Improving IYCF Through Social and Behavior Change Approach

Presenter: Yewelsew Abebe, Alive & Thrive, FHI 360 Addis Ababa Ethiopia

Content Outline

1. Introduction

2. Objectives

3. Results and discussion

4. Conclusions and recommendations

Introduction

Promotion of appropriate IYCF: Recommended intervention for growth & development A priority agenda of the NNP

Alive &Thrive promoted appropriate IYCF through the HEP: To mothers with under two children With IFHP & other partners: Involving HEWs & volunteers At health posts, home visits, community

Federal and regional level advocacy

Overall aim is supporting the governments NNP especially Strategic Objectives 2

Objectives

Improve IYCF by: Maintaining high rates of exclusive breastfeeding Improving complementary feeding practices

Areas of operation: In four large regions: Amhara, Oromia, SNNPR, Tigray

Impact evaluation involves: 2010 baseline vs 2014 end line ( SNNPR & Tigray) Evaluation by IFPRI evaluation team

A&T’s SBCC Approach to Scaling up IYCF

4

1

3

2

Interpersonal communication

Mothers practicing the 7 key IYCF messages on the child nutrition card

Community mobilization

Strengthening social norms around IYCF practices

Mass communication: Delivering Similar IYCF messages in different language

Radio and television spots

Drama based on agrarian analogy were used

MethodologyImpact evaluation ( community & mass media) involves:

An “ adequacy evaluation design” i.e.,

“ Were the program goals achieved?”

Involving pre-& post interventions / without comparison group

Conducted by IFPRI Evaluation

Data analysis methods : Estimation of changes in :

1. In IYCF practices between baseline & end line

2. Among program impact pathways – exposure to uptake

3. Dose-response analysis between program exposure and IYCF practices

4. In child nutrition outcomes between baseline & end line

5. underlying determinants – child, maternal, and household level factors

Methodology: Study Areas

Random selection of 75 enumeration

areas† from 56 woredas

89 IFHP woredas in 2 regions (Tigray & SNNPR)

Cross-sectional endline survey (2014)

Process evaluation survey on implementation and utilization (2013)

Cross-sectional baseline survey (2010)

Process evaluation (qualitative study) on implementation in 8 woredas (2012)

† 75 enumeration areas from 19 woredas in Tigray and 37 woredas in SNNPR.

Household sample 0-5.9 mos: n=6196-23.0 mos: n=87524-59.9 mos: n=1475oversample 24-35.9 mos: n=727

Household sample 0-5.9 mos: n=6076-23.0 mos: n=88324-59.9 mos: n=1502

Results & Discussion

11

Infant & Young Child Feeding Practices

66.7

72.4

98.1

37.4

6.3

45.6

4.6

2.1

81.7

82.8

95.6

59.7

12.4

70.3

10.1

4.1

0 20 40 60 80 100

Early initiation of BF (within 1hour of birth)

Exclusive BF among childrenunder 6 months

Continued BF at 1 year

Introduction of solid, semi-solidor soft food

Minimum diet diversity (≥4 food groups)

Minimum meal frequency

Minimum acceptable diet

Consumption of iron-rich food 2010 2014

IYCF practices( WHO Indicators) increased significantly among children 0-23.9 months

12†Percentage point; adjusted for cluster; *p<0.05, **p<0.01, *** p<0.001

% PP change†

15.0***

10.4***

-2.5

22.3***

6.1***

24.7***

5.5***

2.0*

TIMELY

0

2

4

6

8

10

12

14

16

18

Ch

ild a

ge (

mo

nth

s)

2010 2014

Timely introduction of most liquids and foods improved among children 0-23.9 months

13adjusted for cluster; *p<0.05, **p<0.01, *** p<0.001

*** *** * *** *** *** *** *** *** *** ***

Consumption of most food groups in last 24 hours increased among children 6-23.9 months

14

%

82.9

20.2

32.8

1.5

9.6

20.3

4.1

88.9***

34.9***31.0

3.3*

18.9***

27.0**

4.9

0

20

40

60

80

100

Grains, roots,tubers

Legumes andnuts

Dairy products Flesh foods Eggs Vitamin A-richfruits and

vegetables

Other fruitsand vegetables

%

2010 2014

adjusted for cluster; *p<0.05, **p<0.01, *** p<0.001

Moderate reach of interventions to target households (mothers with <2yrs) achieved

31.5

12.2

30.3

7.2

44.6

31.230.8

11.2

72.5

8.814.1

38.1

11.5

0

20

40

60

80

100

HEW homevisit in last 6

mos

HEW talkedabout IYCF at

last visit

Volunteerhome visit in

last 6 mos

Volunteertalked about

IYCF at last visit

Ever seen CNC Fooddemonstration

in last 6 mos

Villagegathering onIYCF in last 6

mos

Ever heard anyradio spot

Ever seen anyTV spot

%

2010 2014

Interpersonal communication Social mobilizationMass media

Both HEWs and volunteers are needed to optimize reach to target households

HEW25%

Volunteer

11%HEW&Vol20%

Neither44%

N=1494

Implication: Build the capacity of HDAs to deliver appropriate health messages!

