Dates: February 12-14, 2024
Location: Abuja, Nigeria
Event Objectives
- Facilitate dynamic partnerships and collaboration among CROWN implementing partners, government agencies, NGOs, and stakeholders
- Identify and implement strategies to enhance the effectiveness of partnerships across various
- Promote the exchange of information, research findings, and practical tools, with a focus on evidence-based solutions that can be replicated in different settings
Conference Summary
| Project | Population | Supplementation Under Study | Adherence Measures* | Research Design | Timeline | ||
| Design & Develop | Implementation | Evaluation | |||||
 Nigeria Project | Pregnant women, women 3 months postpartum | MMS | Pill count (self-reported), questionnaire (self-reported) | Process and outcome evaluations; formative research (HCD)' cost-effectiveness study | Dec 2023 - Mar 2024 | May 2024 | June 2024 - April 2025 |
 Ethiopia Project | Pregnant women | IFA, MMS | Interviews with different time scale (1 day, 1 week, 2 weeks, 1m, 3m), pill count, behavioral scale items | Baseline and endline evaluations; key informant interviews; additional qualitative interviews; formative research (HCD) | Nov 2023 - April 2024 | April 2024 - July 2024 | Aug 2024 |
| Adolescent girls | June 2024 - Sept 2024 | Oct 2024 - Dec 2024 | Jan 2025 | ||||
 Bihar Project | Pregnant and lactating women, women of reproductive age, adolescent girls | IFA | Methods TBD, but may include: Hemoglobin test, pill count, interviews/questionnaires | Formative research (HCD) - research design still being finalized | Oct 2023 - July 2024 | Aug 2024 - Sept 2025 |
*Adherence measures are still being finalized for each of the three projects. This is a snapshot of potential measures under each intervention.
Nkechinyere Adinoyi and Loloah Chamoun from NI presented on Optimizing Adherence for Maternal MMS in Nigeria. NI found that MMS is a better value for money than IFA, and is working with the Government of Nigeria and Bauchi State on a three-year implementation research project on the transition from IFA to MMS as part of ANC, using HCD.
Dec 2023: Start of MMS-IFA Transition
March 2024: Baseline Evaluation, Costing Study (part 1)
May 2024: Implementation, Costing Study (part 2)
June 2024: Process Evaluation
April 2025: Endline Evaluation, Cost-Effectiveness Analysis
Nigeria Project Timeline
Habtambu Temene from JHU CCP presented updates for the Ethiopia adherence study, which aims to contribute to the reduction of anemia prevalence by developing effective and scalable solutions (1) to optimize adherence to IFA/MMS among pregnant women (PW) as well as (2) to improve uptake and adherence to weekly IFAs among adolescent girls (AGs).
For Pregnant Women:
March 2024 – April 2024: Baseline Survey
April 2024 – July 2024: Implementation
Aug 2024: Endline Evaluation
For Adolescent Girls:
June 2024: Baseline Survey
Oct 2024 – Dec 2024: Implementation
Jan 2025: Evaluation
Ethiopia Project Timeline
Andy Bhanot and Brijesh Rao from PCI and Pratyasha Rath from Final Mile Consulting presented on optimizing adherence to IFA supplements in Bihar, India. The project aims to increase uptake and adherence to IFA supplements among women of reproductive age, including pregnant and lactating women, and adolescents.
Oct 2023 – Jan 2024: Deepen Understanding
Feb 2024 – July 2024: Design and Test Prototype
Aug 2024 – Sept 2025: Implementation and Evaluation
Bihar Implementation Plan
All CROWN projects include an element of Human-Centered Design (HCD). During the Convening, Sonder Design (in partnership with Nutrition International) and the Johns Hopkins University Center for Communications Program shared about the ways in which they are using HCD to develop solutions which improve women’s adherence to nutritional supplements in Ethiopia and Nigeria
These adherence solutions have been selected to:
- Leverage existing community and healthcare structures, resources, and touchpoints.
- Target multiple audiences such as women, husbands, and elder female influencers.
- Address a range of behavioral components required for achieving adherence such as motivation, coping, habit formation, and reinforcement.
