Annex: SPRING Pathways to Better Nutrition Qualitative Methods - Nepal

SPRING has adapted guidance from several sources to develop a methodology for extracting nutrition-specific and nutrition-sensitive funding data from donor and government budget documents. This document is an annex to the Pathways to Better Nutrition (PBN) Case Study Series that outlines SPRING’s methodology and includes limitations of the data presented, as well as references for further information.

Background

Objectives for the qualitative research component of the SPRING Pathways to Better Nutrition (PBN) Nepal case study:

• To explore the processes through which various nutrition stakeholder institutions in-country prioritize their activities to support (financially, politically, and operationally) the rollout of the Multi-Sector Nutrition Plan (MSNP)
• To identify views and opinions of these stakeholders regarding the various aspects ofthe MSNP rollout
• To explore the perceptions of these stakeholder institutions on multisectoral nutrition and the MSNP
• To follow up with potential changes in the priorities over time, to understand the rationale that support such changes, and to analyze the potential impact of these changes on support for the MSNP rollout process

Methods

The PBN case study is a mixed method, prospective study. As an integral part of the case study research, qualitative data are collected throughout the course of the case study. The primary baseline data collection method is the structured key informant interview (KII). The Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) project used the Grounded Theory Approach to identify themes to code data while following the framework and key domains of inquiry for the global PBN case study.

The SPRING project designed the KII questions so that key informants’ (KIs’) responses will enable the case study team to obtain a thorough understanding of the issues stated in the aforementioned objectives. The design also will facilitate insightful interpretations of the key domains of inquiry of the overall case study (listed below) over time. These domains cut across the objective areas.

• Learning on scaling up a multisectoral approach
• Adaptation to local context(s)
• Financing of nutrition-sensitive (sector level) and -specific (within sector) activities
• Long-term planning for sustainability

Baseline

Recruiting Key Informants

National Level

The study research questions center on how each key stakeholder institution will prioritize the activities proposed in the MSNP and how they will be funded while the plan is being rolled out. Individuals had to meet at least one of the following criteria to be considered KIs:

• They were involved in developing the MSNP or are well versed on its objectives, if not previously involved.
• They had designated roles in the rollout of the MSNP within or beyond their specific institutional affiliations.
• They actively participated in or have significant influence on the implementation and financing of the MSNP.

In addition, potential KIs needed to be affiliated with one of the key nutrition stakeholder institutions in Nepal. The Scaling Up Nutrition (SUN) movement categorized such institutions into six groups (SUN 2010).

• Government.
• Donor agencies (bilateral and multilateral aid agencies).
• Civil society organizations (CSOs).
• Business/private sector.
• United Nation (UN) groups.
• Academic/research institutions.

As a result, the final KIs were chosen based on the following attributes:

• They were designated MSNP focal persons within government or were in planning divisions of line ministries or Ministry of Finance and assisted with making budgetary decisions.
• They were recognized technical experts and opinion leaders based on the team’s knowledge.
• They were listed as MSNP working group or committee members.
• They were available and willing to be interviewed by the case study team.

Sampling was purposive, and the sample for KIs included representatives of all six key stakeholder groups. In addition, at least one focal person and one planning division representative were interviewed from each of the implementing line ministries named in the MSNP. The final list of KIs was determined through an iterative process that the case study team members in the SPRING Home Office and country office used.

The SPRING project’s case study country staff made phone calls and visits to the offices of the final list of KIs to schedule interviews. An introduction letter from SPRING and support letter from the National Planning Commission (NPC) were delivered to the KIs to invite them to participate in the study.

District Level

For the local-level interviews, SPRING selected three out of the first six districts where the MSNP approach was rolled out (“prototype,” or pilot, districts). These districts were selected on the basis of diversity in terms of geographic location, nutritional status, and the predominant nutrition-related project within the district. The project’s case study team members in Nepal received approval of district site selection from the NPC before the district visits.

SPRING designed the selection of district-level KIs to have representatives from five of the six key stakeholder groups noted in the National Level section (the district sample did not include members of academia). A few modifications in the recruitment process were made to accommodate circumstances at the district level. First, all members of the District Nutrition Coordination Committee (DNCC) were included as KIs. These members are also MSNP Focal Persons from each of the seven line agencies involved in the MSNP rollout: District Development Council, health, agriculture, women and child development, livestock, education, and water and sanitation. Second, local representatives from the UN and key donor agency implementing nutrition programs were included in the sample: In Parsa, SPRING interviewed representatives from the World Bank’s Sunaula Hazar Din project; in Achham and Kapilvastu, SPRING interviewed KIs from the U.S. Agency for International Development’s Suaahara project. In addition, to the extent possible, SPRING included other CSOs, e.g., representatives of local nongovernmental organization federations and the Civil Society Alliance for Nutrition in Nepal. Third, stakeholders from the business/private sector were contacted, e.g., representatives of the local chambers of commerce.

