IFE RAPID ASSESSMENTS (Sector specific rapid assessments) Common challenges & potential solutions Ali Maclaine Consultant Public Health Nutritionist IFE Regional Meeting, Bali, Indonesia March, 2008

IFE Assessments in general: What are main questions / issues people face?  When should an assessment be done?  What type of assessment should be done at that time?  What is the correct methodology?  What questions should be asked?  What is the correct way to ask them?

Initial Rapid Assessment (qualitative & secondary quantitative)

- NO set guidelines on how to do IFE SSRAs in rapid onset emergencies. - No generic tools - Everyone tackles same questions / issues / problems - People doing it wrong / could do it better 2002 paper on IFE indicators & suggested review……….. (Marie McGrath et al. Infant feeding indicators for use in emergencies: an analysis of current recommendations and practice. Pub Health Nut 2002, 5(3) ) IFE SSRA The problem…

IFE SSRA First question people worry about is? What am I going to do? Should be: What are the objectives?

 Related to assessing CHANGE due to the crisis - Reduction / Increase in exclusive breastfeeding - Mothers’ stopping breastfeeding early - Reduction / increase in mothers’ mix feeding (breast & formula) - Earlier / later introduction of complementary foods - Poorer / better complementary foods being used  WHY there a change e.g. breastfeeding myths, donations  Information used for programming, advocacy, etc. IFE SSRA Main objectives:

IFE SSRA What is the correct methodology? - Qualitative / Quantitative / mix? - FGDs / Key informants / Household visits / Transect walk – one best or mix? - Sampling method: Cluster fixated but convenience more appropriate – purposive sampling - Numbers needed to make outcome ‘significant’, are numbers feasible? - Anthropometry included (< 6 months?)?

IYCF standard core indicators: Early initiation of breastfeeding Exclusive breastfeeding under 6 months Continued breastfeeding at 1 year Timely complementary food (New guidelines: Introduction of solid, semi-solid or soft foods) Minimum dietary diversity (i) Minimum meal frequency (ii) Minimum acceptable diet (composed of (i) + (ii)) Consumption of iron-rich or iron-fortified foods IFE SSRA What questions should be asked? How should questions be phrased?  Are they all relevant and needed in IFE SSRA?  How should they be asked in a crisis? (24hr recall v. quick question = when trying to get rapid over-view)

 Main objective of SSRA to assess CHANGE - Type - Level (to some extent) - Reason Need to determine the key questions required to assess ‘change’ Establish ‘best’ phrasing of question… IFE SSRA What OTHER questions are essential for an IFE SSRA?

 Need to assess the extent & nature of artificial feeding in emergencies – BUT NO agreed guidelines on what data is ‘key’, or ‘correct’ phrasing of questions to get the ‘best’ information in a SSRA  Due to high risk related to donations (BMS, milk powder, bottles/teats) need to assess their impact Need to determine the key questions required to get required detail. Establish ‘best’ phrasing of question… What is the key data? What is ‘best’ phrasing of questions? IFE SSRA ASSESSING ARTIFICIAL FEEDING IN EMERGENCIES

 Need to assess need for complementary food aid - Local foods, fortified foods, micronutrient ‘sprinkles’  Need to assess impact What are the key questions? What is ‘best’ phrasing of questions? IFE SSRA ASSESSING COMPLEMENTARY FEEDING IN EMERGENCIES

 Need to establish what is required to support appropriate IFE in the area  Need to establish acceptability and requirement of specific interventions e.g. wet nursing, ‘breastfeeding support groups’, etc What are the key questions? What is ‘best’ phrasing of questions? IFE SSRA PROGRAMMING DECISIONS

So how are IFE sector specific rapid assessments being done?

BANGLADESH Cyclone hit: 15 th November 2007 Districts: 30 Sub-districts: 200 Unions: 1,950 Population affected: 8.9 mill Families affected: 2 mill. DeathsDeaths: 3363 : 3363

Photos credit: Ali Maclaine, 2007

Save the Children SC great history in IFE One of first agencies to actively look into the issue. Always seeking to attain ‘best practice’ in the field in terms of IFE. Should be commended NOT an example of a bad IFE rapid assessment, but a regional example in order to look at the common challenges and issues.

