Community support model on breastfeeding and complementary feeding practices in remote areas in Vietnam: implementation, cost, and effectiveness.

BACKGROUND: Poor access to healthcare facilities and consequently nutrition counseling services hinders the uptake of recommended infant and young child feeding (IYCF) practices. To address these barriers and improve IYCF practices, Alive & Thrive (A&T) initiated community support groups in remote villages across nine provinces in Vietnam. OBJECTIVE: This study examines the effectiveness of the support group model and related project costs for reaching underserved areas to improve IYCF practices. METHODS: To evaluate the model's implementation and project costs, we reviewed implementation guidelines, expenditure and coverage reports, monitoring data, and budgets for the nine provinces. To evaluate the model's effectiveness, we used a 3-stage sampling method to conduct a cross-sectional survey from April to May 2014 in three provinces entailing interviewing mothers of children aged 0-23 months in communes with (intervention; n = 551) and without support groups (comparison; n = 559). FINDINGS: Coverage: From November 2011 to November 2014, in partnership with the government, A&T supported training for 1513 facilitators and the establishing 801 IYCF support groups in 267 villages across nine provinces. During this period, facilitators provided ~ 166,000 meeting/support contacts with ~ 33,000 pregnant women and mothers with children aged 0-23 months in intervention villages. COSTS: The average project costs for supporting the meetings, compensating village collaborators, and providing supportive supervision through staff in commune health stations were USD 5 per client and USD 1 per contact. After adding expenditures for training, supportive supervision, and additional administrative costs at central and provincial levels, the average project cost was USD 15 per client and USD 3 per contact. Effectiveness: Survey participants in intervention and comparison communes had similar maternal, child, and household characteristics. Multiple logistic regression models showed that living in intervention communes was associated with higher odds of early initiation of breastfeeding (OR: 1.7; 95% CI: 1.1, 2.7), exclusive breastfeeding from 0 to 5 months (OR: 12.5; 95% CI: 6.7, 23.4), no bottle feeding (OR: 2.69; 95% CI: 1.82, 3.99), and minimum acceptable diet (OR: 1.51; 95% CI: 0.98, 2.33) compared to those living in comparison communes. CONCLUSION: The IYCF support group model was effective in reaching populations residing in remote areas and likely contributed to improved IYCF practices. The study suggests that the model could be scaled up to promote equity in breastfeeding support.

Why invest, and what it will take to improve breastfeeding practices?

Despite its established benefits, breastfeeding is no longer a norm in many communities. Multifactorial determinants of breastfeeding need supportive measures at many levels, from legal and policy directives to social attitudes and values, women's work and employment conditions, and health-care services to enable women to breastfeed. When relevant interventions are delivered adequately, breastfeeding practices are responsive and can improve rapidly. The best outcomes are achieved when interventions are implemented concurrently through several channels. The marketing of breastmilk substitutes negatively affects breastfeeding: global sales in 2014 of US$44·8 billion show the industry's large, competitive claim on infant feeding. Not breastfeeding is associated with lower intelligence and economic losses of about $302 billion annually or 0·49% of world gross national income. Breastfeeding provides short-term and long-term health and economic and environmental advantages to children, women, and society. To realise these gains, political support and financial investment are needed to protect, promote, and support breastfeeding.