Interviews also were conducted in one village development council (VDC) per district where the MSNP is being implemented. Key informants at the VDC are members of the Village Nutrition and Food Security Steering Committee. The three VDCs selected were Harpur in Parsa, Siudi in Achham, and Hariharpur in Kapilvastu.

Basic Information of Key Informants

Key informant interview totals by stakeholder group are shown in tables 1–4. At the national level, 32 KIs from 21 agencies were interviewed. At the district level, 58 interviews were conducted, and 31 interviews were conducted at the VDC level.

National Level

Table 1. Key Informant Interviews for PBN Case Study Baseline Data Collection

District and VDC Levels

Table 2a. Key Informant Interviews for PBN Case study Baseline Data Collection in Parsa, District Level

Table 2b. Key Informant Interviews for PBN Case Study Baseline Data Collection in Parsa, VDC Level (MSNP VDC – Harpur)

Table 3a. Key Informant Interviews for PBN Case Study Baseline Data Collection in Achham, District Level

Table 3b. Key Informant Interviews for PBN Case Study Baseline Data Collection in Achham, VDC Level (MSNP VDC – Siudi)

Table 4a. Key Informant Interviews for PBN Case Study Baseline Data Collection in Kapilvastu, District Level

Table 4b. Key Informant Interviews for PBN Case Study Baseline Data Collection in Kapilvastu, VDC Level (MSNP VDC – Hariharpur)

Key Informant Interview Guides

The NPC supported the national- and district-level KIIs by providing introduction letters. The Institutional Review Board (IRB) of John Snow, Inc. and the IRB of the Nepal Health Research Council (NHRC) approved the research protocol and the national KII guide.

National Level

The national KII guide for baseline data collection was developed to capture information related to the study objectives. The national KII guide included four sections: knowledge of and current responsibilities related to MSNP rollout; processes and rationales to identify and budget for selected priority activities to implement MSNP; perceptions of scaling up nutrition and its realization in Nepal through MSNP; and budgeting processes. Due to the differences in the functions that each stakeholder group assumes in support of the MSNP, a core body of questions was developed that applies to all groups. Specific questions were developed to inquire each group of stakeholders about its unique contribution to the MSNP. Six sets of KII guides were developed, all following a similar structure.

The draft KII guide went through several rounds of deliberations and revisions among the case study team and the consultants. It was pilot-tested with a national nutrition leader in-country to assess the clarity and appropriateness of the questions, as well as the time required to complete all the questions. The KII guide was then finalized after the inputs and feedback from the pilot test were incorporated.

District Level

For the district level, the KII guide adopted the overall structure of and many questions in the national KII guide. Modifications were made to fit MSNP and SUN movement within the local context. The first section of the district KII guide asked KIs’ about their perceptions of the nutrition situation in their own districts. Similarly, the last section of questions on the perceptions of scale-up and rollout of MSNP also focused KIs’ attention on the district where they resided and worked. Because each MSNP “prototype” district is required to establish a DNCC to lead the rollout, the questions in the second section (prioritization and funding of the key MSNP-related activities) centered on how the DNCC made prioritization and funding decisions. Therefore, most questions in this section were designed in a way that could be applied to various stakeholder groups in the district. The exceptions to this were representatives from the government sector, who were asked KIs specifically about their relationships with their ministerial counterparts in terms of setting priorities and negotiating budgets. The intention of this section was to establish critical linkages between the national and district levels in MSNP implementation.

Data Collection, Processing, and Analysis

The SPRING project conducted the baseline national interviews in July 2014 in Kathmandu. The baseline district interviews were collected in Parsa, Achham, and Kapilvastu from February to April 2015. The timing for the district interviews was delayed at the request of donors and government officials, to allow for MSNP activities to begin in these districts.

All national- and district-level KIIs were scheduled to occur in the KIs’ offices and lasted for 30 to 80 minutes. The support letter from the NPC was presented to every KI at the national level. Each KI was requested to sign a written informed consent form to give the case study team permission to 1) ask the KI questions and 2) record the conversation. All but two KIs agreed to be interviewed, and slightly more declined to be recorded. All signed consent forms were carefully kept in a safe place and submitted to the IRB of the NHRC upon the completion of the data collection.

When permission was granted, the interviews were recorded with a Sony MP3 Portable Digital Voice Recorder (Model ICD-PX333 and 312). In addition, the case study team and consultants took notes. Debriefing and review of notes were undertaken on the same day of interviews. All handwritten notes were typed up within days of interviews. The majority of interviews were carried out in English, with the remainder a mix of Nepali and English. At the district and village levels, the majority of interviews were conducted in Nepali, with some in Hindi (in Parsa and Achham) and English. Recordings were then directly translated (if applicable) and transcribed into English. The recording was erased from the recorder once it was transferred to a computer for transcription. For interviews that did not have accompanying recordings, notes from each of the case study team members present for the interview were consolidated and finalized. The codes and the transcripts/notes are stored in a folder on the SPRING project’s central portal that is only accessible to authorized case study team members.

