PAGE | 1 2 Incremental Learning Approach (ILA): Learning Note A Transformational Approach to build Capacities and Skills Launched in March 2018, and implemented by the Ministry of Women and Child Development (MWCD), Government of India (GoI), the POSHAN Abhiyaan (or the National Nutrition Mission) aimed at achieving improvement in nutritional status of children from 0-6 years, adolescent girls, pregnant women and lactating mothers in a time-bound manner, and reduction in stunting and wasting in children (0-6 years), as well as reduction in anemia among women, children and adolescent girls. A key program pillar under the POSHAN Abhiyaan was an innovative capacity building approach — the Incremental Learning Approach (ILA) — piloted under the Integrated Systems Strengthening and Nutrition Improvement Project (ISSNIP) of the MWCD, GoI, in 2016 in select eight states, prioritized on the basis of high undernutrition rates, utilizing the Integrated Child Development Services (ICDS)1 platform. This method aimed at building the capacity as well as motivation of program functionaries, which is critical for effective service delivery and behavior change at the community level. What is the Incremental Learning Approach? Incremental Learning Approach (ILA) breaks down learning into smaller modules for easy assimilation. The ILA focuses upon building and enhancing relevant skills for maternal, infant and young child nutrition (MIYCN) till the skills and related actions in the technical area are internalized and put into regular practice by the Anganwadi Workers (AWWs)2. This is different from conventional training approaches, which distribute large amounts of knowledge continuously over a given period of 7-10 days. Under the new approach, the AWWs are oriented on one topic every month, followed by a month of practice to follow up on actions. ILA trainings are provided in a cascade manner from state to sector level by leveraging ongoing learning platforms, where ‘face-to-face’ sessions for field functionaries assist them in absorbing and applying new knowledge in their day-to-day work, and help them reflect on the usefulness of content for improving service delivery. How were the trainings implemented under POSHAN Abhiyaan? 1. Constitution of Resource Groups For the purpose of delivering the trainings in cascade manner, resource groups were formed at state, district and block levels3 comprising members from government departments, development partners, non-government organizations (NGOs), and academia, as recommended by the MWCD under POSHAN Abhiyaan. These groups had well-defined terms of reference (TOR) and resources were allocated for their functioning. The formation of these groups helped to roll out the training. 1 Integrated Child Development Services (ICDS) is a government program in India launched in 1975 which provides nutritional meals, preschool education, primary healthcare, immunization, health check-up, and referral services to children under 6 years of age and their mothers. This is delivered through Anganwadi Centers (a village level rural child care center for every 1000 population). 2 An Anganwadi Worker is a frontline nutrition worker who mans the Anganwadi Center (meaning a 'Courtyard Shelter'), rural child care center in India, and is responsible for delivering key services under the ICDS scheme. 3 In India, the States are divided into Districts which are the primary units for administration of justice and maintenance of law and order, as well as delivery of government services. The Districts are subdivided into Blocks for planning and implementation of development programs at grassroots level in the villages; the implementation is done through the village Panchayats, which are the base level units of rural local self-government in India. PAGE | 2 2. Development of Thematic Content “I have attended various trainings. But no other The content for these trainings was training ever provided us with tools to use during developed in three ways: counseling. The takeaways are such useful aids! a) ILA Thematic Modules: The content focusing on maternal, I refer to them whenever I have to brush up on my infant and young child nutrition (MIYCN) under the POSHAN knowledge, and also use them during home visits.” Abhiyaan, was further divided in thematic modules, which – Anganwadi Worker contained detailed technical information related to the themes. Figure 1: ILA Modules A total of 21 such modules (Figure 1) were developed 1 Why this monthly meeting? in English as well as other regional languages. The key feature of these modules is the simple manner in which the 2 Making or updating home visit planner & initiating home visits technical information is explained along with pictorials. It also 3 Planning and organizing community-based events (CBEs) at AWC addresses locally prevalent myths and misconceptions. For 4 Observing breastfeeding in newborn babies – Why and How? the trainings at state and district levels, a triad of modules on similar themes were covered every quarter; a single 5 Identification and care of a weak newborn baby module per month was covered for the block and the sector 6 Complementary feeding: Diet diversity level trainings. 