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

Background: Rigorous evaluations of health system-based interventions in large-scale programs to improve complementary feeding (CF) practices are limited. Alive & Thrive applied principles of social franchising within the government health system in Vietnam to improve the quality of interpersonal counseling (IPC) for infant and young child feeding combined with a national mass media (MM) campaign and community mobilization (CM).Objective: We evaluated the impact of enhanced IPC + MM + CM (intensive) compared with standard IPC + less-intensive MM and CM (nonintensive) on CF practices and anthropometric indicators.Methods: A cluster-randomized, nonblinded evaluation design with cross-sectional surveys (n = ∼500 children aged 6-23.9 mo and ∼1000 children aged 24-59.9 mo/group) implemented at baseline (2010) and endline (2014) was used. Difference-in-difference estimates (DDEs) of impact were calculated for intent-to-treat (ITT) analyses and modified per-protocol analyses (MPAs; mothers who attended the social franchising at least once: 62%).Results: Groups were similar at baseline. In ITT analyses, there were no significant differences between groups in changes in CF practices over time. In the MPAs, greater improvements in the intensive than in the nonintensive group were seen for minimum dietary diversity [DDE: 6.4 percentage points (pps); P < 0.05] and minimum acceptable diet (8.0 pps; P < 0.05). Significant stunting declines occurred in both intensive (7.1 pps) and nonintensive (5.4 pps) groups among children aged 24-59.9 mo, with no differential decline.Conclusions: When combined with MM and CM, an at-scale social franchising approach to improve IPC, delivered through the existing health care system, significantly improved CF practices, but not child growth, among mothers who used counseling services at least once. A greater impact may be achieved with strategies designed to increase service utilization. This trial was registered at clinicaltrials.gov as NCT01676623.

The Association of a Large-Scale Television Campaign With Exclusive Breastfeeding Prevalence in Vietnam.

OBJECTIVES: To examine the association between exposure to breastfeeding television spots and exclusive breastfeeding (EBF). METHODS: We performed face-to-face interviews with 11 722 mothers of infants younger than 6 months using 5 cross-sectional surveys 6 or more months apart between 2011 and 2014 in Vietnam. Sample sizes were 2065 to 2593, and approximately 50% of participants lived in areas with (Alive & Thrive [A&T]-intensive [I]) and approximately 50% without (A&T-nonintensive [NI]) facilities offering counseling services. We analyzed data at individual and commune levels separately for A&T-I and A&T-NI areas. RESULTS: Exposure to television spots was associated with higher EBF in A&T-I (odds ratio [OR] = 3.33; 95% confidence interval [CI] = 2.70, 4.12) and A&T-NI (OR = 1.31; 95% CI = 1.03, 1.67) areas. In A&T-I areas, mothers who could recall at least 1 message were more likely to report EBF. In A&T-NI areas, only recall of at least 3 messages was associated with higher EBF. In communes, 1 message recalled (mean score range = 0.3-2.4) corresponded to 17 (P = .005) and 8 (P = .1) percentage points higher EBF prevalence in A&T-I and A&T-NI communes, respectively. CONCLUSIONS: Mass media should be part of comprehensive programs to promote EBF.

Estimates of the quality of complementary feeding among Vietnamese infants aged 6-23 months varied by how commercial baby cereals were classified in 24-h recalls.

The World Health Organization's (WHO) standardized questionnaire for assessing infant and young child feeding practices does not include commercial baby cereals (CBC), which are derived from several food groups and are fortified with micronutrients. We examined how different scenarios for classifying CBC affect estimates of the quality of complementary feeding in children ages 6-23 months in Vietnam in 2014 (n = 4811). In addition to the WHO standardized 24-h recall questionnaire for infant and young child feeding, we asked mothers about the consumption of CBC. The five resulting scenarios were S1 - omitted CBC; S2 - CBC classified as grains; S3 - as grains and dairy; S4 - as grains, dairy and fruit/vegetables; and S5 - as grains, dairy, fruit/vegetables and any others. Including CBC resulted in 4-11 percentage points higher in the prevalence of children who were fed each of the six food groups compared with what was reported in the WHO standardized questionnaire. Minimum dietary diversity (% fed ≥ 4 out of the 7 food groups) was higher in S5 (90%) than in S1 (84%), S2 (84%), S3 (85%) and S4 (86%). Minimum acceptable diet was also higher in scenarios S5 (80%) than in S1 (74%), S2 (75%), S3 (75%) and S4 (77%). Consumption of iron-rich foods was 94% when CBC was accounted, which was higher than the alternative scenario (89%). In summary, when CBC were included, population-level estimates of dietary quality were higher than when CBC were omitted. Guidance is required from the WHO about how to account for the consumption of CBC when estimating the quality of complementary feeding.

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.

BACKGROUND: Despite 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 FINDINGS: A 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. CONCLUSIONS: At-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 REGISTRATION: ClinicalTrials.gov NCT01678716 (Bangladesh) and NCT01676623 (Viet Nam).

