Abstract
BackgroundProgram 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.MethodsData 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.ResultsThere 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.ConclusionsThere 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.
Highlights
Program effectiveness is influenced by the degree and quality of implementation, requiring careful examination of delivery processes and how the program is or is not being implemented as intended
Results from the 2013 process evaluation (PE) survey were compared with the 2010 baseline survey data, where similar measures are available such as Frontline worker (FLW) training exposure and infant and young child feeding (IYCF) knowledge
For indicators of IYCF knowledge, un-weighted summary scores were constructed from several key items that constitute knowledge about breastfeeding (BF) or complementary feeding (CF), measured at both baseline and PE
Summary
Program effectiveness is influenced by the degree and quality of implementation, requiring careful examination of delivery processes and how the program is or is not being implemented as intended. There was little effect on institutional or skilled delivery, use of postnatal services [7,10], some newborn health care practices [9], and health outcomes such as the incidence and duration of childhood diarrhea and cough [7]. These variable results have been ascribed to implementation challenges, poor quality and low availability of some services due to weak technical capacity, inadequate infrastructure and management capacity, and poor monitoring and supervision [10,11]. Impacts may not be achieved despite being interventions of proven efficacy due to programmatic constraints, highlighting the need to examine delivery processes and to understand how the program is or is not being implemented as intended
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