Integrating Infant and Young Child Feeding and the Productive Safety Net Programme in Ethiopia

By Adèle Fox

Adèle Fox is currently based in Concern Worldwide Burundi office as Maternal, Newborn and Child Health Trainee. Adèle completed a Masters in Public Health from the London School of Hygiene & Tropical Medicine in 2011. She has prior experience with Save the Children UK, working as Policy & Research Coordinator and with Oxfam GB, as Systems & Resources Team Leader.

The author would like to acknowledge the involvement of Alive & Thrive for providing support and materials for this project. She would also like to thank Peter Gottert and Tigiste Abate of Alive & Thrive and Gashaw Abera, Gwyneth Cotes, Suzanne Fuhrman, and Pankaj Kumar of Concern Worldwide for their assistance in providing information and reviewing this article.

A PSNP beneficary and Model Mother

Concern Worldwide has worked in Ethiopia since 1973, primarily in the areas of health and nutrition, livelihoods, and HIV and AIDS. Two years ago, Concern documented the poor nutritional situation in Dessie Zuria Woreda and the multiple obstacles hampering previous efforts to improve the situation¹. Concern concluded that a multisectoral approach to improve infant and young child feeding (IYCF) practices and to increase access to food was among the responses needed. In 2010, the ‘IYCF into Productive Safety Net Programme (PSNP)’ project (IYCF-PSNP) was launched as a multi-sectoral pilot project aimed at reducing malnutrition in Dessie Zuria. The project targets poor households enrolled in the existing PSNP, as well as the general population, and addresses both the direct and root causes of malnutrition. The project aimed to develop an effective, sustainable and scalable model to improve IYCF practices in the most vulnerable households. The final results have been impressive, with large improvements in IYCF practices and a positive response from the communities and stakeholders involved in the project.

Background

School directors preparing special porridge with egg and vegetables, supervised by Hawla Eshetu , VCHW for Tebasit Kebele. They are wearing t-shirts with various IYCF messages

Dessie Zuria Woreda (district) is situated in the Amhara Region of Ethiopia, to the north of Addis Ababa. It is made up of 31 kebeles (clusters of villages), half of which are largely dependent on a typically unreliable and short rainy season. Dessie Zuria has been listed by the Ethiopian government as chronically food insecure for the past 11 years, and almost 40% of its population are eligible to participate in the Government’s PSNP (see Box 1).

Over half of all children in Dessie Zuria (54%) are chronically malnourished and the woreda suffers from persistently high rates of acute malnutrition. Annual nutrition surveys show that between 2000 and 2011 global acute malnutrition rates have only once, in 2004, dropped below 10%².

Concern Worldwide has supported the Ethiopian Ministry of Health to provide nutrition services for children in the woreda since 2000, through Communitybased Management of Acute Malnutrition (CMAM). However, the persistently high rates of acute and chronic malnutrition showed that management of malnutrition alone was insufficient, and that a preventive approach to undernutrition was needed.

Early assessments identified food insecurity, high rates of illness, and poor IYCF practices as contributing factors leading to high rates of malnutrition. A baseline survey conducted by Concern in November 2010 found low rates of exclusive breastfeeding (31%) and poor complementary feeding practices³. Only 13.3% of children received meals with the recommended dietary diversity, and very few children ate foods rich in iron (4%) and Vitamin A (13.7%). The sample size for the baseline survey was 694 children aged 0-23 months.

Project description

Concern Ethiopia started the two-year project in October 2010 with funding from Alive & Thrive, a Gates Foundation initiative. The project aimed to improve IYCF practices among the most vulnerable households in Dessie Zuria Woreda in order to reduce malnutrition, as well as to test the effectiveness of this model for scaling up and replicating elsewhere.

Concern Worldwide aims to assist people living in extreme poverty to make lasting improvements in their lives. In line with this goal, Concern’s programmes target the poorest and most vulnerable households in the areas where Concern is at work. In Ethiopia, the government’s PSNP programme provides support and assistance to the poorest members of each community. This project was designed to link with the PSNP so that nutrition support would be targeted to those most in need of assistance. The PSNP presented an entry point to help families improve their IYCF practices, as it targets the poorest households, who are more likely to have undernourished children. The PSNP also provides many potential contact points to deliver behaviour change communication (BCC) messages.

The project was implemented through a range of strategies, but the primary focus was on fostering social and behavioural change. At the start of the project, a baseline survey was conducted and formative research was carried out. The project used a Trials of Improved Practices (TIPs) approach to identify key barriers to improving IYCF practices, as well as to identify and pre-test a set of simple, realistic actions that mothers could take to improve their child’s nutrition.