Save the Children Alliance - Bangladesh  Rapid IFE assessment to: - determine whether infants and young children were vulnerable to increased morbidity and mortality due to poor IYCF practices.. - develop strategies to promote optimal feeding practices for the emergency areas

The objectives were: 1. To establish an overview of IYCF patterns pre- cyclone in the assessment area (14 unions) 2. To determine whether there had been changes in these patterns post-cyclone 3. To establish the reasons for these changes 4. To identify ways to promote and support optimal IYCF practices for (i) the breastfeeding infant (ii) the mix-fed infant (iii) the non-breastfed infant, and (iv) the complementary-fed child.

Available capacity for assessment…  SC health and nutrition staff – IYCF experience  Capability to assess all 14 unions in 2 days  SC support  Bangladesh Breastfeeding Foundation and Dr. Khurshid Talukder, Consultant Paediatrician and Research Co-ordinator, Centre for Woman and Child Health

Method (Also looked at secondary data)  Focus Group Discussions (FGD) with caregivers of children aged 0-24 months (half of group infants <6 months)  Key informant interviews with: (i) Government or NGO health workers (ii) Traders  Transect walks  Household interviews with (i) mothers with infants <6 months exclusively breastfeeding, (ii) mothers with infants <6 months who were being mixed fed or not being breastfed at all (iii) mothers/caregivers with infants ≥6 months who were being complementary fed  Additional unstructured rapid assessments

Results led to  SC revising its health and nutrition messages given as part of the emergency programming.  SC further engaging with its partner agencies in IFE at the local and national level.  Provided qualitative data to the nutrition cluster and other agencies as to IFE situation.  Bangla translation of the Operational Guidance.

What could have been done better….

Time flies past…  Early assessment by SC missed out IFE  Due to unavoidable delays assessment not started until 28 th Dec (5 weeks)  So not initial rapid assessment or full assessment (MSS)…..

 The IFE SC designated person became unavailable – important to have a nutrition person sensitive to IFE issues and local knowledge. (Lucky to have BBF to help: Breastfeeding counsellors, trainers, translators, etc!!!) Having IFE designated support throughout…

Tools changed during translation: - To fit with national IYCF strategies - To include other issues - To fit with local context Some IFE questions removed / changed Having agreed tools in advance

Greater time  Only a week on the ground  Team busy  Added time pressure: Long journeys teams had to get back to the field in daylight

Hence: - No time to discuss issues / decide on questions needed and the way to ask them - Training of field workers had to start before team met to finalise assessment tool - Quick discussion & make changes to tools straight into Bangla - No time to fully discuss changes with assessment team or field test new forms - No time to back translate to ensure changes made were correct

Language Challenges  ‘Mixed feeding’ is not a Bangla term and is not well understood  ‘Child’s milk’ could cover infant formula, tinned milk, child powdered milk or any milk (e.g. cow’s milk, milk powder, milk in cartons) that is drunk by a child whether suitable or not  ‘Concerns’ translated as ‘issues’ then interpreted by assessors/interviewees as asking about their knowledge of appropriate IYCF

Challenges caused by misunderstanding (found during analysis):  The terms ‘less’ and ‘more’ were sometimes interpreted as ‘earlier’ and ‘later’ e.g. ‘Since the cyclone are infants being given complementary foods earlier, later or at the normal time? Was answered as ‘later’ when checked mother meant giving it later during the day..  A question such as ‘Are less mothers breastfeeding?’ was sometimes interpreted as ‘Are mothers producing less milk?’

Challenges of assessment method  FGDs were not always free ranging conversations - each mother was asked about her experience on the issue.

Challenges with the rapid assessment tool…  Long  Amalgamating qualitative data from different tools takes time  Questions not phrased the ‘right’ way  Some important questions missed out  It could be done better….

Determine ‘best’ method of conducting IFE SSRA. Review of sampling strategies for infants and determine agreed numbers for ‘acceptability’ of results Need to agree: - what data is ‘key’ - the ‘best’ method of phrasing questions in SSRAs to obtain reliable information with a useful level of detail Need to field test Bring it together to form SSRA guidelines and useable assessment tools based on ‘best practice’. Tools need pre-emergency country review & translation Overview. What is needed?

Your Experiences &Thoughts? Conducting IFE SSRA In Bangladesh, Post-cyclone Sidr Thank you.