Infant Formula Feeding at Birth Is Common and Inversely Associated with Subsequent Breastfeeding Behavior in Vietnam.

BACKGROUND: The association between infant formula feeding at birth and subsequent feeding patterns in a low- or middle-income context is not clear. OBJECTIVE: We examined the association of infant formula feeding during the first 3 d after birth with subsequent infant formula feeding and early breastfeeding cessation in Vietnam. METHODS: In a cross-sectional survey, we interviewed 10,681 mothers with children aged 0-23 mo (mean age: 8.2 mo; 52% boys) about their feeding practices during the first 3 d after birth and on the previous day. We used stratified analysis, multiple logistic regression, propensity score-matching analysis, and structural equation modeling to minimize the limitation of the cross-sectional design and to ensure the consistency of the findings. RESULTS: Infant formula feeding during the first 3 d after birth (50%) was associated with a higher prevalence of subsequent infant formula feeding [stratified analysis: 7-28% higher (nonoverlapping 95% CIs for most comparisons); propensity score-matching analysis: 13% higher (P < 0.001); multiple logistic regression: OR: 1.47 (95% CI: 1.30, 1.67)]. This practice was also associated with a higher prevalence of early breastfeeding cessation (e.g., <24 mo) [propensity score-matching analysis: 2% (P = 0.08); OR: 1.33 (95% CI: 1.12, 1.59)]. Structural equation modeling showed that infant formula feeding during the first 3 d after birth was associated with a higher prevalence of subsequent infant formula feeding (ß: 0.244; P < 0.001), which in turn was linked to early breastfeeding cessation (ß: 0.285; P < 0.001). CONCLUSIONS: Infant formula feeding during the first 3 d after birth was associated with increased subsequent infant formula feeding and the early cessation of breastfeeding, which underscores the need to make early, exclusive breastfeeding normative and to create environments that support it.

Infant and young child feeding practices differ by ethnicity of Vietnamese mothers.

BACKGROUND: Limited studies have examined ethnic variation in breastfeeding and complementary feeding practices in developing countries. This study investigated ethnic variation in feeding practices in mothers with children 0-23 months old in Vietnam. METHODS: We used data on 1875 women who came from the ethnic majority, Kinh (n = 989, randomly sampled from 9875 surveyed Kinh mothers, 10 % from each province) and three ethnic minorities: E De-Mnong (n = 309), Thai-Muong (n = 229) and Tay-Nung (n = 348). Ethnic minorities were compared with the Kinh group using logistic regression model. RESULTS: Prevalence of breastfeeding initiation within an hour of birth was 69 % in Thai-Muong, but ~50 % in other ethnicities. In logistic regression, the prevalence of breastfeeding within one hour was lower in Tay-Nung (OR: 0.54; 95 % CI: 0.38, 0.77) than the majority Kinh. Prevalence of exclusive breastfeeding under 6 months was 18, 10, 17, and 33 % in Kinh, Thai-Muong, Tay-Nung, and E De-Mnong, respectively; compared to the majority Kinh, the prevalence was lower in Thai-Muong (OR: 0.42; 95 % CI: 0.25, 0.71) and higher in E De-Mnong (OR: 1.99; 95 % CI: 1.04, 3.82). Overall prevalence of bottle feeding in Thai-Muong and E De-Mnong (~20 %) was lower than in Kinh (~33 %): Thai-Muong (OR: 0.50; 95 % CI: 0.37, 0.68) and E De-Mnong (OR: 0.69; 95 % CI: 0.50, 0.95). Compared with Kinh (75 %), fewer ethnic minority children received minimum acceptable diets (33 % in Thai-Muong, 46 % in E De-Mnong, and 52 % in Tay-Nung; P < 0.05). Prevalence of minimum acceptable diet (met both dietary frequency and diversity) was lower in Thai-Muong (OR: 0.23; 95 % CI: 0.11, 0.46), Tay-Nung (OR: 0.52; 95 % CI: 0.39, 0.69), and E De-Mnong (OR: 0.55; 95 % CI: 0.33, 0.89) than the majority Kinh. CONCLUSIONS: Breastfeeding practices were suboptimal and differed by ethnicity, which suggests need for tailored interventions at multiple levels to address ethnic-specific challenges and norms. Complementary feeding practices were less optimal among ethnic minorities compared to Kinh, which suggests need for broad intervention including improved food availability, accessibility, and security.

