ACTIVITIES TO PROMOTE MOTHER AND CHILD 
WELL-BEING 
IN CARE’s PL480 TITLE II INTEGRATED 
PROGRAMS: 
A Closer Look at the Honduras & 
Mozambique Programs 
photo: Mozambique/© CARE 2001/Mark Langworthy 
Prepared by: 
Joan M. Jennings, MPH, and Andres Peri, PhD, consultants; 
July 2002 
for CARE USA, PHLS Unit, 
151 Ellis Street, Atlanta, Georgia, 30303
This document was made possible in part 
through support provided by the Office of 
Food for Peace, US Agency for International 
Development under the terms of CARE’s 
Institutional Support Assistance Award 
FAO-A-00-98-00055-00. The opinions 
expressed herein are those of CARE and do 
not necessarily reflect the views of the US 
Agency for International Development. It 
may be reproduced, if credit is given to 
CARE. 
Recommended citation: 
CARE 
Activities to Promote Mother-Child Well￾Being in CARE Title II Integrated 
Programs, prepared for the PHLS Unit 
by: Joan M. Jennings, MPH, and Andres 
Peri, PhD, consultants, 2002 
Copies of this document can be 
obtained from: 
CARE USA, PHLS Unit, 151 Ellis 
Street, Atlanta, Georgia, 30303-2440 
http://www.kcenter.com/phls
Tel: 404-979-9127 
Fax: 404-589-2625 
or 
M. Katherine McCaston 
Household Livelihood Security 
Coordinator, CARE USA, PHLS 
Unit, mccaston@care.org 
(electronic copies only) 
ACTIVITIES TO PROMOTE MOTHER AND CHILD WELL-BEING 
IN CARE TITLE II INTEGRATED PROGRAMS 
TABLE OF CONTENTS PAGE NO.
A. Introduction 1-3 
B. Program Descriptions 3-10 
C. Program Results To-Date 11-15 
D. Discussion 16-17 
LIST OF FIGURES PAGE 
NO.
Fig.No.1: Map of FSP area in Honduras 4 
Fig.No.2: Synergies between Food Security Program 
interventions 
5 
Fig.No.3: Community Health Volunteers 6 
Fig.No.4: Map of VIDA area in Mozambique 7 
Fig.No.5: Women's Nutrition Groups preparing improved 
weaning foods 
9 
Fig.No.6: Synergy between VIDA agriculture and nutrition 
interventions 
10 
Fig.No.7: Graph of the percent of stunting for children 24-59 
months of age 
12 
Fig.No.8: Effect of participation in interventions of CARE Food 
Security Program on child stunting, age 24-59 
months 
13 
Fig.No.9 Severity of chronic malnutrition, children age 24-59 
mos 
14 
Fig.No.10: Percentage of children age 24-59 months with 
chronic malnutrition, by participation in VIDA I 
program activities 
14 
ACTIVITIES TO PROMOTE MOTHER AND CHILD WELL-BEING 
IN CARE TITLE II INTEGRATED PROGRAMS, July 2002. 1 
ACTIVITIES TO PROMOTE MOTHER AND CHILD WELL-BEING 
IN CARE TITLE II INTEGRATED PROGRAMS
A. Introduction
CARE adopted the Household Livelihood Security (HLS) framework in 1994. HLS is an 
integrated framework that promotes participatory problem analysis and program design, 
geographically focused programming strategies, coherent and often cross-sector monitoring 
and evaluation systems, and, importantly, reflective practice and continued learning. 
Household livelihood security is defined as "adequate and sustainable access to income and 
resources to meet basic needs".1
 
HLS uses an integrated or systems approach to programming, with recognition that poor 
people and poor households live and interact within broader socioeconomic and 
sociopolitical systems that influence resource production and allocation decisions. Food and 
livelihood insecure households may make trade-offs between basic needs -- such as food, 
health or education -- within the context of their situation. For example, poor households 
might reduce food purchases in order to pay for school fees or books to ensure that their 
children attend school. 
