Side-by-Side Summary of Two Packages that Support Community-Based Infant and Young Child Feeding Programs

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This document is part of an occasional series produced by SPRING staff and consultants on topics of relevance to practitioners in global nutrition. As "Working Papers," we especially welcome feedback from readers who would like to share their perspectives based on related experience. To provide feedback, please send us an email .

Introduction

This Side-by-Side Summary of Two Packages that Support Community-Based Infant and Young Child Feeding (IYCF) Programs was designed as a quick reference document outlining two internationally-recognized sets of IYCF-related training and counseling materials – the CORE Group’s Essential Nutrition Actions (ENA) Framework, originally produced under the LINKAGES Project, and the UNICEF Community Infant and Young Child Feeding (C-IYCF) Counseling Package. Both packages reflect the latest evidence on high-impact nutrition practices most recently presented in The Lancet Maternal and Child Nutrition Series 2013 and the WHO Essential Nutrition Actions. Although many other frameworks and materials on IYCF exist, these two packages were selected because variations of one or both are prominent in the countries where nutrition is a priority for the USAID Global Health Bureau, USAID missions, and Feed the Future. The document is intended to assist practitioners, particularly those at country level, in understanding the similarities and differences between the two packages, and in making informed decisions about the right materials for their context.

Both packages contain state of the art, technically sound, evidence-based information that follows the latest advances in IYCF, and both have been used with success globally. Skilled and trained staff are needed to support the training and roll out of both packages, which is often a challenge at country level. Each is intended to be adapted to the local context through formative research and a consultative process involving stakeholders. The materials and techniques are not designed to compete with one another and can in fact coexist in the same country.

SPRING is positioned and willing to support the adaptation and implementation of both packages, but will take the lead from the national governments and local partners on the ground to determine which is best suited in a particular context. Much of the content of each package is similar, although differences in focus, organization, and priority topics do exist. Similarities and differences are outlined below. This summary, focused on the main elements of each package, was carefully constructed by technical experts familiar with both packages.

Generic versions of both the ENA Framework and the UNICEF Community IYCF Counselling Package are available in both French and English. The ENA Framework includes four primary components that can be accessed in English and French using the following link: Essential Nutrition Actions (ENA) Trilogy. The complete UNICEF Community IYCF Counseling Package can be accessed in English and French using the following link: UNICEF C-IYCF Counseling Package.

The Side-by-Side Summary

The side-by-side summary is organized around two tables.

Table 1 provides a general overview of each package. It is divided into seven sections:

Overview
Components
Job Aids
Training Guides for Community-based Volunteers/Workers
Training Assessments
Field Practica
Implementation Guidance

Table 2 provides an overview of key content areas and interventions covered by each package. It is divided into nine sections. An “X” indicates that the materials address a given content area or intervention.

Women’s Nutrition
Breastfeeding
Complementary Feeding
Nutrition in Special Circumstances
HIV and Nutrition
Micronutrient Deficiencies
Water, Sanitation, and Hygiene
Nutrition Counseling Skills
Other Skills

In selecting the most appropriate package, stakeholders should consider existing programming, the national policy environment, and the objectives of the work. Whichever package is selected, ensuring high quality local adaptation and consistent messages across programs and sectors is critical.

Table 1: Side-by-Side Summary of the CORE Group’s ENA Framework Trilogy and UNICEF’s Community IYCF Counseling Package

