The Importance of Engaging Frontline Health Workers
Evidence shows that populations do not adopt and sustain high-impact nutrition and hygiene practices solely as a result of increased knowledge and awareness (Bhutta et al. 2008 and Bhutta et al. 2013). Social science research has proven that many complex and contextual factors influence everyday decisions to consider, test, adopt, and/or reject, and ultimately internalize and sustain a behavior (Rogers 2003). Therefore, meaningful sustained change in nutrition-related behavior is unlikely to be achieved solely by a single activity targeting a single subset of the population, introduced at a single period in time.
Similarly, the decisions and steps surrounding the adoption of behaviors are often nonlinear, involving multiple feedback loops across time. This necessitates interventions, often multifaceted in nature, that help to either support and reinforce an individual’s adoption of a behavior, or promote a social change that makes testing or sustaining a behavior possible (The Manoff Group, n.d.).
For these reasons, the Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) project in Bangladesh partners with a multitude of government health staff to reach pregnant and lactating women (PLW) and children under two via numerous contact points in a variety of settings and through a range of interventions over a sustained period of time. We employ a comprehensive, behavior-centered process of social and behavior change communication (SBCC) to improve the nutrition of this population. The process features three strategic elements that work in coordination with one another to accomplish behavioral and social objectives: coordination, capacity development, and community engagement. (Communication for Change [C-Change] Project 2012; McKee 1992).
Working with government health staff is a critical piece of this three-pronged approach, as studies have shown that frontline health workers are a crucial source of information on health and nutrition (Sunguya et al. 2013; Pelto et al. 2004; Bhandari et al. 2005; Black et al. 2008). SPRING/Bangladesh both builds the capacity of these workers and supports the Government of Bangladesh (GOB) in the provision of nutrition services at the frontline.
SPRING/Bangladesh is working in the Barisal and Khulna divisions of the USAID Feed the Future zone of influence, in 9 districts and 40 upazilas (subdistricts) covering 373 unions and approximately 125,000 pregnant and lactating women through SPRING’s direct interventions. Hundreds of thousands more women are being reached through SPRING’s support to the Government of Bangladesh (GOB).
We develop the confidence and capacity of GOB health and agriculture workers and community agents, improving the ability of these frontline staff to deliver nutrition services and provide nutrition and hygiene counseling at a variety of contact points for pregnant and lactating women and children under two.
Funded by the U.S. Agency for International Development, SPRING/Bangladesh aims to decrease undernutrition among women and children by focusing on the 1,000-day window of opportunity among PLW and children under two years of age since the project began in 2012. One major component of the project is to support the Government of Bangladesh’s Ministry of Health and Family Welfare (MOHFW) by providing training and supportive supervision to frontline health workers to ensure that quality nutrition services and messages are being delivered to members of rural communities. In addition, the project assists agriculture extension workers from the Ministry of Agriculture (MOA), community groups, and other projects in promoting nutrition and hygiene practices. The project also facilitates the implementation of a nine-month Farmer Nutrition School (FNS), which serves as a forum to improve the production and consumption of diverse nutritious foods at home alongside the adoption of the Essential Nutrition Actions (ENA) and Essential Hygiene Actions (EHA).
Voice from the Clinic
Jesmin is a community health care provider at the Krisnakathi Community Clinic in Bakerganj upazila of Barisal. The ENA/EHA training enhanced Jesmin’s ability to counsel pregnant and lactating women on improving their nutrition practices through small doable actions—actions that are easily accomplishable but essential for the health of both baby and mother. The ENA/EHA curriculum incorporates information on what pregnant and lactating women should eat, where to obtain vitamin supplementation, why and how to breastfeed, when to introduce complementary feeding, and how to feed young children. The curriculum also conveys a basic understanding of household dietary diversity and hygiene.
"The topic... is so common and familiar in our lives, but we did not know the right information and its importance. This training was quite different than other trainings that I have attended. The most effective thing for me was the counseling technique, which is very relevant to my job. I highly appreciated this training, which has made me a more confident health care provider for my community."
— Jesmin, community health care provider
SBCC for ENA/EHA Framework
The adoption of essential nutrition and hygiene practices by individuals, households, groups, and communities is promoted by and supported through the project’s comprehensive SBCC framework (see Figure 1). Combining coordination, capacity development, and community engagement, the framework illustrates the road map to improve the nutrition of PLW and children under two.
Figure 1. SPRING/Bangladesh Social and Behavior Change Communication Framework
Elements of the Framework
Coordination informs and motivates leadership at upazila and union levels to create supportive health campaigns. Community nurturing furthers MOHFW goals by creating a sensitized community that understands the importance of nutrition and the risks of not following these simple actions carefully, a community that ultimately should help prevent further disease burden within itself.
Capacity development is often most effective through face-to-face dialogue with individuals or groups to inform, motivate, problem-solve, or plan, with the objective of promoting and sustaining behavior change. SPRING develops the capacity of government staff in two major ways: training and supportive supervision. We provide training to improve technical knowledge and to develop interpersonal communication techniques, improving health workers’ ability to clearly and effectively deliver quality messages on nutrition and hygiene. SPRING emphasizes supportive supervision via in-service monitoring and feedback with government supervisors. Regular on-the-job feedback brings MOHFW staff immediate suggestions in areas where they may be able to improve their skills and capacity.