Within this framework, HLS analysis has focused on identifying a limited number of key 
interventions that would, in combination, have the greatest positive impact on the basic needs 
of households. The USAID/BHR Food For Peace Title II Program has provided one avenue 
of opportunity for CARE to operationalize the HLS framework, evolving from school 
feeding and clinic-based food distribution to an integrated food and household livelihood 
security approach. For households to become food secure on a sustainable basis, they must 
rise from the level of poverty that restricts their ability to meet their basic needs. HLS 
poverty analysis of targeted geographic regions informs program design and long-range 
strategic planning for country offices. 
Several of the CARE Title II programs include a component to improve household 
agriculture production, the key source of income for many rural households, along with a 
component to improve the health and nutrition status of mothers and young children, as the 
members of the household most vulnerable to the effects of poverty. 
 
1 Operationalizing Household Livelihood Security: A Holistic Approach for Addressing Poverty and 
Vulnerability, by T.R.Frankenberger, M.Drinkwater and D.Maxwell; CARE 2000. 
ACTIVITIES TO PROMOTE MOTHER AND CHILD WELL-BEING 
IN CARE TITLE II INTEGRATED PROGRAMS, July 2002. 2 
This document takes a closer look at two CARE integrated Title II programs. These are: 
ƒ CARE Honduras Food Security Program (FSP), and 
ƒ CARE Mozambique Viable Initiatives for the Development of Agriculture 
Program (VIDA) 
Both of these programs have completed one five-year cycle of development assistance 
(FY1996-2000 and FY1997-2001 respectively) in a specific targeted geographic area. Both 
have expanded coverage and increased activities within that area for a second cycle of 
assistance (FY2001/2-2005/6). Both programs have included interventions to address 
maternal and child health and nutrition (MCH/N) within integrated programs that also 
address other household basic needs. Yet, these two programs are very different and provide 
a view of the range of MCH/N interventions that can directly contribute to improvements in 
mother-child well-being. 
The CARE USA PHLS Unit Institutional Strengthening Assistance Grant FY1999 calls for 
guidance to be developed on improving the quality of Title II Maternal Child Health and 
Nutrition interventions. This is the second in a series of documents that serve as one method 
for sharing information among for country offices. The first document provided technical 
assistance in identifying strategies and resources used in Child Survival programs.2
 This is 
the first attempt to provide an overview of a few case studies among the many recent 
experiences of CARE Title II programs with MCH/N interventions. 
In addition, this document will take advantage of the opportunities provided by the CARE 
Honduras Food Security Program and the CARE Mozambique VIDA Program monitoring 
and evaluation (M&E) systems that have been established. With the introduction of HLS 
came the commitment to not only improve participatory diagnostic work for program design, 
but also to strengthen capacities to demonstrate measurable impact for program beneficiaries. 
Title II programs are an appropriate vehicle for advancing M&E techniques, in search of the 
balance that obtains sufficient and valid information on program impact while providing 
timely information for continuous improvement during the life of the program. Due to the 
efforts the CARE Honduras and Mozambique programs have invested in M&E, each of these 
programs can demonstrate positive impact for program beneficiaries to-date. 
CARE promotes the use of monitoring and evaluation systems as an iterative process that can 
produce valuable insights on program performance, cross-sector synergies, specific 
vulnerable groups within regions, and more. CARE M&E systems are not developed only to 
report to donors but also to inform the on-going analysis and identification of how 
organizations can best contribute to the alleviation of poverty through sustainable 
development opportunities. Therefore, additional analysis was conducted of the FSP and 
VIDA evaluation databases, to take an introductory look at assessing the effect of potential 
 
2 Strengthening Maternal Child Health and Nutrition Activities in Title II Programs: A Look at Child 
Survival, by R. Charleston and J.Jennings; CARE USA PHLS Unit, October 2001. 
ACTIVITIES TO PROMOTE MOTHER AND CHILD WELL-BEING 
IN CARE TITLE II INTEGRATED PROGRAMS, July 2002. 3 
synergies between program interventions in reducing the percentage of children under age 
five that are stunted in the region. Stunting is a cumulative process that is an indirect 
indicator of household poverty. Children under the age of five are completely dependent 
upon the production and care capacities of others in the family and thereby reflect the status 
of the household. These results are presented in this document. 
As CARE moves forward in the new millennium, additional strategies are increasingly 
important. Initially the HLS focus was on improving the immediate conditions for household 
participants. As HLS has matured, CARE has recognized a need to broaden this perspective 
in order to achieve sustainable impact. In 1999, CARE began to seek ways to improve not 
only peoples' condition but also their position in society, integrating a Rights-Based 
Approach (RBA) into the household livelihood security framework. 