	ENA Framework	UNICEF Community IYCF Counseling Package	Key Similarities or Differences
I. Overview
	In 2010, the CORE Group adapted the Essential Nutrition Actions (ENA) Framework Trilogy training and communication materials to focus on a child’s first 1,000 days of life—from the start of a mother’s pregnancy to the child’s second birthday. The current ENA package has evolved from earlier USAID funded frameworks and materials developed under the BASICS Project (the Minimum Package for Nutrition, or “MinPak”) and under LINKAGES. The ENA framework emphasizes action-oriented nutrition messages and support, and promotes a “nutrition through the life cycle” approach, addressing the following: women’s nutrition during pregnancy and lactation, optimal IYCF (breastfeeding and complementary feeding), nutritional care of sick and malnourished children (including zinc, vitamin A and ready-to-use therapeutic foods), and the control of anemia, vitamin A and iodine deficiencies. The framework recommends that multiple program contact points at health facilities and beyond be used to reach mothers and children in order to give and reinforce ENA messages. To date, the ENA framework has been implemented in Bangladesh, Burkina Faso, Ethiopia, Liberia, Madagascar, Mali, Nepal, Niger, and Tanzania.	In 2010, UNICEF developed a new set of generic tools for programming and capacity development on community-based IYCF counseling. Designed for use in diverse country contexts, the tools guide local adaptation, design, planning, and implementation of community-based IYCF counseling and support services at scale. The counseling package also contains training tools to equip community workers (CWs), using an interactive and experiential adult learning approach, with relevant knowledge and skills on the recommended breastfeeding and complementary feeding practices for children from 0 up to 24 months. The tools focus on CWs’ counseling, problem-solving, negotiation, and communication skills, and prepare them to effectively use the related counseling tools and job aids. To date, 21 countries are at various stages of adapting the materials to the local context, building capacity and rolling out community- based IYCF counseling and communication programs using the package.	Both approaches promote a similar set of IYCF interventions, with minor variations in their key messages, training methodologies, and types of job aids.
II. Components
1. For national and/or district teams or organizations and program managers	Understanding the Essential Nutrition Actions (ENA) Framework (6 pages)	Planning Guide (40 pages) Adaptation Guide (117 pages) Orientation Presentation provides an overview of the IYCF Package and the training approach for various levels (national, sub-national, and district) and partners as part of the process of introducing the package (48 slides) Supportive Supervision, Mentoring, and Monitoring (62 pages)	The ENA framework provides tools and training materials for both community and facility based workers, while the UNICEF package is specifically created for community health workers. This background and orientation to ENA is brief but provides references and additional materials from adaptations of ENA used in specific countries or contexts. The UNICEF package includes an adaptation guide. While the ENA framework emphasizes the need to adapt to local contexts, the authors do not include an adaptation guide.
2. For facilitators/ trainers	The ENA Framework Training Guide for Health Workers (105 pages) The ENA Framework Training Guide for Community Volunteers (59 pages)	Community IYCF Facilitator Guide (261 pages, including 12 Appendices) Community IYCF Training Aids (52 pages) Community IYCF Supportive Supervision, Mentoring, and Monitoring (62 pages)
3. For primary health care staff	Handouts for Health Workers (39 handouts, 79 pages) Booklet on Key ENA messages (34 pages)	Not Applicable
4. For community workers / counselors	Booklet on Key ENA messages (34 pages)	Community IYCF Participant materials (54 pages) Counseling Cards for Community Workers (24 plus 3 Special Circumstance Counseling Cards on HIV) Community IYCF Key Messages Booklet (45 pages, including copies of three take-home brochures) Three take-home brochures on maternal nutrition, breastfeeding, and complementary feeding.
III. Job Aids
	The Booklet on Key ENA Messages is intended as a resource for training community or facility-based workers, or for promoting behavior change at the household level. The goal of this booklet is to make a harmonized set of messages available across all implementing partners working across various programs and regions in a targeted country. The booklet summarizes the “key actions” that mothers and caretakers can take (with support from other family and community members) to improve nutrition and feeding practices, thereby preventing malnutrition. The booklet contains a mix of illustrations and photos supporting each action.	The Counseling Cards for Community Workers present colored illustrations that depict key infant and young child feeding concepts and behaviors for CWs to share with mothers, fathers, and other caregivers. These job aids are designed for use at specific contact points, based on priorities identified during each individual counseling session. The Key Messages Booklet consists of messages related to each of the IYCF Counseling Cards, as well as copies of the 3 Take-home Brochures. Three Take-home Brochures for mothers: “How to Breastfeed your Baby,” “Nutrition during Pregnancy and Breastfeeding,” and “How to Feed a Baby after Six Months”.	The UNICEF package contains counseling cards, a key message booklet and three take-home brochures. The ENA framework includes a key message booklet which is intended to be used as a reference for key messages and a job aid for counseling.
IV. Training Guides for Community-based Volunteers/Health Workers
