Training to Integrate Agriculture and Nutrition in Bangladesh

Despite worldwide efforts to reach the Millennium Development Goal target of halving the proportion of people who suffer from hunger by 2015, 165 million children remain stunted and 870 million people are chronically undernourished. The 2013 Lancet Series on Maternal and Child Nutrition points to a growing consensus that combating the global burden of malnutrition will require collaboration across development sectors.

Recognizing the potential gains that can be made through better coordination, USAID's Bureau for Food Security and Bureau of Global Health commissioned the Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) project to lead a series of practical and program-driven Agriculture and Nutrition Global Learning and Evidence Exchange (AgN-GLEE) events in Uganda, Guatemala, and Thailand between December 2012 and March 2013.

To inform the agendas of the AgN-GLEEs, SPRING conducted a landscape analysis. Its purpose was to review and synthesize current Feed the Future investments being made by USAID, extracting key data and patterns from project documents and telephone interviews with USAID Missions. In addition to completing landscape analysis reports for each of the 19 Feed the Future countries, SPRING also conducted several field studies. These qualitative exercises were designed to gather, analyze, and summarize one or more practical activities being carried out by either a USAID Mission or a Feed the Future implementing partner that demonstrated potential for supporting nutritional outcomes within the country's Feed the Future defined zone of influence.

This field note examines the SPRING/Bangladesh project and its training of project and government agents to deliver nutrition and hygiene messages alongside agricultural interventions at the community level. Following this training, agents deliver messages during routine house visits and modified Farmer Nutrition Schools. A two-week field visit was carried out, using semi-structured interviews to gather information from project staff; government extension agents and supervisors; partner project staff and senior technical officers; and SPRING/Bangladesh Farmer Nutrition School participants. Interviews took place in Dhaka and at project sites in Barisal and Khulna Divisions. The goal was to gather information on: 1) what kinds of messages are promoted during SPRING/Bangladesh nutrition trainings; 2) the rationale behind the message selection; 3) training logistics and support; 4) uptake of messages by trainees; and 5) comprehension of the messages by target community members. Information collected was analyzed using the conceptual pathways between agriculture and nutrition¹ to identify ways in which SPRING/Bangladesh is linking agricultural interventions with nutritional outcomes.

Background

SPRING/Bangladesh is a five-year USAID-funded project focused on the "1,000 days approach,"² promoting essential nutrition and hygiene actions (ENHA) by pregnant and lactating women and children under the age of two years. The project aims to improve the nutritional status of 350,000 households between 2011 and 2016, reaching targeted communities (or unions) using multiple delivery channels that include SPRING-led Farmer Nutrition Schools, as well as training partnerships with government health agents, agricultural extension agents, and development partner facilitators.

Farmer Nutrition Schools

SPRING/Bangladesh is directly responsible for organizing, implementing, and monitoring Farmer Nutrition Schools that have been modified from the standard Farmer Nutrition School approach to target attendance exclusively by pregnant and lactating women.³ These Farmer Nutrition Schools cover three major areas of homestead food production: gardening, poultry-raising, and pond-fish farming. Homestead food production approaches have long been employed in Bangladesh by organizations such as Helen Keller International (HKI) and DANIDA; however, the integration of this food security approach into all-female Farmer Nutrition Schools is a new and potentially powerful approach to securing outcomes in agriculture and maternal and child nutrition. Participants of each Farmer Nutrition School live within one kilometer of the learning plot site, must be functionally landless (50 decimal land), and have an income of under $U.S. 50.00/month. They receive seeds and financial assistance to construct poultry sheds. Farmer Nutrition School facilitators conduct monthly follow-up visits to each Farmer Nutrition School participant. SPRING/Bangladesh began Farmer Nutrition School implementation in 15 subdistricts (upazilas) in June 2012, and has since expanded to 40 upazilas across the USAID's Feed the Future intervention divisions of Khulna and Barisal.

