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Evidence of Effective Approaches to Social and Behavior Change Communication for Preventing and Reducing Stunting and AnemiaFindings from a Systematic Literature Review

August 2014

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ABOUT SPRING The Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) project is a five-year USAID-funded Cooperative Agreement to strengthen global and country efforts to scale up high impact nutrition practices and policies and improve maternal and child nutrition outcomes. SPRING provides state-of-the-art technical support and focuses on the prevention of stunting and maternal and child anemia in the first 1,000 days. The project is managed by JSI Research & Training Institute, Inc., with partners Helen Keller International, The Manoff Group, Save the Children, and the International Food Policy Research Institute.

RECOMMENDED CITATION Lamstein, S., T. Stillman, P. Koniz-Booher, A. Aakesson, B. Collaiezzi, T. Williams, K. Beall, and M. Anson. 2014. Evidence of Effective Approaches to Social and Behavior Change Communication for Preventing and Reducing Stunting and Anemia: Report from a Systematic Literature Review. Arlington, VA: USAID/ Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) Project.

ACKNOWLEDGMENTSThe authors wish to express our profound gratitude to the many individuals who contributed to this review. Anuradha Narayan, Joy Del Rosso and Marcia Griffiths contributed to the development of the protocol, prioritization of practices and categorization of behaviors and approaches. Marcia Griffiths, Michael Manske, and Agnes Guyon provided very thoughtful feedback on earlier drafts of this document. In ad-dition, Vicky Santoso contributed tremendously to the analysis of data extracted; Allison Smith-Estelle expertly edited the entire document cover to cover; Tammy Loverdos provided the beautiful graphic design; and Daniel Cothran shared this on SPRING’s website in a user-friendly interactive format. Thank you all so much!

DISCLAIMERThe contents of this report are the responsibility of the authors, and do not necessarily reflect the views of USAID or the U.S. Government.

SPRING

JSI Research & Training Institute, Inc.1616 Fort Myer Drive16th FloorArlington, VA 22209 USAPhone: 703-528-7474Fax: 703-528-7480Email: [email protected] Internet: www.spring-nutrition.org

Cover photos: left photo, John Nicholson, SPRING; right photos, Peggy Koniz-Booher, SPRING

I EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW

TABLE OF CONTENTS

Table of Contents .....................................................................................................................................................................................I

List of Tables .........................................................................................................................................................................................III

Acronyms .........................................................................................................................................................................................IV

Executive Summary ............................................................................................................................................................................... V

1. INTRODUCTION ..................................................................................................................................................................... 1

A. Background ............................................................................................................................................................................ 1

B. Objectives ............................................................................................................................................................................... 1

2. METHODS .................................................................................................................................................................................. 3

A. Search Procedures ................................................................................................................................................................. 3

B. Organization of Findings .................................................................................................................................................... 4

Priority practices ................................................................................................................................................................... 4

Study design .......................................................................................................................................................................... 5

SBCC approaches ................................................................................................................................................................ 5

Implementation processes .................................................................................................................................................. 5

C. Limitations ............................................................................................................................................................................. 6

D. Works Cited and Literature Reviewed ............................................................................................................................... 7

3. FINDINGS .................................................................................................................................................................................. 8

3.1 PRACTICES DURING PREGNANCY AND LACTATION .......................................................................................... 8

A. Background ........................................................................................................................................................................... 8

B. Search Results ........................................................................................................................................................................ 9

C. Overview of the Evidence, by Practice ............................................................................................................................. 9

Increased energy and protein intake during pregnancy and lactation ......................................................................... 9

Enhanced quality of diet during pregnancy and lactation ........................................................................................... 10

Micronutrientsupplementationorfortification ............................................................................................................ 12

Increased rest and decreased work during pregnancy .................................................................................................. 12

D. Summary of the Evidence ................................................................................................................................................. 12

SBCC approaches utilized ................................................................................................................................................. 12

Implementation processes followed ................................................................................................................................ 14

E. Conclusions ..........................................................................................................................................................................15

F. Works Cited and Literature Reviewed ............................................................................................................................. 20

II EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW

3.2. EVIDENCE OF EFFECTIVE SBCC APPROACHES TO PROMOTE BREASTFEEDING PRACTICES ..... 22

A. Background ..........................................................................................................................................................................22

B. Search Results ......................................................................................................................................................................22

C. Overview of the Evidence, by Practice ........................................................................................................................... 23

Early initiation of breastfeeding ...................................................................................................................................... 23

Exclusive breastfeeding ..................................................................................................................................................... 26

Continued breastfeeding ................................................................................................................................................... 32


SBCC approaches utilized ................................................................................................................................................. 34

Implementation processes followed ................................................................................................................................ 35

E. Conclusions ..........................................................................................................................................................................36

F. Works Cited and Literature Reviewed ............................................................................................................................. 55

3.3. EVIDENCE OF EFFECTIVE SBCC APPROACHES TO IMPROVE COMPLEMENTARY FEEDING PRACTICES ........................................................................................................................................................ 61

A. Background ..........................................................................................................................................................................61

B. Search Results ......................................................................................................................................................................62

C. Overview of the Evidence, by Practice ........................................................................................................................... 63

Timely introduction of appropriate complementary foods ......................................................................................... 63

Dietary diversity .................................................................................................................................................................. 63

Micronutrientsupplementationorfortification ............................................................................................................. 68

Responsive and active feeding........................................................................................................................................... 72

Feeding during and after illness ........................................................................................................................................ 72


E. Conclusions ........................................................................................................................................................................77

F. Works Cited and Literature Reviewed ...........................................................................................................................102

APPENDIX: SBCC LITERATURE REVIEW SEARCHING SETS ......................................................................................106

III EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW

LIST OF TABLES

Table 2.1: High impact nutrition practices reviewed, by intervention area ......................................................................................3

Table 2.2: Number of studies by intervention area and study design ..............................................................................................4

Table 2.3: Categorization of SBCC approaches and activities ...........................................................................................................4

Table 3.1.1: Number of studies reviewed (with number of studies reporting statistically significantresultsinparentheses),byrecommendedpracticeandstudydesign .............................................................................8

Table 3.1.2: Number of studies reviewed (with number of studies reporting statistically significantresultsinparentheses),bySBCCapproachandstudydesign .......................................................................................11

Table 3.1.3: Number of studies reviewed (with number of studies reporting statistically significantresultsinparentheses),bySBCCapproach,practice,andstudydesign ......................................................................13

Table 3.1.4: Studies reporting on maternal dietary practices during pregnancy and lactation ...................................................16

Table 3.2.1: Number of studies reviewed (with number of studies reporting statistically significantresultsinparentheses),byrecommendedpracticeandstudydesign ...........................................................................23



Table 3.2.4: Studies reporting on breastfeeding practices .................................................................................................................39

Table 3.3.1: WHO Guiding Principles for complementary feeding of the breastfed child. .......................................................61

Table 3.3.2: Number of studies reviewed (with number of studies reporting statistically significantresultsinparentheses),byrecommendedpracticeandstudydesign ...........................................................................62

Table 3.3.3: Number of studies reviewed (with number of studies reporting statistically significantresultsinparentheses),bySBCCapproachandstudydesign ......................................................................................73


Table 3.3.5: Studies reporting on complementary feeding practices ..............................................................................................79

IV EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW

ACRONYMS

ANC antenatal care

AOR adjusted odds ratio

BCC behavior change communication

BFH baby-friendly hospital

BFHI Baby-friendly Hospital Initiative

BINP Bangladesh Integrated Nutrition Project

CFG complementary feeding group

CHW Community Health Worker

CI confidenceinterval

DALY disability-adjusted life year

DISH Delivery of Improved Services for Health

EBF exclusive breastfeeding

ENA essential nutrition actions

FeSS iron-fortifiedsoysauce

GMP Growth monitoring and promotion

HKI Helen Keller International

ICFI Infant and Child Feeding Index

IEC Information, Education and Communication

IFA iron-folic acid

IFPRI International Food Policy Research Institute

IG Intervention group

IMCI Integrated Management of Childhood Illness

INE Intensive nutrition education

INE+SF Intensive nutrition education plus supplementary feeding

IPC Interpersonal communication

IYCF infant and young child feeding

IYCN infant and young child nutrition

KAP Knowledge, Attitudes, and Practices

KCAL kilocalories

KJ kilojoule

KSPES Knowledge Sharing Practices with Empowerment Strategies

LAM lactational amenorrhea method

LBW low birthweight

LHW Lay or Lady Health Workers

MAD minimum acceptable diet

MCHIP Maternal and Child Health Integrated Program

MICAH Micronutrient and Health Program

MIYCN maternal, infant, and young child nutrition

NCD noncommunicable disease

NE nutrition education

NEC nutrition, education, and counseling

NGO nongovernmental organization

NLM National Library of Medicine

NRC Nutrition Rehabilitation Center

OR odds ratio

p p-value

PAHO Pan-American Health Organization

PD positive deviance

PROBIT Promotion of Breastfeeding Intervention Trial

RCF&PG Responsive Complementary Feeding and Play Group

RCT randomized controlled trial

RR relative risk

SBCC social and behavior change communication

SC Save the Children

SGA Small for gestational age

SP Sulfadoxine/Pyrimethamine

SPRING Strengthening Partnerships, Results, and Innovations in Nutrition Globally

SUN Scaling Up Nutrition

TIP trials of improved practices

UNICEF United Nations Children’s Fund

USAID United States Agency for International Development

WASH water, sanitation, and hygiene

WHO World Health Organization

WRA women of reproductive age

YYB Ying Yang Bao (a Chinese multiple micronutrientpowder)

ZVITAMBO Zimbabwe Vitamin A for Mother and Babies Trial

V EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW

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EXECUTIVE SUMMARY

Evidence suggests that simply increasing knowledge and awareness of good nutrition practices rarely leads to sus-tained behavior change, nor is sustained change in nutri-tion behavior likely to be achieved through a single activity. Severalspecificbehaviorsorpracticesimpactnutritionalstatusduringthecriticalfirst1,000days(pregnancytoagetwo),whilecomplex,contextualdeterminantsalsoinfluenceindividual decisions to consider, test, adopt and sustain a givenbehaviororpractice.Thefieldof SocialandBe-haviorChangeCommunication(SBCC)isacollectionof approaches and tools informed by behavioral theories and used to design public health interventions.

This review, part of a broader effort by SPRING to sup-port governments and other stakeholders in their delivery of high impact nutrition practices, provides a summary of peer-reviewed evidence regarding the effectiveness of SBCC approaches to increase the uptake of three key nutri-tion behaviors: women’s dietary practices during pregnancy and lactation, breastfeeding practices, and complementary feeding practices. SBCC interventions have been broadly categorized into three areas: interpersonal communication; use of media; and community/social mobilization. This reviewalsoidentifiesgapsintheevidenceandrecommen-dations for further areas of study.

Thisreviewincludesatotalof91studiesidentifiedusingthe Ovid MEDLINE database. Recognizing the potential valueofabroadarrayofstudydesigns,resultsfromfivestudytypesareincluded:reviews(includingmeta-analysis),randomized controlled trials, longitudinal studies, repeated cross-sectional studies, and cross-sectional studies. Ex-cluded studies include those with data from high income countries, those published prior to 2000, those written in a language other than English, and those that focused ex-clusivelyonrefinementofaresearchmethodology.Otherexclusions are noted in the text.

Findings related to women’s dietary practices during pregnancy and lactation

Undernutrition during pregnancy and lactation is a critical determinant of maternal, neonatal, and child health out-comes. Improving dietary adequacy during pregnancy and

lactation is important to help women accommodate their nutritional requirements as well as their children’s require-ments during intrauterine development and while breast-feeding(Haileslassie,etal.,2013).

The body of literature on the effectiveness of SBCC to improve women’s dietary practices during pregnancy and lactation is still small (only 15 peer-reviewed studies met theinclusioncriteria),butindicatesthatSBCCapproachescan and do succeed in improving uptake of the behaviors promoted. The greatest gap in the literature was in evidence of effectiveness of SBCC in improving rest and work-load during pregnancy. Given the importance of women’s dietary practices during pregnancy and lactation, the dearth of evidence is notable.

Findings related to breastfeeding practices

Breastfeeding is widely recognized as one of the most cost-effective investments to improve child survival (UNICEF, 2013),aswellascognitiveandmotordevelopmentandaca-demicperformance(Hortaetal,2013).Breastfeedingalsoimpartscriticalbenefitstothewoman,includingnaturalpostnatal infertility. Despite the promise of optimal breast-feeding practices, rates for WHO recommended breastfeed-ingpracticesremainlow(UNICEF,2013).

The body of literature on the effectiveness of SBCC ap-proaches in improving breastfeeding practices is strong and broad(62peer-reviewedstudiesmettheinclusioncriteria)and supports the claim that SBCC approaches can and do succeed in improving uptake of the behaviors promoted.

Evidence from several studies strongly suggests that increasing the number of contacts increases the positive effect of SBCC on breastfeeding practices. Greater con-sistency in how breastfeeding practices are measured – the definitionsof indicatorsandthemethodsof datacollec-tion – exists for breastfeeding practices when compared to women’s dietary practices and complementary feeding practices, but even with globally-recognized indicators and measurement guidance, considerable variation remains.

Findings related to complementary feeding practices

Timely appropriate complementary feeding are critical to a child’s growth and development and could avert millions of

VI EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW

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disability-adjusted life years, but global coverage of optimal complementary feeding practices remains low.

The evidence of the effect of SBCC on complementary feeding practices is quite broad (30 studies met the inclu-sioncriteria)andclearlyindicatesthatSBCCinterventionscan improve a wide range of complementary feeding practices. However, measures of optimal complementary feeding are so varied that it is particularly challenging to draw conclusions regarding the effectiveness of particular SBCC approaches.

Common findings

The SBCC approach most used, and the only one used without other communication interventions, was inter-personal communication. While media and community/social mobilization were used, they were always used with at least one other communication approach.

Studies included in this review employed a wide range of implementation strategies with variations in the interactions or combinations with other interventions, target groups, content, messages, scale and coverage, length and intensity, as well as context. Very little has been done to compare the effect of differences in the delivery science, particularly when implemented at scale.

The majority of the studies were implemented on a small scale, typically with fewer than 500 people per group.

Additionally, there was considerable variation in how wom-en’s dietary practices and complementary feeding practices weredefinedandmeasured.

Conclusions

Evidence suggests that using multiple SBCC approaches and channels to change behaviors is more effective than using one, that targeting multiple contacts has a greater effect than targeting only the woman herself, and that more visits or contacts results in greater change. However, such comparisons are not well-tested in the literature. Very few

comparisons have been made between the effect of timing of communications and what little has been done presents contradictory evidence. Unfortunately, it can be challenging to conduct such studies that compare differences in deliv-ery and/or disaggregate single approaches within a multi-approach intervention. SBCC practitioners and researchers must assess whether that line of research is useful.

Differences in local context (including social norms, cul-ture,andenvironmentalfactors)aswellasdifferencesintheimplementation and scale of implementation also affect the success of interventions. This underscores the importance of proper context assessments, formative research and/or ethnographic study prior to SBCC implementation.

Finally, if practices and indicators are not standardized, a projectmayimprovebehaviorsbutitwillbedifficulttoattribute changes in outcomes. This underscores the impor-tance of developing practices and indicators that are globally recognized, accepted, and used by the research and program communities. At the same time, many nutrition interven-tions are suited to iterative programming for incremental change toward the optimal, evidence-based behaviors. This means that more easily achieved indicators (components of standardizedindicatorsorshortertimeperiods)mayalsobe needed to measure progress toward the ultimate goal of changes in the standardized indicators of behaviors.

Other areas particularly important for future evaluations and operations research include:n the effect of targeting multiple audiences

orinfluencersof thebehaviorsbeing promoted, rather than focusing on one target population;

n the effect of the same SBCC intervention implemented in different contexts (social and environmental);

n the effectiveness of different approaches (including intensityandtargeting)fordifferentbehaviors;

n the cost and cost effectiveness of various SBCC approaches(particularlyasitrelatestoscalability);and

n the effectiveness and sustainability of these approaches when implemented at scale.

1 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW

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1. INTRODUCTION

A. Background

Evidence suggests that simply increasing knowledge and awareness of good nutrition practices rarely leads to sus-tained behavior change, nor is sustained change in nutri-tion behavior likely to be achieved through a single activity targetingasinglesubsetof thepopulation.Severalspecificbehaviors or practices greatly impact nutritional status duringthecriticalfirst1,000days(pregnancytoagetwo),andmanycomplex,contextualdeterminantsalsoinfluenceindividual decisions to actually consider, test, adopt and sustain a given behavior or practice.

Realizing this, public health practitioners for decades have applied theories from social psychology and marketing about behavior change to improve the potential of inter-ventions to change key practices. These theories address how and why people practice certain behaviors, why they makeandsustainchangesintheirbehaviors(ordon’t),and the way that social and environmental structures af-fect both their current practices and the likelihood they willchangepracticesandsustainthosechanges.Thefieldof SocialandBehaviorChangeCommunication(SBCC)isa collection of approaches and tools informed by behav-ioral theories and used to design public health and nutri-tion interventions.

SBCC theories, approaches, and tools have been widely ac-cepted and integrated into public health, water, sanitation, andhygiene(WASH),disasterpreventionandresponse,as well as maternal, infant, and young child nutrition (MIYCN).Sectorssuchasagricultureandeducationhavealso increased the impact of their interventions by utiliz-ing SBCC, while the private sector, where much of SBCC theory and practice originated, continues to use SBCC to sell existing products and services and develop new ones, andremainsakeyplayerintheevolutionof thefield.

SBCC is at an interesting crossroads. Technology is rapidly increasing access to information, even among remote populations, and the types of, and channels for, commu-nication are ever expanding. New technologies have the potential to democratize SBCC, giving those most affected by health and nutrition problems a greater voice in address-

ing them, and creating a platform for mutual accountability among social actors. While many programs and projects have impacted health and nutrition outcomes using SBCC, including campaigns to reduce tobacco use or increase use of seatbelts or re-usable shopping bags, there is a sense that SBCCmaynotbefulfillingitsfullpotentialtobringaboutsocial and individual changes for improved health and nutrition outcomes.

Under and over-nutrition, cancer and other NCDs, pre-ventable childhood diseases, and maternal and infant/young child mortality remain key global health issues. Some of theseissues,likechronicmalnutrition(stunting)amongchildren, have been surprisingly resistant to improvement, highlighting the need for more evidence about the potential of SBCC.Specificareasof focusincludehowsingleorcombined SBCC interventions change certain types of be-haviorsamongcertaingroupsinspecificcontexts,howtheycan be designed and implemented to ensure cost-effective-ness, scalability and sustainability, and how investments in SBCC can be targeted to take proven interventions to scale and to foster continual innovation.

SPRING seeks to strengthen the SBCC evidence base for stunting and anemia globally. SPRING conducted a system-atic literature review to assess the state of SBCC evidence related to three key areas of nutrition behavior: maternal diet during pregnancy and lactation; breastfeeding; and comple-mentary feeding. The review focused on communication interventions, categorized into three broad areas: interper-sonalcommunication(IPC);useof media;andcommunity/social mobilization. This report summarizes the evidence for the different SBCC approaches related to these three key behavioralorinterventionareas,andfindingsarepresentedfirstbyinterventionarea,thenbySBCCapproach,thenbytype of evidence.

WehopethatSBCCpractitionersandresearcherswillfindthis report a valuable reference tool, and a place from which to start when looking for current evidence regard-ingspecificSBCCapproachesand/orkeyinterventionareas within MIYCN.

B. Objectives

To be effective, SBCC approaches should be grounded in behavioral and social science theories, a deep understand-


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ing of the local context, as well as evidence. This literature review is part of a broader effort by SPRING to docu-ment and disseminate evidence related to effective SBCC approaches, and to develop program guidance to support governments and other stakeholders in the delivery of high impact nutrition practices at the facility, community, and household levels.

This review provides a comprehensive summary of peer-reviewed evidence regarding the effectiveness of SBCC

approaches in increasing the uptake of high impact MIYCN practices, seeking to answer the following questions:

1. What is the state of peer-reviewed evidence regarding the application of SBCC approaches to increase the uptake of high impact nutrition practices?

2. Where are the gaps in the evidence? What SBCC ap-proaches or activities lack evidence of effectiveness in improving nutrition-related practices?


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2. METHODS

A. Search Procedures

The authors searched the United States National Library of Medicine biomedical database (NLM®)OvidMEDLINEbetween May-December 2012. The Ovid MEDLINE da-tabase contains bibliographic citations and author abstracts from more than 4,600 biomedical journals published in the United States and 70 other countries. The database con-tains over 13 million citations dating back to 1950, includ-ing more than 130,000 population-related journal citations (unique to the former POPLINE®database)thatwereadded to MEDLINE in 2002.

The following primary search parameters were used: the practices or behaviors promoted, the SBCC approach uti-lized, and the study design. A complete list of search terms is included as Appendix A.

Excluded from this review are studies with data from high income countries,1 those published prior to 2000, and those

1 The authors used the World Bank’s categorization and list of high income countries. See: http://data.worldbank.org/about/country-classifications/country-and-lending-groups#High_income.

written in a language other than English. Furthermore, articlesfocusedexclusivelyontherefinementof aresearchmethodology, those without a clear description of the prac-tices promoted or the SBCC approach utilized, and those thatdidnotspecificallyquantifyordisaggregatetheeffectof SBCC on behavioral outcomes, were also excluded. Out of 15,847 hits, 91 studies were extracted for detailed review.

Using a standardized procedure, researchers conducted an in-depth review of each of the selected studies and extract-ed the following information:

n location

n objective

n practice(s)promoted

n SBCCapproach(es)utilized

n interventiondesignprocess(e.g.formativere search)

n scale of implementation

n durationof theintervention(whereavailable)

n frequency of contact or of potential exposure (where available)

n population targeted

n study design

n study results and p-values

Table 2.1: High impact nutrition practices reviewed, by intervention area Intervention area Specific practicesWomen’s dietary practices during pregnancy and lactation

n Increased energy and protein intake during pregnancy and lactationn Enhanced quality of diet during pregnancy and lactationn Micronutrient supplementation or fortificationn Increased rest and decreased work during pregnancy

Breastfeeding practices n Early initiation of breastfeeding n Exclusive breastfeedingn Continued breastfeeding

Complementary feeding practices

n Timely introduction of complementary foodsn Dietary diversity

- Feeding children animal source foods- Feeding children fruits and vegetables- Feeding children a minimum number of food groups (dietary diversity)

n Micronutrient supplementation or fortificationn Increased meal frequency and/or density

- Increasing frequency of feeding children- Adding fats or oils to children’s foods- Enhancing the consistency of children’s foods- Increasing the quantity fed to children at each meal

n Responsive/active feedingn Feeding during and after illness


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B. Organization of Findings

The literature review focuses on evidence of effectiveness around three primary intervention areas: women’s dietary practices during pregnancy and lactation, breastfeeding practices, and complementary feeding practices. These intervention areas focus on actions by mothers or other caretakersduringthe“first1000days”–theperiodbetweenconception and a child’s second birthday. The vast majority of stunting occurs during this period, and there is generally little potential for recovery thereafter.

This review is divided into three chapters corresponding to each of these three intervention areas. The chapters can be read together as one document, or read separately as independent documents. With each of these chapters, thefindingsareorganizedbyprioritypractices,SBCCapproach(es)utilized,andstudydesign.Thisorganizationenables the reader to derive an independent judgment re-

gardingfindingsfromdifferentstudydesigns.Inaddition,implementation processes followed are also discussed.

Priority practices

Within each chapter, we identify high impact nutrition practiceswithprovenefficacywithrespecttochildnutri-tion outcomes. This list of practices is consistent with those prioritized in The Lancet’s Maternal and Child Nutri-tionSeries(Bhuttaetal.,2008a;Bhuttaetal.,2013),theWorld Health Organization’s “Essential Nutrition Actions: Improving Maternal, Newborn, Infant and Young Child HealthandNutrition”(WHO,2013),theWHOe-Libraryof Evidence for Nutrition Actions, and the United Nations Children’sFund’s(UNICEF)“ImprovingChildNutrition:TheAchievableImperativeforGlobalProgress”(UNICEF,2013).Wherenormativerecommendationsexist,thechap-ter is organized accordingly. Where such recommendations

Table 2.2: Number of studies by intervention area and study design

Intervention areaReviews

with meta-analysis

RCTLongitudinal

studies

Repeated cross-

sectional studies

Cross-sectional studies

Total

Women’s dietary practices during pregnancy and lactation

1 4 2 8 0 15

Breastfeeding practices 6 27 14 13 2 62

Complementary feeding practices 0 11 9 10 0 30

Table 2.3: Categorization of SBCC approaches and activities

SBCC approaches Specific activities*Interpersonal Communication The following activities can be conducted in facilities, communities, or homes and by health care

providers, lay health workers, or peers:n One-on-one counseling n Group education n Support groups

Media n Mass median Mid-sized media (community radio / video, local billboards)n Small media (posters, flyers, calendars, reminder stickers)n Traditional media (songs, drama)n Social media (Twitter, Facebook, etc.)

Community/Social Mobilization n Campaigns, events, special “days”, ralliesn Issue groups


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do not exist, we review practices with widely acknowledged potential for impact. See Table 1.1.

There was considerable variation in indicators used to measure these practices. This is partly due to the wide range of practices included within each intervention area, but is also because not all studies reviewed used standardized or recommended indicators to measure behavioral outcomes. Any difference in indicators is clearly indicated in the sum-maries associated with each practice.

Finally, because the review is organized around the effec-tivenessof SBCCactivitiesonspecificpractices,studieslooking at the effectiveness of SBCC on more than one of the prioritized practice are cited and discussed multi-ple times. Where this occurs, we have provided a detailed descriptionof thestudyinthefirstreference,andonlydiscuss results in subsequent references.

Study design

Studydesigninfluencesthevalidityandcomparabilityof outcomes. The Grades of Recommendation, Assess-ment,Development,andEvaluation(GRADE)WorkingGroup2 focuses on four key elements to assess the validity of studyfindings:studydesign,studyquality,consistency,anddirectness(GRADEWorkingGroup,2004).Habichtetal.(1999)alsoprovideguidanceonevaluationdesignfor public health program performance based on “type of inference to be made, whether this is a statement of adequacy,plausibility,orprobability”regardingattributionof change to an intervention.

Recognizing the value of a broad array of study designs, resultsfromfiveprimarystudydesignsareincluded:reviews(includingmeta-analysis),randomizedcontrolledtrials(RCT),longitudinal studies, repeated cross-sectional studies, and cross-sectional studies. Additional aspects of study design are noted within each chapter. Table 1.2 summarizes the number of studies reviewed, by intervention area and study design.

We included detailed information and analysis of all studies reportingstatisticallysignificantfindingsrelatedtoprior-ity practices. All studies are included in the summary tables at the back of each chapter. Seventy-four of the studies (includingthesevenliteraturereviewswithmeta-analyses)

2 See: http://www.gradeworkinggroup.org/intro.htm.

reviewedreportedstatisticallysignificantresultsrelevanttothis literature review. Readers may wish to use caution in interpretingstatisticallysignificantfindingsasthequalityand design of studies differ considerably.

SBCC approaches

While the importance of structural, environmental, and systems-related interventions in achieving sustainable social andbehaviorchange(SBC)shouldnotbeunderestimated,thisreviewwasconfinedtotheeffectivenessof communi-cation-related interventions in affecting behavior change. We focused on evidence around three broad SBCC ap-proaches: interpersonal communication, the use of media, and community/social mobilization. Within each approach, furtheridentifiedsub-approachesoractivitieswereidenti-fied.SeeTable1.3.

The SBCC approaches and activities outlined are con-sistent with those referenced in the C-Change/FHI360 Learning Package for Social and Behavior Change Com-munication(2010),theBillandMelindaGatesFoundation“Social & Behavior Change Interventions Landscaping Study:AGlobalReview”(Storeyetal.,2011),theUSAIDInfantandYoungChildNutrition(IYCN)Project“IYCNSocialandBehaviorChangeCommunicationApproach”(2011),theUSAID“CommunityInterventionstoPromoteOptimal Breastfeeding: Evidence on Early Initiation, Any Breastfeeding, Exclusive Breastfeeding, and Continued Breastfeeding”(2012),theUSAID“BehaviorChangeInterventions and Child Nutritional Status: Evidence from the Promotion of Improved Complementary Feeding Prac-tices”(2011)andtheUSAIDMaternalandChildHealthIntegratedProgram(MCHIP)publication“TechnicalRefer-enceMaterials:BehaviorChangeInterventions”(2010).

Most studies used more than one SBCC activity and many used more than one approach.

Implementation processes

There is consensus that delivery systems for nutrition inter-ventions are currently suboptimal (Black et al., 2008; Chopra etal.,2012;LeroyandMenon,2008;Menonetal.,2014).The World Bank’s report on how to improve health service delivery in developing countries reviewed the evidence and concluded that “the evidence base is weak for claiming suc-


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cess of any particular health services strengthening strategy across LMICs3,”notingthat“howastrategyisimplementedisasimportantasthetypeof strategyimplemented”(Ovret-veitetal.,2009).Implementationprocessesinclude,butarenot limited to, the overall program design, intensity and tim-ingof contacts;typeandtrainingof person(s)communicat-ingmessages,supervisionof fieldworkers,andaudience(s)targeted. Acknowledging the importance of how services are delivered, information on targeted audiences, the scale, as well as the timing and intensity of interventions is provided whenever possible in the chapters that follow.

A particularly important aspect of the delivery of SBCC interventions is the target audience. Many people can influencewhetheranindividualadoptsorfailstoadoptapromoted behavior. Successful SBCC strategies target vari-ous audiences and often more than one audience or sphere of influence,including:4

n self/caregivers, such as pregnant and lactating women, as well as other immediate caregivers of children under two;

n directinfluencers,includingpartners/fathers,mothers-in-law, siblings, other family members, and peers;

n actors within the local community, including community members, leaders, social groups, and providers; and

n actors within the enabling environment, including the government (national, sub-regional, district and/or municipal),business,faithandmovementleaders.

3 LMIC stands for Low and Middle Income Countries 4 See the C-Change Social Ecological Model for Change.

C. Limitations

The authors limited this literature review to peer-reviewed studiesandthoseidentifiedintheOvidMEDLINE® database. While use of a second peer-reviewed journal database, Web of Science®, was considered, the high degree of overlap between the two databases made this unnecessary. Since not all projects, programs and national strategies publish in peer-reviewed journals, some relevant SBCC information, experiences, and evidence may have been omitted.

We limited the review to studies published on or after Janu-ary 1, 2000. Studies published prior to 2000 may also in-cludevaluablefindingsthatarenotcapturedinthisreview.

The review excluded research conducted in high income countries. We acknowledge that experience from other coun-try contexts, including the United States, may be valuable to assess the relative success of different SBCC approaches.

Despite comprehensive search terms that included the full rangeof activitiesincludedinthetermSBCC,reviewfind-ings are limited to communication-based approaches. This is consistent with the types of SBCC delivery strategies and in-terventions currently being utilized by the SBCC community.

Differences in local context (including social norms, cul-ture,andenvironmentalfactors)aswellasdifferencesintheimplementation and scale of implementation can impact the success of interventions and may affect generalizability of findingsincludedinthisreview.


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ACC/SCN.2001.WhatWorks?AReviewof theEfficacyandEffectivenessof NutritionInterventions,AllenLHandGillespieSR. ACC/SCN: Geneva in collaboration with the Asian Development Bank, Manila.

Bhutta,ZulfiqarA,JaiKDas,ArjumandRizvi,MichelleFGaffey,Neff Walker,SusanHorton,PatrickWebb,AnnaLartey,andRobert E Black. 2013. “Evidence-based Interventions for Improvement of Maternal and Child Nutrition: What Can Be DoneandatWhatCost?”TheLancet382(9890)(August):452–477.

Bhutta,ZulfiqarA,TahmeedAhmed,RobertEBlack,SimonCousens,KathrynDewey,ElsaGiugliani,BatoolAHaider,BettyKirkwood, Saul S Morris, H P S Sachdev, Meera Shekar, for the Maternal and Child Undernutrition Study Group. 2008a. “WhatWorks?InterventionsforMaternalandChildUndernutritionandSurvival.”TheLancet371(9610)(February):417–440.

Black,RobertE,LindsayHAllen,ZulfiqarABhutta,LauraECaulfield,MercedesdeOnis,MajidEzzati,ColinMathers,andJuanRivera.2008.“MaternalandChildUndernutrition:GlobalandRegionalExposuresandHealthConsequences.”TheLancet371(9608)(January):243–260.

C-Change.CModules:ALearningPackageforSocialandBehaviorChangeCommunication(SBCC).Washington,DC:C-Change/FHI 360.

GRADEWorkingGroup.“GradingQualityof EvidenceandStrengthof Recommendations.”2004.BMJ328(7454):1490–0.Habicht, J P, C G Victora, and J P Vaughan. 1999. “Evaluation Designs for Adequacy, Plausibility and Probability of Public

HealthProgrammePerformanceandImpact.”InternationalJournalof Epidemiology28(1):10–18.LeroyJ.andPurnimaMenon.2008.“FromEfficacytoPublicHealthImpact:ACallforResearchonProgramDeliveryand

UtilizationinNutrition.”TheJournal of Nutrition.138(3):628-629.MaternalandChildHealthIntegratedProgram(MCHIP).2010.TechnicalReferenceMaterials:BehaviorChangeInterventions.

Washington, DC: USAID. Menon, Purnima, NM Covic, PB. Harrigan, SE Horton, NM Kazi, S Lamstein, L Neufeld, E Oakley, and D Pelletier. 2014.

“Strengthening Implementation and Utilization of Nutrition Interventions through Research: A Framework and Research Agenda:NutritionImplementationFrameworkandResearchAgenda.”Annalsof theNewYorkAcademyof Sciencesdoi:10.1111/nyas.12447.

Chopra M, A Sharkey, N Dalmiya , D Anthony , N Binkin, on behalf of the UNICEF Equity in Child Survival, Health and Nu-trition Analysis Team. 2012. “Strategies to improve health coverage and narrow the equity gap in child survival, health, andnutrition.”TheLancet380(9850):1331–1340.

Ota, Erika, R Tobe-Gai, R Mori, and D Farrar. Antenatal Dietary Advice and Supplementation to Increase Energy and Protein Intake. In Cochrane Database of Systematic Reviews 2012, edited by The Cochrane Collaboration and Erika Ota. Chich-ester, United Kingdom: John Wiley & Sons, Ltd.

Ovretveit J, B Siadat, DH Peters, A Thota, and S El-Saharty. 2009. “Chapter 1: Review of Strategies to Strengthen Health Ser-vices.”InImprovingHealthServiceDeliveryinDevelopingCountries:FromEvidencetoAction,editedbyD.H.Peters,Sameh El-Saharty, Bafsheh Siadat, Katja Janovsky and Marko Vujicic, Washington DC: World Bank, 2009.

Storey D, K Lee, C Blake, P Lee, YL Lee, and N Depasquale. “Social & Behavior Change Interventions Landscaping Study: A GlobalReview”Seattle:TheBillandMelindaGatesFoundation,2011.

UNICEF. Improving Child Nutrition: The achievable imperative for global progress. New York: UNICEF, 2013. USAIDInfantandYoungChildNutrition(IYCN)Project.BehaviorChangeInterventionsandChildNutritionalStatus:Evi-

dence from the Promotion of Improved Complementary Feeding Practices. Washington, DC: UNICEF, 2011a.USAIDInfantandYoungChildNutrition(IYCN)Project.IYCNSocialandBehaviorChangeCommunicationApproach.

Washington, DC: USAID, 2011. USAIDInfantandYoungChildNutrition(IYCN)Project.CommunityInterventionstoPromoteOptimalBreastfeeding:

Evidence on Early Initiation, Any Breastfeeding, Exclusive Breastfeeding, and Continued Breastfeeding. Washington, DC: USAID, 2012.

World Health Organization. Essential Nutrition Actions: Improving maternal, newborn, infant, and young child health and nutrition. Geneva: World Health Organization, 2013.

WHO. E-Library of Evidence for Nutrition Actions. Geneva: World Health Organization.

D. Works Cited and Literature Reviewed


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3. FINDINGS

3.1. Evidence of Effective SBCC Approaches to Improve Women’s Dietary Practices during Pregnancy and Lactation

A. Background

Undernutrition during pregnancy and lactation is a criti-cal determinant of maternal, neonatal, and child health outcomes. Maternal undernutrition is associated with an increasedriskof maternalmortality(Christianetal.,2008),and both maternal stunting and wasting are associated with term and preterm births of children small for gestational age (SGA)(Blacketal.,2013)andlowbirthweight(ACC/SCN,2001,amongothers).ChildrenbornSGAaremorelikelyto become stunted children and adults, which, for women, can place them at increased risk for delivery complications, morbidity, and mortality over time (Bhutta, 2013; Mason et al.,2012).Lowbirthweighthasbeenshowntocostsocietyinincreasedinfantmortality(Katzetal2013),lostwagesand productivity in adulthood, increased stunting and related illness, and increased rates of noncommunicable disease (NCDs)inadulthood(AldermanandBehrman,2006).

Maternal anemia is associated with an increased risk of maternal death, and there is a strong causal link between irondeficiencyanemiaandbothlowbirthweight(LBW)andperinatalmortality(RasmussanandStolzfus,2003).MaternalvitaminAdeficiencyisassociatedwithvisual

impairmentamongwomen(Blacketal.,2013)aswellasincreasedriskof infantsbeingLBW(Tielshetal.,2008)andinfantmortality(Christianetal.,2001).Deficienciesof zinc, iodine, folate, and calcium are also implicated in adverse maternal and child health outcomes.

Improving dietary adequacy during pregnancy and lactation is critical to helping women accommodate their nutritional requirements as well as their children’s requirements during intrauterine development and while breastfeeding (Haile-slassie,etal.,2013).

There is limited evidence regarding the effectiveness of protein and energy-related interventions to address mater-nal wasting and SGA. The strongest evidence comes from a Cochrane Review which concluded that balanced energy protein supplementation reduced the incidence of SGA by 32%. A subsequent meta-analysis found that balanced en-ergy protein supplementation increased birth weight by 73g andreducedtheriskof SGAby34%(Bhuttaetal.,2013).

Evidencesupportingthebenefitsof maternalmicronutri-entsupplementationandfortificationismorerobust.Ironfolic acid supplementation during pregnancy is associated with improved mean birth weight and a 79% reduction in megaloblasticanemia(Lassietal.,2013).Multiplemicro-nutrient supplementation in pregnant women is associated with a 10% reduction in SGA and 11% reduction in LBW babies(HaiderandBhutta,2012).Theconsumptionof micronutrient and iron-rich foods can also contribute to improved maternal nutritional status. Increasing the con-

Table 3.1.1: Number of studies reviewed (with number of studies reporting statistically significant results in parentheses), by recommended practice and study design

Reviews with meta-

analysisRCT

Longitudinal studies

Repeated cross-

sectional studies


Total

Increased energy and protein intake during pregnancy and lactation

1 (1) 0 1 (0) 3 (2) 0 5 (3)

Enhanced quality of diet during pregnancy and lactation 1 (0) 1 (1) 0 4 (3) 0 6 (4)

Micronutrient supplementation or fortification 0 3 (2) 0 3 (1) 0 6 (3)

Increased rest and decreased work during pregnancy 0 0 0 1 (0) 1 (1) 2 (1)

*Notethatcolumnsdonotsumtothe“total”sincesomearticlesreportedonmultiplepractices.


