Jean Baker

The Case for Promoting Multiple Vitamin and Mineral Supplements for Women of Reproductive Age in Developing Countries

Women in developing countries often consume inadequate amounts of micronutrients because of their limited intake of animal products, fruits, vegetables, and fortified foods. Intakes of micronutrients less than the recommended values increase a womans risk of having micronutrient deficiencies. the adverse effects of deficiencies in vitamin A, iron, and folic acid, including night-blindness in pregnant and lactating women and iron-deficiency anaemia, are well known. Low intakes of these and other nutrients, including zinc, calcium, riboflavin, vitamin B6, and vitamin B12, also have consequences for womens health, pregnancy outcome, and the health and nutritional status of breastfed children. Multiple deficiencies coexist, so the benefit of multiple micronutrient supplements is becoming increasingly apparent. Supplementation of women with multiple vitamins and minerals should be one component of a strategy to improve micronutrient status among women in developing countries. However, there are several issues for programme managers to consider before implementing programmes. Which reference standards will be used to determine nutrient levels to include in the supplements? Which nutrients will be included and in what quantities? Which factors need to be considered in purchasing supplements? These issues are discussed, and guidance is provided on the selection of appropriate supplements for pregnant women and women of reproductive age in developing countries.

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.

Combining Intensive Counseling by Frontline Workers with a Nationwide Mass Media Campaign Has Large Differential Impacts on Complementary Feeding Practices but Not on Child Growth: Results of a Cluster-Randomized Program Evaluation in Bangladesh

Background: Complementary feeding (CF) contributes to child growth and development, but few CF programs are delivered at scale. Alive & Thrive addressed this in Bangladesh through intensified interpersonal counseling (IPC), mass media (MM), and community mobilization (CM). Objective: The objective was to evaluate the impact of providing IPC + MM + CM (intensive) compared with standard nutrition counseling + less intensive MM + CM (nonintensive) on CF practices and anthropometric measurements. Methods: We used a cluster-randomized, nonblinded evaluation with cross-sectional surveys [n = ∼600 and 1090 children 6–23.9 mo and 24–47.9 mo/group, respectively, at baseline (2010) and n = ∼500 and 1100 children of the same age, respectively, at endline (2014)]. We derived difference-in-difference impact estimates (DDEs), adjusting for geographic clustering, infant age, sex, differences in baseline characteristics, and differential change in characteristics over time. Results: Groups were similar at baseline. CF improvements were significantly greater in the intensive than in the nonintensive group [DDEs: 16.3, 14.7, 22.0, and 24.6 percentage points (pp) for minimum dietary diversity, minimum meal frequency, minimum acceptable diet, and consumption of iron-rich foods, respectively]. In the intensive group, CF practices were high: 50.4% for minimum acceptable diet, 63.8% for minimum diet diversity, 75.1% for minimum meal frequency, and 78.5% for consumption of iron-rich foods. Timely introduction of foods improved. Significant, nondifferential stunting declines occurred in intensive (6.2 pp) and nonintensive (5.2 pp) groups in children 24–47.9 mo. Conclusions: The intensive program substantially improved CF practices compared with the nonintensive program. Large-scale program delivery was feasible and, with the use of multiple platforms, reached 1.7 million households. Nondifferential impacts on stunting were likely due to rapid positive secular trends in Bangladesh. Accelerating linear growth further could require accompanying interventions. This study establishes proof of concept for large-scale behavior change interventions to improve child feeding. This trial was registered at clinicaltrials.gov as NCT01678716.

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 benefits from investing in nutrition during the 1000 day period. Objective Summarize major lessons from Alive & Thrives 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 IYCF 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 societys 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 and contribute to accelerated scale up of IYCF programs globally.

Achieving behaviour change at scale: Alive & Thrive's infant and young child feeding programme in Bangladesh.

Abstract The Alive & Thrive programme scaled up infant and young child feeding interventions in Bangladesh from 2010 to 2014. In all, 8.5 million mothers benefited. Approaches – including improved counselling by frontline health workers during home visits; community mobilization; mass media campaigns reaching mothers, fathers and opinion leaders; and policy advocacy – led to rapid and significant improvements in key practices related to breastfeeding and complementary feeding. (Evaluation results are forthcoming.) Intervention design was based on extensive formative research and behaviour change theory and principles and was tailored to the local context. The programme focused on small, achievable actions for key audience segments identified through rigorous testing. Promotion strategies took into account underlying behavioural determinants and reached a high per cent of the priority groups through repeated contacts. Community volunteers received monetary incentives for mothers in their areas who practised recommended behaviours. Programme monitoring, midterm surveys and additional small studies to answer questions led to ongoing adjustments. Scale‐up was achieved through streamlining of tools and strategies, government branding, phased expansion through BRAC – a local non‐governmental implementing partner with an extensive community‐based platform – and nationwide mainstreaming through multiple non‐governmental organization and government programmes. Key messages Well‐designed and well‐implemented large‐scale interventions that combine interpersonal counselling, community mobilization, advocacy, mass communication and strategic use of data have great potential to improve IYCF practices rapidly. Formative research and ongoing studies are essential to tailor strategies to the local context and to the perspectives of mothers, family members, influential community members and policymakers. Continued use of data to adjust programme elements is also central to the process. Scale‐up can be facilitated through strategic selection of partners with existing community‐based platforms and through mass media, where a high proportion of the target audience can be reached through communication channels such as broadcast media. Sustaining the impacts will involve commitments from government and capacity building. The next step for capacity building would involve understanding barriers and constraints and then coming up with appropriate strategies to address them. One of the limitations we experienced was rapid transition of staff in key positions of implementing agencies, in government leadership, donors and other stakeholders. There was a need for continued advocacy, orientation and teaching related to strategic programme design, behaviour change, effective implementation and use of data.