Exposure to home visits in last 6 months among mothers with <2-y-o, 2014

IYCF knowledge among HEWs increased over time

17

2010 2014

WHO IYCF Indicators Tigray(n=25)

SNNPR(n=48)

All(n=73)

Tigray(n=48)

SNNPR(n=90)

All(n=138)

Breast feeding Put the baby on breast immediately (<1 hr after birth) 100.0 100.0 100.0 95.8 98.9 97.8***

Give colostrum to baby 88.0 89.6 89.0 77.1 96.7 89.9*

Water should not be given even in hot weather 92.0 89.6 90.4 95.8 98.9 97.8***

Mothers can give expressed milk if she needs to leave the baby <6 mos 44.0 33.3 37.0 70.8 96.7 87.7***

Complementary feedingAt 6 mos babies should first start to receive foods 96.0 97.9 97.3 97.9 100.0 99.3***

Special food to complement BF: Enriched porridge with egg 20.0 14.6 16.4 64.6 53.3 57.2***

A 6–9-mo-old child should eat at least 3 times per day 88.0 95.8 93.2 97.9 97.8 97.8***

A 12–23-mo-old child should eat at least 3 times per day 96.0 93.8 94.5 100.0 100.0 100.0***

*p<0.05, **p<0.01, *** p<0.001

What were the key exposure indicators of A&T interventions?

Type of intervention Exposureindicator (Y/N)

Intensityindicator (varied)

Interpersonalcounseling

1- Received home visit by HEW to discuss about IYCF in last 6 mos

Number of home visits in last 6 months

2- Received home visit by community volunteer to discuss IYCF in last 6 mos

Number of home visits in last 6 months

3- Ever seen Child Nutrition Card (CNC) with 7 IYCF actions (BF: 1-2, CF: 3-7)

Number of CNC messages recalled

Group education/ social mobilization

4- Attended in village gatheringdiscussing about IYCF in last 6 mos

---

Mass media 5- Ever heard radio spot (BF spots 1-2, CF spots 3-6)

No. of radio spots heard No. of radio spot messages

recalled

= Overall program intensity score (0-5)

Higher intensity of BF radio spot exposure and program intensity score associated with early initiation of BF

80.5 82.695.5

0

20

40

60

80

100

None 1 message 2 messages

%

BF radio messages recalled**

76.3 81.4 82.1 91.7

0

20

40

60

80

100

None Low(1 exposure)

Medium(2-3 exposures)

High(4-5 exposures)

%

Program intensity score**

Indicator Odds ratio1

Intensity of BF radio spot exposure:

None ref

1 BF message recalled 1.17

2 BF messages recalled 4.91**

Program exposure intensity:

None ref

Low (1 exposure) 1.3

Medium (2-3 exposures) 1.21

High (4-5 exposures) 2.60**p<0.05, **p<0.01, ***p<0.0011Fully adjusted model

(n=193) (n=480) (n=100)(n=445)

(n=1044) (n=90)(n=84)

Higher intensity of volunteer home visits, CNC exposure, CF radio spot exposure, and program intensity score

associated with minimum diet diversity

Indicator OR1

Intensity of CF radio spot exposure:

None ref

1-2 CF spots heard 2.47*

3-4 CF spots heard 3.37**

None Ref

1-2 CF messages recalled 2.94**

3-4 CF messages recalled 2.04

Program exposure intensity:

None ref

Low (1 exposure) 2.28

Medium (2-3 exposures) 3.45*

High (4-5 exposures) 11.81**

Indicator Odds ratio1

Intensity of volunteer home visits:

None ref

1-2 visits in last 6 mos 1.41

3+ visits in last 6 mos 2.15*

Intensity of CNC exposure:

None ref

1-2 CF messages recalled 1.54

3-5 CF messages recalled 4.16**

*p<0.05, **p<0.01, ***p<0.0011Fully adjusted model

Similar patterns for minimum acceptable diet

Small but significant change in stunting only among children 24-59.9 months

55.9

30.2

4.4

51.5

28.4

3.8

0

20

40

60

80

100

Stunting Underweight Wasting

%

2010 2014

-1.7 pp, p=0.31

-0.6 pp, p=0.47

*p<0.05

-4.4 pp, p=0.04

*

Conclusion & Recommendations

22

“ Our children are not getting sick any more, children are not dying these days as before”.

Conclusion

IYCF practices improved significantly over time in intervention areas.

EBF increased, MDD doubled,

Gaps remain in consumption of >4 food groups & iron-rich foods

Higher intensities of program exposures i.e., radio spots, volunteer home visits , CNC exposure are associated with

Early initiation of breast feeding

Minimum diet diversity

Minimum meal frequency

Minimum acceptable diet

Recommendations

1. Ensure higher intensity of contacts for long term change in IYCF

practices

2. Target multiple actors- particularly household influentials

3. Use multiple SBCC approaches and channels than using one

4. Use community friendly tools & job aids for increased knowledge &

quality of contact

Building on Lessons Learned in Phase 2

25

In collaboration with the RHB refined IPC tools to improve coverage at community level

Planned to Increase the intensity of contacts by working through health and agriculture systems

Intensifying the learning around

the community component

Acknowledgements

• IFPRI MLE team

• Tigray and SNNPR: Regional health bureaus, woreda health

offices, and study participants

• Data collection by Addis Continental Institute of Public Health

• Funded by Bill & Melinda Gates Foundation, through A&T,

managed by FHI360; and by the CGIAR A4NH, led by IFPRI.

Thank you