Countries' experiences scaling up national breastfeeding, protection, promotion and support programmes: Comparative case studies analysis.

Scaling up effective interventions, policies and programmes can improve breastfeeding (BF) outcomes. Furthermore, considerable interest exists in learning from relatively recent successful efforts that can inform further scaling up, with appropriate adaptations, across countries. The purpose of this four-country case studies analysis was to examine why and how improvements in BF practices occurred across four contrasting countries; Burkina Faso, the Philippines, Mexico and the United States of America. Literature reviews and key informant interviews were conducted to document BF trends over time, in addition to why and how BF protection, promotion and support policies and programmes were implemented at a national level. A qualitative thematic analysis was conducted. The 'Breastfeeding Gear Model' and RE-AIM (Reach; Effectiveness; Adoption; Implementation; and Maintenance) frameworks were used to understand and map the factors facilitating or hindering the scale up of the national programmes and corresponding improvements in BF practices. Each of the studied countries had different processes and timing to implement and scale up programmes to promote, protect and support breastfeeding. However, in all four countries, evidence-based advocacy, multisectoral political will, financing, research and evaluation, and coordination were key to fostering an enabling environment for BF. Furthermore, in all countries, lack of adequate maternity protection and the aggressive marketing of the breast-milk substitutes industry remains a strong source of negative feedback loops that are undermining investments in BF programmes. Country-specific best practices included innovative legislative measures (Philippines), monitoring and evaluation systems (United States of America), engagement of civil society (Mexico) and behavior change communication BF promotion (Burkina Faso) initiatives. There is an urgent need to improve maternity protection and to strongly enforce the WHO Code of Marketing of Breast-Milk Substitutes.

Strengthening advocacy and policy change for infant and young child feeding.

The creation of environments that are more supportive of optimal infant and young child feeding (IYCF) requires countries to enact policies, such as those related to the Maternity Protection Convention, the International Code of Marketing of Breast-milk Substitutes (the Code), and the Baby-Friendly Hospital Initiative. However, challenges are experienced in the translation of international policy standards into national legal measures, and there is an important gap in understanding how countries achieve progress. Policy advocacy is a nearly universal feature, but there are methodological challenges and few studies evaluating strategies and effects. The purpose of this supplement to Maternal & Child Nutrition is to address those gaps. This supplement contains three papers that present findings from a real-time evaluation of the advocacy efforts of Alive & Thrive (A&T), United Nations International Children's Emergency Fund (UNICEF), and partners, that sought to support governments in fostering enabling environment for optimal IYCF in Southeast Asia (SEA) and Africa. A combination of two emergent, theory-based evaluation approaches was used: developmental evaluation and contribution analysis. The overall objective of the evaluation was to document the extent to which policy objectives were or were not achieved in each country and to identify the key drivers of policy change. One contribution of the supplement is a distinction between and illustration of triggers and drivers of policy change. Three main drivers of policy change were identified: (a) the use of an explicit advocacy approach; (b) the creation of a strategic group of actors; and (c) the realization of 15 critical tasks (more specifically for the Code). Each of the critical tasks has been identified as having triggered progress on the Code in those countries. This supplement provides evidence that the advocacy efforts of A&T, UNICEF, and partners contributed to enhanced IYCF policies in SEA and reveals how it helped to achieve progress. The insights contained in this supplement can serve as a guide for policy advocates for enhanced IYCF policies. A short communication puts findings into perspective within global context.

Translating the International Code of Marketing of Breast-milk Substitutes into national measures in nine countries.

