoH) [Cambodia], and ICF. 2022. Cambodia Demographic and Health Survey 2021–22 Key Indicators Report. Phnom Penh, Cambodia, and Rockville, Maryland, USA: NIS, MoH, and ICF. CARD. (2019). The second national strategy for food security and nutrition 2019 – 2023. RGC, Phnom Penh. World Bank. (2018). Report on gender analysis water supply for the proposed Bank-supported Water Supply and Sanitation Improvement Project. Phnom Penh. Royal Government of Cambodia. (2022). National Action Plan on Early Childhood Care and Development 2022 – 2026. Phnom Penh. USAID, RTI Internationa and Helen Keller International. (2021). Situational Analysis Report: The Integrated early Childhood Development Activity. Phnom Penh. Simkiss, D.E., Blackburn, C.M., Mukoro, F.O. et al. (2011). Childhood disability and socio￾economic circumstances in low and middle income countries: systematic review. BMC Pediatr 11, 119. Pov, S. (2021), "Education of Children with Disabilities in Cambodia: Trends, Collaborations, and Challenges", Semon, S.R., Lane, D. and Jones, P. (Ed.) Instructional Collaboration in International Inclusive Education Contexts (International Perspectives on Inclusive Education, Vol. 17), Emerald Publishing Limited, Bingley, pp. 139 - 150. OECD. (2017). Social protection system review of Cambodia, OECD Development Pathways, OECD Publishing, Paris. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 166 USAID/Cambodia Integrated Early Childhood Development Activity (IECD) Monitoring, Evaluation and Learning (MEL) Plan. Revised April, 6, 2021. USAID/Cambodia Integrated Early Childhood Development Activity. FY2022 Annual Report October 2021 - September 2022. Revised November 17, 2022. UNICEF. (2020) Guidance Note: New Guidance for the Mid-Upper Arm Circumference Tape. USAID Cambodia Integrated Early Childhood Development Activity. 2020. Program Description. Arlinghaus K.R., & Johnston C.A. (2017). Advocating for Behavior Change With Education. American Journal of Lifestyle Medicine.12(2):113-116. WHO. (2018). WASH and Health working together: a ‘how-to’ guide for neglected tropical disease programmes. Geneva. Schneiders ML, Phou M, Tun V, Kelley M, Parker M, and Turner C. (2021). Grandparent caregiving in Cambodian skip-generation households: Roles and impact on child nutrition. Maternal Child Nutrition. Suppl 1(Suppl 1). Klein A, Uyehara M, Cunningham A, Olomi M, Cashin K, Kirk CM. (2023). Nutritional care for children with feeding difficulties and disabilities: A scoping review. PLOS Global Public Health. 17;3(3). National Institute of Statistics, Directorate General for Health, and ICF International. (2015). Cambodia Demographic and Health Survey 2014. Phnom Penh, Cambodia, and Rockville, Maryland, USA: National Institute of Statistics, Directorate General for Health, and ICF International. Vaivada T, Akseer N, Akseer S, Somaskandan A, Stefopulos M, Bhutta ZA. (2020). Stunting in childhood: an overview of global burden, trends, determinants, and drivers of decline. American Journal of Clinical Nutrition. 112(Suppl 2):777S-791S. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 167 Key Informants List of Key Informant Interviews by Target and Gender No. Target Participant's Name Position/Role Gender 1 Female Caregiver Mrs. Vann Ny Mother Female 2 Female Caregiver Mrs. Im Youra Mother Female 3 Female Caregiver Mrs. Mi Chenda Mother Female 4 Female Caregiver Mrs. Saem Yat Mother Female 5 Female Caregiver Mrs. Vuth Pum Mother Female 6 Female Caregiver Mrs. Ret Rina Mother Female 7 Female Caregiver Mrs. Sai Soriya Mother Female 8 Female Caregiver Mrs. Duk Lean Mother Female 9 Female Caregiver Mrs. Tha Dany Mother Female 10 Male Caregiver Mr. Yin Biyou Father Male 11 Male Caregiver Mr. San Pros Father Male 12 Male Caregiver Mr. Tong Ry Father Male 13 Male Caregiver Mr. Te Ty Father Male 14 Male Caregiver Mr. Chea Ol Father Male 15 Male Caregiver Mr. Phoung Savoeun Father Male 16 Male Caregiver Mr. Pheng Pheanith Father Male 17 Male Caregiver Mr. Ya Sy Father Male 18 Male Caregiver Mr. Vy Vong Father Male 19 Male Caregiver Mr. San Kimporn Father Male 20 Grandparents/ Alternate Caregivers Mrs. Tor Chrik Grandmother Female 21 Grandparents/ Alternate Caregivers Mrs. Toy Sokkhim Grandmother Female 22 Grandparents/ Alternate Caregivers Mrs. Siv Eav Grandmother Female 23 Grandparents/ Alternate Caregivers Mrs. Soy San Grandmother Female 24 Grandparents/ Alternate Caregivers Mrs. Chum Hea Grandmother Female 25 Grandparents/ Alternate Caregivers Mr. Phim Ly Grandfather Male 26 Grandparents/ Alternate Caregivers Mrs. Hang Ly Grandmother Female 27 Parents of CLDDD Mrs. Sin Visal Mother Female 28 Parents of CLDDD Mrs. Say Ly Grandmother Female 29 Parents of CLDDD Mrs. Chhoeun Sreymao Mother Female Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 168 List of Key Informant Interviews by Target and Gender No. Target Participant's Name Position/Role Gender 30 Parents of CLDDD Mrs. Ben Sopheap Mother Female 31 Parents of CLDDD Mrs. Oun Run Mother Female 32 Parents of CLDDD Mrs. Hy Tann Mother Female 33 Parents of CLDDD Mrs. Pak Sokheng Mother Female 34 Parents of CLDDD Mrs. Soth Kimhong Mother Female 35 Parents of CLDDD Mrs. No Vanny Mother Female 36 Female VHSG Mrs. Ros Samnang VHSG Female 37 Female VHSG Mrs. Um Vanny VHSG Female 38 Female VHSG Mrs. Long Sophon VHSG Female 39 Female VHSG Mrs. Chouk Nara VHSG Female 40 Female VHSG Mrs. Pheung Phach VHSG Female 41 Female VHSG Mrs. Pheam Lay VHSG Female 42 Female VHSG Mrs. Chim Sopheak VHSG Female 43 Female VHSG Mrs. Meas Kunthea VHSG Female 44 Female VHSG Mrs. Phai Sinat VHSG Female 45 Female VHSG Mrs. Choem Sophai VHSG Female 46 Male VHSG Mr. Ket Kao VHSG Male 47 Male VHSG Mr. Sorn Ram VHSG Male 48 Male VHSG Mr. Prum Piseth VHSG Male 49 Male VHSG Mr. Ven Van VHSG Male 50 Male VHSG Mr. Lay Sambo VHSG Male 51 Male VHSG Mr. Chheang Chhing VHSG Male 52 Male VHSG Mr. Chiv Thok VHSG Male 53 Male VHSG Mr. Toun Travit VHSG Male 54 CDL Mr. Young Sophy CDL Male 55 CDL Mrs. Puth Sokline CDL Female 56 CDL Mr. Siv Sokha CDL Male 57 CDL Mr. Khen Sokkhim CDL Male 58 CDL Mr. Chak Pheap CDL Male 59 CDL Mrs. Rem Mara CDL Female 60 CDL Mr. Noy Thaet CDL Male 61 Commune Committees for Women and Children (CCWC) Mrs. Saom Lai CCWC Female Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 