Training Processes and Tools
- SPRING/Bangladesh conducts four-day master training sessions in ENA/EHA with supervisory-level health and family planning workers from the MOHFW, who in turn lead cascade trainings for frontline health and family planning workers.
- Trainers use two sets of training materials: 1) the ENA/EHA for health workers curriculum builds communication skills; and 2) since its approval in 2014, the Government of Bangladesh’s Basic Nutrition Training curriculum has helped frontline health workers gain a deeper technical understanding of the key concepts in nutrition for pregnant and lactating women and mothers with young children.
Community engagement encourages institutions, community networks, and social/civic and religious groups to demand progress toward a development objective. SPRING facilitates community engagement by supporting community health facilities, agriculture extension workers, existing community groups, and the FNS. Working with the MOHFW, we support community clinics by helping with health campaigns and involving them in SPRING’s FNS work at the village level. This support to the MOHFW builds a stronger relationship with the community and encourages it to make better use of frontline health services. SPRING/Bangladesh’s efforts to link its FNS graduates with community clinics and their support groups have helped to catalyze grassroots-level change and to strengthen the ties between the community clinics and the communities they serve, thus giving the MOHFW greater credibility and influence.
The SBCC for ENA/EHA Framework outlines a set of evidence-based interventions to improve nutritional practices during the critical 1,000 days between conception and two years of age (John Snow, Inc., n.d., World Health Organization 2013). It promotes a "nutrition through the life cycle" approach that defines the right action to be taken by the right person at the right time in the life cycle. These actions help improve child and adolescent nutrition; women’s nutrition during pregnancy and lactation; optimal breastfeeding and complementary feeding practices; nutritional care of sick and malnourished children; control of anemia and iodine deficiencies; and vitamin A, calcium, and iron supplementation. In addition, the framework delivers a complementary set of evidence-based hygiene practices related to food hygiene, handwashing, and access to a simple water source near cooking areas and latrines. As part of its ENA/EHA work, SPRING/Bangladesh promotes the use of the "tippy-tap," a simple and low-cost solution for handwashing.
The framework emphasizes the use of a multi-channel, multi-contact approach, using consistent, repeated messaging and support through various activities and mechanisms. We work through several arms of the MOHFW to reach as many people as possible, taking advantage of the interface among family planning, immunization, and health services, and with institutions like regional hospitals. This multi-channel approach multiplies the effect of the ENA/EHA framework and fosters behavior change around nutrition and hygiene at many different points.
Figure 2. A "Life Cycle Approach for Nutrition" from SPRING/Bangladesh Training Materials.
1. Secure Buy-in
To achieve sustainability, SPRING focuses on ensuring that support for improvement in nutrition is given through the government and by the government. In addition to coordinating with health staff cadres, SPRING/Bangladesh also coordinates with a number of directorates within the MOHFW, including the Directorate General of Family Planning (DGFP) and the Directorate General of Health Services (DGHS), which includes the Community Based Health Care (CBHC) directorate general (formerly the Revitalization of Community Health Care Initiatives in Bangladesh) and the National Nutrition Services (NNS). SPRING/Bangladesh uses routine meetings and supportive supervision visits with DGHS and DGFP staff to advocate for the inclusion of nutrition indicators and nutrition-related activities into the government’s routine work. This coordination happens at many levels of the system—centrally in Dhaka, as well as at division, district, sub-district, and union levels. It even happens in meetings at the village level.
2. Provide SBCC Support and Leverage Existing Resources
SPRING/Bangladesh’s SBCC framework outlines the activities and partnerships planned and currently being leveraged to promote prioritized nutrition behaviors to specific target audiences, which will help achieve desired changes in behavior and social norms. The framework follows the national guidelines and format of the Government of Bangladesh (Government of Bangladesh 2014).
SPRING participates in the national Behavior Change Communication (BCC) Working Group and was a member of the technical committee that reviewed and finalized the national BCC framework for improved nutrition in Bangladesh during 2014.
SPRING participates in scheduled MOHFW field-level meetings at central, division, district, and upazila levels. Further, we assist the Government of Bangladesh at these levels by supporting national goals and objectives through our nutrition work at the community level and by helping build the capacity of the government workforce with regular field visits, coaching, training, and supportive supervision. These central and local coordination and collaborative efforts are vital to ensuring long-term behavior change and improvements in service delivery.
SPRING/Bangladesh also makes use of materials already available and, rather than creating new materials, has focused on using only those endorsed by the government, such as the Sonali Alo materials, those for Mainstreaming Nutrition, and the infant and young child feeding brochure of the Institute of Public Health Nutrition (IPHN).