The Rights-Based Approach seeks to deepen holistic analysis to address the root causes of 
poverty, which are often part of larger systemic sociopolitical structures. Current RBA 
efforts within CARE Title II programs include the promotion of good governance and 
institutional capacity-building of local government structures, as well as policy- and 
advocacy-related issues. No additional analysis in this area was conducted for this 
document; however, a good example of CARE efforts in this area can be found in 
descriptions of the Conflict and Rights Project in Sierra Leone.3
 In addition, the final 
evaluation results of local government capacity-building activities are available in the CARE 
Honduras FSP Final Evaluation report for FY1996-2000. 
At present, this document confines itself to a description of two different sets of activities to 
improve mother-child well-being in integrated Title II programs and to an introductory 
analysis of the potential for synergistic impact on child malnutrition from integrated 
interventions.
B. Program Descriptions
The two programs discussed in this document, the CARE Honduras Food Security Program 
(FSP) and the CARE Mozambique Viable Initiatives for Development in Agriculture 
(VIDA), have been selected because they represent some of the variation possible between 
two integrated Title II programs. 
 
The CARE Honduras Title II program has developed hand-in-hand with the Government of 
Honduras (GOH) strategies for improving the quality of life for its citizens. The GOH food 
and nutrition security policies of the early 1990's grew into the present targeted plans for 
poverty reduction. The CARE Honduras Title II program evolved from a program that was 
geographically dispersed, and in which food distribution was the primary focus as an 
 
3
 Food Forum, Fourth Quarter 2001, Issue 58. 
ACTIVITIES TO PROMOTE MOTHER AND CHILD WELL-BEING 
IN CARE TITLE II INTEGRATED PROGRAMS, July 2002. 4 
incentive for mothers to access available health services, into a geographically focused 
synergistic set of interventions based on food security analysis.
The CARE Honduras Food Security Program targets households in three geographic 
Departments in the region of Western Honduras -- one of the poorest regions of the country. 
It is an integrated program with direct food distribution and monetization of commodities. It 
includes three interventions: 
a) PODER: a food-for-work intervention for tertiary road construction and/or rehabilitation 
with a strong focus on activities for environmental mitigation; this intervention also serves as 
the entrance for local government capacity-building activities; 
b) EXTENSA: an agriculture extension intervention to promote sustainable diversified 
production in a zone with limited land availability and poor soil quality, but with good 
potential for linkage with secondary economic corridors for marketing; and 
c) HOGASA: a community-based maternal-child health intervention. 
The PODER component reaches the greatest number of direct beneficiaries, followed by 
HOGASA. EXTENSA has limited coverage, due to financial limitations. Figure No.2 
below describes the desired synergies between program interventions.
Border with El Salvador 
Nicaragua 
Guatemala 
Caribbean Ocean 
Figure No.1: Map of FSP area in Honduras 
CARE Honduras Title II 
Program: Western Region 
ACTIVITIES TO PROMOTE MOTHER AND CHILD WELL-BEING 
IN CARE TITLE II INTEGRATED PROGRAMS, July 2002. 5 
Figure No.2: Synergy between Food Security Program interventions 
 
 
 
The HOGASA MCH/N intervention has a strong partnership with the Ministry of Health 
(MOH), which has been steadily increasing its institutional capacities for supporting mother￾child well-being through the Integrated Management of Childhood Illness framework. Local 
Health education 
Food-for-work for 
improved rural 
roads & municipal 
markets 
Improved maternal and 
child health 
Increased access to 
and use of health 
services 
Improved household food 
consumption 
Increased and 
diversified food 
production 
Nutrition 
education and 
food 
distribution 
Increased 
income & 
decreased 
transport 
costs 
Reduction of household poverty 
and child malnutrition. 