Below are some snapshots of the HCD process for the two projects, including proposed adherence solutions for MMS and IFA.
MMS Project Process
Nutrition International and Sonder Design for the Nigeria Project:
MMS Script Prototypes
MMS messaging was drafted into scripts for the various MMS adherence interactions.
- Scripts to guide the delivery of MMS group health talks and individual counselling by ANC facility health workers.
- Scripts to guide ANC adherence monitoring and counseling by CHIPs
and Mamma-to-Mamma agents during home visits. - A script to guide a WDC-led community talk on antenatal supplements.
MMS Counselling Tools
A series of additional counselling and adherence tools were also developed and tested
- A tool for surfacing women’s adherence challenges and providing supportive counselling using storytelling.
- A tool for coaching women to build MMS adherence routines.
- An MMS “adherence tracking” tool for women to use at home.
Women and men participating in a design thinking workshop
Example Adherence Solution: Tool for coaching women to build MMS adherence routines
A pictorial tool for women to take home to remind them of different ways they can incorporate taking MMS into their daily routine. This includes taking it at the same time each day, with a meal, prayer, or alarm, or using visual and family reminders. The photo is just an example as this is still in the prototyping phase at the time of presentation.
Advantages of HCD Approach
Value in our diverse perspectives
IFA/MMS Project Process
JHU CCP for the Ethiopia Project:
Reimagining support for pregnant women to increase adherence to IFA/MMS
Women and men testing prototypes of adherence solutions
Adherence Solutions
- Repositioning of IFA/MMS messaging
- Daily reminders for pregnant women in the house
- Encouraging stronger follow-up by HEWs and HDAs
- Improving counseling at the health center
How Might We Statements
- How might we improve counseling for pregnant women so that it leads to more pregnant women adhering to IFA/MMS over 90 days?
- How might we remind pregnant women to take IFA/MMS daily so that they adhere to it over 90 days?
- How might we inspire community volunteers (HDAs, TBA) to support pregnant women so that they can adhere to IFA/MMS over 90 days?
The Design Approach Used
Example Adherence Solution: Daily Sticker Reminder
A sticker tool for women to use at home after they have taken their daily micronutrient supplement. After they have completed a blister pack or bottle of tablets, the stickers will form a complete image. The photo is just an example as this is still in the prototyping phase at the time of presentation
How does CROWN coordinate across the four projects?
- CROWN was born out of the need for collaboration in terms of improving the quality of implementation research across diverse contexts and facilitating cross-country & cross-setting comparisons. Read more about CROWN here.
- CROWN’s key objectives are to:
The CROWN Internal Team
So, what does fostering collaboration among women’s nutrition projects in Ethiopia, Nigeria, and India look like in practice?
- CROWN Meetings
- One in-person Annual Meeting
- Three hybrid/virtual Quarterly Convenings
- Monthly one-on-one meetings between CROWN and project partners
- Other meetings as needed
- Knowledge Management (external)
- Sharing updates via the CROWN website, including via the Resource Repository
- Twitter and YouTube accounts
- Quarterly newsletter
- Publishing technical briefs and other papers in conjunction with country teams and making those publicly available
- Resource Sharing (internal)
- Microsoft Teams
- CROWN listserv for immediate e-mail sharing with all members
- Mentorship
- Pairing CROWN members with nutrition and other professionals with expertise in their field
- Professional development, skill-building, and promotion of well-being
On Day 3 of the Convening, CROWN conducted an internal Human-Centered Design (HCD) workshop to brainstorm “solutions” that would improve coordination across these four pillars. The following solutions were ideated, presented, and ranked by priority/timeline to be completed:
| COMPLETED | NOW | NEXT (by July 15, 2024) | LATER (by Feb. 2025) | |
| CROWN Meetings | During Quarterly Convenings: • “Hybrid” team meetings – Country teams will come together in one space • More interactive – include games, puzzles, breaks | During Annual Convening: • Field visits • Events organized by host country team • Incorporate capacity building activities/ training modules | ||
| Knowledge Management | • Appoint Knowledge Management focal person from each team, assign admin permissions in Whatsapp | • Expand collaboration outside CROWN projects • Create project tracking sheets to update in real-time (Teams) | • Facilitate external knowledge sharing through journal articles, published papers, etc. | |
| Resource Sharing | ✓ Created library/repository of key concepts | • Newsletter: highlight progress report key messages and link to Teams | • Create progress report template that includes successes AND learnings | • Facilitate external knowledge sharing through journal articles, published papers, etc. |
| Mentorship | ✓ Got started! Identified mentors outside of CROWN with diverse expertise ✓ Created goal-oriented worksheets for mentors/ mentees | • Set up meetings/ networking events on various platforms for mentors/ mentees | ||
| Other | ✓ Created Whatsapp group of all CROWN partners | • Organize trainings by internal and external experts (e.g., non-CROWN projects doing similar work) |
World Café Passport
The second day of the convening revolved around a World Café Activity, which allowed participants to visit different café tables and discuss pertinent questions related to adherence interventions.
