scaling up interventions to improve infant and young child feeding: the role of frontline workers in...
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Scaling Up Interventions to Improve Infant and Young Child Feeding: The Role of Frontline
Workers in Alive & Thrive
Purnima Menonwith
Rahul Rawat, Kuntal Saha, Phuong Nguyen, Disha Ali, Andrew Kennedy, Adiba Khaled, Parul Tyagi, Lan Tran Mai, Roman Tesfaye &
Marie RuelInternational Food Policy Research Institute
International Congress of Nutrition, Granada, Spain; Sept 18, 2013
Frontline workers and nutrition• Frontline workers – community health workers,
community health volunteers, health staff in facilities – are where the rubber hits the road for public health and nutrition interventions.
• Health systems literature is expanding on role of frontline workers for delivering life-saving interventions such as immunization
• Less is known about how best to engage, motivate and deploy these frontline forces for nutrition behavior change– Challenges: sustained performance for non-tangible interventions, types
of capacity strengthening investments needed, roles of incentives, monitoring and performance improvement in scaling up effective FLW contact for nutrition
Mostly frontline workers!
Elements of Alive & Thrive models, by country
Some core elements but variability across country program models in platforms, and extent of emphasis on mass media
See Food & Nutrition Bulletin Sept 2013 Supplement for more information!
Frontline workers in Alive & Thrive interventions
Bangladesh• Existing worker: Shashtya Sebika (frontline volunteer)• New worker: Pushtikormi (skilled nutrition worker)• CONTACT : OUTREACH TO FAMILIES THROUGH HOME VISITS (NGO
Platform)
Vietnam• Existing health staff at commune health centers• Village nutrition workers for demand-creation• CONTACT : FACILITY-BASED THROUGH SOCIAL FRANCHISE APPROACH
LINKED TO GOVERNMENT HEALTH SYSTEM
Ethiopia• Existing worker: Health Extension Workers• Diverse frontline volunteers• CONTACT : OUTREACH TO FAMILIES THROUGH HOME VISITS,
COMMUNITY GROUPS, AT HEALTH POSTS (Government Health System)
Implementation durations and exposures, by country
Duration of implementation Exposures (in intervention areas)
Community-based interventions
Mass media intervention
Community-based interventions
Mass media intervention
Bangladesh 3 years 2.5 years 69-98% 61-77%Ethiopia 1.5 years 1 year 35-73% 8-17%Vietnam 2 years 1.5 -2 years 45% 33-70% (spot-
specific)
Exposures are ranges capturing household exposure to any of the A&T-supported FLWs or mass media interventions. Exposure measures based on recall/aided recall. Source: Process evaluation surveys, 2013
There is variability across country program models in duration of implementation of program components and household-level exposure to these components
Insights on A&T-linked frontline workers from baseline surveys
• Strong knowledge of BF, but less on skills for EBF; poorer knowledge on complementary feeding, hygiene care, and feeding during illness
• Regression analysis of predictors of FLW motivation highlighted the roles of knowledge, training, supportive supervision
Bangladesh (SS) Ethiopia (HEW) Vietnam (CHC staff)Motivating factors:• Positive, supportive supervision
(high)• IYCF knowledge• Refresher training with 1-3
months• Job duration equal or more 24
months
Motivating factors:• Positive, supportive supervision
(high)• Education (technical/vocational)• Supervision visits on specified
topics
Motivating factors:• Positive, supportive supervision
(high)• Participated in training within
12 months
A&T core interventions in all three countries
aim to strengthen these motivational
factors
BANGLADESH: ENGAGING FLWS FOR DELIVERING INTERVENTIONS THROUGH A LARGE-SCALE NGO PLATFORM IMPLEMENTED BY BRAC
60 rural subdistricts
20 (paired) rural subdistricts
10 subdistrictsA&T-intensive
Intensive IYCF counselingby BRAC frontline workers
+ mass media
10 subdistrictsA&T non-intensive
Standard care by BRAC frontline workers
+ mass media only
Baseline survey (April-July 2010) & early process evaluation (late 2010)
Endline survey (April-July 2014)
Process evaluation survey of implementation and utilization (subsample only, June-July 2012) & qualitative research
Process evaluation survey on implementation and utilization (all areas, April-July 2013)
Process evaluation survey on implementation (September-October 2011) & qualitative research
At scale implementation
in 40+ subdistricts
Randomized
DATA
CO
LLEC
TIO
NBANGLADESH IMPACT EVALUATION DESIGN
Early in
itiation of bre
astfeeding
Exclusiv
e Breastf
eeding (<6 m
o)
Continued BF at 1
year
Intro of C
F at 6
-8 mo
Minim
um Dietary
Diversi
ty (6-23 m
o)
Minim
um Meal F
req
Minim
um Acceptable D
iet
Consumption of Ir
on-Rich
Foods (
6-23 mo)
0
10
20
30
40
50
60
70
80
90
100
2010 A&T Intensive 2010 A&T Non-Intensive2013 A&T Intensive 2013 A&T Non-Intensive
26.6 *** 7.6 (n.s.)