Exposure to mass media and interpersonal counseling has additive effects on exclusive breastfeeding and its psychosocial determinants among Vietnamese mothers.

The pathways through which behavior change interventions impact breastfeeding practices have not been well studied. This study aimed to examine: (1) the effects of exposure to mass media and interpersonal counseling on exclusive breastfeeding (EBF) and hypothesized psychosocial determinants (i.e. knowledge, intention, beliefs, social norms, and self-efficacy); and (2) the pathways through which exposure to mass media and interpersonal counseling are associated with EBF. We used survey data from mothers with children < 2 year (n = 2045) from the 2013 process evaluation of Alive & Thrive's program in Viet Nam. Multiple linear regression analyses and structural equation modeling were used to estimate effects. Exposure to mass media only, interpersonal counseling only, both or neither was 51%, 5%, 19% and 25%, respectively. Exposure to both mass media and interpersonal counseling had additive effects on EBF as well as on related psychosocial factors, compared with no exposure. For example, EBF prevalence was 26.1 percentage points (pp) higher in the group that received interpersonal counseling only, 3.9 pp higher in the mass media group and 31.8 pp higher in the group that received both interventions. As hypothesized, more than 90% of the total effect of the two interventions on EBF was explained by the psychosocial factors measured. Our findings suggest that combining different behavior change interventions leads to greater changes in psychosocial factors, which in turn positively affects breastfeeding behaviors.

Gaps between breastfeeding awareness and practices in Vietnamese mothers result from inadequate support in health facilities and social norms.

BACKGROUND: Although gaps between breastfeeding awareness and practices have been described, determinants of the gaps have not been well investigated. OBJECTIVE: The aim of this study was to examine determinants of the gap between breastfeeding awareness and practices in Vietnam. METHODS: We interviewed 10,834 mothers with children aged 0-23 mo in 11 of 63 Vietnam provinces about breastfeeding practices, awareness, barriers, and support. A gap between awareness and practice was defined when a mother was aware of the benefit but did not perform the corresponding practice. Logistic regression models were used to examine determinants associated with the gaps. RESULTS: The percentages of mothers with an awareness-practice gap for early initiation of breastfeeding, exclusive breastfeeding (EBF), continued breastfeeding at 1 y, and continued breastfeeding at 2 y were 34%, 66%, 19%, and 49%, respectively. Mothers had a lower awareness-practice gap in early initiation of breastfeeding if they received breastfeeding support from a health worker during pregnancy (OR: 0.79; 95% CI: 0.69, 0.92) or at birth (OR: 0.73; 95% CI: 0.60, 0.88). This gap was more likely to occur among those with a natural birth in the hospital (OR: 1.92; 95% CI: 1.50, 2.45), cesarean delivery (OR: 28.95; 95% CI: 20.1, 44.7), and breastfeeding difficulties (OR: 1.52; 95% CI: 1.21, 1.90). For EBF, the gap was lower among mothers with a higher social norm (OR: 0.20; 95% CI: 0.15, 0.27) or when they received breastfeeding support at birth by a health worker (OR: 0.82; 95% CI: 0.70, 0.95). In addition, intention of feeding infant formula at birth and having breastfeeding difficulties were associated with an increased gap in EBF [ORs (95% CIs): 1.28 (1.08, 1.51) and 1.29 (1.06, 1.57), respectively]. For continued breastfeeding at 1 y, social norms were associated with a lower gap (OR: 0.61; 95% CI: 0.41, 0.91), whereas breastfeeding difficulties were associated with an increased gap (OR: 1.70; 95% CI: 1.12, 2.57). CONCLUSION: Reducing breastfeeding awareness-practice gaps requires strengthening breastfeeding support in health facilities and the sociocultural environment to make desired practices normative.

