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

"There is evidence of strong fidelity in training and delivery of program tools and messages at higher FLW [frontline worker] 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 [health extension workers] and volunteers further can help to reach the target households and deliver IYCF [infant and young child feeding] results at scale."

Published in the BMC Public Health Journal, this was the conclusion from a process evaluation that used an "implementation fidelity" framework to assess the Alive & Thrive (A&T) programme in Ethiopia, a large-scale initiative designed to improve infant and young child feeding (IYCF). Implementation fidelity can be defined as "adherence to intervention design, exposure or dose, quality of delivery, and participant responsiveness." Simply put, implementation fidelity "is the degree to which programs are implemented as intended." For example, adherence refers to whether the intervention is being delivered as it was designed, while dosage and exposure refers to whether the frequency and duration of the intervention are as full as prescribed. Participant responsiveness measures how participants respond to or are engaged by an intervention. Researchers used a qualitative study to assess these 4 fidelity elements along 3 components of the community-based intervention: training of frontline workers (FLWs), delivery of programme tools and messages, and supportive supervision.

Started in 2009, A&T is working in the Amhara, Oromia, Southern Nations, Nationalities and Peoples Region (SNNPR), and Tigray regions to deliver age-appropriate child feeding messages and counselling to mothers and caregivers of children less than 2 years of age, primarily in communities through health extension workers (HEWs) and volunteer community health promoters. The key resource for the HEWs and volunteers was the 7 Excellent Feeding Actions poster. In addition to the community-based intervention, a large scale mass-media campaign in various local languages promoted IYCF messages through radio, TV, and mobile vans showing video clips. Programme activities were organised based on a cascading model. HEWs were trained and received the behaviour change communication (BCC) materials to use as tools. These HEWs then had to train and equip community volunteers who would pass this information and, in some cases individual tools, on to mothers.

The study found that participants responded very positively to the A&T training content and delivery, and found the materials to be useful and of high quality. However, despite "the highly positive responses about the appearance and usefulness of the program tools, these opinions appeared to have little effect on the adherence to their proper use and delivery." Significant gaps were found between each of the cascading stages, and the volunteers in many cases were underutilised. For example, "despite increases in the overall number of contacts with HEWs and volunteers, only 55.4% of mothers in Tigray and 49.5% in SNNPR had ever seen the 7 Excellent Feeding Actions individual tool, with far fewer (31.4% in Tigray and 18.5% in SNNPR) having received a copy to keep as a reminder in their homes.

Delivery quality was also assessed through recall of the 7 Excellent Feeding Actions and knowledge of the messages using recall aids (pictures of the 7 Actions) among those who were exposed to the tool. In Tigray, more than 50% of supervisors and HEWs correctly identified 6 out of the 7 key messages, but knowledge of the messages was lower among community volunteers. The study also found significant regional differences. Given little difference in the participant characteristics between regions, researchers attributed the variations as mainly resulting from programme intensity delivered by partner organisations. In Tigray, the primary A&T partners have strong technical capacities in the areas of health and nutrition, while in SNNPR, the most rural region of Ethiopia, women's association and the evangelical church were the primary partners and had more limited levels of technical capacity. "These factors likely play an important role in the ability to reach beneficiaries and provide quality service delivery."

The study concluded that, "while fidelity in program training has been high, gaps remain in the delivery of program tools and messages to beneficiaries, directly by HEWs and via community volunteers, as well as in the supervision of HEWs and volunteers. Unless these gaps are addressed, it is unlikely that the expected impact at household level will be observed at scale. Given that the delivery of the BCC intervention for improved IYCF requires a sequence of programmatic components and actions to work together, the use of program impact pathways helped to identify how and where the components are or are not implemented as intended."

It terms of future phases of A&T and similar programmes, it is recommended that the volunteer corps be better trained, adequately supported and supervised by the HEW, and be given the required materials for delivering BCC to the households in their catchment area. This may be accomplished through a combination of approaches, such as more implementing intense supervision and clarity of roles for HEWs, offering performance-based incentives, assessing workloads and HEW-to-volunteer ratios, and possibly simplifying the IYCF interventions, for example, by targeting fewer IYCF behaviours or prioritising age-specific practices that require greater improvement.