IFE RAPID ASSESSMENTS (Sector specific rapid assessments) Common challenges

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IFE RAPID ASSESSMENTS(Sector specific rapid
assessments)Common challenges potential
solutions
Ali Maclaine
Consultant Public Health Nutritionist IFE
Regional Meeting, Bali, Indonesia 10-13 March,
2008
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IFE Assessments in general What are main
questions / issues people face?

• When should an assessment be done?
• What type of assessment should be done at that
  time?
• What is the correct methodology?
• What questions should be asked?
• What is the correct way to ask them?

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IFE SSRAThe problem

• NO set guidelines on how to do IFE SSRAs in rapid
  onset emergencies.
• No generic tools
• Everyone tackles same questions / issues /
  problems
• People doing it wrong / could do it better
• 2002 paper on IFE indicators suggested
  review..
• (Marie McGrath et al. Infant feeding indicators
  for use in emergencies an analysis of current
  recommendations and practice. Pub Health Nut
  2002, 5(3) 365-372)

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IFE SSRA
First question people worry about is? What am I
going to do? Should be What are the
objectives?
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IFE SSRA Main objectives

• Related to assessing CHANGE due to the crisis
• Reduction / Increase in exclusive breastfeeding
• Mothers stopping breastfeeding early
• Reduction / increase in mothers mix feeding
  (breast formula)
• Earlier / later introduction of complementary
  foods
• Poorer / better complementary foods being used
• WHY there a change e.g. breastfeeding myths,
  donations
• Information used for programming, advocacy, etc.

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IFE SSRAWhat is the correct methodology?

• - Qualitative / Quantitative / mix?
• FGDs / Key informants / Household visits /
  Transect walk one best or mix?
• Sampling method Cluster fixated but convenience
  more appropriate purposive sampling
• Numbers needed to make outcome significant, are
  numbers feasible?
• Anthropometry included (lt 6 months?)?

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IFE SSRA What questions should be asked? How
should questions be phrased?

• IYCF standard core indicators
• Early initiation of breastfeeding
• Exclusive breastfeeding under 6 months
• Continued breastfeeding at 1 year
• Timely complementary food (New guidelines
  Introduction of solid, semi-solid or soft foods)
• Minimum dietary diversity (i)
• Minimum meal frequency (ii)
• Minimum acceptable diet (composed of (i) (ii))
• Consumption of iron-rich or iron-fortified foods

• Are they all relevant and needed in IFE SSRA?
• How should they be asked in a crisis? (24hr
  recall v. quick question when trying to get
  rapid over-view)

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IFE SSRA What OTHER questions are essential for
an IFE SSRA?

• Main objective of SSRA to assess CHANGE
• Type
• Level (to some extent)
• Reason

Need to determine the key questions required to
assess change Establish best phrasing of
question
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IFE SSRA
ASSESSING ARTIFICIAL FEEDING IN
EMERGENCIES

• Need to assess the extent nature of artificial
  feeding in emergencies
• BUT NO agreed guidelines on what data is key,
  or correct phrasing of questions to get the
  best information in a SSRA
• Due to high risk related to donations (BMS, milk
  powder, bottles/teats) need to assess their
  impact

What is the key data? What is best phrasing of
questions?
Need to determine the key questions required to
get required detail. Establish best
phrasing of question
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IFE SSRA ASSESSING COMPLEMENTARY FEEDING IN
EMERGENCIES

• Need to assess need for complementary food aid
• Local foods, fortified foods, micronutrient
  sprinkles
• Need to assess impact

What are the key questions? What is best
phrasing of questions?
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IFE SSRA PROGRAMMING DECISIONS

• Need to establish what is required to support
  appropriate IFE in the area
• Need to establish acceptability and requirement
  of specific interventions e.g. wet nursing,
  breastfeeding support groups, etc

What are the key questions? What is best
phrasing of questions?
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So how are IFE sector specific rapid assessments
being done?
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BANGLADESH Cyclone hit 15th November
2007 Districts 30 Sub-districts 200 Unions
1,950 Population affected 8.9 mill Families
affected 2 mill. DeathsDeaths 3363 3363
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Photos credit Ali Maclaine, 2007
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Save the Children

• SC great history in IFE
• One of first agencies to actively look into the
  issue.
• Always seeking to attain best practice in the
  field in terms of IFE.
• Should be commended
• NOT an example of a bad IFE rapid assessment, but
  a regional example in order to look at the common
  challenges and issues.