Purchase of 
healthy foods 
Purchase of 
agriculture 
inputs 
Local government 
institutional & 
human resource 
capacity-building
environmental 
mitigation 
disaster 
preparedness 
civil society 
participation 
cross-cutting activities 
HOGASA 
HOGASA 
PODER EXTENSA 
ACTIVITIES TO PROMOTE MOTHER AND CHILD WELL-BEING 
IN CARE TITLE II INTEGRATED PROGRAMS, July 2002. 6 
health centers achieve good coverage for the immunization of children and tetanus toxoid for 
women of reproductive age. They have sufficient supplies of oral rehydration solution, 
which is regularly provided to HOGASA community health volunteers. They collaborate 
with HOGASA in the development of a model for community-based treatment and referral of 
pneumonia cases. 
The HOGASA MCH/N intervention directly supports all MOH maternal-child primary 
health care activities and further complements the strengths of the MOH by focusing on the 
following areas at the community level: 1) nutrition education for the use of appropriate 
complementary feeding practices; 2) growth monitoring of children that is community-based; 
and 3) the appropriate community-based 
case management for common childhood 
illnesses, such as diarrhea and/or acute 
respiratory infection. 
These activities are carried out through 
training and support for community 
health volunteers. Direct food 
distribution of a monthly family ration to 
households with children age 6 to 24 
months or pregnant or breastfeeding 
mothers provides a mechanism for 
nutrition education outreach. 
It should be noted, however, that the 
program has been careful to maintain as 
separate the actual food distribution 
activity from growth monitoring 
nutrition education activities. Research 
has shown that growth monitoring 
activities have a tendency to become 
focused on the first stage - measuring 
and recording growth - and fail to 
appropriately make use of the 
opportunity of this activity to provide 
nutrition education and counsel 
individual mothers.4
 
4 A UNICEF Nutrition Information Strategy: Improving Decision-Making at Household, Community and 
National Levels, by U.Jonsson, D. Pelletier and R. Shrimpton; UNICEF 1998. 
photo: Honduras/©CARE 2000
Figure No.3: Community Health Volunteers
ACTIVITIES TO PROMOTE MOTHER AND CHILD WELL-BEING 
IN CARE TITLE II INTEGRATED PROGRAMS, July 2002. 7 
In addition, the HOGASA intervention collaborates with other strong partners in the region, 
especially in the area of family planning and reproductive health, such as ASHONPLAFA 
(the IPPF affiliate) and the Population Council. 
As described in Figure No.2, the conceptual model of expected synergy between 
interventions, the program also includes cross-cutting activities for local government 
capacity-building to increase civil society participation that are woven through the three 
distinct interventions of HOGASA, PODER and EXTENSA. 
The CARE Mozambique Viable Initiatives for the Development of Agriculture (VIDA) 
program began as an agricultural extension program but has recently evolved into a program 
including interventions to directly promote mother-child well-being through a route very 
different to that of the CARE Honduras program. 
Figure No.4: Map of VIDA area in Mozambique 
Zimbabwe 
Malawi 
CARE Mozambique Title II 
program in Nampula 
Province 
ACTIVITIES TO PROMOTE MOTHER AND CHILD WELL-BEING 
IN CARE TITLE II INTEGRATED PROGRAMS, July 2002. 8 
The VIDA program grew out of a successful CARE Mozambique program to promote an 
economically viable rural-based vegetable oil production capacity among poor households in 
the province of Nampula, in northern Mozambique (Figure 4). This area had historically 
been a strong area for commerce, with a railroad extending from the coastal port of Nacala to 
the border with Nacala. Today, one of the main highways of Mozambique parallels the 
railroad. The area is fertile and the low population density means there is little land pressure. 
In spite of all this potential, however, the province is among the poorest in Mozambique. 
The VIDA program built upon the successful establishment of rural oil production capacity 
through a pilot project originally funded by other sources. As one of the objectives of the 
food security strategy of the USAID mission for Mozambique is to increase rural household 
income through increased sustainable agriculture output, CARE Mozambique sought funding 
from this source to expand coverage when the project's potential for success was apparent. 
The VIDA I program (FY1997-2001) was implemented in roughly two-thirds of the districts 
in Nampula Province. The agricultural intervention went beyond oil seed crops to a variety 
of crops for diversified production and sale, along with a focus on extending the harvest 
period for staple crops to promote food security throughout the year. 
After 3 years of project implementation, there was evidence that there were increases in 
household income for participants. However, household livelihood security analysis raised 
the question as to whether increasing household income would immediately translate into 
improved household food consumption (an expected "natural" synergy), especially for 
vulnerable members of the household, such as women and children. At this point, the VIDA 
I program chose to incorporate a nutrition intervention that would be specifically targeted to 
mothers with children under age five in a limited number of program districts, or 
approximately one-third of the VIDA program target area. 
