Section 1. Introduction
About SPRING/Kyrgyz Republic
Since late 2014, the SPRING project has been working to improve the nutritional status of children under two years of age and women of reproductive age in Kyrgyzstan by promoting the uptake of 11 evidence-based practices. SPRING works through strategic partnerships in health, agriculture, and education to improve the nutritional capacity of health providers and households; increase the nutritional sensitivity of agriculture programs; and support national-level initiatives likely to improve nutrition outcomes. Partners include local government, village health committees, district health centers, local and international nongovernmental organizations, and other USAID projects. SPRING works in 11 rayons and townships of Jalalabad oblast and the entirety of Naryn oblast, all within the Feed the Future zone of influence.
How to Use This Toolkit
This toolkit is designed to provide program implementers with training session modules, job aids, and social and behavior change communication (SBCC) materials to help community volunteers (referred to as ‘activists’) and other frontline workers promote household nutrition and hygiene. The modules can be used in any order, with the exception of Module 1 (activist mobilization, mapping, and action-planning), which provide basic information and should be completed before the specific topic modules.
The work of the Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) project to deliver nutrition SBCC interventions through activists is part of a broader program to improve national nutrition policy and quality of nutrition service provision at health facilities. SPRING builds activist capacity to raise family and community awareness of nutrition during the first 1,000 days; promote improved nutrition, hygiene, and sanitation behaviors; and generate demand for nutrition and health services. The long-term social and behavior changes needed for improved nutrition require integrating ongoing SBCC activities into existing structures and systems, including health promotion units (HPUs) and village health committees (VHCs).
SPRING collaborates with local health education and communication mechanisms—including HPUs, VHCs, and activists—to reach communities with SBCC activities. Each district-level administration of primary health services (referred to as ‘family medicine center’) has an HPU staffed by one or two nurses who, with guidance from the health education arm of the Ministry of the Health (MOH) and the Republican Center for Health Promotion (RCHP), conduct outreach to all communities in their catchment area. HPU staff are also responsible for training and supporting VHCs, and coordinating health education through other government entities and schools through their established cadres of community volunteers. VHCs began in 2002 with funding from the Swiss Red Cross as a pilot project in one rayon (district) and quickly scaled up to more than 1,700 VHCs in 84 percent of the nation’s villages. VHCs are organized into regional networks at the rayon level and operate under the umbrella of the Kyrgyz Association of Village Health Committees (KVHC). VHCs conduct activities to improve the health of their communities. As independent civil society organizations, they collaborate with the government health system through RCHP.
To maintain engagement with the large number of community volunteers, SPRING, through a subgrant, entered into a formal partnership with KVHC. KVHC, a national NGO, operates an extensive network of community-led health committees, and routinely disseminates important health information nationally. KVHC provided a team of coordinators who work with SPRING field staff (community mobilizers) to extend the program’s reach by recruiting, training, and supporting activists. Activists are unpaid volunteers who are incentivized through regular training, quality-improvement efforts, and public recognition. They also get mugs (which they use to demonstrate the correct amount to feed children at different ages), bags to carry materials, and t-shirts.
SRING and KVHC help activists roll out the topical modules through household visits and community meetings in program areas according to a seasonal schedule. In addition to supporting RCHP on the development of nutrition content, SPRING builds HPU staff capacity to deliver nutrition SBCC to people at schools, health facilities, and in rural and urban communities.
Evidence-Based Practices Promoted by SPRING
- Consumption of iron supplements by pregnant women.
- Dietary diversity for women, with emphasis on food sources of iron and foods that enhance iron absorption.
- Dietary diversity for children 6 to 23 months of age with emphasis on food sources of iron and vitamin A and foods that enhance iron absorption.
- Optimal meal frequency for children 6 to 23 months of age.
- Early initiation of breastfeeding.
- Exclusive breastfeeding from birth through six months.
- Timely introduction of appropriate complementary foods.
