The SHIKHA Project: Improving Knowledge and Practice of Infant and Child Feeding and Maternal Nutrition

"Social and behavior change (SBC) interventions have been applied in the past to improve the diets and nutrition of pregnant women and children less than two years. However, knowledge gaps exist regarding the effectiveness of large-scale SBC programs."

As part of efforts to reduce undernutrition among pregnant women and children under the age of 2 in 26 subdistricts in Bangladesh, FHI 360 designed a study to evaluate the effect of a large-scale social and behaviour change (SBC) project, the SHIKHA intervention, to provide a strategic direction for quality improvement and to document the lessons learned during the project. SHIKHA is a name inspired by the Bangla term, "shisukekhawano", which means infant and young child feeding (IYCF). The project is implemented by FHI 360 and funded by the United States Agency for International Development (USAID) under the Feed the Future initiative. BRAC, another project partner, implements community-level activities.

As noted here, the levels of malnutrition in Bangladesh are among the highest in the world. The etiology of childhood malnutrition is complex, involving interactions of biological, cultural, and socioeconomic factors. In addition to the underlying contributors to malnutrition in most South Asian countries - poverty, high population density, low status of women, poor antenatal care, high rates of low birth weight, unfavourable child caring practices, and poor access to child healthcare - many families in Bangladesh do not have the knowledge or skills to practice proper IYCF and the women often have little power to make decisions in the family.

SHIKHA engages 4,830 community volunteers, 395 community health workers, and 667 nutrition workers through BRAC and trains them in maternal nutrition and IYCF. The intervention in the Barisal and Khulna divisions of Bangladesh focused on changing feeding practice behaviours through 5 core interventions:

1. Home visits: Nutrition workers record every pregnancy in the community in a registry and follow up with mothers until their children are 2 years old, for a total of 16 home visits (4 visits during pregnancy and 12 after the child is born). Click here [PDF] to learn about one dietary counseling tool used by SHIKHA, the food plate.
2. Social mobilisation: Project staff engage fathers of children under 2 and doctors to encourage good IYCF behaviour in the community.
3. Health forums: Community meetings, comprised of pregnant women, mothers of children under 2, mothers-in-law, and adolescent girls, are held to discuss issues about health and hygiene practices in the community.
4. Antenatal and postnatal visits: Pregnant women and lactating mothers receive medical care and counseling from community health workers.
5. Mass media and communication campaign: Seven advertisements, which address specific barriers to good IYCF practices, appear on national television channels. FHI 360 works in partnership with Asiatic Marketing and Communications Limited to design and execute media campaigns in 1,351 villages in project sub-districts that otherwise lack access to media.

The project partnered with The Centre for Injury Prevention and Research, Bangladesh to conduct household surveys at 3 intervals: December 2013, January 2015, and January 2016. At baseline, midline, and end line, the researchers randomly selected 509, 515, and 1,275 pregnant women, respectively, from the intervention area and collected data about diet-related knowledge, dietary intake, and socio-demographic characteristics. From randomly selected non-intervention (control) areas, they interviewed 514 and 1,016 pregnant women at midline and end line, respectively. The dietary diversity score (DDS) for each woman in the study was calculated by totaling the number of food groups (from 9 groups) consumed in the 24 hours before the women were interviewed. In addition to pregnant women, ~1,500 mothers of children less than 2 years of age were randomly selected from the intervention area in the 3 (baseline, midline, and end line) surveys and interviewed about feeding practices for infants and young children.

The evaluation found that SHIKHA intervention achieved almost all its objectives for the dietary diversity of pregnant women (PW) and ICYF practices. The lone exception was exclusive breast-feeding (EBF), which was already high at the baseline, most likely due to inclusion of predominantly breastfed women as exclusively breastfed. The PW's mean DDS was 4.28 at baseline, but it improved to 4.48 by midline, and 4.76 by end line. There was no change in the baseline and midline scores among adolescent PW, but their scores eventually improved after special efforts including involving their family members in the counseling and demonstration sessions. The intake of dairy products, eggs, and leafy vegetables were low (17%, 28%, and 50%, respectively) at baseline, even though two-thirds or more of the respondents knew that pregnant women should eat these foods. By the end of the project, knowledge about the importance of eating a variety of foods improved, and the intake of eggs, vitamin-A-rich fruits, and vegetables substantially improved.

A significant improvement was also seen in all the IYCF indicators, despite the brevity of the intervention period. Proportion of children fed a minimally diversified diet almost tripled from 21% at the baseline to 57% at the end line; this contributed to a substantial improvement in the proportion of children who had the minimum acceptable diet, from 18% to 52%. At baseline, the practice of complementary feeding was very poor - only a fifth of the mothers gave complementary foods (with the minimum diversity) to their children. Less than a fifth of the mothers were giving food with the minimum acceptable diet. About two-thirds of the mothers started complementary feeding before their children were 6 months old. However, after the intervention, the rate of improvement far exceeded the annual target of 6% and was similar for males and females. The progress in the minimum dietary diversity (12.9% and 35.9%), minimum meal frequency (10.6% and 18.7%), minimum acceptable diet of children (10.6% and 33.2%), and the intake of iron-rich food (8.9% and 18.4%) far exceeded the annual target of 6% at midline and endline, respectively. The presence of a hand-washing station at the child feeding area also improved substantially, from 12.2% to 69.9%. At baseline, only 20% of the mothers of children (6-23 months old) washed their hands before feeding their children, but this rate doubled (40.4%) at midline and tripled (60.98%) by endline. By endline, the increase was significant across all age groups, among males and females, and in all districts. At midline, the mothers recalled the television commercials (TVCs) on hand-washing the most (38.8%), and the TVCs on the father's involvement the least (12%). However, the recollection of both TVCs increased by endline. These results are consistent with observed (double and triple) increases in hand-washing practices by mothers at midline and endline, respectively.

Noting some suggestions such as that a greater emphasis should be placed on ensuring that PW and mothers received all scheduled counseling visits, project organisers conclude that, overall this large-scale SBC project helped to improve the dietary diversity of pregnant women and the IYCF practices among children under 2 years old in rural southwest Bangladesh. "The scale-up of such projects to cover wider areas should be considered for the future."