Figure 3. Dietary Diversity Counseling Poster Used in More Than 1,400 Community Clinics and Other Health Facilities
3. Conduct Practical Training on ENA/EHA at All Levels
SPRING works closely with trainees to address knowledge gaps through supportive supervision, refresher training, mentoring, and coaching on aspects of ENA/EHA. All frontline workers deliver nutrition and hygiene messages and services during routine consultations in health facilities and during household and community visits; they agree that the addition of these messages does not add too much time to their schedules and is, therefore, acceptable when delivered at already existing contact points. Trainings complement ongoing government initiatives, such as exclusive breastfeeding campaigns, vitamin A campaigns, FNS nutrition fairs, and other community events. ENA/EHA message delivery coupled with government-sponsored activities helps ensure that communities stay mobilized around nutrition.
4. Offer Supportive Supervision
SPRING/Bangladesh focuses a major part of its work on supportive supervision, an important technique for capacity-building. Although key to sustainability and long-term change, supportive supervision can be accomplished simply by creating an enabling environment and via behavior change (Marquez and Kean 2002). Supportive supervision visits take place every two to three months at each frontline health facility that SPRING supports. SPRING also works with the next level government supervisor to ensure that he or she participates in site visits and is taking the lead in giving feedback to site staff.
Guidance That Builds Capacity
Supportive supervision is a process of guiding, helping, and encouraging staff members at their place of work to improve their knowledge, skills, and performance and thus meet defined performance standards.
Benefits of Supportive Supervision
- Creates and supports an environment of continuous learning
- Supports professional and personal growth of staff
- Improves staff communication skills
- Increases confidence
- Improves job satisfaction
- Enhances quality of practice
Challenges of Supportive Supervision
- Encouraging supervisors to participate requires substantial effort because they are often very busy
- There is a dearth of experienced supervisors who can conduct supportive supervision
Supportive supervision teams can use a checklist to capture data from health facilities in project intervention sites that will help them assess caregiver knowledge and quality of nutrition services provided by service providers. Teams guide service providers in their work based on the results of the data collected. This guidance strengthens the capacity of both supervisors and supervisees. SPRING upazila-level staff coordinators and Government of Bangladesh supervisory-level staff jointly visit health facilities to support service providers and observe their growth monitoring skills, counseling, use of SBCC materials, record keeping, and follow-up. Based on observations, supervisors provide service providers with relevant guidance and suggestions.
Data are aggregated and analyzed to identify any weakness across the system; if gaps are found, then supervisors take immediate action to bridge them. The process shown in figure 4 indicates how this information is collected and its flow through the system.
For example, in FY15 alone, SPRING managed approximately 2,200 supportive supervision visits across 1,379 health facilities; on average, supervisors made 550 visits to 345 health facilities every quarter in SPRING intervention areas.
5. Invest in Community Nutrition Champions and Community Mobilization
Figure 4. Flow of Data on Health Worker Knowledge and Skills
SPRING/Bangladesh is pioneering a new approach to establishing sustainable, community-based nutrition linkages. The Chief Coordinator of CBHC endorsed this model—community nutrition champions (CNCs)1—by signing a circular that invited SPRING CNCs to become coopted members of community support groups affiliated with government community clinics. Community nutrition champion participation in government community clinic management helps mobilize the community around health and nutrition, dispels myths about health-seeking behavior, strengthens community–health facility ties, and helps ensure that health care providers are aware of the issues facing women in their communities.
The SPRING CNC concept is simple: at the end of the nine-month FNS session, each FNS group selects a CNC to promote the learned practices in the community and to serve as an advocate for nutrition in that community. The post is voluntary and not remunerated. Community Nutrition Champions become important community voices, invited to participate in government community support groups, the administrative bodies that help ensure that community clinics are running smoothly and are addressing community needs. This position serves as an important link between households and the government system and allows SPRING to scale up ENA/EHA throughout its working area in a way that is both effective and sustainable. The GOB also engages CNCs to help with community mobilization for various national campaigns, such as the "Vitamin A Plus" campaign.
Results for the Period March 2012 through September 2015
Since March 2012, SPRING/Bangladesh has made significant strides in mobilizing individuals and communities around nutrition by drawing on frontline government staff to catalyze change around nutrition and hygiene.
- We conducted 1,873 trainings for supervisory-level health staff and 7,481 trainings for frontline health staff within DGHS and DGFP in approximately 1,100 community clinics, 300 union health and family welfare centers, and 40 upazila hospitals between March 2012 and September 2015.
- For the same period, trained health staff recorded 5,326,448 contacts related to ENA/EHA with pregnant and lactating women and mothers with children under age two.
Figure 5. Contacts Made through the Health System (FY12-FY15)
SPRING/Bangladesh has been able to demonstrate that support across a wide geographical area to a variety of departments/institutions within the MOHFW is not only feasible but can also be successful in reaching a large number of people. We have been able to scale up ENA/EHA for the MOHFW both rapidly and meaningfully by supporting the Government of Bangladesh using its own materials and trainers and finding discrete areas of opportunity within the system. Working consistently with all upazila-, union-, and subunion-level health facilities to improve nutrition counseling and service delivery has been critical to the program’s success.