24.6***
20.3***
Bangladesh: Early Impacts on IYCF Practices (2013)
*** p<0.01; ** p<0.05; *p<0.1† Double difference estimates with clustered standard errors comparing A&T intensive and non-intensive areas in 2010 and 2013
24.2 pp ***
Perc
ent
18.7 pp ***
12.3 pp (n.s)
Bangladesh: IYCF indicators, by intervention exposure (based on aided recall; unadjusted preliminary estimates)
EBF Min. Diet Diversity Min acceptable diet0
10
20
30
40
50
60
70
80
90
100
Baseline (all) Seen TVC; Seen A&T SS Seen TVC; See non-A&T SSSeen TVC; Not seen any SS Not seen TVC; Seen A&T SS Not seen TVC; Seen non-A&T SSNot seen TVC; Not seen any SS
Base
line
2013
Cont
act w
ith A
&T
FLW
& m
edia
Cont
act w
ith A
&T
FLW
Med
ia +
unt
rain
ed F
LW
Med
ia a
lone
, no
FLW
No
med
ia n
on-A
&T
FLW
Nei
ther
%
ETHIOPIA: BUILDING FRONTLINE WORKER CAPACITY FOR IYCF IN ETHIOPIA’S HEALTH EXTENSION SYSTEM
Health Extension Worker Health Volunteer
89 IFHP woredas in 2 regions (Tigray & SNNPR)
Random selection of 75 enumeration areas from 56 woredas for evaluation surveys*
Cross-sectional baseline survey in 2010
Cross-sectional endline survey for impact assessment in 2014
Process evaluation (qualitative research) on implementation in 8 woredas (2012)
Process evaluation survey on implementation and utilization (2013)
*The survey covered 75 enumeration areas in 19 woredas from Tigray and 37 woredas from SNNPR
ETHIOPIA IMPACT EVALUATION DESIGNDA
TA C
OLL
ECTI
ON
Shifts in IYCF practices between 2010-13, in Tigray & SNNPR (combined), Ethiopia
0
10
20
30
40
50
60
70
80
90
100
Baseline, 2010 Process Evaluation, 2013
%
Ethiopia: IYCF practices in 2013, by exposure to health extension workers and radio spot (Tigray region only)
Early initiation of BF Exclusive BF Minimum diet diversity
Iron-rich foods0
10
20
30
40
50
60
70
80
90
100
Baseline (all) Heard radio spot; Seen HEW Heard radio spot; Not seen HEW
Not Heard radio spot; Seen HEW Not Heard radio spot; Not seen HEW
Base
line
2013
Cont
act w
ith A
&T
FLW
& ra
dio
Cont
act w
ith A
&T
FLW%
Ethiopia: IYCF practices in 2013, by exposure to frontline volunteers and radio spot (Tigray region only)
Early initiation of BF Exclusive BF Minimum diet diversity Iron-rich foods0
10
20
30
40
50
60
70
80
90
100
Baseline (all) Heard radio spot; Seen volunteerHeard radio spot; Not seen volunteer Not Heard radio spot; Seen volunteerNot Heard radio spot; Not seen volunteer
Base
line
2013
Cont
act w
ith A
&T
FLW
& ra
dio
Cont
act w
ith A
&T
FLW
%
VIETNAM: A SOCIAL FRANCHISE MODEL FOR DELIVERING IYCF COUNSELING AT GOVERNMENT HEALTH FACILITIES
40 Commune Health Centers (CHCs) from 4 provinces
Randomization
20 Comparison CHCsStandard Government Service+ mass media
20 Intervention CHCsIYCF social franchise +
Standard Government Service + mass media
Cross-sectional baseline survey in 2010
Cross-sectional impact survey in 2014
Process evaluation on implementation (2012)
Process evaluation on implementation and utilization (2013)
Full implementation
in 11 non-evaluation
provinces (660 franchises)
VIETNAM IMPACT EVALUATION DESIGN
DATA
CO
LLEC
TIO
N
Impact on IYCF practices in Vietnam – 2010 vs 2013
EIBFEBF
Continued BF
Introducti
on of CF
Minimum diet d
iversity
Minimum m
eal frequency
Minimum acce
ptable diet
Iron ric
h foods
0102030405060708090
100
2010 A&T franchise 2010 non-franchise 2013 A&T franchise 2013 non-franchise
21.0 pp **
*** p<0.01; ** p<0.05; *p<0.1† Double difference estimates with clustered standard errors comparing A&T intensive and non-intensive areas in 2010 and 2013
%
Complementary feeding practices better at baseline: lower potential to benefit
Vietnam: Breastfeeding, by exposures to media spots and the social franchise
Early initiation of BF Exclusive BF0
20
40
60
80
100
Baseline Seen TVC; visit MTBT Seen TVC; Not visit MTBTNot seen TVC; visit MTBT Not seen TVC; Not visit MTBT
%
Base
line
Fran
chis
e &
med
ia
Use
of f
ranc
hise
2013
Med
ia o
nly
Nei
ther
Conclusions on early impactDespite variability in the models, durations of implementation and exposures, we find: • In Bangladesh: large, and significant,
impacts for several indicators of IYCF • In Vietnam: Large, and significant, impacts
for exclusive breastfeeding• In Ethiopia: Improvements in most IYCF
practices• Impact linked to potential to benefitIn all three countries, contact with A&T-supported frontline workers appears to be linked with improved practices; media interventions are playing a supportive & synergistic role
2.5 month old exclusively breastfed baby in Bangladesh, 2013 (Photo: Purnima Menon)
Acknowledgments• Alive & Thrive leadership at HQ and at the country level• BRAC, Save the Children• Country research and data-collection collaborators: DATA,
Bangladesh; Institute for Social and Medical Studies, Vietnam; Addis Continental Institute for Public Health, Ethiopia
• Dozens of enumerators and field researchers• Mothers, fathers, grandmothers and program implementers• Bill & Melinda Gates Foundation for funding to Alive & Thrive
& Ellen Piwoz for her support
More information on Alive & Thrive programs, implementation lessons and evaluation designs: Food & Nutrition Bulletin Special Supplement
STAY TUNED – more to come on full impact, process evaluation results, costs, policy wins, ethnographic insights, and more!