7 Preventing anemia in women 8 Assessment of growth in children “As a supervisor, it was a blessing to attend 9 Ensuring that complementary feeding improves over time these systematic ILA training sessions. I realized there were many topics I had only superficial 10 Ensuring exclusive breastfeeding knowledge about, but after the trainings, I felt 11 Care of the weak newborn: How many weak babies are we missing? equipped and could guide my AWWs appropriately.” 12 How to ensure timely initiation of complementary feeding? - ICDS Supervisor 13 Identifying and preventing severe acute malnutrition (SAM) b) e-ILA: An online adaptation of the in-person 14 Feeding during illness incremental learning modules, known as ‘e-ILA’, was also 15 Supporting mothers with issues in breastfeeding developed with 21 interactive modules for both web and 16 Taking care of a weak newborn with the help of Kangaroo Mother Care mobile-based platforms. 17 Identification and referral of sick newborn These online modules complemented the face-to-face learning and provided readily available content to the 18 Preventing illnesses to avert malnutrition and death AWWs for refreshing and updating their knowledge. 19 Prevention of anemia in girls and adolescents Assessments at the end of each module provided feedback 20 Birth preparedness for institutional and home delivery on learning outcomes. 21 Preparation during pregnancy – for newborn care and family planning “This entire training is like the telecast of a film! 3. Training Modality If we miss something, we can rewind and watch a) Frequency of Sessions: it again and again until we have full grip over The frequency of training sessions and the subject. I feel that the visual medium is the the amount of content to be covered in best for retaining knowledge.” each session, were finalized keeping - ICDS Supervisor in mind the educational levels and learning capacity of the ICDS staff and c) AWW Takeaways: Additionally, a series of job aids, in the functionaries. A two-day training session covering three ILA form of brochure-style AWW takeaways, were developed for modules, was to be organized every quarter for the state every corresponding ILA module. These takeaways presented and district level groups, while one thematic module was to the content in a pictorial manner which was both simple be covered in each monthly cycle at the block level for the and interesting, and appealed to the workers. AWWs used AWWs. This helped the participants to thoroughly absorb the these takeaways as ready reckoners for the topic covered technical knowledge as well as develop the skills to plan and in the corresponding ILA module, as well as during their deliver services to the beneficiaries. interactions with beneficiaries on different platforms. PAGE | 3 Figure 2: Training Modality In order to make these sessions interactive and interesting, the facilitators made use of different participatory methods Training level: State of training, such as role play, group discussion and periodic SRG Training frequency: 2 days/quarter question & answer sessions. Trainer: Central team Figure 3: ILA Session Flow Training level: State DRG Training frequency: 2 days/quarter Review Trainer: SRG • Review status of their Training level: District actions agreed upon in BRG last session Training frequency: 1 day/month Trainer: DRG • Solve problems/issues faced in service delivery Training level: Sector Sector Training frequency: 4 hours/month Trainer: BRG (ICDS Supervisors) b) Training Sessions: Each ILA session, delivered by Plan Input a facilitator and a co-facilitator, encompassed three • Develop an action • Introduce a thematic crucial steps, as illustrated in Figure 3. At the beginning plan to deliver topic of the month, of the session, the facilitator would ‘review’ the status of acquired knowledge and discuss technical implementation of agreed actions in the last training session. on the ground content and steps to deliver interventions This was followed by delivering the ‘input’ in the form of content of the selected thematic topic; and finally, guiding the participants to develop a ‘plan’ of action to implement c) Monitoring and Supervision: Regular supervisory visits the acquired knowledge on the topic in the field. The plan by the state/district/block ICDS officials, and pre- and of action to deliver the acquired knowledge contained the post- training assessments, were undertaken to ensure expected outputs for the following month for the AWWs, and quality of training delivered, and to assess AWWs’ knowledge were monitored during supervisory interactions. and skills, respectively. What is unique about ILA? • Small capsules of knowledge, easy to understand and assimilate. • Learning-by-doing approach to put learning into action. • Ongoing cascading learning platforms within the government system operated by government staff. • Monthly training session to absorb technical knowledge and develop skills to impart acquired knowledge on the ground. • Recurring training, without a fixed timeline. • ILA platform can be effectively used for supportive supervision of the frontline workforce. • E-learning platform to complement the face-to-face sessions, supported by job-aids for AWWs. Outcomes During the course of implementation of ILA, both during ISSNIP and POSHAN Abhiyaan, the impact of this unique capacity building approach was evaluated