The focus of the nutrition intervention has been to promote appropriate complementary 
feeding practices for the weaning period (extended breastfeeding is a traditional practice for 
the majority of women, while the introduction of solids occurs later than recommended). 
Due to the low educational levels of women in the area, the number of nutrition education 
messages were limited and careful efforts to assess the comprehension and retention of 
nutrition education materials were a part of the initial design of the activity. 
The nutrition education strategy is based on improving the traditional weaning food, which is 
porridge made of corn or cassava. The recipes promoted for improved weaning foods rely 
upon available foods traditionally produced by households or food crops that are promoted 
through the agricultural extension intervention of VIDA. In addition, the nutrition 
intervention is linked with the agricultural intervention for the promotion of dark orange￾fleshed sweet potatoes as a source of Vitamin A.
Mothers' Nutrition Groups have been formed and trained to further multiply the key 
messages regarding the appropriate frequency of feeding for children age 6 to 24 months, the 
importance of calorie-dense food and the importance of Vitamin A consumption for health 
ACTIVITIES TO PROMOTE MOTHER AND CHILD WELL-BEING 
IN CARE TITLE II INTEGRATED PROGRAMS, July 2002. 9 
within their communities (Figure No.5). A diversified diet is also promoted, based on the
linkage between nutritionally balanced diets and greater diversity in food consumption.5
Photo: Mozambique/©CARE 2001 
Figure No.5: Women's Nutrition Groups preparing improved weaning foods 
The program is entering a second funding period and has chosen to expand the coverage of 
the nutrition component to all program target districts and broaden the range of nutrition 
education messages disseminated. With high rates of anemia among women and children, 
nutrition education will begin to focus on the importance of the consumption of foods rich in 
iron by children during the weaning period. The intervention will also target pregnant 
women, providing nutrition education on appropriate diet during pregnancy and highlighting 
the importance of the sufficient consumption of calories, vitamins and micronutrients, such 
as iron. These actions will complement national micronutrient initiatives by the Helen Keller 
Institute, provincial initiatives for capacity-building activities for the Ministry of Health in 
Nampula and a CARE Child Survival program operating in two of the VIDA districts. 
Staff will conduct formative investigation with focus groups to better understand the 
traditional and/or modified traditional dietary practices during pregnancy so that nutrition 
education messages can be tailored in response. It is likely the intervention will need to 
address issues related to gender equity as part of this process.
Besides the fact that the VIDA II agriculture and nutrition activities are targeted to the same 
areas, there are several distinct linkages between the interventions. To achieve the
 
5 Measuring Household Food Consumption: A Technical Guide, by A.Swindale and P.Ohri￾Vachaspati; Food and Nutrition Technical Assistance Project; November 1999. 
ACTIVITIES TO PROMOTE MOTHER AND CHILD WELL-BEING 
IN CARE TITLE II INTEGRATED PROGRAMS, July 2002. 10 
sustainability of the Mothers' Nutrition Groups, the groups are provided with seeds through 
the agricultural intervention and encouraged to produce and sell these crops for the financial 
support of group nutrition education activities. Mothers' Nutrition Groups are also linked 
with legally inscribed Farmers' Associations and are expected to participate in periodic 
events in which the two groups participating in VIDA interventions share new information 
and discuss program successes and challenges (Figure No.6). 
Figure No.6: 
Synergy between VIDA agriculture and nutrition interventions
All of the VIDA program actions directly support the goals of the program counterpart, the 
Ministry of Agriculture and Fisheries, and the objectives of the Technical Secretariat for the 
Food and Nutritional Security Strategy (SETSAN) adjunct to that ministry and created as a 
focal point for coordination of the Action Plan for Food and Nutrition Security of the 
Republic of Mozambique.
