Using an evidence-based approach to design large-scale programs to improve infant and young child feeding.

BACKGROUND: Global interest in scaling up nutrition outcomes has focused attention on the need for more effective programs to improve infant and young child feeding (IYCF). However there are few examples in the literature of comprehensive programs that have been systematically designed. OBJECTIVE: To describe an evidence-based approach for designing large-scale yet tailored IYCF programs in varied country settings. METHODS: Behavior change principles, epidemiological data, situational analysis, stakeholder consultations, formative research, and feasibility studies informed the design of IYCF programs delivered at scale in Bangladesh, Ethiopia, and Vietnam. RESULTS: Impact, scale, and sustainability objectives guided the choice of partners, service delivery platforms, and advocacy, systems strengthening, and communication strategies for reaching mothers and decision makers. All programs focused on the critical first 2 years of life, followed global World Health Organization and UNICEF guidelines for IYCF, and applied a common theory of change. Formative research, stakeholder consultations, trials of improved practices, and assessments of media habits were most useful for making program decisions. Opinion leader research, monitoring of the policy environment, and stakeholder analysis were key elements in the design of advocacy strategies. All programs found that setting measurable and explicit targets, strengthening systems to provide support for mothers, multichannel communication, and advocacy for opinion leaders were vital components in the design. CONCLUSIONS: A systematic, evidence-based collaborative approach can facilitate the design of comprehensive IYCF programs. Programs should also embed design flexibility to enable changes as new challenges and opportunities arise.

Strengthiening systems to support mothers in infant and young child feeding at scale.

BACKGROUND: Systems strengthening is essential for implementation of large-scale nutrition interventions, including infant and young child feeding (IYCF), since rapid geographic expansion places additional burdens on service delivery systems. OBJECTIVE: To document approaches for building capacity and supporting programs to scale up IYCF counseling in three different country contexts. METHODS: Situational assessments, stakeholder consultations, formative research, household and frontline health worker surveys, other related studies, and program monitoring in three countries identified gaps and opportunities for strengthening IYCF service delivery. RESULTS: Variations in program platforms, level and roles of service providers, places of service delivery, community factors, and the needs of managers and frontline workers influenced the intervention mix used for strengthening IYCF services. The programs ranged from a highly structured and standardized package of IYCF counseling services in Vietnam delivered through government health facilities to counseling delivered at the doorstep by incentivized nongovernmental organization volunteers in Bangladesh. In Ethiopia, government health extension workers based at health posts conducted outreach visits with support from volunteers. CONCLUSIONS: Guidelines and standards of care, training, job aids, supportive supervision, incentives, and monitoring data can enhance performance and strengthen systems for delivering IYCF counseling services in the community or at health facilities. Leadership, financing, partnerships, and logistics support are essential to support large-scale implementation of the IYCF counseling package in diverse service delivery environments.

Implementing an integrated nutrition package at large scale in Madagascar: the Essential Nutrition Actions framework.

BACKGROUND: Madagascar has some of the highest rates of child stunting, maternal malnutrition, and infant mortality in sub-Saharan Africa. OBJECTIVE: To improve infant and young child feeding practices, increase uptake of micronutrient supplements, and improve women's dietary practices through implementation of a nutrition project based on the Essential Nutrition Actions (ENA) framework. METHODS: Interventions included training, interpersonal communication, community mobilization, and mass media. Changes in practices were assessed through a comparison of data for children under 2 years of age from representative cross-sectional household surveys collected at baseline in 2000 (n = 1,200) and at the end of program implementation in 2005 (n = 1,760). The surveys were conducted in six districts with a population of 1.4 million. RESULTS: The rate of initiation of breastfeeding within 1 hour of birth increased from 32% to 68%, the rate of exclusive breastfeeding of infants under 6 months of age increased from 42% to 70%, the rate of continuation of breastfeeding at 20 to 23 months increased from 43% to 73%, the rate of feeding children the minimum recommended number of meals per day at 6 to 23 months increased from 87% to 93%, the rate of iron-folic acid supplementation during pregnancy increased from 32% to 76%, and the rate of postpartum vitamin A supplementation increased from 17% to 54% (p < .001 for all changes). Modest improvement was achieved in maternal dietary practices during lactation and feeding of the sick child after illness. The results were inconclusive regarding food diversity for complementary feeding. No improvements were reported in increasing food intake during child illness or pregnancy. CONCLUSIONS: The ENA framework allows broad-scale improvement of nutritional practices to be achieved through the maximization of contacts using multiple program opportunities within existing health systems and community structures and through mass media.

Improving breastfeeding practices on a broad scale at the community level: success stories from Africa and Latin America.