through qualitative assessments. The innovative Polling Booth Survey, conducted in 2017 and 2018, assessed the implementation of activities, including the ILA. Findings from the survey highlight improvement in knowledge among functionaries as well as beneficiaries on aspects related to maternal and child nutrition. Additionally, a process documentation exercise was conducted in 2017, and then in 2020, with AWWs reporting high appreciation of the ILA and e-ILA system and using it extensively during home visits. The POSHAN Knowledge and Behavior Survey, carried out telephonically in 2021, showed that 80% of women received nutrition information during pregnancy, with the majority receiving it from an AWW during counseling. PAGE | 4 ILA during the COVID-19 pandemic During the COVID-19 pandemic, the states adopted different strategies to continue the program implementation while social distancing restrictions were in force. In the initial outbreak and subsequent lockdown situations, several states carried out virtual training sessions for the resource group members. This was followed by sessions for the AWWs, organized virtually with a limited number of participants to ensure sufficient and effective interactions, with the facilitators and amongst themselves, which is a key feature of these ILA sessions. Once the restrictions eased, the sessions were organized physically, while following adequate precautionary measures. In addition to the virtual face-to-face ILA sessions, e-ILA videos and ILA takeaways were extensively promoted through the WhatsApp groups, to be used by AWWs as ready reckoners, and for messaging and counseling of beneficiaries. Lessons Learned ILA is acknowledged as a welcome departure from the traditional classroom training methodology. The field functionaries and officials alike have reported that knowledge imparted using this methodology is easy to follow and internalize, as there is strong emphasis on the ‘why’ and ‘how’ of the concepts. The key lessons learnt during the process of implementing ILA are: Government ownership: The state governments' complete ownership in implementing ILA trainings significantly improved its effectiveness, as the state leadership proactively identified challenges and provided local context-specific solutions. • Systematic planning & delivery of training sessions: a) Systematic planning is the key: Efficient planning and implementation of training involves getting the sanction, allocation, and timely disbursement of training budgets; translation of the ILA modules/takeaways in local languages; printing and timely distribution of modules and takeaways to the respective districts; preparing a calendar of ILA sessions per district at the beginning of the month; and ensuring availability of trained facilitators. b) Participatory method of delivering sessions: The modules include in-built questions, discussion points, and exercises such as role-plays, as well as demonstrations to guide the facilitators. When followed, the content is delivered more effectively ensuring better understanding among participants, and higher absorption of content. c) Follow recommended frequency: It is critical to follow the minimum recommended training session frequency as increase in frequency of these sessions led to dilution in the quality of delivery of the sessions, and lesser time available with the AWWs to put the learnings into practice before coming for the next session. • Monitoring & supervision mechanism to ensure quality: During the initial implementation of ILA, a progressive dilution in the quality of sessions was observed down the cascade. It was learnt that it is important to include systematic monitoring and supervision of ILA sessions by state, district and block level officials, using clear guidelines and tools to facilitate the same. • Complementary approaches to emphasize key content: The complementarity brought by the e-ILA platform and the job aids makes ILA an effective approach. Once learnt during the face-to-face ILA sessions, the AWWs had access to the e-ILA to go back to whenever required and refresh at self- pace. Likewise, the takeaways are used by the AWWs in the field, during community-based events (CBEs)4 and home visits, to counsel mothers and other caregivers. The ILA methodology revolutionized capacity building by implementing a systematic, creative and participatory approach to training, where a standard training package was delivered for every cadre in small capsules focusing on planning and service delivery of the content, thereby promoting behavioral change among beneficiaries. Several states like Gujarat, Andhra Pradesh and Tamil Nadu continue to use these modules in their training curriculum and conduct refresher training sessions. These training modules have been made available on the MWCD portal online, and select modules have been uploaded onto the POSHAN Tracker5 app for use by the AWWs. 4 CBEs are community events, organized in a systematic and structured way to promote behavior change among beneficiaries and the community around maternal and child nutrition. CBEs achieve this by capitalizing on traditional celebrations of key milestones in the mother’s/child’s life, to promote adoption of positive behaviors. 5 POSHAN Tracker is the digital MIS for POSHAN Abhiyaan.