NUTRITION PROGRAM ADAPTATIONS AND IMPLEMENTATION SCIENCE DURING COVID-19: THE CASE OF SOUTH ASIA

Nutrition program adaptations and implementation science during COVID-19: The case of South Asia

As COVID-19 surges through South Asia, nutrition programs are devising new ways to ensure participants receive program benefits. Implementation science aims to improve how programs are implemented by closing the gap between what is known (research) and what is done (practice). In this blog, the authors share their experiences with implementation challenges and solutions from three nutrition programs. We learn that technology has been a valuable aid to frontline workers as they deliver nutrition services amidst COVID-19, and also that many research questions still remain unanswered. – Samuel Scott, series co-editor and Research Fellow at IFPRI

Madhya Pradesh, India: A Poshan Sakhi, or frontline worker pre-COVID-19 , using a visual chart to talk about nutritious foods to SHG women. PC /POSHAN

COVID-19 has necessarily and fundamentally altered implementation of community-based nutrition programs in low- and middle- income countries. Implementers are attempting to ensure continuity, while preserving the safety of frontline workers (FLWs) and participants and fulfilling new pandemic-related functions. FLWs are navigating new pressures around time, skills, and workloads. Program participants face safety concerns and newer challenges related to program uptake, yet their needs for information and services are as immediate as ever.

Service delivery modalities are being re-thought by governments and development partners out of necessity, creating opportunities to advance innovation and efficacy in implementation. An implementation science learning agenda on how to respond to FLW and participant needs, while maintaining (and perhaps improving) program implementation, is emerging.

In a workshop co-sponsored by the Society for Implementation Science in Nutrition and American Society for Nutrition on June 3, 2020, three program implementers shared their perspectives on the challenges and opportunities for adapting nutrition programming and supporting FLWs and participants in India and Bangladesh. This blog shares key takeaways from their presentations, along with implications for the implementation science agenda.

Dr. Rasmi Avula highlighted challenges faced by FLWs in India in delivering government-led nutrition services during the COVID-19 crisis, and by decision-makers in identifying and addressing needs to better support frontline workers.

In India, three cadres of FLWs from the Integrated Child Development Services (ICDS) and the National Health Mission (NHM) together deliver all national nutrition-specific interventions, mostly at the community-level. The National Nutrition Mission, launched in 2018, instituted new mechanisms to improve intervention coverage. On March 25, 2020, India responded to the COVID-19 pandemic with a national lockdown. Some ICDS and NHM interventions were suspended and new delivery modalities were adopted for other interventions. Anecdotes are emerging from the field on adaptations and coping strategies used by the FLWs to deliver the services. For example, food supplementation, typically delivered at ICDS centers, were home delivered by FLWs. Given limited transportation, some FLWs are delivering food supplements on foot, using pushcarts, or on tricycles[1]. Audio and video calls are being used in some places to communicate health and nutrition information. FLWs are also coordinating with health facilities to facilitate antenatal check-ups for pregnant women.

In addition, many FLWs have taken on additional COVID-19 related responsibilities such as COVID-19 communications, tracking people with symptoms, and referring them to healthcare providers. In some instances, FLWs are being recognized by their communities for their work, while in others, they have faced violence and stigma.

How FLWs perceive these additional duties, particularly those that are physically taxing and put them at risk of contracting the virus, is unclear. The degree of support from their family and community members is also unknown. This raises important questions around the challenges faced by FLWs and the perceptions and anxieties related to their work and life, particularly vis-à-vis current adaptations to program delivery. Long-standing systemic challenges related to FLW roles and remuneration, supervisory support and capabilities might get amplified during the pandemic. A comprehensive research agenda is needed to unpack these issues and identify solutions that benefit both FLWs and communities during the pandemic, and beyond.

Jennifer Crum of FHI 360 spoke about a multi-sectoral nutrition program in Bangladesh, program adaptations made during COVID-19, and FLW and beneficiary reactions to these adaptations.

Before the pandemic, the USAID-funded and FHI 360-led ‘Strengthening Multisectoral Nutrition Programming through Implementation Science Activity’ in Bangladesh delivered two nutrition-related voice messages a week to approximately 10,000 pregnant women and lactating mothers along with a weekly message to their husbands or mothers-in-law. The activity approach was designed using mobile communication to supplement the in-person counseling, trialing a less resource-intensive approach to traditional programming.

