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1. 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, AdibaKhaled, Parul Tyagi, Lan Tran Mai, Roman Tesfaye & Marie Ruel International Food Policy Research Institute International Congress of Nutrition, Granada, Spain; Sept 18, 2013

2. 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

3. Mostly frontline workers!

4. 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!

5. Frontline workers in Alive & Thrive interventions

6. Implementation durations and exposures, by country There is variability across country program models in duration of implementation of program components and household-level exposure to these components 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

7. Insights on A&T-linked frontline workers from baseline surveys A&T core interventions in all three countries aim to strengthen these motivational factors 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

8. BANGLADESH: Engaging FLWs for delivering interventions through A LARGE-SCALE NGO PLATFORM IMPLEMENTED BY BRac

9. At scale implementation in 40+ subdistricts BANGLADESH IMPACT EVALUATION DESIGN 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 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 DATA COLLECTION Process evaluation survey on implementation and utilization (all areas, April-July 2013) Endlinesurvey (April-July 2014)

10. Bangladesh: Early Impacts on IYCF Practices (2013) 18.7 pp*** 12.3 pp (n.s) 24.2 pp*** Percent *** 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

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

12. Health Extension Worker Health Volunteer ETHIOPIA: BUILDING FRONTLINE WORKER CAPACITY FOR IYCF IN ETHIOPIA’S HEALTH EXTENSION SYSTEM

13. ETHIOPIA IMPACT EVALUATION DESIGN 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 Process evaluation (qualitative research) on implementation in 8 woredas (2012) DATA COLLECTION Process evaluation survey on implementation and utilization (2013) *The survey covered 75 enumeration areas in 19 woredas from Tigray and 37 woredas from SNNPR Cross-sectional endline survey for impact assessment in 2014

14. Shifts in IYCF practices between 2010-13, in Tigray & SNNPR (combined), Ethiopia %

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

16. Ethiopia: IYCF practices in 2013, by exposure to frontline volunteers and radio spot (Tigrayregion only) % Contact with A&T FLW & radio Contact with A&T FLW Baseline 2013

17. VIETNAM: A social franchise model for delivering IYCF counseling at government health facilities

18. Full implementation in 11 non-evaluation provinces (660 franchises) VIETNAM IMPACT EVALUATION DESIGN 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 Process evaluation on implementation (2012) DATA COLLECTION Process evaluation on implementation and utilization (2013) Cross-sectional impact survey in 2014

19. Impact on IYCF practices in Vietnam – 2010 vs 2013 21.0 pp ** % Complementary feeding practices better at baseline: lower potential to benefit *** 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

20. Vietnam: Breastfeeding, by exposures to media spots and the social franchise Franchise & media Use of franchise Media only Neither Baseline 2013

21. 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)

22. 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!