Program impact pathway analysis of a social franchise model shows potential to improve infant and young child feeding practices in Vietnam.

By mapping the mechanisms through which interventions are expected to achieve impact, program impact pathway (PIP) analysis lays out the theoretical causal links between program activities, outcomes, and impacts. This study examines the pathways through which the Alive & Thrive (A&T) social franchise model is intended to improve infant and young child feeding (IYCF) practices in Vietnam. Mixed methods were used, including qualitative interviews with franchise management board members (n = 12), surveys with health providers (n = 120), counseling observations (n = 160), and household surveys (n = 2045). Six PIP components were assessed: 1) franchise management, 2) training and IYCF knowledge of health providers, 3) service delivery, 4) program exposure and utilization, 5) maternal behavioral determinants (knowledge, beliefs, and intentions) toward optimal IYCF practices, and 6) IYCF practices. Data were collected from A&T-intensive areas (A&T-I; mass media + social franchise) and A&T-nonintensive areas (A&T-NI; mass media only) by using a cluster-randomized controlled trial design. Data from 2013 were compared with baseline where similar measures were available. Results indicate that mechanisms are in place for effective management of the franchise system, despite challenges to routine monitoring. A&T training was associated with increased capacity of providers, resulting in higher-quality IYCF counseling (greater technical knowledge and communication skills during counseling) in A&T-I areas. Franchise utilization increased from 10% in 2012 to 45% in 2013 but fell below the expected frequency of 9-15 contacts per mother-child dyad. Improvements in breastfeeding knowledge, beliefs, intentions, and practices were greater among mothers in A&T-I areas than among those in A&T-NI areas. In conclusion, there are many positive changes along the impact pathway of the franchise services, but challenges in utilization and demand creation should be addressed to achieve the full intended impact.

Prelacteal feeding practices in Vietnam: challenges and associated factors.

BACKGROUND: Despite the importance of early initiation of and exclusive breastfeeding, prelacteal feeds continue to pose a barrier to optimal breastfeeding practices in several countries, including Vietnam. This study examined the factors associated with prelacteal feeding among Vietnamese mothers. METHODS: Data from 6068 mother-child (<6 m) dyads were obtained from a cross-sectional survey conducted in 11 provinces in Vietnam in 2011. Multivariate logistic regression analyses were used to examine factors associated with prelacteal feeding. RESULTS: During the first three days after birth, 73.3% of the newborns were fed prelacteals, 53.5% were fed infants formula, and 44.1% were fed water. The odds of feeding prelacteals declined with increased breastfeeding knowledge, beliefs about social norms in favor of exclusive breastfeeding, and confidence in one's own breastfeeding behaviors. Women who harbored misconceptions about breastfeeding had twice the odds of feeding any prelacteals (OR: 2.09, 95% CI: 1.74-2.50). Health care factors increasing the odds of prelacteal feeding included delivery by caesarean section (OR: 2.94, 95% CI: 2.39-3.61) or episiotomy (OR: 1.36, 95% CI: 1.17-1.58) and experiencing breastfeeding problems (OR: 1.31, 95% CI: 1.04-1.66). Health staff support during pregnancy and after birth reduced the odds of feeding formula. However, family support after delivery increased the odds of feeding water to newborns. CONCLUSIONS: The multiple factors contributing to the high prevalence of prelacteal feeding behaviors stress the need for early and appropriate breastfeeding interventions in Vietnam, particularly during routine healthcare contacts. Improving breastfeeding practices during the first days of an infant's life could be achieved by improving knowledge and confidence of mothers through appropriate perinatal counseling and support. Ensuring that health facilities integrate these practices into routine ante-natal care and post-delivery management is critical.

Learning from the design and implementation of large-scale programs to improve infant and young child feeding.