- Reduced consumption of foods of low nutrient value (junk food).
- Presumptive treatment for helminth infections in pregnant women and young children.
- Handwashing at four critical times (after using the latrine; after changing a diaper/cleaning a child; before preparing food; and before feeding a child).
- Adoption of methods for safe and prolonged storage of nutrient-dense produce in winter.
SPRING’s Experience: Using Local Networks
SPRING’s SBCC interventions rely on an existing network of community volunteers (‘activists’) distributed throughout the country who have been used in the past to disseminate a variety of social messages. This network includes people from a wide range of backgrounds (e.g., school teachers, housewives, local government leaders) who have varying levels of influence and access to social circles and communication channels. Activists have become the primary mode of delivery for community-level behavior change work. SPRING, KVHC, and local government authorities have recruited more activists to complement the existing network, expand its reach, and reduce the burden on individual activists.
Acknowledging SPRING activists’ voluntarism and competing priorities for time and effort, training consists of a short session every 4– 6 weeks on a different topic, followed by occasional support visits during household visits and community meetings. Short training sessions ensure that capacity is built without taking too much of volunteers’ time, the majority of which is spent on household visits and/or community events and meetings. Activists, with additional support from SPRING staff and activist coordinators, may also participate in community campaign events related to the SBCC strategy. As acknowledged community leaders, the activists raise awareness of simple, priority family behaviors that are taught in each topical module, and generate demand for the services of health workers.
SPRING’s work on in-service training of health facility staff to improve the quality of nutrition services and counselling helps program staff and activists feel confident recommending the facility-level workers as an important source of information and care for mothers and children up to two years of age. This is reinforced at each contact with activists, with the tone and content of modules and job aids reflecting this role of general awareness-raising, focused promotion of a few simple family behaviors, and generating demand for the services of health workers. It is health workers’ responsibility to provide in-depth, personalized counseling to mothers and their families about maternal and child nutrition, so activists are instructed to encourage mothers and families to seek regular information, preventive services, and care from health workers. This two-pronged approach also ensures that mothers and family members hear consistent messages at multiple contact points, which reinforces community-level communication.
Establishing a Structure: Targeting and Training Strategies
SPRING uses community mobilizers, activist coordinators, and activists to disseminate messages in communities. On a bimonthly basis, community mobilizers and activist coordinators are trained as activist trainers and supervisors, using the selected training module. These trainings typically last half a day and are conducted at the oblast (regional) level. During trainings, master trainers model methods that will be used to train activists in their coverage area. The trained activist coordinators and mobilizers cascade training to activists at the township and rayon levels.
All of the training modules are:
- Limited to priority messages about a subset of SPRING’s 11 evidence-based behaviors, so that activists are not overwhelmed and can promote the behaviors with different groups in different settings with confidence.
- Interactive and participatory, respecting learners as adults who bring knowledge and experience to the training.
- Focused on skills, allowing time for role play to practice listening and talking to community members; using job aids to strengthen promotion and to respond to questions or objections from community members.
- Facilitate experience-sharing so trainees learn from each other and find solutions to challenges.
Activist Mobilization, Mapping, and Action Planning.
Complementary Feeding of Young Children
Handwashing and Clean Latrines
Dietary Diversity for the Whole Family
Food Storage and Preservation
Deworming and Preventing Helminth Infections
Strengthening Community Work
Dietary Diversity and the Reduction of Junk Food Consumption
SPRING orients activists to a different theme every two months through a two-hour training on technical content, key messages, job aids, and SBCC materials (generally to be given to families) associated with the topical module. The training includes guidance on how to conduct household visits, community meetings, and data collection. SPRING’s initial activist training module was “social mobilization and general nutrition,” which was an introduction to the project and its content. This module was given to more than 2,000 activists who mapped “1,000-day households”—those with pregnant and lactating women and/or children younger than 2 years of age—as well as community resources in respective catchment areas. This module is an orientation and planning exercise, and does not include its own community engagement component.