Transcripts were uploaded and processed in NVivo 10 (QSR International, Australia). The SPRING project adopted the grounded theory approach to allow the key themes to emerge from the transcripts and notes (Lingard, Albert, and Levinson 2008). During the initial review of the transcripts/notes, special attention was made to emerging themes that were most aligned with the case study’s primary concerns (the prioritization and funding of activities for the rollout of MSNP), as well as the key domains of the case study.

Follow-up Plan

Key Informants

Due to changes of personnel in the government and other stakeholder groups, some KIs who had been interviewed in the baseline did not serve the same role throughout the course of this prospective study. As such, the case study interviewed the incumbents of the “positions,” not the individual KIs. The in-country case study researchers are active members in the country’s nutrition community and will closely observe the personnel changes of KI positions, so follow-up interviews can be scheduled with the right individuals. With any new interviewee, the same procedures are followed regarding introduction letters and signing and filing of the consent forms. If in-country staff members identify new funding or activities over the course of the study through the other data streams, KIs from new organizations are also interviewed.

Data Sources

The research team collects relevant information through multiple sources. The primary source is KIIs with MSNP stakeholders at the policy and nutrition governance levels. These interviews follow a general tool but are open-ended enough to be influenced by the other data streams; the country team in Nepal continuously collects these data. These data streams are—

• Event documentation: These events include workshops, nutrition-related conferences, MSNP working group meetings, and fora that discuss MSNP. Where possible, the SPRING in-country team participates in these events, takes notes, and obtains related materials (such as meeting minutes or presentation slides).
• Newspaper review: These are articles from English- and Nepali-language news sources that mention partnerships among nutrition- specific and -sensitive sectors; new funding commitment from the donors, UN agencies, and the government sectors; debates about MSNP design and implementation; and sociopolitical, natural, cultural, and economic changes in-country that may impact the rollout of MSNP. A retrospective search was conducted for news dating up to when the MSNP was first instituted; after completion, a prospective news search is conducted weekly.
• Key documents: New or modified documents of MSNP-related strategies and implementation plans will be obtained and cited as needed for evidence of change in policy, plans, or implementation approach.

Data Collection, Management, and Analysis

Information from all data streams added to a national- and district-level NVivo file. To generate themes, the research team meets weekly to discuss the information collected (or interviews transcribed), to determine the relevance to the research questions, and to generate action items for events that the research team needs to find out more about. For the interviews, the data streams serve as probes for information or reactions.

These weekly research meetings also form the basis for developing the emergent themes. These themes may change over time depending on the information coming in and the direction of these research discussions. Research team members read through selected interviews and shared overall impressions; from these discussions, the qualitative lead of the case study team selected a limited number of broad codes. Data from all streams are then coded as such in NVivo. A research analyst performs the coding, and the qualitative lead reviews it with the principle investigator. For longer documents, select passages or sections are coded according to the case study’s main research questions.

Endline

Key Informants and Key Informant Interview Guides (National and District Levels)

The case study team plans to conduct a full round of endline KIIs at the national level. It is anticipated that the selection of the KIs and the design of the KII guides may be revised as in the endline, as knowledge of the country situation evolves. Nonetheless, the design of the KII guide is expected to follow a similar iterative process to ensure that the questions asked are relevant to KIs from all stakeholder institutions and are tightly built around the overall research questions of the case study.

Strengths and Limitations

Qualitative research methods have unique strengths and are appropriate to study a small number of cases in depth. They are also appropriate to describe and explain a complex process, such as implementing a country’s scaled-up nutrition plan. For a longitudinal case study, qualitative methods have the flexibility to be responsive to changes in the field; this improves the utility of the findings and recommendations through adaptation of data collection instruments and analysis. Asking the same questions to different individuals helps to detect discrepancies on accounts of facts and sequences, triangulate information to reach a consensus, and collect views and opinions—which could be divergent—on the implementation of national rollout. Such an exercise will reveal insights into why things are moving or not and potential resolutions to challenges in the rollout.

Some general weaknesses of qualitative research also apply in this case study, namely that it has a small sample size and is relatively resource intensive. Perhaps the weakness of greatest concern is that the results may not be directly generalizable to the other countries. The case study will focus the discussions following the cross-contextual issues (themes), so domestic and global users of the research outputs will also appreciate the challenges and innovations that the study augments in Nepal. In addition, the users will also benefit from seeing how systematic research can generate observations and identify opportunities that can be capitalized on to strengthen the rollout.

The strengths and limitations of the quantitative portion of this study are addressed in the Budget Methods Annex and Snapshot Methods Annex.