Transcript frontline volunteer

Scaling Up Interventions to Improve Infant and
Young Child Feeding: The Role of Frontline
Workers in Alive & Thrive
Purnima Menon
with
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)
Ethiopia
• Existing worker: Health Extension Workers
• Diverse frontline volunteers
• CONTACT : OUTREACH TO FAMILIES THROUGH HOME VISITS,
COMMUNITY GROUPS, AT HEALTH POSTS (Government Health System)
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
Implementation durations and exposures, by country
Duration of implementation
Bangladesh
Exposures
(in intervention areas)
Communitybased
interventions
Mass media
intervention
Communitybased
interventions
Mass media
intervention
3 years
2.5 years
69-98%
61-77%
There is variability
duration of implementation
of
Ethiopia
1.5across
yearscountry 1program
year models in35-73%
8-17%
program components and household-level exposure to these components
Vietnam
2 years
1.5 -2 years
45%
33-70% (spotspecific)
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
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:
Motivating factors:
•
•
Motivating factors:
•
•
•
Positive, supportive supervision
(high)
IYCF knowledge
Refresher training with 1-3
months
Job duration equal or more 24
months
•
•
Positive, supportive supervision
(high)
Education (technical/vocational)
Supervision visits on specified
topics
•
•
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
BANGLADESH IMPACT
EVALUATION DESIGN
At scale
implementation
in 40+
subdistricts
60 rural subdistricts
20 (paired) rural subdistricts
Randomized
10 subdistricts
A&T-intensive
Intensive IYCF counseling
by BRAC frontline workers
+ mass media
10 subdistricts
A&T non-intensive
Standard care
by BRAC frontline workers
+ mass media only
DATA COLLECTION
Baseline survey (April-July 2010) & early process evaluation (late 2010)
Process evaluation survey on implementation (September-October 2011) &
qualitative research
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)
Endline survey (April-July 2014)
Bangladesh: Early Impacts on IYCF Practices (2013)
100
90
2010 A&T Intensive
2010 A&T Non-Intensive
2013 A&T Intensive
2013 A&T Non-Intensive
18.7 pp ***
24.2 pp
***
12.3 pp (n.s)
80
70
26.6 ***
20.3***
7.6 (n.s.)
Percent
60
24.6***
50
40
30
20
10
0
Early initiation
Exclusive Continued BF at Intro of CF at 6- Minimum Minimum Meal Minimum
Consumption
of
Breastfeeding
1 year
8 mo
Dietary
Freq
Acceptable Diet of Iron-Rich
breastfeeding
(<6 mo)
Diversity (6-23
Foods (6-23
mo)
mo)
*** 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
Neither
No media non-A&T FLW
Contact with A&T FLW
Media alone, no FLW
Media + untrained FLW
Contact with A&T FLW & media
100
90
80
70
60
%
50
40
30
20
10
0
Baseline
Bangladesh: IYCF indicators, by intervention exposure
(based on aided recall; unadjusted preliminary estimates)
2013
EBF
Min. Diet Diversity
Min acceptable diet
Baseline (all)
Seen TVC; Seen A&T SS
Seen TVC; See non-A&T SS
Seen TVC; Not seen any SS
Not seen TVC; Seen A&T SS
Not seen TVC; Seen non-A&T SS
Not seen TVC; Not seen any SS
Health Extension Worker
Health Volunteer
ETHIOPIA: BUILDING FRONTLINE
WORKER CAPACITY FOR IYCF IN
ETHIOPIA’S HEALTH EXTENSION SYSTEM
ETHIOPIA IMPACT EVALUATION DESIGN
89 IFHP woredas in 2 regions (Tigray & SNNPR)
Random selection of 75 enumeration areas
from 56 woredas for evaluation surveys*
DATA COLLECTION
Cross-sectional baseline survey in 2010
Process evaluation (qualitative research) on implementation
in 8 woredas (2012)
Process evaluation survey on implementation and utilization
(2013)
Cross-sectional endline survey for impact assessment in 2014
*The survey covered 75 enumeration areas in 19 woredas from Tigray and 37 woredas from
SNNPR
Shifts in IYCF practices between 2010-13, in
Tigray & SNNPR (combined), Ethiopia
Baseline, 2010
Process Evaluation, 2013
100
90
80
70
60
%
50
40
30
20
10
0
Early
initiation of
BF
EBF
Continued Intro of CF at Minimum
BF at 1 year 6-8 mo
DD
Minimum
meal
frequency
Minimum
acceptable
diet
Iron rich
foods
Ethiopia: IYCF practices in 2013, by exposure to health
extension workers and radio spot (Tigray region only)
100
90
60
%
50
40
20
10
0
Baseline
30
Contact with A&T FLW
70
Contact with A&T FLW & radio
80
2013
Early initiation of BF
Exclusive BF
Minimum diet
diversity
Iron-rich foods
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
Ethiopia: IYCF practices in 2013, by exposure to frontline
volunteers and radio spot (Tigray region only)
100
70
% 60
50
40
20
10
0
Baseline
30
Contact with A&T FLW
80
Contact with A&T FLW & radio
90
2013
Early initiation of BF
Exclusive BF
Minimum diet
diversity
Iron-rich foods
Baseline (all)
Heard radio spot; Seen volunteer
Heard radio spot; Not seen volunteer
Not Heard radio spot; Seen volunteer
Not Heard radio spot; Not seen volunteer
VIETNAM: A SOCIAL FRANCHISE
MODEL FOR DELIVERING IYCF
COUNSELING AT GOVERNMENT HEALTH
FACILITIES
VIETNAM IMPACT
EVALUATION DESIGN
40 Commune Health
Centers (CHCs) from 4 provinces
Randomization
DATA COLLECTION
20 Comparison CHCs
Standard Government
Service+ mass media
Full
implementation
in 11 nonevaluation
provinces (660
franchises)
20 Intervention CHCs
IYCF social franchise +
Standard Government Service +
mass media
Cross-sectional baseline survey in 2010
Process evaluation on implementation (2012)
Process evaluation on implementation and utilization (2013)
Cross-sectional impact survey in 2014
Impact on IYCF practices in Vietnam – 2010 vs 2013
2010 A&T franchise
2010 non-franchise
2013 A&T franchise
2013 non-franchise
100
90
80
70
%
21.0 pp **
60
50
40
Complementary feeding practices better at baseline:
lower potential to benefit
30
20
10
0
EIBF
EBF
Continued BF Introduction Minimum
Minimum
of CF
diet diversity
meal
frequency
Minimum
acceptable
diet
*** 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
Iron rich
foods
Vietnam: Breastfeeding, by exposures to media
spots and the social franchise
100
80
Neither
Use of franchise
20
Baseline
40
Media only
%
Franchise & media
60
2013
0
Early initiation of BF
Baseline
Not seen TVC; visit MTBT
Exclusive BF
Seen TVC; visit MTBT
Not seen TVC; Not visit MTBT
Seen TVC; Not visit MTBT
Conclusions on early impact
Despite 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 benefit
In all three countries, contact with A&Tsupported 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!