Discussions centered around the four following topics and questions:
Topic 1: Adherence Measurement
Discussion Prompt: Triangulation refers to the use of multiple measures or modalities to assess a behavior or phenomena. We define modalities of adherence as channels used for assessing adherence or the way that adherence information is collected. We define measures as the means of data collection that can be classified within a modality. So, for example, pill count may be a modality and, within that, two measures might be: using an electronic monitoring system and counting the number of pills taken or remaining. Since the “gold standard” of adherence remains elusive, CROWN recommends the use of triangulation to understand adherence using a variety of techniques and measures through different lenses. Today, we want to think about how projects might use (or not use) triangulation, and the impacts this has on adherence measurement.
Question: How does your project use triangulation to assess adherence?
Modalities and Measures
Source: “Adherence Measurement Literature Review,” Presentation given at 1st Annual CROWN Convening, Julia Burleson, CROWN
Topic 2: Intervention Strategies vs. Implementation Strategies
Discussion Prompt: The socioecological model is often used to appreciate the fact that outcomes we care about in public health (women’s nutrition, institutional delivery, early and forced child marriage) are driven by factors at multiple levels.
Question: Think about the barriers someone might face to adhering to nutritional supplements at each of these different levels. What are interventions that could address multiple barriers to adherence?
Socio-Ecological Model Framework
Source: Centers for Disease Control (CDC)
Topic 3: Applying Vulnerability and Gender Lenses to Interventions
Discussion Prompt: Understanding social, cultural, and economic vulnerability is key to implementing interventions that improve women’s health and wellbeing. The vulnerability approach helps us to see the specific ways in which women are made more vulnerable by their location in society’s multiple power hierarchies and the way in which they constrain their abilities to access, use and engage with health services. In CROWN, we want to explore how we can use this lens (and others) to tailor adherence interventions to specific populations.
Question:
- Within the population(s) of interest to your project, how might you segment that population into sub-populations based on their levels of vulnerability? (What factors would increase a person’s level of vulnerability in that population?)
- How might you segment the population on the basis of other factors like gender, demographics (age, education, area of residence), psychographics (perceptions of barriers, knowledge about risk factors), etc.?
Pathways Segmentation is a Cross Cutting Segmentation
Source: “Learnings from Audience Segmentation Work,” Presentation given at 1st Annual CROWN Convening, Tracy Johnson, BMGF, Melanie Wendland, Sonder Design
Topic 4: HCD and Adherence Interventions
Discussion Prompt: Human-centered design is a framework that emphasizes the human at the center of design. Design thinking is NOT a scientific formula for predictable results – it is a transdisciplinary, creative, problem-solving process that emphasizes empathy, perspective-taking, iterative prototyping, and testing. CROWN projects each includes an HCD component, though by nature it looks quite different across projects, cultural settings, and goals of the process. We therefore want to understand how and why projects might use HCD, and what learnings from the process can mean for other adherence interventions.
Human-Centered Design
Source: “Brief Intro to Human-Centered Design,” Presentation given at 1st Annual CROWN Convening, Danielle Piccinini Black, JHU CCP