BACKGROUND: Improving and sustaining infant and young child feeding (IYCF) practices requires multiple interventions reaching diverse target groups over a sustained period of time. These interventions, together with improved maternal nutrition, are the cornerstones for realizing a lifetime of benefitsfrom investing in nutrition during the 1000 day period. OBJECTIVE: Summarize major lessons from Alive & Thrive's work to improve IYCF in three diverse settings--Bangladesh, Ethiopia, and Vietnam. METHODS: Draw lessons from reports, studies, surveys, routine monitoring, and discussions on the drivers of successful design and implementation of lYCF strategies. RESULTS: Teaming up with carefully selected implementing partners with strong commitment is a critical first step. As programs move to implementation at scale, strategic systems strengthening is needed to avoid operational bottlenecks. Performance of adequate IYCF counseling takes more than training; it requires rational task allocation, substantial follow up, and recognition of frontline workers. Investing in community demand for IYCF services should be prioritized, specifically through social mobilization and relevant media for multiple audiences. Design of behavior change communication and its implementation must be flexible and responsive to shifts in society's use of media and other social changes. Private sector creative agencies and media companies are well equipped to market IYCF. Scaling up core IYCF interventions and maintaining quality are facilitated by national-level coordinating and information exchange mechanisms using evidence on quality and coverage. CONCLUSIONS: It is possible to deliver quality IYCF interventions at scale, while creating new knowledge, tools, and approaches that can be adapted by others

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.

And young child feeding practices in different country settings.

BACKGROUND: Alive & Thrive aims to increase exclusive breastfeeding and complementary feeding practices in Bangladesh, Ethiopia, and Vietnam. OBJECTIVE: To develop and execute comprehensive communication strategies adapted to each context. METHODS: We documented how three countries followed an established iterative planning process, with research steps followed by key decisions, to develop a communication strategy in each country. Secondary analysis and formative research identified the priority practices to focus on, and locally specific constraints to proper infant and young child feeding (IYCF). Communication strategies were then developed based on the social, cultural, economic, epidemiological, media use, and programmatic contexts of each country. RESULTS: There were widespread gaps between recommended and actual feeding practices, and these varied by country. Gaps were identified in household, community, and institutional levels of awareness and skills. Strategies were designed that would enable mothers in each specific setting to adopt practices. To improve priority behaviors, messaging and media strategies addressed the most salient behavioral determinants through face-to-face communication, social mobilization, and mass media. Trials of improved practices (TIPs), concept testing, and pretesting of materials proved useful to verify the relevance and likely effectiveness of communication messages and materials tailored for different audiences in each setting. Coordination and collaboration with multiple stakeholders from the start was important to harmonize messages and approaches, expand geographic coverage to national scale, and sustain the interventions. CONCLUSIONS: Our experience with designing large-scale communication strategies for behavior change confirms that systematic analysis and local planning cannot be omitted from the critical process of strategic design tailored to each context. Multiple communication channels matched to media habits in each setting can reach a substantial proportion of mothers and others who influence their IYCF practices. Preliminary data suggest that exposure to mass media plays a critical role in rapidly reaching mothers, household members, community influentials, and health workers on a large scale. Combining face-to-face interventions for mothers with social mobilization and mass media was effective in improving IYCF practices.

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.

Change strategies to protect, promote, and support infant and young child feeding.

BACKGROUND: Despite the existence of a strong evidence base for investing in infant and young child feeding (IYCF), sufficiently supported IYCF policies and programs are rare. OBJECTIVE: To develop evidence-based advocacy strategies in Bangladesh, Ethiopia, and Vietnam to enable policy change and to increase investments in and ensure scale-up and sustainability of IYCF programs. METHODS: Situational analysis, formative and opinion leader research, and stakeholder consultations were used to develop three contextualized advocacy strategies. RESULTS: Data were used to determine how IYCF was perceived and prioritized, identify opinion leaders and partners, identify barriers to and opportunities for strengthening commitment, and select messages, materials, and communication channels. Opinion leader research showed that malnutrition was a concern but not a priority for policy action. Where food security was an issue, poverty reduction strategies rather than IYCF programs were viewed as the solution. Few opinion leaders were aware of the importance of the first 1000 days of life. In addition to policy gaps, awareness and implementation of existing policies were limited. This was often complicated by intragovernment conflicts and perspectives. Advocacy messages needed to be evidence based and delivered by credible champions. Engaging medical associations and the media presented an opportunity rarely leveraged in IYCF advocacy. CONCLUSIONS. Although sociopolitical contexts may vary, awareness of the importance of IYCF is an overarching advocacy challenge. Consequently, investments in IYCF programs and policies lag. Evidence-based advocacy design has a potential for impact on national policies, investments, and commitment to implementation and should be used more widely to inform program design.

