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) 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 implementationExposures (in intervention areas) Community- based interventions Mass media intervention Community- based interventions Mass media intervention Bangladesh3 years2.5 years69-98%61-77% Ethiopia1.5 years1 year35-73%8-17% Vietnam2 years years45%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 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 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 COLLECTION BANGLADESH IMPACT EVALUATION DESIGN

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 pp *** Percent 18.7 pp *** 12.3 pp (n.s)

Bangladesh: IYCF indicators, by intervention exposure (based on aided recall; unadjusted preliminary estimates) Baseline 2013 Contact with A&T FLW & mediaContact with A&T FLWMedia + untrained FLW Media alone, no FLW No media non-A&T FLW Neither %

ETHIOPIA: BUILDING FRONTLINE WORKER CAPACITY FOR IYCF IN ETHIOPIAS 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 DESIGN DATA COLLECTION

Shifts in IYCF practices between , in Tigray & SNNPR (combined), Ethiopia %

Ethiopia: IYCF practices in 2013, by exposure to health extension workers and radio spot (Tigray region only) Baseline 2013 Contact with A&T FLW & radio Contact with A&T FLW %

Ethiopia: IYCF practices in 2013, by exposure to frontline volunteers and radio spot (Tigray region only) Baseline 2013 Contact with A&T FLW & radio Contact with 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 CHCs Standard Government Service+ mass media 20 Intervention CHCs IYCF 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 COLLECTION

Impact on IYCF practices in Vietnam – 2010 vs 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 Baseline Franchise & media Use of franchise 2013 Media only Neither

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&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!