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 Ruel

International 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 countryDuration 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 breastf

eeding

Exclusiv

e Breastfeeding (<

6 mo)

Continued BF at 1

year

Intro of C

F at 6

-8 mo

Minimum Dietary

Diversi

ty (6-23 m

o)

Minimum M

eal Freq

Minimum Acce

ptable Diet

Consumption of Iron-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

102030405060708090

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

EIBF

EBF

Continued BF

Introducti

on of CF

Minimum diet d

iversity

Minimum m

eal freq

uency

Minimum ac

ceptab

le 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!