169 List of Key Informant Interviews by Target and Gender No. Target Participant's Name Position/Role Gender 62 Commune Committees for Women and Children (CCWC) Mr. Prak On CCWC Male 63 Commune Committees for Women and Children (CCWC) Mrs. Lai Leak CCWC Female 64 Commune Committees for Women and Children (CCWC) Mrs. Srun Layheang CCWC Female 65 Commune Committees for Women and Children (CCWC) Mrs. Hoem Chhunhong CCWC Female 66 Commune Committees for Women and Children (CCWC) Mr. Yorn Heng CCWC Male 67 Commune Committees for Women and Children (CCWC) Mrs. Chea Dany CCWC Female 68 Commune Committees for Women and Children (CCWC) Mrs. Sum Sophal CCWC Female 69 Health Center Staff Mr. Chom Samnang Nurse Male 70 Health Center Staff Mr. Heu Seung Hai Nurse Male 71 Health Center Staff Mr. Por Virath Nurse Male 72 Health Center Staff Mrs. Bin Sophy Nurse Female 73 Health Center Staff Mr. Tey Tevin Nurse Male 74 USAID Cambodia Mr. Sam Oeurn Ke Alternate AOR Male 75 USAID Cambodia Dr. Sopheanarith Sek AOR IECD Male 76 Implementing Partners Phnom Penh Mr. John Ames Chief of Party, IECD RTI International Male 77 Implementing Partners Phnom Penh Ms. Chanpheakdey Chhuor Deputy Chief of Party, IECD RTI International Female 78 Implementing Partners Phnom Penh Ms. Rany Koy ECD Specialist, IECD RTI International Female 79 Implementing Partners Phnom Penh Mr. Yeng Seng Monitoring, Evaluation and Learning (MEL) Manager, IECD RTI International Male 80 Implementing Partners Phnom Penh Ms. Sreignep Say Gender Specialist, IECD Helen Keller International Female Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 170 List of Key Informant Interviews by Target and Gender No. Target Participant's Name Position/Role Gender 81 Implementing Partners Phnom Penh Mr. Vannary Hou Senior Technial Lead, Nutrition, IECD Helen Keller International Male 82 Implementing Partners Phnom Penh Ms. Sophary Phan WASH Specialiat, IECD RTI International Female 83 Implementing Partners Phnom Penh Mr. Chhany Check Disability Specialist, IECD RTI International Male 84 Implementing Partners Phnom Penh Mr. Meanlenp Heng Provincial Coordinator, Preah Vihear, IECD RTI International Male 85 Implementing Partners Phnom Penh Mr. Sokkhy Chan Provincial Coordinator, Kampong Thom, IECD RTI International Male 86 Implementing Partners Phnom Penh Mr. Kroeun Hou Country Director, Helen Keller International Male 87 Implementing Partners Phnom Penh Mr. Anirudh Singh Bhati Director, Mekhala Radiant Communication Male 88 Implementing Partners Phnom Penh Ms. Kounilla Keo Managing Partner, Mekhala Radiant Communication Female 89 Implementing Partners Phnom Penh Ms. Clara Mloza-Banda Technical Project Managaer, Dimagi Female 90 Implementing Partners Siem Reap Ms. Jessica Whitney Executive Director, Safe Haven Female 91 Implementing Partners Siem Reap Ms. Rebecca Crockett Physiotherapy Trainer/ IECD Project Manager Female 92 Implementing Partners Siem Reap Ms Leakna Chon Deputy Director, Safe Haven Female 93 Implementing Partners Siem Reap Dr. Ngoun Chanpheaktra Hospital Director, Angkor Hospital for Children Male 94 International Development Organizations, Donors, and Donor-Funded Projects Ms. Selemawit Negash Belayneh Nutrition Specialist, UNICEF Female 95 International Development Organizations, Donors, and Donor-Funded Projects Mr. Davy Chhean Early Child Development Specialist, UNICEF Male 96 International Development Organizations, Donors, and Donor-Funded Projects Ms. Anne Provo, World Bank Nutrition Specialist, World Bank Female 97 International Development Organizations, Donors, and Donor-Funded Projects Dr. Sanne Sigh Advisor, GIZ Female Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 171 List of Key Informant Interviews by Target and Gender No. Target Participant's Name Position/Role Gender 98 International Development Organizations, Donors, and Donor-Funded Projects Mr. Sam Oeurn Nutrition Adivsor, GIZ Male 99 National State Organizations HE Say Ung Director Department Food Security Nutrition and Health, CARD Male 100 National State Organizations Dr. Mary Chea Director National Nutrition Program, MoH Female 101 National State Organizations HE Prak Kosal, MOE Deputy Secretary General of Nurturing Care and ECCD Early Childhood Education Department, MoEYS Male 102 National State Organizations Mr. Men Thavro Officer of Welfares for Persons with Disabilities Department, MoSVY Male 103 Provincial Departments Mrs. Dith Radeth (PoEYS) Officer Chief of Provincial Department of Education, Youth and Sport, Kampong Thom Province Female 104 Provincial Departments Dr. Keo Dary (PHD) Deputy Director of Provincial Health Department, Kampong Thom Province Male 105 Provincial Departments Mrs. Ly Sita Nutrition Program Manager of Provincial Health Department, Kampong Thom Province Female 106 Provincial Departments Mr. Kour Lyhout Manager of Physical Rehabilitation Center, PoSVY, Kampong Thom Province Male 107 Provincial Departments Mr. Chan Sim PoEYS, Preah Vihear Province Male 108 Provincial Departments Mr. Phan Saren Deputy Director of Provincial Department of Social Affair, Vetaran and Youth Rehabilitation, Preah Vihear Province Male 109 Provincial Departments Dr. Ly Meng MCH of Provincial Department of Health, Preah Vihear Province Male Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 172 List of Key Informant Interviews by Target and Gender No. Target Participant's Name Position/Role Gender 110 District Deparments Mrs. Taing Kivsophea DoEYS, Kampong Thom Female 111 District Deparments Mrs. Nov Leakkena Operational District, Stoung District, Kampong Thom Province Female 112 District Deparments Mr. Keo Piseth DoSVY, Kampong Thom Province Male 113 District Deparments Mrs. Chheang Soniya DoEYS, Rovieng District, Preah Vihear Province Female 114 District Deparments Mr. Chek Vy DoSVY, Rovieng Distict, Preah Vihear Province Male 115 Operational District Mr. Taon Thoeng Operational District, Tbaeng Mean Chey District, Preah Vihear Province Male 116 Operational District Mrs. Kong Sophy DoSVY, Prasat Sambour District, Kampong Thom Province Female Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 173 ANNEX 6: CONFLICT OF INTEREST DISCLOSURE FORMS Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 174 Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 