The International Code of Marketing of Breast-milk Substitutes (the Code) adopted by the World Health Assembly (WHA) in 1981 and regularly updated through subsequent WHA resolutions, represents the international policy framework for protecting breastfeeding against inappropriate marketing practices. By March 2016, at least 135 countries had some measures covering provisions of the Code in their legislation. The translation of the International Code into national measures was investigated in the context of the advocacy efforts undertaken by the Alive & Thrive (A&T) initiative with UNICEF and partners. A real-time evaluation was carried out over 22 months in seven Southeast Asian countries (Cambodia, Indonesia, Lao People's Democratic Republic [Lao PDR], Myanmar, Thailand, Vietnam, and Timor-Leste) and two African countries (Burkina Faso and Ethiopia). Drivers of policy change and progress were examined. Two theory-based approaches were used: developmental evaluation and contribution analysis. Data collection methods included participant observation, key informant meetings, in-depth interviews, reflective practice, and desk review. Overall, countries made significant progress in translating the International Code into national measures and in moving forward throughout the policy cycle. The main driver of policy change was the creation of a strategic group, which engaged key relevant actors and supported the government in the performance of 15 critical tasks, which the analysis reveals is a second driver. Those critical tasks are described in this paper and could help public health advocates to anticipate the stages and challenges of policy change and develop more effective strategies to translate the Code into their legal framework.

Contribution of the Alive & Thrive-UNICEF advocacy efforts to improve infant and young child feeding policies in Southeast Asia.

Evaluating the impact of advocacy for policy change presents many challenges. Recent advances in the field of evaluation, such as contribution analysis (CA), offer guidance on how to make credible claims regarding such impact. The purposes of this article are (a) to detail the application of CA to assess the contribution of an advocacy initiative to improve infant and young child feeding policies and (b) to present the emergent theory of change and contribution story of how progress was achieved. An evaluation applying developmental evaluation and CA was conducted on the Alive & Thrive (A&T)-UNICEF initiative in seven Southeast Asian countries to document the extent to which policy objectives were achieved and identify key drivers of policy change. A contribution story was developed based on these experiences. The advocacy approach, which involved a four-part process, contributed directly to (a) set the agenda of various actors and (b) create a strategic group; and indirectly to (a) set and maintain the issue on the agenda at all stages of the policy cycle, (b) support the government to carry out a set of critical tasks, and (c) extend commitment. All of this helped to achieve progress towards policy change. External influences were at play. The flexibility of A&T allowed key actors to utilize the positive external influences and address some of the negative ones through developing responsive strategies mitigating their effects. The emerging contribution story supports that A&T-UNICEF initiative contributed to the progress achieved in the participating countries.

A comparison of exclusive breastfeeding in Belgian maternity facilities with and without Baby-friendly Hospital status.

A retrospective cross-sectional study was carried out in Wallonia (the southern region of Belgium) in which a 20-question breastfeeding (BF) module was included in an immunization survey. The purpose of this paper is to compare exclusive breastfeeding (EBF) prevalences and BF practices for mothers giving birth in Baby-friendly Hospital Initiative (BFHI) and non-BFHI maternity facilities. A total of 557 mothers responded to BF questions when their child was 18-24 months old; 26.7% of them delivered in a BFHI maternity facility. At discharge, a larger proportion of children were exclusively breastfed if they were born in a BFHI maternity facility (76.5% vs. 65.8%, p = .02). The median duration of EBF (15.0 vs. 12.9 weeks, p = .3), and the proportion of children exclusively breastfed at 5 months (16.8% vs 15.8%, p = 1.0) were similar in both groups. Few mothers knew that EBF was recommended for the first 6 months of life (28.6% in BFHI vs 23.1% in non-BFHI, p = .2). For most groups of the population examined, the rates of BF tended to be higher in BFHI facilities, but many differences were not significant. More specifically, BFHI seemed to boost BF practices among mothers more likely to breastfeed, but the Initiative did not seem to trigger enhanced BF practices in mothers traditionally less likely to breastfeed (except for indifferent/negative partner's attitude and mothers of Belgian origin). Influencing the BF practices of mothers less likely to breastfeed requires a special attention with complementary actions in maternity facilities as well as in community services.

Enhancing governance and strengthening advocacy for policy change of large Collective Impact initiatives.