Exposure to Large-Scale Social and Behavior Change Communication Interventions Is Associated with Improvements in Infant and Young Child Feeding Practices in Ethiopia.

Optimal breastfeeding (BF) practices in Ethiopia are far below the government’s targets, and complementary feeding practices are poor. The Alive & Thrive initiative aimed to improve infant and young child feeding (IYCF) practices through large-scale implementation of social and behavior change communication interventions in four regions of Ethiopia. The study assessed the effects of the interventions on IYCF practices and anthropometry over time in two regions–Southern Nations, Nationalities and Peoples Region and Tigray. A pre- and post-intervention adequacy evaluation design was used; repeated cross-sectional surveys of households with children aged 0–23.9 mo (n = 1481 and n = 1494) and with children aged 24–59.9 mo (n = 1481 and n = 1475) were conducted at baseline (2010) and endline (2014), respectively. Differences in outcomes over time were estimated using regression models, accounting for clustering and covariates. Plausibility analyses included tracing recall of key messages and promoted foods and dose-response analyses. We observed improvements in most WHO-recommended IYCF indicators. Early BF initiation and exclusive BF increased by 13.7 and 9.4 percentage points (pp), respectively. Differences for timely introduction of complementary foods, minimum dietary diversity (MDD), minimum meal frequency (MMF), minimum acceptable diet (MAD), and consumption of iron-rich foods were 22.2, 3.3, 26.2, 3.5, and 2.7 pp, respectively. Timely introduction and intake of foods promoted by the interventions improved significantly, but anthropometric outcomes did not. We also observed a dose-response association between health post visits and early initiation of BF (OR: 1.8); higher numbers of home visits by community volunteers and key messages recalled were associated with 1.8–4.4 times greater odds of achieving MDD, MMF, and MAD, and higher numbers of radio spots heard were associated with 3 times greater odds of achieving MDD and MAD. The interventions were associated with plausible improvements in IYCF practices, but large gaps in improving children’s diets in Ethiopia remain, particularly during 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)

Spotlight on infant formula: coordinated global action needed

www.thelancet.com Vol 387 January 30, 2016 413 support as part of national tobacco control programmes, addressing tobacco use by health-care workers and helping them stop, ensuring that tobacco use is recorded in all medical notes, integrating brief advice into existing health-care systems, establishing a text messaging support programme, making aff ordable drugs available, and using the media to promote cessation. Implementation of these core recommendations will save many lives and health-care resources. We believe that the availability of new low-cost interventions and methods to help countries select aff ordable treatments will remove large barriers in development of tobacco dependence treatment. It is time that the FCTC article 14 and its guidelines are taken seriously.

Using behavior change approaches to improve complementary feeding practices

This paper applies an implementation framework, based on a behavior change model, to compare four case studies of complementary feeding programs. It aims to expand our understanding of how to design and implement behavior change interventions aimed at improving complementary feeding practices. Four programs met the selection criteria of scale and documented improvements: Bangladesh, Malawi, Peru, and Zambia. We examined commonalities and differences in the design and implementation of social and behavior change approaches, use of program delivery platforms, challenges encountered, and lessons learned. We conclude that complementary feeding practices, in particular dietary diversity, can be improved rapidly in a variety of settings using available program platforms if interventions focus on specific constraints to food access and use effective strategies to encourage caregivers to prepare and feed appropriate foods. A five-step process is presented that can be applied across a range of complementary feeding programs to strengthen their impacts.

Large-Scale Behavior-Change Initiative for Infant and Young Child Feeding Advanced Language and Motor Development in a Cluster-Randomized Program Evaluation in Bangladesh

BACKGROUND Promoting adequate nutrition through interventions to improve infant and young child feeding (IYCF) has the potential to contribute to child development. OBJECTIVE We examined whether an intensive intervention package that was aimed at improving IYCF at scale through the Alive & Thrive initiative in Bangladesh also advanced language and gross motor development, and whether advancements in language and gross motor development were explained through improved complementary feeding. METHODS A cluster-randomized design compared 2 intervention packages: intensive interpersonal counseling on IYCF, mass media campaign, and community mobilization (intensive) compared with usual nutrition counseling and mass media campaign (nonintensive). Twenty subdistricts were randomly assigned to receive either the intensive or the nonintensive intervention. Household surveys were conducted at baseline (2010) and at endline (2014) in the same communities (n = ∼4000 children aged 0-47.9 mo for each round). Child development was measured by asking mothers if their child had reached each of multiple milestones, with some observed. Linear regression accounting for clustering was used to derive difference-in-differences (DID) impact estimates, and path analysis was used to examine developmental advancement through indicators of improved IYCF and other factors. RESULTS The DID in language development between intensive and nonintensive groups was 1.05 milestones (P = 0.001) among children aged 6-23.9 mo and 0.76 milestones (P = 0.038) among children aged 24-47.9 mo. For gross motor development, the DID was 0.85 milestones (P = 0.035) among children aged 6-23.9 mo. The differences observed corresponded to age- and sex-adjusted effect sizes of 0.35 for language and 0.23 for gross motor development. Developmental advancement at 6-23.9 mo was partially explained through improved minimum dietary diversity and the consumption of iron-rich food. CONCLUSIONS Intensive IYCF intervention differentially advanced language and gross motor development, which was partially explained through improved complementary feeding. Measuring a diverse set of child outcomes, including functional outcomes such as child development, is important when evaluating integrated nutrition programs. This trial was registered at clinicaltrials.gov as NCT01678716.