Production of oil 
seed crops, 
staple crops, 
orange sweet 
potatoes, fruits 
& vegetables 
Nutrition 
education for use 
of diverse foods 
in weaning 
recipes Improved 
household 
food 
consumption 
Seed and 
cuttings 
multiplication Women's 
Nutrition 
Group plots 
Increased 
household or 
group income 
Formation of 
Farmers' 
Associations 
Women's 
Nutrition Groups 
present to FA Sustainability 
of program 
activities 
ACTIVITIES TO PROMOTE MOTHER AND CHILD WELL-BEING 
IN CARE TITLE II INTEGRATED PROGRAMS, July 2002. 11 
C. Program Results To-Date
In line with CARE's commitment to demonstrate measurable positive impact for program 
beneficiaries and to monitor information in a timely fashion for the continuous improvement 
of program activities, both the CARE Honduras Food Security Program ((FSP) and the 
CARE Mozambique Viable Initiatives for the Development of Agriculture program (VIDA) 
include a strong focus on monitoring and evaluation. 
CARE Honduras has invested heavily in the monitoring and evaluation of its Title II Food 
Security Program. The FSP program has contracted the same external firm to conduct 
baseline survey in 1996, midterm evaluation in 1998 and final evaluation in 2000, which also 
served as a baseline for the FY2001-FY2005 period. This firm developed the survey 
instruments and has organized the training of external surveyors, with technical assistance 
from the Food and Nutrition Technical Assistance Project (FANTA) and from the CARE 
Honduras FSP Monitoring and Evaluation Specialist. The firm is also responsible for data 
entry and the production of frequency tables, cross-tabulations and analysis for statistical 
significance when comparing results over time. The CARE Honduras FSP staff internally 
conduct all quarterly monitoring activities and regularly participate in team workshops, along 
with program partners, to reflect upon both monitoring and evaluation results and adjust 
program strategies accordingly. 
Among the higher-level indicators that are evaluated by the CARE Honduras FSP are 
indicators of household income, household food consumption and child malnutrition. The 
tools and techniques for the measurement of household income from agricultural production 
and other sources of income were developed with significant assistance from FANTA and 
have not changed over the life of the program. However, the indicators reported upon from 
these tools have been adapted over time to better reflect the direct effects of the program. 
At baseline in 1996, the survey also included a separate activity to measure household food 
consumption through repeated observational visits to a limited number of households, during 
which the food to be consumed was weighed and/or compared to containers calibrated for 
size and weight. This technique was exchanged for the 24 hour diet recall method for 
household consumption and is now included in the household survey instrument. The 
diversity of household food consumption, which has been found to correlate well with 
observational methods to calculate diet sufficiency, is now reported as the key indicator. 
Anthropometric tools, or measurement of the weight and height of children from 0-59 
months of age, have been a mainstay among the program's evaluation techniques. One of the 
most exciting results found during final evaluation FY2000 was a decrease in the percentage 
of children age 24-59 months classified as stunted (height-for-age <-2 standard deviations, Z￾scores) when compared to baseline values. At baseline, 54.9% of children age 24-59 months
were classified as chronically malnourished, or stunted. This had decreased to 47.2% by 
final evaluation (Figure No.7).
ACTIVITIES TO PROMOTE MOTHER AND CHILD WELL-BEING 
IN CARE TITLE II INTEGRATED PROGRAMS, July 2002. 12 
Figure No.7 
Graph of the percent of stunting for children 24-59 months of age
47.2*
65.8
54.9
0
10
20
30
40
50
60
70
80
BASELINE INTEGRATED
AREA
NEW AREA
 * Statistical significance at p<0.01. 
As a baseline survey for the FY2001-2005 period was conducted at the same time, it was also 
found that for another comparison group, the communities that would enter the program in 
FY2001 as coverage in the region is expanded, chronic malnutrition was even higher, at 
65.8%. 
Child malnutrition is a higher-level indicator that reflects multiple factors related to 
household livelihood security. One of these factors is child health care. When considering 
the activities addressed by the CARE Honduras FSP maternal-child health and nutrition 
intervention, improvement was found in multiple indicators of mothers' knowledge and 
practices for the care of child health and nutrition. As improvements were also found in 
household food consumption, along with other indicators of the agricultural extension 
intervention, EXTENSA, and the food-for-work and local government capacity-building 
activities of PODER, the next question was whether the synergies between interventions as 
conceived in the design of the program had also contributed to the achievement of reducing 
child malnutrition. 
