Can complex programs be sustained? A mixed methods sustainability evaluation of a national infant and young child feeding program in Bangladesh and Vietnam

Abstract

Background: Poor early-life nutrition is a major barrier to good health and cognitive development, and is a global health priority. Alive & Thrive (A&T) was a multi-pronged initiative to improve infant and young child feeding behaviors. It aimed to achieve at-scale child health and nutrition improvements via a comprehensive approach that included nutrition counseling by health workers, policy change, social mobilization and mass media activities. This study evaluated the sustainability of activities introduced during A&T implementation (2009-2014) in Bangladesh and Vietnam. Methods: This was a mixed methods study that used a quasi-experimental design. Quantitative data (surveys with 668 health workers, and 269 service observations) were collected in 2017; and analysis compared outcomes (primarily dose and fidelity of activities, and capacity) in former A&T intervention areas versus areas that did not receive the full A&T intervention. Additionally, we conducted interviews and focus groups with 218 stakeholders to explore their impressions about the determinants of sustainability, based on a multi-level conceptual framework. Results: After program conclusion, stakeholders perceive declines in mass media campaigns, policy and advocacy activities, and social mobilization activitiesbut counseling activities were institutionalized and continued in both countries. Quantitative data show a persisting modest intervention effect: health workers in intervention areas had significantly higher child feeding knowledge, and in Bangladesh greater self-efficacy and job satisfaction, compared to their counterparts who did not receive the full package of A&T activities. While elements of the program were integrated into routine services, stakeholders noted dilution of the program focus due to competing priorities. Qualitative data suggest that some elements, such as training, monitoring, and evaluation, which were seen as essential to A&T's success, have declined in frequency, quality, coverage, or were eliminated altogether.

Trends in complementary feeding practices and caregivers’ feeding knowledge among children aged 6-23 months: Repeated cross-sectional surveys in rural Qinghai China 2012-18

“…Improving complementary feeding is particularly challenging globally because of the multiple complex behaviors involved [ 38 ]. Previous study showed that training, monitoring, and evaluation declined in frequency and quality, or were eliminate altogether which influenced the Sustainability of the Alive & Thrive initiative (A&T) in Bangladesh and Vietnam [ 39 ], which was in accordance with our findings. Regular monitoring along with process and impact evaluations feed information back to programs is necessary [ 38 ].…”

What is the impact of removing performance-based financial incentives on community health worker motivation? A qualitative study from an infant and young child feeding program in Bangladesh

“…When A&T ended in December 2014, project support ceased for IYCF-specific financial incentives, refresher trainings, or job aids, although BRAC still expected IYCF counseling and education services to continue. While some A&T program activities and benefits continued, other activities, such as training and reporting, ceased altogether or experienced a substantial attenuation in implementation [51]. For example, 2 years after A&T ended, exposure to volunteer CHWs for interpersonal counseling was higher in intensive intervention areas than comparison areas; however, it had still experienced a decrease from 87.4% to 59.3% in intervention areas [44].…”

“…As part of a larger effort to assess the sustainability of A&T in Bangladesh, focus groups were conducted with representatives from multiple sub-districts in which A&T was implemented [51]. Seven districts were purposively selected to achieve geographic variability from a sample of 10 districts that had participated in a previous A&T endline evaluation.…”

Implementation science in nutrition: a summary and synthesis

“…The issues of sustainability are becoming increasingly important in implementation science and are of interest among researchers, implementers, donors and stakeholders who wish to improve the sustainability of effective public health programmes (32)(33)(34)(35) . Previous literature suggests considering sustainability in implementation science frameworks as a theory-driven approach to guide the design, development, implementation, evaluation and sustainability of interventions (36) .…”