Kim Sunny S, Ali Disha, Kennedy Andrew, Tesfaye Roman, Tadesse Amare W, Abrha Teweldebrhan H, Rawat Rahul, Menon Purnima
International Food Policy Research Institute, 2033 K Street, NW Washington, DC, 20006, USA.
International Food Policy Research Institute, IFPRI-ESARO-ILRI Campus, Addis Ababa, Ethiopia.
BMC Public Health. 2015 Apr 1;15:316. doi: 10.1186/s12889-015-1650-4.
Program effectiveness is influenced by the degree and quality of implementation, thus requiring careful examination of delivery processes and how the program is or is not being implemented as intended. Implementation fidelity is defined by adherence to intervention design, exposure or dose, quality of delivery, and participant responsiveness. As part of the process evaluation (PE) of Alive & Thrive in Ethiopia, a large-scale initiative to improve infant and young child feeding (IYCF), we assessed these four fidelity elements along three components of its community-based intervention: training of frontline workers (FLWs), delivery of program tools and messages, and supportive supervision.
Data from a qualitative study among three levels of FLWs (n = 54), i.e. supervisors, health extension workers (HEWs), and community volunteers, and among mothers with children under two years of age (n = 60); and cross-sectional PE surveys with FLWs (n = 504) and mothers (n = 750) in two regions (Tigray and SNNPR) were analyzed to examine program fidelity.
There was strong adherence to the intended cascading design (i.e. transfer of knowledge and information from higher to lower FLW levels) and high exposure to training (95% HEWs and 94% volunteers in Tigray, 68% and 81% respectively in SNNPR). Training quality, assessed by IYCF knowledge and self-reported capacity, was high and increased since baseline. Job aids were used regularly by most supervisors and HEWs, but only 54% of volunteers in Tigray and 39% in SNNPR received them. Quality of program message delivery was lower among volunteers, and aided recall of key messages among mothers was also low. Although FLW supervision exposure was high, content and frequency were irregular.
There is evidence of strong fidelity in training and delivery of program tools and messages at higher FLW levels, but gaps in the reach of these to community volunteers and mothers and variability between regions could limit the potential for impact. Strengthening the linkages between HEWs and volunteers further can help to reach the target households and deliver IYCF results at scale.
项目效果受实施程度和质量的影响，因此需要仔细审查实施过程以及项目是否按预期实施。实施保真度由对干预设计的遵循、暴露或剂量、实施质量以及参与者反应性来定义。作为埃塞俄比亚“活力与繁荣”项目（一项改善婴幼儿喂养（IYCF）的大规模倡议）过程评估（PE）的一部分，我们沿着其社区干预的三个组成部分评估了这四个保真度要素：一线工作人员（FLW）培训、项目工具和信息的传递以及支持性监督。
对三个层级的一线工作人员（n = 54）（即监督员、健康推广工作者（HEW）和社区志愿者）以及有两岁以下儿童的母亲（n = 60）进行定性研究的数据；并对两个地区（提格雷和南方各族州人民区域州）的一线工作人员（n = 504）和母亲（n = 750）进行横断面过程评估调查，以检查项目保真度。
对预期的级联设计（即知识和信息从较高层级的一线工作人员向较低层级传递）有很强的遵循，并且培训暴露率很高（提格雷地区95%的健康推广工作者和94%的志愿者，南方各族州人民区域州分别为68%和81%）。根据婴幼儿喂养知识和自我报告的能力评估，培训质量很高，自基线以来有所提高。大多数监督员和健康推广工作者经常使用工作辅助工具，但提格雷地区只有54%的志愿者和南方各族州人民区域州39%的志愿者收到了这些工具。志愿者传递项目信息的质量较低，母亲对关键信息的辅助回忆也很低。虽然一线工作人员监督暴露率很高，但内容和频率不规律。
有证据表明在较高层级一线工作人员的培训以及项目工具和信息的传递方面有很强的保真度，但这些内容传递到社区志愿者和母亲的范围存在差距，且地区之间存在差异，这可能会限制产生影响的潜力。进一步加强健康推广工作者与志愿者之间的联系有助于覆盖目标家庭并大规模实现婴幼儿喂养成果。