Activists then conduct household visits and community meetings in their catchment areas to raise awareness and promote simple key messages and behaviors. They also help to promote facility-level workers as an important source of information and health care. Accompanying SBCC materials convey and reinforce the project’s key messages in memorable and compelling ways. They include an informational brochure for mothers, a cookbook, and posters and leaflets on handwashing and clean latrines, dietary diversity, and anemia prevention. These materials complement activists’ messages, which are also displayed in HPUs and health facilities.
SPRING aims for a 1:30 ratio between activists and households, with activist coordinators and community mobilizers dividing the tasks of training, coordinating, and supervising the activists in their areas (Figure 1). While the primary target group for most module topics is 1,000-day households, messages target the whole family to build support for improved behaviors. Activists are encouraged to explain to husbands and mothers-in-law in 1,000-day households that it is important that they support the recommended behaviors, including helping with the work needed to practice them. Although 1,000-day households are prioritized for visits, general community members are also reached by activists through community meetings and other communication channels including media spots, posters in health facilities, social media, and special campaigns and events.
Figure 1. SPRING's structure for reaching communities
Quality Assurance, Monitoring, and Reporting
Each member of the team (nine KVHC activist coordinators and six SPRING community mobilizers) visits 10 activists each month to assess the quality of communication and build skills through coaching. SPRING gives its team mobile data collection devices to facilitate timely collection and analysis of observational checklist data. Training on data collection tools is integrated into team trainings.
Team members plan and implement a rotating schedule of observation to maximize on-the-job coaching. Coaching—observing someone at work and providing feedback including suggestions for improvement—helps ensure that interventions are implemented as intended and helps volunteers feel valued and motivated. Annexes 1 and 2 contain sample guides to help community mobilizers and activist coordinators provide effective supportive supervision.
SPRING developed monthly planning and reporting forms for activists to use with guidance from the team (See annexes). Every month, project staff collect information from activists and give it to the SPRING monitoring and evaluation team in the Bishkek office. SPRING encourages opportunities to share data with activists, families, and communities to build awareness of SPRING and Government of Kyrgyz Republic investments in nutrition to encourage community ownership of health and nutrition and motivate activists.
Lessons and Considerations for Future Implementation
1. Supporting Activists and Sustaining Interest
Because paying activists is not sustainable, volunteers are not compensated for their time on the SPRING project. SPRING encountered challenges to convening activists and maintaining their attendance. The expansion of field presence with a subgrant to KVHC increased personal communication with activists, increased participation, and supported their work in communities. SPRING sought to simplify the activists’ tasks through additional job aids and streamlined data collection, and found low-cost ways to motivate, recognize, and reward excellent performance and ideas. The project also encourages activists to find creative ways to interact with communities.
Midway through the program, in response to volunteers’ varying levels of communication, facilitation, and reporting skills, SPRING created a module to build capacity in these areas. Modules are delivered on a cyclical basis and repeated occasionally to encourage sustained behavior change. When a module is repeated, it is updated with new information, activities, and materials. SPRING also combines topics in new ways to keep the exercises interesting for both activists and community members, while reinforcing the content of the nutrition messages. Activists love using and giving families copies of SPRING’s SBCC materials—colorful brochures, a cookbook with recipes using diverse, nutritious, and affordable foods, and a guidebook on storing and preserving vitamin-rich foods—to reinforce key messages.
Working with volunteers from various backgrounds has yielded unintended secondary benefits for SPRING’s reach of nutrition and hygiene messages. Volunteers are encouraged to use their personal networks to convey messages to the broader community. In some cases, volunteers and subgrantee staff have taken this a step further, expanding their communications beyond the scope of the project. With its focus on the 1,000 days, SPRING had not planned to provide content to school-aged children. However, some volunteers are elementary school teachers and principals and are including SPRING messages on hygiene and clean latrines in lessons. SPRING welcomes this kind of initiative to reinforce and increase the effectiveness the project’s SBCC activities.
