SHIKHA Project: Final Report

The final report for the SHIKHA Project, conducted in the Barisal and Khulna divisions of southern Bangladesh from October 2013 to September 2016, describes how the project used a proven behaviour change strategy to improve infant and young child feeding (IYCF) practices and maternal dietary diversity for pregnant women. As the report shows, SHIKHA achieved its goal of reducing under-nutrition in pregnant women and children under 2 years of age in Bangladesh by communicating about 4 high-impact behaviours: early initiation of breastfeeding; exclusive breastfeeding; complementary feeding; and handwashing. SHIKHA's experience in doing so reveals lessons to inform future health and nutrition policies.

Funded by the United States Agency for International Development (USAID) and carried out by FHI 360 in partnership with BRAC, the Center for Injury Prevention and Research, Bangladesh (CIPRB), and Asiatic Marketing and Communication Limited, SHIKHA developed a technical approach that was based on lessons learned from the Alive & Thrive (A&T) Project and followed a community-centred model. The project team: (i) conducted home visits, (ii) established counseling and promotion of services, (iii) performed supportive supervision, (iv) provided oversight for monitoring and use of data for improvement of services and for demand creation, and (v) provided social and behaviour change communication (SBCC) activities, while establishing a vigorous monitoring system and building capacity.

Overall, the SHIKHA Project provided 161,570 pregnant women with counseling on maternal diet and 298,465 children under 2 years with nutrition services during home visits. The project further reached 1,190,353 people with mass media campaigns covering 2,400 media-dark villages (81% of total villages in the 26 project sites). Key messages from USAID-supported programmes were incorporated into the SHIKHA Project media campaign. These shows also provided an opportunity for viewers to speak about what they had learned and to ask questions about IYCF and handwashing. Male participation did vary during the media campaigns, and to increase men's involvement, project staff developed a show to be staged in village markets where men gathered to trade and socialise. A total of 40 shows were organised at 40 village markets, reaching 9,265 men with nutrition messages.

SHIKHA health forums and "courtyard meetings" reached a total of 711,393 participants, comprising pregnant women, adolescents, and mothers of children under 2 years. At these events, staff disseminated messages about maternal dietary diversity during pregnancy, IYCF, handwashing before food preparation, child feeding, and proper disposal of child faeces. The project also trained a total of 7,148 health staff on basic IYCF and maternal nutrition, and provided refresher trainings on use of specific tools, materials, and job aids in IYCF and maternal nutrition for 21,157 health staff (104.7% of target).

According to FHI 360, influential members of the community - husbands of pregnant women, village doctors, religious leaders, Union Parishad (local government figures), and other community leaders - played had an important role in the project. These members of the community contributed to addressing the cultural barriers and taboos that reinforce harmful dietary practices at the household level. The project engaged these influential people at the beginning of Year 2 and conducted orientations for a total of 40,378 individuals on maternal nutrition, IYCF, and correct feeding practices (111.2% of target).

One notable success of the project was the introduction of the "Food Plate", a plastic plate with printed images of nutritious food types in the correct proportions, which was used for nutrition education with mothers and children. The Ministry of Health and Family Welfare (MOHFW) Technical Committee on Information, Education & Communication endorsed the Food Plate and approved its use in other nutrition projects. Looking further afield, SHIKHA offered technical support to the Bangladesh Institute of Public Health Nutrition (IPHN) and to organisations in the IYCF Alliance, and facilitated the publication of the semi-annual bulletin of the IYCF Alliance as a key editorial member. SHIKHA staff also participated in a best-practices event called Safolloa Gatha, or "success story", organised by the Ministerial Working Group on Behavior Change Communication (BCC) in collaboration with the USAID-funded Bangladesh Knowledge Management Initiative (BKMI), managed by Johns Hopkins University and the Bangladesh Center for Communication Programs (BCCP). The team demonstrated SHIKHA's BCC materials, tools, projects, brochures, and television spots, and performed a stage show on community outreach during a showcasing event.

The SHIKHA Project began with a preparatory phase that included a baseline survey. CIPRB also conducted two subsequent surveys over the life of the Project, including an endline survey in 2016 (see Related Summaries, below). Analysis of the baseline and endline surveys showed:

• Increase in the percentage of women who reported initiating breastfeeding within an hour of childbirth from 62% to 83%.
• Increase in percentage of children eating a minimum acceptable diet from 18% to 52%.
• Increase in the percentage of mothers with children ages 6 to 23 months who reported that they had a handwashing station at child feeding areas from 12% to 70%.
• Improvements in mean dietary diversity for less-educated women, which helped close the gap with women of higher levels of education in dietary diversity score (DDS); a similar trend was also observed for women of lower socio-economic status (SES).

In addition to sharing these and other accomplishments, the report outlines some of the challenges encountered in implementing the project, such as lack of maternal dietary counseling materials (addressed through the development of the Food Plate). Some lessons learned include:

• Comprehensive BCC is essential to improving nutrition outcomes.
• Adolescent nutrition needs stronger programming that includes mothers-in-law and other household members.
• Male engagement in nutrition is important for improving dietary diversity and IYCF practices.
• Since maternal nutrition is critical to ensure safe pregnancy and to improve nutritional and development outcomes for children, it is important to integrate maternal nutrition through existing reproductive, maternal, neonatal, and adolescent and child health (RMNACH) platforms.
• Cooperation of village doctors was instrumental in the promotion of breastmilk substitutes; it is imperative to work closely with them to promote exclusive breastfeeding.

Recommendations are shared, including:

• Integrate maternal nutrition as a critical component of RMNACH services in the next government health sector programme, and focus on adolescents as a key group to be reached for all RMNACH programmes.
• Strengthen community-based programmes.
• Include water, sanitation, and hygiene (WASH) messages in counseling to improve exclusive breastfeeding and complementary feeding practices, as WASH contributes to improved nutrition outcomes.
• Establish specific intended groups for key issues - e.g., include husbands and in-laws (gatekeepers) in counseling and community outreach.
• Institute regular reviews of nutrition data at the upazila and district levels to monitor performance and share contributions from non-governmental organisations (NGOs) and other players for stronger monitoring, accountability, and coordination.
• Provide high-quality technical assistance and competency-based training on nutrition to build capacity, knowledge, and skills among healthcare workers.
• Utilise existing healthcare workers and RMNACH platforms for nutrition programming.