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sumption of certain plant-based foods (such as green leafy vegetables)ormeatandfishcanhaveaconsiderableimpactonanindividual’sironstatus(Allenetal.,2001).

This chapter focuses on the effectiveness of Social and BehaviorChangeCommunication(SBCC)approachestoincrease the quantity and quality of women’s dietary intake during pregnancy and lactation.

B. Search Results

Fifteen peer-reviewed studies on women’s dietary prac-tices met the review’s inclusion criteria.5 A complete list of the studies reviewed, including a summary of the SBCC approach(es)utilized,thestudydesign,practicesmeasured,andlevelsof significanceispresentedinTable3.1.4attheend of this chapter.

Tenstudiesreportedastatisticallysignificantchangeinatleast one of the priority practices. Each of those articles is described in greater detail below. Studies reporting a statisti-callysignificantchangeinmorethanoneof theprioritizedpractices and/or utilizing more than one SBCC approach are cited and discussed multiple times. Where this occurs, we haveprovidedadetaileddescriptionof thestudyinthefirstreference, and only discuss results in subsequent references.

Thefindingsareorganizedbypracticestargeted,SBCCapproach(es)utilized,andstudydesign.Thisorganizationenables the reader to derive an independent judgment re-gardingfindingsfromeachstudy.Inaddition,implementa-tion processes followed are also discussed.

Of the 15 studies reviewed for this chapter, one was a literature review including a meta-analysis, four were rand-omizedcontrolledtrials(RCT),onewasalongitudinalstudy(includingacontrolgroup),eightwererepeatedcross-sectionalstudies(fiveof whichincludedcontrolgroupsandthreethatdidnot)andwasacross-sectionalstudyimple-mented only at one point in time. See Table 3.1.1.

C. Overview of the Evidence, by Practice

The evidence focuses on four key maternal nutrition prac-tices: increased energy and protein intake during pregnancy, enhanced quality of diet during pregnancy and lactation,

5 See the introductory chapter of this literature review for a full description of search procedures and inclusion/ exclusion criteria.

consumption of micronutrient supplements, and reduced work during pregnancy and lactation. While health status is also an important determinant of women’s nutritional sta-tus, practices associated with improved health status were not explored in this review.

Of thestudiesreviewed,fiveexploredenergyandproteinintake among pregnant and lactating women, six assessed enhanced quality of diet among pregnant and lactating women, six reported on the intake of micronutrient supple-ments, and two looked at increased rest and reduced work during pregnancy. See Table 3.1.1.

Increased energy and protein intake during pregnancy and lactation

Of thefivestudiesthatdiscussedincreasedenergyandprotein intake, two measured the proportion of women consuming more food during pregnancy, one measured the proportion of women consuming more food during lacta-tion, two measured caloric intake and two measured protein intake.Threeof thefivestudiesreportedstatisticallysignifi-cant results.

Literature Reviews with meta-analysis

Otaetal.(2012)conductedameta-analysisof fourRCTslooking at energy and protein intake among pregnant women. The authors included three studies in each of the analyses comparing intake among women who received nutritional advice during pregnancy and those who did not. Following a pooled analysis, the authors concluded that “advice to increase protein intake seems to be successful in achieving its goal [mean difference of +6.99 g/day], but therewasnosignificantincreaseinenergyintake.”


GargandKashyap(2006)conductedarepeatedcross-sectional study looking at mean daily energy and protein intake among pregnant women in one village in India. The nutrition education intervention included facility-based counseling, weekly home visits to pregnant women, and six group meetings for pregnant women over a period of two to four months. Following baseline data collection, the intervention was delivered to 50 pregnant women having completed 5-7 months of gestation. Another 50 women in month 8-9 of pregnancy were considered to be the control


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group. By the time women in the intervention group had reached 8-9 months of gestation they consumed 686 kcal more per day than those in the control group.

Guyonetal.(2009)lookedatdietaryintakeduringlacta-tion in two highland provinces in Madagascar. The inter-vention included training of health workers, interpersonal communication including small and large group activities, one-to-one counseling in homes and at local health facili-ties, community/social mobilization events such as festivals celebrating breastfeeding and child health days, and the use of mass media to air breastfeeding promotion songs. The authors found that women in intervention communities were 12% more likely to report increased food intake dur-ing lactation than women in control communities.

Enhanced quality of diet during pregnancy and lactation

Of the six studies explored the effectiveness of SBCC interventionsontheconsumptionof specificnutrient-richfoods,includingfortifiedfoods,duringpregnancy,fourreportedstatisticallysignificantresults.

Randomized controlled trials

Sunetal.(2007)conductedanRCTexploringthe“effec-tivenessof socialmarketing(SM)ontheimprovementof women’sknowledge,attitudes,andbehaviors”regardingconsumptionof ironfortifiedsoysauce(FeSS)inGuidzhouProvince, China. The intervention included the use of mass media and “social marketing strategies using an integrated 6 Ps approach (product, price, place, promotion, policy, and partnership).”TheSMstrategyincludedphysician-ledcoun-selingof patientsonthebenefitsof consumingFeSS,aswellas the distribution of FeSS samples and calendars with FeSS information at the community level. The authors reported an increase in eating and purchasing behaviors in rural and urban interven-tion site as well as in control sites. In rural sites there was a net increase in FeSS purchase in intervention sites of 35 percentage points compared with rural control sites. Likewise, the net increase in was 29.5 percent-age points in urban intervention sites compared with urban control sites. With regard to the consumption of FeSS, the authors reported a net increase of 21.1 percentage points in rural intervention sites compared with rural control sites and a net increase of 25.6 percentage points in the proportion of urban women consuming FeSS.

Repeated cross-sectional studies

GargandKashyap(2006)conductedarepeatedcross-sectional study looking at mean daily intake of green leafy vegetables. By the time women in the intervention group had reached 8-9 months of gestation they consumed 49.3g of green leafy vegetables daily compared with only 12.9g among women in the control group.

Ndiayeetal.(2009)lookedattheintakeof animalprod-ucts among pregnant women in rural Senegal. The study compared two intervention packages within the Micronutri-entandHealthProgram(MICAH).Controlcommunitiesreceived the standard MICAH intervention package which included basic nutrition education and a supply of iron sup-plements and other products through health centers. Inter-vention communities received the standard MICAH package alongwithapositivedeviance(PD)/Hearth6 intervention, exposure to mid-sized media (such as community radio/video,localbillboards),homecounselingbypeers,andgroupeducation. After eight months, the percent of pregnant womenconsumingmeatorfishincreasedfrom49.4%to70.7% in PD/Hearth intervention communities while it had declined from 41.5% to 32.0% in control communities.

Finally,Wangetal.(2009)conductedastudytolookat“theeffectiveness of social mobilization and social marketing in improvingknowledge,attitudesandpractices(KAP)andFestatusinanFe-deficientpopulation.”Theinterventionincluded a kick-off meeting with key stakeholders as well as the training of community health workers, community heads and store owners/market managers. In addition, “schoolchildren were mobilized to distribute information, educationandcommunication(IEC)materialstothewholefamily after they learned the relevant knowledge through speciallydesignedclasses”and“trainedvolunteerswererecruited to disseminate IEC materials in public areas like hospitals,cultureandsportscentres.”Afteroneyear,thepercentage of women in the intervention area who had ever purchased FeSS increased from 8.9% to 36.6%.

6 According to the CORE Group’s Resource Guide for Sustainably Rehabili-tating Malnourished Children, “a Positive Deviance/Hearth Nutrition Pro-gram is a home- and neighborhood-based nutrition program for children who are at risk for protein-energy malnutrition in developing countries. The programusesthe“positivedeviance”approachtoidentifythosebehaviorspracticed by the mothers or caretakers of well-nourished children from poor families and to transfer such positive practices to others in the com-munitywithmalnourishedchildren.The“Hearth”orhomeisthelocationforthenutritioneducationandrehabilitationsessions.”(McNulty,2005).


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Table 3.1.2: Number of studies reviewed (with number of studies reporting statistically significant results in parentheses), by SBCC approach and study design

SBCC approachReviews

with meta-analysis

RCTsLongitudinal

studies

Repeated cross-

sectional studies


TOTAL

Interpersonal Communication 1 (1) 4 (3) 1 (0) 8 (5) 1 (1) 15 (10)

One-on-One Counseling 1 (1) 3 (2) 1 (0) 6 (4) 1 (1) 12 (8)

Counseling in facilities 0 1 (1) 1 (0) 1 (1) 0 3 (2)

Counseling in communities 0 1 (1) 0 0 0 1 (1)

Counseling in homes (home visits) 0 2 (1) 0 5 (3) 1 (1) 8 (5)

Counseling in other settings 1 (1) 0 0 1 (1) 0 2 (2)

Group Education 1 (1) 1 (1) 1 (0) 6 (2) 0 9 (4)

Education in facilities 0 0 1 (0) 2 (1) 0 3 (1)

Education in communities 0 1 (1) 0 3 (0) 0 4 (1)

Education in other settings 1 (1) 0 0 1 (0) 0 2 (1)

Support Group 0 0 0 2 (1) 0 2 (1)

Support group in facilities 0 0 0 1 (0) 0 1

Support group in communities 0 0 0 0 0 0

Support group in other settings 0 0 0 1 (0) 0 1

Media 0 3 (3) 0 3 (3) 1 (1) 7 (7)

Mass media 0 1 (1) 0 1 (1) 0 2 (2)

Mid-sized media (community radio / video, local billboards) 0 1 (1) 0 1 (0) 0 2 (1)

Small media (posters, flyers, calendars, reminder stickers) 0 3 (3) 0 1 (0) 0 4 (3)

Traditional media (songs, drama) 0 0 0 0 1 (1) 1 (1)

Social media (Twitter, Facebook, etc.) 0 0 0 1 (0) 0 1

Community/Social Mobilization 0 0 0 3 (2) 0 3 (2)

Campaign, event, special “days” 0 0 0 1 (1) 0 1 (1)

Issue groups 0 0 0 2 (1) 0 1 (1)

Other 0 0 0 1 (1) 0 1 (1)


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Micronutrient supplementation or fortification

Although many studies reported on micronutrient sup-plementationorfortificationamongpregnantandlactatingwomen, just six presented results in a way that allowed for examination of the distinct effect of SBCC approaches on uptake, and all of these were associated with iron supplemen-tation.Threeof thesereportedstatisticallysignificantresults.


Adhikarietal.(2009)assessedtheeffectof an“educationprogram and/or pill count on the change in hemoglobin levelsandtheprevalenceof anemiainpregnantwomen”among 320 pregnant women receiving prenatal care at the Tribhuvan University Teaching Hospital in Nepal. Women were randomly assigned to one of four groups (education, pillcount,educationwithpillcount,andcontrol).Bytheend of the intervention, women in the education with pill countgroupweresignificantlymorelikelytocomplywithiron supplementation recommendations than women in the pillcountalonegroup(88%and73%,respectively).

Risonaretal.(2008)assesseda“redesignedFesupple-mentationdeliverysystem”ontheislandof NegrosintheSouthern Philippines. The project included providing iron tablets to all pregnant women in two provinces (one inter-ventionandonecontrol).Intheinterventiongroup,villagehealth workers and traditional birth attendants also identi-fiedandregisteredpregnantwomenforantenatalcare,andusedIECmaterialssuchaspostersandflyerstopromoteiron supplementation. After six months, the percentage of women in the intervention group taking iron tablets had in-creased from 57.4% to 79.2%, an increase nearly four times greaterthaninthecontrolgroup(OR=3.79).


Baquietal.(2008b)conductedarepeatedcross-sectionalstudyfocusedonironfolicacid(IFA)supplementationforpregnant women in two districts in India. Both interven-tion and control groups received counseling on preventive care, nutrition, preparedness for child birth, and health-care utilization for complications during home visits by health care providers. In intervention communities, community health workers recruited additional community volunteers (“changeagents”)tofurtherthereachof theprogramthrough additional counseling. The authors report a net increase

of 14.7 percentage points in the number of women consum-ing≥100IFAtabletsduringpregnancyin intervention sites compared with control sites.

Increased rest and decreased work during pregnancy

Two studies reported on rest and work during pregnancy. Oneof thosetworeportedstatisticallysignificantresults.Omeretal.(2008)conductedacross-sectionalstudyfocused on reducing heavy workload during pregnancy (suchaslifting),attendingprenatalcheck-ups,andfeedingcolostrum to newborns in the Sindh province of Pakistan. Theinterventiontrainedladyhealthworkers(LHW)topre-sent and discuss an embroidered cloth panel portraying key messages during routine home visits with pregnant women. Following the intervention, the authors found no difference in overall workload practices between the intervention and controlgroups,butdidfindthatwomenintheinterventiongroup were 50% more likely to reduce routine heavy work comparedwiththoseinthecontrolgroup(OR=1.48).Nobaseline data were collected.

D. Summary of the Evidence

SBCC approaches utilized

SBCC approaches are organized SBCC activities into three primary categories or approaches: interpersonal communi-cation, media, and community/social mobilization. These approachesandthespecificactivitiesassociatedwitheachare described in further detail in the introductory chapter.

The studies reviewed in this chapter included a broad range of approaches to promote optimal dietary intake among pregnant and lactating women. Most included morethanonespecificSBCCactivityandmanyutilizedmore than one approach.

ThereviewconductedbyOtaetal.(2012)includedseveralstudiesinvolvinginterpersonalcommunication(IPC)ap-proaches–specificallyindividualcounselingandgroupeduca-tion for the promotion of women’s energy and protein intake.

Amongthenineotherstudiesreportingstatisticallysignifi-cant results, all included IPC approaches, seven included some form of media, and two included community/social mobilization.One-on-onecounseling(inthehome)wasthe


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Table 3.1.3: Number of studies reviewed (with number of studies reporting statistically significant results in parentheses), by SBCC approach, practice, and study design

SBCC ap-proach

Increased energy and protein intake during pregnancy and lacta-

tion

Enhanced quality of diet during pregnancy and

lactation

Micronutrient sup-plementation or

fortification

Increased rest and decreased work

during pregnancy

Interpersonal Communication

5, 3 reporting statistical significance:

1 Review with meta-analysis

(intake of protein)

2 Repeated cross-sectional

(1 intake of protein & energy; 1 food intake)


1 RCT

(intake of iron-fortified soy sauce)


(1 intake of green leafy vegetables; 1 intake of animal products; 1 purchase of iron-

fortified soy sauce)


2 RCTs

(2 iron supplementation - 1 compliance, 1 likelihood of

consumption)


(intake of ≥100 IFA tablets)


1 Cross-sectional

(workload)

Media 1, 1 reporting statistical significance:


(food intake )


1 RCT

(intake of iron-fortified soy sauce)


(1 intake of animal products ; 1 purchase of iron-fortified soy

sauce)


2 RCTs

(iron supplementation compliance; likelihood of

taking iron tablets)


1 Cross-sectional (workload)

Community/ Social Mobilization



(food intake )



(purchase of iron-fortified soy sauce)

1, none reporting statistical significance

No studies

most commonly used IPC approach, and small media (such asposters,flyers,stickers)wasthemostcommonlyusedmedia approach. See Table 3.1.2.

The breadth of evidence regarding the effectiveness of SBCC in changing dietary practices during pregnancy and lactation varies greatly by type approach. Table 3.1.3 pro-videsasummaryof thesefindings.

Interpersonal communication

There is some evidence of the effectiveness of IPC approach-es in increasing protein/energy intake, enhancing the quality of diet, and increasing intake of micronutrient supplements.

Themeta-analysisconductedbyOtaetal.(2012)foundastatisticallysignificantincreaseinwomen’sproteinintake

as a result of individual counseling and group education (pooledmeandifferenceof 6.99gperday),butnoincreasein energy intake.

In addition to the meta-analysis, two other studies reported significantoutcomesrelatedtotheeffectof IPCapproachesonprotein/energyconsumption,fourreportedsignificantoutcomes related to enhanced quality of diet, three report significantoutcomeswithrespecttoironintake,andonereportedasignificanteffectonworkloadduringpregnancy.

Among these studies, two reported on the effectiveness of IPC, even after controlling for other SBCC approaches. In a repeatedcross-sectionalstudy,Baquietal.(2008b)docu-mented an increase from 5% to 21.3% in the percentage of women consuming <100 IFA tables as a result of an IPC


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intervention,whileGargandKashyap(2006)reportedanincrease from 13.9g to 49.3g in the daily intake of green leafy vegetables as a result of an IPC intervention.

We found no evidence to support the effectiveness of IPC approaches on the intake of other micronutrients during pregnancy and lactation, or related to decreasing work load or increasing rest during pregnancy.

Media

Weidentifiedsixprimaryresearchstudiesthatreportedpositive outcomes associated with interventions that in-cluded media-based SBCC approaches. One study reported positive outcomes related to protein/energy consump-tion, three reported positive outcomes related to enhanced quality of diet, two reported positive outcomes related to iron intake, and one reported a positive effect on workload during pregnancy.

None of these media-based interventions was delivered in isolation. All included some form of IPC, one included both IPC and community/social mobilization approaches, and the independent effect of media-based approaches was notassessed.Itisthereforedifficulttoderiveconclusionsregarding the independent, net effective of these media-basedapproaches.Weidentifiednoevidencerelatedtointake of micronutrients other than iron.

Community/social mobilization

Weidentifiedtwoprimaryresearchstudieslookingattheeffect of community/social mobilization approaches on the uptake of optimal dietary practices during pregnancy and lactation. Both studies, however, included IPC and media ap-proaches in addition to community/social mobilization, and the independent effect of community/social mobilization approaches on maternal dietary practices was not assessed.

Multiple SBCC approaches

Weidentifiednineprimaryresearchstudiesthatassessedthe effectiveness of multiple SBCC approaches to improve maternal dietary practices, and seven of the nine reported statisticallysignificantresults.Guyonetal.(2009)reporteda difference of 12 percentage points between intervention andcontrolcommunities,whileNdiayeetal.(2009)re-ported a difference of 21 percentage points in the intake of animalproducts.Sunetal.(2007)reportedadifferenceof

21-26percentagepointsinintakeof ironfortifiedsoysaucebetween intervention and control communities in rural and urbanareas,andAdhikarietal.(2009)andRisonaretal.(2008),bothRCTs,reporteddifferencesinmicronutrientintake of 15 and 22 percentage points respectively. Finally, Omeretal.(2008)reportedapositive,statisticallysignifi-cant effect with respect to reduction in workload during pregnancy(OR=1.48);however,nobaselinedatawerecol-lected,makingattributiontotheinterventiondifficult.

Justonestudy,Adhikarietal.(2009),comparedtheef-fect of more than one SBCC approach to a single SBCC approach. The authors found higher compliance rates with iron supplementation recommendations in an intervention that combined education with pill counting (88% compli-ance)comparedwithaninterventionthatincludedpillcountingalone(73%compliance).Ironsupplementationcompliance was not reported for the control group.

Implementation processes followed

Noneof thestudiesreviewedinthischapterspecificallyassessed the effect of implementation processes (e.g. inten-sity and timing of communications; type and training of personcommunicatingmessages,ortargetaudience)ontheeffectiveness of the SBCC approach on women’s dietary practices during pregnancy or lactation, nor did they con-sistently report all aspects of the implementation processes.

The intensity of communications ranged between one and four visits/sessions or weekly to monthly visits/sessions for various lengths of time. None of the studies com-pared the effect of timing or frequency.

In terms of target audiences, the studies reviewed primarily targeted the potential or actual breastfeeding woman. The literaturereviewbyOtaetal.(2012)conductedameta-analysis of studies of interventions targeting the woman alone, and among nine primary research studies reporting atleastonestatisticallysignificantdifference,eighttargetedthewomanherself,threetargeteddirectinfluencers,fourtargeted local community actors, and two targeted actors of the enabling environment. Six targeted more than one targetaudienceorbehavioralinfluencer,butnonecom-pared the effect of targeting one vs. multiple audiences or of targeting different audiences.


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E. Conclusions

The body of literature on the effectiveness of SBCC to improve women’s dietary practices during pregnancy and lactation is small, but indicates that SBCC approaches can and do succeed in improving uptake of those practic-es.Whiletheliteraturemayreflectabiastopublishpositiveresults, it also underscores the important role of SBCC approaches to improve nutrition practices – practices which have been shown to have an impact on nutritional status of women, infants, and children.

What stands out from this review is the lack of evidence (orattention)thathasbeengiventoimprovingwomen’sdi-etary practices during pregnancy and lactation. The greatest gap was in evidence of effectiveness of SBCC approaches in improving rest and workload during pregnancy.

In addition, there is considerable variation in the descrip-tion of SBCC interventions, interactions or combinations with other interventions, target groups, content, messages, scale and coverage, length and intensity, as well as context.

There is also variation in how nutrition practices are definedandmeasured.Of thefivestudiesthatdiscussedenergy and protein intake during pregnancy and lactation, four different indicators were measured and no one indica-tor was measured more than twice. Of the six studies that looked at the quality of diet during pregnancy and lacta-tion,fourreportedstatisticallysignificantresultsrelatedtodistinct indicators. Each of the three studies reporting on micronutrientsupplementationorfortificationmeasuredaslightly different indicator. This underscores the impor-tance of developing indicators related to women’s dietary practices during pregnancy and lactation that are globally recognized, accepted, and used by the research and program communities alike.

The SBCC approach most used, and the only one used without other communication interventions, was IPC. While media and community/social mobilization were used, they were always used with at least one other communica-tion approach. Evidence suggests that using multiple SBCC approaches and channels to change behaviors is more effective than using one, but this is not tested in the literature. It is difficult and expensive to disag-gregate the contribution of single channels within a multi-channel intervention, and an important question

for SBCC practitioners and researchers is whether that line of research is useful.

All but one of the studies reviewed targeted the pregnant or lactating woman herself. More than half targeted other audiencesorinfluencersaswell.

The majority of the studies were implemented on a relatively smallscale(e.g.,inonehospitalorcommunity)andtypicallywith between 50 and 350 people per group. The small scale of research on this topic constrains the generalizability of findings and raises important questions about the scalability and sustainability of approaches used.

Differences in local context (including social norms, cul-ture,andenvironmentalfactors)aswellasdifferencesinthe implementation and scale of implementation affect the success of interventions. This underscores the importance of proper context assessments, formative research and/or ethnographic study prior to SBCC implementation.

Because of the relatively limited body of evidence on this topic and due to the lack of standardization in the way research related to SBCC is designed and described, it is chal-lenging to make conclusions beyond the fact that projects with SBCC result in uptake of promoted practices. While there is much to be learned from this body of literature to aid us in developing future programs, there are also many questions generated from reviewing this literature that can and hopefully will guide future evaluations and operations research. These include questions related to:

n globally recognized indicators related to women’s dietary practices during pregnancy and lactation;

n the generalizability of research in this area;n thepositive(ornegative)effectof usingmultipleSBCC

approaches compared with focusing on only one;n thepositive(ornegative)effectof targetingmultiple

audiencesorinfluencersof thebehaviorsbeingpromoted, rather than focusing on just one target population;

n the role of context, in other words, the effect of the same SBCC intervention implemented in different contexts;





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Tabl

e 3.

1.4:

Stu

dies

rep

ortin

g on

mat

erna

l die

tary

pra

ctic

es d

urin

g pr

egna

ncy

and

lact

atio

n C

olor

cod

ing

key

Incr

ease

d en

ergy

and

pro

tein

inta

ke d

urin

g pr

egna

ncy

and

lact

atio

n In

take

of m

icro

nutr

ient

and

iron

sup

plem

ents

Enha

nced

qua

lity

of d

iet

duri

ng p

regn

ancy

and

lact

atio

nR

est

and

wor

k du

ring

pre

gnan

cy

ST

UD

YA

PP

RO

AC

HE

S

US

ED

SC

AL

E /

SC

OP

EE

VA

LU

AT

ION

DE

SIG

NO

UT

CO

ME

(S)

ME

AS

UR

ED

RE

SU

LTS

7P

-VA

LU

Es

/ CIs

8

Adh

ikar

i et

al (

2009

); N

epal

Cou

nsel

ing

in fa

cilit

ies

by p

rovi

ders

; Sm

all

med

ia

1 ho

spita

lR

CT

– p

regn

ant

wom

en r

ecei

ving

pr

enat

al c

are:

71

in e

duca

tion

grou

p, 7

0 in

pill

cou

nt g

roup

, 73

educ

atio

n +

pill

cou

nt g

roup

, 70

in

cont

rol g

roup

Iron

sup

plem

enta

tion

com

plia

nce

Educ

atio

n +

Pill

cou

nt

vs. P

ill c

ount

alo

ne: 8

8%

vs. 7

3%

p <

0.0

01

Ahr

ari e

t al

. (20

06);

Egyp

tG

roup

edu

catio

n in

fa

cilit

ies

by p

rovi

ders

; Su

ppor

t gr

oup

in

faci

litie

s by

pro

vide

rs

and/

or la

y vo

lunt

eers

; C

ouns

elin

g in

hom

es

by la

y vo

lunt

eers

2 la

rge

com

mun

ities

R

epea

ted

cros

s-se

ctio

nal –

519

w

omen

(34

4 in

terv

entio

n, 1

75

cont

rol)

% o

f wom

en w

ho r

epor

ted

cons

umpt

ion

of m

ore

food

du

ring

pre

gnan

cy

54.9

% v

s. 10

.6%

Not

cle

ar in

ar

ticle

% o

f wom

en w

ho r

epor

ted

cons

umpt

ion

of m

ore

mea

t du

ring

pre

gnan

cy

% o

f wom

en w

ho r

epor

ted

cons

umpt

ion

of m

ore

vege

tabl

es d

urin

g pr

egna

ncy

57.1

% v

s. 4.

2%

66.9

% v

s. 5.

3%

Not

cle

ar in

ar

ticle

% o

f pre

gnan

t w

omen

who

re

port

ed t

akin

g IF

A

% o

f pre

gnan

t w

omen

who

re

port

ed t

akin

g 7

or m

ore

IFA

tab

lets

per

wee

k

97.5

% v

s. 80

.6%

86.2

% v

s. 0.

0%

NS9

NS

% o

f wom

en w

ho r

epor

ted

an in

crea

se in

day

time

rest

du

ring

pre

gnan

cy

64.1

% v

s. 11

.7%

Not

cle

ar in

ar

ticle

Akt

er e

t al

. (20

12);

Bang

lade

shC

ouns

elin

g in

faci

litie

s by

pro

vide

rs; G

roup

ed

ucat

ion

in fa

cilit

ies

by p

rovi

ders

1 ho

spita

l Lo

ngitu

dina

l – 1

15 w

omen

(57

in

terv

entio

n, 5

8 co

ntro

l)%

of p

regn

ant

wom

en w

ho

incr

ease

d fr

eque

ncy

of m

eals

fr

om t

hree

to

five

times

a d

ay

34%

mor

e N

ot r

epor

ted

7 C

ompa

rison

is in

terv

entio

n vs

. con

trol g

roup

, unl

ess i

ndic

ated

oth

erw

ise.

8Differencesreportedasnotsignificantlydifferentatthe0.05levelareindicatedby“NS”.Differencesforwhichstatisticalsignificancewasnotreportedareindicatedby“--“.

9NS=notsignificanteitheraccordingtowhatisreportedintheoriginalarticleorp<0.05.


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ST

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PP

RO

AC

HE

S

US

ED

SC

AL

E /

SC

OP

EE

VA

LU

AT

ION

DE

SIG

NO

UT

CO

ME

(S)

ME

AS

UR

ED

RE

SU

LTS

7P

-VA

LU

Es

/ CIs

8

Baqu

i et

al. (

2008

b);

Indi

aC

ouns

elin

g in

hom

es

by la

y vo

lunt

eers

; C

ouns

elin

g in

hom

es

by p

rovi

ders

2 di

stri

cts

Rep

eate

d cr

oss-

sect

iona

l –

base

line:

14,

952

rece

ntly

del

iver

ed

wom

en (

8,75

6 in

terv

entio

n,

6,19

6 co

ntro

l); e

ndlin

e: 1

3,82

6 re

cent

ly d

eliv

ered

wom

en (

7,81

2

inte

rven

tion,

6,0

14 c

ontr

ol)

endl

ine

vs. b

asel

ine

% o

f w

omen

who

con

sum

ed

equa

l to

or m

ore

than

100

IFA

tabl

ets d

urin

g pr

egna

ncy

Inte

rven

tion

grou

p: 2

1.3%

vs. 5

%

Con

trol g

roup

: 8.3

% v

s.

6.7%

p<

0.00

110

Bort

olin

i and

Vito

lo

(201

2); B

razi

lC

ouns

elin

g in

hom

es

by p

rovi

ders

1 ho

spita

lR

CT

– 3

97 (

163

inte

rven

tion,

234

co

ntro

l)%

of w

omen

who

use

fo

rtifi

ed fl

our

% o

f wom

en w

ho c

onsu

me

diet

ary

iron

tha

t is

hig

hly

bioa

vaila

ble

% o

f wom

en w

ith d

aily

iron

in

take

≥ 3

mg/

day

Base

d on

a 2

4 ho

ur d

ieta

ry

reca

ll am

ong

child

ren

12-1

6 m

onth

s ol

d, m

ean

inta

ke o

f…

- m

eat

(g)

- ir

on (

mg)

- he

me

iron

(m

g)

45.2

% v

s. 44

.2%

18.1

% v

s. 9.

8%

83.2

% v

s. 82

.8%

54.3

vs.

47.3

5.1

vs. 5

.4

1.5

vs. 1

.2

NS

NS

NS

p=0.

024

NS

p=0.

003

Cas

ey e

t al

. (20

10);

Vie

tnam

Mob

iliza

tion

of is

sue

grou

ps; C

ouns

elin

g in

ho

mes

by

peer

s

2 di

stri

cts

Rep

eate

d cr

oss-

sect

iona

l –

base

line

(Nov

200

5): 3

89 w

omen

of

rep

rodu

ctiv

e ag

e (W

RA

); 1st

fo

llow

-up

(July

200

6): 2

53 W

RA

; 2nd

fo

llow

-up

(Sep

t 20

07):

276

WR

A;

3rd fo

llow

-up

(Apr

200

9): 3

22 W

RA

3rd f

ollo

w-u

p vs

. 2nd

fo

llow

-up

vs. 1

st fo

llow

-up

% o

f wom

en w

ho t

ook

at

leas

t 75

% o

f tab

lets

rec

eive

d du

ring

pre

gnan

cy

87%

vs.

90%

vs.

51%

95

% C

Is: (

80%

-

93%

) vs

. (8

4% -

95%

) vs

. (37

% v

s. 65

%)

Gar

g an

d K

ashy

ap

(200

6); I

ndia

Cou

nsel

ing

in

faci

litie

s by

pro

vide

rs;

Gro

up e

duca

tion

in c

omm

uniti

es b

y pr

ovid

ers;

Cou

nsel

ing

in h

omes

by

prov

ider

s

1 vi

llage

Rep

eate

d cr

oss-

sect

iona

l – 1

00

wom

en (

50 in

terv

entio

n, 5

0

cont

rol)

Ener

gy (

kcal

) in

take

dur

ing

preg

nanc

y

Prot

ein

(g)

inta

ke d

urin

g pr

egna

ncy

1521

.23

vs. 8

35.1

4

48.0

5 vs

. 25.

00

p<0.

001

p<0.

001

Mea

n da

ily in

take

of g

reen

le

afy

vege

tabl

es (

g) d

urin

g pr

egna

ncy

49.3

vs.

13.9

p<0.

001

10

P-v

alue

for d

iffer

ence

-in-d

iffer

ence

test

adj

uste

d fo

r age

, edu

catio

n, p

arity

, rel

igio

n an

d st

anda

rd-o

f-liv

ing

scor

e.


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ST

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PP

RO

AC

HE

S

US

ED

SC

AL

E /

SC

OP

EE

VA

LU

AT

ION

DE

SIG

NO

UT

CO

ME

(S)

ME

AS

UR

ED

RE

SU

LTS

7P

-VA

LU

Es

/ CIs

8

Guy

on e

t al

. (20

09);

Mad

agas

car

Mob

iliza

tion

of is

sue

grou

ps; M

obili

zatio

n of

cam

paig

ns, e

vent

s, or

spe

cial

day

s; M

ass

med

ia

2 hi

ghla

nd

prov

ince

s; ta

rget

ed

popu

latio

n va

ried

th

roug

hout

pro

ject

fr

om 1

.4 m

illio

n in

6 d

istr

icts

to

6 m

illio

n in

23

dist

rict

s

Rep

eate

d cr

oss-

sect

iona

l –

base

line

(200

0): 1

,200

chi

ldre

n un

der

two

year

s ol

d; e

ndlin

e (2

005)

: 1,7

60 c

hild

ren

unde

r tw

o ye

ars

old

endl

ine

vs. b

asel

ine

% o

f mot

hers

of i

nfan

ts <

6

mon

ths

who

rep

orte

d in

crea

sed

food

inta

ke d

urin

g pr

egna

ncy

% o

f mot

hers

of i

nfan

ts <

6

mon

ths

who

rep

orte

d in

crea

sed

food

inta

ke d

urin

g la

ctat

ion

55%

vs.

51%

74

% v

s. 62

%

NS

p<0.

001

Ndi

aye

et a

l. (2

009)

; Se

nega

lM

id-s

ized

med

ia;

Cou

nsel

ing

in

hom

es b

y pe

ers;

Gro

up e

duca

tion

in

com

mun

ities

by

lay

volu

ntee

rs

2 co

mm

uniti

es

Rep

eate

d cr

oss-

sect

iona

l –

base

line:

171

pre

gnan

t w

omen

(89

in

terv

entio

n, 8

2 co

ntro

l); e

ndlin

e:

200

(100

inte

rven

tion,

100

con

trol

)

endl

ine

vs. b

asel

ine

% o

f pre

gnan

t w

omen

who

re

port

ed e

atin

g m

eat

or fi

sh

at le

ast

once

a w

eek

Inte

rven

tion:

70

.7%

vs.

49.4

%

Con

trol

: 32

.0%

vs.

41.5

%

p ≤

0.00

3

p ≤

0.01

9 (d

iffer

ence

-in

- di

ffere

nces

: p=

0.00

01)

Om

er e

t al

. (20

08);

Paki

stan

Trad

ition

al m

edia

; C

ouns

elin

g in

hom

es

by p

eers

10 c

omm

uniti

es

from

thr

ee d

istr

icts

(5

inte

rven

tion

and

5 co

ntro

l)

Cro

ss-s

ectio

nal s

tudy

– 1

,070

w

omen

wer

e pr

egna

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11Notethattherewerenosignificantsocio-demographicdifferencesbetweeninterventionandcontrolcommunities.


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ACC/SCN. 2001. What Works? A Review of the Efficacy and Effectiveness of Nutrition Interventions, Allen LH and Gillespie SR. ACC/SCN: Geneva in collaboration with the Asian Development Bank, Manila.

Adhikari, Kamala, Tippawan Liabsuetrakul, and Neelam Pradhan. 2009. “Effect of Education and Pill Count on Hemoglobin StatusDuringPrenatalCareinNepaleseWomen:aRandomizedControlledTrial.”The Journal of Obstetrics and Gynaecology Research35(3)(June):459–466.

Ahrari, Mahshid, Robert F Houser, Siham Yassin, Mona Mogheez, Y Hussaini, Patrick Crump, Gary L Darmstadt, David Marsh, and F James Levinson. 2006. “A Positive Deviance-based Antenatal Nutrition Project Improves Birth-weight in Upper Egypt.”Journal of Health, Population, and Nutrition24(4)(December):498–507.

Akter, S.M., S.K. Roy, S.K. Thakur, M. Sultana, W. Khatun, R. Rahman, S.S. Saliheen, and N. Alam. 2012. “Effects of Third Trimester Counselling on Pregnancy Weight Gain, Birthweight, and Breastfeeding Among Urban Poor Women in Bangla-desh.”Food & Nutrition Bulletin33(3)(September):194–201.

Alderman, H, and JR Behrman. 2006. “Reducing the Incidence of Low Birth Weight in Low-Income Countries Has Substantial EconomicBenefits.”The World Bank Research Observer21(1):25–48.

Allen,LindsayH.2005.“MultipleMicronutrientsinPregnancyandLactation:AnOverview.”The American Journal of Clinical Nutrition81(5)(May):1206S–1212S.

Baqui, Abdullahh, Emma K Williams, Amanda M Rosecrans, Praween K Agrawal, Saifuddin Ahmed, Gary L Darmstadt, Vish-wajeet Kumar, Usha Kiran, Dharmendra Panwar, Ramesh C Ahuja, Vinod K Srivastava, Robert E Black, and Manthuram Santoshama. 2008. “Impact of an Integrated Nutrition and Health Programme on Neonatal Mortality in Rural Northern India.”Bulletin of the World Health Organization86(10)(October):796–804.

Bhutta,ZulfiqarA,JaiKDas,ArjumandRizvi,MichelleFGaffey,Neff Walker,SusanHorton,PatrickWebb,AnnaLartey,andRobert E Black. 2013. “Evidence-based Interventions for Improvement of Maternal and Child Nutrition: What Can Be DoneandatWhatCost?”The Lancet382(9890)(August):452–477.

Black,RobertE,CesarGVictora,SusanPWalker,ZulfiqarABhutta,ParulChristian,MercedesdeOnis,MajidEzzati,SallyGrantham-McGregor, Joanne Katz, Reynaldo Martorell, Ricardo Uauy, and the Maternal and Child Nutrition Study Group.2013.“MaternalandChildUndernutritionandOverweightinLow-incomeandMiddle-incomeCountries.”The Lancet382(9890)(August):427–451.

Bortolini, Gisele Ane, and Márcia Regina Vitolo. 2012. “The Impact of Systematic Dietary Counselling During the First Year of LifeonPrevalenceRatesof AnemiaandIronDeficiencyat12-16Months.”Jornal de Pediatria88(1)(February):33–39.

Casey, Gerard J, Damien Jolley, Tran Q Phuc, Ta T Tinh, Dang H Tho, Antonio Montresor, and Beverley-Ann Biggs. 2010. “Long-term Weekly Iron-folic Acid and De-worming Is Associated with Stabilised Haemoglobin and Increasing Iron StoresinNon-pregnantWomeninVietnam.”PloS One5(12):e15691.

Cochrane Database of Systematic Reviews.

De-Regil,LuzMaria,ParminderSSuchdev,GunnEVist,SilkeWalleser,andJuanPabloPeña-Rosas.2011.“HomeFortificationof FoodswithMultipleMicronutrientPowdersforHealthandNutritioninChildrenUnderTwoYearsof Age.”Cochrane Database of Systematic Reviews 2011, edited by The Cochrane Collaboration and Luz Maria De-Regil. Chichester, United Kingdom: John Wiley & Sons, Ltd.

F. Works Cited and Literature Reviewed


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Dewey, K G, R J Cohen, K H Brown, and L L Rivera. 2001. “Effects of Exclusive Breastfeeding for Four Versus Six Months on MaternalNutritionalStatusandInfantMotorDevelopment:Resultsof TwoRandomizedTrialsinHonduras.”The Journal of Nutrition131(2)(February):262–267.

Garg,Aashima,andSushmaKashyap.2006.“Effectof CounsellingonNutritionalStatusDuringPregnancy.”Indian Journal of Pediatrics73(8)(August):687–692.