1. Title	ENA Framework Training Guide for Community Volunteers (59 pages) ENA Framework Training Guide for Health Workers (105 pages) Booklet on Key ENA messages (34 pages)	Community IYCF Facilitator Guide (261 pages including 12 Appendices) Community IYCF Training Aids (52 pages) Community IYCF Participant materials for community workers/ counselors and primary health care staff as well as master and other facilitators/trainers (54 pages)	The UNICEF package counseling cards are designed for community-based providers – the package does not include counseling materials for facility-based staff as ENA does. Though the UNICEF counseling cards have been adapted in several settings for facility use by changing the illustration on the cover with the same content.
2. Length of Training	Nine Sessions over three days: two days at training site, a half-day for a practical field visit, and a half-day for development of Action Plans	Nineteen Sessions over five days: four days at the training site and one day (two half days) for a practical field visit	The ENA training lasts three days, while the UNICEF training is five days with a three-day adaptation option. Both trainings include practica.
3. Description	The ENA Framework Training Guide for Community Volunteers is intended to equip semi-literate or literate community volunteers with the basic action-oriented nutrition knowledge and counseling skills needed to support pregnant women, mothers with children under two years of age, and other key family members to adopt optimal nutrition practices. The ENA Framework Training Guide for Health Workers is intended to equip health service providers with the technical, action-oriented nutrition knowledge and counseling skills needed to support pregnant women, mothers with children under two years of age, and other key family members to adopt optimal nutrition practices. The Booklet on Key ENA messages is intended to be a resource for training community or facility-based workers.	The Community IYCF Facilitator Guide and Training Aids are intended to prepare CWs with technical knowledge on the recommended breastfeeding and complementary feeding practices for children from 0 to 24 months, enhance their counseling, problem solving, and negotiation skills, and prepare them to effectively use the related counseling tools and job aids. The September and November 2012 editions contain material on early childhood development as it relates to responsive feeding, and the addition of micronutrient powders (MNPs) to complementary foods. Session 19 includes the development of Action Plans for Community IYCF programming post-training. The training component of the package (the Facilitator Guide) contains 12 Appendices with supplementary information. The Community IYCF Participant Materials include key technical content presented during the training (“handouts” from the Facilitator Guide) and tools for assessment of IYCF 3-Step counseling (‘assess, analyze, and act’) implementation and supportive supervision activities.
V. Training Assessments
	Pre/post-test (written)	Pre/post-assessment (not written, participants respond by raising hands)
VI. Field Practica
	Session 8 Two-and-a-half hour field visit and 45 minute feedback session, including: counseling with actual mothers/ fathers/ caregivers in a facility and/or community setting	Sessions 11 and 13 One day-long (or two half-day sessions) field visit, including: counseling with actual mothers of children under 6 months of age counseling with actual mothers or caregivers of children over 6 months of age facilitating an action-oriented group facilitating a support group Session 8 50 minute cooking practicum: Using locally available, feasible, affordable, and seasonal foods (animal-source foods, legumes and seeds, vitamin A-rich fruits and vegetables, other fruits and vegetables, staples, and oils) participants “prepare a meal” for a different age-group while discussing age-appropriate characteristics of complementary feeding: frequency, amount, texture (thickness/ consistency), variety, responsive feeding, and hygiene.	The UNICEF package includes a more intensive practicum, with a full day of practice as compared to the half day included in ENA.
VII. Implementation Guidance
1. Supportive Supervision	Understanding the Essential Nutrition Actions (ENA) Framework (6 pages): Includes a reference for additional resources specific to supportive supervision.	Supportive Supervision, Mentoring, and Monitoring Module (62 pages)	The UNICEF package includes a module on supportive supervision and mentoring, which the ENA materials do not address directly. However, additional references are linked to from adaptations of the framework.
2. Planning and Scale	Understanding the Essential Nutrition Actions (ENA) Framework (6 pages): Includes a reference for an additional resources that contains nine modules on rational for ENA and steps for large scale implementation.	Planning Guide (40 pages): outlines a series of steps and includes some key points about the systems and structures needed to make IYCF counseling in the community function optimally and sustainably as part of a broader IYCF, or nutrition/ health program. Adaptation Guide (117 pages): provides a number of specific tools, or job aids, for use by national or local stakeholders interested in adapting the generic package for use in their setting. The Adaptation Guide recognizes that each country or setting potentially interested in working with the Community IYCF Counselling Package has unique socio-cultural differences, including dietary behaviours, clothing styles and linguistic characteristics that need to be taken into consideration and ultimately reflected in the training content and communication materials (both text and graphics). Suggestions are also made for bringing relevant stakeholders together to review the generic package, identify opportunities, clarify roles and responsibilities and decide on a process and timeline for adapting this set of tools.	The Planning Guide and Adaption Guides included in the UNICEF package provide a more extensive tutorial for planning and adaptation compared to the ENA materials which provides links to additional resources from adaptations of the framework.