Regression analysis was conducted of household participation in the different program 
interventions. The idea was to see if there was a difference in the impact on child 
malnutrition between household participation in one, two or all three of the interventions, 
after controlling for a set of household and individual characteristics. The characteristics of 
household access to water and sanitation, gender of the head-of-household, and the child's 
age and sex were controlled, as well as the number of months of participation in the program. 
The regression model predicted the probability that a child within the household was 
chronically malnourished (Figure No.8).
ACTIVITIES TO PROMOTE MOTHER AND CHILD WELL-BEING 
IN CARE TITLE II INTEGRATED PROGRAMS, July 2002. 13 
Figure No.8 
Effect of household participation in interventions of the 
CARE Food Security Program on child stunting, age 24-59 months
Variable Coefficient 
Participation in any 1 intervention (reference) 1.0000 
Participation in 2 interventions 1.1115 
Participation in all 3 interventions 0.3441 * 
 * Significant at 0.01 
The coefficient expresses the increase or reduction in the probability of finding a chronically 
malnourished child within the household as compared to the reference case (participation in 
any 1 intervention). A coefficient of 1.000 represents no difference in probability. Little 
difference was found for households participating in any two interventions. However, a clear 
relation between improvements in chronic malnutrition and participation by households in all 
three interventions was evident. When a household benefits from the expected synergies 
between all program components, the probability of finding a child with chronic malnutrition 
in that household is reduced by two-thirds (from 1.0000 to 0.3441). 
Although this analysis is very preliminary, it may indicate that there is a "threshold" level 
where various changes and effects accumulate sufficiently to result in measurable positive 
impact on higher-level indicators. This analysis has encouraged the CARE Honduras Food 
Security Program to continue to seek to integrate project activities within communities as the 
results are clearly worth the effort. The database established will permit broader and more 
detailed regression analysis and comparison of evaluation results in FY2005. 
For the CARE Mozambique VIDA program, it is still too early to expect to demonstrate a 
synergistic effect from combined program interventions as the nutrition component was 
integrated with the agricultural activity in only one-third of the target area and in only the 
final two years of the first program cycle. Comparison of the final evaluation results of 2002 
to results from the baseline survey in 1997 revealed no statistically significant change in the 
overall percentage of chronic malnutrition found in children age 24-59 months, 60.0% to 
59.2%. 
However, a decrease in the severity of stunting was demonstrated, with 9.2% (more than 75 
children) moving from the classification of severe stunting (height-for-age 
<-3 standard deviations) to the category of moderate stunting (<-2 sd but >-3 sd), as seen in 
Figure No.9.
ACTIVITIES TO PROMOTE MOTHER AND CHILD WELL-BEING 
IN CARE TITLE II INTEGRATED PROGRAMS, July 2002. 14 
Figure No.9 
Severity of chronic malnutrition in children age 24-59 months 
Z score Baseline 1997 Survey 2002 
Height-for-age n % n % 
Severe (<-3 sd) 304 34.5 210 25.3 
Moderate (<-2 sd and >-3 sd) 224 25.5 282 33.9 
Mild or none (>-2 sd) 352 40.0 341 41.0 
TOTAL 880 100.0 831 100.0 
A reduction in stunting among children age 24-35 months was also found, from 65.2% to 
57.7%, another positive effect that may accumulate to show measurable change in the 
stunting of children age 24-59 months by FY2006. 
The sample selection for evaluation of Title II programs uses a population-based cross￾sectional analysis over time and includes both participating and non-participating 
households. Although it is too soon to invest in additional analysis beyond that necessary to 
track and report on program indicators, simple cross-tabulation of program participation and 
nutritional status reveals a positive trend for program participants (Figure No.10).
Figure No.10 
Percentage of children age 24-59 months with 
chronic malnutrition, by participation in VIDA I program activities
HEIGHT-FOR-AGE 
Household Participation < -2 s.d. 
in VIDA Project Activities n % 
Any project activity 181 56.9 
No participation 225 64.1 
Agriculture only 77 49.3 
Nutrition only 86 62.7 
Agriculture and nutrition 18 72.0 
No participation 225 64.1 
ACTIVITIES TO PROMOTE MOTHER AND CHILD WELL-BEING 
IN CARE TITLE II INTEGRATED PROGRAMS, July 2002. 15 
The results show a benefit from household participation in any project activity as compared 
to non-participation, although the benefit is greater for households participating in the 
agriculture intervention. However, even with only two years of intervention in one-third of 
the program's target area, a benefit is seen for those participating in the nutrition activity. 