Pathways Linking Agriculture and Nutrition

Global evidence has led to the development of a theoretical framework that presents seven key pathways linking agriculture and nutrition (Annex 1). While several of these pathways are being actively employed through interventions under SPRING/Bangladesh, the most salient connection between agriculture and nutrition is via the Own Production → Food Consumption pathway. The extensive ENHA trainings, as well as the Farmer Nutrition School model, reinforce combined and often complementary messages about the steps necessary to plant, grow, harvest, cook, and consume nutritious foods at the household level.

Own Production → Food Consumption

Improvements in production practices and diversification of crops can lead to better nutrition when coupled with appropriate nutrition messaging. In the context of the 1,000 days approach, SPRING/Bangladesh uses homestead food production as a centerpiece for promoting immediately accessible nutritious vegetables and animal-source protein for pregnant and lactating women and children over six months of age. The nutrition and agriculture cross-training of Farmer Nutrition School facilitators allows them to directly bridge the practical concerns of production (how to plant, how to save seeds, how to fertilize) with the behavioral and knowledge components of consumption (what nutritious foods to grow, who should eat it, how to prepare it). In this way, the Farmer Nutrition School can be considered SPRING/Bangladesh's practical alignment with the conceptual pathways between agriculture and nutrition.

In addition, SPRING/Bangladesh conducts nutritional cross-training for production-focused government extension agents or partner project facilitators, effectively adding an ENHA component to its scope of work, and in some cases, co-targeting households with pregnant and lactating women and children. In the case of sub-assistant agricultural officers, most beneficiaries are male rice growers, meaning there will be less immediate connection between growing nutritious foods at the household level and having it consumed by SPRING/Bangladesh targets. In all cases, however, SPRING/Bangladesh trainings focus on the capacity to disseminate the same ENHA messages, such that Farmer Nutrition School facilitators, subassistant agricultural officers, project partners, and community health agents consistently promote food utilization behaviors.

Training Philosophy and Approaches

SPRING/Bangladesh acts as a "Master Trainer" for an array of government and project technical partners by planning, designing, and conducting ENHA training sessions, either directly to community agents or as part of a cascade "Training of Trainers" (see figure on page 5). These trainings began in 2011 and benefit from strong government and project partnerships.

The cross-training component of SPRING/Bangladesh is based on evidence from prior activities and conceptual frameworks, including BASICS in Madagascar, Alive & Thrive in Bangladesh, and the UNICEF conceptual framework on nutrition. Additional consultations with IFPRI, Save the Children, HKI, and the Ministry of Health and Family Planning helped determine which nutrition and hygiene messages were most likely to result in the behavior change necessary for nutrition impacts. This idea is captured by the phrase "Small Do-Able Actions"—those nutrition and hygiene behaviors most easily implemented by a household, regardless of means or prior education. SPRING/Bangladesh selected from among the 12 ENHA topics a total of 5 (see Box 1) that can be directly tied to homestead food production, are most critical to nutrition for pregnant and lactating women and children under two years of age, and can be understood and practiced by vulnerable and landless families.

The figure illustrates the SPRING/Bangladesh training structure. It highlights the different channels—Farmer Nutrition Schools, government, and partner projects—along with respective actors implicated in training on, and delivery of, select ENHA.

Figure. The SPRING/Bangladesh Training Structure⁴

Particularly important to its cross-training approach, SPRING/Bangladesh streamlined the instruction and delivery of messages so that government service providers and project facilitators will not feel overburdened when asked to effectively expand their scope of work. Streamlining also helps minimize the dissemination of incorrect information; the less material cross-trained agents are asked to memorize, understand, and disseminate, the less likely participants will receive inaccurate information. Finally, standardizing the ENHA messages through multiple channels puts key social and behavior change communication principles into practice, as the same information is reinforced through Farmer Nutrition Schools and government and project partners. For a detailed list of elements in the SPRING/Bangladesh training approach, see Annex 2.

Challenges

SPRING/Bangladesh's approach to agriculture-nutrition cross-training partnerships promotes the dissemination of ENHA messages through multiple channels, but faces a number of ongoing challenges related to cross-training buy-in, monitoring and evaluation, dissemination, and workload.