Guyon, Agnès B, Victoria J Quinn, Michael Hainsworth, Priscilla Ravonimanantsoa, Voahirana Ravelojoana, Zo Rambeloson, and Luann Martin. 2009. “Implementing an Integrated Nutrition Package at Large Scale in Madagascar: The Essential NutritionActionsFramework.”Food and Nutrition Bulletin30(3)(September):233–244.

Haider,BA,andZABhutta.2012.“Multiple-MicronutrientSupplementationforWomenDuringPregnancy.”

Haileslassie, Kiday, Afework Mulugeta, and Meron Girma. 2013. “Feeding Practices, Nutritional Status and Associated Factors of LactatingWomeninSamreWoreda,SouthEasternZoneof Tigray,Ethiopia.”Nutrition Journal12(1):28

Katz, Joanne, Anne CC Lee, Naoko Kozuki, Joy E Lawn, Simon Cousens, Hannah Blencowe, Majid Ezzati, et al. 2013. “Mor-tality Risk in Preterm and Small-for-Gestational-Age Infants in Low-Income and Middle-Income Countries: A Pooled CountryAnalysis.”The Lancet382(9890):417–25.

Mason, John B, Lisa S Saldanha, and Reynaldo Martorell. 2012. “The Importance of Maternal Undernutrition for Maternal, Neonatal,andChildHealthOutcomes:AnEditorial.”Food and Nutrition Bulletin33(2Suppl)(June):S3–5.

McNulty J. and CORE Group. Positive Deviance / Hearth Essential Elements: A Resource Guide for Sustainably Rehabilitating Malnourished Children (Addendum), Washington, D.C.: CORE Group, 2005.

Ndiaye, Mamadou, Kendra Siekmans, Slim Haddad, and Olivier Receveur. 2009. “Impact of a Positive Deviance Approach to Improve the Effectiveness of an Iron-supplementation Program to Control Nutritional Anemia among Rural Senegalese PregnantWomen.”Food and Nutrition Bulletin30(2)(June):128–136.

Omer, Khalid, Sharmila Mhatre, Noor Ansari, Jorge Laucirica, and Neil Andersson. 2008. “Evidence-based Training of Front-line Health Workers for Door-to-door Health Promotion: a Pilot Randomized Controlled Cluster Trial with Lady Health WorkersinSindhProvince,Pakistan.”Patient Education and Counselling72(2)(August):178–185.

Ota, Erika, Ruoyan Tobe-Gai, Rintaro Mori, and Diane Farrar. Antenatal Dietary Advice and Supplementation to Increase En-ergy and Protein Intake. In Cochrane Database of Systematic Reviews 2012, edited by The Cochrane Collaboration and Erika Ota. Chichester, United Kingdom: John Wiley & Sons, Ltd.

Risonar, Maria Grace D, Pura Rayco-Solon, Lorena W Tengco, Jesus N Sarol, Lourdes S Paulino, and Florentino S Solon. 2008. “Effectiveness of a Redesigned Iron Supplementation Delivery System for Pregnant Women in Negros Occidental, Phil-ippines.”Public Health Nutrition12(07)(August27)

Senanayake, Hemantha M, Samanthi P Premaratne, Thilina Palihawadana, and Sumeda Wijeratne. 2010. “Simple Educational InterventionWillImprovetheEfficacyof RoutineAntenatalIronSupplementation.”The Journal of Obstetrics and Gynaecol-ogy Research36(3)(June):646–650.

Sun,Xinying,YanGuo,SisunWang,andJingSun.2007.“SocialMarketingImprovedtheConsumptionof Iron-fortifiedSoySauceAmongWomeninChina.”Journal of Nutrition Education and Behavior39(6)(December):302–310.

Wang, Bo, Siyan Zhan, Jing Sun, and Liming Lee. 2009. “Social Mobilization and Social Marketing to Promote NaFeEDTA-fortifiedSoyaSauceinanIron-deficientPopulationthroughaPublic-privatePartnership.”Public Health Nutrition12(10)(October):1751–1759.


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3.2. Evidence of Effective SBCC Approaches to Promote Breastfeeding Practices

A. Background

Breastfeeding is widely recognized as one of the most cost-effective investments to improve child survival (UNICEF, 2013).AccordingtoTheLancetSeriesonMaternalandChild Under Nutrition, the adoption of exclusive breast-feeding through six months of age and continued breast-feeding through age two in 36 high burden countries could avert 11.6% of all deaths in children under the age of one, and nearly 10% of all deaths in children under the age of two(Bhuttaetal.,2008a).Thebenefitsof breastfeedingstretch beyond a child’s survival. Breastfed children do bet-ter on cognitive and motor development tests, and gener-ally achieve better academic outcomes than non-breastfed children(Hortaetal.,2013).

Additionally,breastfeedingimpartscriticalbenefitstothewoman. When practiced exclusively, breastfeeding is as-sociated with lactational amenorrhea, the natural postnatal infertility that occurs when a woman is amenorrheic (not menstruating).Thelactationalamenorrheamethod(LAM)is considered a modern method of contraception that prevents a second pregnancy within six months of giving birth, and helps to conserve maternal iron stores (Dewey etal.,2001).Increasedbirthspacingimprovesboththehealth of the woman and her infant’s chances of survival, while suboptimal pregnancy intervals are associated with an increased risk of adverse perinatal and infant/child out-comes including preterm birth, low birth weight, small for gestationalage(SGA),stunting,andunderweightinfants/children (Bhutta et al, 2013; Conde-Agudelo, 2006; Conde-Agudeloetal.,2012;Rutstein,2008).

TheWorldHealthOrganization(WHO)recommendsthree primary breastfeeding practices: initiation of breast-feeding within one hour after birth (also referred to as immediatebreastfeeding),exclusivebreastfeeding(EBF)through six months of age, and continued breastfeeding until24monthsof age(Dysonetal.,2005;WHO,2008).Evidence associated with the recommendation for imme-diate breastfeeding is limited and likely operates through theeffectof exclusivebreastfeeding(Bhuttaetal.,2013).The Lancet, therefore, includes only EBF and continued

breastfeeding in the modeling of optimal breastfeeding practices cited above.

Despite the promise of optimal breastfeeding practices, rates for the three WHO recommended breastfeeding practices remain low, and negligible progress has been made to increase these rates over the past two decades (UNICEF, 2013).Accordingtoananalysisof datafrom78lowandmiddle income countries, rates of immediate breastfeed-ing range from a mean of 36% in Eastern Europe to a mean of 58% in Latin America, and the rate of exclusive breastfeedinginchildrenonetofivemonthsof ageisjust30%(Blacketal,2013).AccordingtotheUNICEFglobaldatabase of national surveys from 2007-2011, the current rate of breastfeeding at one year is 76%, while the rate of breastfeeding at age two years is 58%.12

This chapter reviews the effectiveness of social and behav-iorchangecommunication(SBCC)approachesonimprov-ing breastfeeding practices.

B. Search Results

Sixty-two peer-reviewed studies met the literature review’s inclusion criteria.2 A complete list of the studies reviewed, includingasummaryof theSBCCapproach(es)utilized,thestudydesign,practicesmeasured,andlevelsof signifi-cance is presented in Table 3.2.4 at the end of this chapter.

Forty-eightreportedastatisticallysignificantchangeinatleast one of the priority breastfeeding practices. Each of those articles is described in greater detail below. Studies reportingastatisticallysignificantchangeinmorethanoneof the prioritized practices and/or utilizing more than one SBCC approach are cited and discussed multiple times. Where this occurs, we have provided a detailed description of thestudyinthefirstreference,andonlydiscussresultsin subsequent references.

Thefindingsareorganizedbypracticestargeted,SBCCapproach(es)utilized,andstudydesign.Thisorganizationenables the reader to derive an independent judgment re-gardingfindingsfromeachstudy.Inaddition,implementa-tion processes followed are also discussed.

12 See: http://www.childinfo.org/breastfeeding_status.html.13 See the introductory chapter of this literature review for a full description

of search procedures and inclusion/exclusion criteria.


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Of the 62 studies reviewed for this chapter, six were literature reviews that included meta-analysis, 27 were randomizedcontrolledtrials(RCT),14werelongitudinalstudies, 13 were repeated cross-sectional studies, and two were cross-sectional studies. See Table 3.2.1.

The literature reviews were published between 2010 and 2012. Twenty-one of the 56 studies included in the previ-ously published reviews met the inclusion criteria for the present review, and these studies are included in the sum-maries below.


This chapter is organized around the three WHO recom-mended breastfeeding practices: early initiation of breast-feeding, EBF through six months of age, and continued breastfeeding until 24 months of age. The feeding of colostrumisincludedintheearlyinitiationsection.Specificindicators used to measure these practices varied consider-ably among studies.

Of thestudiesreviewed,22reportedfindingsrelatedtoearly initiation of breastfeeding (including six which report-edonfeedingcolostrum),41reportedonfindingsrelatedtoEBF,and16reportedonfindingsrelatedtocontinuedbreastfeeding. See Table 3.2.1.

Early initiation of breastfeeding

Of the 22 studies that measured breastfeeding initiation, 17reportedstatisticallysignificantresults.Fifteenof thoselookedatearlyinitiationof breastfeeding(definedasinitiatingbreastfeedingwithinonehourof birth)andthree

reportedstatisticallysignificantresultsrelatedtothefeedingof colostrum to infants.

Literature reviews with meta-analysis

GogiaandSachdev(2010)conductedaliteraturereviewand meta-analysis to “determine whether home visits forneonatalcarebycommunityhealthworkers(CHW)canreduceinfantandneonataldeathsandstillbirths.”The review included four studies that assessed breast-feeding counseling provided during home visits.14 All of these studies have been included and are described in the present review. The authors found that women in the in-tervention group were more than three times more likely to initiate breastfeeding compared with women in control groups(pooledRR3.35).

Lassietal.(2010)conductedareviewof 18cluster-RCTs/quasi-RCTs of community-based interventions that in-volved training outreach workers in maternal care during pregnancy, delivery and in the postpartum period as well as newborn care. Six of the 18 studies assessed the impact of these interventions on initiation of breastfeeding within one hour after birth. The meta-analysis from these studies revealed that following community-based interventions, thepracticenearlydoubled(RelativeRisk(RR)=1.94).All but one of the six studies included in the meta-analysis matched the inclusion criteria for the present review. These studies are included in the summaries that follow.15

14 Theseinclude:Baquietal.(2008a);Baquietal.(2008b);Bhuttaetal.(2008b);andKumaretal.(2008).

15 Theseincludethetwoarmsof Baquietal.(2008a);Kumaretal.(2008);Manandharetal.(2004);Syedetal.(2006).


Practice

Literature reviews

with meta-analysis

RCTLongitudinal

studies

Repeated cross-

sectional studies


Total

Early initiation of breastfeeding 2 (2) 8 (6) 2 (1) 10 (8) 0 22 (17)

Exclusive breastfeeding 4 (4) 20 (14) 12 (8) 7 (5) 2 (2) 41 (32)

Continued breastfeeding 2 (1) 7 (6) 3 (1) 4 (1) 0 16 (9)



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Sixstudiesreportingstatisticallysignificantchangesinearlyinitiation of breastfeeding were RCTs. Two of these were included in the meta-analyses described above.16 Bang et al. (2005)lookedatearlyinitiationof breastfeedingasanout-come associated with delivery of a home-based neonatal care package in Gadchiroli District of India. The intervention in-cludedthetrainingof femalevillagehealthworkers(VHWs)andtraditionalbirthattendants(TBAs)toprovidehealtheducation to mothers and grandmothers about care of preg-nant women and of neonates through advice, demonstration, and assistance. Messaging addressed traditional beliefs and practicesaswellasbarrierstocareidentifiedduringthefirsttwo years of the program, and was delivered during group meetings conducted once every four months, during home visits in the eighth and ninth months of pregnancy, and on thefirstdayafterdelivery.Bytheendof theinterventionpe-riod, the percentage of women initiating breastfeeding within six hours of birth had increased from 47.5% to 89.7%. The authors did not report on the standard indicator of initiation of breastfeeding within one hour of birth.

Baquietal.(2008a)conductedalarge-scaleRCTinSylhetDistrict, Bangladesh. Twenty-four clusters, each with a population of approximately 20,000 people, were randomly assigned to one of three study groups – a community-care (CC)group,ahome-care(HC)group,oracontrolgroup.Inbothinterventiongroups(CCandHC),“maleandfemalecommunity mobilisers were recruited to hold group meet-ings for the dissemination of birth and newborn-care pre-parednessmessages…”Eachfemalecommunitymobilizerheld community meetings once every four months, while each male community mobilizer did so every 10 months. In theCCarm,femalevolunteersidentifiedpregnantwomenand encouraged them to attend community meetings organ-ized by the community mobilizers, receive routine antenatal care, and seek care for signs of serious illness in mothers or newborns. In the HC arm, CHWs “promoted birth and newborn care preparedness through two scheduled ante-natalandthreeearlypostnatalhomevisits.”Furthermore,female community mobilizers conducted group meetings with women in the HC group once every eight months. After nearly three years, breastfeeding initiation within one hour of birth was dramatically higher in both interven-

16 Theseinclude:Baquietal.(2008a)andKumaretal.(2008).

tion arms compared with the control group. While a total of71% of women in the CC group and 81% in the HC group reported initiating breastfeeding within one hour of birth, only 57% in the control group reported the same. Differences between both intervention groups and the controlgroupwerestatisticallysignificant.

Guldanetal.(2000)lookedatInfantandYoungChildFeeding(IYCF)practicesinruralSichuan,China.Thestudyincluded two intervention and two control groups. The intervention included counseling by CHWs during monthly growth monitoring and promotion sessions, and visits to the homes of pregnant women and women with children under the age of one. At the conclusion of the one year intervention, the percentage of women reporting feeding newborns colostrum was higher in the intervention group thaninthecontrolgroup(91%vs.80%).However,theauthors explained that complete randomization in group selection was not possible as the “[intervention] and control group townships could not be contiguous and needed to be roughlyequalgeographicallyandsocioeconomically”andthere were important differences between the women in the intervention and control groups in terms of mean years of educationandmainincomesource,makingitdifficultto draw conclusions about the effect of the intervention or thegeneralizabilityof thefindings.

Haideretal(2000)lookedatearlyinitiationandEBFinDha-ka, Bangladesh. The intervention included home-based peer counselingoveraperiodof fivemonths.Trainedcounselorsconductedatotalof 15homevisitsinthefivemonthstudyperiod:twointhelasttrimesterof pregnancy,fourinthefirstmonth postpartum, and every fortnight afterward until the completionof fivemonths.Attheconclusionof thestudyperiod, the percentage of women initiating breastfeeding withinthefirsthourafterbirthwas64%intheinterventiongroup, compared with 15% in the control group.

Kumaretal.(2008)conductedacluster-RCTlookingatearlyinitiation of breastfeeding in the context of a neonatal mor-tality intervention in Uttar Pradesh, India. The intervention included training CHWs to hold community meetings with folk songs and conduct home visits targeting community leaders,priests,teachers,birthattendants,unqualifiedmedicalcare providers, healthcare workers, fathers-in-law, husbands, mothers-in-law, pregnant women or mothers, neighbors, and relatives. After 16 months of implementation, the rate of


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breastfeeding within one hour of birth was 70.6% among women in intervention areas compared with 15.5% among women in non-intervention areas.

Finally,Omeretal.(2008)conductedanRCTfocusedonreducingheavyworkload(suchaslifting)duringpregnancy,attending prenatal check-ups, and feeding colostrum to newborns in Sindh Province of Pakistan. The intervention trainedladyhealthworkers(LHW)topresentanddiscussan embroidered cloth panel portraying key messages dur-ing routine home visits with pregnant women. Following the interventions, the authors found that women advised by a LHW were more likely to feed their newborn colos-trum than those who were not advised by a LHW to do so (79.2%vs.65.3%).


Akteretal.(2012)lookedatbreastfeedinginitiationinalongitudinal study conducted in one hospital in Bangladesh. The intervention involved four group counseling ses-sions during the last trimester of pregnancy. Following the intervention, 75.4% of women in the intervention group reported initiating breastfeeding within one hour of birth, compared with 34.4% of women in the control group.


Eightof the15studiesreportingstatisticallysignificantresults were repeated cross-sectional studies. Baqui et al.(2008b)lookedattheimpactof aninterventionthatincluded counseling during home visits on preventive care practices for mothers, newborn care practices, and the use of health care services in India. In intervention areas, CHWs recruited additional community volunteers (“change agents”)toexpandthereachof theprogram.Followingintervention, the number of women initiating breastfeeding within one hour of birth increased by 31.2%.

Crookstonetal.(2007)lookedatbreastfeedingbehaviorsin rural Cambodia. The intervention “assess[ed] the impact of Buddhistnunsandwat(pagoda)granniesonoptimalbreastfeedingbehaviours.”Youngnunsweretrainedtopro-motebreastfeedingintheirvillagesusingleaflets,visualaidsand home visits. In addition, the nuns mobilized communi-ty groups, provided one-on-one counseling, and conducted educational sessions with groups of 6-10 women. After one year, women in the intervention group were 62% more

likely to initiate breastfeeding within one hour after birth than those in the control group.

Quinnetal.(2005)conductedarepeatedcross-sectionalstudy looking at timely initiation and EBF in three coun-tries: Madagascar, Bolivia, and Ghana. The interventions varied slightly by country, but all were implemented at scale as part of the USAID-funded Linkages project. In all three countries, “women were reached through small- and large-group activities, one-on-one counseling in homes and at local health posts, breastfeeding promo-tion songs performed by women’s groups and musical troupes, and community mobilization events such as local theater, health fairs, and festivals celebrating breastfeeding andchildhealthdays.”Massmediawasusedtocomple-ment this community-based work. After four years of implementation, rates of early initiation of breastfeeding increased from 34% to 78% in Madagascar, from 56% to 74% in Bolivia, and from 32% to 50% in Ghana. All changeswerestatisticallysignificant.

Guyonetal.(2009)reportedonthesameinterventioninMadagascarafterfiveyearsof implementation,findinganincrease from 33% to 68% in rates of early initiation of breastfeeding.NeitherQuinnetal.(2005)norGuyonetal.(2009)includedacontrolgroup.

Saowakonthaetal.(2000)lookedatthefeedingof colos-trum to newborns in three districts in northeastern Thai-land.Theinterventionincludedtraininghealthofficials,health care workers, and villagers, and disseminating mes-saging through broadcasting systems, events and exhibi-tions, and bulletin boards. By the end of the study period, the percentage of women reporting feeding colostrum to their newborns increased from 63.5% to 97.2%. There was no control group in this study.

Sunetal.(2011)lookedatinfantandyoungchildfeedingpractices as part of an intervention to promote consumption of YingYangBao(YYB),amultiplemicronutrientpow-der, in Shan’xi Province, China. The intervention included formative research and message testing as well as behavior changecommunication(BCC)targetinghealthworkersandfamily members. BCC materials included handbooks about IYCF for parents, booklets about YYB for health work-ers, and television spots for the public. After 20 months of project implementation, the percentage of women reporting


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early initiation of breastfeeding had increased from 8.6% to 16.8%.17 There was no control group in this study.

Syedetal(2006)lookedattheprovisionof newborncarein10upazilas(sub-districts)inBangladesh.Theinterven-tion involved “increasing the coverage of health workers and community-based caregivers trained and competent in providing essential newborn care and promoting positive maternalandnewborn-carepractices.”Activitiestargetedpregnant mothers as well as family decision-makers, such as husbands, mothers-in-law, and village leaders. After less than two years of the intervention, the percentage of women initiating breastfeeding within one hour of birth had increased from 38.6% to 76.2%. Though this dif-ferencewasstatisticallysignificant,thelackof acontrolgroupmakesitdifficulttoconclusivelyattributethechange to the intervention.

Finally,ThompsonandHarutyunyan(2009)lookedatEBFthrough six months of age in Martuni region in northeastern Armenia. The intervention was delivered through a com-munity-based Integrated Management of Childhood Illness (IMCI)platform,andincludedhomevisitsforpregnantandlactating women, group education classes for new parents, and a local mass media campaign. By the end of the study period, the number of women initiating breastfeeding within one hour of birth was 16.2% greater among women exposed to the IMCI campaign compared with those who were not exposed(72.5%.and56.3%,respectively).

Exclusive breastfeeding

Of the 45 studies reporting on EBF practices, 33 reported statisticallysignificantresults.Fiveof thesestudiesreportedon duration of EBF, 14 reported on EBF for six months, fivereportedonEBFamongthoseundersixmonthsof age, 19 reported on EBF at other ages, and two reported on EBFatunspecifiedages.


Hall(2011)conductedameta-analysisof fourRCTsto“as-sess the effectiveness of community-based interventions to improve the rates of exclusive breastfeeding at four to six months in infants in low- and low-to-middle income coun-

17 Notethatthestudyauthorsdidnotdefineearlyinitiation;however,giventhat the authors used many globally recognized indicators, it is assumed thatthiswasdefinedtobewithinonehourof birth.

tries.”Community-basedinterventionsweredefinedasinter-ventions accessible locally to the woman (whether in her own homeoralocalbuildingsuchasaclinicorschool);deliveredby a health professional or trained lay person; and provided either individually or in a group. Interventions could be provided antenatally, postnatally or both, and participants were limited to women who were pregnant or currently breastfeeding an infant less than six months of age. The meta-analysisfoundasignificanteffectof community-basedinterventionsonratesof EBF(pooledOR=5.9).Threeof the four studies reviewed by Hall met the inclusion criteria of the present review and these studies are summarized below.18

Imdadetal.(2011)conductedameta-analysisof atotalof 53 RCTs and quasi-RCTs looking at the impact of educa-tion and support strategies on breastfeeding outcomes. Fourteen of those studies were conducted in developing countries.Theinterventionsweredefinedas“breastfeed-ing education and/or additional support given to mothers through counselors (be they doctors, nurses, midwives, lactationconsultantsorpeercounselors)inindividualorgroupsessions.”Theauthorsfoundasix-foldincreaseinrates of EBF at six months of age and an 89% increase in rates of EBF at 4-6 weeks of age following interventions in developing countries. In sub-group analyses, the au-thors found that changes in prenatal counseling, postnatal counseling and a combination of both were statistically significant,with“thehighestimpactbeingthatof prena-talcounselling.”Furthermore,“groupcounsellinghadagreaterimpact(67%increaseinEBFrateat4-6weeks),comparedwithindividualcounselling(38%increase).Theresultswerestatisticallysignificantatalllevelsof care(com-munity,facilityandbothcombined).”Fiveof thefourteenstudiesincludedintheImdadetal.(2011)reviewmettheinclusion criteria of the present review and these studies are included in the summaries below.19

Jollyetal.(2012)conductedasystematicliteraturereviewand meta-regression analysis of RCTs conducted in high-, middle- and low-income countries “to examine the effect of setting, intensity, and timing of peer support on breast-feedingpractices.”Thereviewincluded17RCTs;however,only six were conducted in low income countries. In a

18 TheseincludeBashouretal.(2008);Bhandarietal.(2003);andHaideretal.(2000).

19 TheseincludeAidametal.(2005);Aksuetal.(2011);Bhandarietal.(2003);Haideretal.(2000);andKrameretal.(2001).


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sub-analysis of low income countries, those who received peersupportweresignificantlylesslikelytohavestoppedEBFatthelaststudyfollowup(RR=0.63).Fourof thesixlow-income country studies included in this meta-analysis met the inclusion criteria for the present review and are included in the summaries below.20

Finally,Renfrewetal.(2012)conductedaCochraneReviewlooking at the effect of extra support for women on EBF at sixmonthsof age.Extrasupportwasdefinedasreassurance,praise, information, and the opportunity to discuss questions with professionals, trained lay people or both during home visits or facility-based counseling sessions. This meta-analysis used data from 52 RCTs or quasi-RCTs, 16 of which were conducted in middle- to low-income countries. Extra support led to a lower risk of having stopped EBF at 4-6 weeks (aver-ageRR=0.74)aswellasalowerriskof havingstoppedEBFatsixmonths(averageRR=0.86).Inasub-groupanalysis,theauthors found a greater treatment effect on EBF cessation at six months “in settings where there were high background ratesof breastfeedinginitiation(averageRR=0.83)comparedwithareaswheretherewasintermediate(averageRR=0.89)orlowbackgroundinitiationrates(averageRR=1.00),[…]Re-sults were even more pronounced for cessation of exclusive breastfeeding at up to four to six weeks with interventions seeming to be most effective for women living in areas with highbackgroundinitiationrates(averageRR=0.61)comparedwithareaswithintermediate(averageRR=0.81)orlowrates(averageRR=0.97)”(Renfrewetal.,2012).Fourteenof the16 middle- to low-income studies included in Renfrew et al. (2012)mettheinclusioncriteriaforthepresentreviewandthese studies are included in the summaries below.21


Fifteenof the33studiesreportingstatisticallysignificantresults were RCTs. Thirteen of these were included in the meta-analyses described previously.22 Agrasada et

20 TheseincludeAgrasadaetal.(2005);Coutinhoetal.(2005);Leiteetal.(2005);andTylleskäretal.(2011).

21 TheseincludeAidametal.(2005);Aksuetal.(2011);Albernazetal.(2003);Bashouretal.(2008);Bhandarietal.(2003);Bhandarietal.(2005);Coutinhoetal.(2005);deOliveiraetal.(2006);Haideretal.(2000);Khreshehetal.(2011);Krameretal.(2001);Leiteetal.(2005);Santiagoetal.(2003);andTylleskäretal.(2011).

22 TheseincludeAgrasadaetal.(2005);Aidametal.(2005);Aksuetal.(2011);Bashouretal.(2008);Bhandarietal.(2003);Bhandarietal.(2005);Coutinhoetal.(2005);Haideretal.(2000);Krameretal.(2001);Kupra-takuletal.(2010);Leiteetal.(2005);Santiagoetal.(2003);andTripathyetal.(2010).

al.(2005)lookedattheefficacyof postnatalpeercoun-seling conducted in a hospital in Manila, Philippines. The study included two intervention groups – one in which peer counselors were trained to provide breastfeeding counseling and the other in which peer counselors were trained to provide general childcare counseling. Women in the control group did not receive any counseling. Both intervention groups included eight counseling sessions conducted at home at the following child ages: 3-5 days, 7-10 days, 21 days, and 1.5 months. Women then received counseling monthly until their children reached the age of 5.5 months. Data on breastfeeding practices were col-lected during well-child hospital visits at child age two and four weeks and monthly until the child was six months old. The authors found that women in the breastfeeding counseling intervention group were more likely to report EBF in the previous seven days at six months of age (44%)thanthoseinthechildcarecounselinggroup(7%)orthecontrolgroup(0%).Statisticalmodelingrevealedthat women in the breastfeeding counseling group were 6.3 times more likely to EBF in the previous seven days at six months than those in the other groups.

Aidametal.(2005)conductedanRCTlookingatEBFatsix months of age in Thema Township, Ghana. The inter-vention involved provider counseling and home visits, and includedtwointerventiongroups:thefirstinterventiongroup(IG1)includedtwoprenatalcounselingsessions,onecounseling session 48 hours postpartum, and six postpartum homevisits.Thesecondgroup(IG2)excludedtheprenatalcounseling, but included the rest. Following the intervention, the rate of EBF at 6 months of age was 90% in IG1, 79.5% in IG2, and 54.5% in the control group.23 The differences werestatisticallysignificantforbothinterventiongroups.

Aksuetal.(2011)lookedatbreastfeedingpracticesamongwomen who gave birth in a hospital following a Baby-friend-lyHospitalInitiative(BFHI)interventioninAydın,Turkey.Inadditiontoeducationinthefirstfewhoursafterdelivery,which was provided to all women in the hospital, women in the intervention group received breastfeeding education at home three days after delivery and were then monitored for six months. At each time point, women in the intervention group were more likely to exclusively breastfeed than women

23 Aidam et al. measured EBF at 6 months through both monthly recall and 24hourrecall.Wesitefiguresfromthe24hourrecall.


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in the control group – 67% vs. 40% at two weeks, 60% vs. 33% at six weeks, and 43% vs. 23% at six months. At six months postpartum, women in the intervention group exclu-sively breastfed an average of 0.8 months longer more than womeninthecontrolgroup(4.7vs.3.9months).

Bashouretal.(2008)exploredtheimpactof homevisitsonEBF in Damascus, Syria. Women who had recently given birth at the Maternity Teaching Hospital in Damascus, Syria were randomly assigned to one of two intervention groups – women in IG1 received four home visits (on days 1, 3, 7, and30followingdelivery),whilewomeninIG2receivedonehome visit on the third day after delivery. Registered midwives were trained to provide information, education, and support to women during the home visits. Following the intervention, EBFatfourmonthswassignificantlyhigheramongwomeninboth intervention groups – 28.5% among women in IG1 and 30.1% among those in IG2 compared with those who received nohomevisits(20.2%).Followingasub-analysisof find-ings, the authors found that “the effect was major among the groups of women who had normal vaginal delivery but not thewomenwhohadac-sectionorwereprimigravidae,”andsuggested that other factors such as hospital policy regarding the practice of rooming-in (the practice of mothers and babies stayingtogetherafterbirth)mayplayaroleandthatsuchsub-groupsmay“requireaspecialpackageof intervention.”

Bhandarietal.(2003)lookedatmediandurationof EBF,andEBFatthree,four,five,andsixmonthsof ageinHaryana, India. The intervention included counseling by traditional birth attendants at birth, monthly home visits bycommunity-basedhealthworkersduringthechild’sfirstyear of life, and counseling during weighing sessions every three months. By the end of the study period, median durationof EBFwassignificantlyhigherintheinterven-tion group compared with the control group (122 days vs. 41days),theproportionof womenreportingEBFatfourmonths was 69% in the intervention group compared with 12% in the control group, and EBF at six months was 42% in the intervention group compared with 4% in the control group.Inafollow-uparticle,Bhandarietal.(2005)reportedthat women exposed to three or more communication channels were more likely to be practicing EBF at three months than those exposed to just one or two communica-tionchannelsornoneatall(≥3channels:93.6%,1-2chan-nels:81.3%,nochannels:70.8%).

BortoliniandVitolo(2012)lookedatEBFpracticesamong infants born in one hospital in Brazil. The inter-vention group received home visits during the children’s firstyearof lifeonamonthlybasisupto6months,andat8, 10 and 12 months. Results showed that children in the intervention group were more likely to be EBF for four or more months than those in the control group (45.1% vs. 28.6%)andatsixmonths(19.1%vs.8.2%).

Coutinhoetal.(2005)lookedatEBFatsixmonthsof agein Pernambuco, Brazil. Following the training for health care providers on the BFHI,24 the proportion of infants exclusively breastfed during the hospital stay increased sig-nificantly,butEBFwasnotsustainedbeyondthehospitalstay. In an effort to increase the length of EBF, researchers randomly assigned women who gave birth in two BFHI hospitals to the intervention group, which received ten postnatal home visits by trained community health agents, or to the control group, which did not receive home visits but still received the breastfeeding support provided during the hospital stay. At six months post-partum, rates of EBF among women in the intervention group was 45% com-pared with 13% among women in the control group.

Haideretal(2000)lookedatbreastfeedingpracticesinDhaka,Bangladesh.Followingafivemonthpeercounselingintervention, the proportion of children exclusively breast-fedatfivemonthsof agewas70%intheinterventiongroup compared with 6% in the control group.

Krameretal.(2001)lookedatbreastfeedingpracticesin31hospitals in Belarus. The objective of the Promotion of BreastfeedingInterventionTrial(PROBIT)wasto“assessthe effects of breastfeeding promotion on breastfeeding duration and exclusivity and gastrointestinal and respiratory infectionandatopiceczemaamonginfants.”Theinterven-tion was “modeled on the Baby-Friendly Hospital Initiative

24 According to the WHO website: “The Baby-friendly Hospital Initiative (BFHI)waslaunchedbyWHOandUNICEFin1991,followingtheIn-nocenti Declaration of 1990. The initiative is a global effort to implement practices that protect, promote and support breastfeeding. To help in the implementation of the initiative, different tools and materials were devel-oped,field-testedandprovided,includingacourseformaternitystaff,aself-appraisaltoolandanexternalassessmenttool.”TherevisedBFHIpackage includes background and implementation; material for training/raising the awareness of policy and decision-makers in relation of BFHI and IYCF in general; materials for a 20-hour course for training facility staff (clinicalandnon-clinical);self-appraisalandmonitoringtools;andassessment and re-assessment tools. See: http://www.who.int/nutrition/topics/bfhi/en/


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of the World Health Organization and United Nations Chil-dren’s Fund, which emphasizes health care worker assistance with initiating and maintaining breastfeeding and lactation and postnatal breastfeeding support, or a control interven-tion of continuing usual infant feeding practices and poli-cies.”Attheendof thestudyperiod,ratesof EBFatthreemonths were 43.3% in the intervention group and 6.4% in the control group. Rates of EBF at six months were 7.9% in the intervention group and 0.6% in the control group.

Kupratakuletal.(2010)lookedatEBFinthecontextof an intervention aimed at improving antenatal and postnatal support in Bangkok, Thailand. The intervention included Knowledge Sharing Practices with Empowerment Strategies (KSPES)duringantenataleducation(storytelling,demonstra-tion,andpractice)aswellaspostnatalsupport.Attheendof the six month intervention period, 20% of the women in the intervention group reported EBF through six months, while none in the control group reported EBF through six months.

Leiteetal.(2005)assessed“theeffectivenessof home-based peer counselling on breastfeeding rates for unfavour-ablylowbirthweightbabies”inBrazil.Womenandtheirnewbornbabiesidentifiedinthematernityservicesthatmetthe inclusion criteria were randomly assigned to the inter-vention or control group. The intervention group received six home visits from trained lay counselors at 5, 15, 30, 60, 90 and 120 days following birth. In addition to counseling, home visits included “interviews with the mother; observa-tion of the home environment; observation of all aspects involved with the breastfeeding, including technical ones, as wellasthemother-childrelationship;andidentificationof thedifficultiesfacedbythemotherduringbreastfeeding.”Following the intervention, rates of EBF at four months weresignificantlyhigheramongtheinterventiongroupthanthecontrolgroup(24.7%vs.19.4%).

MorrowandGuerrero(2001)conductedanRCTtodeter-mine the effectiveness of three vs. six home visits by peer counselors on EBF rates among women in a peri-urban area of Mexico. The intervention was informed by an eth-nographic study identifying maternal beliefs, practices, and needs. Lay counselors were recruited from each interven-tion community and trained by La Leche League. Women were enrolled during pregnancy and randomly assigned to one of two intervention groups –women in IG1 received six home visits and women in IG2 received three home

visits. In IG1, “mothers were visited by [peer counselors] twiceduringpregnancy(midandlatepregnancy),imme-diatelypostpartum,andatweeks2,4,and6postpartum.”In IG2, women were visited once late in pregnancy, once immediately postpartum, and once two weeks after delivery. The authors found that women in IG1 who received six home visits had higher rates of EBF than women in IG2 whoreceivedthreevisits(67%vs.52%)ornovisits(12%).

Santiagoetal.(2003)exploredtheroleof pediatriciansinimproving EBF rates at four months in Brazil. Healthy, full term infants born at the pediatrics outpatient clinic in the Triângulo Mineiro teaching hospital in Minas Gerais were randomly divided into three groups. Women in IG1 received advice from a multidisciplinary breastfeeding support team (including a pediatrician trained in breastfeeding, a social worker,apsychologist,adentistandanurse)duringwhichtimebreastfeedingdifficultieswerediscussedandpotentialsolutions were offered as a group. Women in IG2 received advice from the same trained pediatrician, but in individual consultations, while those in the control group received ad-vice from a pediatrician with no breastfeeding training. Fol-lowing the intervention, 82.9% of women in IG1, 66.7% of women in IG2, and 30.3% of women in the control group reported EBF at four months. The difference between IG1 andIG2wasnotstatisticallysignificant;however,thediffer-encebetweenIG1andthecontrolwasstatisticallysignificant.

Finally,Tripathyetal.(2010)conductedanRCTlookingatEBF in Orissa and Jharkhand, India. In intervention areas, female facilitators conducted monthly meetings with new mothers for a period of 20 months. The meetings revolved around participatory learning and action, and led to the development and implementation of strategies to address maternal and newborn health problems. Following adjusted analysis of surveillance data from years one and three, the authors reported that the proportion of infants exclusively breastfed at six weeks was higher in intervention areas than incontrolareas(OR=1.82).25


Eightof the33studiesreportingstatisticallysignificantresultswerelongitudinalstudies.Akteretal.(2012)studiedan intervention which involved four group counseling ses-

25 Theseinclude:Baquietal.(2008a);Baquietal.(2008b);Bhuttaetal.(2008b);andKumaretal.(2008).


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sions during the last trimester of pregnancy. Following the intervention, 64.9% of women in the intervention group reported EBF at one month after birth, compared with 37.9% of women in the control group.

Balalukaetal.(2012)conductedalongitudinalstudylookingatmediandurationof EBF,andEBFatfour,five,andsixmonths in two health districts in the Democratic Republic of Congo. The intervention involved a combination of home visits, community based counseling, and community mobiliza-tion,includingmonthlycommunity“weighingsessions.”Afterapproximately three years of implementation, the authors compared EBF practices in the intervention health district with another health district that resembled the intervention district. They found that median duration of EBF was two months longer in the intervention district than in the control district(sixvs.fourmonths).Likewise,theprevalenceof EBFwas higher in the intervention district compared with the control district at all of the following points in time: at four months(91.8%vs.50.7%),atfivemonths(81.3%vs.9.6%),andatsixmonths(57.7%vs.2.7%).Alldifferenceswerestatis-ticallysignificant;however,thelackof baselinevaluesmakesitdifficulttoattributethesedifferencestotheintervention.

Braunetal.(2003)lookedattheeffectof theBFHIonEBF by following two cohorts of babies born at a hospital in Porto Alegre, Brazil – one cohort of babies born before the BFHI initiative had been introduced and the other born after the BFHI initiative had been introduced. Mothers wereinterviewedattheendof thefirst,second,fourth,and sixth months after birth. The authors found that the median duration of EBF increased from one month to two months after BFHI had been introduced.

Alametal.(2002)conductedalongitudinalstudycompar-ing EBF rates in two hospitals in Dhaka, Bangladesh. The interventionhospitalwascertified“baby-friendly,”whilethe control hospital was not. The authors assessed EBF practices at 30, 60, 90, 120, and 150 days postpartum. At each time point, EBF rates were higher among women who delivered in the baby-friendly hospital compared with those who delivered in the control hospital, but the sta-tisticalsignificanceof thesedifferenceswasnotreported.Thelikelihoodof EBFformorethanfivemonthswasstatistically greater in the intervention hospital compared withthecontrolhospital(8.1%vs.6.5%)aswastheme-diandurationof EBF(69.74daysvs.48.4days).

Piwozetal.(2005)conductedalongitudinalstudywithinthe Zimbabwe Vitamin A for Mother and Babies Trail (ZVITAMBO),inwhich14,110mother-babypairswereenrolled within 96 hours of delivery. “Formative research was undertaken to guide the design of the program that included group education, individual counselling, videos, and brochures. Exclusive breast-feeding was recommend-ed for mothers of unknown or negative HIV status, and forHIV+motherswhochosetobreast-feed.”Com-parisons were made between women who were enrolled in the trial before, during, and after the education and counseling program was implemented. The authors found that women who enrolled in ZVITAMBO while the coun-seling and education program was being fully implement-ed were 8.4 times more likely to EBF at three months compared with those who enrolled in ZVITAMBO before the program began and, therefore, only partially partici-pated in the program.

