Using formative research to design a context-specific behaviour change strategy to improve infant and young child feeding practices and nutrition in Nepal.

Global recommendations on strategies to improve infant feeding, care and nutrition are clear; however, there is limited literature that explains methods for tailoring these recommendations to the local context where programmes are implemented. This paper aims to: (1) highlight the individual, cultural and environmental factors revealed by formative research to affect infant and young child feeding and care practices in Baitadi district of Far Western Nepal; and (2) outline how both quantitative and qualitative research methods were used to design a context-specific behaviour change strategy to improve child nutrition. Quantitative data on 750 children aged 12-23 months and their families were collected via surveys administered to mothers. The participants were selected using a multistage cluster sampling technique. The survey asked about knowledge, attitude and behaviours relating to infant and young child feeding. Qualitative data on breastfeeding and complementary feeding beliefs and practices were also collected from a separate sample via focus group discussions with mothers, and key informant interviews with mothers-in-law and husbands. Key findings revealed gaps in knowledge among many informants resulting in suboptimal infant and young child feeding practices - particularly with relation to duration of exclusive breastfeeding and dietary diversity of complementary foods. The findings from this research were then incorporated into a context-specific nutrition behaviour change communication strategy.

Determinants of delayed initiation of breastfeeding in rural Ethiopia: programmatic implications.

BACKGROUND: A number of studies have examined the possible adverse impact of services offered by health workers and community members on postpartum infant feeding practices. The present analysis utilized extant data collected previously through the baseline surveys of two related child health and nutrition projects implemented in rural Ethiopia and explored key risk factors associated with delayed initiation of breastfeeding for more than 1 hour after birth. OBJECTIVE: To investigate the most important determinants of delayed initiation of breastfeeding. METHODS: Multivariate logistic regression was performed to analyze data from baseline cross-sectional surveys carried out in 2003 and 2004 in selected districts across three regions in Ethiopia. RESULTS: Attendance at delivery by a health worker was found to be an important risk factor for the delayed initiation of breastfeeding, whereas attendance by traditional birth attendants or family and/or friends represented a protective factor for early initiation of breastfeeding. Additional analysis suggests that targeting of behavior change interventions on optimal infant feeding to these health workers could reverse the risk relationship and lead to improvements in the rate of early initiation of breastfeeding. CONCLUSIONS: Provision of inadequate breastfeeding information in the health system and attendance at delivery by health workers are associated with a delay in the initiation of breastfeeding. Births attended by trained traditional birth attendants and family members are associated with better practices. Targeting health workers, community members, families, and women to promote optimal infant feeding practices is likely to hold much potential to increase the adoption of early initiation of breastfeeding.

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.

Promotion and advocacy for improved complementary feeding: can we apply the lessons learned from breastfeeding?

Although many successes have been achieved in promoting breastfeeding, this has not been the case for complementary feeding. Some successes in promoting complementary feeding at the community level have been documented, but few of these efforts have expanded to a larger scale and become sustained. To discover the reasons for this difference, the key factors for the successful promotion of breastfeeding on a large scale were examined and compared with the efforts made in complementary feeding. These factors include definition and rationale, policy support, funding, advocacy, private-sector involvement, availability and use of monitoring data, integration of research into action, and the existence of a well-articulated series of steps for successful implementation. The lessons learned from the promotion of breastfeeding should be applied to complementary feeding, and the new Global Strategy for Infant and Young Child Feeding provides an excellent first step in this process.