Intervention Design Elements Are Associated with Frontline Health Workers' Performance to Deliver Infant and Young Child Nutrition Services in Bangladesh and Vietnam

Phuong Hong Nguyen, Sunny S Kim, Lan Mai Tran, Purnima Menon, Edward A Frongillo, Phuong Hong Nguyen, Sunny S Kim, Lan Mai Tran, Purnima Menon, Edward A Frongillo

Abstract

Background: Frontline health workers (FLWs) are needed for delivering interventions at scale to reduce maternal and child undernutrition, but low- and middle-income countries often face inadequate FLW performance.

Objectives: We examined whether and how intervention design elements such as training, supervision, and mass media improved FLW performance in delivering nutrition services.

Methods: Survey data were collected in 2010 and 2014 as part of impact evaluations of Alive & Thrive (A&T) interventions to improve infant and young child feeding (IYCF) practices in Bangladesh and Vietnam. FLWs in A&T intensive (A&T-I) areas received specialized IYCF training, job aids, and regular supportive supervision. Those in non-intensive (A&T-NI) areas received standard government training and supervision. There was mass media exposure in both areas. Multiple regression was used to test differences in exposure to intervention design elements and performance outcomes between the 2 program areas. Path analyses were conducted to examine the paths from exposure to performance outcomes measured at FLW and end-user levels.

Results: Compared to FLWs in A&T-NI areas, those in A&T-I areas had higher scores in training (by 1.3-3.6 of 10 points), supportive supervision (0.3-3.5 points), and mass media exposure (0.3-3.5 points). These intervention design elements were significantly associated with FLW knowledge and motivation, which in turn improved service delivery. FLW-level performance outcomes contributed to improving end-user-level outcomes such as higher service received (β = 0.12-1.04 in Bangladesh and 0.11-0.96 in Vietnam) and maternal knowledge (β = 0.12-0.17 in Bangladesh and 0.04-0.21 in Vietnam).

Conclusions: Training, supervision, and mass media exposure can be implemented at large scale and contribute to improved FLW service delivery by enhancing knowledge and motivation, which in turn positively influence mother's service utilization and IYCF knowledge. Training, supervision, and mass media to enhance service provision should be considered when designing interventions. This trial was registered at clinicaltrials.gov as NCT01678716 (Bangladesh) and NCT01676623 (Vietnam).

Keywords: Bangladesh; Vietnam; frontline workers; intervention design element; knowledge; motivation; performance.

Figures

FIGURE 1
FIGURE 1
Exposure to intervention design elements among frontline health workers, by program group, in Bangladesh and Vietnam. Bangladesh SK (A), Bangladesh SS (B), Vietnam HS (C), and Vietnam VHW (D). All intervention exposures are presented as scores with a range of 0–10 (see Supplemental Table 1 for details). *, **, ***Significant difference between intensive and non-intensive areas, accounting for geographic clustering: *P < 0.05, **P < 0.01, ***P < 0.001. A&T-I, Alive & Thrive–intensive; A&T-NI, Alive & Thrive–non-intensive; HS, health staff; SK, Shasthya Kormi; SS, Shasthya Sebika; VHW, village health worker.
FIGURE 2
FIGURE 2
Performance measured at frontline worker and end-user levels, by program group, in Bangladesh and Vietnam. Bangladesh SK (A), Bangladesh SS (B), Bangladesh mothers (C), Vietnam HS (D), Vietnam VHW (E), and Vietnam mothers (F). *, **, ***Significant difference between intensive and non-intensive areas, accounting for geographic clustering: *P < 0.05, **P < 0.01, ***P < 0.001. A&T-I, Alive & Thrive–intensive; A&T-NI, Alive & Thrive–non-intensive; HS, health staff; SK, Shasthya Kormi; SS, Shasthya Sebika; VHW, village health worker.
FIGURE 3
FIGURE 3
Paths from exposure to performance outcomes measured at the FLW and end-user levels. Bangladesh SS (A) and Vietnam HS (B). Values are coefficients. +, *, **, ***Significant difference between intensive and non-intensive areas, accounting for geographic clustering: +P < 0.10, *P < 0.05, **P < 0.01, ***P < 0.001. A&T, Alive & Thrive; FLW, frontline worker; HS, health staff; SS, Shasthya Sebika.

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