Building the capacity of multi-sectoral actors at woreda, kebele and community level to deliver effective IYCF messages and encourage behaviour change

Concern used a cascading approach to train key decision-makers and community members on malnutrition, the PSNP, optimal IYCF practices and methods for promoting behaviour change (see Figure 1). At the woreda level, a task force of key officials from across different sectors was formed and trained. The woreda officials then trained the kebele-level Food Security Task Force members, including Health Extension Workers (HEWs), Development Agents (DAs), kebele administration staff, school directors, girl’s clubs in schools, Women’s Affairs members and religious leaders. HEWs then trained Voluntary Community Health Workers (VCHWs) to work directly with mothers’ support groups, which included one VCHW and six female members of the community. Through the mother’s groups, the VCHW promoted key IYCF messages to the community.

Supporting the promotion of effective IYCF messages at key contact points, including those linked to the PSNP

BCC was a central aspect of the IYCF-PSNP project. Findings from formative research were used to help design programme activities and messages, and the project utilised many different contact points for disseminating messages. Health workers carried out education sessions at PSNP pay days, public work days, child health days, screenings for growth promotion, and targeted supplementary feeding programme sites. Local radio and drama were also used to convey messages to the community.

Concern made use of existing resources as much as possible. One key tool was the Child Nutrition Card developed by the Alive & Thrive project, which lists ‘7 Excellent Actions’ (See Figure 2). This tool emphasised seven simple actions that mothers and fathers could carry out to improve their child’s nutrition. Families were given the poster-sized card, which lists the seven actions with a tick box next to each one for the mothers to complete. Mothers were encouraged to place them on their walls and show them off proudly to their neighbours. The messages in the nutrition card were reinforced through mother’s groups, school clubs, and community outreach. Once mothers completed the seven actions, they attained the title of "Model Mother" and graduation ceremonies were held to celebrate their success. Another aspect of BCC focused on equipping community members with practical skills to improve child feeding practices. Health workers and mothers’ support group members conducted house visits to provide one-on-one counselling on breastfeeding and preparation of complementary foods. Cooking demonstrations conducted at health facilities and community events allowed people to learn through observation and participation. Recipes were developed by Concern, based on food availability in the area and vegetables promoted through seed distribution.

Enabling communities to improve their IYCF practices

Formative research at the start of the project found that there were a number of barriers to adopting recommended IYCF practices, beyond limited knowledge and skills. Given the high levels of food insecurity in the woreda the project found it was necessary to support families and communities with practical tools and resources to enable them to carry out the recommended feeding practices.

To improve food production, Development Agents disseminated seeds and tools to the poorest households, provided advice and support on how to diversify their crops, and promoted home gardens as well as IYCF messages. To improve the health of women and children, VCHWs referred pregnant mothers to health institutions to encourage iron supplementation during pregnancy as well as vitamin A during the postnatal period. Protected springs were also constructed by Concern to improve water, hygiene and sanitation practices.

Engaging the entire community to foster social change

The IYCF - PSNP programme looked beyond the traditional target population of mothers and young children, harnessing the power of a broad range of influential groups to change overall social norms around IYCF. For example, BCC targeted fathers to encourage them to provide healthy foods for their children’s meals. Religious leaders were trained on key IYCF messages and were involved in local task forces.

A PSNP beneficary and Model Mother

The Smart and Strong Schools Approach is another unique concept piloted by the project. Through this activity, children in girl’s afterschool clubs are taught about breastfeeding, complementary feeding and hygiene, and encouraged to bring home the lessons they have learned. School directors and students enthusiastically embraced the project. According to School Director Endris Mohammed, "The girls are very motivated to share the messages with their friends and families because they understand their importance."

Results

During the two year project, 978 families achieved a ‘model family’ status. More than 850 Mother’s Support Groups were trained. An endline survey⁴ was conducted in June 2012, on a sample of 807 children aged 0-23m. There are four main seasons in the woreda: Kiremt/long rains (July-September), Meher/harvest (October- January), Bega /dry summer (February to May) and Belg/short rainy season (May to June). The baseline study was done in November, which is the beginning of the harvest and the end line was in June which is the beginning of the hunger period. Both periods can be considered as similar with regards to the food security situation and child feeding practices. Comparing baseline with endline strongly suggests that in just a short period of time, IYCF practices have greatly improved. The percentage of mothers who reported that they had started breastfeeding their child within the first hour after birth rose from 26% to 75%, and the proportion of children less than 6 months old who were exclusively breastfed rose from 36% to 91% - a remarkable increase (see Table 1). It is the nature of the EBF indicator that the exclusive breastfeeding rate is likely to be somewhat overestimated, as it only measures whether a child received breastmilk exclusively in the previous 24 hours, and includes very young infants who are more likely to be exclusively breastfed. There was a reduction in the percentage of mothers who reported giving their children water in the first month of life, from 48% to 18%, but almost one in five children are still given water at a very young age.

The end line survey also noted improvements in complementary feeding practices, although these were less dramatic (see Table 2). Approximately one-third of children (32.7%) aged 6-23 months consumed a minimum acceptable diet, up from 10% at baseline. This increase is due to improvements in both dietary diversity and meal frequency. However, the majority of children still received foods from only 3 food groups or fewer in the previous day.