The principles and practices of nutrition advocacy: evidence, experience and the way forward for stunting reduction.

Advocacy represents an intervention into complex, dynamic and highly contextual socio-political systems, in which strategies and tactics must be adjusted on a continual basis in light of rapidly changing conditions, reactions from actors and feedback. For this reason, the practice of advocacy is often considered more art than science. However, capacities and practices for advocacy can be strengthened by sharing and analysing experiences in varying contexts, deriving general principles and learning to adapt these principles to new contexts. Nutrition is a particular context for advocacy, but to date, there has been little systematic analysis of experiences. The purpose of this paper is to illustrate and draw lessons from the practice of nutrition advocacy, especially in relation to stunting and complementary feeding, and suggest ways to strengthen capacities and practices in the future. The strategies and tactics, achievements and lessons learnt are described for three case studies: Uganda, Vietnam and Bangladesh. These cases, and experience from elsewhere, demonstrate that concerted, well-planned and well-implemented advocacy can bring significant achievements, even in short period of time. In light of the global and national attention being given to stunting reduction through the SUN (Scaling Up Nutrition) movement and other initiatives, there is now a need for much stronger investments in strategic and operational capacities for advocacy, including the human, organisational and financial resources for the advocacy and strategic communication themselves, as well as for monitoring and evaluation, supportive research and institutional capacity-building.

Introducing infant and young child feeding indicators into national nutrition surveillance systems: lessons from Vietnam.

A comprehensive set of infant and young child feeding (IYCF) indicators for international use was published in 2008. We describe the process followed to incorporate these indicators into Vietnam's National Nutrition Surveillance System (NNSS). Following its establishment in 1980, the National Institute of Nutrition introduced the Vietnam NNSS to provide an evidence base for nutrition interventions. While anthropometric indicators based on international standards were regularly used for programme purposes, data on IYCF could not be collected with similar rigor until 2010. In 2009, with support from Alive & Thrive and UNICEF, the NNSS questionnaire was reviewed and additional content incorporated to measure IYCF practices. The tool was pilot-tested in 10 provinces and revised before nationwide roll-out in 2010.The tool comprises four pages, the first three of which focus on collecting data relating to maternal nutrition and IYCF. The last page is flexibly designed to incorporate planners' data requests for other relevant activities (e.g. mass media interventions, food security). Once analysed, the data are presented in a report comprising provincial profiles and maps illustrating IYCF practices. Importantly, the IYCF data have been used for policy advocacy (e.g. maternity leave legislation, advertisement law), programme planning, trend monitoring and capacity building. Adoption of the IYCF indicators was successful due to strategic timing, a phased approach, buy-in from stakeholders and capacity building at all levels to ensure the quality and use of data. Further revisions to the NNSS (e.g. sampling methodology, quality assurance systems) will be important to ensure the reliability of indicators.

Multi-sectoral interventions for healthy growth.

The risk of stunted growth and development is affected by the context in which a child is born and grows. This includes such interdependent influences as the political economy, health and health care, education, society and culture, agriculture and food systems, water and sanitation, and the environment. Here, we briefly review how factors linked with the key sectors can contribute to healthy growth and reduced childhood stunting. Emphasis is placed on the role of agriculture/food security, especially family farming; education, particularly of girls and women; water, sanitation, and hygiene and their integration in stunting reduction strategies; social protection including cash transfers, bearing in mind that success in this regard is linked to reducing the gap between rich and poor; economic investment in stunting reduction including the work with the for-profit commercial sector balancing risks linked to marketing foods that can displace affordable and more sustainable alternatives; health with emphasis on implementing comprehensive and effective health care interventions and building the capacity of health care providers. We complete the review with examples of national and subnational multi-sectoral interventions that illustrate how critical it is for sectors to work together to reduce stunting.