Inafollow-uparticle,Piwozetal.(2007)assessedtheas-sociation between exposure to the counseling and educa-tion program described directly above and postnatal HIV transmission among a subset of 437 HIV+ women, 365 of whom did not know their HIV status. They found that EBF was higher in the intervention group at six weeks and three months, but no such effect was found at six months.

Saludetal.(2009)evaluatedapeercounselinginterven-tion aimed at increasing EBF rates in the Philippines. The intervention targeted 312 “mothers with infants less than 2 months of age who were not exclusively breastfeeding or haddifficultybreastfeeding.”Eachwomanthenreceivedthree peer counseling visits: one at baseline, another after one week, and the third after two weeks. Following inter-vention, EBF had increased from 1% to 53.5%.

Finally,Suleetal.(2009)evaluatedtheimpactof nutritionaleducationonIYCFknowledge,attitudeandpractices(KAP)of women in southwest Nigeria. The intervention included group-based nutrition education and demonstrations of complementary food once every two weeks for a period of six months. Participating women were also visited in their homes monthly for six months to monitor their EBF practices. After six months, women with children six months orolderintheinterventioncommunityweresignificantlymore likely to report EBF for six months than women in the controlcommunity(66.7%and52.0%,respectively).


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Crookstonetal.(2007)lookedatbreastfeedingbehaviorsina repeated cross-sectional study conducted in rural Cambo-dia. At baseline, women in program communities were 54% more likely than women in control communities to have breastfed exclusively in the previous 24 hours. At follow-up, they were 81% more likely to do so. After one year, the RR associated with EBF through six months of age had increased from 1.54 to 1.81.

Harkinsetal.(2008)evaluatedtheeffectivenessof IMCIinterventions on EBF for six months in San Luis, Hondu-ras. The authors described the community IMCI approach asusingthe“social-actormethodology”tocreateandpromote “linkages between partners that create syner-giesinlocalandregionalsocialmobilizations.”Teachersand Red Cross volunteers trained in community IMCI conducted home visits to promote prenatal care, exclusive breastfeeding, vaccinations, and the healthy growth and developmentof infantsandchildren.”Afteroneyear,the percentage of women reporting EBF for six months increased from 11% to 19%.

ThompsonandHarutyunyan(2009)lookedatEBFthrough six months of age in Martuni region in northeast-ern Armenia. The intervention was delivered through a community-based IMCI platform, and included home visits for pregnant and lactating women, group education classes for new parents, and a local mass media campaign. By the end of the study period, rates of EBF through six months increasedfrom16.7%to48.1%.Thefindingwasstatisti-callysignificant;however,thelackof datafromacontrolgroup limits claims of attribution.

Quinnetal.(2005)lookedatEBFinthreecountries:Madagascar, Bolivia, and Ghana. Following a four year multi-channel behavior change program, rates of exclusive breastfeeding among children under six months of age increased from 46% to 68% in Madagascar, from 54% to 65% in Bolivia, and from 68% to 79% in Ghana.

Inafollow-upanalysistotheQuinnetal.(2005)article,Guyonetal.(2009)reportedanincreaseinEBFfrom42%to70%afterfiveyearsof implementationinMadagascar.NeitherQuinnetal.(2005)orGuyonetal.(2009)includedcontrol communities.


Guptaetal.(2004)“evaluatedtheextenttowhichexpo-sure to BCC messages in the media determined improve-ments in exclusive breastfeeding knowledge and practices in areas targeted by the Delivery of Improved Services for Health(DISH)Projectof Uganda.”TheDISHProjectdeveloped and disseminated materials that targeted both men and women of reproductive age and promoted EBF forthefirstsixmonthsandappropriatecomplementaryfeeding practices. The intervention used radio, television, video, posters, and print materials (newspapers, magazines, orleaflets).Multiplelogisticregressionanalysisshowedthat women exposed to multiple BCC messages were more likely to exclusively breastfeed their infant for six months than women exposed to just one message. How-ever, women with no exposure were more likely to EBF than those with exposure to any one message. The authors cautioned that “even the positive effects of self-reported BCC exposure on the outcomes of interest do not neces-sarily imply a direct causation, since precise information on the timing of changes in knowledge and practices of individuals with respect to exposure to the mass media was lacking.”Theyalsodiscussedconfoundingfactorswhichmay be related both to exposure and to EBF practices, including age of respondent, marital status, parity and other socio-demographic factors, and suggested that the effects of media on breastfeeding practices “were less conclusive possibly because of the short interval between the launch of theBCCcampaignandsurveyimplementation.”

Matovuetal.(2008)conductedaretrospectivestudycomparing adherence to EBF recommendations among HIV+ Ugandan women attending individual client-provider counseling at a health facility and receiving education with those who only received group counseling or education. At enrollment all women opted to EBF. At the conclusion of the study period, women who had received individual counseling were more likely to EBF at six months than those who had received only group counseling or educa-tion(OR=3.43).Furthermore,thosewhohadattendedatleastfourantenatalcare(ANC)visitswereevenmorelikely to EBF at 6 months (OR=5.95, Adjusted Odds Ratio(AOR)=3.86),whilethosewhoattendedatleastsixpostnatal counseling sessions were more likely to EBF at six months than those who received less (OR=3.34,


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AOR=12.52).Finally,thosewhoconsultedahealthworkerregarding breastfeeding problems were also more likely to EBFatsixmonths(OR=4.97,AOR=13.11).However,theretrospective nature and the lack of randomization make it impossible to attribute these differences to the intervention.

Continued breastfeeding

Of the 16 studies reporting on continued breastfeed-ingpractices,ninereportedstatisticallysignificantresults.Continued breastfeeding was measured at six months (two studies),at12months(fourstudies),andat24months(onestudy).Statisticallysignificantresultswithregardtotheduration of any breastfeeding were reported in two studies.


Imdadetal.(2011)conductedameta-analysisof 53RCTsandquasi-RCTs looking at the impact of education and support strategies on breastfeeding outcomes. The authors reviewed twenty studies which reported on breastfeeding at six months, two of which were from developing countries. They found a 12%increaseinanybreastfeedingatsixmonths(RR=1.12).


Sixof theninestudiesreportingstatisticallysignificantresultswereRCTs.Aksuetal.(2011)lookedattheimpactof both facility and home-based counseling on continued breastfeeding rates in Turkey. Following the intervention, women in the intervention group breastfed for an average of three months longer than those in the control group (15.1vs.12.1months).

Bhandarietal.(2001)conductedanRCTinwhichwomenwererandomizedtooneof fourgroups:thefirstreceivedamicronutrient-fortifiedfoodsupplementalongwithmonthly nutrition counseling, the second received monthly nutrition counseling alone, the third received a twice-weekly home visit, and the fourth received no intervention. Following intervention, breastfeeding at 12 months was actually lower among those who received the supplement and counseling compared with those who received no inter-vention(83.9%vs.96.7%).Theauthorsreportednootherstatisticallysignificantfindings.

BortoliniandVitolo(2012)conductedastudyof infantsborn in Rio Grande do Sul, Brazil. Newborns and their

mothers were randomly assigned to the intervention or control group. Women in the intervention group received homevisitsduringthechildren’sfirstyearof lifeonceamonth through the age of six months, and then every other month until the child reached 12 months. Following the in-tervention, the proportion of children breastfed at both six and 12 months was higher in the intervention group than the control group (66.3% vs. 55.6% at 6 months and 52.8% vs.41.9%at12months).

Guldanetal.(2000)lookedattheimpactof home-basedpeer counseling on continued breastfeeding practices. Fol-lowing a year-long intervention, the percentage of women reporting breastfeeding infants between the ages of 4-12 months was higher in the intervention group than in the controlgroup(83%and75%,respectively).Thefindingswerestatisticallysignificant;however,asnotedbefore,thelack of baseline and/or randomization of the interven-tion and control groups makes attribution of change to the intervention challenging.

Krameretal.(2001)lookedattheimpactof facilityandlay counseling and small media on continued breastfeeding practices in Belarus. Following the intervention, breast-feeding rates at 12 months were 19.7% in the intervention group compared with 11.4% in the control group (adjusted OR=0.47).

Kupratakuletal.(2010)foundthattheproportionof womenpracticing“predominant”breastfeedingat6months,definedas “infants … fed with the mothers’ breast milk and water, sweetenedwaterandjuiceswithoutformula”wassignificant-ly higher among women in the intervention group compared withthoseincontrolgroup(40.0%vs.5.3%).


DuyanCamurdanetal.(2007)conductedalongitudinalstudylooking at the impact of the BFHI initiative on breastfeeding practices in Gazi University Hospital in Turkey. All women delivering in the hospital were invited to participate in peri-odic well-child visits. During each visit, providers reinforced thebenefitsof breastfeedingandprovidedcounseling.Theaverage duration of breastfeeding was 21.17 months among women giving birth after the introduction of BFHI, com-pared with 17.83 months among those giving birth prior to the introduction of BFHI. Following regression analysis


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SBCC approaches and activities

Reviews with meta-

analysisRCTs


Repeated cross-

sectional studies


TOTAL

Interpersonal Communication 6 (6) 27 (21) 14 (9) 11 (9) 1 (1) 59 (46)

One-on-One Counseling 6 (5) 25 (20) 12 (9) 10 (9) 1 (1) 48 44)

Counseling in facilities 0 8 (5) 9 (6) 2 (2) 1 (1) 20 (14)

Counseling in communities 2 (2) 0 2 (2) 2 (2) 0 6 (6)

Counseling in homes (home visits) 4 (4) 23 (18) 4 (3) 5 (3) 0 32 (28)

Counseling in other settings 2 (2) 0 0 2 (2) 0 4 (4)

Group Education 3 (3) 6 (5) 6 (3) 4 (4) 1 (1) 17 (16)

Education in facilities 0 1 (1) 3 (3) 0 1 (1) 5 (4)

Education in communities 1 (1) 5 (4) 4 (2) 3 (3) 0 12 (10)

Education in other settings 2 (0) 0 0 1 (0) 0 3(0)

Support Group 1 (1) 4 (3) 5 (3) 5 (3) 0 14 (10)

Support group in facilities 0 2 (2) 4 (3) 1 (1) 0 7 (6)

Support group in communities 1 (1) 2 (1) 1 (0) 2 (0) 0 5 (2)

Support group in other settings 0 0 0 2 (0) 0 2 (0)

Media 0 5 (5) 8 (6) 9 (6) 2 (2) 24 (19)

Mass media 0 0 0 4 (3) 1 (1) 5 (4)

Mid-sized media (community radio / video, local billboards)

0 0 2 (2) 5 (3) 1 (1) 8 (6)

Small media (posters, flyers, calendars, reminder stickers) 0 4 (4) 7 (5) 7 (5) 1 (1) 19 (15)

Traditional media (songs, drama) 0 3 (3) 0 0 0 3 (3)

Social media (Twitter, Facebook, etc.) 0 0 0 0 0 0

Community/Social Mobilization 1 (1) 4 (3) 2 (1) 9 (6) 0 16 (11)


Issue groups 1 (1) 3 (2) 2 (1) 5 (2) 0 11 (7)

Other 0 1 (1) 0 3 (3) 0 4 (4)


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that controlled for variables that might affect breastfeeding practices (mother’s occupation, educational status, age, way of birth,parity,durationof pregnancy,birthweight)thebreastfeeding rate was 1.5 times higher among women giving birth after the introduction of BFHI, compared with those giving birth prior to the introduction of BFHI.


Guyonetal.(2009)conductedarepeatedcross-sectionalstudy looking at breastfeeding practices in Madagascar. Fol-lowing an intervention that included community mobiliza-tion, campaign events, and mass media, rates of breastfeed-ing among children 12-15 months of age increased from 89% to 94%, and among children 20-23 months of age the rate increased from 43% to 73%.



For the purposes of analysis, we organized SBCC activi-ties into three primary categories or approaches: inter-personal communication, media, and community/social mobilization.Theseapproachesandthespecificactivitiesassociated with each are described in further detail in the introductory chapter.

The studies reviewed included a broad range of approaches to promote optimal breastfeeding practices. Most included morethanonespecificSBCCactivityandmanyutilizedmore than one approach.

All six literature reviews focused on interpersonal commu-nication(IPC)approaches.Onereviewincludedfindingsrelated to community/social mobilization.

Amongthe42otherstudiesreportingstatisticallysignifi-cant results, 40 included interpersonal communication (IPC)approaches,19includedsomeformof media,and10 included community/social mobilization. One-on-one counseling in the home was the most commonly used IPC approach, small media was the most commonly used media approach and the gathering of issues groups was the most commonly used community/social mobilization approach (seeTable3.2.2).

Nine of the reviewed studies explored the impact of the BFHI on breastfeeding practices. In some cases an SBCC

intervention was added to the standard BFHI package, while in other cases, facilities implementing BFHI were compared with those who were not doing so.

There is a wide breadth of evidence regarding the effective-ness of various SBCC approaches in changing breastfeeding practices.Table3.2.3providesasummaryof thesefindings.


Six reviews with meta-analysis establish the effectiveness of IPC approaches with respect to uptake of optimal breastfeeding practices. All but one looked solely at IPC interventions.GogiaandSachdev(2010)reportedapositiveeffect of IPC with respect to early initiation of breastfeed-ing(RR=3.35),whileImdadetal.(2011)reportedasix-foldincrease in EBF rates at six months following breastfeed-ingpromotionindevelopingcountries(RR=1.37overall).Renfrewetal.(2012)foundthatextrasupportledtoalowerriskof havingstoppedEBFatsixmonths(RR=0.86),Hall(2011)andJollyetal.(2012)reportedsimilareffectrelatedtoEBFatothertimes,andImdadetal.(2011)reportedaposi-tive effect of IPC on continued breastfeeding at six months (RR=1.12).Lassietal.(2010)reportedanRRof 1.94withrespect to early initiation of breastfeeding, but the inter-vention package included both IPC and community/social mobilization,makingattributiontoIPCdifficult.Noneof thereviewsreportedfindingsassociatedwithbreastfeedingattwo years of age, the universally recommended practice.

In addition to the reviews, 41 primary research studies re-portedstatisticallysignificantoutcomesrelatedtotheeffectof IPC interventions on breastfeeding initiation, 14 reported significantoutcomeswithrespecttobreastfeedinginitiation,27reportedonEBF,andninereportedsignificantoutcomeswith respect to continued breastfeeding rates.

Eighteen studies measured the effectiveness of IPC inde-pendent of other SBCC approaches, including six which were not included in the previously described reviews: three RCTs, two longitudinal studies, and one repeated cross-sec-tionalstudy.AmongtheRCTs,BortoliniandVitollo(2012)reportedthemostcompellingfindings,adifferencebetweenintervention and control communities of 10.7 percentage points with respect to breastfeeding at six months and 10.9 percentage points with respect to breastfeeding at 12 months.

In the only study looking at continued breastfeeding at two


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yearsof age,Guyonetal.(2009)reportedanincreaseof 30percentage points in their repeated cross-sectional study.

Indicators and study design varied considerably among studies,makingconsolidationof findingsfromstudiesnotincludedinpreviousliteraturereviewsdifficult.

Media

We did not identify any reviews documenting the effective-ness of media-related interventions on breastfeeding out-comes, but did identify 19 primary research studies report-ingsignificantoutcomesassociatedwithinterventionsthatincluded media-based SBCC approaches. Nine reported a significanteffectwithrespecttobreastfeedinginitiation,13reportedasignificanteffectwithrespecttouptakeof EBF,andthreereportedasignificanteffectwithrespecttocontinued breastfeeding practices.

Onlyoneof thesestudies,Guptaetal.(2004),presentedfindingsregardingtheeffectof media-basedapproachesindependent of other SBCC approaches. Researchers measured the impact of exposure to messaging through four different media channels: radio, television, posters, and print materials. They reported a greater likelihood of EBF for six months among those exposed to messages through these forms of media two or more times.

Community/Social mobilization

Lassietal.,(2010)includedfindingsrelatedtocommunity/social mobilization. The review, however, looked at both community/social mobilization and IPC, and did not disag-gregate results between the two approaches. It is therefore not possible to assess the effect of IPC independent of other SBCC approaches.

Eightprimaryresearchstudiesreportedasignificanteffectof interventions including community/social mobiliza-tion with respect to breastfeeding initiation, six reported a significanteffectwithrespecttoEBF,andonereportedasignificanteffectwithrespecttocontinuedbreastfeeding.

None of these studies reported on the effect of com-munity/social mobilization in isolation from other SBCC approaches,soitisdifficulttoderiveconclusionsregardingthe singular effectiveness of community/social mobiliza-tion in changing breastfeeding practices.


One review documented the effect of multiple SBCC ap-proaches on the uptake of breastfeeding practices. Lassi et al.(2010)reportedanRRof 1.94amongstudiesemployingIPC and/or community/social mobilization to improve uptake of early initiation of breastfeeding. They did not, however, distinguish among studies employing IPC, com-munity/social mobilization, or both.

InadditiontothereviewbyLassietal.(2010),weidenti-fiedtwenty-threeprimaryresearchstudiesreportingposi-tive outcomes associated with interventions that included more than one SBCC approach. Eleven reported a posi-tive effect with respect to early initiation of breastfeed-ing, 15 report a positive effect with respect to EBF, and three reported a positive effect with respect to continued breastfeeding at six months or older. Among the most no-tablearethreeRCTsnotincludedintheLassietal.(2010)review:Bangetal.(2005);MorrowandGuerrero(2001);andOmeretal.(2008).

None of these studies measured the effect of the utiliza-tion of more than one SBCC approach compared with the utilization of just one approach. One must use caution, therefore, in drawing conclusions about the effectiveness of interventions employing multiple approaches versus those employing just one approach.


Few of the studies reviewed in this chapter assessed the effect of implementation processes (e.g. intensity and timing of communications; type and training of person communicatingmessages,ortargetaudience)ontheeffectiveness of the SBCC approach on breastfeeding practices, nor did they consistently report all aspects of the implementation processes.

Little work has been done to compare the effect of timing orfrequencyof interventions.Imdadetal.(2011)con-ducted a sub-analysis which showed that “prenatal counsel-ling had greater impacts on breastfeeding rates at 4-6 weeks, while combined prenatal and postnatal promotion were im-portantforbreastfeedingratesat6months.”Renfrewetal.(2012)foundnoeffectof thetimingof thesupport(duringtheantenatalorpostnatalvisit),whileJollyetal.(2012)found that “combined antenatal and postnatal peer support


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wasnotassociatedwithasignificantimprovementinnotbreast feeding at last study follow-up, whereas postnatal onlyinterventionsdidsignificantlyreducenotbreastfeed-ing.”Likewise,Aidametal.(2005)foundthatwomenwhoreceived two prenatal counselling sessions, one counseling session 48 hours postpartum, and six postpartum home visits were just as likely to EBF at six months as those who received only postpartum counselling.

The intensity of communications ranged between one and twenty visits or sessions, and several meta-analyses and studies did make comparisons between the effectiveness of interven-tionswithvariedintensities.Jollyetal.(2012)foundthatwom-eninthemoreintensiveinterventions(≥5contactsplanned)were more likely to report breastfeeding at last follow-up com-paredwithusualcare.Similarly,Renfrewetal.(2012)foundthat “studies with four to eight visits seemed to be associated withamorepronouncedtreatmenteffect.”However,theau-thors warned that “care is needed in the interpretation of this findingasthereisinconsistentreportingduetovariationsinthe timing of outcome assessments, and the settings of studies and the population groups included in studies with more face-to-face visits also varied. It is likely that support will be most effectivewhenitreflectsthelocalneedsof thepopulation.”Renfrew et al. also found a greater treatment effect on EBF at six months when the “intervention was delivered by non-professionals(averageRR=0.74)comparedwithprofessionals(averageRR=0.93)orboth(averageRR=0.76).”Likewise,women who received face-to-face support were 19% less likely to have given up EBF at six months compared with those who didnot(averageRR=0.81).

Piwozetal.(2007)conductedanRCTcomparingthosewho received no visits, one visit, two visits or three visits when counselling on HIV and infant feeding was provided. They found that EBF at six weeks and three months was incrementally higher with each additional visit. Statistical significanceof thedifferencesbetweenthegroupswerenotreported, but the authors did conclude that “frequency of intervention contact was associated with safer breastfeeding knowledgeandexclusivebreastfeedingpractices.”

Finally,MorrowandGuerrero(2001)conductedanRCTinwhich they compared EBF at three months between those who received six home visits and those who received three home visits. While those receiving six home visits appeared to be more likely to EBF at three months than their counter-

partswhoreceivedonlythreehomevisits(a15%difference),thestatisticalsignificanceof thedifferencewasnotreported.Both were effective when compared with a control group.

In terms of target audiences, the majority of the studies reviewed focused attention on the mother or caregiver. Among the 48 studies (literature reviews and primary re-search)reportingstatisticallysignificantresults,alltargetedthe mother of the child herself. Twenty-six targeted only the mother of the child herself. Fourteen also targeted directinfluencers,18targetedlocalcommunityactors,andthree targeted actors of the enabling environment in addi-tion to pregnant or lactating women.

OnlyLassietal.(2010)comparedtheeffectof targetingonevs. multiple audiences or of targeting different audiences. The authors found that “the most successful packages were those that emphasized involving family members through community support and advocacy groups and community/social mobilization and education strategies, provision of care through trained CHWs via home visitation, and strengthened properreferralsforsickmothersandnewborns.”

E. Conclusions

The body of literature focusing on SBCC approaches be-ing used to improve breastfeeding practices is strong and broad, supporting the claim that SBCC approaches can and do succeed in improving uptake of the behaviors promot-ed.Whiletheliteraturemayreflectabiastopublishpositiveresults, it also underscores the important role of SBCC ap-proaches in improving nutrition practices – practices which have been shown to have an impact on the nutritional status of women, infants, and children.

There is more consistency in how breastfeeding practices aredefinedandmeasuredthanintheotherchaptersof thisreview. This is particularly so in the case of early initiation of breastfeeding. However, even with globally-recognized indica-tors and measurement guidance from the WHO, consider-able variation remains. For example, while fourteen studies re-portedstatisticallysignificantfindingsrelatedtoEBFchildrensix months old, 19 reported on EBF at a range of other ages.

There is considerable variation in the SBCC interven-tions designed to improve breastfeeding practices – in the interactions or combinations with other interven-tions, target groups, content, messages, scale and


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SBCC approachInitiating

breastfeeding earlyExclusive

breastfeeding Continued

breastfeeding Interpersonal Communication


2 Review with meta-analysis (within one hour)

6 RCTs (3 within one hour; 1 within 6

hours; 2 colostrum, 2 included in previous meta-analysis)

1 Longitudinal (within one hour)

7 Repeated cross-sectional (6 within one hour; 1 “early

initiation”; 1 colostrum, 1 included in previous meta-analysis)


4 Review with meta-analysis (2 any EBF; 2 at 4-6 weeks;

2 at 6 months)

14 RCTs (8 at 6 months; 1 at 5 months; 8 at 4 months; 5 at 3 months; 1 at 2 months; 1 at 6 weeks; 2 at 30 days; 1 at 15 days;

1 at 7 days; 13 included in previous meta-analysis)

8 Longitudinal (1 at 1 month, 1 at 6 weeks, 3 at 3

months, 1 at 4 months, 1 at 5 months, 3 at 6 months, 2 duration)

5 Repeated cross-sectional (1 at 6 months; 4 among children < 6

months)

1 Cross-sectional (at 6 months among HIV+ women)


1 Review with meta-analysis (at 6 months)

7 RCTs (3 at 6 months; 2 at 12 months; 1 among those 4-12 months; 1 duration; 4 included in previous

meta-analysis)

1 Longitudinal (duration)

1 Repeated cross-sectional (at 24 months)

Media 10, 9 reporting statistical significance:

3 RCTs (1 within 1 hour; 1 within 6 hours; colostrum; 1 included in previous

meta-analysis)

7 Repeated cross-sectional (4 within one hour; 1 within 30

minutes, 1 “early initiation”; 1 colostrum)


2 RCTs (2 at 3 months; 1 at 6 months)

5 Longitudinal (2 at 3 months; 1 at 5 months; 1 at 6 months; among children < 6 months;

duration)

4 Repeated cross-sectional (among children < 6 months)

2 Cross-sectional (2 at 6 months, 1 among

HIV+ women)


1 RCTs (1 at 12 months)

1 Longitudinal (duration)




1 Review with meta-analysis (within one hour)

1 RCT (initiation within one hour; 1 within 6 hours, included in previous meta-

analysis)

7 Repeated cross-sectional (5 within one hour; 1 within 30

minutes, 2 colostrum, 1 included in previous meta-analysis)


1 RCT (at 4 months; at 6 months, included in

previous meta-analysis)

1 Longitudinal (at 3 months; at 4 months)

4 Repeated cross-sectional (1 at 6 months; 3 among children < 6

months)




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coverage, length and intensity, as well as context.

Interpersonal communication was the most prevalent SBCC approach found to be effective at improving breastfeeding practices in both implementation and research. While media and community/social mobilization were used, they were almost always used with at least one other communication approach.Theevidenceincludedinthereviewalsoreaffirmsthe importance of peer support for improving breastfeeding practices, whether one-on-one or in groups. The question remains as to whether many projects use IPC because it is more effective than other approaches at improving breast-feeding practices, or whether it has become the default ap-proach. Given the complex and personal nature of the suite of behaviors making up optimal breastfeeding, it is likely the former. Unfortunately it is both difficult and expensive to disaggregate the contribution of single channels or specific activities within a multi-channel intervention, and an important question for SBCC practitioners and researchers is whether that line of research is useful.

SBCC interventions to promote breastfeeding practices are suited to iterative programming, because even if standards for behaviors aren’t met, there can be signifi-cant movement toward the standard. In a hypothetical ex-ample, the target number of women exclusively breastfeeding at six months might not be met, but many women may have continued EBF for a month or two more than they would have had the intervention not happened. In this example, the intervention may not have succeeded in achieving the stand-ardized indicator, but moved the EBF duration in the right di-rection. Iterative interventions can learn what supported that move in the right direction, and build on them.

Allof thestudiesreportingstatisticallysignificantresultstargeted the woman herself. Nearly half targeted other audiencesorinfluencersaswell.Littlehasbeendonetocompare the effect of targeting one vs. multiple audiences or of targeting different audiences, but what was done suggested that targeting multiple contacts has a greater effect than targeting only the woman herself, given the important role of husbands, mothers-in-law, and community leaders. With regard to timing, few compari-sons were made between the effect of different timings and

what little was done presents contradictory evidence.

Thereissomeevidencethatintensity(numberof contacts)influencestheeffectivenessof SBCCinterventionsinpro-moting adoption of optimal breastfeeding practices. The in-tensity of communications ranged between one and twenty visits or sessions. While some studies reported statistically significantimprovementsinbreastfeedingpracticesafteronly one or a few contacts, evidence from several meta-analyses and primary research studies strongly suggests that increasing the number of contacts increases the positive effect of SBCC interventions on breastfeeding practices.

The majority of studies were implemented on a relatively small scale, within a few health facilities or communities and typically with fewer than 500 study participants per group. Because of these limitation and due to the lack of standardization in the way research related to SBCC is designed and described, it is challenging to make conclu-sions beyond the fact that projects with SBCC will result in uptake of promoted practices.

The evidence for SBCC and breastfeeding suggests the effect of context (including social norms, culture, and envi-ronmentalfactors)aswellasexistingnationalbreastfeedingrates. This underscores the importance of proper context assessments, formative research and/or ethnographic study prior to SBCC implementation.

While there is much to be learned from this large body of literature to aid us in developing future programs, a number of questions remain. These include questions related to:

n thepositive(ornegative)effectof usingmultipleSBCCapproaches compared with focusing on only one;

n thepositive(ornegative)effectof targetingmultipleaudiencesorinfluencersof thebehaviorsbeingpromoted,rather than focusing on just one target population;






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Tabl

e 3.

2.4:

Stu

dies

rep

ortin

g on

bre

astfe

edin

g pr

actic

esC

olor

cod

ing

key

Brea

stfe

edin

g in

itiat

ion

Excl

usiv

e br

east

feed

ing

Con

tinue

d br

east

feed

ing

ST

UD

YA

PP

RO

AC

HE

S

US

ED

SC

OP

E /

SC

AL

EE

VA

LU

AT

ION

D

ES

IGN

OU

TC

OM

E(S

) M

EA

SU

RE

DR

ES

ULT

S26

P-V

AL

UE

s /

CIs

27

Abo

lyan

(20

06);

Rus

sia

Cou

nsel

ing

in fa

cilit

ies

by

prov

ider

s; Su

ppor

t gr

oup

in fa

cilit

ies

by p

rovi

ders

an

d/or

lay

volu

ntee

rs; S

mal

l m

edia

8 m

ater

nity

hos

pita

ls

Long

itudi

nal –

741

hea

lthy

post

part

um w

omen

(38

3 in

terv

entio

n, 3

58 c

ontr

ol)

Med

ian

time

until

initi

atio

n of

bre

astfe

edin

g 2

hrs.

vs. 1

2 hr

s.N

S28

% E

BF fr

om b

irth

unt

il di

scha

rge

from

hos

pita

l88

.9%

vs.

32.6

%N

S

Agr

asad

a et

al.

(200

5); P

hilip

pine

sC

ouns

elin

g in

hom

es b

y la

y vo

lunt

eers

1 ho

spita

l R

CT

– 1

79 p

ostp

artu

m

wom

en (

60 IG

1, 6

0 IG

2,

59 c

ontr

ol)

coun

selin

g gr

oup

vs. “

othe

r gr

oups

”29

% E

BF d

urin

g pr

evio

us 7

da

ys a

t 6

mon

ths

Like

lihoo

d of

EBF

44%

vs.

0%

OR

=6.

3 (b

ased

on

gen

eral

ized

es

timat

ing

equa

tion

mod

els)

--

p<0.

001

(95%

CI:

3.53

-11

.3)

Aid

am e

t al

. (20

05);

Gha

naC

ouns

elin

g in

faci

litie

s by

pr

ovid

ers;

Cou

nsel

ing

in

hom

es b

y pr

ovid

ers

2 ho

spita

lsR

CT

– 1

23 p

regn

ant

wom

en a

tten

ding

pre

nata

l cl

inic

s: 40

IG1,

39

IG2,

44

cont

rol)30

IG1

vs. I

G2

vs.

cont

rol

% E

BF d

urin

g pr

evio

us

mon

th a

t 6

mon

ths

% E

BF d

urin

g pr

evio

us 2

4 ho

urs

at 6

mon

ths

% E

BF “

sinc

e bi

rth”

at

6 m

onth

s

90.0

% v

s. 74

.4%

vs

. 47.

7%

90.0

% v

s. 79

.5%

vs

. 54.

5%

Pool

ed

inte

rven

tion

vs.

cont

rol

39.5

% v

s. 19

.6%

p=0.

008

p=0.

001

p=0.

02

26

Com

paris

on is

inte

rven

tion

vs. c

ontro

l gro

up, u

nles

s ind

icat

ed o

ther

wise

.27Differencesreportedasnotsignificantlydifferentareindicatedby“NS”.Differencesforwhichstatisticalsignificancewasnotreportedareindicatedby“--“.


29

The

aut

hors

com

pare

d E

BF ra

tes a

mon

g th

e br

east

feed

ing

coun

selin

g gr

oup

with

rate

s fou

nd a

mon

g th

ose

in th

e gr

oup

whe

re p

eer c

ouns

elor

s wer

e tra

ined

to p

rovi

de g

ener

al c

hild

care

cou

nsel

ing,

and

the

cont

rol

arm

who

did

not

rece

ive

any

coun

selin

g.30Interventiongroup1(IG1)includedtwoprenatalcounselingsessions,onecounselingsession48hourspostpartum,andsixpostpartumhomevisits.IG2excludedtheprenatalcounseling,butincludedtheother

inte

rven

tions

.


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

ST

UD

YA

PP

RO

AC

HE

S

US

ED

SC

OP

E /

SC

AL

EE

VA

LU

AT

ION

D

ES

IGN

OU

TC

OM

E(S

) M

EA

SU

RE

DR

ES

ULT

S26

P-V

AL

UE

s /

CIs

27

Akt

er e

t al

. (20

12);

Bang

lade

shC

ouns

elin

g in

faci

litie

s by

pro

vide

rs; G

roup

ed

ucat

ion

in fa

cilit

ies

by

prov

ider

s

1 ho

spita

l Lo

ngitu

dina

l – 1

15 w

omen

at

six

mon

ths

gest

atio

n (5

7 in

terv

entio

n, 5

8 co

ntro

l)

% b

reas

tfeed

ing

initi

atio

n w

ithin

one

hou

r of

bir

th

% E

BF a

t 1

mon

th

75.4

% v

s. 34

.5%

64.9

% v

s. 37

.9%

p=0.

001

p=0.

003

Aks

u et

al.

(201

1); T

urke

yC

ouns

elin

g in

hom

es

by p

eers

; Cou

nsel

ing

in

faci

litie

s by

pro

vide

rs

(BH

FI a

nd in

faci

lity

coun

selin

g al

so g

iven

to

cont

rol g

roup

)

1 ho

spita

lR

CT

– 6

0 w

omen

who

ga

ve b

irth

in s

tudy

hos

pita

l (3

0 in

terv

entio

n, 3

0 co

ntro

l)

% E

BF a

t 2

wee

ks

% E

BF a

t 6

wee

ks

% E

BF a

t 6

mon

ths

Dur

atio

n of

EBF

(m

onth

s)

Mea

n du

ratio

n of

br

east

feed

ing

(mon

ths)

67%

vs.

40%

60%

vs.

33%

43%

vs.

23%

4.7

vs. 3

.9

15.1

vs.

12.1

p=0.

0038

p=0.

038

p=0.

04

p=0.

014

p=0.

001

Ala

m e

t al

. (20

02);

Bang

lade

shC

ouns

elin

g in

faci

litie

s by

pr

ovid

ers;

Supp

ort

grou

p in

faci

litie

s by

pro

vide

rs

and/

or la

y vo

lunt

eer;

Smal

l m

edia

2 ho

spita

ls (

1 in

terv

entio

n, 1

co

ntro

l)

Long

itudi

nal –

209

wom

en

who

gav

e bi

rth

in s

tudy

ho

spita

l (10

5 in

terv

entio

n,

104

cont

rol)

% E

BF a

t 1

mon

th

(30

days

)

% E

BF a

t 2

mon

ths

(6

0 da

ys)

% E

BF a

t 3

mon

ths

(9

0 da

ys)

% E

BF a

t 4

mon

ths

(1

20 d

ays)

% E

BF a

t 5

mon

ths

(1

50 d

ays)

% E

BF >

5 m

onth

s

Med

ian

dura

tion

of E

BF

82.3

% v

s. 50

.0%

63.2

% v

s. 40

.0%

34.7

% v

s. 21

.5%

20.8

% v

s.11

.4%

16.2

% v

s. 6.

5%

8.1%

vs.

6.5%

69.7

4 vs

. 48.

4 da

ys

--

--

--

--

--

p<0.

001

p<0.

001

Alb

erna

z et

al.

(200

3); B

razi

lSm

all m

edia

; Cou

nsel

ing

in fa

cilit

ies

by p

rovi

ders

; C

ouns

elin

g in

hom

es u

sing

H

otlin

e

1 ci

ty

RC

T –

157

new

born

s (8

2 in

terv

entio

n, 7

5 co

ntro

l)%

EBF

at

4 m

onth

s40

% v

s. 31

%N

S

% b

reas

tfeed

ing

at 4

m

onth

s (o

ther

food

or

milk

in a

dditi

on t

o br

east

m

ilk)

Like

lihoo

d of

hav

ing

stop

ped

brea

stfe

edin

g at

4

mon

ths

32%

vs.

28%

Pr

eval

ence

ra

tio::

1.85

NS

p=0.

04

(95%

CI:

1.01

-3.

41)


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

ST

UD

YA

PP

RO

AC

HE

S

US

ED

SC

OP

E /

SC

AL

EE

VA

LU

AT

ION

D

ES

IGN

OU

TC

OM

E(S

) M

EA

SU

RE

DR

ES

ULT

S26

P-V

AL

UE

s /

CIs

27

Alb

erna

z et

al.

(200

8); B

razi

lSm

all M

edia

; Cou

nsel

ing

in fa

cilit

ies

by p

rovi

ders

; C

ouns

elin

g in

hom

es u

sing

H

otlin

e

1 ci

ty

Long

itudi

nal –

421

from

19

82 c

ohor

t, 56

1 fr

om

1993

coh

ort,

310

from

19

97-1

998

coho

rt, 3

17

from

200

4 co

hort

Post

vs.

imm

edia

tely

pr

ior

to

inte

rven

tion31

% E

BF a

t 1

mon

th

% E

BF a

t 3

mon

ths

% E

BF a

t 6

mon

ths

40%

vs.

26%

19%

vs.

16%

no d

iffer

ence

-- -- --

% b

reas

tfeed

ing

at 6

m

onth

s

% b

reas

tfeed

ing

at 2

4 m

onth

s

% b

reas

tfeed

ing

at 2

4 m

onth

s

64%

vs.

46%

33%

vs.

22%

11%

vs.

14%

--

--

--

Ald

erm

an (

2007

); U

gand

aG

roup

edu

catio

n in

co

mm

uniti

es b

y la

y vo

lunt

eers

; Mob

iliza

tion

of is

sue

grou

ps; S

uppo

rt

grou

p in

com

mun

ities

by

peer

s

34 d

istr

icts

Lo

ngitu

dina

l – 2

,250

ho

useh

olds

with

a c

hild

un

der

6 (7

50 IG

1, 7

50 IG

2,

750

cont

rol)

% o

f inf

ants

wea

ned

befo

re 6

mon

ths

(~BF

at

6 m

onth

s)

“sig

nific

ant

decl

ine”

--

Aza

d et

al.

(201

0); B

angl

ades

hG

roup

edu

catio

n in

co

mm

uniti

es b

y la

y vo

lunt

eers

18 c

lust

ers

from

th

ree

rura

l dis

tric

ts

(9 in

terv

entio

n, 9

co

ntro

l)

RC

T –

36,

113

birt

hs

(17,

514

inte

rven

tion,

18

,599

con

trol

)

% E

BF fo

r si

x w

eeks

68·0

% v

s. 61

·5%

RR

: 1·1

0 (0

·98–

1·24

)

Adj

uste

d R

R:

1·10

(0·

98–

1·23

)

Bala

luka

et

al. (

2012

); D

emoc

ratic

R

epub

lic o

f Con

goM

obili

zatio

n of

issu

e gr

oups

; Cou

nsel

ing

in

com

mun

ities

by

peer

s; C

ouns

elin

g in

hom

es b

y pe

ers

2 di

stri

cts

(1

inte

rven

tion,

1

cont

rol)

Long

itudi

nal –

385

ne

wbo

rns

(208

in

terv

entio

n, 1

78 c

ontr

ol)

Med

ian

dura

tion

of E

BF

% E

BF a

t 4

mon

ths

% E

BF a

t 5

mon

ths

% E

BF a

t 6

mon

ths

6 vs

. 4 m

onth

s

91.8

% v

s. 50

.7%

81.3

% v

s. 9.

6%

57.7

% v

s. 2.

7%

p<0.

001

p<0.

001

p<0.

001

p<0.