Nutrition issues are increasingly being addressed through global partnerships and multi-sectoral initiatives. Ensuring effective governance of these initiatives is instrumental for achieving large-scale impact. The Collective Impact (CI) approach is an insightful framework that can be used to guide and assess the effectiveness of this governance. Despite the utility and widespread use of this approach, two gaps are identified: a limited understanding of the implications of expansion for an initiative operating under the conditions of CI and a lack of attention to advocacy for policy change in CI initiatives. In this paper, a case study was undertaken in which the CI lens was applied to the advocacy efforts of Alive & Thrive (A&T), UNICEF and partners. The initiative expanded into a regional movement and achieved meaningful policy changes in infant and young child feeding policies in seven countries in Southeast Asia. These efforts are examined in order to address the two gaps identified in the CI approach. The objectives of the paper are (a) to examine the governance of this initiative and the process of expansion from a national to a regional, multilayered initiative, with attention to challenges, adaptations, and key elements, and (b) to compare advocacy in the A&T-UNICEF initiative and in typical CI initiatives and gain insight into how the practice of advocacy for policy change can be strengthened in CI initiatives.

Alimentation infantile et changements climatiques : une opportunité prometteuse.

The method of infant feeding has consequences for the production of greenhouse gases (GHG) as well as for the risks to infants posed by climate change. Breastfeeding can reduce the carbon footprint associated with the use of commercial infant formula by nearly 50% while reducing its water footprint and waste. It is also an excellent way of coping with emergencies associated with climate change, such as water shortages, since breastfed children are better protected than those fed with formula. To ensure that the protection offered by breastfeeding can be realized, we present elements that can help decision-makers seize a promising opportunity: improve infant feeding support for women and families.

RéSUMé: Le mode d'alimentation infantile a des répercussions sur les émissions de gaz à effets de serre (GES) de même que sur les risques que posent les changements climatiques pour les nourrissons. L'allaitement peut réduire de près de 50 % l'empreinte carbone associée à l'utilisation des préparations commerciales pour nourrissons (PCN) et diminuer leur empreinte hydrique et les déchets associés. C'est aussi une excellente façon de faire face aux situations d'urgence associées aux changements climatiques, telles les difficultés d'accès à l'eau, puisque l'enfant allaité est mieux protégé que celui alimenté avec des PCN. Pour s'assurer que la protection offerte par l'allaitement puisse se concrétiser, nous présentons des éléments pouvant aider les décideurs à saisir une opportunité prometteuse : améliorer le soutien à l'alimentation infantile pour les femmes et les familles.

"Stronger with Breastmilk Only" Initiative in 5 African Countries: Case Study on the Implementation Process and Contribution to the Enabling Environment for Breastfeeding.

Background: The practice of giving water before 6 mo of age is the biggest barrier to exclusive breastfeeding in West and Central Africa. To address this challenge, a regional initiative, "Stronger with Breastmilk Only" (SWBO), was rolled out at country level in several countries of the region. Objective: We examined the implementation process of the SWBO initiative and the contribution of its advocacy component to a more supportive environment for breastfeeding policies and programs. Methods: This study was based on 2 assessments at the national level carried out in 5 countries (Burkina Faso, Chad, Democratic Republic of the Congo, Senegal, and Sierra Leone) using qualitative methods. We combined 2 evaluative approaches (contribution analysis and outcome harvesting) and applied 2 theoretical lenses (Breastfeeding Gear Model and Consolidated Framework for Implementation Research) to examine the implementation process and the enabling environment for breastfeeding. Data sources included ∼300 documents related to the initiative and 43 key informant interviews collected between early 2021 and mid-2022. Results: First, we show how a broad initiative composed of a set of combined interventions targeting multiple levels of determinants of breastfeeding was set up and implemented. All countries went through a similar pattern of activities for the implementation process. Second, we illustrate that the initiative was able to foster an enabling environment for breastfeeding. Progress was achieved notably on legislation and policies, coordination, funding, training and program delivery, and research and evaluation. Third, through a detailed contribution story of the case of Burkina Faso, we illustrate more precisely how the initiative, specifically its advocacy component, contributed to this progress. Conclusion: This study shed light on how an initiative combining a set of interventions to address determinants of breastfeeding at multiple levels can be implemented regionally and contributes to fostering an enabling environment for breastfeeding at scale.

Operationalizing Implementation Science in Nutrition: The Implementation Science Initiative in Kenya and Uganda.