When Bangladesh was hit by COVID-19, direct interactions between FLWs and program participants were discontinued. FHI 360 immediately shifted to trial mobile phone-based group sessions and individual phone counseling as replacements for in-person communication. Group phone sessions were unsuccessful for several reasons: FLWs lacked the skills to remotely manage sessions with multiple persons; limited technology interrupted connections; and participants were unaccustomed to remote group sessions and reported feeling uncomfortable talking via telephone. The new remote counseling, however, was successful. FHI 360 and its partners moved from detailed program counseling modules to simple phone counseling tools for FLWs to ease the transition. As FLWs developed confidence and comfort with phone counseling, they were able to lead more productive sessions. Husbands were initially reluctant to allow women’s participation in phone counseling, though this reluctance declined over time, with FLWs explaining the process and addressing needs of the families to the best of their ability.

These modified implementation methods raise important research questions. Considering risks of future pandemics, civil unrest and climate crises that could result in similar isolation contexts, implementation research should assess the feasibility, effectiveness, and cost of remote versus in-person counseling. Implementation scientists should also answer how best to prepare program implementers and participants to give and receive services remotely.

Dr. Ame Stormer of Helen Keller International shared her experience with COVID-19-related program adaptations in another donor-funded multi-sectoral nutrition program in Bangladesh.

As a result of the COVID-19 induced lockdown in the Chittagong Hill Tracts of Bangladesh, the Sustainable Agriculture and Production Linked to Improved Nutrition Status, Resilience and Gender Equity (SAPLING) project pivoted to use technology to train FLWs and participants. To date, SAPLING staff and community members have created over 40 short how-to videos to help prevent and mitigate COVID-19. These videos have been shared via Facebook, YouTube, and SAPLING’s management information system (iSTREAM) used by all FLWs via tablets and smart phones.

Moving to video-based programming presents both opportunities and challenges. The video format allows staff to quickly and visually demonstrate promoted behaviors, ensure standardization and quality control over messaging and content, and efficiently translate messages into multiple languages. The new video format also raises some fundamental and pressing questions:

• Are the videos reaching the intended audiences? Given failures in internet coverage and electricity brown-outs, can all participants access the videos?
• If the participants are able to access the videos, do they understand the messaging?
• Are the messages actionable? Participants are facing pandemic-related resource constraints that are difficult to predict, identify, and track, which may present challenges for uptake of even minor prevention actions.
• Is remote behavior change communication convincing enough or is face-to-face interaction with FLWs necessary to achieve desired outcomes?

These questions constitute the focus of an upcoming implementation research agenda. Ultimately, technology-driven solutions to deliver information could enable breakthroughs in terms of time, effort and quality assurance. However, there are many potential pitfalls along the way. It may take several iterations to get it right, and only rigorous documentation and implementation science can ensure that lessons are learned along the way.

Reflections and opportunities for implementation research

Reflecting on the workshop, Purnima Menon, Senior Research Fellow at IFPRI, shared several points for consideration moving forward. She noted that South Asia might not see a huge decline in COVID-19 soon. As the pandemic unfolds in the region and affects health and nutrition services, there is a real urgency to develop and conduct implementation research, alongside major program adaptations being undertaken. Emerging data need to be quickly distilled into practical insights that can be acted upon locally and nationally. Finally, where non-existent, local knowledge networks should be established to consolidate, interpret and share evidence and insights for health and nutrition programs.

Dr. Rasmi Avula is a Research Fellow at the International Food Policy Research Institute in the Poverty, Health, and Nutrition Division. Jennifer Crum is Chief of Party, Multisectoral Nutrition Project in Bangladesh at FHI 360. Dr. Kenda Cunningham is Helen Keller International’s Sr. Technical Advisor for the Suaahara II program in Nepal and Assistant Professor, Department of Population Health, London School of Hygiene and Tropical Medicine and is a Recruitment, Engagement, and Outreach Councilor with the Society for Implementation Science in Nutrition. Dr. Edward Frongillo is a professor in the Department of Health Promotion, Education, and Behavior at the University of South Carolina and holds the position of Methods Councilor with the Society for Implementation Science in Nutrition. Dr. Ame Stormer is Helen Keller International’s Sr. Technical Advisor for the Asia Pacific Region. Dr. Andrea Warren is a research associate in the Department of Health Promotion, Education, and Behavior at the University of South Carolina and is a Councilor-at-Large with the Society for Implementation Science in Nutrition. The analysis and opinions expressed in this piece are solely those of the authors.

This blog has been published as a part of the International Food Policy Research Institute (IFPRI), South Asia, blog series on analyzing the impacts of the COVID-19’s pandemic on the sub-national, national, and regional food and nutrition security, poverty, and development. To read the complete blog series click here

 [1] UNICEF. #PoshanWeekly 8 May 2020 “Voices from the field” Experiences with Implementing COVID-Sensitive Nutrition in the States.