TABLE 2.

Formative research results and implications for training design¹

Phase	Key finding	Implication for training design
Situation analysis/formative research	The health institutions have complex structures and hierarchies.	Design of a 4-level cascade training for physicians and supervisors of IMSS delegations and state-level responsible for the health component of CCT-POP at the Secretary of Health (level 1); IMSS physicians with role of supervisors, supervisors of community actions, and coordinators of health education at regional level (level 2); physicians, nurses, and health promoters at IMSS local level and physicians, nurses, nurse technicians, and health promoters of the local Secretary of Health (level 3); volunteer health promoters, midwives, and rural health assistants of IMSS and health assistants and midwives of the Secretary of Health and community health volunteers managed by Sedesol (level 4).
Situation analysis/formative research	The Secretary of Health and IMSS have different structures, personnel, roles, and ways of working. Both are state led and thus function differently across states.	Design a flexible training that could be adapted to each organization in the different states. Raise awareness among high-level decision makers about the importance of EsIAN.
Situation analysis/formative research	Health personnel have different roles, and there is a strong hierarchy within health services.	Conduct separate, in-person training for different types of personnel. Promote physicians who train physicians and nurses who train nurses.
Formative research	Health personnel counsel on nutrition but in an unstandardized way and providing inconsistent messages.	Develop a simple counseling model that can be used by physicians and nurses to counsel program beneficiaries. Develop simple, relevant, and clear messages that could be used as part of the counseling model. Promote consistent use of messages, making sure that the same messages are used by all the different types of personnel.
Formative research	CCT-POP communication materials (such as flipcharts) used for group counseling provide inconsistent messages, some of them outdated.	Recommend revision and updating of messages to CCT-POP, to be consistent with international guidelines and EsIAN's recommendations.
Formative research	There are technical norms that address some of EsIAN's key nutrition topics, but some of them are outdated and/or not used by health personnel.	Review technical norms and make reference to them. Identify outdated content in the technical norms and advocate for change.
Formative research	Community health volunteers are motivated to provide nutrition counseling but have low literacy levels.	Develop a training for low-literacy groups.
Formative research	The Mexican population is diverse and has different traditions and customs across areas (urban, rural, and indigenous) and states.	Promote diversity and tolerance of traditions and local customs and context, creating messages that could be adapted to local conditions and resonate with the target audience.
Formative research/feasibility study	Health personnel are motivated to provide nutrition counseling but have limited time to do so.	Develop a simple counseling model that can be used by physicians and nurses to counsel program beneficiaries. Diversify the moments and personnel that provide nutrition counseling. Prioritize key messages that could be used during counseling.
Formative research/feasibility study	Health personnel lack counseling skills.	Develop a simple counseling model that can be used by physicians and nurses to counsel program beneficiaries. Include an in-person component of the training that could be used to train and practice counseling skills.
Formative research/feasibility study/redesign and scale up	There is a high rotation of personnel each year, especially of physicians.	Develop a simple cascade training that can be adopted and replicated by health personnel. Raise awareness among high-level decision makers about the importance of EsIAN to ensure sufficient resources and commitment for its continuous implementation.
Formative research/feasibility study	Health personnel lack technical knowledge about key nutrition topics.	Identify and prioritize key nutrition topics that are most relevant for EsIAN. Identify and address knowledge gaps about these key nutrition topics.
Feasibility study	Health personnel found training difficult to replicate.	Simplify topics and information included in the training. Simplify cascade training.
Redesign and scale up	Health personnel had basic technological skills and were able to take the virtual course.	Continue implementation of virtual training.
Redesign and scale up	Health personnel in level 1 failed the final exam and had to retake the training.	Design and implement a replacement course.

¹CCT-POP, conditional cash transfer program PROSPERA; EsIAN, Integrated Strategy for Attention to Nutrition; IMSS, Mexican Institute of Social Security.