Several other indicators showed little change. There was a small increase in the percentage of children aged 6-8 months who had started complementary foods (see Table 3). The consumption of iron rich foods did not change significantly despite recipes and messages promoting the consumption of eggs and meat. The agricultural aspect of the project did not have a livestock component, so there was no support for increasing production of animal source foods. This is something that may be considered in future projects. Another Concern project in Ethiopia has found that eggs are fairly widely available, but they are usually sold for profit.

Interviews with programme participants found that this project has been extremely well received by stakeholders at all levels, from Woreda officials to Model Mothers, many of whom can now list the recommended actions without hesitation.

One unexpected outcome of the project has been increased implementation of appropriate maternity leave for pregnant and lactating women. Prior to the project, these women normally participated in public work days as part of the PSNP. The project has been effective in creating an understanding of the importance of rest for mothers to give them time to recover and establish breastfeeding. As a result, women were excused from doing public works during pregnancy and for the first 4 months after birth, attending health and nutrition sessions instead (PSNP payments continued during this time).

Lessons learned

The multi-level Guguftu Kebele team including Zewditu Jemal and Amakel Ahmed (HEWs), Hawa Hussein (VCHW), Fato Assen (support group member) and Seada Mohammed and Aminat Seid (Model Mothers), who work together to reach all households in the kebele with the essential IYCF actions.

A number of factors contributed to the success of the IYCF - PSNP project. The project took a multi-sectorial approach, involving actors across a wide range of groups and sectors. It went beyond simply BCC, targeting the enabling environment as well as social norms, and involving the community at large. The project used multiple platforms and approaches to disseminate messages, and used a targeted approach to behaviour change, basing project activities and messages on formative research and emphasizing simple, do-able actions rather than health education messages.

The project engaged with actors from agriculture, education, women’s affairs, and health sectors. Each sector worked together towards a common purpose, leading to increased ownership and accountability. In an interview, one School Director described IYCF as now being "everyone’s responsibility." This approach also provided greater opportunities for engaging with communities. Cooking demonstrations, school clubs, and agricultural support were all combined to provide an overall aim of preventing malnutrition among children.

The project worked across levels, creating strong links between woreda, kebele and community levels through a cascading style of training and through the continued provision of support and supervision. This multi-level approach has had many advantages; for example, Hawa Hussein, a VCHW in Guguftu Kebele explained that if she has a problem, such as a lack of knowledge on an issue, she can contact the HEW or other member of the Kebele Food Security Task Force.

The project went beyond traditional communication approaches, using a social and behavioural change model. Early assessments showed that simply providing messages alone was unlikely to be effective, given widespread food insecurity and other barriers to behaviour change. This project aimed to influence the wider community and social norms as a whole, as well as address barriers to practising recommended IYCF behaviours. For example, policies around women’s maternity leave were strengthened, agricultural support addressed food insecurity, and support to water and health services aimed to prevent common illnesses.

Conclusions

Beyu Mohammed, a PSNP beneficiary and Model Mother in Tebasit kebele, received vegetable seeds from Concern and has grown carrots, kale, potatoes and beetroot, all of which she uses in the complementary food she has learned to feed her child. She sells any vegetables that are left over and has been able to buy soap with the money.

Using a comprehensive, multi-sectorial approach to social and behaviour change has resulted in impressive improvements in a number of IYCF practices over a short time. The IYCF-PSNP project has been commended as innovative, effective, and sustainable by a wide range of stakeholders within Ethiopia, and interviews with community members showed that mothers and other community members have enthusiastically embraced the project and materials.

The approach has been able to reach a large number of people who are widely dispersed over challenging terrain. Channelling activities through the PSNP creates additional contact points and ensures targeting of the poorest households. The two year pilot also suggests that despite strong linkages with the Government and a sense of community ownership, longer term support will continue to be necessary to address underlying factors of malnutrition such as food security, health, and hygiene, as well as to reinforce the gains made.

Possible areas for future investigation include engaging the private sector for producing ready to use fortified complementary foods, increased water and sanitation activities within communities, strengthening linkages with livestock support to promote consumption of ironrich foods, and the integration of Concern IYCF centres with community gardens to alleviate food insecurity.

Concern is currently in the process of replicating this project in four other woredas in Ethiopia.

For more information, contact: Pankaj Kumar, Assistant Country Director, Concern Ethiopia, email: pankaj.kumar@concern.net.

¹Style S. History of nutritional status and Concern’s response in Dessie Zuria Woreda, Ethiopia, Field Exchange, Feb 2011, Issue 40.

²GAM based on z-scores, using NCHS 1977 reference as per Ethiopian National Guidelines.

³Standard WHO indicators were used in baseline and endline surveys of IYCF practices.

⁴Hailu, W, Infant and Young Child Feeding Practices in Dessie Zuria Woreda. End line survey report, Concern Worldwide, 2012