001

Bang

et

al. (

2005

); In

dia

Mob

iliza

tion

of is

sue

grou

ps; C

ouns

elin

g in

co

mm

uniti

es b

y pe

ers;

Cou

nsel

ing

in h

omes

by

peer

s

86 v

illag

es (

39

inte

rven

tion

villa

ges,

popu

latio

n: 3

8,99

8;

47 c

ontr

ol v

illag

es,

popu

latio

n: 4

2,14

9)

RC

T –

2,3

61 n

eona

tes;

base

line

(199

5-19

96):

763;

1st fo

llow

-up

(199

6–19

97):

685;

2nd

follo

w-u

p (1

997–

1998

): 91

3

2nd fo

llow

-up

vs.

1st fo

llow

-up

vs.

base

line

% b

reas

tfeed

ing

initi

atio

n w

ithin

six

hou

rs o

f bir

th89

.7%

vs.

81.9

%

vs. 4

7.5%

Sign

ifica

nce

of

tren

d p

<0.

001

Baqu

i et

al. (

2008

a); B

angl

ades

hC

ouns

elin

g in

hom

es

by la

y vo

lunt

eers

; Ev

ents

tar

getin

g po

licy

mak

ers

and

regu

lato

rs;

Mob

iliza

tion

of c

ampa

ign,

ev

ent,

or s

peci

al “

days

”

24 u

nion

s (p

opul

atio

n:

appr

oxim

atel

y 20

,000

eac

h) fr

om

thre

e ru

ral upazilas

of S

ylhe

t di

stri

ct (

8 un

ions

per

gro

up)

RC

T –

14,

769

live

birt

hs fr

om h

ome

care

in

terv

entio

n, 1

6,32

5 liv

e bi

rths

from

com

mun

ity

care

inte

rven

tion,

15,

350

from

con

trol

% b

reas

tfeed

ing

initi

atio

n w

ithin

one

hou

r of

bir

th

Hom

e ca

re v

s. co

ntro

l

Com

mun

ity c

are

vs.

cont

rol

81%

vs.

57%

71%

vs.

57%

p<0.

0001

p=0.

0158

31

Not

e th

at a

utho

rs a

lso re

port

ed a

dditi

onal

tim

e po

ints.


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

ST

UD

YA

PP

RO

AC

HE

S

US

ED

SC

OP

E /

SC

AL

EE

VA

LU

AT

ION

D

ES

IGN

OU

TC

OM

E(S

) M

EA

SU

RE

DR

ES

ULT

S26

P-V

AL

UE

s /

CIs

27

Baqu

i et

al. (

2008

b); I

ndia

Cou

nsel

ing

in h

omes

by

lay

volu

ntee

rs; C

ouns

elin

g in

hom

es b

y pr

ovid

ers;

man

y ot

her

inte

rven

tions

to

impr

ove

curr

ent

heal

th

care

2 di

stri

cts

in U

ttar

Pr

ades

h st

ate

(1

inte

rven

tion,

1

cont

rol)

Rep

eate

d cr

oss-

sect

iona

l –

base

line:

14,

952

wom

en

who

had

had

a li

ve b

irth

or

stil

lbir

th w

ithin

the

re

fere

nce

peri

od (

8,75

6 in

terv

entio

n, 6

,196

co

ntro

l); e

ndlin

e:13

,826

w

omen

who

had

had

a li

ve

birt

h or

stil

lbir

th w

ithin

th

e re

fere

nce

peri

od

(7,8

12 in

terv

entio

n, 6

,014

co

ntro

l)

%br

east

feed

ing

initi

atio

n w

ithin

one

hou

r of

bir

thA

t ba

selin

e:

3.1%

vs.

2.4%

At

endl

ine:

37

.7%

vs.

5.8%

Diff

eren

ce in

di

ffere

nces

: p<

0.00

132

Bash

our

et a

l. (2

008)

; Syr

iaC

ouns

elin

g in

hom

es b

y pr

ovid

ers

1 ho

spita

l in

Dam

ascu

sR

CT

– 8

76 w

omen

who

ha

d re

cent

ly g

iven

bir

th

(285

in IG

1, 2

94 in

IG2,

29

7 in

con

trol

)

IG1

vs. I

G2

vs.

CG

33

% E

BF a

t 4

mon

ths

(usi

ng

no o

ther

flui

ds e

xcep

t br

east

milk

for

the

baby

)

28.5

% v

s. 30

.1%

vs

. 20.

2%

p=0.

023

Bert

i et

al. (

2010

); Et

hiop

ia, G

hana

, M

alaw

i and

Tan

zani

aM

eetin

gs t

arge

ting

polic

y m

aker

s an

d re

gula

tors

; Ev

ents

tar

getin

g po

licy

mak

ers

and

regu

lato

rs;

Supp

ort

grou

p in

co

mm

uniti

es; M

obili

zatio

n of

issu

e gr

oups

; Mas

s m

edia

4 co

untr

ies,

4 m

illio

n be

nefic

iari

es

Rep

eate

d cr

oss-

sect

iona

l –

seco

ndar

y da

ta fr

om

2-3

time

poin

ts fr

om

prog

ram

eva

luat

ions

of

mod

erat

e or

hig

h qu

ality

an

d D

emog

raph

ic H

ealth

Su

rvey

s (D

HS)

; pro

gram

su

rvey

sam

ple

size

s pe

r co

untr

y w

ere

betw

een

900

and

4801

ran

dom

ly

sele

cted

hou

seho

lds

per

surv

ey

endl

ine

vs.

mid

line

vs.

base

line

% E

BF fo

r 6

mon

ths

Ethi

opia

Gha

na

Mal

awi

Tanz

ania

49%

vs.

38%

vs.

25%

49%

vs.

27%

vs.

17%

70%

vs.

47%

vs.

15%

21%

vs.

15%

vs

. ---

--

--

--

--

32

P-va

lue

for d

iffer

ence

-in-d

iffer

ence

test

adj

uste

d fo

r age

, edu

catio

n, p

arity

, rel

igio

n an

d st

anda

rd-o

f-liv

ing

scor

e.33

IG

1 re

ceiv

ed fo

ur h

ome

visit

s on

days

one

, thr

ee, s

even

, and

30

follo

win

g de

liver

y. IG

2 re

ceiv

ed o

ne h

ome

visit

on

day

thre

e. T

he c

ontro

l gro

up re

ceiv

ed c

urre

nt st

anda

rd o

f ca

re in

Syr

ia, w

hich

incl

uded

no

hom

e vi

sits f

ollo

win

g ho

spita

l disc

harg

e


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

ST

UD

YA

PP

RO

AC

HE

S

US

ED

SC

OP

E /

SC

AL

EE

VA

LU

AT

ION

D

ES

IGN

OU

TC

OM

E(S

) M

EA

SU

RE

DR

ES

ULT

S26

P-V

AL

UE

s /

CIs

27

Bhan

dari

et

al. (

2001

); In

dia

Cou

nsel

ing

in h

omes

by

prov

ider

s1

com

mun

ity in

D

elhi

RC

T –

418

infa

nts

four

m

onth

s of

age

(96

in fo

od

supp

lem

ent

grou

p; 9

5 in

nut

ritio

nal c

ouns

elin

g gr

oup;

and

96

in v

isita

tion

grou

p; 1

00 in

con

trol

gr

oup)

; dat

a co

llect

ed

whe

n in

fant

s w

ere

6, 9

and

12

mon

ths

of a

ge

Supp

lem

ent

+ c

ouns

elin

g vs

. cou

nsel

ing

alon

e vs

. vi

sita

tion

vs.

cont

rol

Com

pari

sons

w

ith fi

nal g

roup

(v

isita

tion)

% b

reas

tfeed

ing…

at 6

mon

ths

at

9 m

onth

s

at 1

2 m

onth

s

93.8

% v

s. 97

.9%

vs

. 99.

0% v

s. 93

.0%

,

92.0

% v

s. 95

.5%

vs

. 97.

9% v

s. 91

.4%

83.9

% v

s. 96

.9%

vs

. 96.

7% v

s. 89

.2%

NS,

NS,

NS

N

S, N

S, N

S p<

0.05

, NS,

NS

Bhan

dari

et

al. (

2003

); In

dia

Gro

up e

duca

tion

in

com

mun

ities

by

prov

ider

s; C

ouns

elin

g in

hom

es b

y pe

ers

8 co

mm

uniti

es

(4 in

terv

entio

n, 4

co

ntro

l)

RC

T –

1,1

15 in

fant

s bo

rn w

ithin

9 m

onth

s of

st

art

of in

terv

entio

n; 3

m

onth

ass

essm

ent:

895

infa

nts

(483

inte

rven

tion,

41

2 co

ntro

l); 6

mon

th

asse

ssm

ent:

880

infa

nts

(468

inte

rven

tion,

412

co

ntro

l)

% E

BF a

t 3

mon

ths

% E

BF a

t 4

mon

ths

% E

BF a

t 5

mon

ths

% E

BF a

t 6

mon

ths

Med

ian

dura

tion

of E

BF

EBF

amon

g lo

w-b

irth

w

eigh

t ba

bies

79%

vs.

48%

69%

vs.

12%

49%

vs.

6%

42%

vs.

4%

122

days

vs.

41

days

high

er r

ates

at

eve

ry t

ime

poin

t

p-<

0.00

01

p-<

0.00

01

p-<

0.00

01

p-<

0.00

01

p-<

0.00

01

p<0.

001

Bhan

dari

et

al. (

2005

); In

dia

Cou

nsel

ing

in fa

cilit

ies

by p

rovi

ders

; Cou

nsel

ing

in h

omes

by

peer

s; M

obili

zatio

n of

issu

e gr

oups

8 co

mm

uniti

es

(4 in

terv

entio

n, 4

co

ntro

l)

RC

T –

102

5 ne

wbo

rns

0 vs

. 1-2

vs.

3+

chan

nels

% E

BF a

t 3

mon

ths

% E

BF a

t 4

mon

ths

Mea

n du

ratio

n of

EBF

(d

ays)

70.8

% v

s. 81

.3%

vs

. 93.

6%

data

not

re

port

ed

114.

1 vs

. 127

.3

vs. 1

28.7

day

s

p=0.

0002

ad

j. p=

0.00

2

p=0.

001

p=0.

090

adj.

p= 0

.064


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

ST

UD

YA

PP

RO

AC

HE

S

US

ED

SC

OP

E /

SC

AL

EE

VA

LU

AT

ION

D

ES

IGN

OU

TC

OM

E(S

) M

EA

SU

RE

DR

ES

ULT

S26

P-V

AL

UE

s /

CIs

27

Bhut

ta e

t al

. (20

08b)

; Pak

ista

nG

roup

edu

catio

n in

co

mm

uniti

es b

y pr

ovid

ers;

Cou

nsel

ing

in h

omes

by

lay

volu

ntee

rs; M

obili

zatio

n of

is

sue

grou

ps; S

mal

l med

ia;

Mid

-siz

ed m

edia

8 vi

llage

clu

ster

s fr

om 2

sub

-dis

tric

ts

in S

indh

pro

vinc

e (4

in

terv

entio

n w

ith a

to

tal p

opul

atio

n of

13

8,60

0, 4

con

trol

)

Rep

eate

d cr

oss-

sect

iona

l –

data

wer

e co

llect

ed a

t ba

selin

e (Ju

n-A

ug 2

003)

an

d th

ree

othe

r tim

e po

ints

; End

line

data

(Se

pt

2005

) re

port

ed a

re fr

om

395

and

375

wom

en

from

the

inte

rven

tion

and

cont

rol v

illag

e cl

uste

rs

% b

reas

tfeed

ing

initi

atio

n w

ithin

one

hou

r of

bir

th66

.1%

vs.

21.1

%

Not

rep

orte

d

% E

BF fo

r fir

st 4

mon

ths

64.6

% v

s. 18

.1%

Not

rep

orte

d

Bort

olin

i and

Vito

lo (

2012

); Br

azil

Cou

nsel

ing

in h

omes

by

prov

ider

s1

hosp

ital

RC

T –

397

new

born

s (1

63in

terv

entio

n, 2

34

cont

rol)

% E

BF a

t…

< 1

mon

th

= o

r >

4 m

onth

s

= o

r >

6 m

onth

s

33.3

% v

s. 48

%

45.1

% v

s. 28

.6%

19.1

% v

s. 8.

2%

p=0.

004

p=0.

001

p=0.

001

% b

reas

tfeed

ing

at…

- at

6 m

onth

s

- at

12

mon

ths

66.3

% v

s. 55

.6%

52.8

% v

s. 41

.9%

p=0.

04

p=0.

04

Brau

n et

al.

(200

3); B

razi

lC

ouns

elin

g in

faci

litie

s by

pr

ovid

ers;

Supp

ort

grou

p in

faci

litie

s by

pro

vide

rs

and/

or la

y vo

lunt

eers

; Sm

all

med

ia

1 ho

spita

lLo

ngitu

dina

l – 4

37

new

born

s (in

terv

entio

n:

250

born

in 1

999,

2 y

ears

af

ter

BFH

I im

plem

enta

tion;

co

ntro

l: 18

7 bo

rn in

199

4)

Dur

atio

n of

EBF

2

vs. 1

mon

thp=

0.01

Cou

tinho

et

al. (

2005

); Br

azil

Cou

nsel

ing

in h

omes

by

lay

volu

ntee

rs2

hosp

itals

R

CT

– 3

50 w

omen

w

ho g

ave

birt

h in

ta

rget

hos

pita

ls (

175

inte

rven

tion,

175

con

trol

)

% E

BF a

t 6

mon

ths

45%

vs.

13%

p<0.

0001

% b

reas

tfeed

ing

at 6

m

onth

s 78

% v

s. 62

%p<

0.00

01

Cro

okst

on e

t al

. (20

07);

Cam

bodi

aC

omm

unity

/soc

ial

mob

iliza

tion;

Gro

up

educ

atio

n in

com

mun

ities

by

lay

volu

ntee

rs;

Cou

nsel

ing

in c

omm

uniti

es

by la

y vo

lunt

eers

; Sm

all

med

ia; S

uppo

rt g

roup

in

faci

litie

s by

pro

vide

rs a

nd/

or la

y vo

lunt

eers

4 di

stri

cts

(3

inte

rven

tion,

1

cont

rol)

Rep

eate

d cr

oss-

sect

iona

l –

base

line

(sum

mer

of

2004

): 44

0 w

omen

with

a

child

less

tha

n 6

mon

ths

of

age

(206

inte

rven

tion,

234

co

ntro

l); 1

yea

r fo

llow

-up

: 467

wom

en (

222

inte

rven

tion,

245

con

trol

)

% b

reas

tfeed

ing

initi

atio

n w

ithin

one

hou

r of

bir

thA

t ba

selin

e:

RR

=1.

1

At

follo

w-u

p:

RR

=1.

62

(95%

CI:

0.74

–1.6

8)

(95%

CI:

1.30

–2.0

1)

EBF

in t

he p

revi

ous

24

hour

s am

ong

infa

nts

< 6

m

onth

s of

age

At

base

line:

R

R=

1.54

At

follo

w-u

p:

RR

=1.

81

(95%

CI:

1.21

–1.9

6)

(95%

CI:

1.49

–2.2

1)

de O

livei

ra e

t al

. (20

06);

Braz

ilC

ouns

elin

g in

faci

litie

s by

pr

ovid

ers;

Cou

nsel

ing

in

hom

es b

y pr

ovid

ers

1 ho

spita

lR

CT

– 2

11 m

othe

r-in

fant

pa

irs

(74

inte

rven

tion,

137

co

ntro

l)

% E

BF a

t 7

days

po

stpa

rtum

% E

BF a

t 30

day

s po

stpa

rtum

79.7

% v

s. 82

.5%

60.8

% v

s. 53

.3%

NS

NS


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

ST

UD

YA

PP

RO

AC

HE

S

US

ED

SC

OP

E /

SC

AL

EE

VA

LU

AT

ION

D

ES

IGN

OU

TC

OM

E(S

) M

EA

SU

RE

DR

ES

ULT

S26

P-V

AL

UE

s /

CIs

27

Duy

an C

amur

dan

et a

l. (2

007)

; Tu

rkey

Cou

nsel

ing

in fa

cilit

ies

by

prov

ider

s; Su

ppor

t gr

oup

in fa

cilit

ies

by p

rovi

ders

an

d/or

lay

volu

ntee

rs; S

mal

l m

edia

1 ho

spita

l C

ross

-sec

tiona

l – 2

97

babi

es b

orn

in t

he fo

ur

mon

ths

afte

r BF

HI

(Nov

embe

r 20

02-F

ebru

ary

2003

) (in

terv

entio

n)

and

258

babi

es b

orn

befo

re B

FHI (

Nov

embe

r 20

01-F

ebru

ary

2002

) (c

ontr

ol)

af

ter-

BFH

I gr

oup

vs.

befo

re-B

FHI

% E

BF a

t 15

day

s ol

d

% E

BF a

t 2

mon

ths

% E

BF-a

t 4

mon

ths

% E

BF a

t 6

mon

ths

97.4

% v

s. 93

.1%

76.1

% v

s. 67

.2%

53.7

% v

s. 45

.6%

9.3%

vs.

9.8%

NS

NS

NS

NS

Mea

n du

ratio

n of

br

east

feed

ing

(mon

ths)

21.1

7 vs

. 17.

83

mon

ths

O

R=

1.5

p=0.

0036

(9

5% C

I: 1.

16–2

.03)

Gog

ia a

nd S

achd

ev (

2010

); In

dia,

Paki

stan

, Ban

glad

esh

Cou

nsel

ing

in h

omes

by

lay

volu

ntee

rsva

ried

Lite

ratu

re r

evie

w –

four

R

CT

s Br

east

feed

ing

initi

atio

n w

ithin

one

hou

r of

bir

thPo

oled

RR

:

3.35

p=

0.01

2 (9

5% C

I: 1.

31-

8.59

)

Gul

dan

et a

l. (2

000)

; Chi

naC

ouns

elin

g in

hom

es b

y pe

ers

4 to

wns

hips

(2

inte

rven

tion,

2

cont

rol)

RC

T –

new

born

s w

ere

enro

lled

thro

ugho

ut

the

year

of p

roje

ct

impl

emen

tatio

n, a

t co

mpl

etio

n of

the

ye

ar in

fant

s ha

d be

en

mon

itore

d fo

r 4-

12

mon

ths;

495

infa

nts

born

du

ring

stu

dy p

erio

d an

alyz

ed (

250

inte

rven

tion,

24

5 co

ntro

l); in

fant

s 4-

6 m

onth

s ol

d: 5

7 in

terv

entio

n, 6

9 co

ntro

l; in

fant

s 7-

9 m

onth

s ol

d: 8

5 in

terv

entio

n, 7

6 co

ntro

l; in

fant

s 10

-12

mon

ths

old:

10

8 in

terv

entio

n, 1

00

cont

rol

% b

reas

tfeed

ing

initi

atio

n w

ithin

one

hou

r of

bir

th

% b

reas

tfeed

ing

initi

atio

n w

ithin

24

hour

or

mor

e of

bir

th

% g

ave

colo

stru

m t

o in

fant

23%

vs.

18%

23%

vs.

35%

91

% v

s. 80

%

NS

p=0.

031

p<0.

004

% b

reas

tfeed

ing

at 4

-12

mon

ths

83%

vs.

75%

p=0.

034

Gup

ta e

t al

. (20

04);

Uga

nda

Mas

s m

edia

12 d

istr

icts

C

ross

-sec

tiona

l – 2

12

wom

en a

ged

15-4

9 ye

ars

who

se y

oung

est

child

was

un

der

six

mon

ths

of a

ge

EBF

for

6 m

onth

s

No

BCC

m

essa

ge

expo

sure

: O

R=

2.32

Expo

sure

to

1 BC

C t

ype:

O

R=

1.00

Expo

sure

to

>1

BCC

typ

e:

OR

=2.

79

p<0.

05

NS

p<

0.05


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

ST

UD

YA

PP

RO

AC

HE

S

US

ED

SC

OP

E /

SC

AL

EE

VA

LU

AT

ION

D

ES

IGN

OU

TC

OM

E(S

) M

EA

SU

RE

DR

ES

ULT

S26

P-V

AL

UE

s /

CIs

27

Guy

on e

t al

. (20

09);

Mad

agas

car

Mob

iliza

tion

of is

sue

grou

ps; M

obili

zatio

n of

ca

mpa

ign,

eve

nt, o

r sp

ecia

l “d

ays”

; Mas

s m

edia

2 hi

ghla

nd p

rovi

nces

; ta

rget

ed p

opul

atio

n va

ried

thr

ough

out

proj

ect

from

1.4

m

illio

n in

6 d

istr

icts

to

6 m

illio

n in

23

dist

rict

s

Rep

eate

d cr

oss-

sect

iona

l –

base

line

(200

0): 1

,200

ch

ildre

n un

der

two

year

s ol

d; e

ndlin

e (2

005)

: 1,7

60

child

ren

unde

r tw

o ye

ars

old

endl

ine

vs.

base

line

% b

reas

tfeed

ing

initi

atio

n w

ithin

one

hou

r of

bir

th68

% v

s. 33

%p<

0.00

1

% E

BF o

f inf

ants

< 6

m

onth

s ol

d70

% v

s. 42

%p<

0.00

1

% b

reas

tfeed

ing

of

child

ren

12-1

5 m

onth

s of

age

% b

reas

tfeed

ing

of

child

ren

20-2

3 m

onth

s of

age

94%

vs.

89%

73

% v

s. 43

%

p<0.

05

p<0.

001

Hai

der

et a

l. (2

000)

; Ban

glad

esh

Cou

nsel

ing

in h

omes

by

peer

s40

zon

es in

Dha

ka

(20

inte

rven

tion,

20

cont

rol)

RC

T –

573

wom

en in

last

tr

imes

ter

of p

regn

ancy

w

ho c

ompl

eted

all

five

mon

ths

of s

tudy

(28

8 in

terv

entio

n, 2

85 c

ontr

ol)

% b

reas

tfeed

ing

initi

atio

n w

ithin

one

hou

r of

bir

th64

% v

s. 15

%

p<0.

001

% E

BF a

t 5

mon

ths

70%

vs.

6%p<

0.00

01

Hal

l (20

11);

Indi

a, Sy

ria,

Paki

stan

, and

Ba

ngla

desh

Cou

nsel

ing

in c

omm

uniti

es;

Cou

nsel

ing

in h

omes

by

peer

s; G

roup

edu

catio

n in

co

mm

uniti

es

vari

edLi

tera

ture

rev

iew

– fo

ur

RC

Ts

EBF

in lo

w a

nd m

iddl

e-in

com

e co

untr

ies

(effe

ct

of c

omm

unity

-bas

ed

inte

rven

tions

)

pool

ed O

R=

5.9

(9

5% C

I: 1.

81-

18.6

)

Haq

ue e

t al

. (20

02);

Bang

lade

shC

ouns

elin

g in

faci

litie

s by

pr

ovid

ers

3 co

unse

ling

cent

ers

Long

itudi

nal –

114

m

othe

r-ch

ild p

airs

co

mpl

eted

one

-yea

r fo

llow

-up

(59

inte

rven

tion,

55

con

trol

)

% g

ave

colo

stru

m t

o in

fant

10

0% v

s. 98

.9%

--

% E

BF fo

r 5

mon

ths

54.2

% v

s. 36

.4%

NS

Har

kins

et

al. (

2008

); H

ondu

ras

Mob

iliza

tion

of is

sue

grou

ps; C

ouns

elin

g in

ho

mes

1 co

mm

unity

R

epea

ted

cros

s-se

ctio

nal34

–H

ondu

ras:

300

hous

ehol

ds w

ith

child

ren

unde

r tw

o ye

ars

old

inte

rvie

wed

in A

ugus

t 20

04 a

nd D

ecem

ber

2005

(p

ost-

inte

rven

tion)

en

dlin

e vs

. ba

selin

e

EBF

for

6 m

onth

s 19

% v

s. 11

%p<

0.05


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

ST

UD

YA

PP

RO

AC

HE

S

US

ED

SC

OP

E /

SC

AL

EE

VA

LU

AT

ION

D

ES

IGN

OU

TC

OM

E(S

) M

EA

SU

RE

DR

ES

ULT

S26

P-V

AL

UE

s /

CIs

27

Imda

d et

al.

(201

1); v

ario

usC

ouns

elin

g; G

roup

ed

ucat

ion/

coun

selin

gva

ried

Lite

ratu

re r

evie

w –

53

RC

Ts

and

quas

i-RC

Ts

EBF

at 4

-6 w

eeks

- in

dev

elop

ed a

nd

deve

lopi

ng c

ount

ries

- in

dev

elop

ing

coun

trie

s

EBF

at 6

mon

ths

- in

dev

elop

ed a

nd

deve

lopi

ng c

ount

ries

- in

dev

elop

ing

coun

trie

s

RR

=2.

37

RR

= 1

.89

RR

=1.

43

RR

= 6

.32

(95%

CI:

1.33

-4.

24)

p<0.

001

(95%

CI:

1.50

-2.

37)

p<0.

001

(95%

CI:

1.28

-1.

60)

p<0.

001

(95%

CI:

3.35

-11

.93)

p<

0.00

1

Brea

stfe

edin

g at

6 m

onth

s

- in

dev

elop

ed a

nd

deve

lopi

ng c

ount

ries

RR

= 1

.12

(95%

CI:

1.01

-1

.24)

Jolly

et

al. (

2012

); va

riou

sC

ouns

elin

g in

hom

es

by p

eers

; Cou

nsel

ing

in c

omm

uniti

es b

y pe

ers;

Sup

port

gro

up in

co

mm

uniti

es b

y pe

ers

vari

edLi

tera

ture

rev

iew

– 1

7 R

CT

s R

isk

of n

ot E

BF a

t la

st

stud

y fo

llow

-up

in lo

w

inco

me

coun

trie

s (P

eer

supp

ort

vs. n

one)

RR

= 0

.63

(95%

CI:

0.52

-

0.78

)

Ris

k of

not

bre

astfe

edin

g at

last

stu

dy fo

llow

-up

in lo

w in

com

e co

untr

ies

(Pee

r su

ppor

t vs

. non

e)

RR

= 0

.70

(95%

CI:

0.60

-

0.82

)

Khr

eshe

h et

al.

(201

1); J

orda

nC

ouns

elin

g in

faci

litie

s by

pr

ovid

ers;

Cou

nsel

ing

in

hom

es b

y pr

ovid

ers

(vi

a ph

one)

2 ho

spita

lsR

CT

– 9

0 po

stpa

rtum

w

omen

(45

inte

rven

tion,

45

con

trol

)

% E

BF a

t 6

mon

ths

39%

vs.

27%

NS

34

It n

ot c

lear

from

the

artic

le if

this

was

a lo

ngitu

dina

l or r

epea

ted

cros

s-se

ctio

nal s

tudy

. Giv

en th

e in

dica

tor r

epor

ted,

it is

ass

umed

to b

e re

peat

ed c

ross

-sec

tiona

l.


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

ST

UD

YA

PP

RO

AC

HE

S

US

ED

SC

OP

E /

SC

AL

EE

VA

LU

AT

ION

D

ES

IGN

OU

TC

OM

E(S

) M

EA

SU

RE

DR

ES

ULT

S26

P-V

AL

UE

s /

CIs

27

Kra

mer

et

al. (

2001

); R

epub

lic o

f Be

laru

sC

ouns

elin

g in

faci

litie

s by

pr

ovid

ers;

Supp

ort

grou

p in

faci

litie

s by

pro

vide

rs

and/

or la

y vo

lunt

eers

; Sm

all

med

ia

31 m

ater

nity

ho

spita

ls a

nd

poly

clin

ics

(16

inte

rven

tion,

15

cont

rol)

RC

T –

16,

442

mot

her-

infa

nt p

airs

(8,

547

inte

rven

tion,

7,8

95

cont

rol)

% E

BF a

t 3

mon

ths

% E

BF a

t 6

mon

ths

43.3

% v

s. 6.

4%

AO

R=

0.47

7.9%

vs.

0.6%

p<0.

001

(95%

CI:

0.32

-0.

69)

p= 0

.01

% b

reas

tfeed

ing

at 1

2 m

onth

s19

.7%

vs.

11.4

%

AO

R=

0.47

(9

5% C

I: 0.

32-

0.69

)

Kum

ar e

t al

. (20

08);

Indi

aG

roup

Edu

catio

n in

co

mm

uniti

es b

y la

y vo

lunt

eers

; Cou

nsel

ing

in

hom

es b

y la

y vo

lunt

eers

; Sm

all m

edia

; Tra

ditio

nal

med

ia

39 v

illag

es

(pop

ulat

ion:

10

4,12

3) (

13 v

illag

es

in e

ach

grou

ps)35

RC

T –

2,6

01 li

ve b

irth

s (1

,522

inte

rven

tion,

1,0

79

cont

rol)

% p

re-la

ctea

l fee

d

% b

reas

tfeed

ing

initi

atio

n w

ithin

one

hou

r of

bir

th

38·4

% v

s. 79

·9%

70

·6%

vs.

15·5

%

Rat

e ra

tio: 0

·49

(0·4

2–0·

57)

p<0·

0001

Rat

e ra

tio: 4

·57

(3·3

8–6·

15)

p<0·

0001

Kup

rata

kul e

t al

. (20

10);

Tha

iland

Supp

ort

grou

p in

faci

litie

s by

pro

vide

rs a

nd/o

r la

y vo

lunt

eer;

Cou

nsel

ing

in h

omes

by

prov

ider

s; C

ouns

elin

g in

hom

es b

y pr

ovid

ers

(vi

a ph

one)

5 ho

spita

lsR

CT

– 8

0 pr

egna

nt

wom

en o

f mor

e th

an

32 w

eeks

’ ges

tatio

n (4

0 in

terv

entio

n; 4

0 co

ntro

l)

% E

BF a

t …

-

14 d

ays

- 1

mon

th

- 2

mon

ths

- 4

mon

ths

- 5

mon

ths

- 6

mon

ths

82.5

% v

s. 52

.6%

77

.5%

vs.

52.6

%

62.5

% v

s. 36

.8%

35

.0%

vs.

7.9%

25

.0%

vs.

2.6%

20

.0%

vs.

0%

p =

0.0

05

p =

0.0

21

p =

0.0

23

p =

0.0

08

p =

0.0

12

p =

0.0

05

% p

redo

min

ant

brea

stfe

edin

g at

6 m

onth

s %

par

tial b

reas

tfeed

ing

at

6 m

onth

s

40.0

% v

s. 5.

3%

15.0

% v

s. 15

.8%

p =

0.0

002

p =

0.9

23

Lass

i et

al. (

2010

); va

riou

sEv

ents

tar

getin

g po

licy

mak

ers

and

regu

lato

rs;

Mob

iliza

tion

of is

sue

grou

ps; C

ouns

elin

g in

ho

mes

by

peer

s

vari

edLi

tera

ture

rev

iew

– 1

8 R

CT

s an

d qu

asi-R

CT

s BF

initi

atio

n w

ithin

one

ho

ur o

f bir

thR

R =

1.9

4 p<

0.00

1

(95%

CI:

1.56

-

2.42

)

Leite

et

al. (

2005

); Br

azil

Cou

nsel

ing

in h

omes

by

peer

s8

heal

th c

ente

rs

RC

T –

1,0

03 w

omen

an

d th

eir

new

born

s (5

03

inte

rven

tion,

500

con

trol

)

% E

BF a

t 4

mon

ths

24.7

% v

s. 19

.4%

p =

0.0

44

35

The

focu

s her

e is

on th

e co

ntro

l gro

up, w

hich

“re

ceiv

ed th

e us

ual s

ervi

ces o

f go

vern

men

tal a

nd n

on-g

over

nmen

tal o

rgan

izat

ions

in th

e ar

ea; a

n in

terv

entio

n gr

oup,

whi

ch re

ceiv

ed a

pre

vent

ive

pack

age

of in

terv

entio

ns fo

r ess

entia

l new

born

car

e (b

irth

prep

ared

ness

, cle

an d

eliv

ery

and

cord

car

e, th

erm

al c

are

[incl

udin

g skin-to-skincare],breastfeedingpromotion,anddangersignrecognition)”(Kumaretal.,2008).


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

ST

UD

YA

PP

RO

AC

HE

S

US

ED

SC

OP

E /

SC

AL

EE

VA

LU

AT

ION

D

ES

IGN

OU

TC

OM

E(S

) M

EA

SU

RE

DR

ES

ULT

S26

P-V

AL

UE

s /

CIs

27

Li e

t al

. (20

07);

Chi

naM

obili

zatio

n of

issu

e gr

oups

; Mid

-siz

ed m

edia

; Sm

all m

edia

10 v

illag

es (

2 fr

om

each

of fi

ve s

ampl

ed

tow

nshi

ps in

Lux

i ci

ty (

popu

latio

n of

app

roxi

mat

ely

321,

000)

Rep

eate

d cr

oss-

sect

iona

l –

352

infa

nts

born

dur

ing

refe

renc

e pe

riod

endl

ine

vs.

base

line

Ave

rage

tim

e un

til

initi

atio

n of

bre

astfe

edin

g (h

ours

)

- M

ale

child

- Fe

mal

e ch

ild

- Tot

al

% b

reas

tfeed

ing

initi

atio

n w

ithin

30

min

utes

- M

ale

child

- Fe

mal

e ch

ild

- Tot

al

17.7

vs.

27.8

20.3

vs.

29.8

19.0

vs.

28.5

47.4

% v

s. 37

.6%

42.4

% v

s. 36

.8%

44.9

% v

s. 37

.2%

-- -- -- -- -- --

Mea

n du

ratio

n of

br

east

feed

ing

(mon

ths)

- M

ale

child

- Fe

mal

e ch

ild

- Tot

al

12.0

vs.

12.6

12.9

vs.

12.9

12.5

vs.

12.8

-- -- --

Mac

kint

osh

et a

l. (2

002)

; Vie

tnam

Cou

nsel

ing

in h

omes

by

peer

s; G

roup

edu

catio

n in

com

mun

ities

by

lay

volu

ntee

rs

5 co

mm

unes

(4

inte

rven

tion,

1

cont

rol)

Rep

eate

d cr

oss-

sect

iona

l –

46 h

ouse

hold

s in

in

terv

entio

n (fa

mily

had

on

e ch

ild w

ho p

revi

ousl

y pa

rtic

ipat

ed in

the

pro

ject

an

d on

e yo

unge

r ch

ild

who

had

not

par

ticip

ated

), 25

hou

seho

lds

in c

ontr

ol

(had

no

prev

ious

exp

osur

e to

pro

gram

act

iviti

es a

nd

incl

uded

an

olde

r an

d yo

unge

r si

blin

g in

the

age

ra

nge

of t

he in

terv

entio

n ho

useh

olds

)

% c

urre

ntly

bre

ast-

feed

ing36

“yo

unge

r” c

hild

Mea

n du

ratio

n of

br

east

feed

ing

(mon

ths)

41.3

% v

s. 20

%

16.8

vs.

16.6

NS

NS

Man

andh

ar e

t al

. (20

04);

Nep

alSu

ppor

t gr

oup

in

com

mun

ities

by

peer

s; M

obili

zatio

n of

issu

e gr

oups

; Cou

nsel

ing

in

hom

es b

y pe

ers

42 r

ural

vill

age

deve

lopm

ent

com

mitt

ees

from

on

e di

stri

ct (

21

inte

rven

tion,

21

cont

rol)

RC

T –

6,7

14 (

3,19

0 in

terv

entio

n, 3

,524

co

ntro

l)

% b

reas

tfeed

ing

initi

atio

n w

ithin

one

hou

r of

bir

th

% d

isca

rded

col

ostr

um

62%

vs.

54%

, A

OR

37 =

1.4

0

29%

vs.

42%

, A

OR

=0.

55

(95%

CI:

0.52

–3.7

9)

(95%

CI:

0.27

–1.1

0)

36Womenwereaskedaboutcurrentbreastfeedingpracticesofthe“younger”child.Themeanageofthe“younger”childwas26monthsininterventioncommunitiesand29monthsincontrolcommunities.The

differencewasnotstatisticallysignificant.


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

ST

UD

YA

PP

RO

AC

HE

S

US

ED

SC

OP

E /

SC

AL

EE

VA

LU

AT

ION

D

ES

IGN

OU

TC

OM

E(S

) M

EA

SU

RE

DR

ES

ULT

S26

P-V

AL

UE

s /

CIs

27

Mat

ovu

et a

l. (2

008)

; Uga

nda

Cou

nsel

ing

in fa

cilit

ies

by p

rovi

ders

; Gro

up

educ

atio

n in

faci

litie

s by

pr

ovid

ers;

Smal

l med

ia;

Mid

-siz

ed m

edia

3 he

alth

faci

litie

s (2

ho

spita

ls, 1

cen

ter)

R

etro

spec

tive

cros

s-se

ctio

nal s

tudy

– 1

39

HIV

infe

cted

wom

en w

ith

child

ren

6-12

mon

ths

old

who

adh

ered

to

EBF

for

six

mon

ths,

139

HIV

in

fect

ed w

omen

who

did

no

t ad

here

to

EBF

for

six

mon

ths

EBF

for

6 m

onth

s am

ong

HIV

+ w

omen

(in

divi

dual

vs

. gro

up c

ouns

elin

g)

EBF

for

6 m

onth

s am

ong

HIV

+ w

omen

(at

leas

t 4

AN

C s

essi

ons

atte

nded

vs.

few

er t

han

4)

% E

BF fo

r 6

mon

ths

amon

g H

IV+

wom

en

(att

ende

d at

leas

t 6

post

nata

l cou

nsel

ing

sess

ions

vs.

few

er t

han

6)

EBF

for

6 m

onth

s am

ong

HIV

+ w

omen

(di

scus

sed

with

hea

lth w

orke

r de

cisi

on r

egar

ding

EBF

vs.

did

not)

OR

=3.

43

OR

=5.

95

OR

=3.

34

OR

= 4

.97

p<0.

05

p<0.

05

p<0.

05

p<0.

05

Mor

row

and

Gue

rrer

o (2

001)

; M

exic

oC

ouns

elin

g in

hom

es b

y pe

ers;

Smal

l med

ia1

com

mun

ity

(pop

ulat

ion

of

appr

oxim

atel

y 30

,000

)

RC

T –

130

wom

en 3

m

onth

s po

stpa

rtum

(44

IG

1, 5

2 IG

2, 3

4 co

ntro

l)

IG

1 vs

. IG

2 vs

. co

ntro

l gro

up

% E

BF a

t 3

mon

ths

67%

vs.

52%

vs.

12%

p <

0.0

01, l

og

rank

tes

t

Om

er e

t al

. (20

08);

Paki

stan

Trad

ition

al m

edia

; C

ouns

elin

g in

hom

es b

y pe

ers

10 c

omm

uniti

es

from

3 d

istr

icts

(5

inte

rven

tion,

5

cont

rol),

8 o

f whi

ch

wer

e ru

ral

RC

T –

1,0

70 w

omen

w

ho h

ad b

een

preg

nant

an

d de

liver

ed d

urin

g th

e th

ree

year

s pr

ior

to

the

inte

rven

tion

(529

in

terv

entio

n, 5

41 c

ontr

ol)

% g

ave

colo

stru

m t

o in

fant

79

.2%

vs.

65.3

%

OR

=1.

