Exposure to Large-Scale Social and Behavior Change Communication Interventions Is Associated with Improvements in Infant and Young Child Feeding Practices in Ethiopia.

Optimal breastfeeding (BF) practices in Ethiopia are far below the government's targets, and complementary feeding practices are poor. The Alive & Thrive initiative aimed to improve infant and young child feeding (IYCF) practices through large-scale implementation of social and behavior change communication interventions in four regions of Ethiopia. The study assessed the effects of the interventions on IYCF practices and anthropometry over time in two regions-Southern Nations, Nationalities and Peoples Region and Tigray. A pre- and post-intervention adequacy evaluation design was used; repeated cross-sectional surveys of households with children aged 0-23.9 mo (n = 1481 and n = 1494) and with children aged 24-59.9 mo (n = 1481 and n = 1475) were conducted at baseline (2010) and endline (2014), respectively. Differences in outcomes over time were estimated using regression models, accounting for clustering and covariates. Plausibility analyses included tracing recall of key messages and promoted foods and dose-response analyses. We observed improvements in most WHO-recommended IYCF indicators. Early BF initiation and exclusive BF increased by 13.7 and 9.4 percentage points (pp), respectively. Differences for timely introduction of complementary foods, minimum dietary diversity (MDD), minimum meal frequency (MMF), minimum acceptable diet (MAD), and consumption of iron-rich foods were 22.2, 3.3, 26.2, 3.5, and 2.7 pp, respectively. Timely introduction and intake of foods promoted by the interventions improved significantly, but anthropometric outcomes did not. We also observed a dose-response association between health post visits and early initiation of BF (OR: 1.8); higher numbers of home visits by community volunteers and key messages recalled were associated with 1.8-4.4 times greater odds of achieving MDD, MMF, and MAD, and higher numbers of radio spots heard were associated with 3 times greater odds of achieving MDD and MAD. The interventions were associated with plausible improvements in IYCF practices, but large gaps in improving children's diets in Ethiopia remain, particularly during complementary feeding.

Assessing implementation fidelity of a community-based infant and young child feeding intervention in Ethiopia identifies delivery challenges that limit reach to communities: a mixed-method process evaluation study.

BACKGROUND: Program effectiveness is influenced by the degree and quality of implementation, thus requiring careful examination of delivery processes and how the program is or is not being implemented as intended. Implementation fidelity is defined by adherence to intervention design, exposure or dose, quality of delivery, and participant responsiveness. As part of the process evaluation (PE) of Alive & Thrive in Ethiopia, a large-scale initiative to improve infant and young child feeding (IYCF), we assessed these four fidelity elements along three components of its community-based intervention: training of frontline workers (FLWs), delivery of program tools and messages, and supportive supervision. METHODS: Data from a qualitative study among three levels of FLWs (n = 54), i.e. supervisors, health extension workers (HEWs), and community volunteers, and among mothers with children under two years of age (n = 60); and cross-sectional PE surveys with FLWs (n = 504) and mothers (n = 750) in two regions (Tigray and SNNPR) were analyzed to examine program fidelity. RESULTS: There was strong adherence to the intended cascading design (i.e. transfer of knowledge and information from higher to lower FLW levels) and high exposure to training (95% HEWs and 94% volunteers in Tigray, 68% and 81% respectively in SNNPR). Training quality, assessed by IYCF knowledge and self-reported capacity, was high and increased since baseline. Job aids were used regularly by most supervisors and HEWs, but only 54% of volunteers in Tigray and 39% in SNNPR received them. Quality of program message delivery was lower among volunteers, and aided recall of key messages among mothers was also low. Although FLW supervision exposure was high, content and frequency were irregular. CONCLUSIONS: There is evidence of strong fidelity in training and delivery of program tools and messages at higher FLW levels, but gaps in the reach of these to community volunteers and mothers and variability between regions could limit the potential for impact. Strengthening the linkages between HEWs and volunteers further can help to reach the target households and deliver IYCF results at scale.