Improving Nepal's Female Community Health Volunteers’ (FCHV) Infant and Young Child Feeding (IYCF) Exposure and Knowledge: Results from Implementation Research on the Suaahara Program
Authors: Cunningham Kenda , Singh Akriti , Menon Purnima , Avula Rasmi , Rana Pooja Pandey , Oyloe Peter , Alayon Silvia 
Published: June 2021

Nepal has a cadre of thousands of Female Community Health Volunteers (FCHVs), whose primary responsibility is to deliver health and nutrition services to rural households. Suaahara, a program which integrates family planning, nutrition, water, sanitation and hygiene and homestead food production, aimed to use FCHVs to deliver information to improve the nutritional status of women and children <2 years. Using mixed methods, we examined the effectiveness of the Suaahara program on improving FCHVs’ IYCF knowledge in the context of a quasi‐experimental impact and process evaluation. We surveyed the FCHVs of 120 wards in 8 districts, 60 in Suaahara (S) and 60 in comparison (C) areas, at baseline (2012) and follow‐up (2014). We used difference–in‐difference (DID) regression analysis, with adjustment for clustering and socio‐demographic characteristics, to analyze changes in IYCF knowledge between groups and over time. At follow‐up we also conducted a qualitative assessment using focus group discussions and observations of the same 60 FCHVs in Suaahara areas. We found that Suaahara had a positive impact on FCHVs’ knowledge of optimal complementary feeding: more Suaahara FCHVs became aware of the appropriate age (6–8.9 months) for introducing meat (S: 31% to 88%; C: 60% to 76%; P: 0.02 DID). Suaahara also had a positive influence on FCHVs’ knowledge relating to breastfeeding (BF) and what advice to give when a mother states that her child <6 months of age does not breastfeed well: many more FCHVs in Suaahara areas reported that they discussed attachment (S: 10% to 70% vs. 15% to 40%; P: 0.06 DID) and discussed positioning (S: 20% to 83% vs. 30% to 54%; P: 0.09 DID). Many more FCHVs in Suaahara areas knew that if the mother had insufficient milk, she should BF more often, BF on demand, or BF by emptying 1 breast and switching to the other (S: 36% to 61% vs. 37% to 40%; P: 0.04 DID). Suaahara also had a positive influence on FCHVs’ understanding on the importance of giving more food or an extra meal to help a child recover from illness (S: 34% to 73%; C: 73% to 59%; P: 0.01 DID). These findings were consistent with qualitative findings in which the majority of FCHVs noted that although they had previously received health or nutrition training, the Suaahara training involved more detailed information including how to assist mothers with attachment and positioning and clarification that all foods, including animal source foods, should be introduced once a child is 6 months of age. Our study highlights the feasibility of improving FCHVs’ knowledge and skills. They are not only readily able to absorb more nuanced IYCF information rather than simple messages, but also report routinely incorporating the skills acquired during training, such as helping new mothers with positioning and attachment for successful breastfeeding.Support or Funding InformationFunding provided by the United States Agency for International Development, through Suaahara.