60

(95%

CI:

1.17

–2.1

8)

Pach

ón e

t al

. (20

02); V

ietn

amG

roup

edu

catio

n in

co

mm

uniti

es b

y la

y vo

lunt

eers

12 c

omm

unes

from

on

e ru

ral V

ietn

am

(6 in

terv

entio

n, 6

co

ntro

l)

Long

itudi

nal –

238

ch

ildre

n 5-

25 m

onth

s ol

d (1

19 in

terv

entio

n, 1

19

cont

rol)

% b

reas

tfeed

ing

prev

ious

da

y at

mon

th 0

% b

reas

tfeed

ing

prev

ious

da

y at

mon

th 1

2

72.3

% v

s. 65

.5%

13.4

% v

s. 13

.9%

NS

NS

37

Adj

uste

d od

ds ra

tio


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

ST

UD

YA

PP

RO

AC

HE

S

US

ED

SC

OP

E /

SC

AL

EE

VA

LU

AT

ION

D

ES

IGN

OU

TC

OM

E(S

) M

EA

SU

RE

DR

ES

ULT

S26

P-V

AL

UE

s /

CIs

27

Piw

oz e

t al

. (20

05);

Zim

babw

eC

ouns

elin

g in

faci

litie

s by

pr

ovid

ers;

Cou

nsel

ing

in

com

mun

ities

by

prov

ider

s; G

roup

edu

catio

n in

fa

cilit

ies;

Gro

up e

duca

tion

in c

omm

uniti

es; M

id-s

ized

m

edia

14 m

ater

nity

clin

ics

from

gre

ater

H

arar

e

RC

T –

14,

110

wom

en

from

the

Zim

babw

e V

itam

in A

for

Mot

hers

an

d Ba

bies

Pro

ject

clin

ical

(Z

VIT

AM

BO)

clin

ical

tri

al;

11,3

62, 1

311,

and

143

7 w

ere

enro

lled

duri

ng

the

pre,

par

tial,

and

full

inte

rven

tion

peri

od; d

ata

wer

e co

llect

ed a

t m

ultip

le

time

poin

ts

% E

BF fo

r at

leas

t 3

mon

ths

Part

ial

part

icip

atio

n:

AO

R=

1.75

Full

part

icip

atio

n:

AO

R=

8.43

No

part

icip

atio

n vs

. gro

up o

nly

vs. i

ndiv

idua

l co

unse

ling

only

vs

. gro

up +

in

divi

dual

5.

5% v

s. 13

.4%

vs

. 15.

9% v

s. 23

.7%

p<0.

001

(95%

CI:

1.31

-2.

35)

p<0.

0001

(9

5% C

I: 6.

13–1

1.59

) p<

0.00

01

Piw

oz e

t al

. (20

07);

Zim

babw

eG

roup

edu

catio

n in

fa

cilit

ies

by p

rovi

ders

; Sm

all

med

ia; M

id-s

ized

med

ia;

Cou

nsel

ing

in fa

cilit

ies

by

prov

ider

s

14 m

ater

nity

clin

ics

from

gre

ater

H

arar

e

RC

T –

437

HIV

+ p

ost-

inte

rven

tion

wom

en fr

om

the

ZV

ITA

MBO

clin

ical

tr

ial (

20 r

ecei

ved

3 vi

sits

, 10

8 re

ceiv

ed 2

vis

its,

234

rece

ived

1 v

isit,

75

rece

ived

no

visi

ts);

used

da

ta c

olle

cted

at

6 w

eeks

po

stpa

rtum

, 3 m

onth

s po

stpa

rtum

, and

eve

ry 3

m

onth

s th

erea

fter

for

up

to 2

4 m

onth

s

Dos

e re

spon

se:

0 vs

. 1 v

s. 2

vs. 3

vi

sits

% E

BF a

t 6

wee

ks

% E

BF a

t 3

mon

ths

%

EBF

at

6 m

onth

s

8% v

s. 15

% v

s. 14

.8%

vs.

30%

6.7%

vs.

12.8

%

vs. 1

7.6%

vs.

25%

4.0%

vs.

6.0%

vs.

4.6%

vs.

5.0%

p=0.

02

p=0.

005

p=0.

48

Qui

nn e

t al

. (20

05);

Boliv

ia,

Mad

agas

car

and

Gha

naIn

divi

dual

cou

nsel

ing;

Supp

ort

grou

p; M

ass

med

ia; S

mal

l med

ia;

Mob

iliza

tion

Boliv

ia -

3

ecor

egio

ns i

n ru

ral

and

urba

n ar

eas

(1

mill

ion

peop

le)

G

hana

– 3

0 di

stri

cts

(3.5

mill

ion

peop

le)

Mad

agas

car

- 10

fo

cus

dist

rict

s of

2

high

land

pro

vinc

es

(exp

ande

d an

d co

ntra

cted

due

to

polit

ical

cri

ses)

Rep

eate

d cr

oss-

sect

iona

l –

larg

e re

peat

ed s

urve

ys in

ea

ch c

ount

ry

% t

imel

y in

itiat

ion

of

brea

stfe

edin

g

Boliv

ia

Mad

agas

car

Gha

na

74%

vs.

56%

78%

vs.

34%

50%

vs.

32%

p<0.

001

p<0.

001

p<0.

05

% E

BF o

f inf

ants

< 6

m

onth

s ol

d

Boliv

ia

Mad

agas

car

Gha

na

65%

vs.

54%

68%

vs.

46%

79%

vs.

68%

p<0.

001

p<0.

001

p<0.

001


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

ST

UD

YA

PP

RO

AC

HE

S

US

ED

SC

OP

E /

SC

AL

EE

VA

LU

AT

ION

D

ES

IGN

OU

TC

OM

E(S

) M

EA

SU

RE

DR

ES

ULT

S26

P-V

AL

UE

s /

CIs

27

Ren

frew

et

al. (

2012

); va

riou

sIn

divi

dual

cou

nsel

ing;

Gro

up e

duca

tion

/ co

unse

ling

vari

edLi

tera

ture

rev

iew

– 5

2 R

CT

s or

qua

si-R

CT

s; 37

in

hig

h-in

com

e co

untr

ies,

12 in

upp

er-m

iddl

e-in

com

e co

untr

ies,

2 in

low

-mid

dle-

inco

me

coun

trie

s, an

d 2

in

low

-inco

me

coun

trie

s38

risk

rat

ios

follo

win

g al

l for

ms

of

extr

a su

ppor

t to

geth

er

Ris

k of

hav

ing

stop

ped

EBF

at s

ix m

onth

s (a

ll co

untr

ies)

Ris

k of

hav

ing

stop

ped

EBF

at 4

-6 w

eeks

(al

l co

untr

ies)

RR

= 0

.86

R

R =

0.7

4

(95%

CI:

0.82

-

0.91

)

(95%

CI:

0.61

-

0.89

)

Dur

atio

n of

bre

astfe

edin

g (a

ll co

untr

ies)

Ris

k of

sto

ppin

g br

east

feed

ing

befo

re s

ix

mon

ths

(all

coun

trie

s)

posi

tive

effe

ct

RR

= 0

.91

--

(95%

CI:

0.88

-

0.96

)

Salu

d et

al.

(200

9); P

hilip

pine

sC

ouns

elin

g in

hom

es b

y pe

ers;

15 z

ones

from

one

ci

ty (

popu

latio

n 25

,499

)

Long

itudi

nal –

312

wom

en

with

infa

nts

less

tha

n 2

mon

ths

old

who

wer

e no

t ex

clus

ivel

y br

east

feed

ing

at b

asel

ine

endl

ine

vs.

base

line

% E

BF o

f inf

ants

< 3

m

onth

s ol

d53

.5%

vs.

1%

Not

e: b

asel

ine

= in

fant

< 2

m

onth

s, en

dlin

e =

3 w

eeks

late

r

p<0.

001

Sant

iago

et

al. (

2003

); Br

azil

Cou

nsel

ing

in fa

cilit

ies

by

prov

ider

s; C

ouns

elin

g in

fa

cilit

ies

by la

y vo

lunt

eers

; G

roup

edu

catio

n in

fa

cilit

ies

by p

rovi

ders

1 cl

inic

RC

T –

101

bab

ies

(35

in

IG1,

33

in IG

2, a

nd 3

3 in

co

ntro

l) 39

IG1

vs. I

G2

vs.

cont

rol

% E

BF o

f inf

ants

4 m

onth

s ol

d82

.9%

vs.

66.7

%

vs. 3

0.3%

OR

=1.

00 v

s. O

R=

0.39

vs.

O

R=

0.11

p<0.

001

(95%

CI:

0.12

-1.

36)

vs. (

95%

C

I: 0.

03-

0.39

)

Saow

akon

tha

et a

l. (2

000)

; Tha

iland

Mob

iliza

tion

of c

ampa

ign,

ev

ent,

or s

peci

al “

days

”; M

id-s

ized

med

ia; S

mal

l m

edia

90 v

illag

es (

targ

et

popu

latio

n w

as

appr

oxim

atel

y 33

,000

wom

en o

f re

prod

uctiv

e ag

e)

Rep

eate

d cr

oss-

sect

iona

l –

700

endl

ine

vs.

base

line

% g

ave

colo

stru

m t

o in

fant

97

.2%

vs.

65.3

%p=

0.00

0

Sule

et

al. (

2009

); N

iger

iaSm

all m

edia

; Gro

up

educ

atio

n in

com

mun

ities

by

pro

vide

rs; C

ouns

elin

g in

ho

mes

by

prov

ider

s

2 ru

ral c

omm

uniti

es

(1 in

terv

entio

n w

ith a

pop

ulat

ion

of 5

,202

, 1 c

ontr

ol

with

a p

opul

atio

n of

8,

121)

Long

itudi

nal –

300

m

othe

rs o

f chi

ldre

n ag

ed 0

-18

mon

ths

(150

in

terv

entio

n, 1

50 c

ontr

ol)

% E

BF fo

r 6

mon

ths

amon

g in

fant

s w

ere

≥ 6

mon

ths

base

line:

59.0

%

vs. 4

7.9%

endl

ine

(6

mon

ths

late

r):

66.7

% v

s. 52

%

NS

p=0.

01

38

Not

e th

at o

ne st

udy

was

con

duct

ed in

two

coun

tries

.


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

ST

UD

YA

PP

RO

AC

HE

S

US

ED

SC

OP

E /

SC

AL

EE

VA

LU

AT

ION

D

ES

IGN

OU

TC

OM

E(S

) M

EA

SU

RE

DR

ES

ULT

S26

P-V

AL

UE

s /

CIs

27

Sun

et a

l. (2

011)

; Chi

naSm

all m

edia

; Mas

s m

edia

; Mid

-siz

ed m

edia

; C

ouns

elin

g in

faci

litie

s by

pr

ovid

ers

2 co

untie

s in

Sh

an’x

i pro

vinc

e (a

ppro

xim

atel

y 6,

000

child

ren

6-24

m

onth

s of

age

)

Rep

eate

d cr

oss-

sect

iona

l –

bas

elin

e (Ju

ne 2

008)

: 22

6 ca

regi

vers

and

the

ir

child

ren

6-24

mon

th-o

ld;

endl

ine

(Janu

ary

2010

): 22

1 ca

regi

vers

and

the

ir

child

ren

6-24

mon

th-o

ld

endl

ine

vs.

base

line

% e

arly

initi

atio

n of

br

east

feed

ing

16.8

% v

s. 8.

6%

p=0.

01

% b

reas

tfeed

ing

at 1

2 m

onth

s

% b

reas

tfeed

ing

at 2

4 m

onth

s

66.7

% v

s. 76

%

37.0

% v

s. 42

.3%

NS

NS

Syed

et

al. (

2006

); Ba

ngla

desh

Cou

nsel

ing

in fa

cilit

ies

by p

rovi

ders

; Soc

ial

and

com

mun

ity

mob

iliza

tion/

eng

agem

ent/

em

pow

erm

ent;

Cou

nsel

ing

in h

omes

by

prov

ider

s

11 upazilas

(sub

-di

stri

cts)

(10

in

terv

entio

n, 1

co

ntro

l)

Rep

eate

d cr

oss-

sect

iona

l –

base

line:

3,3

25 w

omen

w

ith c

hild

ren

aged

less

th

an o

ne y

ear

(2,9

89

inte

rven

tion,

336

con

trol

); en

dlin

e: 3

,110

wom

en w

ith

child

ren

aged

less

tha

n on

e ye

ar (

2,78

2 in

terv

entio

n,

323

cont

rol)

% b

reas

tfeed

ing

initi

atio

n w

ithin

one

hou

r of

bir

th

% g

ave

colo

stru

m t

o in

fant

base

line:

38.

6%

vs. 3

2.7%

endl

ine:

76.

2%

vs. 4

6.7%

Diff

eren

ce in

di

ffere

nces

: 23.

6

base

line:

86.

3%

vs. 9

1.7%

endl

ine:

96.

5%

vs. 9

3.5%

Diff

eren

ce in

di

ffere

nces

: 8.4

p=0.

01

--

Tho

mps

on a

nd H

arut

yuny

an (

2009

); A

rmen

iaC

ouns

elin

g in

hom

es b

y pe

ers;

Supp

ort

grou

p in

co

mm

uniti

es b

y pe

ers;

Smal

l med

ia; M

id-s

ized

m

edia

16 v

illag

es a

cros

s M

artu

ni r

egio

n of

G

egha

rkun

ik m

arz

Rep

eate

d cr

oss-

sect

iona

l –

600

with

at

leas

t on

e ch

ild a

ged

24 m

onth

s or

you

nger

(30

0 pr

e-in

terv

entio

n; 3

00 p

ost-

inte

rven

tion)

endl

ine

vs.

base

line

% b

reas

tfeed

ing

initi

atio

n w

ithin

one

hou

r of

bir

th

endl

ine

vs.

base

line:

66.

9%

vs. 7

0.4%

expo

sed

vs.

unex

pose

d:

72.5

% v

s. 56

.3%

p<0.

05

p<0.

05

% E

BF in

the

pas

t 24

ho

urs

amon

g in

fant

s <

6

mon

ths

old

endl

ine

vs.

base

line:

48.

1%

vs. 1

6.7%

expo

sed

vs.

unex

pose

d:

58.1

% 3

7.5%

p<0.

05

p<0.

05

39

Wom

en in

IG1

rece

ived

adv

ice

from

a m

ulti-

prof

essio

nal b

reas

tfeed

ing

team

; wom

en in

IG2

rece

ived

adv

ice

from

a p

edia

trici

an tr

aine

d in

bre

astfe

edin

g; a

nd w

omen

in th

e co

ntro

l gro

up re

ceiv

ed a

dvic

e fr

om a

pe

diat

ricia

n w

ith n

o br

east

feed

ing

train

ing.


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

ST

UD

YA

PP

RO

AC

HE

S

US

ED

SC

OP

E /

SC

AL

EE

VA

LU

AT

ION

D

ES

IGN

OU

TC

OM

E(S

) M

EA

SU

RE

DR

ES

ULT

S26

P-V

AL

UE

s /

CIs

27

Trip

athy

et

al. (

2010

); In

dia

Supp

ort

grou

p in

co

mm

uniti

es b

y pe

ers

36 c

lust

ers

(18

inte

rven

tion,

18

cont

rol)

with

a

popu

latio

n of

ap

prox

imat

ely

228,

186

RC

T –

liv

e bi

rths

id

entifi

ed o

ver

stud

y pe

riod

; ana

lysi

s of

br

east

feed

ing

indi

cato

rs

was

lim

ited

to 1

6,92

6 in

fant

s al

ive

at 1

mon

th

(8,8

07 in

terv

entio

n; 8

,119

co

ntro

l)

% b

reas

tfeed

ing

initi

atio

n w

ithin

four

hou

rs o

f bir

th61

% v

s. 61

%

OR

= 1

.0140

(95%

CI:

0·38

– 3·

11)

% E

BF fo

r 6

wee

ks80

% v

s. 69

%

OR

=1·

82(9

5% C

I: 1.

14–2

.92)

Tylle

skar

et

al. (

2011

); Bu

rkin

a Fa

so,

Uga

nda,

Sout

h A

fric

aC

ouns

elin

g in

hom

es b

y pe

ers

24 c

omm

uniti

es in

Bu

rkin

a Fa

so, 2

4 in

U

gand

a, an

d 34

in

Sout

h A

fric

a (v

illag

es

rand

omly

ass

igne

d in

a

1:1

ratio

to

cont

rol

or in

terv

entio

n cl

uste

rs)

RC

T –

2,5

79 m

othe

r-in

fant

pai

rs

Burk

ina

Faso

: 392

in

terv

entio

n, 4

02 c

ontr

ol

Uga

nda:

396

inte

rven

tion,

36

9 co

ntro

l

Sout

h A

fric

a: 53

5 in

terv

entio

n, 4

85 c

ontr

ol

% E

BF d

urin

g pr

evio

us

7 da

ys a

t 3

mon

ths

(12

wee

ks)

Burk

ina

Faso

Uga

nda

Sout

h A

fric

a

% E

BF d

urin

g pr

evio

us

7 da

ys a

t 6

mon

ths

(24

wee

ks)

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40Oddsratiosareadjustedforclustering,stratification,maternaleducation,assets,andanytribalaffiliation.


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Tylleskär,Thorkild,DebraJackson,NicolasMeda,IngunnMarieSEngebretsen,MickeyChopra,AbdoulayeHamaDiallo,TanyaDoherty, Eva-Charlotte Ekström, Lars T Fadnes, Ameena Goga, Chipepo Kankasa, Jørn I Klungsøyr, Carl Lombard, Victoria Nankabirwa, Jolly K Nankunda, Philippe Van de Perre, David Sanders, Rebecca Shanmugam, Halvor Sommer-felt, Henry Wamani, James K Tumwine, for the PROMISE-EBF Study Group. 2011. “Exclusive Breastfeeding Promotion byPeerCounsellorsinsub-SaharanAfrica(PROMISE-EBF):aCluster-randomizedTrial.”The Lancet378(9789)(July30):420–427.

Uruakpa,FO,MAHIsmond,ENTAkobundu.2002.“Colostrumanditsbenefits:areview”Nutrition Research, Volume 22, Issue 6, June 2002, Pages: 755-767.

USAIDInfantandYoungChildNutrition(IYCN)Project.Community Interventions to Promote Optimal Breastfeeding: Evidence on Early Initiation, Any Breastfeeding, Exclusive Breastfeeding, and Continued Breastfeeding. Washington, DC: USAID, 2012.

World Health Organization. Indicators for assessing infant and young child feeding practices: conclusions of a consensus meeting held 6–8 Novem-ber 2007 in Washington D.C., USA. Geneva: World Health Organization Press, 2008.


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3.3. Evidence of Effective SBCC Approaches to Improve Complementary Feeding Practices

A. Background

At the age of six months, breast milk alone is no longer sufficienttomeetthenutritionalrequirementsof agrowingchild(WorldHealthOrganization(WHO)/UNICEF,1998).Timely and appropriate complementary feeding is critical to a child’s growth and development. According to the 2008 maternal and child undernutrition series in The Lancet, the adoption of optimal complementary feeding practices and other supportive strategies at scale could result in a 17% relative reduction in the prevalence of stunting at 24 months, andavert5.5milliondisability-adjustedlifeyears(DALY)(Bhutta,2008a).Inasimilarseriesin2013,TheLancetreiter-ated the association between appropriate complementary feeding and nutritional outcomes, citing a study by Ruel and Menon(2002)thatfoundapositive,statisticallysignificantassociation between feeding practices and height-for-age infiveLatinAmericancountries.Finally,inananalysisof datasetsfrom14lowincomecountries,Marriottetal.(2012)reported that “consumption of a minimum acceptable diet

with dietary diversity reduced the risk of both stunting and underweight whereas minimum meal frequency was associ-atedwithlowerriskof underweightonly.”

Despite the promise of timely appropriate complementary feeding, global coverage of optimal complementary feeding practices remains low. According to an analysis of 2002-2008 data on complementary feeding practices in 46 coun-tries, just one-third of children aged 6-23 months received the recommended dietary diversity,41 approximately half received the recommended number of feeds, and only 20% receivedtheminimumacceptablediet(Lutter,2012).42

This chapter focuses on the effectiveness of Social and BehaviorChangeCommunication(SBCC)approachestoimproving complementary feeding practices of children 6-24 months of age. The chapter focuses on the WHO guiding

principles for complementary feeding for the breastfed

41 This refers to the number of food groups consumed over a given period indicating variety as stated in the guidance. Household level dietary diver-sity is an indicator for household food security (though this indicator is moreaccuratewhenaggregatedtoreflectthefoodsecurityof thesurveyarea),whileindividualdietarydiversityisanindicatorof dietaryqualityforanindividual(usuallymeasuredforwomenoryoungchildren).

42 Minimal acceptable diet is a composite of dietary diversity and meal frequency.

Table 3.3.1: WHO Guiding Principles for complementary feeding of the breastfed child 1 What When How

Timely introduction of appropriate complementary foods

Start at six months of age

Start with small amounts of food, increase quantity as child gets older. At six months, infants can eat pureed, mashed or semi-solid foods; at eight months, most can eat “finger foods;” by 12 months, most can eat “family foods.”

Dietary diversity After six months, daily

Feed a variety of foods: meat, poultry, fish or eggs; vitamin A-rich fruits and vegetables; diets with adequate fat content.43

Supplementation or fortification

After six months of age, as needed

Use fortified complementary foods or vitamin-mineral supplements for the infant, preferably mixed with or fed with food.

Increased meal frequency and/or energy density

Gradual age-dependent increase

Increase the number of times that a child is fed as he or she gets older: for the “average” child, 2-3 times/day at 6-8 months; 3-4 times/day at 9-23 months. Additional nutritious snacks may be offered 1-2 times per day.

Active and responsive feeding Always Feed infants directly; assist older children in feeding themselves; minimize distractions during meals; talk to children during feeding with eye-to-eye contact.

Safe food preparation and storage practices

Always Store foods safely and serve immediately after preparation; use clean utensils, cups and bowls; avoid using baby bottles.

Feeding during and after illness Always Increase fluid intake during illness; including more frequent breastfeeding; and encourage the child to eat soft, varied, appetizing, favorite foods. After illness, give food more often than usual and encourage the child to eat more.

AdaptedfromPAHO/WHO(2003).

43 The dietary diversity of complementary foods helps to ensure that the nutrient needs of infants and young children are met. For example, evidence shows that the adequate consumption of fruits and dark green, leafy vegetables alone can meet the vitamin A requirements for infants and young children (ACC/SCN, 2001).However,plant-basedcomplementaryfoodsalonearenotsufficienttomeetthebreadthof nutrientrequirementsof infantsandyoungchildren,unlessfortifiedfoodsorsupplementsarealsoconsumed.Animalproducts,includingmeat,poultry,fishandeggs,shouldbeconsumedonadailybasis(Dewey,2003).Meatandfishprovidemoreabsorbableironandincreasetheabsorptionof non-haemiron(ACC/SCN,2001).


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child(Pan-AmericanHealthOrganization(PAHO)/WHO,2003).SeeTable3.3.1.

B. Search Results

Thirty peer-reviewed studies met the literature review inclu-sion criteria.443A complete list of the studies reviewed, in-cludingasummaryof theSBCCapproach(es)utilized,thestudydesign,practicesmeasured,andlevelsof significanceis provided in Table 3.3.5 at the end of this chapter.

Twenty-fivestudiesreportedastatisticallysignificantchange in at least one of the recommended complementary

44 See the introductory chapter of this literature review for a full description of search procedures and inclusion/exclusion criteria.

feeding practices. Each of those articles is described in

greaterdetailbelow.Studiesreportingastatisticallysignifi-

cant change in more than one of the prioritized practices

and/or utilizing more than one SBCC approach are cited

and discussed multiple times. Where this occurs, we have

providedadetaileddescriptionof thestudyinthefirstref-

erence, and only discuss results in subsequent references.

Thefindingsareorganizedbypracticestargeted,SBCC

approach(es)utilized,andstudydesign.Thisorganization

enables the reader to derive an independent judgment re-

gardingfindingsfromeachstudy.Inaddition,implementa-

tion processes followed are discussed.


Practice Sub-practice

Literature reviews

with meta-analysis

RCTsLongi- tudinal studies

Repeated cross-

sectional studies


Total

Timely introduction of complementary foods

0 1 (1) 1 (0) 3 (1) 0 5 (2)

Dietary diversity

Feeding children animal source foods 0 7 (7) 4 (3) 2 (2) 1 (1) 14 (13)

Feeding children fruits and vegetables 0 3 (3) 3 (2) 3 (3) 1 (1) 10 (9)

Feeding children a minimum number of food groups

0 2 (0) 0 2 (1) 2 (1) 6 (2)


0 4 (1) 0 1 (1) 0 5 (2)

Increased meal frequency and/or density

Increasing frequency of feeding children 0 3 (2) 2 (2) 3 (2) 2 (1) 10 (7)

Adding fats or oils to children’s foods 0 5 (4) 0 0 0 5 (4)

Enhancing the consistency of children’s foods

0 2 (2) 1 (0) 0 0 3 (2)

Increasing the quantity fed to children at each meal

0 3 (2) 1 (1) 0 0 4 (3)

Responsive/active feeding 0 2 (2) 1 (0) 0 0 (0) 3 (2)

Feeding during and after illness 0 1 (1) 0 2 (0) 0 3 (1)



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Of the 30 studies reviewed for this chapter, eleven were rand-omizedcontrolledtrials(RCT),ninewerelongitudinalstudies(fivewithcontrolgroupsandfourwithnocontrolgroup),andtenwererepeatedcross-sectionalstudies(fivewithcon-trolgroupsandfivewithnocontrolgroup).SeeTable3.3.2.


With the release of the PAHO/ WHO’s Guiding Principles for Complementary Feeding of Breastfed Children(2003),theneedtodevelop standardized indicators to capture the breadth of recommended complementary feeding practices was estab-lished.Thisrecognitionresultedinthedevelopmentof fivestandardized indicators of complementary feeding: intro-duction of solid, semi-solid or soft foods, minimum dietary diversity, minimum meal frequency, minimum acceptable diet(MAD),andconsumptionof iron-richoriron-fortifiedfoods(WHO,2008).

The studies reviewed in this chapter, however, revealed very little consistency in how complementary feeding prac-tices were measured, and few employed the standardized indicators described above. The review is therefore focused on the WHO Guiding Principles rather than the “recom-mended”indicators.SeeTable3.3.1.Theguidingprinciplerelated to the safe preparation and storage of food was considered beyond the scope of this review.

Ofthe30studiesreviewed,fivemeasuredtheintroductionof complementary foods (mean age at or the frequency of intro-ductionof foodsatspecifiedages);20exploredthenutrientcontentof foods;fivestudiedtheuseorconsumptionof for-tifiedproductsorsupplements;16measuredmealfrequency,energy density, or energy intake; three looked at how children werefed(responsivelyoractively),andthreemeasuredfeed-ing practices during and after illness. See Table 3.3.2.

Timely introduction of appropriate complementary foods

Of thefivestudieslookingattheintroductionof comple-mentary foods or particular food types, two reported at leastonestatisticallysignificantresult.Eachof thestudiesmeasured the practice differently, and neither reported on the recommended standard indicator, namely the “propor-

tion of infants 6-8 months of age who receive solid, semi-solidorsoftfoods”(WHO,2008).

DeOliveiraetal.(2012)conductedanRCTmeasuringthemean age of introduction of complementary foods in a hospital in Brazil. The intervention included client-provider counseling in the facility and follow-up home visits. At the conclusion of the study period, the mean age at introduction of complementary foods was 153 days in the intervention group, compared with 95 days in the control group. Similarly, 22.8% of children were introduced to complementary foods at four months of age in the intervention group, compared with 41% in the control group. However, the authors found that “at 6 months, the prevalence of infants receiving com-plementary foods was similar for the two groups: 87.1% for theinterventiongroupand88.4%forthecontrolgroup.”

Lietal.(2007)conductedarepeatedcross-sectionalstudylooking at the mean age of introduction of seven wean-ingfoodsinfivetownshipsinYunanProvince,China.Theintervention included one-on-one counseling, food prepa-ration demonstrations, peer education, growth monitoring from birth through 17 months, and dissemination of a maternal and child nutrition video and pamphlet. The pro-ject also supported the strengthening of integrated man-agementof childhoodillness(IMCI)-relatedservices,andprovided thiamine to women just before or after delivery. Following the intervention, the age of introduction of all food groups except cow’s milk had increased.

Dietary diversity

Of the 20 studies that looked at the nutrient content of complementaryfoods,15reportedstatisticallysignificantresults.Of thosereportingstatisticallysignificantfindings,13 reported on the feeding of animal source foods, nine reported on the feeding of fruits and vegetables, and three reported on dietary diversity. Just one article (Sun et al., 2011)reportedontherecommendedstandardindicator,“proportion of children 6-23 months of age who receive foodsfrom4ormorefoodgroups.”(WHO,2008)

Feeding children animal source foods

Of the 14 studies that measured the feeding or consump-tion of animal source foods, all but one reported statisti-


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callysignificantresults.Theoutcomesmeasured,however,varied considerably among studies. There was little con-sistency among studies with respect to the meat product promoted (meat, cow’s milk, buffalo milk, eggs, positive deviance(PD)foodsincludinganimalsourcefoods,and/or“iron-richfoods”),themeasurementof milkintake(quantityconsumedandfrequencyof consumption),andmeasurement of egg consumption (mean number of times consumed and percentage of children fed three or more eggs).Furthermore,referenceperiodsandagerangesvariedconsiderably among studies.


Sevenof thestudiesreportingstatisticallysignificantresultswereRCTs.Bhandarietal.(2004)lookedattheconsump-tion of milk, fruit, and vegetables in India. The intervention involved “monthly home visits for new births until aged 12 months and weighing once every 3 months for children under 2 years of age conducted by Anganwadi workers, immuniza-tion clinics run by the auxiliary nurse midwives and sick child contactswithhealthcareproviders.”Additionally,auxiliarynurse midwives discussed key messages during monthly meet-ings with community representatives who, in turn, shared them during monthly neighborhood meetings. Following the intervention, the percentage of children nine months of age consuming any type of milk was 91.8% in the interven-tion group, compared with 82.6% in the control group. This findingwasstatisticallysignificant.Whilethedifferenceat18monthsof agewasnotstatisticallysignificant,differencesinmean energy intake from milk between the intervention and controlgroupwerestatisticallysignificantatboth9monthand 18 months – 837kcal vs. 607kcal at 9 months of age and 2021kcal vs. 1289kcal at 18 months of age.

BortoliniandVitolo(2012)lookedatmeanintakeof cow’smilk and meat among children 12 to 16 months of age in Rio Grande do Sul, Brazil. Women in the intervention group received monthly home visits during their child’s firstsixmonthsof life,andfollowupvisitswhenthechildren reached 8, 10 and 12 months of age. Following the intervention, the proportion of women postponing the introduction of cow’s milk was higher in the intervention group(50.9%)thanthecontrolgroup(36.6%).Further-more, mean intake of cow’s milk and meat in children 6-12 months of age was higher in the intervention group (588.1

mland54.3g,respectively)thaninthecontrolgroup(501.6mland47.3g,respectively).

Guldanetal.(2000)lookedatthefrequencyof feedingchildreneggs,meat,andfishormeatbrothinruralSichuan,China. The intervention included counseling by community healthworkers(CHW)duringmonthlygrowthmonitoringsessions, and visits to the homes of pregnant women and women with children under the age of one. During the home visits “nutrition educators disseminated a feeding guidebook and growth chart to each family, [provided] age-appropriate breastfeeding and complementary feeding suggestions and advice, answered questions and weighed each infant, marking theinfant’sweightonthegrowthchart.”Followingtheinter-vention, the percentage of children ages 4-6 months and 7-9 months that were fed eggs was 37% and 66% respectively in the intervention group, compared with 16% and 41% respec-tively in the control group. The percentage of children ages 7-9monthsand10-12monthsthatwerefedfishormeatbroth on a daily basis was 9% and 13% respectively in the intervention group, compared with 1% and 3% respectively in the control group, while the proportion of children ages 7-9 months and 10-12 months that were fed meat was 19% and 23% respectively in the intervention group, compared with 8% and 9% in the control group.

Pennyetal.(2005)lookedattheconsumptionof egg,chick-enliver,orfishinTrujillo,Peru.Theinterventionaimedto“enhance the quality of nutrition counseling through training and provision of simple, standardized, age-appropriate mes-sages to be used at all points of contact with young children [ortheircaregivers]inthefacility.”Datawerecollectedonacohort of children from intervention and control facilities from birth to age 18 months. Following the intervention, a higher proportion of women in the intervention group reportedfeedingegg,chicken,liver,orfishacrossthesixmeasurement points (at 6, 8, 9, 12, 15, and 18 months of age)thanwomeninthecontrolgroup;however,resultswereonlysignificantatsixandeightmonthsof age.Thepracticeof feeding animal foods improved in the immediate period following counseling; but diminished over time.

Royetal.(2007)lookedatthefeedingof eggs,theadditionof oil to children’s food, the feeding of energy and protein


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rich local complementary foods rich in micronutrients,45 and the feeding of children from a separate pot in Bangladesh. The intervention included the delivery of nutrition education sessions to small groups of women through trained commu-nityhealthworkers.Thegroupsmetweeklyforthefirstthreemonths and biweekly for the second three months. Forma-tive research guided development of messages, and the ses-sions included food preparation demonstrations. In addition to the mothers groups, men and older family members were targeted through monthly community/social mobilization ef-forts. Following the intervention, the percentage of children receiving three or more eggs increased from 11.3% to 29.8% in the intervention group and from 10% to 11.9% in the control group. Furthermore, the percentage of caregivers reporting feeding an animal-based complementary food in-creased from 30.4% to 88.5% in the intervention group and declined from 31% to 24.5% in the control group.

Vaziretal.(2013)lookedatconsumptionof iron-richfoods among children 9-15 months of age in 60 villages in India. The intervention, implemented over a period of 12 months, included regular home visits by trained village women (twice a month or four times a month depend-ingontheageof theinfant).Thecomplementaryfeedinggroup(CFG),receivedelevennutritioneducationmessageson sustained breastfeeding and complementary feeding, while the responsive complementary feeding and play group(RCF&PG),receivedthesesamemessagesaswellaseight messages on responsive feeding and eight messages ondevelopmentalstimulationusingfivesimpletoys.Thecontrol group received routine services provided under India’s Integrated Child Development Services program.

At nine months of age, 30.7% of children in the CFG and 25.6% of children in the RCF&PG consumed goat or chicken liver during the previous week compared with 2.3%

45 This complementary food is called kitchuri in Bangladesh. According to the authors, “Khichuri is a home-based transitional complementary food made with locally available inexpensive items in which rice and lentils complement each other to provide limiting amino acids (lysine and methionine,respectively),andtheadditionof aneggfurtherincreasedtheprotein quality. Moreover, egg yolk and vegetables increased the vitamin A, carotene, and other micronutrient contents of khichuri. Although animal-origin foods are a rich source of iron, they were not affordable to a large proportion of the families in our study population. During the intervention, there was a sharp increase in the use of khichuri as the main complementary food, but subsequently the practice decreased to some extent, largely due to the increase in age of the study children, when they werealreadyhabituatedtothefamilyfoods.”(Royetal.,2007)

of children in the control group. In addition, 22.3% of chil-dren in the CFG and 11.3% of children in the RCF&PG consumed goat meat during the previous week compared with 4.5% of children in the control group. At 15 months of age, 43.5% of children in the CFG group and 44% in the RCF&PG group consumed liver compared with 13.1% of children in the control group, while 37.5% of children in the CFG group and 45.2% of children in the RCF&PG group had consumed poultry in the previous week com-paredwith18.9%inthecontrolgroup.Thefindingswerestatisticallysignificant.Theauthorsfoundnostatisticaldifference with respect to intake of eggs.

Finally,Zamanetal.(2008)lookedatthefeedingof eggs,meat, and liver, the addition of ghee or butter to children’s foods,andfeedingof afortifiedcomplementaryfoodinLahore, Pakistan. The intervention was introduced as part of an IMCI program, and included counseling of sick women and children seeking care at a local health center. The counseling was provided by trained health workers equipped with counseling cards that had been adapted to the local culture and language. Eight to 14 days after re-cruitment, the proportion of women offering their children eggs was 16 percentage points higher among children in the intervention compared with those in the control group. Six months after recruitment, the difference was 21 percent-age points. The proportion of women offering children chicken, beef, or mutton 8-14 days after recruitment was approximately 18 percentage points higher in the interven-tiongroupthanthecontrolgroup.Thesefindingswerestatisticallysignificant.Theauthorsfoundnostatisticallysignificantdifferencesinthefeedingof chicken,beef ormutton six months after recruitment, or in the feeding of liver during any period of follow up.


Pachónetal.(2002)conductedalongitudinalrandomizedstudy looking at the consumption of locally available PD foods in rural Vietnam.46 The intervention was based on

46 PDfoodsincluded:crab,fish,fruit,peanut,sesameseed,vegetables,eggs, shrimp, tofu, beans, cassava, meat, potatoes, rice, snail, clams, corn, sweet potatoes, bananas, green vegetables, oranges, papaya, starches, and tangerines.


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the PD/Hearth approach.47 Theauthorsidentifiedseverallocally available highly nutritious foods, which were then promoted in intensive nutrition rehabilitation sessions for mothers of malnourished children. Women attended the sessions for two weeks each month for up to nine months. Duringtheintensiveinterventionperiod(months2-6)chil-dren under the age of three in the intervention group were fed PD foods an average of 4.1 times per day compared with an average of 3.6 times per day among children in the control group.

Palwalaetal.(2009)conductedalongitudinalstudywithoutcontrols looking at mean intake of cow’s milk, eggs, meat, legumes, fruits, and vegetables in Mumbai, India. Trained fieldworkersworkedwithgroupsof 8-10mothersusingwhat the authors describe as “innovative modules and dem-onstrations.”Theworkersthenfollowedupweeklyusing“a simple checklist … to assess impact, identify practices notadopted,andprovidefurtherinputs.”Bytheendof the study period, mean intake of milk among children 6-36 months of age had increased from 134 mL to 202 mL, while mean intake of egg had increased from 20 g to 29 g,andmeanintakeof meat(mutton,chicken,orfish)hadincreased from 4 g to 9 g.


Aboudetal.(2008)lookedatmeanegg,fish,andcow’smilk consumption among children in Sripur, Bangladesh. Both intervention and control groups received 12 education sessionsonchilddevelopment,includingfiveoncomple-mentary feeding. The intervention group received an ad-ditional six sessions on responsive feeding. Although both the intervention and control groups participated in sessions oncomplementaryfeeding,atthefivemonthfollowupchildren in the intervention group consumed a mean of 0.28 eggs during the previous 24 hours, while children in the control group consumed just 0.09 eggs in the previous 24hours.Thedifferencewasstatisticallysignificant.Differ-

47 According to the CORE Group’s Resource Guide for Sustainably Rehabili-tating Malnourished Children, “a Positive Deviance/Hearth Nutrition Pro-gram is a home- and neighborhood-based nutrition program for children who are at risk for protein-energy malnutrition in developing countries. The programusesthe“positivedeviance”approachtoidentifythosebehaviorspracticed by the mothers or caretakers of well-nourished children from poor families and to transfer such positive practices to others in the com-munitywithmalnourishedchildren.The“Hearth”orhomeisthelocationforthenutritioneducationandrehabilitationsessions”(McNulty,2005).

encesintheconsumptionof fishandcow’smilkwerenotsignificantlydifferent.

