1. Alive & Thrive World Vision Operations Research project on Timed and Targeted Counseling TOPS East Africa Knowledge Sharing Meeting Mesfin Beyero June 12, 2012 Addis Ababa

2. Presentation outline: Program overview Core intervention Progress to-date Mid-term evaluation and lesson’s learnt Monitoring mechanisms The way forward

3. Program overview Alive & Thrive, launched with a grant from the Bill & Melinda Gates Foundation, is an initiative to improve infant and young child feeding in Bangladesh, Ethiopia, and Viet Nam, reduce stunting and inform policies and programs around the world. Alive & Thrive is managed by FHI 360 with consortium members including: BRAC, GMMB, International Food Policy Research Institute (IFPRI), Save the Children, University of California – Davis, and World Vision.

4. Woreda (District) Kebele (sub-district) village HEW supervisors/PHCU HEWs Peer mothers Mothers, fathers, other caregivers household training super Timed and Targeted Counseling Program overview…cont’d 10 Counseling sessions Home visits training super

5. Why Stunting! Reduced physical stature (short) Reduced cognitive development Delays in starting school (7 months) Losses of schooling (0.7 grades) Reductions in lifetime earnings Overall reduced economic productivity, wages, income Smaller babies, inter-generational transmission of malnutrition and poverty

6. The core intervention: The core intervention for the community-based program is the ‘Timed and Targeted Counseling’ (TTC) approach. Peer Mothers are the primary counselors.

7. The core intervention …cont’d: Why Peer Mothers (PMs)? IYCF counseling at the household level is very weak because Health Extension Workers (HEWs) are busy with the 16 packages of the health extension program, and other engagements, The PMs work to improve IYCF counseling at the household level focusing on the mother and other influential family members.

8. The core intervention…cont’d: Events Opportunities for Cross-sector Cooperation Developing Media Coverage Shared Message Platform Information & Materials Advocacy Training Media Training Coalition Building Cross-sector Outreach Champion Identification Media Outreach Do mothers prefer to be counseled by Peer Mothers? Yes, because… They belong to the community the mothers are living, They are experienced (have children), Are trusted by the community, The community value both formal training and experience rather than just training alone.

9. The core intervention…cont’d: Events Opportunities for Cross-sector Cooperation Developing Media Coverage Shared Message Platform Information & Materials Advocacy Training Media Training Coalition Building Cross-sector Outreach Champion Identification Media Outreach Timed – information given when behaviors can best be put into practice, Targeted – information given to both those who practice the recommended behaviors and those who influence adoption of the behaviors (mother +), and Counseling steps need to be followed.

10. The core intervention…cont’d: Events Opportunities for Cross-sector Cooperation Developing Media Coverage Shared Message Platform Information & Materials Advocacy Training Media Training Coalition Building Cross-sector Outreach Champion Identification Media Outreach Research has shown that caregivers require skilled support to adequately feed their infants, Inappropriate feeding practices are often a greater determinant of inadequate intakes than the availability of foods in the households. (WHO)

11. Progress to date…cont’d The ToT Guide for health workers (HWs) has been developed, and are trained on IYCF in the context of TTC, - 50 HWs have been trained in the 1 st year and 38 have been refreshed in the 2 nd year.

12. Progress to date…cont’d The HWs then trained the Health Extension Workers (HEWs) using the training manual developed in Amharic - 259 HEWs have been trained in the 1 st year and refreshed in the 2 nd year.

13. Progress to date…cont’d The HEWs in turn trained the Peer Mothers (PMs) using the 15 TTC counseling cards (Ten cards for the 10 visits and 5 for the cross-cutting issues,) – 2303 PMs have been trained so far.

14. Progress to date…cont’d Peer Mothers make a series of 10 visits, the message at each visit being TIMED (the right message for the particular contact point) based on scientific evidence and experience from the field. 1.9 th month of pregnancy 2. Delivery 3. 2 nd day 4. 1 st week 5. 4 th week 6. 3 rd month 7. 6 th month 8. 8 th month 9. 12 th month 10. 18 th month

15. Results from midterm evaluation Peer Mothers’ visits (11 indicators) – Are the PMs conducting the visits on the specified schedules? IYCF practices by mothers (16 indicators) – Have mothers adopted the optimal infant and young child feeding (breastfeeding and complementary feeding)practices?

16. Results from midterm evaluation…cont’d Day of delivery and 2nd day visits were poor: - Difficult to catch mothers - Guests not allowed to come into the room during delivery Suggestions for improving the visits: - More than one visit during pregnancy

17. Results from midterm evaluation…cont’d Breastfeeding: - early initiation of breastfeeding - good - feeding of colostrum - poor - avoidance of pre-lacteals - good - continuation of breastfeeding - good Why good? The expulsion of the placenta as the result of the early initiation of breastfeeding has encouraged mothers to adopt the behavior.

18. Results from midterm evaluation…cont’d Complementary feeding: - timely introduction of CF - good - frequency - good - dietary diversity – poor

19. Results from midterm evaluation…cont’d Why poor? Expensive, unavailable, causes tapeworm even if cooked, ignorance on how to prepare meat for the baby (“Meat powder”) Seasonality, Available in most households; tendency to sell; not used to buying eggs from market, Mainly sour skimmed milk or “Arera”

20. Questions?