Table 2: Side by Side Summary of the CORE Group’s ENA Framework Trilogy and the UNICEF Community IYCF Counseling Package: Topics Covered

Topics Covered, By Category	ENA Framework	UNICEF Community IYCF Counseling Package
I. Women’s Nutrition	X	X
Nutrition of pregnant women	X	X
Iron supplementation during pregnancy	X	X
Nutrition of lactating mother	X	X
Family planning		X
II. Breastfeeding	X	X
Early initiation of breastfeeding	X	X
Exclusive breastfeeding	X	X
Good attachment and positioning	X	X
Breastfeeding on demand/frequency	X	X
Common breastfeeding difficulties		X
Early childhood development as it relates to responsive feeding		X
Mother who is separated from her infant	X	X
Hand expression and cup feeding		X
Continue breastfeeding until 2 years and beyond	X	X
III. Complementary Feeding	X	X
Introducing complementary feeding at 6 months	X	X
Feed a variety of foods	X	X
Complementary feeding for various ages – frequency, consistency, variety and amount	Feeding from 6-11 m. Feeding from 12-24 m.	Feeding from 6-9 m. Feeding from 9-12 m. Feeding from 12-24 m.
Available local foods	X
IV. Nutrition in Special Circumstances	X	X
Feeding of the sick child during illness	X	X
Feeding of the sick child after illness	X	X
Nutritional care of infants and children with diarrhea	X	X
Nutritional care of infants and children with moderate acute malnutrition	X
Feeding a low birth weight baby		X
When to bring your child to the health facility		X
IYCF in emergencies		X
V. HIV and Nutrition		X
Exclusively breastfeed and take ARVs		X
Exclusively breastfeed even when there are no ARVs		X
Conditions needed to avoid all breastfeeding		X
VI. Micronutrient Deficiencies	X	X
Addition of micronutrient powders (MNPs) to complementary foods		X^*
Prevention of malaria and anemia	X	X
Iodized salt	X	X
Importance of Vitamin A	X	X
Preventing anemia from parasites	X
VII. Water, Sanitation, and Hygiene		X
Handwashing	**	X
Food hygiene	**	X
Sanitation/latrine use	**
VIII. Nutrition Counseling Skills	X	X
Counseling and negotiation	X	X
IYCF support groups		X
Home visits		X
Development of action plans	X	X
IX. Other Skills	X	X
Regular growth monitoring and promotion		X

*added to the revised package from 2012

** Essential Hygiene Actions (EHA) is the ENA framework’s WASH component and is often added to ENA trainings and materials; ENA and EHA can be combined into an ENHA approach. There are no EHA-only materials available online, but a sample ENHA combination can be found at this link on the SPRING website which was used in Bangladesh.