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Save the Children Alliance - Bangladesh

• Rapid IFE assessment to
• determine whether infants and young children were
  vulnerable to increased morbidity and mortality
  due to poor IYCF practices..
• develop strategies to promote optimal feeding
  practices for the emergency areas

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The objectives were

• To establish an overview of IYCF patterns
  pre-cyclone in the assessment area (14 unions)
• 2. To determine whether there had been changes in
  these patterns post-cyclone
• 3. To establish the reasons for these changes
• 4. To identify ways to promote and support
  optimal IYCF practices for
• the breastfeeding infant
• the mix-fed infant
• the non-breastfed infant, and
• the complementary-fed child.

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Available capacity for assessment

• SC health and nutrition staff IYCF experience
• Capability to assess all 14 unions in 2 days
• SC support
• Bangladesh Breastfeeding Foundation and Dr.
  Khurshid Talukder, Consultant Paediatrician and
  Research Co-ordinator, Centre for Woman and Child
  Health

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Method (Also looked at secondary data)

• Focus Group Discussions (FGD) with caregivers of
  children aged 0-24 months (half of group infants
  lt6 months)
• Key informant interviews with (i) Government or
  NGO health workers (ii) Traders
• Transect walks
• Household interviews with
• mothers with infants lt6 months exclusively
  breastfeeding,
• mothers with infants lt6 months who were being
  mixed fed or not being breastfed at all
• mothers/caregivers with infants 6 months who
  were being complementary fed
• Additional unstructured rapid assessments

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Results led to

• SC revising its health and nutrition messages
  given as part of the emergency programming.
• SC further engaging with its partner agencies in
  IFE at the local and national level.
• Provided qualitative data to the nutrition
  cluster and other agencies as to IFE situation.
• Bangla translation of the Operational Guidance.

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What could have been done better.
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Time flies past

• Early assessment by SC missed out IFE
• Due to unavoidable delays assessment not started
  until 28th Dec (5 weeks)
• So not initial rapid assessment or full
  assessment (MSS)..

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Having IFE designated support throughout

• The IFE SC designated person became unavailable
  important to have a nutrition person sensitive to
  IFE issues and local knowledge.
• (Lucky to have BBF to help Breastfeeding
  counsellors, trainers, translators, etc!!!)

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Having agreed tools in advance

• Tools changed during translation
• To fit with national IYCF strategies
• To include other issues
• To fit with local context
• Some IFE questions removed / changed

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Greater time

• Only a week on the ground
• Team busy
• Added time pressure Long journeys teams had to
  get back to the field in daylight

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Hence

• No time to discuss issues / decide on questions
  needed and the way to ask them
• Training of field workers had to start before
  team met to finalise assessment tool
• Quick discussion make changes to tools straight
  into Bangla
• No time to fully discuss changes with assessment
  team or field test new forms
• No time to back translate to ensure changes made
  were correct

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Language Challenges

• Mixed feeding is not a Bangla term and is not
  well understood
• Childs milk could cover infant formula, tinned
  milk, child powdered milk or any milk (e.g. cows
  milk, milk powder, milk in cartons) that is drunk
  by a child whether suitable or not
• Concerns translated as issues then
  interpreted by assessors/interviewees as asking
  about their knowledge of appropriate IYCF

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Challenges caused by misunderstanding (found
during analysis)

• The terms less and more were sometimes
  interpreted as earlier and later
• e.g. Since the cyclone are infants being given
  complementary foods earlier, later or at the
  normal time? Was answered as later when checked
  mother meant giving it later during the day..
• A question such as Are less mothers
  breastfeeding? was sometimes interpreted as Are
  mothers producing less milk?

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Challenges of assessment method

• FGDs were not always free ranging conversations -
  each mother was asked about her experience on the
  issue.

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Challenges with the rapid assessment tool

• Long
• Amalgamating qualitative data from different
  tools takes time
• Questions not phrased the right way
• Some important questions missed out
• It could be done better.

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Overview. What is needed?

• Determine best method of conducting IFE SSRA.
• Review of sampling strategies for infants and
  determine agreed numbers for acceptability of
  results
• Need to agree
• what data is key
• the best method of phrasing questions in SSRAs
  to obtain reliable information with a useful
  level of detail
• Need to field test
• Bring it together to form SSRA guidelines and
  useable assessment tools based on best
  practice.
• Tools need pre-emergency country review
  translation

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• Your Experiences Thoughts?

Conducting IFE SSRA In Bangladesh, Post-cyclone
Sidr
Thank you.