2. Adapting for Different Program Settings and Audiences
While this model is highly effective in rural areas, urban settings pose some challenges. SPRING found that rural community leaders are highly motivated to serve as activists but those in urban areas are not as interested. There are several potential reasons for this. For one, urban leaders tend to be employed or otherwise occupied during the day and do not have time for the role (to attend trainings, conduct visits for 1,000-day households, and organize community meetings). In addition, urban households are not as likely as rural households to perceive activists as credible sources of information on nutrition and hygiene, and feel too busy to participate in community meetings on general health issues. And in cities, the intrinsic and powerful motivator of peer recognition is less present. Without this key incentive, sustainability of the model is greatly compromised.
SPRING therefore modified its strategy to engage urban dwellers, based on understanding that while the prevalence of malnutrition in the Kyrgyz Republic is high in urban as well as rural areas, communication interventions to support behavior change and reduce malnutrition in urban areas needs more emphasis on campaigns or events, and social and mass media communication channels, rather than household visits.
SPRING conducted nutrition- and hygiene-focused events in urban areas (townships) in partnership with local government and HPUs to raise awareness of nutrition during the first 1,000 days and to promote improved nutrition, hygiene, and sanitation behavior. The local HPUs, which had higher capacity and involvement, lead events with support from SPRING and activists. Events have included musical entertainment, akyn (narrated singing), drama troupe skits, cooking demonstrations, information booths, speeches by authority figures, pop concerts, comedy shows, television appearances, and distribution of SBCC materials for families to take home.
3. Ensuring sustainability through capacity building
To the extent possible, SPRING delivers its SBCC activities through and in support of existing institutions and community mechanisms. All key messages and promotional materials were developed with and approved by the MOH’s RCHP. These materials are owned by the government of Kyrgyz Republic and are available for further use. At community level, SPRING participates and supports health promotion efforts using existing health resources and socially conscious volunteers.
Through its partnership with KVHC, SPRING has built 27 activist coordinators’ institutional capacity on nutrition, hygiene, and community and social mobilization. These trained individuals are a resource for their peers and can serve as master trainers should donors or other development partners want to hire KVHC to roll out this toolkit in other regions of the country.
SPRING also conducted a two-day HPU staff training on key messages, job aids, and SBCC materials from the modules (supplemented with technical background, as they are public health professionals). The training also had planning sessions on how to deliver messages and use the materials to complement their own programs and campaigns. This document will be turned over to RCHP for its work with communities through VHCs, HPUs, kindergartens, libraries, and schools.
Key Considerations for Adapting the Modules and Materials
SPRING and implementing partners hope that these modules will be used to support community volunteers and health workers in Kyrgyzstan and potentially elsewhere in the region. High levels of literacy, strong local administrations, and commitment to nutrition by key government departments (e.g., RCHP) and civil-society organizations (e.g., KVHC) all contribute to the effectiveness of the activist approach to deliver SBCC interventions. However, SPRING recommends that before use, the modules, job aids, and SBCC materials be adapted to the needs of the target communities. Below are factors to consider during adaptation.
1. Nutrition challenges and enabling environment
- What are the main nutrition problems in the implementation area? Will the practices promoted in a given module help to solve those problems? It’s important to understand the challenges from the community perspective as well as that of technical experts or secondary data, and agree on priority challenges at the beginning of the intervention. This increases community ownership, which in turn provides a more supportive environment for volunteers or workers.
- How big is the population that is affected by the nutrition problems? How many volunteers/workers would be needed to reach the population with regular SBCC activities? Are there more vulnerable subgroups that need special outreach or approaches? Is there a system to train, supervise, and support that many volunteers/workers?