Large-scale community-level behavior change programs designed to improve breastfeeding practices were implemented in Bolivia, Ghana, and Madagascar. These programs reached sizable populations: Bolivia, 1 million; Ghana, 3.5 million; and Madagascar, 6 million. Over 3 to 4 years, timely initiation of breastfeeding (within 1 hour of birth) increased from 56% to 74% (P < .001) in Bolivia, 32% to 40% (P < .05) in Ghana, and 34% to 78% (P < .001) in Madagascar. Marked increases in exclusive breastfeeding of infants 0 to 6 months of age were also documented: from 54% to 65% (P < .001) in Bolivia, 68% to 79% (P < .001) in Ghana, and 46% to 68% (P < .001) in Madagascar. In Ghana and Madagascar, significant results were seen within 1 year of community interventions. The authors conclude that large-scale programs designed to improve breastfeeding practices are feasible and should be a central component of any child survival strategy.

Preferred health resources and use of social media to obtain health and depression information by adolescent mothers.

PROBLEM: Little is known about how adolescent mothers use social media and the Internet, especially to access health information. METHODS: In this cross-sectional, descriptive study, adolescent mothers were recruited from an academic medical center after the birth of their child (n = 94) or from a state-funded, home visitation program during the first year after birth (n = 91). They completed the Pew Internet Survey: 37 questions related to use of social media and Internet, particularly in regard to obtaining health information. FINDINGS: All adolescent mothers used a computer and almost all went online. Most accessed the Internet by cell phone (67.4%) and used social media. The health topics searched most frequently were pregnancy/birth control (85.8%), sexually transmitted diseases (n = 134, 72.6%) and HIV (66.3%). Response to survey questions differed between the two groups (adolescent mothers surveyed after birth from academic medical center and adolescent mothers surveyed in the first postpartum year in the community). CONCLUSIONS: Adolescent mothers spend significant time on the Internet including searching for health information. Cell phones are their preferred methods for accessing the Internet, and they use social media. Thus, social media and the Internet are potentially feasible and acceptable vehicles to deliver health interventions to adolescent mothers.

Breastfeeding promotion, support and protection: review of six country programmes.

Reviews of programmes in Bangladesh, Benin, the Philippines, Sri Lanka, Uganda, and Uzbekistan sought to identify health policy and programmatic factors that influenced breastfeeding practices during a 10 to 15 year period. Exclusive breastfeeding rates and trends were analysed in six countries in general and from an equity perspective in two of them. Success factors and challenges were identified in countries with improved and stagnated rates respectively. The disaggregated data analysis showed that progress may be unequal in population subgroups, but if appropriately designed and implemented, a programme can become a "health equalizer" and eliminate discrepancies among different subgroups. Success requires commitment, supportive policies, and comprehensiveness of programmes for breastfeeding promotion, protection and support. Community-based promotion and support was identified as a particularly important component. Although health workers' training on infant feeding support and counselling was prioritized, further improvement of interpersonal counselling and problem solving skills is needed. More attention is advised for pre-service education, including a stronger focus on clinical practice, to ensure knowledge and skills among all health workers. Large-scale communication activities played a significant role, but essential steps were often underemphasized, including identifying social norms and influencing factors, ensuring community participation, and testing of approaches and messages.

Cuantificación de los Beneficios de la Lactancia Materna: Reseña de la Evidencia

[Introducción]: La presente bibliografía comentada reseña la literatura publicada en torno a seis temas relacionados con los beneficios de la lactancia materna: • Morbilidad infantil por diarrea, infecciones respiratorias agudas, otitis media e infecciones del oído y otras enfermedades infecciosas • Mortalidad infantil por diarrea, infección respiratoria aguda, y por todas las causas • Desarrollo infantile • Enfermedades crónicas, en especial, obesidad, diabetes y cancer • Efectos en la salud materna, es especial, cáncer de mama y cáncer de ovario • Beneficios económicos. Los artículos vinculados a la asociación entre lactancia materna, salud y desarrollo infantile alcanzado son analizados en torno a cuatro criterios principales: 1) evitando el sesgo de detección y la causalidad reversa mediante el empleo de un diseño de estudio adecuado; 2) realizando un control adecuado de los factores de confusión mediante el análisis estadístico; 3) proporcionando una clara definición de la lactancia materna; y, 4) brindando una clara definición de el/los parámetro/s evaluado/s. Los artículos aparecen organizados cronológicamente; los más recientes al comienzo. En aquellos casos en que existe suficiente información cuantitativa, se ofrecen cuadros con una síntesis de los principales hallazgos. Dichos cuadros están disponibles con información vinculada a los temas sobre morbilidad infantil, mortalidad infantil, enfermedades crónicas y efectos en la salud maternal...