Mackintoshetal.(2002)conductedarepeatedcross-sectional study with controls looking at consumption of specificfoods,48 hygiene, and health practices in Tan Hoah, Vietnam. The intervention included growth monitoring andpromotion(GMP)forallchildrenunderthreeyearsof age, and a PD/Hearth nutrition rehabilitation program for malnourished children that involved education and dem-onstration with their caretakers. At the conclusion of the study period, 93.3% of children in the intervention group had consumed shrimp in the previous week compared with 76% of children in the control group, and 97.8% of children in the intervention group had consumed eggs in the past week, compared with 72% in the control group. Thesefindingswerestatisticallysignificant.Similarly,themean frequency of shrimp and egg consumption in the in-terventiongroup(3.2and4.0,respectively)wassignificantlygreater than consumption in the control group (1.0 and 1.5, respectively).Differencesintheconsumptionof meatandfreshfishwerenotstatisticallysignificant.

Sunetal.(2011)measuredthepercentageof childrenfediron-richfoods(definedhereasmeat,fish,poultry,liverandironsupplements)beforeandafteraneightmonthbehaviorchangecommunication(BCC)interventioninShan’xi, China. The program, which was primarily aimed at increasing children’s consumption of a multiple micro-nutrient powder, included formative research and develop-ment of messaging and materials. The BCC materials in-cludedinfantandyoungchildfeeding(IYCF)handbooksfor parents, booklets for health workers, and television spots. Caregivers “were educated about [IYCF] (includ-ingtheuseof YYB)duringtheirchildren’sregularvillagedoctor visits. Brochures were also distributed by pediatri-cians to families with infants and young children during sick and well child visits at maternal and child health care hospitals.”Datafromtheendlinesurveyrevealedthatthepercentage of children fed iron-rich foods had increased from19.2% to 56.8%; however, the lack of baseline values oracontrolgroupmakesitdifficulttoattributethesedif-ferences to the intervention.

48 FoodsincludedlocallyidentifiedPDfoods(peanuts,sesame,driedfish,snails,shrimp,crab,andgreens)andotherfoods(sweetpotatoes,soybeans,eggs,freshfish,meat,fruit,andoil/fat).


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Ghoshetal.(2002)lookedattheconsumptionof animalmilk, the number of food groups consumed, and feeding fre-quency among children in a cross-sectional study conducted in 13 villages in India. The intervention included monthly home visits by trained workers for a period of four to six months. Comparisons were made between infants included in the baseline study who reached 12 months of age before the interventionbegan(controlgroup)andthosewhowerelessthan six months old at the start of the intervention and con-tinued to participate until the child reached 12 months of age (interventiongroup).Bytheendof thestudyperiod,53.2%of children between six and 10 months of age in the inter-vention group had been fed animal milk in the previous 24 hours compared with 31.9% of children in the control group.

Feeding children fruits and vegetables

Of the ten studies that measured fruit and vegetable intake, ninereportedstatisticallysignificantresults.Theindica-tors measured varied considerably between studies, making comparisonsacrossstudiesdifficult.


Bhandarietal.(2004)conductedanRCTlookingatvegeta-ble and fruit consumption among children in India. At the end of the study period, the percentage of children nine months of age consuming any type of vegetables was 6.7% in the intervention group, compared with 2% in the control group.Thisdifferencewasstatisticallysignificant.Theau-thorsfoundnostatisticallysignificantdifferencesbetweenthe intervention group and control group with respect to fruit consumption, or children’s consumption of vegetables at 18 months of age.

Guldanetal.(2000)lookedattheconsumptionof fruitsand vegetables in rural Sichuan, China. Following a peer counseling intervention, the percentage of children in the intervention group consuming fruit exceeded the percent-age among controls in all age groups (26% vs. 10% at 4-6 months of age, 68% vs. 42% at 7-9 months of age, and 79%vs.52%at10-12monthsof age).Thesefindingswerestatisticallysignificant.Vegetableconsumptionamongchil-drenintheinterventiongroupwassignificantlygreaterthan

the control group in children 7-9 months of age (79% vs. 65%),butnotinchildren4-6or10-12monthsof age.

Finally,Vaziretal.(2013)lookedattheconsumptionof bananas and spinach by children in India. The study included two different intervention groups: a CFG and an RCF&PG. At nine months of age, 60.9% of children in the CFG and 59.4% of children in the RCF&PG consumed bananas dur-ing the previous week, compared with 38.6% of children in the control group, while 20.1% of children in the CFG and 14.4% of children in the RCF&PG consumed spinach during the previous week, compared with 5.1% of children inthecontrolgroup.Bothfindingswerestatisticallysignifi-cant. At 15 months of age, 79.3% of children in the CFG group and 78.3% in the RCF&PG group consumed bananas, compared with 61.9% of children in the control group, while 42.4% of children in the CFG group and 45.2% of children in the RCF&PG group had consumed spinach in the previ-ous week, compared with 29.5% in the control group.


Pachónetal.(2002)childrenunderthreeintheinterven-tion group were fed PD foods,49 including vegetables, green vegetables, sweet potatoes, bananas, oranges, papayas, and tangerines, an average of 4.1 times per day compared with only 3.6 times per day among children in the control group. Thisfindingwasstatisticallysignificant.

Palwalaetal.(2009)measuredchildren’smeanconsumptionof fruits and the proportion of children consuming veg-etables in Mumbai, India. By the end of the study period, mean intake of fruit in children between six and 36 months of age had increased from 41g to 82g, the percentage of children consuming green leafy vegetables had increased from 16.7% to 87.6%, and the percentage of children consuming carrots had increased from 8.3% to 52.1%. The resultswerestatisticallysignificant.


Aboudetal.(2008)conductedarepeatedcross-sectionalstudy looking at mean fruit and vegetable intake among chil-

49 PDfoodsidentifiedthroughaPDinquiryincluded:crab,fish,fruit,peanut, sesame seed, vegetables, eggs, shrimp, tofu, beans, cassava, meat, potatoes, rice, snail, clams, corn, sweet potatoes, bananas, green vegeta-bles, oranges, papaya, starches, and tangerines.


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dren in Sripur, Bangladesh. Five months after the responsive feeding intervention, the mean number of times children consumed fruit and vegetables during the previous day was .6 and1.37(respectively)intheinterventiongroup,comparedwith.32and.8(respectively)inthecontrolgroup.

Mackintoshetal.(2002)lookedatconsumptionof greens,sweet potatoes, and fruit in Thanh Hoa, Vietnam. At the conclusion of a GMP and PD/Hearth intervention, 100% of children in the intervention group consumed fruit in the previous week, compared with 88% in the control group. Similarly, the mean frequency of fruit consumption in the previous week was 5.4 in the intervention group, compared with1.5inthecontrolgroup.Thesefindingswerestatisti-callysignificant.Differencesintheconsumptionof greensandsweetpotatoeswerenotstatisticallysignificant,althoughthe authors did report an increase in the mean frequency of sweet potato consumption (6.7 times/week in the interven-tiongroupvs.3.2times/weekinthecontrolgroup).

Parvantaetal.(2007)lookedatchildfeedingpractices,particularly associated with iron-rich foods, in northwest Bangladesh.Interventiongroup1(IG1)includedhome-basedcounseling(onceinathreemonthperiod)byhealtheducators to pregnant women and mothers of children 6–24 monthsold.Interventiongroup2(IG2)includeddiscussionof role modeling stories facilitated by peer group leaders dur-ing gardening group or credit group meetings. Participants were asked to share these stories with related women who fell into the eligibility categories mentioned above. Following the intervention, 52% of women in IG2 reported feeding children 6-24 months of age the recommended portion of green leafy vegetables, compared with 33% of women in IG1, and 17% of women in the control group.


Finally,Kilaruetal.(2005)lookedattheconsumptionof bananas and dietary diversity in rural Karnataka, India. The intervention included monthly counseling (referred to as “education”inthearticle)forcaregiversof infantsfrombirth through a child’s second birthday. The nutrition edu-cationwasprovidedinthehomebytrainedfieldresearchstaff (highschoolorcollegeeducatedfieldworkerswholiveincloseproximitytothestudyvillages).“Afteradminister-ingthemonthlyquestionnaire,thefieldstaff woulddiscuss

reported feeding practices with the primary caregiver. The total time for the questionnaire and counseling was about 1½ hours. Field staff would review dietary information from the questionnaires and talk about ways of improving the quality and quantity of the diet through questions and probesaskedinafriendlymanner.Thefieldstaff wouldoften provide personal examples of how to overcome challenges in feeding young children, including the kind of communication skills needed to coax young children to eat.”Followingtheintervention,33%of caregiversintheintervention group reported feeding children 7-11 months of age bananas, compared with 4% in the control group.

Feeding children a minimum number of food groups (dietary diversity)

Two of six studies that measured dietary diversity reported statisticallysignificantresults.Sunetal.(2011)conductedarepeated cross-sectional study looking at dietary diversity in Shan’xi, China. Following a provider counseling and media intervention, the percentage of women reporting that they fed their six to 24 month old children more than four food groups50 had increased from 57.5% to 74.1% among breastfed children, and from 27.6% to 53.9% among non-breastfed children. Furthermore, the percentage of children fed a minimal acceptable diet had increased from 42.1% to 73.5% among breastfed children and from 25.0% to 45.0% among non-breastfed children. There was no control group included in the study.

Kilaruetal.(2005)conductedacross-sectionalanalysislooking at dietary diversity in Karnakaka, India. Following a home-based counseling intervention, the percentage of children11monthsof ageconsumingatleastfivedifferentfood groups was 42% in the intervention group, compared with 19% in the control group.


Althoughweidentifiedmanystudiesreportingontheconsumptionof micronutrientsupplementsorfortifiedproducts,onlyfivepresentedresultsinawaythatenabledanexaminationof thedistincteffectof specificSBCC

50 The authors did not explain if dietary data were based on a food recall and, if so, the recall period.


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approaches on uptake. Two of these reported statistically significantresults.

Bonvecchioetal.(2007)conductedanRCTlookingatthe impact of a behavior change intervention designed to improve the utilization of a multi-micronutrient nutritional supplement (papilla)amongchildren6-23monthsof agein Mexico. Papilla was provided as part of the Oportunidades Program free of charge, but conditional upon mothers’ participation in monthly education sessions on health and nutrition in all study communities. In intervention communi-ties, these education sessions were complemented by home visits in which volunteers conveyed four key messages related to the preparation and use of papilla, and demonstrated its preparation. Health care service providers conveyed similar messaging during consultations, and videos on these top-ics were screened in health facility waiting rooms. Posters were mounted in multiple sites, including health centers, stores, community centers, and churches, while megaphones mounted on trucks broadcast messages and announcements. At follow up, the authors reported a net increase of 43.5 percentage points in proper preparation of papilla in inter-vention communities compared with control communities, a net increase of 64.4 percentage points in daily provision of papilla, and a net increase of 61.5 percentage points in those providing papilla between breakfast and dinner.

Dongreetal.(2011)conductedarepeatedcross-sectionalstudy with controls focused on increasing coverage of iron supplementation among children under the age of three in 23 villages in India. The intervention included nutritional education sessions conducted during the Bal Suraksha Diwas (childhealthday)celebrationandduringhomevisits,freedistribution of iron syrup, and monthly village-level commu-nity/social mobilization meetings. Furthermore, “a photo-graph of locally available iron-rich foods and citrus fruits was shown to mothers to increase their awareness of sources of iron.[…]”Afterthreemonths,thepercentageof childrenunder the age of three who took iron supplementation in-creased from 8.8% to 41.6%. It is important to note that this intervention distributed the iron syrup free of charge.

Increased meal frequency and/or energy density

Sixteen studies measured meal frequency and energy den-sityand12of themreportedstatisticallysignificantresults.Four broad categories of practices were reported: seven studies reported on frequency of feeding, four reported on the addition of fats or oils to children’s foods, two reported on enhancing the energy density of children’s foods (i.e. decreasingwatercontent),andthreereportedonincreasingquantity fed to children at each meal.

Increasing frequency of feeding children

Seven of eleven studies that looked at the frequency or numberof mealsfedtochildrenoveraspecifiedperiodof timereportedstatisticallysignificantresults.


Bhandarietal.(2004)lookedatmealfrequencyamongchildren at nine and 18 months of age in India. At the conclusion of the facility and home based counseling intervention, children nine months of age in the interven-tion group consumed a mean of 4.4 meals in the previ-ous 24 hours, compared with a mean of 3.9 meals in the control group, while children 18 months of age in the intervention group consumed a mean of 5.9 meals in the previous 24 hours, compared with a mean of 5.4 among children in the control group. Both differences were statisticallysignificant.Meanenergyintakeintheprevious24 hours was higher among children in the intervention groupthaninthecontrolgroup(1556kilojoule(kJ)of energy vs. 1025 kJ among 9 month olds, and 3807 kJ vs. 2577kJamong18montholds).

Royetal.(2007)lookedatchildrenfedthreeormoretimesper day in Bangladesh. At the conclusion of the group education and small media intervention, 83.8% of children in the intervention group were fed three or more times per day compared with 19.4% of children in the control group. Thesedifferencesremainedstatisticallysignificantatfollowupsixmonthslater(88.5%vs.24.5%respectively).


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Pachónetal.(2002)lookedatmealfrequencyamongchil-dren under the age of three in rural Vietnam. After two to six months of a PD/Hearth group education intervention, children in the intervention group were fed a mean of 4.6 times per day compared with a mean of 4.2 times per day among children in the control group. After 12 months of the intervention, children in the intervention group consumed a mean of 4.9 meals per day compared with a mean of 4.6 meals per day among children in the control group. Further-more, during the intensive intervention period (months two tosix)childrenintheinterventiongroupweremorelikelytomeetenergyintakerequirements(kcal/kg)thanthoseinthecontrolgroup(49.0%vs.35.1%).Thisdifferencewasstatisti-callysignificant.Atthe12monthfollow-upperiod,however,the difference in the percentage of children meeting the recommendedintakewasnotstatisticallysignificant.


Guyonetal.(2009)lookedattheimpactof interventionsdesigned to increase food intake during pregnancy and lacta-tion and feeding frequency in children in two highland prov-inces in Madagascar. The intervention included training of health workers, interpersonal communication, community/social mobilization, and the use of mass media. At the end of the study period, “the proportion of breastfed children 6-23 months of age fed the recommended number of times increased from 87% to 92%. There was no increase in the rate of feeding the recommended times per day among chil-dren6-8monthsof age,buttherewasasignificantincreaseamongchildren9to23monthsof age(from85%to93%).”

Kimmonsetal.(2004)reportedonseveralstudiesassess-ing the feasibility of different approaches for improving complementary feeding practices in rural Bangladesh. Each study was conducted for seven days among approximately 30 women. One tested the feasibility and effectiveness of educational messages to increase the frequency of meals fed to children. Women were asked to feed at least three meals per day, and more if possible. They were advised that snackfoods(amountslessthan10g)werenottobeconsid-ered meals, and they were encouraged to continue to give snacks as usual. By the end of the seven day trial, the num-ber of meals provided to children in the previous 24 hours

had increased from a mean of 2.2 to a mean of 4.1. The second study focused on increasing the quantity of food offered to, and consumed by, infants at each meal. This trial did not have an effect on meal frequency, but did improve the quantity of food consumed by children (see below in discussionof quantityfedtochildrenateachmeal).Inthethird small study, women were taught to decrease viscosity of children’s food (and therefore increase food or energy consumption)by“changingtherecipeoraddingamylase,increasing energy density by adding sugar or oil, or chang-ingthefood’sorganolepticcharacteristics.”

Mackintoshetal.(2002)conductedarepeatedcross-sectionalstudy looking at feeding frequency among children in Tan Hoa, Vietnam. Following a PD/Hearth intervention, children in the intervention group consumed a mean of 2.9 full meals per day compared with a mean of 2.2 meals per day among children in the control group, and children in the intervention group consumed a mean of 2.5 snacks per day compared with a mean of 1.6 snacks per day in the control group.


Kilaruetal.(2005)lookedatthefrequencyof feedingintwo age groups in India. Following a provider counseling intervention, the percentage of children 7 to 11 months of age that were fed at least four times in addition to breast milk in the previous 24 hours was 78% in the intervention group and 51% in the control group.

Adding fats or oils to children’s foods

Five studies looked at the addition of oil, butter, or other fat to children’s diets to increase energy density, and all but one reportedstatisticallysignificantresults.Bhandarietal.(2004)conducted an RCT looking at the addition of oil or butter to infant foods in India. Following an intervention that included home visits and counseling at the facility level, the percentage of children nine months of age consuming foods with added oil or butter was 8.6% in the intervention group compared with 0.5% in the control group, and the percentage of chil-dren 18 months of age consuming foods with added oil or butter was 24.1% in the intervention group compared with 5.8% in the control group. The researchers found a corre-spondingchangeinenergyintakefromoil(kJper24hours)among children nine months and 18 months of age.


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InasecondRCT,Mackintoshetal.(2002)conductedare-peated cross-sectional study in Tan Hoa, Vietnam. Among other foods, they looked at the consumption of oil/fat by children between 7-9 months of age. Following a PD/Hearth intervention, children in the intervention group were fed oil/fat 6.6 times per week on average compared with 2.8 times among children in the control group.

Royetal.(2007)lookedattheadditionof oiltochildren’sfood in Bangladesh. Following the intervention, the per-centage of children at six months of age that received food with added oil was 69.8% in the intervention group com-pared with 20.9% in the control group, and the percentage of children at 12 months of age that received food with added oil was 61.3% in the intervention group compared with 21.5% in the control group.

Finally,Vaziretal.(2013)lookedattheadditionof fattocomplementary foods and the energy intake of children in India. The study included two different intervention groups: a CFG and an RCF&PG. At nine months of age, 51.4% of children in the CFG and 44.4% of children in the RCF&PG consumed added fat during the previous week compared with 24.4% of children in the control group. At 15 months of age, 42.4% of children in the CFG and 52.5% of children in the RCF&PG consumed added fat during the previous week compared with 29.5% of children in the control group. Similar differences in median energy intake following intervention were also reported. At nine months of age, median energy intake among children in the CFG group was 348 kcal and 331kcal in the RCF&PG group, compared with 209 kcal in the control group. At 15 months of age, median energy intake among children in both intervention groups was 569 kcal compared with 460 kcal among children in the control group.

Enhancing the consistency of children’s foods

Four studies evaluated the effect of an SBCC intervention on energy density of complementary food by enhancing theconsistencyof foods.Tworeportedstatisticallysignifi-cantresults.Zamanetal.(2008)conductedanRCTlookingat the feeding of kitchuri, a thick complementary food in Lahore, Pakistan. At 8 to 14 days after recruitment, 61.6% of women in the intervention group had offered their chil-dren kitchuri compared with 45% of women in the control

group, and at 180 days after recruitment, 65.9% of women had offered their children kitchuri compared with 44.3% in the control group. Findings 8 to 14 days after recruitment werenotstatisticallysignificant,whilefindingsfrom180daysafterrecruitmentwerestatisticallysignificant.

Pennyetal.(2005)conductedanRCTlookingatthefeed-ing of thick consistency foods among six age groups in Trujillo,Peru.Asignificantlyhigherpercentageof caregiv-ers in the intervention group compared with the control group fed food of a thick consistency to their children at measurementstakenatsixmonthsof age(31%vs.20%),atninemonthsof age(35%vs.17%),andat12monthsof age(42%vs.26%).Differencesattheagesof 8,15,and18monthswerenotstatisticallysignificant.

Increasing the quantity fed to children at each meal

While several studies measured energy intake among children,onlythreereportedstatisticallysignificantresultsspecificallyrelatingtoincreasingthequantityof foodfedto children at each meal. Two studies reported on the use of a separate feeding pot, and one article reported on an increase in the quantity of food offered and time allocated for feeding children.

Royetal.(2005)conductedanRCTlookingattheuseof a separate feeding pot for malnourished children 6 to 24 months of age in rural Chandpur, Bangladesh. The inter-vention took place within the Bangladesh Integrated Nutri-tionProject(BINP),andincludedtwointerventiongroupsof mothers.Inthefirstgroup,womenreceivedintensivenutritioneducation(INEgroup)twiceeachweekforthreemonths. In the second group, women received the same nu-trition education as well as supplementary feeding (INE+SF group).ThecontrolgroupreceivedstandardBINPservicesof twice-monthly nutrition education. After three months, 99% of women in the INE group and 100% of women in the INE+SF group reported the use of a separate pot for children, compared with 47% in the control group. At the end of six months of observation, 100% of women in both intervention groups reported use of separate pots for chil-dren, compared with 48% in the control group.


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Royetal.(2007)alsolookedattheuseof aseparatefeed-ing pot for children 6 to 9 months of age in four upazilas (administrativeunitswithindistricts)infourgeographicregions of Bangladesh. Following the intervention, the authors reported an increase of 14.3% in the proportion of children served from their own pots.

Finally,Kimmonsetal.(2004)conductedalongitudinalstudy looking at the quantity of food and duration of feed-inginBangladesh.Followinganinterventioninwhichfieldworkers encouraged women to increase the quantity of food fed to their children and allocate more time for meals, theresearchersobservednostatisticallysignificantdiffer-ence in the amount of food offered. However, they did observeastatisticallysignificantdifferenceinthequantityof foodconsumedbetweendayoneof thestudy(40g)andday7(64g),andinthedurationof themeal–fromsixto13 minutes.

Responsive and active feeding

Three studies looked at responsive or active feeding and two(bothRCTs)reportedstatisticallysignificantresults.Bhandarietal.(2004)lookedatseveralactivefeedingprac-tices in Indian children at nine and 18 months of age. The intervention included provider counseling, peer counseling, and group education to mothers. At nine months of age, 34.8% of women in the intervention group reported active encouragement, compared with 7.7% in the control group. At 18 months of age, 89.7% of women in the interven-tion group reported active encouragement, compared with 49.0% in the control group. Differences between the intervention group and control group held across a series of specificpractices,includingfeedingwithloveandaffec-tion(41%vs.11%),tryingrepeatedlyif thechilddidnoteat(15.4%vs.1%),womanfeedingherchildherself (34.9%vs.26.4%),womanmakingthechildsitinherlap(18.2%vs.6.6%),andfeedingthechildwithotherfamilymembers(12.4%vs.2.5%).

Zhangetal.(2013)lookedatactivefeedingandfeed-ing during illness among infants in rural Lasihui, China. Children were enrolled at two to four months of age and were assessed at 6, 9, 12, 15 and 18 months of age. The intervention included group training sessions conducted

by trained township doctors for mothers, grandmothers, and fathers, and home visits by trained providers every three months “with the purpose of identifying possible feedingproblemsandprovidingindividualcounselling.”The project disseminated child feeding booklets, and con-ducted demonstrations of food preparation using locally available, affordable, acceptable and nutrient-dense foods. After 18 months of the intervention, 88.0% of women in the intervention group encouraged their children to eat when they refused food, compared with 53.9% in the control group.

Feeding during and after illness

Three studies measured practices related to complementary feeding of sick or malnourished children, but only one reportedstatisticallysignificantresults.Zhangetal.(2013)conducted an RCT looking at feeding of breast milk and easy-to-digest foods to sick children in rural Laishui, China. Following the intervention, 88.8% of women reported feeding breast milk and easy-to-digest foods to their chil-dren with diarrhea, compared with 65% of women in the control group, while 67.3% of women in the intervention group reported preparing easy-to-digest food separately for their children with diarrhea, compared with 32.8% in the control group.



For the purposes of analysis, we organized SBCC activi-ties into three primary categories or approaches: inter-personal communication, media, and community/social mobilization.Theseapproachesandthespecificactivitiesassociated with each are described in further detail in the introductory chapter.

The studies reviewed included a broad range of approaches to promote optimal complementary feeding practices. Most includedmorethanonespecificSBCCactivityandmanyutilized more than one approach.

Of the25studiesreportingstatisticallysignificantfindings,24utilizedinterpersonalcommunication(IPC)approaches,


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SBCC approaches and activities

Literature reviews with meta-anal-

ysis

RCTsLongitudinal

studies

Repeated cross-sec-

tional studies

Cross-sec-tional studies

TOTAL

Interpersonal Communication 0 12 (12) 8 (7) 7 (4) 2 (2) 29 (25)

One-on-One Counseling 0 10 (6) 4 (0) 5 (1) 2 (2) 21 (9)

Counseling in facilities 0 5 (3) 1 (0) 0 2 (2) 8 (5)

Counseling in communities 0 0 0 1 (1) 0 1 (1)

Counseling in homes (home visits) 0 7 (3) 3 (2) 3 (1) 0 13 (6)

Counseling in other settings 0 0 0 1 (0) 0 1

Group Education 0 4 (3) 5 (5) 4 (3) 0 13 (11)

Education in facilities 0 0 1 (1) 0 0 1 (1)

Education in communities 0 4 (3) 4 (4) 3 (2) 0 11 (9)

Education in other settings 0 0 0 1 (0) 0 1

Support Group 0 0 0 3 (2) 0 3 (2)

Support group in facilities 0 0 0 0 0 0

Support group in communities 0 0 0 2 (1) 0 2 (1)

Support group in other settings 0 0 0 1 (0) 0 1

Media 0 7 (7) 2 (2) 5 (4) 0 14 (13)

Mass media 0 0 0 2 (2) 0 2 (2)

Mid-sized media (community radio / video, local billboards)

0 0 0 4 (3) 0 4 (3)

Small media (posters, flyers, calendars, reminder stickers)

0 7 (7) 2 (2) 4 (3) 0 13 (12)

Traditional media (songs, drama) 0 0 0 1 (1) 0 1 (1)

Social media (Twitter, Facebook, etc.) 0 0 0 0 0 0

Community/Social Mobilization 0 2 (2) 0 4 (3) 0 6 (5)


Issue groups 0 0 0 4 (3) 0 4 (3)

Other 0 2 (2) 0 0 0 2 (2)


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12utilizedsomeformof media,andfiveemployedcom-munity/social mobilization. Group education in commu-nities was the most commonly used IPC approach; small media was the most commonly used media approach; and issue groups were the most commonly used forms of com-munity/social mobilization. See Table 3.3.3.

The breadth of evidence regarding the effectiveness of SBCC in changing complementary feeding practices varies by type approach. Below, we discuss the evidence associ-ated with each of the primary SBCC approaches utilized to promoted complementary feeding practices. Table 3.3.4 providesaconsolidatedsummaryof thesefindings.


Weidentifiednopreviousreviewslookingattheeffective-ness of IPC on uptake of optimal complementary feeding practices, but did identify 24 primary research studies reportingstatisticallysignificantoutcomesassociatedwithinterventions that included IPC. One study reported a positive effect with respect to the timely introduction of complementary foods, 15 reported a positive effect with respect to dietary diversity, two documented a positive effectwithrespecttosupplementationorfortification,12reported a positive effect with respect to meal frequency or density, two reported a positive effect with respect to responsive or active feeding, and one reported a posi-tive effect with respect to feeding during or after illness. Twelve of these studies measured the effectiveness of IPC independent of other SBCC approaches, including four RCTs. Indicators and study design varied consider-ablybetweenstudies,makingconsolidationof findingsdifficult.Intheonlystudycomparingtheeffectivenessof different IPC approaches in changing complemen-taryfeedingpractices,Parvantaetal.(2007)comparedindividual stage-based counseling by a trained agent and education through storytelling led by a group leader. They found that “twice as many women who met with the trained agent (in contrast to those who met with the groupleaders)demonstratedfeedingaportionof greenvegetables equal to or surpassing the recommended quan-tity.”Thoughstatisticalsignificanceof thisdifferencewasnot reported, it was suggested in the authors’ analysis.

Media

Weidentifiednopreviousreviewsdocumentingtheeffec-tiveness of media-related interventions on complementary feeding outcomes, but did identify 13 primary research studies that reported positive outcomes associated with interventions including media-based SBCC approaches. One study reported a positive effect with respect to the timely introduction of complementary foods, nine studies reported a positive effect with respect to dietary diversity, one study documented a positive effect with respect to supplementationorfortification,sevenreportedapositiveeffect with respect to meal frequency or density, one study reported a positive effect with respect to responsive or ac-tive feeding, and one study reported a positive effect with respect to feeding during or after illness.

None of these studies, however, measured the effect of media interventions independent of other SBCC ap-proaches,makingitdifficulttomakedefinitiveconclusionsregarding the effectiveness of media related interventions on complementary feeding outcomes.


Weidentifiednoreviewsdocumentingtheeffectivenessof community/social mobilization approaches on complemen-taryfeedingoutcomes,butdididentifyfiveprimaryresearchstudiesreportingstatisticallysignificantoutcomesthatinclud-ed community/social mobilization approaches: One study reported a positive effect with respect to the timely introduc-tion of complementary foods, one reported a positive effect with respect to dietary diversity, one documented a positive effectwithrespecttosupplementationorfortification,tworeported a positive effect with respect to meal frequency or density, one reported a positive effect with respect to respon-sive or active feeding, and one reported a positive effect with respect to feeding during or after illness.

None of these studies measured the effectiveness of com-munity/social mobilization independent of other SBCC approaches.Itisthereforedifficulttoderiveconclusionsre-garding the effectiveness of community/social mobilization with respect to uptake of complementary feeding practices.


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Tabl

e 3.

3.4:

Num

ber

of s

tudi

es r

evie

wed

(w

ith n

umbe

r of

stu

dies

rep

ortin

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by S

BCC

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ch a

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des

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ach

Tim

ely

intr

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ods

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tyM

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up-

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Incr

ease

d m

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requ

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and

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/ ac

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fe

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afte

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Feed

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child

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anim

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a m

inim

um

num

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of f

oo

d gr

oup

s

Incr

easi

ng

freq

uenc

y o

f fee

ding

ch

ildre

n

Add

ing

fats

or

oils

to

ch

ildre

n’s

foo

ds

Enh

anci

ng

the

con-

sist

ency

of

child

ren’

s fo

ods

Incr

easi

ng

the

quan

-ti

ty fe

d to

ch

ildre

n at

eac

h m

eal

Inte

rper

-so

nal C

om

-m

unic

atio

n

4 (1

)

1 R

CT

(a

ge a

t in

tro-

duct

ion)

14 (

13)

6

RC

Ts

(5

egg

, 1

liver

, 1 fi

sh, 3

m

eat)

3 Lo

ngitu

-di

nal

(2 m

ilk, 1

eg

g, 1

mea

t, 1

PD)

3 R

epea

ted

cros

s-se

c-tio

nal

(1 e

gg, 1

fish

, 1

iron

- ri

ch)

1 C

ross

-sec

-tio

nal (

milk

)

10 (

9)

3

RC

Ts

(2

frui

ts, 2

ve

geta

bles

; ba

nana

and

sp

inac

h)

2

Long

itu-

dina

l (1

PD

, 1

vege

tabl

es)

3

Rep

eate

d cr

oss-

sec-

tiona

l (2

frui

ts, 2

ve

geta

bles

, 1

swee

t po

tato

)

1 C

ross

-se

ctio

nal

(ban

ana)

6 (2

)

1 R

epea

ted

cros

s-se

c-tio

nal

(>=

4 fo

od

grou

ps)

1 C

ross

-se

ctio

nal

(≥ 5

food

gr

oups

)

5 (2

)

1 R

CT

(fo

rtifi

ed

com

plem

en-

tary

food

)

1 Lo

ngitu

-di

nal

(iron

sup

-pl

emen

tatio

n co

vera

ge)

10 (

7)

2

RC

Ts

(≥

3 m

eals

; #

of m

eals

)

2 Lo

ngitu

-di

nal

(2 #

of

mea

ls)

2

Rep

eate

d cr

oss-

sec-

tiona

l (#

of m

eals

)

1 C

ross

-se

ctio

nal (

≥ 4

times

)

5 (4

)

4 R

CT

s

(2 a

dded

fat/

oil/b

utte

r; ve

geta

ble

oil d

aily

; lar

d da

ily; w

oman

ad

ded

fat

to

her

chil-

dren

’s fo

od)

4 (2

)

1 R

CT

(t

hick

food

s)

1

Rep

eate

d cr

oss-

sec-

tiona

l (t

hick

food

s)

4 (3

)

2 R

CT

s

(sep

arat

e

pot)

1 Lo

ngitu

-di

nal

(mea

l dur

a-tio

n)

3 (2

)

2 R

CT

s

(enc

oura

ge-

men

t)

3 (1

)

1 R

CT

(fe

edin

g du

r-in

g di

arrh

ea)


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SB

CC

ap

pro

ach

Tim

ely

intr

odu

c-ti

on

of

com

ple-

men

tary

fo

ods

Die

tary

div

ersi

tyM

icro

nu-

trie

nt s

up-

plem

enta

-ti

on

or

fort

ifica

-ti

on

Incr

ease

d m

eal f

requ

ency

and

/or

dens

ity

Res

pon-

sive

/ ac

tive

fe

edin

g

Feed

ing

duri

ng

and

afte

r ill

ness

Feed

ing

child

ren

anim

al

sour

ce

foo

ds

Feed

ing

child

ren

frui

ts a

nd

vege

ta-

bles

Feed

ing

child

ren

a m

inim

um

num

ber

of f

oo

d gr

oup

s

Incr

easi

ng

freq

uenc

y o

f fee

ding

ch

ildre

n

Add

ing

fats

or

oils

to

ch

ildre

n’s

foo

ds

Enh

anci

ng

the

con-

sist

ency

of

child

ren’

s fo

ods

Incr

easi

ng

the

quan

-ti

ty fe

d to

ch

ildre

n at

eac

h m

eal

Med

ia1

(1)

1

Rep

eate

d cr

oss-

sec-

tiona

l (a

ge a

t in

tro-

duct

ion)

5 (5

)

3 R

CT

(3

egg

, 2 li

ver,

1 fis

h, 1

goa

t, 1

poul

try)

1 Lo

ngitu

di-

nal (

egg)

1 R

epea

ted

cros

s-se

c-tio

nal

(iron

-ric

h)

3 (3

)

1 R

CT

(b

anan

a an

d sp

inac

h)

1

Long

itudi

-na

l (ve

geta

-bl

es)

1

Rep

eate

d cr

oss-

sec-

tiona

l (v

eget

able

s)

2 (1

)

1 R

epea

ted

cros

s-se

c-tio

nal

(>=

4 fo

od

grou

ps)

2 (1

)

1 R

CT

(fo

rtifi

ed

com

plem

en-

tary

food

)

4 (2

)

1 R

CT

(≥

3 m

eals

)

1 R

epea

ted

cros

s-se

c-tio

nal

(# o

f mea

ls)

2 (2

)

2 R

CT

s (1

ad

ded

fat/

oil/b

utte

r; w

oman

ad

ded

fat

to

her

chil-

dren

’s fo

od)

2 (1

)

1 R

epea

ted

cros

s-se

c-tio

nal

(thi

ck fo

ods)

2 (2

)

2 R

CT

s (s

epar

ate

po

t)

1 (1

)

1 R

CT

(e

ncou

rage

-m

ent)

2 (1

)

1 R

CT

(fe

ed-

ing

duri

ng

diar

rhea

)

Co

mm

u-ni

ty/ S

oci

al

Mo

biliz

a-ti

on

1 (1

)

1 R

epea

ted

cros

s-se

c-tio

nal (

age

at

intr

oduc

tion)

1 (1

)

1 R

CT

0 (0

)0

(0)

1 (1

)

1 R

epea

ted

cros

s-se

c-tio

nal

(iron

sup

-pl

emen

tatio

n co

vera

ge)

1 (1

)

1 R

epea

ted

cros

s-se

c-tio

nal (

# o

f m

eals

)

1 (0

)1

(1)

1

RC

T

(thi

ck fo

ods)

0 (0

)1

(1)

1

RC

T

(enc

oura

ge-

men

t)

3 (1

)

1 R

CT

(fe

ed-

ing

duri

ng

diar

rhea

)


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Weidentifiednoreviewsdocumentingtheeffectivenessof multiple SBCC approaches on complementary feeding outcomes. Of the 25 primary research studies reporting statisticallysignificantresultswithrespecttocomplemen-tary feeding outcomes, one study reported a positive effect with respect to timely introduction of complementary foods, seven reported a positive effect with respect to dietary diversity, two reported a positive effect with respect tomicronutrientsupplementationandfortification,sixreported a positive effect with respect to meal frequency and/or density, one reported a positive effect with respect to responsive or active feeding, and one reported a positive effect with respect to feeding during or after illness.

No studies compared the effect of different SBCC ap-proaches or measured the effect of the utilization of more than one SBCC approach compared with the utilization of just one approach. One must use caution, therefore, in deriving conclusions regarding the effectiveness of inter-ventions employing multiple approaches vis-à-vis those employing just one approach.


None of the studies reviewed in this chapter assessed the effect of implementation processes (e.g. intensity and timing of communications; type and training of person communicatingmessages,ortargetaudience)ontheeffec-tiveness of the SBCC approach on complementary feeding practices, nor did they consistently report all aspects of the implementation processes.

The intensity of communications ranged from one to 24 visits/sessions, conducted weekly or monthly for various lengths of time. However, none of the studies compared the effect of timing or frequency.

In terms of target audiences, all of the studies reviewed in this chapter targeted the mother or primary caregiver of the child.Amongthe25studiesreportingstatisticallysignificantresults, fourteen targeted only the mother/caregiver while eleven targeted an additional audience as well. Eight also targeteddirectinfluencers,eighttargetedlocalcommunityactors, and one targeted actors of the enabling environment.

None of the studies compared the effect of targeting one vs. multiple audiences or of targeting different audiences.

E. Conclusions

The evidence of the effect of SBCC on complementary feeding practices is quite broad, and clearly indicates that SBCC interventions can improve a wide range of comple-mentaryfeedingpractices.Whiletheliteraturemayreflecta bias to publish positive results, it also underscores the important role of SBCC approaches in improving nutrition practices – practices which have been shown to have an im-pact on nutritional status of women, infants, and children.

There is very little consistency in how complementary prac-ticesaredefined,thenormativestandardsfollowedforthem,and the indicators used to measure them. This is the case, even with the existence of globally recognized indicators and measurement guidance from the WHO. An additional challengeisthatbehaviorsarehighlycontext-specificwhenit comes to complementary feeding – with different food taboos and different foods available that are appropriate for complementary feeding. If behaviors aren’t standardized, a projectmayimprovebehaviorsbutitwillbedifficulttoat-tribute changes in outcomes to those behaviors.

Similarly, there is considerable variation in the descrip-tion of SBCC interventions – the interactions or combinations with other interventions, target groups, content, messages, scale and coverage, length and intensity, as well as context.

SBCC interventions to promote complementary feed-ing practices are suited to iterative programming, be-cause even if standards for behaviors aren’t met, there can be significant movement toward the standard. In a hypothetical example, the target number of families introducing leafy green vegetables at six months might not be met, but many families may have begun introducing by eight months, whereas before the intervention they were not introducing until one year. Iterative interventions can learn what supported that move in the right direction, and build on them.

Interpersonal communication is the most prevalent SBCC approach used and researched, and is consistently effective


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EAST

FEED

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PREG

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ND

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at improving complementary feeding practices. All but one of the studies in this chapter used IPC, and half of these measured the effectiveness of IPC independent of other SBCC approaches. While media and com-munity/social mobilization were used, they were always used with at least one other communication approach. No studies compared the effectiveness between differ-ent approaches or between one versus multiple SBCC channels or specific activities. This may be due to the difficultandcostof implementingmultiplearmsof astudy or disaggregating the contribution of single channels orspecificactivitieswithinamulti-channelintervention.Whatever the reason, it is important for SBCC practitioners and researchers to consider whether this line of research is worth the effort it will require.