- Are there local policies or conditions that would make it difficult to recruit and work with volunteers/workers? For example, it may be acceptable for volunteers/workers to visit homes, but not acceptable for them to visit classrooms for SBCC activities.
- Is there an existing pool of people who have a mandate to improve nutrition (e.g., through health, hygiene and sanitation, education, or agriculture)? Are they open to partnering with you? Will they volunteer or be paid? What will their role be? If a group doesn’t exist, will you be able to create one?
2. Project/organization/resources fit
- What is the mission of the project or organization, and within that, what are the specific nutrition-related objectives? Will using these modules and materials to train and support community-level workers or volunteers contribute to that mission or those objectives? What other interventions will be needed to achieve these objectives?
- Is it feasible (in terms of time, capacity, and human and financial resources) for the project to promote all the practices in the modules? Will your organization be able to roll out all the modules and support community-level workers with equity and high-quality? If not, ask partners and community members which modules or topics are most relevant to the local context.
- Trying to do too much at once can overwhelm resources, volunteers/workers and community members. Think about promoting practices in phases that build on each other. Consider promoting the practices that require the least time and fewest resources for community members first.
3. Audience fit
- Are community members in your implementation area open to learning from volunteers/workers about nutrition? Do they prefer to meet in their homes or public places? Have they been asked about nutrition priorities? If possible, show the materials to small groups of people, such as mothers, fathers, and grandmothers, to find out if the materials make sense to them and if they can suggest ways to adapt the materials to their local area.
- Are the practices promoted in each module feasible for target groups to adopt and to maintain? It’s more effective to promote small, doable actions, and not ask for too many changes at one time. You may need to conduct a context assessment or formative research to determine whether community members will be able to implement and sustain the practices that the modules promote.
- How many people in the community already practice what the modules promote? If few do and there aren’t significant barriers like lacking resources, it might make sense to prioritize that module. For example, if only a few people wash hands with soap and water at the five critical times, getting a lot more people to do it could reduce illnesses that contribute to malnutrition.
Thinking through these considerations will help you decide whether the SBCC approach of working with community-level volunteers or workers to promote awareness and key behaviors and increase demand for services fits your needs, and which materials fit your audience and its context. We wish you the best in bringing about improved nutrition outcomes for Kyrgyz families!
Section 2. Activist Modules
|Module No.||Module topic||Materials for trainer||Materials for activists|
|1||Activist mobilization, mapping, and action planning||Mapping tools||N/A|
|2||Exclusive breastfeeding||Booklet for moms (Nutrition for Children under 2 years old)||Booklet for moms (Nutrition for Children under 2 years old)|
|3||Complementary feeding of young children||Cookbook (Recipes for children and for the whole family)|
SPRING demonstration cup
|Cookbook (Recipes for children and for the whole family)|
SPRING demonstration cups
|4||Handwashing and clean latrines||Leaflet (Handwashing and clean latrines)||Leaflet (Handwashing and clean latrines)|
|5||Dietary diversity for the whole family||Food pyramid (includes 10 steps of healthy nutrition)|
|Food pyramid (includes 10 steps of healthy nutrition)|
|6||Anemia prevention||Calendar (Preventing anemia through consuming iron-rich food); reminder card (I am protecting my child and myself)||Calendar (Preventing anemia through consuming iron-rich food)|
Reminder card (I am protecting my child and myself)
|7||Maternal nutrition||Maternal nutrition leaflet||Maternal nutrition leaflet|
|8||Storage and preservation of healthy foods||Guidebook (Storing foods at home)||Guidebook (Storing foods at home)|
|9||Deworming and prevention of helminth infections||Handout (Preventing helminths)||Handout (Preventing helminths)|
|10||Strengthening community work||Communication tools||N/A|
|11||Dietary diversity and reduced consumption of junk food||Food pyramid (includes 10 steps of healthy nutrition)|
|Food pyramid (includes 10 steps of healthy nutrition)|
To view the activist modules and annex, please download the full module toolkit above.