The fidelity and dose of message delivery on infant and young child feeding practice and nutrition sensitive agriculture in Ethiopia: a qualitative study from the Sustainable Undernutrition Reduction in Ethiopia (SURE) programme

Abstract

BackgroundIn Ethiopia, 38% of children under 5 years of age are stunted (low height for age). A novel government-led intervention called the Sustainable Undernutrition Reduction in Ethiopia (SURE) aims to tackle the burden of stunting by improving complementary feeding and dietary diversity among young children. The SURE programme design applies a transtheoretical model of behaviour change, whereby exposure to recommended infant and young child feeding (IYCF) and nutrition-sensitive agriculture messages is a first stage to adopting key behaviours. This qualitative study explored the fidelity and dose of the IYCF and nutrition-sensitive agriculture messages delivered by extension workers.MethodsA qualitative study was conducted across four regions in Ethiopia (Oromiya, Amhara, SNNP and Tigray) between April and October 2017. Across the four regions, 81 key informant interviews, 90 FGDs and 81 observations were conducted with 180 extension workers, 18 development agents and 54 mother-father pairs. Digitally recorded audio files were transcribed verbatim, and the data were analysed based on a framework analysis approach using NVivo (version 12) by coding and categorising texts into major themes and sub-themes.ResultsSURE target households had the intended exposure to messages about exclusive breastfeeding, timing of initiation of complementary feeding, food groups, diversified food consumption, irrigation, rearing small animals and vegetables. Few households reported receiving messages on the content or frequency of complementary feeding of a child beyond 6 months of age. Frequency of household visits and hence exposure to SURE messages was also variable. Agricultural messages delivered during household visits focussed on improving standard agricultural practices and rarely covered the importance of nutrition-sensitive agriculture to improve household or child nutrition.ConclusionDespite variability observed in the breadth and depth of messages delivered, large-scale behaviour change communication programmes can achieve moderate to good message exposure among target groups. Qualitative data provide an in-depth insight into fidelity and may supplement our understanding of programme roll-out and implementation. Further research is required to understand longer-term message saturation including frequency and reach.

Engaging family members in maternal, infant and young child nutrition activities in low‐ and middle‐income countries: A systematic scoping review

“…The formative research methods included focus group discussions, in‐depth interviews, and Trials of Improved Practices. Four used the Theory of Planned Behaviour (Ajike et al, 2020 ; Downs et al, 2019 ; Gu et al, 2016 ; Rempel et al, 2017 ), two used the Theory of Reasoned Action (Hoddinott et al, 2018 ; Nguyen et al, 2018 ), two used Social Cognitive Theory (Rabiepoor et al, 2019 ; Singla et al, 2015 ), two used the socioecological model (DeLorme et al, 2018 ; Mukuria et al, 2016 ), two used theoretical concepts related to social support and social networks (Bootsri & Taneepanichskul, 2017 ; Martin et al, 2017 ), one used the transtheoretical model (Salasibew et al, 2019 ), and one used the Beliefs, Attitudes, Subjective Norms and Enabling Factors (BASNEF) model (Akbarzadeh et al, 2015 ). Four studies based intervention design on multiple theories and constructs (Aidam et al, 2020 ; Aubel, 2012 ; Hoddinott et al, 2018 ; H. S. Kim et al, 2016 ; Nguyen et al, 2019 ).…”

“…Other family members were sometimes counselled together with mothers (Nunes et al, 2011 ) or encouraged to participate if they were available during the home visit for the mother (Nguyen et al, 2018 ). In Ethiopia, health and agriculture extension workers jointly visited mothers and fathers together (Salasibew et al, 2019 ).…”

“…Our understanding of these interventions is further limited by the lack of process data describing attendance and coverage; fidelity of delivery; participant views on acceptability, quality, and relevance; and implementer views on feasibility. While a small number of studies explored these issues (Downs et al, 2019 ; Flax et al, 2019 ; Martin et al, 2015 , 2018 ; Nguyen et al, 2018 ; Salasibew et al, 2019 ; Tall et al, 2018 ) these gaps highlight the importance of utilizing reporting guidelines for social and behavioural interventions and related implementation research to ensure transparency and replicability (Yousafzai et al, 2018 ). In addition to examining the impact of interventions, it is also important to assess their implementation by evaluating intervention acceptability, adoption, appropriateness, cost, feasibility, fidelity and sustainability (Proctor et al, 2011 ).…”

“…While current global movements encourage multisectoral nutrition approaches, most interventions in this review were located primarily within the health sector. Exceptions included the following nutrition‐sensitive interventions: agriculture (Bezner Kerr et al, 2019 ; Kumar et al, 2018 ; Salasibew et al, 2019 ; Satzinger et al, 2009 ), cash transfer or food transfer (Hoddinott et al, 2018 ), parenting and early child development (Betancourt et al, 2020 ; Singla et al, 2015 ) and community development (Fiorella et al, 2019 ).…”

Engaging fathers to improve complementary feeding is acceptable and feasible in the Lake Zone, Tanzania

“…ASTUTE used the findings to develop participatory training materials for community health workers to counsel families about dietary diversity, feeding animal‐source foods, responsive feeding and healthy snacks (IMA World Health, 2019 ). Reaching mothers and fathers through home visits has been used elsewhere (Bilal, Spigt, et al, 2016 ; Salasibew et al, 2019 ). Other approaches to engage fathers in complementary feeding or maternal and child nutrition broadly, include counselling couples together at health facilities (Dinga et al, 2018 ), community‐based fathers' groups (Mukuria et al, 2016 ), and support groups that bring family members together with other families (Bezner Kerr, Lupafya, et al, 2016 ; DeLorme et al, 2018 ).…”