BACKGROUND: Implementation science (IS) has the potential to improve the implementation and impact of policies, programs, and interventions. Most of the training, guidance, and experience has focused on implementation research, which is only 1 part of the broader field of IS. In 2018, the Society for Implementation Science in Nutrition borrowed concepts from IS in health to develop a broader and more integrated conceptual framework, adapted to the particular case of nutrition and with language and concepts more familiar to the nutrition community: it is called the IS in Nutrition (ISN) framework. OBJECTIVE: The purpose of this research was to generate knowledge concerning challenges and strategies in operationalizing the ISN framework in low- and middle-income country (LMIC) settings. METHODS: The ISN framework was operationalized in partnership with country teams in Kenya and Uganda over a 3-y period as part of the Implementation Science Initiative. An action research methodology (developmental evaluation) was used to provide timely feedback to the country teams, facilitate adaptations and adjustments, and generate the data presented in this article concerning challenges and strategies. RESULTS: Operationalization of the ISN framework proceeded by first articulating a set of guiding principles as touchstones for the country teams and further articulating 6 components of an IS system to facilitate development of work streams. Challenges and strategies in implementing these 6 components were then documented. The knowledge gained through this experience led to the development of an IS system operational model to assist the application of IS in other LMIC settings. CONCLUSIONS: Future investments in IS should prioritize a system- and capacity-building approach in order to realize its full potential and become institutionalized at country level. The operational model can guide others to improve the implementation of IS within a broad range of programs.

Improving Iron and Folic Acid Supplementation Among Pregnant Women: An Implementation Science Approach in East-Central Uganda.

INTRODUCTION: To address maternal iron-deficiency anemia and low uptake of iron and folic acid supplementation (IFAS) among antenatal care (ANC) clinic attendees in East-Central Uganda, the Anemia Implementation Science Initiative embedded enhanced quality improvement (QI) activities into an integrated health project utilizing QI methodologies. METHODS: To address 2 bottlenecks of stock-outs and inadequate health education for pregnant women during ANC, an enhanced QI intervention was implemented from July 2019 to September 2020 in 2 districts. We conducted a mixed-methods effectiveness quasi-experimental study to assess whether the intervention increased the availability of IFAS in the intervention districts. We used longitudinal facility-level data from 2 treatment districts and 1 comparison district for the quantitative results. Difference-in-difference estimation was used to measure the impact of the intervention on IFAS health education and IFA availability at the health facility. We used logistic regression modeling to control for factors associated with IFAS uptake and potential differences in baseline values. Researchers conducted exit interviews with ANC clients and in-depth interviews with providers and district managers for greater insights into the implementation process. RESULTS: The intervention increased the probability, at a statistically significant level, of pregnant women both receiving IFAS and receiving health education on IFAS during ANC. According to inter-viewees, the intervention approach improved stakeholder engagement and buy-in, which brought about change at all levels of the health system. DISCUSSION: The intervention successfully addressed the 2 main bottlenecks to availability of IFAS for pregnant women attending ANC-inadequate provision of IFAS education and a weak drug quantification process. Even without additional funds to purchase commodities, this approach improved district capacity to advocate for and manage IFAS commodities. It could also be used to strengthen overall ANC quality.

Understanding the challenges related to breastfeeding education and barriers to curricular change: a systems perspective for transforming health professions education.

Objectives: A majority of women and families wish that their babies be breastfed. However, too many still receive insufficient or inappropriate initial care from health professionals (HPs) who have limited breastfeeding (BF) competencies. We investigated barriers and potential solutions to improve the undergraduate training programs for various HPs. Methods: Focus groups were carried out in three universities in Quebec and one in Ontario (Canada), with 30 faculty and program directors from medicine, midwifery, nursing, nutrition, and pharmacy. Discussions were subjected to thematic content analysis, before being validated in a strategic planning workshop with 48 participants from the same disciplines, plus dentistry and chiropractic. Findings: Substantive improvements of undergraduate training programs for BF could be obtained by addressing challenges related to the insufficient, or lack of, (i) interactions among various HPs, (ii) opportunities for practical learning, (iii) specific standards to guide course content, (iv) real-life experience with counselling, and (v) understanding of the influence of attitudes on professional practice. Several potential solutions were proposed and validated. The re-interpretation of the results in light of various literature led to an emerging framework that takes a systems perspective for enhancing the education of HPs on BF. Conclusions: To improve the education of HPs so as to enable them to provide relevant support for future mothers, mothers and their families, solutions need to be carried out to address challenges in the health system, the education system as well as regarding the curricular change process.