175 Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 176 Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 177 Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 178 ANNEX 7: EVALUATION TEAM MEMBER QUALIFICATIONS Program Cycle Specialist/Evaluation Team Leader, Ms. Abigail Beeson, MSc, MPH, is a childhood nutrition expert with 20 years of experience, including more than six years living and working in Cambodia, focusing on early childhood development, maternal, newborn and child health, infant and young child feeding (IYCF), as well as significant experience in health systems integration, community-based approaches, gender integration and mainstreaming, women’s economic empowerment, food security, and monitoring, evaluation, and assessment. As Senior Health and Nutrition Specialist for Save the Children Cambodia for three years, Ms. Beeson designed and led a mixed-methods adolescent nutrition baseline evaluation for Kampong Cham; developed an integrated early childhood development and nutrition project for SIDA, developed a Gender Mainstreaming and Childhood Development and Protection national training under the USAID￾funded NOURISH project; participated in the NOURISH baseline and midterm evaluations; and led the completion of the final year evidence-informed learning of the Partnering to Save Lives (PSL) national reproductive, maternal and newborn health project. With CARE Cambodia, Ms. Beeson guided the development of the baseline and midterm evaluations for the PSL project with the National Institute of Public Health and developed social and behavior change initiatives focused on vulnerable groups. Also with CARE, Ms. Beeson served as Co-investigator on a longitudinal case/control cohort evaluation study in Bangladesh; contributed to the evaluation of the CARE and Save the Children Essential Package for Orphans and Vulnerable Children (OVC) in Southern Africa, focusing on holistic early years development; and designed and facilitated nutrition and infant and young child feeding baseline, mid-term and final evaluation assessments for the Window of Opportunity Project. National Evaluation Advisor on Nutrition and/or Childhood Development, Ms. Soksophea Suong, is a child health and protection expert with more than a decade of experience in designing and conducting evaluations, assessments, and research on nutrition and childhood development in Cambodia. Ms. Suong has deep knowledge of quantitative and qualitative evaluation methodologies, including the design of effective survey instruments and semi-structured interview guides, as well as facilitation of focus group discussions, and has been responsible for reviewing, analyzing, and interpreting qualitative and quantitative data specific to various evaluations. She also has substantial experience in leading, managing, and implementing robust advocacy campaigns related to malnutrition, access to education, child rights, and child protection, and has a strong contextual knowledge of nutrition and childhood development in Cambodia. As Senior Campaign Manager for World Vision, Ms. Suong led, managed, and planned the Child Health Now advocacy campaign, which included mass public mobilization and media mobilization to protect and prevent the death of children under five from preventable cause such as malnutrition. Ms. Suong’s recent consulting assignments under UNICEF have included the Cambodia Child Protection Outcome Evaluation; the Social and Behaviour Change Communication Nutrition Capacity Assessment; and the Assessment of the Social Service Workforce to Prevent and Respond to Violence against Children in Cambodia. Program/Logistics Assistant, Ms. Bopha Kong, is a Cambodian national with extensive experience providing data collection, logistics, and translation support for research and evaluation in Cambodia. She has 10 years of experience in international donor-funded project implementation, including more than five years of experience with gender and social inclusion, Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 179 and women’s rights and advocacy, and has significant experience in primary education, social protection, gender equality, public health, and rural livelihoods. She has worked on several evaluations in Cambodia with international teams, using qualitative and quantitative data collection methods and tools. She holds a master’s degree in Primate Law from the Royal University of Law and Economics in Phnom Penh, with certificates in monitoring and evaluation coaching, child’s rights programming, skillful parenting, and human rights, peace, and security. Translator, Ms. Sophea Seng, is a Cambodian national with extensive experience providing data collection and translation support for research and evaluation in Cambodia. Since 2000, she has carried out innumerable consultancies as a researcher, facilitator, and interpreter, including many assignments working on project evaluation teams. She has extensive experience providing consecutive and simultaneous translation for conferences, workshops, trainings, meetings, and research assignments, including many evaluations. She is experienced conducting FGDs and KIIs and is skilled at engaging government officials, NGO staff, project beneficiaries, and local community members. She holds a master’s degree in Khmer Literature from the Royal Academy of Cambodia. Senior Field Research Specialist, Dr. Chey Tech, has 22 years of experience providing a broad range of services to international donor-funded initiatives in Cambodia, including project design and planning, monitoring and evaluation, policy research and strategy development, studies, project mid-term and final evaluation, baseline surveys, program implementation, and organizational management. He has conducted program evaluations of child protection, agricultural value chain, livelihood and rural economic development, research and policy development, social protection, climate change, and democracy and governance programming for a wide range of international NGOs, government agencies, international development contractors, and multilateral and bilateral donors such as UNDP, the EU, the World Bank, USAID, ADB, UNICEF, WFP, and GIZ. