Effectiveness of a combined online and in-person training model in improving village health workers’ counselling quality and infant and young child feeding practices: a mixed-methods study in rural China

Background: To promote optimal nutrition and appropriate infant and young child feeding (IYCF), a national programme in China implemented a combined two-day online and one-day in-person IYCF counselling training ('2 + 1' training model) for primary health workers. However, evidence on its effectiveness remains limited. We aimed to assess improvements in the quality of counselling by village health workers (VHWs) and changes in key IYCF practices. Methods: We conducted a mixed-methods study in Changyang County, Hubei Province, China, from September 2023 to August 2025. Townships/villages were allocated into intervention and control groups. Intervention VHWs received the '2 + 1' training model and provided IYCF counselling. We assessed counselling quality through non-participant observation at baseline and endline, with the quality rate defined as achieving at least four of six key skills. IYCF practices were evaluated through two cross-sectional surveys of caregivers of children aged six to 23 months, administered via a WeChat online questionnaire. In addition, we conducted focus group discussions and semi-structured interviews. Results: At baseline, the counselling quality rate was low in both groups (12.0% vs. 3.9%, P = 0.0072). At endline, it increased substantially in the intervention group (84.8% vs. 32.2% in controls). The overall counselling skills score showed similar trends. VHWs reported that their IYCF knowledge, skills and communication confidence improved after training. For the IYCF practices, there was no difference in minimum dietary diversity (MDD), minimum meal frequency, and minimum acceptable diet (MAD) between the two groups at baseline; however, at endline, the intervention group achieved higher MDD (70.2% vs. 59.4%, P = 0.0415) and MAD (58.4% vs. 46.7%, P = 0.0342) prevalence compared to the control group. Caregivers expressed high satisfaction with the counselling services. Conclusions: The combined online and in-person IYCF counselling training could effectively improve VHWs' feeding counselling quality and subsequently maintain IYCF practices in a rural area in China.