title: Assessing implementation fidelity of a community-based infant and young child feeding intervention in Ethiopia identifies delivery challenges that limit reach to communities: a mixed-method process evaluation study.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors: International Food Policy Research Institute, 2033 K Street, NW Washington, DC, 20006, USA. sunny.kim@cgiar.org.
authors: Sunny S
authors: SS
authors: Kim
authors: International Food Policy Research Institute, IFPRI-ESARO-ILRI Campus, Addis Ababa, Ethiopia. disha_nan@yahoo.com.
authors: Disha
authors: D
authors: Ali
authors: International Food Policy Research Institute, 2033 K Street, NW Washington, DC, 20006, USA. a.l.kennedy@cgiar.org.
authors: Andrew
authors: A
authors: Kennedy
authors: International Food Policy Research Institute, IFPRI-ESARO-ILRI Campus, Addis Ababa, Ethiopia. r.tesfaye@cgiar.org.
authors: Roman
authors: R
authors: Tesfaye
authors: Addis Continental Institute of Public Health, Road 8, Zone 8, Yeka Subcity, Addis Ababa, Ethiopia. amareworku@addiscontinental.edu.et.
authors: Amare W
authors: AW
authors: Tadesse
authors: FHI 360, House No. 193, Kebele 02, Kirkos Subcity, Addis Ababa, Ethiopia. teweldebrhan.hailu@gmail.com.
authors: Teweldebrhan H
authors: TH
authors: Abrha
authors: International Food Policy Research Institute, Titre 3396, Lot #2, BP 24063, Dakar Almadies, Senegal. r.rawat@cgiar.org.
authors: Rahul
authors: R
authors: Rawat
authors: International Food Policy Research Institute, NASC Complex, CG Block, Dev Prakash Shastri Road, Pusa, New Delhi, 110012, India. p.menon@cgiar.org.
authors: Purnima
authors: P
authors: Menon
mesh_terms: D000328:Adult; D001942:Breast Feeding / Q000379:methods*; D015362:Child Nutrition Disorders / Q000517:prevention & control*; D002675:Child, Preschool; D003150:Community Health Workers / Q000193:education / Q000458:organization & administration; D003376:Counseling; D003430:Cross-Sectional Studies; D004032:Diet; D005002:Ethiopia; D005260:Female; D006266:Health Education / Q000458:organization & administration*; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D009035:Mothers; D011247:Pregnancy; D015397:Program Evaluation; D036301:Qualitative Research; D014838:Volunteers