The expected benefit from synergy between interventions is not seen, but the total number of 
households that participated in both interventions was very limited during the VIDA I period. 
 
It is expected that the positive trends seen at the end of the first cycle of the CARE 
Mozambique VIDA program will continue and accentuate as the program implements a 
second cycle. Although program expansion brings additional challenges to reach new 
participants, the expansion of the nutrition component to all of the targeted districts is likely 
to result in a synergy between interventions that will potentiate positive impact for 
households, as seen in the CARE Honduras Food Security Program. The excellent database 
being established by the CARE Mozambique VIDA program will permit for a variety of 
analyses at final evaluation in FY2006 that can inform CARE's long-range strategic planning 
and program design for northern Mozambique.
ACTIVITIES TO PROMOTE MOTHER AND CHILD WELL-BEING 
IN CARE TITLE II INTEGRATED PROGRAMS, July 2002. 16 
D. Discussion
This document, which reflects upon the design and activities of maternal-child health 
interventions in two CARE Title II integrated programs, highlights several points worthy of 
further discussion. 
Both programs have designed their interventions for maternal-child health and nutrition in 
response not only to the needs of the target population but also as complementary to the 
capacities of their government counterparts. The CARE Mozambique VIDA program has 
multiple direct linkages between the activities of its agricultural extension component and the 
nutrition education intervention. It directly supports the food security goals of its 
counterpart, the Ministry of Agriculture and Fisheries and the adjunct Technical Secretariat 
for the Food and Nutritional Security Strategy (SETSAN). The CARE Honduras MCH/N 
intervention complements and strengthens the efforts of local Ministry of Health partners. 
Program activities are integrated at the community level through a focus on local government 
capacity building that includes strengthening the abilities of community organizations to 
work effectively with local government. 
Both programs show signs of a positive impact on household livelihood security, as 
measured by the nutritional status of one of the household's more vulnerable members, from 
the design of programs that include interventions to address mother and child well-being. 
The impact for the CARE Honduras Food Security Program is dramatic and statistically 
significant, with the program continuing to build upon its years of experience in maternal￾child health and nutrition. For the CARE Mozambique VIDA program, the nutritional 
intervention is a new addition that is beginning to show positive results and can be expected 
in the future to synergistically multiply the positive effects already seen for households 
participating in the agriculture extension component and, to a lesser degree, participating in 
the nutrition component. 
As the evaluation of Title II programs is population-based and cross-sectional over time, the 
need becomes apparent for Title II programs to not only focus on continuous improvement of 
the design of program activities for direct participants but also on the ways and means to 
reach non-participants. The opportunity provided by the programs' evaluation systems to 
look at new areas for program expansion as comparison groups, along with the opportunity to 
look at the indicators over time, addresses some of the issues which are naturally raised 
regarding participants vs. non-participants and external factors beyond the control of the 
programs. 
The investment both country offices have made in conducting rigorous and large-scale 
evaluation is providing a wealth of information to assist program planning and design. 
Although only a few evaluation results were presented in this document, both programs 
ACTIVITIES TO PROMOTE MOTHER AND CHILD WELL-BEING 
IN CARE TITLE II INTEGRATED PROGRAMS, July 2002. 17 
monitor and evaluate between 20 and 30 indicators, along with gathering information on 
demographic variables. Both programs have arranged for the training and materials 
necessary to conduct anthropometric measurement of children, which is an activity both 
technically and functionally different from household survey. (Additional information is 
available in either program's reports for final evaluation, which can be obtained through the 
CARE USA PHLS Unit.) In addition, although not discussed in this document, both 
programs regularly monitor a large number of indicators in the field, tracking a significant 
amount of information on program implementation, participant activities and seasonal effects 
or impact. 
It is interesting to note that further analysis, beyond that needed to track and report upon the 
programs' performance indicators, was necessary to assess the effects of synergy between 
interventions and other variable levels of program participation and potential impact 
discussed in this document. CARE can continue to take advantage of the databases that have 
been developed and arrange for additional analyses to contribute to a better understanding of 
program design and integration, synergy between interventions, and other areas of interest, 
such as the effects of program activities on gender equity.