SCALING UP IN AGRICULTURE, RURAL DEVELOPMENT, AND NUTRITION
Alive & Thrive: Expanding Community Interventions to Improve Nutrition in Bangladesh | RAISUL HAQUE, KAOSAR AFSANA, TINA SANGHVI, SAIQA SIRAJ, AND PURNIMA MENON
Focus 19 • brIeF 10 • June 2012 T
he levels of stunting, underweight, wasting, and childhood anemia are very high in Bangladesh, as are levels of maternal
chronic energy deficiency and maternal and child anemia. A combination of poor maternal nutrition and postnatal factors cause child undernutrition, which in turn can have far-reaching consequences for national and global development, as well as individual health. Studies in Bangladesh show that infant and young child feeding (IYCF) practices, a critical determinant of child nutrition, are poor. Interventions to address them at a large scale are urgently needed, including behavior-change counseling for early and exclusive breastfeeding, age-appropriate complementary feeding and micronutrient supplementation, provision of micronutrient supplements or fortified complementary foods, hygiene interventions, and nutritional management of severe-acute undernutrition Alive & Thrive (A&T) seeks to develop scaled-up models for
preventing child undernutrition by improving IYCF practices. Funded by the Bill & Melinda Gates Foundation, A&T’s interventions focus on achieving behavior change through existing service-delivery platforms, especially the health worker network of BRAC, the largest nongovernmental organization in Bangladesh. This brief focuses on A&T’s use of BRAC’s Essential Health Care (EHC) program in 2009–2011 as its operational platform. During this time, 9,000 managers, mid-level staff, workers, and volunteers were trained in interpersonal counseling, and an IYCF-oriented social mobilization strategy reached 15 million people.
Addressing IYCF in Bangladesh: The Alive & Thrive community-based interventions
The A&T model includes three cadres of BRAC community health workers who are responsible for counseling, coaching, training, and helping mothers use good IYCF practices: volunteers assigned to 250–300 households each, health workers who specialize in pre- and postnatal health services, and dedicated IYCF promoters who record services provided and fill in gaps in home visits. Mothers are counseled in the use of locally available resources to encourage healthy growth in children under two years of age. The model requires repeated home visits by trained workers, and priority is given to reaching mothers with infants less than 12 months old: the period of greatest vulnerability to growth faltering. Through social mobilization, local opinion leaders such as
imams, government health workers, and village doctors are engaged through forums and meetings to highlight the importance of nutrition, particularly in IYCF. Recently, BRAC has added forums for adolescents, parents, school teachers, local leaders, and elderly people. A&T reinforces and extends the impact of BRAC’s community interventions through national mass media campaigns, policy initiatives, and partnerships with other community- based organizations.
Implementation: Rolling out the pilot and expanding scale
BRAC’s A&T initiative began with a pilot in mid-2009 to test the A&T model under three different program platforms: (1) the EHC program; (2) maternal, newborn, and child health (MNCH) interventions; and (3) EHC plus a water and sanitation program. The pilot phase was carried out in one urban slum and three upazilas (rural subdistricts). During the pilot, many elements were adjusted: the selection criteria and hiring process for a new cadre of staff (the IYCF promoter) and their integration into BRAC’s structure; division of roles and responsibilities among frontline workers; and an improved basic training module to account for local foods, the quantities needed to satisfy age-specific nutrient requirements, typical feeding bowls, the limited educational level of many of the frontline workers, global recommendations, and findings from the formative research. The pilot provided time to test and improve the data collection indicators, incentives for service delivery, and the process for identifying children and tracking home visitation. The final selection of EHC as the program platform on which
IYCF would be built was a major outcome of the pilot phase. The pilot resulted in a scaling-up target of 50 upazilas across the country, a decision to scale up in two phases, and the development of methods for ensuring accountability of cash incentives. Examples of
lessons learned from the pilot:
• The listing of target households by child’s age was initially done by data collectors. Later, during scale up, the IYCF promoters conducted child listing in their catchment areas, which was less costly and more efficient.
• Basic training was conducted in the pilot through 20 batches consisting of mixed groups of health workers, staff, and volunteers at five BRAC training venues. The project later increased the training venues to 16, allowing multiple simultaneous sessions.
• The roles and responsibilities of frontline workers and the timing and number of home visits evolved during the pilot. When worker gaps were identified, new workers were hired using modified criteria when needed to ensure adequate coverage without losing momentum.
Reflections on the scaling-up experience
Since IYCF promotion and counseling was already a known effective intervention, A&T relied on expansion through replication. IYCF was integrated into existing programs reaching the same target age groups. This was more rapid and affordable than establishing a new infrastructure and helped ensure that other preventive and disease control interventions would be offered alongside IYCF interventions. Adapting and simplifying the IYCF intervention for BRAC’s EHC was considered essential, since it would be
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