Planned study on feasibility and efficacy of IYCF in CMAM integration in Ethiopia
Dr Ferew, MOH Advisor, Government of Ethiopia, addressing the consultation on Day 1
The Alive and Thrive Project1 is supporting a two-year, field-based study on the integration of Infant and Young Child Feeding (IYCF) into Community-based Management of Acute Malnutrition (CMAM) in Ethiopia. IYCFCMAM rollout is hampered by the lack of a clearly defined operational model for integrated programming and a weak evidence base in terms of impact of IYCF integration on nutritional and health outcomes, programme outputs, coverage, staff time, and costs2. Led by Save the Children US, the study will be implemented through a consortium of partners including World Vision, the Emergency Nutrition Network (ENN), Nutrition Policy and Practice (NPP) and other national and international experts, in close coordination with the Government of Ethiopia. The study will investigate the feasibility (including impact on cost and staff time) and efficacy of integrating activities that support, promote and protect IYCF into CMAM.
The study has three phases: consultation and planning (6 months), implementation (1 year) and evaluation, documentation and dissemination (6 months). As part of the study's planning phase, a technical consultation was held in Addis Ababa, Ethiopia from March 29 - 31, 2011. The aim of the consultation was to learn from Ethiopian experiences on CMAM and IYCF programming to-date, to consider operational models appropriate to Ethiopian priorities and context, and to explore research approaches to investigate an agreed operational model(s) in the context of the proposed study site.
The workshop was facilitated by Save the Children US and included representatives from the Alive and Thrive Project, the Ministry of Health of Ethiopia, World Vision, ENN, NPP, Concern Worldwide, Hawassa University, and the SNNPR Regional Health Bureau.
The consensus and main recommendations of the consultation are summarised here.
Timeline and study sites
The study will be implemented in World Vision's existing CMAM programme sites in Durame and Shone Area Development Programmes (ADP) in the Southern Nations Nationalities and Peoples Region (SNNPR) of Ethiopia. Four Woredas (districts) have been selected, two within each ADP, including East and West Badewacho in Shone and Demboya and Kedida Gamela in Durame, about 330 km south of Addis Ababa. CMAM was established in these ADPs in 2009 and are Government of Ethiopia priority areas for nutrition response.
The study will focus primarily on intervention and control cohorts of children 6-24 months of age and their caregivers in the selected Woredas. The study will also consider collecting weight gain and maintenance data from siblings (between 6-24 months of age) of CMAM patients enrolled in the study. Infants less than six months of age have been excluded from the study due to limited sample size in this age range enrolled in these programmes. Healthcare providers and community volunteers will also be targeted through training and capacity building.
The IYCF Model
A set model for integrating IYCF into CMAM does not exist. An operational model was therefore proposed that includes four main activities identified as important means of conveying IYCF messages and providing a supportive environment: messaging, action-oriented groups, support groups, and one-on-one counselling (see Box 1).
Box 1: IYCF Model
Evidence shows that mothers are more likely to make IYCF behaviour changes within a supportive environment/community. This often includes the husband, older children, grandmother, mother-in-law, traditional birth attendant (TBA) and traditional healer. Consideration for including and fostering these supportive functions must be made in an operational model for integration.
Mothers who are exposed to IYCF promotional activities through various activities/venues or 'contact points' are likely to have greater uptake, especially when mothers receive consistent and appropriate messages. However, messages alone are not enough. Most mothers already know about breastfeeding and that they should be doing it, but assistance needs to be provided to enable mothers to act on this knowledge. The more mothers feel supported, the more enabled they will feel to act on knowledge. The enabling environment in terms of resources and policy are also important.
Four main activities are identified to include in the IYCF Model:
Messaging: The delivery of limited and relevant information on IYCF promotion that can reach caregivers, influential community members, and communities at large.
Action-Oriented Groups: Action-Oriented Groups incorporate IYCF messages into group activities that are facilitated by health workers (HEW/VCHW) in a way to personalize information and encourage participants to try an action that is new or different. Facilitators are trained on Observe, Think, Try, Act (OTTA) skills to use stories, mini-dramas, or visuals to convey information and engage the group of participants.
Support Groups: An IYCF support group is a group of approximately 10-12 individuals (i.e. pregnant women, mothers, fathers, caregivers, etc.) to promote recommended breastfeeding and complementary feeding behaviours and provide mutual support.
One-on-One Counselling: The most effective but highly skills-based and resource-intensive of the four activities is one-on-one counselling which involves healthcare providers or trained counsellors providing individual assessments of mothers' feeding practices and developing IYCF plans to fit their specific needs. The activity is based on the WHOrecommended counselling guidelines of listening and learning, building confidence, and giving support. The intent is to move mothers in small, doable steps toward an ideal practice.
Integration approach
An IYCF in CMAM model requires identifying appropriate, feasible and beneficial contact points throughout the CMAM programme where key activities can be integrated3. The standard CMAM protocol is comprised of four components, including inpatient care (stabilisation centre), outpatient care (Outpatient Therapeutic Programme (OTP)), Supplementary Feeding Programme (SFP) and community outreach for screening, mobilisation, and messaging. In the consultation, the four activities from the IYCF model were considered at each of the standard CMAM component levels to identify possible entry points for effective integration. No options were considered that would add additional levels to the standard CMAM programme. Further investigation will be needed at each of the levels to operationalise the activities, i.e. who, how often, where, etc. Training of staff at key contact points will be a key part of the intervention.
Primary indicators
Consensus was reached to focus research questions exclusively on feasibility and efficacy. A number of primary indicators were identified although more work in this regard is needed:
- Assessing the feasibility of IYCF-CMAM integration was deemed an essential component of the study. Discussions revolved around what would be included in this question and how it would be measured. Measures should include delivery costs, opportunity costs, and staffing. One of the key considerations is the training needs of existing staff.
- It was agreed that indicators used to demonstrate efficacy should be limited to relapse/readmission and/or target weight gain or maintenance. These would be a measurable demonstration of improved IYCF practices. Benefits of integration on improving CMAM quality of care outcomes (i.e. cure rate) would be limited because it would not increase coverage or effectiveness of acute malnutrition management, but would use CMAM as an entry point to affect IYCF practices and improve malnutrition prevention.
- Coverage and cost effectiveness were excluded, mainly because of unique methodologies involved in measuring these outcomes, the limited time frame and specific confounders related to these measures.
Immediate follow up
Recruitment of a lead research partner was identified as a priority by project partners during the planning phase and was reinforced during the consultation. Subsequent follow-up by Save the Children US with the Centre for Disease Control (CDC) regarding the study design took place, which advised a longitudinal cohort study to follow two groups of children between 6-24 months, their caregivers and their siblings in intervention and comparison cohorts. Further refinement of the study design will be based on recommendations from a principal investigator from Addis Ababa University who will consult with the project partners on this research.
For further information on the project, including a full report of the March consultation, contact: Sarah Butler, Save the Children US, email: sbutler@savechildren.org
1Alive & Thrive (A&T) is a 5-year initiative (2009-2013) to improve infant and young child nutrition by increasing rates of exclusive breastfeeding and improving complementary feeding practices. A&T aims to reach more than 16 million children under 2 years old in Bangladesh, Ethiopia, and Viet Nam. Initial funding for A & T is provided by the Bill & Melinda Gates Foundation. http://www.aliveandthrive.org
2Training and workshop to integrate IYCF in CMAM. Summary of report. Field Exchange 40. p80.
3Full guidance and recommendations can be found in the Integration of IYCF Support into CMAM Facilitator's Guide. Available at: http://www.ennonline.net/resources/722
Imported from FEX website