Abstract
ABSTRACTBackgroundFrontline health workers (FLWs) are needed for delivering interventions at scale to reduce maternal and child undernutrition, but low- and middle-income countries often face inadequate FLW performance.ObjectivesWe examined whether and how intervention design elements such as training, supervision, and mass media improved FLW performance in delivering nutrition services.MethodsSurvey data were collected in 2010 and 2014 as part of impact evaluations of Alive & Thrive (A&T) interventions to improve infant and young child feeding (IYCF) practices in Bangladesh and Vietnam. FLWs in A&T intensive (A&T-I) areas received specialized IYCF training, job aids, and regular supportive supervision. Those in non-intensive (A&T-NI) areas received standard government training and supervision. There was mass media exposure in both areas. Multiple regression was used to test differences in exposure to intervention design elements and performance outcomes between the 2 program areas. Path analyses were conducted to examine the paths from exposure to performance outcomes measured at FLW and end-user levels.ResultsCompared to FLWs in A&T-NI areas, those in A&T-I areas had higher scores in training (by 1.3–3.6 of 10 points), supportive supervision (0.3–3.5 points), and mass media exposure (0.3–3.5 points). These intervention design elements were significantly associated with FLW knowledge and motivation, which in turn improved service delivery. FLW-level performance outcomes contributed to improving end-user-level outcomes such as higher service received (β = 0.12–1.04 in Bangladesh and 0.11–0.96 in Vietnam) and maternal knowledge (β = 0.12–0.17 in Bangladesh and 0.04–0.21 in Vietnam).ConclusionsTraining, supervision, and mass media exposure can be implemented at large scale and contribute to improved FLW service delivery by enhancing knowledge and motivation, which in turn positively influence mother's service utilization and IYCF knowledge. Training, supervision, and mass media to enhance service provision should be considered when designing interventions. This trial was registered at clinicaltrials.gov as NCT01678716 (Bangladesh) and NCT01676623 (Vietnam).
Highlights
Millions of mothers and children die unnecessarily each year due to undernutrition [1, 2], mostly in low- and middle-income countries (LMICs)
Sample characteristics Frontline health workers (FLWs) were younger in Bangladesh compared with Vietnam (Table 1)
This article examined the intervention design elements intended to improve performance measured at both service-provider (FLW knowledge, motivation, and service delivery) and end-user levels and the paths that link these intervention design elements and performance outcomes
Summary
Millions of mothers and children die unnecessarily each year due to undernutrition [1, 2], mostly in low- and middle-income countries (LMICs). Reducing maternal and child undernutrition requires implementation of effective health and nutrition interventions at scale [3]. To deliver these interventions, frontline workers (FLWs), paid or volunteer, at the local health facility or community levels, are the first and often the only point of contact with the health care system for Keywords: frontline workers, intervention design element, knowledge, motivation, performance, Bangladesh, Vietnam millions of people [4]. Frontline health workers (FLWs) are needed for delivering interventions at scale to reduce maternal and child undernutrition, but low- and middle-income countries often face inadequate FLW performance
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