Impacts on Breastfeeding Practices of At-Scale Strategies That Combine Intensive Interpersonal Counseling, Mass Media, and Community Mobilization: Results of Cluster-Randomized Program Evaluations in Bangladesh and Viet Nam

Abstract

BackgroundDespite recommendations supporting optimal breastfeeding, the number of women practicing exclusive breastfeeding (EBF) remains low, and few interventions have demonstrated implementation and impact at scale. Alive & Thrive was implemented over a period of 6 y (2009–2014) and aimed to improve breastfeeding practices through intensified interpersonal counseling (IPC), mass media (MM), and community mobilization (CM) intervention components delivered at scale in the context of policy advocacy (PA) in Bangladesh and Viet Nam. In Bangladesh, IPC was delivered through a large non-governmental health program; in Viet Nam, it was integrated into government health facilities. This study evaluated the population-level impact of intensified IPC, MM, CM, and PA (intensive) compared to standard nutrition counseling and less intensive MM, CM, and PA (non-intensive) on breastfeeding practices in these two countries.Methods and FindingsA cluster-randomized evaluation design was employed in each country. For the evaluation sample, 20 sub-districts in Bangladesh and 40 communes in Viet Nam were randomized to either the intensive or the non-intensive group. Cross-sectional surveys (n ~ 500 children 0–5.9 mo old per group per country) were implemented at baseline (June 7–August 29, 2010, in Viet Nam; April 28–June 26, 2010, in Bangladesh) and endline (June 16–August 30, 2014, in Viet Nam; April 20–June 23, 2014, in Bangladesh). Difference-in-differences estimates (DDEs) of impact were calculated, adjusting for clustering. In Bangladesh, improvements were significantly greater in the intensive compared to the non-intensive group for the proportion of women who reported practicing EBF in the previous 24 h (DDE 36.2 percentage points [pp], 95% CI 21.0–51.5, p < 0.001; prevalence in intensive group rose from 48.5% to 87.6%) and engaging in early initiation of breastfeeding (EIBF) (16.7 pp, 95% CI 2.8–30.6, p = 0.021; 63.7% to 94.2%). In Viet Nam, EBF increases were greater in the intensive group (27.9 pp, 95% CI 17.7–38.1, p < 0.001; 18.9% to 57.8%); EIBF declined (60.0% to 53.2%) in the intensive group, but less than in the non-intensive group (57.4% to 40.6%; DDE 10.0 pp, 95% CI −1.3 to 21.4, p = 0.072). Our impact estimates may underestimate the full potential of such a multipronged intervention because the evaluation lacked a “pure control” area with no MM or national/provincial PA.ConclusionsAt-scale interventions combining intensive IPC with MM, CM, and PA had greater positive impacts on breastfeeding practices in Bangladesh and Viet Nam than standard counseling with less intensive MM, CM, and PA. To our knowledge, this study is the first to document implementation and impacts of breastfeeding promotion at scale using rigorous evaluation designs. Strategies to design and deliver similar programs could improve breastfeeding practices in other contexts.Trial registrationClinicalTrials.gov NCT01678716 (Bangladesh) and NCT01676623 (Viet Nam)

A comparison of minimum dietary diversity in Bangladesh in 2011 and 2014

“…Media exposure is thought to be an important source of women's empowerment as it acts as a “catalyst for activities that increase women's access to and control over resources” (Gupta & Yesudian, ). Additionally, Alive & Thrive conducted an intensive infant and young child feeding media campaign during 2011–2014 (Menon et al, ).…”

“…These findings are relevant to researchers and can help them design and evaluate interventions in subgroups to better increase adherence to recommendations for dietary diversity. Across several countries, the use of peer counselling, mass media delivery, community mobilization, and policy advocacy have had positive effects on infant and young child feeding practices across a wide range of diverse settings (Menon et al, ). Extending these strategies further to focus on women with low education, poor media exposure, and lack of access to antenatal care may prove beneficial to increasing dietary diversity among infants in the future.…”

“…Additionally, Alive & Thrive conducted an intensive infant and young child feeding media campaign during 2011-2014 (Menon et al, 2016).…”

Social Franchising and a Nationwide Mass Media Campaign Increased the Prevalence of Adequate Complementary Feeding in Vietnam: A Cluster-Randomized Program Evaluation

“…Information on social franchising to address other health issues, including nutrition, is sparse. We previously reported on evidence that showed that incorporating elements of social franchising into government health facilities significantly enhanced the quality of nutrition counseling services (18) and had large, significant impacts on breastfeeding practices (17). Social franchising elements were built into the existing health care system without altering fundamental structures of health service delivery, such as staffing composition and the availability of services and providers.…”

“…Mass media (MM) and community mobilization (CM) were used in all 3 countries to complement interpersonal counseling (IPC). Thus far, these studies have shown varying, but positive, impacts on breastfeeding in all 3 contexts (16, 17) and on CF in Bangladesh and Ethiopia (15, 16). …”