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 180 ANNEX 8: FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS MATRIX Summary of Findings for EQ 1 Caregivers learned from nurturing care sessions, community dialogue and home visits to improve how they have nurtured their children Strengths Areas for Improvement Challenges ● Collaborative in the design process ● Nurturing care materials are user-friendly, integrated and reflect current national recommendations, policies, and processes across all ministries and departments ● Home visits are considered very useful in reaching caregivers ● Screenings for MUAC and CBDMAT ● Engaging grandparents with messages that matter to them ● Turnover of staff and busy communities can result in misinformation and recall of messages ● Language development of young children ● Length of the IECD activity cohort ● Community time constraints and frequency of meetings for nurturing care sessions ● Migration is an unresolved challenge for IECD IPs. ● Literacy and devices Recommendations WASH infrastructure improvements for latrines, filters, year round water access and handwashing stations are required in many communities. Particularly as some of the IECD communities are not ODF. All infrastructure improvements should meet the needs of women and men and absolutely require both in the decision-making process. Consider public toilets near farms and plantations to enable ODF and test for arsenic as part of the infrastructure plan for improvement (High Priority). Access to enough potable water for year-round growing of food and to meet household sanitation and hygiene demands is an issue. Respondents regularly mentioned links between lack of water and the availability of food including fish. Observations at households demonstrated that while infrastructure for WASH might be in place, the same water might be used over and over particularly for handwashing to reduce the demand for collecting. Develop water safety plan with private sector and department of rural development and utilize the World Bank WASH analysis on gender to inform thinking on relevant gender issues. 69 (High Priority). 69 World Bank. (2018). Report on Gender Analysis of Water Support for the proposed Bank-supported Water Supply and Sanitation Improvement Project. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 181 Summary of Findings for EQ 1 Work with local engineers and private sector to ensure WASH infrastructure meets the needs of women and girls for safety and use (e.g. locks for at night), is flood resistant, and provides options for households in different socio-economic situations (High Priority). Grandparents are helping with childcare in IECD activity target areas. There is literature available in Cambodia and experiences from efforts such as the Grandmother Project70 to better understand how to effectively engage grandparents in holistic caregiving to inform a pilot for Cambodia. Identify ways to better integrate them into IECD interventions in ways that are meaningful for them and address their caregiving realities (Medium Priority).71, 72 Create a case study to document the design and creation of the nurturing care materials to capture the multi-sectoral process for development and include results from the final evaluation to capture outcomes. Present the case study at CARD working group meetings, National Committee for ECD working group, SUN civil society meetings, and national and provincial nutrition and food security technical workings groups to enable other projects to learn about how to successfully collaborate and create and deliver integrated materials for ECD, nutrition, nutrition-sensitive agriculture, WASH, and CLWD (Medium Priority). Continue to coach and mentor the VHSG and CDL to use the nurturing care sessions with attention to completing the first coaching session within two weeks of the VHSG training or the first time that VHSG hold community meetings or deliver messages, which ever is sooner. Consider more coaching and mentoring within the first six months with the plan that VHSG and CDL would graduate from more intensive coaching. Encourage VHSG to use the nurturing care materials to practice between coaching sessions, meetings, and message delivery and meet with one another to support each other (Medium Priority). Expectations of staff with the IECD activity particularly in the provinces is high. More staff are specifically required to support mentoring and coaching of VHSGs, support caregivers with CLWD, and possibly to advocate and work more with national and local government mechanisms to share learning and identify on-going or future opportunities to align outcomes of the IECD activity (Medium Priority). CBDMAT screenings do not currently fall under the investment of CNP or any MoH funding. Advocate with MoSVY or in the long term work with MoH under the PRC to add this into any programming (Medium Priority). Work with NNP to identify synergies between the CommCARE app and current nutrition monitoring with the HMIS. Identify ways to link the monitoring processes and handover the app (Lower Priority). 70 The Grandmother Project website has various resources and experience with programming mainly in Africa, but has done some work in Laos. It would be worth checking out their website: https://grandmotherproject.org/programs Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 182 Summary of Findings for EQ 1 Caregiving and household tasks are time intensive, which means that home visits are an effective way to reach target populations with IECD messages. Share learning and advocate with government, international donors, and other implementing agencies to include them as part of the model of IECD care (Lower Priority). During the creation of the BCC package, MRC to the best of their ability reviewed and utilized existing data to inform the messages in the BCC package and materials. Gaps however exist in the Cambodia evidence base for engaging grandparents and caregivers of CLWD. Create evidence with the IECD activities to ensure that future BCC projects can benefit from IECD learning and inform future work with these target populations (Lower Priority). Summary of Findings for EQ 1.1 Nurturing Care for Children Strengths Areas for Improvement Challenges ● Communities understand the importance of