Objectifs: La majorité des femmes et des familles souhaitent que leur bébé soit allaité. Toutefois, plusieurs ne reçoivent pas un soutien adéquat de la part de professionnels de la santé (PS) qui ont des compétences limitées en allaitement. Nous avons étudié les barrières et les solutions potentielles en vue de rehausser la formation initiale de divers PS. Méthodes: Des groupes de discussion ont été organisés dans trois universités du Québec et une en Ontario (Canada) avec 30 directeurs de programmes et membres du corps professoral en médecine, pratique sage-femme, sciences infirmières, nutrition et pharmacie. Les discussions ont fait l'objet d'une analyse de contenu thématique laquelle fut ensuite validée dans un atelier de planification stratégique avec 48 participants des mêmes disciplines auxquelles se sont ajoutées dentisterie et chiropratique. Résultats: Des améliorations substantielles des compétences en allaitement dans les programmes de formation initiale pourraient être obtenues en travaillant sur les défis associés à l'insuffisance, ou à l'absence de, (i) interactions entre les divers PS, (ii) opportunités d'apprentissages pratiques, (iii) normes spécifiques pour guider les contenus de cours, (iv) expériences réelles avec le counseling, et (v) compréhension de l'influence des attitudes sur la pratique professionnelle. La ré-interprétation des résultats à la lumière de la littérature a fait émerger un cadre conceptuel avec une perspective systémique pour guider le rehaussement de la formation en allaitement des divers PS. Conclusions: Afin d'améliorer la formation des PS pour qu'ils/elles puissent fournir un soutien pertinent aux futures mères, aux mères et à leurs familles, des solutions visant à la fois les défis dans le système de santé, dans le système d'éducation et dans le processus de changement curriculaire doivent être mises en œuvre.

A whole-food, plant-based nutrition program: Evaluation of cardiovascular outcomes and exploration of food choices determinants.

OBJECTIVES: An ideal diet to prevent cardiovascular diseases contains an unlimited intake of various plant foods and a reduced intake of animal and highly processed foods. Researchers have reported that nutrition education programs that prioritize whole-plant foods effectively contribute to the prevention of unhealthy cardiovascular outcomes. We examined whether a 12-wk nutrition education program in adults from Montreal (Quebec, Canada) with at least one risk factor of cardiovascular disease was effective in modifying their eating patterns toward including more whole-plant foods. We further evaluated the effects of this program on participants' cardiovascular outcomes and explored determinants influencing food choices toward whole-food, plant-based diets. METHODS: A sequential, explanatory, mixed-methods, research design was used. A quantitative step (i.e., single-arm, quasi-experimental trial) preceded participant recruitment for a qualitative phase (i.e., phenomenological study; semistructured interview; thematic analysis). The examined outcomes were changes in cardiovascular risk factors (paired t tests) and determinants of food choice (thematic analysis). RESULTS: Weight (-10.5 lbs; 95% confidence interval [CI]: -9.0 to -12.0), waist circumference (-7.4 cm; 95% CI: -6.5 to -8.4), total cholesterol (-0.87 mmol/L; 95% CI: -0.57 to -1.17), and low-density lipoprotein cholesterol (-29.7% or -0.84 mmol/L; 95% CI: -0.55 to -1.13) all improved significantly (P ˂ 0.001). Encouraging ad libitum intake of various whole-food plant-based items appealed more to participants than traditional strategies. Altruistic and societal motives, in addition to health, were identified as key determinants of an increased adoption of whole-food plant-based diets. CONCLUSIONS: The whole-food, plant-based nutrition program improves cardiovascular health in adults and features characteristics that may inform future nutrition programs and public health interventions.