Using Implementation Science to Evaluate a Home-Fortification Programme in Bangladesh

Home-fortification of foods with micronutrient powder is an innovative nutrition interventions have been developed to reduce the high burden of micronutrient malnutrition and childhood anaemia in low-income settings. BRAC, formerly known as the Bangladesh Rural Advancement Committee, adopted such a home-fortification intervention and scaled it up nationally between 2014-2018 to reduce prevalence of anaemia among children 6-59 months in Bangladesh. The home-fortification BRAC model relies on home visits by volunteer community health workers (CHWs) to distribute and sell micronutrient powders (MNP) at low-cost to caregivers in their homes who apply it to children's food. This thesis describes my research that used an implementation science framework to conceptualise and evaluate the BRAC home-fortification programme in Bangladesh. The BRAC home-fortification programme was evaluated using a multi-methods concurrent evaluation, including periodic coverage surveys, qualitative investigations, a process evaluation, operations research and economic evaluation. For the first stage of this research, I conducted a narrative review to identify a comprehensive implementation science framework. Based on this review, I developed a comprehensive framework, which I have consisted of three domains: Domain i - efficacy to effectiveness trials, Domain ii - scaling-up and Domain iii - sustainability. These three domains encompass five components: identifying an 'effective' intervention; scaling-up and implementation fidelity; course corrections during implementation; promoting sustainability of interventions and consideration of a comprehensive methodological paradigm to identify 'effective' interventions and to assess the process and outcome indicators of implementation. This was followed by a multilevel modelling study to assess the factors operating at different levels of programme-implementation by caregivers and CHWs associated with implementing the home-fortification intervention. The number of home-visits by the CHW is a function of characteristics of the BRAC CHWs, factors that characterise the households they serve, and characteristics of their organisational context, particularly to implement home-fortification of food with MNP. A qualitative analysis assessed the influence of organisation, programme, community and individual-level factors on the performance of CHWs. Younger, better educated and more experienced SS with positive self-efficacy were perceived to have performed better than their peers. Social and community factors, such as community recognition of the SS's services, social and religious norms, family support, and household distance, also affected the performance of the SS. I then reviewed the process documentation of the use of concurrent evaluation and identified that the partners regularly discussed evaluation results during and after implementation activities to assess progress in programme coverage and any needs for modification. BRAC initiated a series of corrections to the original implementation plan to address the implementation challenges, which improved the design of the home-fortification programme; this resulted in enhanced programme outcomes. I also measured coverage outcomes and the results suggested that a home visit from an SS positively impacts message coverage at both midline (ratio of OR 1.70; 95 % CI 1.25, 2.32; P < 0.01) and endline (ratio of OR 3.58; 95 % CI 2.22, 5.78; P < 0.001), and contact coverage both at midline (ratio of OR 1.48; 95 % CI 1.06, 2.07; P = 0.021) and endline (ratio of OR 1.74; 95 % CI 1.23, 2.47; P = 0.002). I concluded that an implementation science framework was useful in evaluating a home-fortification programme using micronutrient powders. The lessons learned during this research will enhance the capacity of researchers, policy-makers and key stakeholders in the nutrition field to scale-up new nutrition interventions and sustain them until malnutrition is alleviated