child development ● Responsive caregiving practices ● Safety and security for children ● Caregivers who participate in IECD activities are not consistently sharing information with other household members ● Caregiver time constraints Recommendations On a national level, the IECD activity should continue to share its learning and progress specific to training and working with VHSGs on MUAC screening. The IECD activity should explore with the NNP, UNICEF and the CNP ways to ensure investments in capacity strengthening are sustained and can be leveraged with the roll out of the GMP trainings. Additionally, explore how VHSG in Preah Vihear can be targeted under CNP to be eligible for an allowance, as a means to sustain the IECD investment for delivering an integrated approach (High Priority). The length of the cohorts presents some challenges with reinforcing messages, ensuring capacity and confidence with delivering nurturing care sessions and missed opportunities for continued home visits to support the various needs of households in achieving the recommended messages. While the messages are important there is a lot of information that caregivers are expected to put into practice in a short period of time. In the future, there should be a consideration of a two-to-two-and-a-half-year implementation cycle for the cohorts (Medium Priority). 71 Schneiders ML, Phou M, Tun V, Kelley M, Parker M, and Turner C. (2021). Grandparent caregiving in Cambodian skip-generation households: Roles and impact on child nutrition. Matern Child Nutrition. Suppl 1(Suppl 1). 72 Schneiders ML, Phou M, Tun V, Kelley M, Parker M, and Turner C. (2021). Grandparent caregiving in Cambodian skip-generation households: Roles and impact on child nutrition. Matern Child Nutrition. Suppl 1(Suppl 1). Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 183 Summary of Findings for EQ 1.1 Caregiver time constraints are a reality. Home visits can help alleviate time expectations of caregivers, but increase the workload of the VHSGs or CDLs. Home visits would be opportunities to engage all caregivers including males and grandparents to ensure all caregiver engagement (Lower Priority). Summary of Findings for EQ 1.2 Nurturing Care for Children Living with Disability Strengths Areas for Improvement Challenges ● CLWD are being identified, referred, and followed up with ● Partnership with Safe Haven and AHC in Siem Reap ● Male and female caregiver engagement ● Integration of CLWD needs across nurturing care messages ● Share learning about CLWD activities ● Caregiver time constraints ● Length of the cohort/ implementation ● Lack of evidence for CLWD and nurturing care Accessing primary health care services for CLWD Recommendations Advocate for longer-term investments for interventions that serve CLWD by utilizing IECD activity learning of supporting CLWD in an integrated multi-sectoral effort (Medium Priority). Integration of CLWD needs across nurturing care messages will benefit from more evidence. The IECD activity cohort implementation framework presents opportunities to generate evidence. Any evidence generated that is specific to the core focus of identifying, referring and following up with CLWD in the community should be documented and disseminated widely. While all efforts should be made to also capture learning on integration with nutrition and WASH specifically. The IECD activity should advocate with agencies working in the child disability space to make IECD learning available in working groups or other technical meetings, so that information specific to the needs of CLWD becomes more accessible for programming design and implementation (Lower Priority). Safe Haven and AHC have valuable expertise working with CLWD. Optimize the partnerships to increase capacity of IECD medical staff (e.g., nurse, physical therapist, and interventionists) to ensure appropriate care for CLWD specifically with nutrition and WASH-related interventions. Work with them to identify some doable tasks that can be integrated into Cohort 3. This might include more specific training for the IECD interventionists or nurses on nutrition and food security. Also connect local WASH suppliers in Kampong Thom and Preah Vihear with those in Siem Reap to learn about modifications for people with mobility devices (Medium Priority). Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 184 Summary of Findings for EQ 1.2 Create and disseminate reminder cards to VHSGs about key overarching needs for caregivers of CLWD. These cards should focus on reminding caregivers of their client and provider rights to medical care. Provide a training to the caregivers of CLWD on their rights and support them to increase their confidence to ask questions, and remain in touch with the same medical provider. Make and distribute to Commune Councils cards with visuals that include contact information for CLWD services (Medium Priority). Advocate for longer-term investments for interventions that serve CLWD by utilizing IECD activity learning of supporting CLWD in an integrated multi-sectoral effort (Medium Priority). Summary of Findings for EQ 1.3 Role of Different Family Members Strengths Areas for Improvement Challenges ● Men are supporting women when they are at home ● Domestic violence and alcohol abuse are not as common ● Grandparents are helping families ● Target messages for and identify ways to meaningful engage grandparents ● Migration ● Income generation activities Recommendations Identify ways to further engage men. Utilize a male positive deviance or male engagement champion model to increase male caregiver participation. Consider meeting in rice paddies, near plantations and other locations where men might be working or passing to and from work. Meet with men on Saturday or Sunday. The IECD activity should consider using social media, TV and radio or other media that men can access when they are away from home working in fields, forests and on plantations. Document the best practices through a quarterly report case study in fiscal year five and share the findings in working groups with CARD, NNP, and MoEYS (High Priority). Access to enough potable water for year-round growing of food and to meet household sanitation and hygiene demands is an issue. Respondents regularly mentioned links between lack of water and the availability of food including fish. Observations at households demonstrated that while infrastructure for WASH might be in place, the same water might be used over and over particularly for handwashing to reduce the demand for collecting. Develop water safety plan with private sector and department of rural development and utilize the World Bank WASH analysis on gender to inform thinking on relevant gender issues. 