• Pregnant and lactating women contribute the majority of labor for homestead food production, which can negatively affect healthy pregnancy and time for child care.
• Working through staff funded by governments and activities separate from SPRING presents challenges of oversight, and SPRING has no mandate to dictate staff activities.
• Production technicians in partner activities may view nutrition training as creating extra work for which they were not previously responsible. Consequently, clear communication is needed between supervisory and field staff.
• Currently, no system exists to assess the impact of nutrition messaging delivered by subassistant agricultural officers, reducing the certainty that cross-training is supporting nutrition outcomes.
• Additional complexities with monitoring and evaluation arise when determining how many Farmer Nutrition School participants are at the same time receiving visits from SPRING-trained community agents within the Ministry of Health and Family Welfare.
• While SPRING/Bangladesh is taking a leadership role as an ENHA trainer, discrepancies in message content may occur when delivered by other channels to target community members, which can affect the uptake of new behaviors.
• Farmer Nutrition School facilitators are expected to provide their own transport to eight Farmer Nutrition Schools every two weeks, in addition to 160 participants that must receive household visits each month.

Conclusion

The SPRING/Bangladesh project offers several important lessons. The first is around the adaptation of the Farmer Nutrition School model, which typically is reserved for male farmers. SPRING/Bangladesh has used the Farmer Nutrition School approach to instead focus hands-on agricultural trainings for pregnant and lactating women, promoting up to three varieties of homestead food production (pond-fish aquaculture still according to availability of water). The inclusion of targeted ENHA activities is likewise a new approach and there is great interest in seeing whether the selected Small Do-Able Actions are effectively translated into results such as improved hand-washing, increased complementary feeding frequency, and improved nutrition for pregnant and lactating women. At the same time, a nine-month, biweekly class is no small undertaking and, while it creates significant opportunities around homestead food security, it also demands time and energy among a nutritionally vulnerable population.

Regarding the cross-training of production agents (agriculture, horticulture, aquaculture) in government agencies or technical projects, SPRING/Bangladesh is clearly focused on identifying partners, advocating for cross-training and— in certain cases—co-targeting. Perhaps the greatest achievement to date is building and maintaining a role as master trainer for its own brand of selected ENHA messages; SPRING/Bangladesh appears well accepted by the health and agricultural ministries, which strongly indicates the messaging is approved by the Bangladeshi government and not overly redundant or in conflict with other initiatives. The close ties with the agricultural ministry, and the department of extension in particular, is laudable—the only caveat in terms of lessons learned is that not every project will benefit from such willing government partners.

Finally, mapping SPRING/Bangladesh onto the pathways between agriculture and nutrition framework, project activities fit predominantly within the Production → Consumption pathway. The modified Farmer Nutrition School combines practical knowledge on establishing and maintaining homestead food production, with both improved food utilization and hygiene practices targeted toward pregnant and lactating women and children under two years of age. Similarly, the use of other production agents and government extension services to reinforce nutrition messaging falls along similar lines—placing nutrition knowledge in the hands of producers, commercial and homestead alike.

Future Research Questions

This brief field note was based on initial desk research, interviews with donors and activity staff, and one site visit by SPRING research staff. As with any field research, the visit raised additional areas of inquiry that are of interest. Some of the potential research questions may already be part of the Mission or project's learning agenda. For SPRING/Bangladesh, the following research questions warrant additional consideration:

• How effective is the Farmer Nutrition School training format in delivering ENHA messages, and what are its advantages and disadvantages compared with other methods? Do ENHA messages benefit from the same practice and discovery-based training approach of Farmer Nutrition Schools? Are there observed advantages in limiting participation to women only? How effective are nutrition messages delivered by agricultural agents versus health agents?
• How do the homestead food production activities targeted to women affect the health of pregnant women and the time availability and energy levels of lactating mothers? How does the project mitigate the negative effects on mother's health, and the care and feeding of infants?
• Homestead food production may directly increase household food consumption, diet diversity, and individual food intake, but the impact on child nutrition outcomes is less direct as health and care determinants become prominent. Given this context, what activity approaches are most promising for influencing intra-household behavior that could likely impact mother and child health and nutrition?