73 (High Priority). 73 World Bank. (2018). Report on Gender Analysis of Water Support for the proposed Bank-supported Water Supply and Sanitation Improvement Project. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 185 Summary of Findings for EQ 1.3 The Royal Government of Cambodia (RGC) is supporting private sector investments for WASH. Opportunities should be explored for WASH vocational training to increase access to local expertise for fixing and constructing toilets, hand washing facilities and water access points. A CDL in Kampong Thom inquired to the ET about why the IECD activity is not fostering a social enterprise to create and make locally available toys. Another vocational opportunity to explore would be to have local workers who can create toys for children (High Priority). Work with local engineers and private sector to ensure WASH infrastructure meets the needs of women and girls for safety and use (e.g. locks for at night), is flood resistant, and provides options for households in different socio-economic situations (High Priority). Explore local solutions for childcare. This could include extending community preschools to operate as nurseries or childcare facilities, or to explore community childcare models as a local enterprise for caregivers. UNICEF and World Bank are considering options, but very little work has been done to date in Cambodia to invest in alternative home based or very localized community based childcare solutions (Lower Priority). Summary of Findings for EQ 1.4 Male and Female Roles Strengths Areas for Improvement Challenges ● Male and female caregivers are sharing responsibilities at home ● Underlying norms around women’s and men’s domains of influence Men are viewed as the primary ones to earn an income Recommendations Identify ways to further engage men. Utilize a male positive deviance or male engagement champion model to increase male caregiver participation. Consider meeting in rice paddies, near plantations and other locations where men might be working or passing to and from work. Meet with men on Saturday or Sunday. The IECD activity should consider using social media, TV and radio or other media that men can access when they are away from home working in fields, forests and on plantations. Document the best practices through a quarterly report case study in fiscal year five and share the findings in working groups with CARD, NNP, and MoEYS (High Priority). Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 186 Summary of Findings for EQ 1.5, 1.6, 1.7, 1.8 and 1.9 Male Engagement with Caregiving Strengths Areas for Improvement Challenges ● Male caregivers are engaged with caregiving tasks at the household ● Identify ways to further engage men in all household tasks and encourage them to lead on caregiving to learn cues ● Men are busy with income generation activities Recommendations Identify ways to further engage men. Utilize a male positive deviance or male engagement champion model to increase male caregiver participation. Consider meeting in rice paddies, near plantations and other locations where men might be working or passing to and from work. Meet with men on Saturday or Sunday. The IECD activity should consider using social media, TV and radio or other media that men can access when they are away from home working in fields, forests and on plantations. Document the best practices through a quarterly report case study in fiscal year five and share the findings in working groups with CARD, NNP, and MoEYS (High Priority). Summary of Findings for EQ 1.10 Nutrition Screening Strengths Areas for Improvement Challenges ● VHSGs have been trained to use the tool ● More children are being screened and referred ● Confidence to complete a MUAC screening ● Treatment compliance ● Improve breastfeeding and responsive feeding practices in the household where a child has been identified as malnourished ● Sustainability Recommendations On a national level, the IECD activity should continue to share its learning and progress specific to training and working with VHSGs on MUAC screening. The IECD activity should explore with the NNP, UNICEF and the CNP ways to ensure investments in capacity strengthening are sustained and can be leveraged with the roll out of the GMP trainings. Additionally, explore how VHSG in Preah Vihear can be targeted under CNP to be eligible for an allowance, as a means to sustain the IECD investment for delivering an integrated approach (High Priority). Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 187 Summary of Findings for EQ 1.10 Some households are struggling with treatment compliance using BP100. IECD should track households and ensure VHSG are following up with households to check on households’ treatment compliance. Use the opportunity to follow up on breastfeeding and responsive feeding particularly to understand if there are any barriers or misinformation about either feeding practice. Consider intensive twice weekly visits during treatment (Medium Priority). CBDMAT screenings do not currently fall under the investment of CNP or any MoH funding. Advocate with MoSVY or in the long term work with MoH under the PRC to add this into any programming (Medium Priority). Summary of Findings for EQ 2 Home Gardens Strengths Areas for Improvement Challenges ● Easy access to vegetables ● Organic gardening techniques ● Income for women ● Acccess to water year round ● Flooding ● Low water tables Income Generation Activity Strengths Areas for Improvement Challenges ● Income for women ● Primarily from home gardens ● Challenging cultural norms about women’s financial contributions ● Market fluctuations ● Timeline of the cohort Child Nutrition Screening Strengths Areas for Improvement Challenges ● More children were identified for malnutrition ● Improve treatment adherence ● Address children’s aversion to BP100 ● Sustainability WASH Strengths Areas for Improvement Challenges ● Knowledge is present for handwashing, toilet use, and clean environments ● Access to WASH infrastructure ● Misconceptions about clean water ● Flooding ● Lack of subsidies for poor households for WASH Recommendations On a national level, the IECD activity should continue to share its learning and progress specific to training and working with VHSGs on MUAC screening. The IECD activity should explore with the NNP, UNICEF and the CNP ways to ensure investments in capacity strengthening are sustained and can be leveraged with the roll out of the GMP trainings. Additionally, explore how VHSG in Preah Vihear can be targeted under CNP to be eligible for an allowance, as a means to sustain the IECD investment for delivering an integrated approach (High Priority). Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 188 Summary of Findings for EQ 2 WASH infrastructure improvements for latrines, filters, year round water access and handwashing stations are required in many communities. Particularly as some of the IECD communities are not ODF. All infrastructure improvements should meet the needs of women and men and absolutely require both in the decision-making process. Consider public toilets near farms and plantations to enable ODF and test for arsenic as part of the infrastructure plan for improvement (High Priority). Access to enough potable water for year-round growing of food and to meet household sanitation and hygiene demands is an issue. Respondents regularly mentioned links between lack of water and the availability of food including fish. Observations at households demonstrated that while infrastructure for WASH might be in place, the same water might be used over and over particularly for handwashing to reduce the demand for collecting. Develop water safety plan with private sector and department of rural development and utilize the World Bank WASH analysis on gender to inform thinking on relevant gender issues74 (High Priority). Some households are struggling with treatment compliance using BP100. IECD should track households and ensure VHSG are following up with households to check on households’ treatment compliance. Use the opportunity to follow up on breastfeeding and responsive feeding particularly to understand if there are any barriers or misinformation about either feeding practice. Consider intensive twice weekly visits during treatment (Medium Priority). The length of the cohorts presents some challenges with reinforcing messages, ensuring capacity and confidence with delivering nurturing care sessions and missed opportunities for continued home visits to support the various needs of households in achieving the recommended messages. While the messages are important there is a lot of information that caregivers are expected to put into practice in a short period of time. In the future, there should be a consideration of a two-to-two-and-a-half-year implementation cycle for the cohorts (Medium Priority). Work with local restaurants and food vendors to ensure that there are appropriate foods available for families to purchase, while working with sellers in the market to sell bundles of fruits and vegetables that meet diversity recommendations. Advocate with households to prioritize ensuring diverse foods at home and identify local solutions with neighbors and family members to prepare enriched porridge regularly (Lower Priority). 74 World Bank. (2018). Report on Gender Analysis of Water Support for the proposed Bank-supported Water Supply and Sanitation Improvement Project. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 189 Summary of Findings for EQ 2.1 Improving Household Food Security and Child Nutrition Strengths Areas for Improvement Challenges ● Cooking demonstrations ● Animal source protein consumption for young children ● Net food buyers ● Lean seasons ● Water availability Recommendations Households are not consuming animal source protein year-round. Chicken is not consumed, but depended upon as a livelihood. The IECD activity needs to understand why chicken is not being consumed or if chickens are solely for egg production and consumption. Some community volunteers suggested introducing more animal source proteins, but fish and cricket powders as an example have not proven sustainable either as mentioned in KII with international organizations. The IECD activity needs to focus on what is being consumed or desired for consumption and work to identify strategies for increased consumption within households and particularly for young children. Consider liaising with Danish Care Foods to get the results of relevant ongoing pilots (Lower Priority). Summary of Findings for EQ 2.2 Gender Power Dynamics in Improving Household Food Security, Child Nutrition, Home Gardening, Income Generation and WASH Strengths Areas for Improvement Challenges ● Men are more engaged in household activities ● Putting knowledge into practice with WASH ● Understanding water usage demands for men and women ● Volatility of incomes for households ● Climate change and access to water for growing food and household consumption Recommendations Identify ways to further engage men. Utilize a male positive deviance or male engagement champion model to increase male caregiver participation. Consider meeting in rice paddies, near plantations and other locations where men might be working or passing to and from work. Meet with men on Saturday or Sunday. The IECD activity should consider using social media, TV and radio or other media that men can access when they are away from home working in fields, forests and on plantations. Document the best practices through a quarterly report case study in fiscal year five and share the findings in working groups with CARD, NNP, and MoEYS (High Priority). Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 190 Summary of Findings for EQ 2.2 WASH infrastructure improvements for latrines, filters, year round water access and handwashing stations are required in many communities. Particularly as some of the IECD communities are not ODF. All infrastructure improvements should meet the needs of women and men and absolutely require both in the decision-making process. Consider public toilets near farms and plantations to enable ODF and test for arsenic as part of the infrastructure plan for improvement (High Priority). Access to enough potable water for year-round growing of food and to meet household sanitation and hygiene demands is an issue. Respondents regularly mentioned links between lack of water and the availability of food including fish. Observations at households demonstrated that while infrastructure for WASH might be in place, the same water might be used over and over particularly for handwashing to reduce the demand for collecting. Develop water safety plan with private sector and department of rural development and utilize the World Bank WASH analysis on gender to inform thinking on relevant gender issues. 75 (High Priority). Work with local engineers and private sector to ensure WASH infrastructure meets the needs of women and girls for safety and use (e.g. locks for at night), is flood resistant, and provides options for households in different socio-economic situations (High Priority). Summary of Findings for EQ 2.3 Improvements for CLWD Strengths Areas for Improvement Challenges ● Identification, referral and follow up of CLWD is a priority ● Integration with IECD across all sectors ● Client and Provider Rights ● Missed screenings ● Access to increased agriculture production activities given caregiving realities ● Reliability of social protection funds with payments and ensuring enough cash flow Recommendations Work with local engineers and private sector to ensure WASH infrastructure meets the needs of women and girls for safety and use (e.g. locks for at night), is flood resistant, and provides options for households in different socio-economic situations, and has disability modifications (High Priority). Advocate for longer-term investments for interventions that serve CLWD by utilizing IECD activity learning of supporting CLWD in an integrated multi-sectoral effort (Medium Priority). 75 World Bank. (2018). Report on Gender Analysis of Water Support for the proposed Bank-supported Water Supply and Sanitation Improvement Project. Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 191 Summary of Findings for EQ 2.3 Safe Haven and AHC have valuable expertise working with CLWD. Optimize the partnerships to increase capacity of IECD medical staff (e.g., nurse, physical therapist, and interventionists) to ensure appropriate care for CLWD specifically with nutrition and WASH-related interventions. Work with them to identify some doable tasks that can be integrated into Cohort 3. This might include more specific training for the IECD interventionists or nurses on nutrition and food security. Also connect local WASH suppliers in Kampong Thom and Preah Vihear with those in Siem Reap to learn about modifications for people with mobility devices (Medium Priority). Create and disseminate reminder cards to VHSGs about key overarching needs for caregivers of CLWD. These cards should focus on reminding caregivers of their client and provider rights to medical care. Provide a training to the caregivers of CLWD on their rights and support them to increase their confidence to ask questions, and remain in touch with the same medical provider. Make and distribute to Commune Councils cards with visuals that include contact information for CLWD services (Medium Priority). Advocate for longer-term investments for interventions that serve CLWD by utilizing IECD activity learning of supporting CLWD in an integrated multi-sectoral effort (Medium Priority). Summary of Findings for EQ 2.4 Unintended Consequences or Results Strengths Areas for Improvement Challenges ● Men participated more readily during COVID-19 ● Correctly aligned with current government policies and frameworks ● Staff time and commitments ● VHSG engagement ● VHSGs and sustainability ● Commune Investment Plan (CIP) budgets ● Community vulnerability to debt Recommendations On a national level, the IECD activity should continue to share its learning and progress specific to training and working with VHSGs on MUAC screening. The IECD activity should explore with the NNP, UNICEF and the CNP ways to ensure investments in capacity strengthening are sustained and can be leveraged with the roll out of the GMP trainings. Additionally, explore how VHSG in Preah Vihear can be targeted under CNP to be eligible for an allowance, as a means to sustain the IECD investment for delivering an integrated approach (High Priority). Create a case study to document the design and creation of the nurturing care materials to capture the multi-sectoral process for development and include results from the final evaluation to capture outcomes. Present the case study at CARD working group meetings, National Committee for ECD working group, SUN civil society meetings, and national and provincial nutrition and food security technical workings groups to enable other projects to learn about how to successfully collaborate and create and deliver integrated materials for ECD, nutrition, nutrition-sensitive agriculture, WASH, and CLWD (Medium Priority). Mid-Term Performance Evaluation, Cambodia Integrated Early Childhood Development (IECD) Activity 192 Summary of Findings for EQ 2.4 Continue to coach and mentor the VHSG and CDL to use the nurturing care sessions with attention to completing the first coaching session within two weeks of the VHSG training or the first time that VHSG hold community meetings or deliver messages, which ever is sooner. Consider more coaching and mentoring within the first six months with the plan that VHSG and CDL would graduate from more intensive coaching. Encourage VHSG to use the nurturing care materials to practice between coaching sessions, meetings, and message delivery and meet with one another to support each other (Medium Priority). Expectations of staff with the IECD activity particularly in the provinces is high. More staff are specifically required to support mentoring and coaching of VHSGs, support caregivers with CLWD, and possibly to advocate and work more with national and local government mechanisms to share learning and identify on-going or future opportunities to align outcomes of the IECD activity (Medium Priority).