Allof thestudiesreportingstatisticallysignificantresultstargeted the mother of the child herself. More than half of thosetargetedoneormoreotheraudiencesorinfluencersas well. No studies were identified that compared the effect of targeting one vs. multiple audiences or of targeting different audiences.

Little was mentioned in the articles reviewed regarding the timing of communications. The intensity of communica-tions ranged from one to 24 visits or sessions, conducted weekly or monthly for various lengths of time. None of the studies compared the effect of timing or intensity of communications.

Most studies were implemented on a relatively small scale, within only a few communities and typically having fewer than 300 study participants per group.

Finally, differences in local context (including social norms, culture,andenvironmentalfactors)aswellasdifferencesinthe implementation and scale of implementation affect the success of interventions. This underscores the importance of proper context assessments, formative research and/or ethnographic study prior to SBCC implementation.

Due to the lack of standardization in the way research re-lated to SBCC is designed and described, it is challenging to make conclusions beyond the fact that projects with SBCC will result in uptake of promoted practices. While there is much to be learned from this body of literature to aid us in developing future programs, a number of questions remain. These include questions related to:

n thepositive(ornegative)effectof usingmultipleSBCCapproaches compared with focusing on only one;

n thepositive(ornegative)effectof targetingmultipleaudiencesorinfluencersof thebehaviorsbeingpromoted, rather than focusing on just one target population;






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FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

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Tabl

e 3.

3.5:

Stu

dies

rep

ortin

g on

com

plem

enta

ry fe

edin

g pr

actic

es

Col

or c

odin

g ke

y

Intr

oduc

tion

of c

ompl

emen

tary

food

sEn

suri

ng n

utri

ent

cont

ent

of fo

ods

Prov

idin

g su

pple

men

ts o

r fo

rtifi

ed p

rodu

cts

Prov

idin

g ad

equa

te m

eal f

requ

ency

and

ene

rgy

dens

ity

Feed

ing

resp

onsi

vely

or

activ

ely

Feed

ing

duri

ng a

nd a

fter

illn

ess

ST

UD

YA

PP

RO

AC

HE

S

US

ED

S

CA

LE

/SC

OP

EE

VA

LU

AT

ION

M

ET

HO

DS

OU

CO

ME

(S)

ME

AS

-U

RE

DR

ES

ULT

S51

P-V

AL

UE

s / C

Is 5

2

Abo

ud e

t al

. (20

08);

Bang

lade

shG

roup

edu

catio

n in

co

mm

uniti

es b

y la

y vo

lunt

eers

36 v

illag

e cl

uste

rs

in a

rur

al S

ripu

r su

b-di

stri

ct (

18

inte

rven

tion,

18

cont

rol)

Rep

eate

d cr

oss-

sect

iona

l –

183

wom

en w

ith

child

ren

12 t

o 24

mon

ths

old

(91

inte

rven

tion,

92

cont

rol);

dat

a co

llect

ed

at b

asel

ine

and

5 m

onth

fo

llow

-up

Mea

n nu

mbe

r of

tim

es

food

s w

ere

eate

n by

chi

ld

yest

erda

y

-ani

mal

(fis

h)

-egg

-cow

’s m

ilk

0.86

vs.

1.01

0.28

vs.

0.09

0.85

vs.

0.73

NS53

p=0.

02

NS

Mea

n nu

mbe

r of

tim

es

frui

t w

as e

aten

by

child

ye

ster

day

Mea

n nu

mbe

r of

tim

es

vege

tabl

es w

ere

eate

n by

ch

ild y

este

rday

0.60

vs.

0.32

1.37

vs.

0.80

p=0.

04

p=0.

004

Abo

ud e

t al

. (20

09);

Bang

lade

shG

roup

edu

catio

n in

co

mm

uniti

es b

y la

y vo

lunt

eers

37 v

illag

e cl

uste

rs

in a

rur

al Ja

lakh

a su

b-di

stri

ct (

19

inte

rven

tion,

18

cont

rol)

Rep

eate

d cr

oss-

sect

iona

l –

203

wom

en w

ith

child

ren

8 to

20

mon

ths

old

(108

int

erve

ntio

n; 9

5 co

ntro

l)

Mea

n n

umbe

r of

food

ty

pes

eate

n (o

f sev

en)

by

child

ren

as r

epor

ted

by

mot

her

Mea

n n

umbe

r of

food

ty

pes

eate

n (o

f sev

en)

by

child

ren

as r

epor

ted

by

mot

her

3.25

vs.

2.93

2.22

vs.

2.26

NS

NS

Mea

n nu

mbe

r of

mou

thfu

ls

of fo

od t

aken

by

child

ren

at m

idda

y m

eal

-Pre

-tes

t

-Pos

t-te

st

-Fol

low

-up

13.7

7 v

s. 15

.10

20.7

8 v

s. 20

.11

21.2

3 vs

. 21.

62

NS

NS

NS

51

Com

paris

on is

inte

rven

tion

vs. c

ontro

l gro

up, u

nles

s ind

icat

ed o

ther

wise

.52Differencesreportedasnotsignificantlydifferentareindicatedby“NS”.Differencesforwhichstatisticalsignificancewasnotreportedareindicatedby“--“.



INTR

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S51

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Bhan

dari

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al. (

2001

); In

dia

Cou

nsel

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in h

omes

by

prov

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s1

com

mun

ity in

D

elhi

R

CT

– 4

18 in

fant

s fo

ur

mon

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of a

ge (

96 in

food

su

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men

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oup;

95

in n

utri

tiona

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nsel

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grou

p; 1

00 in

con

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gr

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and

96

in v

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); d

ata

colle

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whe

n in

fant

s w

ere

6, 9

and

12

mon

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of a

ge

Supp

lem

ent

+

coun

selin

g vs

. co

unse

ling

alon

e vs

. vis

itatio

n vs

. co

ntro

l

Com

pari

sons

w

ith fi

nal

grou

p (v

isita

tion

cont

rol)

Med

ian

ener

gy (

kJ)

inta

ke/

day

from

usu

al fo

ods

am

ong

child

ren

- at

26

wee

ks

- at

38

wee

ks

- at

52

wee

ks

Med

ian

tota

l ene

rgy

(kJ)

inta

ke/ d

ay a

mon

g ch

ildre

n

- at

26

wee

ks

- at

38

wee

ks

- at

52

wee

ks

171

vs. 4

72 v

s. 19

2 vs

. 268

476

vs. 9

78 v

s. 43

0 vs

. 577

761

vs. 1

417

vs.

665

vs. 9

24

1409

vs.

472

vs.

192

vs. 2

68

2169

vs.

978

vs.

430

vs. 5

77

2922

vs.

1417

vs

. 665

vs.

924

NS,

p<0.

05,

NS

NS,

p<0.

05,

NS

NS,

p<0.

05,

NS

--

--

--


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PP

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S

US

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/SC

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M

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S51

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Bhan

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al. (

2004

); In

dia

Cou

nsel

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in fa

cilit

ies

by p

rovi

ders

; Gro

up

educ

atio

n in

com

mun

ities

by

pro

vide

rs; C

ouns

elin

g in

ho

mes

by

peer

s

8 co

mm

uniti

es

(4 in

terv

entio

n, 4

co

ntro

l)

RC

T –

1,0

25 n

ewbo

rns

(552

inte

rven

tion,

473

co

ntro

l); d

ata

colle

cted

ev

ery

3 m

onth

s fo

r 18

m

onth

s

% o

f chi

ldre

n w

ho

cons

umed

any

milk

- at

9 m

onth

s

- at

18

mon

ths

Mea

n en

ergy

inta

ke fr

om

milk

, kJ/2

4 hr

s

- at

12

mon

ths

- at

18

mon

ths

% o

f chi

ldre

n w

ho

cons

umed

veg

etab

les

- at

12

mon

ths

- at

18

mon

ths

% o

f chi

ldre

n w

ho

cons

umed

frui

ts

- at

12

mon

ths

- at

18

mon

ths

91.8

% v

s. 82

.6%

98.6

% v

s. 95

.9%

837

vs. 6

07

2021

vs.

1289

6.7%

vs.

2%

26%

vs.

24.1

%

16.2

% v

s. 11

.9%

44.8

% v

s. 40

.4%

p<0.

01

NS

p<0.

01

p<0.

001

p<0.

05

NS

NS

NS

Ener

gy in

take

(al

l foo

ds),

kJ/2

4 h

- at

9 m

onth

s

- at

18

mon

ths

Ener

gy in

take

from

oil,

kJ/2

4 h

- at

9 m

onth

s

- at

18

mon

ths

% o

f chi

ldre

n w

ho

cons

umed

add

ed o

il or

bu

tter

to

reci

pes

- at

9 m

onth

s

- at

18

mon

ths

Mea

n nu

mbe

r of

mea

ls

cons

umed

by

child

in t

he

prev

ious

24

hour

s

- at

9 m

onth

s

- at

18

mon

ths

1556

vs.

1025

3807

vs.

2577

134

vs. 5

8

335

vs. 1

84

8.6%

vs.

0.5%

24.1

% v

s. 5.

8%

4.4

vs. 3

.9

5.9

vs.

5.4

p<0.

001

p<0.

001

p<0.

001

p<0.

001

p<0.

01

p<0.

001

p<0.

01

p<0.

01


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

ST

UD

YA

PP

RO

AC

HE

S

US

ED

S

CA

LE

/SC

OP

EE

VA

LU

AT

ION

M

ET

HO

DS

OU

CO

ME

(S)

ME

AS

-U

RE

DR

ES

ULT

S51

P-V

AL

UE

s / C

Is 5

2

% o

f wom

en t

hat

repo

rted

ac

tivel

y en

cour

agin

g th

eir

child

ren

to e

at m

ore

- at

9 m

onth

s

- at

18

mon

ths

At

18 m

onth

s…

- %

of w

omen

tha

t re

port

ed fe

edin

g th

eir

child

ren

with

love

- %

of w

omen

tha

t re

port

ed t

ryin

g re

peat

edly

if t

heir

chi

ld

did

not

eat

- %

of w

omen

tha

t re

port

ed fe

edin

g th

eir

child

her

self

- %

of w

omen

tha

t re

port

ed m

akin

g he

r ch

ild s

it in

her

lap

- %

of w

omen

tha

t re

port

ed fe

edin

g th

eir

child

with

oth

er fa

mily

m

embe

rs

34.8

% v

s. 7.

7%

89.7

vs.

49%

41%

vs.

11%

15

.4%

vs.

1%

34.9

vs.

26.4

%

18.2

% v

s. 6.

6%

12.4

% v

s. 2.

5%

p<0.

0001

p<0.

0001

p<0.

0001

p<

0.00

01

p<0.

0001

p<

0.00

01

p<0.

0001


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

ST

UD

YA

PP

RO

AC

HE

S

US

ED

S

CA

LE

/SC

OP

EE

VA

LU

AT

ION

M

ET

HO

DS

OU

CO

ME

(S)

ME

AS

-U

RE

DR

ES

ULT

S51

P-V

AL

UE

s / C

Is 5

2

Bonv

ecch

io e

t al

. (20

07);

Mex

ico

Cou

nsel

ing

in fa

cilit

ies

by

prov

ider

s; C

ouns

elin

g in

ho

mes

by

lay

volu

ntee

rs;

Smal

l med

ia

4 co

mm

uniti

es

from

Ver

acru

z an

d C

hiap

as s

tate

s (1

in

terv

entio

n an

d 1

cont

rol c

omm

unity

fr

om e

ach

stat

e)

RC

T –

715

hou

seho

lds

part

icip

ated

in t

he

Oportunidades

pro

gram

an

d ha

d a

child

6-

23 m

onth

s of

age

pr

esen

t (V

erac

ruz:

171

inte

rven

tion,

173

con

trol

; C

hiap

as: 1

90 in

terv

entio

n,

181

cont

rol);

dat

a co

llect

ed a

t ba

selin

e an

d 5

mon

ths

late

r

Prep

ared

pap

illa

(nut

ritio

nal s

uppl

emen

t)

corr

ectly

Gav

e pa

pilla

eve

ry d

ay

Gav

e pa

pilla

bet

wee

n br

eakf

ast

and

dinn

er

Vera

cruz

: 82.

8%

vs. 1

9.3%

Chi

apas

: 80.

8%

vs. 1

5.6%

[net

incr

ease

of

42.9

per

cent

age

poin

ts in

in

terv

entio

n co

mpa

red

with

co

ntro

l]

Vera

cruz

: 78.

2%

vs. 1

7%

Chi

apas

: 71.

6%

vs. 2

2.2%

[net

incr

ease

of

64.4

per

cent

age

poin

ts in

in

terv

entio

n co

mpa

red

with

co

ntro

l]

No

data

on

Vera

cruz

an

d C

hiap

as

prov

ided

[net

incr

ease

of

61.5

per

cent

age

poin

ts in

in

terv

entio

n co

mpa

red

with

co

ntro

l]

p<0.

0554

p<

0.05

p<0.

05


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

ST

UD

YA

PP

RO

AC

HE

S

US

ED

S

CA

LE

/SC

OP

EE

VA

LU

AT

ION

M

ET

HO

DS

OU

CO

ME

(S)

ME

AS

-U

RE

DR

ES

ULT

S51

P-V

AL

UE

s / C

Is 5

2

Bort

olin

i and

Vito

lo (

2012

); Br

azil

Cou

nsel

ing

in h

omes

by

prov

ider

s1

hosp

ital

RC

T –

397

new

born

s (1

63 in

terv

entio

n , 2

34

cont

rol)

Base

d on

a 2

4 ho

ur d

ieta

ry

reca

ll am

ong

child

ren

12-1

6 m

onth

s ol

d, m

ean

inta

ke o

f…

- co

w’s

milk

(m

L)

- m

eat

(g)

- ir

on (

mg)

- he

me

iron

(m

g)

- no

n-he

me

iron

(m

g)

501.

6 vs

. 588

.1

54.3

vs.

47.3

5.1

vs. 5

.4

1.5

vs. 1

.2

3.8

vs. 4

.5

p=0.

03

p=0.

024

p=0.

22

p=0.

003

p=0.

002

% ir

on s

uppl

emen

tatio

n of

ch

ildre

n at

0-6

mon

ths

% ir

on s

uppl

emen

tatio

n of

ch

ildre

n at

6-1

2 m

onth

s

18.2

% v

s. 19

.6%

23%

vs.

21.8

%

NS

NS

Col

ecra

ft e

t al

. (20

04);

Gha

naG

roup

edu

catio

n in

fa

cilit

ies

by p

rovi

ders

four

pri

mar

y he

alth

ca

re fa

cilit

ies

in

Acc

ra

with

a fu

nctio

ning

da

y-ca

re n

utri

tion

reha

bilit

atio

n

cent

er (

NR

C)

Long

itudi

nal –

108

ca

regi

vers

and

the

ir 1

16

child

ren

who

wer

e ne

wly

en

rolle

d in

an

NR

C

betw

een

Nov

embe

r 19

99

and

July

200

0

base

line

vs.

endl

ine

vs.

follo

w u

p

% o

f eat

ing

even

ts

cont

aini

ng fi

sh p

owde

r

% o

f eat

ing

even

ts

cont

aini

ng o

ther

ani

mal

pr

otei

n

% o

f eat

ing

even

ts

cont

aini

ng m

ilk

% o

f eat

ing

even

ts

cont

aini

ng e

ggs

% o

f eat

ing

even

ts

cont

aini

ng g

reen

leaf

y ve

geta

bles

24.1

% v

s. 23

.6%

vs

. 14.

3%

49.1

% v

s. 58

.2%

vs

. 50.

0%

39.3

% v

s. 25

.5%

vs

. 11.

9%

18.7

% v

s. 14

.6%

vs

. 4.8

%

13.4

% v

s. 23

.6%

vs

. 38.

1%

NS

NS

p=0.

007

NS

NS


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

54

P-va

lues

are

for m

ean

incr

emen

ts fr

om b

asel

ine

to e

ndlin

e in

inte

rven

tion

sites

com

pare

d w

ith c

ontro

l site

s.

ST

UD

YA

PP

RO

AC

HE

S

US

ED

S

CA

LE

/SC

OP

EE

VA

LU

AT

ION

M

ET

HO

DS

OU

CO

ME

(S)

ME

AS

-U

RE

DR

ES

ULT

S51

P-V

AL

UE

s / C

Is 5

2

De

Oliv

eira

et

al. (

2012

); Br

azil

Cou

nsel

ing

in fa

cilit

ies

by

prov

ider

s1

hosp

ital

RC

T –

dat

a fr

om 2

55

adol

esce

nt g

irls

del

iver

ing

in t

he h

ospi

tal a

naly

zed

(132

mot

her-

child

pai

rs

inte

rven

tion,

123

con

trol

); da

ta c

olle

cted

at

base

line

and

mon

thly

for

six

mon

ths

post

part

um

Mea

n ag

e of

intr

oduc

tion

of n

on-b

reas

t m

ilk a

nd

com

plem

enta

ry fo

ods

(day

s)

% o

f chi

ldre

n fe

d co

mpl

emen

tary

food

s at

4

mon

ths

% o

f chi

ldre

n fe

d co

mpl

emen

tary

food

s at

6

mon

ths

153

(95%

CI,

114.

6–19

1.4)

vs.

95 d

ays

(95%

CI,

8.7–

111.

3)

22.8

% (

95%

CI:

15.9

–29.

7) v

s. 41

% (

95%

CI:

32.8

–49.

2)

87.1

% (

95%

CI:

81.4

–92.

8) v

s. 88

.4%

(95

% C

I: 82

.9–9

3.9)

CIs

did

not

ov

erla

p C

Is d

id n

ot

over

lap

CIs

ove

rlap

Don

gre

et a

l. (2

011)

; Ind

iaM

obili

zatio

n of

cam

paig

n,

even

t, or

spe

cial

“da

ys”;

Mob

iliza

tion

of is

sue

grou

ps

23 v

illag

es

Rep

eate

d cr

oss

sect

iona

l –

child

ren

6 to

35

mon

ths

of a

ge (

base

line:

261

; en

dlin

e / 3

mon

ths

follo

w-

up: 3

72)

endl

ine

vs.

base

line

% ir

on s

uppl

emen

tatio

n

amon

g ch

ildre

n 6-

35

mon

ths

of a

ge

41.6

% v

s. 8.

8%p=

0.00

1

Gho

sh e

t al

. (20

02);

Indi

aC

ouns

elin

g in

hom

es b

y pr

ovid

ers

13 v

illag

es

Cro

ss s

ectio

nal –

infa

nts

aged

less

tha

n si

x m

onth

s

wer

e en

rolle

d on

an

on-g

oing

bas

is b

etw

een

1997

-199

9; 2

42 in

fant

s 5-

11 m

onth

s ol

d w

ere

incl

uded

in t

his

anal

ysis

(1

73 in

fant

s <

6 m

onth

s of

age

at

base

line

form

ed

inte

rven

tion

grou

p, 6

9 in

fant

s w

ho r

each

ed

12 m

onth

s pr

ior

to t

he

inte

rven

tion

form

ed

cont

rol g

roup

); da

ta

colle

cted

mon

thly

unt

il th

e ch

ild r

each

ed 2

4 m

onth

s of

age

% o

f chi

ldre

n 6-

10 m

onth

s of

age

fed

anim

al m

ilk

Mea

n nu

mbe

r of

diff

eren

t fo

od g

roup

s fe

d in

a 2

4-ho

ur p

erio

d

- at

9 m

onth

s

- at

10

mon

ths

- at

11

mon

ths

53.2

%

vs. 3

1.9%

3.61

vs.

2.86

3.87

vs.

3.1

4.34

vs.

3.4

p<0.

01

Not

rep

orte

d

Mea

n nu

mbe

r of

chi

ld

feed

s in

the

pre

viou

s 24

ho

urs

- at

9 m

onth

s

- at

10

mon

ths

- at

11

mon

ths

3.7

vs. 2

.71

4.17

vs.

3.03

4.28

vs.

3.09

Not

rep

orte

d


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

ST

UD

YA

PP

RO

AC

HE

S

US

ED

S

CA

LE

/SC

OP

EE

VA

LU

AT

ION

M

ET

HO

DS

OU

CO

ME

(S)

ME

AS

-U

RE

DR

ES

ULT

S51

P-V

AL

UE

s / C

Is 5

2

Gul

dan

et a

l. (2

000)

; Chi

naC

ouns

elin

g in

hom

es b

y pe

ers

4 to

wns

hips

(2

inte

rven

tion,

2

cont

rol)

RC

T –

new

born

s w

ere

enro

lled

thro

ugho

ut

the

year

of p

roje

ct

impl

emen

tatio

n, a

t co

mpl

etio

n of

the

ye

ar in

fant

s ha

d be

en

mon

itore

d fo

r 4-

12

mon

ths;

495

infa

nts

born

dur

ing

stud

y pe

riod

ana

lyze

d (2

50

inte

rven

tion,

245

con

trol

); in

fant

s 4-

6 m

onth

s ol

d: 5

7 in

terv

entio

n, 6

9 co

ntro

l; in

fant

s 7-

9 m

onth

s ol

d: 8

5 in

terv

entio

n, 7

6 co

ntro

l; in

fant

s 10

-12

mon

ths

old:

10

8 in

terv

entio

n, 1

00

cont

rol

% o

f chi

ldre

n fe

d eg

gs d

aily

- at

4-6

mon

ths

- at

7-9

mon

ths

- at

10-

12 m

onth

s

% o

f chi

ldre

n fe

d fis

h/m

eat

brot

h da

ily

- at

4-6

mon

ths

- at

7-9

mon

ths

- at

10-

12 m

onth

s

% o

f chi

ldre

n fe

d m

eat

daily -

at 4

-6 m

onth

s

- at

7-9

mon

ths

- at

10-

12 m

onth

s

% o

f chi

ldre

n fe

d ve

geta

bles

dai

ly

- at

4-6

mon

ths

- at

7-9

mon

ths

- at

10-

12 m

onth

s

% o

f chi

ldre

n fe

d fr

uit

daily

- at

4-6

mon

ths

- at

7-9

mon

ths

- at

10-

12 m

onth

s

37%

vs.

16%

66%

vs.

41%

66%

vs.

62%

4% v

s. 0%

9% v

s. 1%

13%

vs.

3%

4% v

s. 0%

19%

vs.

8%

23%

vs.

9%

35%

vs.

32%

79%

vs.

65%

89%

vs.

89%

26%

vs.

10%

68%

vs.

42%

79%

vs.

52%

p<0.

01

p<0.

01

NS

NS

p<0.

05

p<0.

01

NS

p<0.

05

p<0.

01

NS

p<0.

05

NS

p<0.

05

p<0.

01

p<0.

001

% o

f chi

ldre

n fe

d ve

geta

ble

oil d

aily

- at

4-6

mon

ths

- at

7-9

mon

ths

- at

10-

12 m

onth

s

% o

f chi

ldre

n fe

d la

rd d

aily

- at

4-6

mon

ths

- at

7-9

mon

ths

- at

10-

12 m

onth

s

32%

vs.

29%

65%

vs.

58%

82%

vs.

82%

9% v

s. 4%

31%

vs.

9%

46%

vs.

28%

NS

NS

NS

NS

p<0.

01

p<0.

01


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

ST

UD

YA

PP

RO

AC

HE

S

US

ED

S

CA

LE

/SC

OP

EE

VA

LU

AT

ION

M

ET

HO

DS

OU

CO

ME

(S)

ME

AS

-U

RE

DR

ES

ULT

S51

P-V

AL

UE

s / C

Is 5

2

Guy

on e

t al

. (20

09);

Mad

agas

car

Mob

iliza

tion

of is

sue

grou

ps; M

obili

zatio

n of

ca

mpa

ign,

eve

nt, o

r sp

ecia

l “d

ays”

; Mas

s m

edia

2 hi

ghla

nd p

rovi

nces

; ta

rget

ed p

opul

atio

n va

ried

thr

ough

out

proj

ect

from

1.4

m

illio

n in

6 d

istr

icts

to

6 m

illio

n in

23

dist

rict

s

Rep

eate

d cr

oss-

sect

iona

l –

base

line

(200

0): 1

,200

ch

ildre

n un

der

two

year

s ol

d; e

ndlin

e (2

005)

: 1,7

60

child

ren

unde

r tw

o ye

ars

old

endl

ine

vs.

base

line

% o

f chi

ldre

n fe

d th

e m

inim

um r

ecom

men

ded

num

ber

of m

eals

per

day

at

6-23

mon

ths

92%

vs.

87%

p<

0.00

1

% o

f chi

ldre

n (6

–8 m

onth

s)

fed

com

plem

enta

ry fo

ods

in t

he p

revi

ous

24 h

ours

96%

vs.

92%

NS

% s

ick

infa

nts

and

child

ren

(6-2

3 m

onth

s) fe

d m

ore

than

usu

al d

urin

g ill

ness

in

prev

ious

2 w

eeks

%

sic

k in

fant

s an

d ch

ildre

n (6

-23

mon

ths)

fed

mor

e th

an u

sual

aft

er il

lnes

s

5% v

s. 4%

20

% v

s. 25

%

NS

NS

Haq

ue e

t al

. (20

02);

Bang

lade

shC

ouns

elin

g in

faci

litie

s by

pr

ovid

ers

3 ce

nter

s (2

br

east

feed

ing

coun

selin

g ce

nter

s an

d 1

mai

n ce

nter

)

Long

itudi

nal –

59

child

-mot

her

pair

s in

in

terv

entio

n co

mpl

eted

on

e-ye

ar fo

llow

-up,

55

in

cont

rol

% o

f wom

en w

ho

intr

oduc

ed c

ompl

emen

tary

fo

ods

at 6

mon

ths

of a

ge

88%

vs.

53%

NS

Har

kins

et

al. (

2008

); Pe

ru

Mob

iliza

tion

of is

sue

grou

ps; C

ouns

elin

g in

ho

mes

1 co

mm

unity

(p

opul

atio

n: 2

5,00

0)R

epea

ted

cros

s-se

ctio

nal

– Pe

ru: 7

8 w

omen

55

inte

rvie

wed

in 2

002

and

in

2004

(af

ter

inte

rven

tion)

endl

ine

vs.

base

line

% o

f sic

k ch

ildre

n fe

d m

ore

freq

uent

ly a

nd in

sm

alle

r qu

antit

ies

61%

vs.

22%

Not

rep

orte

d


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

ST

UD

YA

PP

RO

AC

HE

S

US

ED

S

CA

LE

/SC

OP

EE

VA

LU

AT

ION

M

ET

HO

DS

OU

CO

ME

(S)

ME

AS

-U

RE

DR

ES

ULT

S51

P-V

AL

UE

s / C

Is 5

2

Kila

ru e

t al

. (20

05);

Indi

aC

ouns

elin

g in

hom

es b

y pr

ovid

ers

13 v

illag

es

Cro

ss-s

ectio

nal –

infa

nts

aged

less

tha

n si

x m

onth

s w

ere

enro

lled

on a

n on

-goi

ng b

asis

bet

wee

n 19

97-1

999;

242

infa

nts

5-11

mon

ths

old

wer

e in

clud

ed in

thi

s an

alys

is

(173

infa

nts

< 6

mon

ths

of a

ge a

t ba

selin

e fo

rmed

in

terv

entio

n, 6

9 in

fant

s w

ho r

each

ed 1

2 m

onth

s pr

ior

to t

he in

terv

entio

n fo

rmed

con

trol

); da

ta

colle

cted

long

itudi

nally

, m

onth

ly u

ntil

the

child

re

ache

d 24

mon

ths

of a

ge,

how

ever

ana

lysi

s is

cro

ss-

sect

iona

l

NO

TE:

The

se a

re t

he s

ame

data

ana

lyze

d by

Gho

sh

et a

l. (2

002)

use

d he

re

to r

epor

t on

diff

eren

t in

dica

tors

.

% o

f car

egiv

ers

feed

ing

child

ren

(7-1

1 m

onth

s)

bana

nas

% o

f car

egiv

ers

feed

ing

child

ren

(11

mon

ths)

at

leas

t 5

diffe

rent

food

gr

oups

56

33%

vs.

4%

adju

sted

OR

=

3.23

42%

vs.

19%

ad

just

ed O

R =

10

.00

p<0.

001

(95%

CI:

1.28

-7

.69)

p=0.

01

(95%

CI:

2.78

-

33.3

3)

% o

f chi

ldre

n (7

-11

mon

ths)

fed

at le

ast

4 tim

es in

add

ition

to

brea

st

milk

in t

he p

revi

ous

24

hour

s

78%

vs.

51%

ad

just

ed

OR

=4.

35

p<0.

001

(95%

CI:

1.96

- 10

.00)


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

55

It is

not

cle

ar fr

om th

e ar

ticle

, but

bas

ed o

n th

e in

dica

tors

repo

rted

one

wou

ld a

ssum

e th

ese

are

mot

hers

of

child

ren

unde

r the

age

of

two

year

s.

ST

UD

YA

PP

RO

AC

HE

S

US

ED

S

CA

LE

/SC

OP

EE

VA

LU

AT

ION

M

ET

HO

DS

OU

CO

ME

(S)

ME

AS

-U

RE

DR

ES

ULT

S51

P-V

AL

UE

s / C

Is 5

2

Kim

mon

s et

al.

(200

4); B

angl

ades

hG

roup

edu

catio

n in

co

mm

uniti

es b

y la

y vo

lunt

eers

seve

ral s

mal

l rur

al

villa

ges

Long

itudi

nal –

30

mot

hers

w

ith in

fant

s 6-

12 m

onth

s of

age

in t

he m

eal q

uant

ity

stud

y; 30

in t

he m

eal

freq

uenc

y st

udy

Day

7 v

s. da

y 1

(bas

elin

e)

Mea

l qua

ntity

stu

dy:

- Q

uant

ity o

f foo

d of

fere

d (g

)

- Q

uant

ity o

f foo

d co

nsum

ed (

g)

- M

ean

num

ber

of m

eals

fe

d to

chi

ldre

n in

the

pr

evio

us 2

4 ho

urs

- D

urat

ion

of m

eal

(min

utes

)

- Vis

cosi

ty o

f foo

d fe

d to

ch

ildre

n57

Mea

l fre

quen

cy s

tudy

:

- M

ean

num

ber

mea

ls d

urin

g w

hich

co

mpl

emen

tary

food

w

as t

o ch

ildre

n in

the

pr

evio

us 2

4 ho

urs

95 v

s. 67

64 v

s. 40

2.9

vs. 2

.3

13 v

s. 6

3.1

vs. 3

.7

4.1

vs. 2

.2

NS

p<0.

05

NS

p<0.

05

NS

p<0.

05

Li e

t al

. (20

07);

Chi

naM

obili

zatio

n of

issu

e gr

oups

; Mid

-siz

ed m

edia

; Sm

all m

edia

10 v

illag

es (

2 fr

om

each

of fi

ve s

ampl

ed

tow

nshi

ps in

Lux

i ci

ty (

popu

latio

n of

app

roxi

mat

ely

321,

000)

Rep

eate

d cr

oss-

sect

iona

l –

352

infa

nts

(age

gro

up

not

clea

r fr

om a

rtic

le)

endl

ine

vs.

base

line

Ave

rage

age

(in

mon

ths)

of

intr

oduc

tion

for

each

w

eani

ng fo

od

-Egg

-Por

k

-Fis

h

-Ani

mal

live

r

-Milk

-Veg

etab

le

-Fru

it

9.0

vs. 6

.5

7.5

vs. 6

.2

10.6

vs.

8.3

10.1

vs.

9.5

5.9

vs. 7

.5

7.7

vs. 6

.3

8.4

vs. 6

.6

p<0.

01

p<0.

01

p<0.

01

p<0.

05

p<0.

01

p<0.

01

p<0.

01


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

56

Food

gro

ups e

xam

ined

wer

e da

iry, c

erea

l, pr

otei

n, fr

uit,

vege

tabl

es, o

il an

d fa

t, su

gar a

nd sa

vory

snac

ks.

ST

UD

YA

PP

RO

AC

HE

S

US

ED

S

CA

LE

/SC

OP

EE

VA

LU

AT

ION

M

ET

HO

DS

OU

CO

ME

(S)

ME

AS

-U

RE

DR

ES

ULT

S51

P-V

AL

UE

s / C

Is 5

2

Mac

kint

osh

et a

l. (2

002)

; Vie

tnam

Cou

nsel

ing

in c

omm

uniti

es

by p

eers

; Gro

up e

duca

tion

in c

omm

uniti

es b

y la

y vo

lunt

eers

5 co

mm

unes

(4

inte

rven

tion,

1

cont

rol)

Rep

eate

d cr

oss-

sect

iona

l – 4

6 ch

ildre

n in

in

terv

entio

n gr

oup

(fam

ily

had

one

child

who

pre

viou

sly

part

icip

ated

in t

he p

roje

ct

and

one

youn

ger

child

w

ho h

ad n

ot p

artic

ipat

ed),

25 h

ouse

hold

s in

con

trol

gr

oup

(had

no

prev

ious

ex

posu

re t

o pr

ogra

m

activ

ities

and

incl

uded

an

olde

r an

d yo

unge

r si

blin

g in

the

age

ran

ge o

f the

in

terv

entio

n ho

useh

olds

)

% o

f wom

en r

epor

ting

feed

ing

thei

r ch

ild…

- dr

ied

fish

- sh

rim

p

- fr

esh

fish

- m

eat

- eg

gs

- gr

eens

- sw

eet

pota

toes

- fr

uit

Mea

n #

of t

imes

/wk

wom

an r

epor

ted

feed

ing

her

child

…

- dr

ied

fish

- sh

rim

p

- fr

esh

fish

- m

eat

- eg

gs

- gr

eens

- sw

eet

pota

toes

- fr

uit

20.9

% v

s. 64

.0%

93.3

% v

s. 76

.0%

95.6

% v

s. 96

.0%

97.8

% v

s. 92

.0%

97.8

% v

s. 72

.0%

93.3

% v

s. 96

.0%

97.7

% v

s. 88

.0%

100.

0% v

s. 88

.0%

2.3

vs. 0

.8

3.2

vs. 1

.0

5.6

vs. 4

.6

2.6

vs. 0

.7

4.0

vs. 1

.5

6.9

vs. 6

.4

6.7

vs. 3

.2

5.4

vs. 1

.5

p<0.

01

p<0.

05

NS

NS

p<0.

01

NS

NS

p<0.

05

p<0.

05

p<0.

01

NS

p<0.

01

p<0.

01

NS

p<0.

01

p<0.

01

Mea

n #

of m

ain

mea

ls/d

ay

fed

to c

hild

% o

f wom

en t

hat

repo

rt

feed

ing

thei

r ch

ild s

nack

s

Mea

n #

of s

nack

s fe

d/da

y fe

d to

chi

ld

2.9

vs. 2

.2

95.7

% v

s. 52

%

2.5

vs. 1

.6

p<0.

001

p<0.

001

p<0.

001


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

57Scalerangesfrom1(liketea)to4(likecookedrice).

ST

UD

YA

PP

RO

AC

HE

S

US

ED

S

CA

LE

/SC

OP

EE

VA

LU

AT

ION

M

ET

HO

DS

OU

CO

ME

(S)

ME

AS

-U

RE

DR

ES

ULT

S51

P-V

AL

UE

s / C

Is 5

2

Pach

ón e

t al

. (20

02); V

ietn

amG

roup

edu

catio

n in

co

mm

uniti

es b

y la

y vo

lunt

eers

12 c

omm

unes

from

on

e ru

ral V

ietn

am

(6 in

terv

entio

n, 6

co

ntro

l)

Long

itudi

nal –

238

ch

ildre

n 5-

25 m

onth

s ol

d (1

19 i

nter

vent

ion,

119

co

ntro

l)

Freq

uenc

y of

con

sum

ing

PD fo

ods

(tim

es p

er d

ay

- ba

selin

e

- m

onth

2-6

of

inte

rven

tion

- m

onth

12

of

inte

rven

tion

4.3

vs.

4.2

4.1

vs.

3.6

3.8

vs.

3.7

NS

p<0.

05

NS

Qua

ntity

of f

ood

cons

umed

(g)

- ba

selin

e

- m

onth

2-6

of

inte

rven

tion

- m

onth

12

of

inte

rven

tion

Mea

l tim

e fr

eque

ncy

(p

er d

ay)

- ba

selin

e

- m

onth

2-6

of

inte

rven

tion

- m

onth

12

of

inte

rven

tion

Ener

gy in

take

(kc

al)

- ba

selin

e

- m

onth

2-6

of

inte

rven

tion

- m

onth

12

of

inte

rven

tion

Prop

ortio

n m

et e

nerg

y (k

cal/k

g) r

equi

rem

ents

- ba

selin

e

- m

onth

2-6

of

inte

rven

tion

- m

onth

12

of

inte

rven

tion

262.

2 v

s. 24

3.5

299.

7 v

s. 25

4.5

409.

8 v

s. 34

0.3

4.6

vs.

4.4

4.6

vs.

4.2

4.9

± 1

.5 v

s. 4.

4

629.

2 vs

. 596

.6

662.

7 vs

. 597

.4

826.

9 vs

. 718

.4

66.4

% v

s. 62

.2%

49.0

% v

s. 35

.1%

31.3

% v

s. 23

.5%

NS

p<0.

05

p<0.

01

NS

p<0.

01

p<0.

01

NS

NS

NS

NS

p<0.

01

NS


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

ST

UD

YA

PP

RO

AC

HE

S

US

ED

S

CA

LE

/SC

OP

EE

VA

LU

AT

ION

M

ET

HO

DS

OU

CO

ME

(S)

ME

AS

-U

RE

DR

ES

ULT

S51

P-V

AL

UE

s / C

Is 5

2

Palw

ala

et a

l. (2

009)

; Ind

iaG

roup

edu

catio

n in

co

mm

uniti

es b

y pr

ovid

ers;

Smal

l med

ia

5 co

mm

uniti

es in

M

umba

i Lo

ngitu

dina

l – 3

98 w

omen

w

ith c

hild

ren

6-3

6 m

onth

s ol

d

Mea

n am

ount

s of

food

-st

uffs

fed

to c

hild

ren

Milk

(m

L)

- ba

selin

e vs

. 1st

follo

w-

up

- 1s

t fo

llow

-up

vs. 2

nd

follo

w-u

p

- 2n

d fo

llow

-up

vs. 3

rd

follo

w-u

p

Egg

(g)

- ba

selin

e vs

. 1st

follo

w-

up

- 1s

t fo

llow

-up

vs. 2

nd

follo

w-u

p

- 2n

d fo

llow

-up

vs. 3

rd

follo

w-u

p

Mut

ton/

chi

cken

/ fish

(g)

- ba

selin

e vs

. 1st

follo

w-

up

- 1s

t fo

llow

-up

vs. 2

nd

follo

w-u

p

- 2n

d fo

llow

-up

vs. 3

rd

follo

w-u

p

Mea

n am

ount

of f

ruit

(g)

fed

to c

hild

ren

- ba

selin

e vs

. 1st

follo

w-

up

- 1s

t fo

llow

-up

vs. 2

nd

follo

w-u

p

- 2n

d fo

llow

-up

vs. 3

rd

follo

w-u

p

% o

f chi

ldre

n fe

d gr

een

leaf

y ve

geta

bles

(ba

selin

e vs

. 3rd

follo

w-u

p)

134

vs. 1

53

153

vs. 1

96

196

vs. 2

02

20 v

s. 21

21 v

s. 26

26 v

s. 29

4 v

s. 7

7 v

s. 9

9 v

s. 9

41 v

s. 61

61 v

s. 79

79 v

s. 82

16.7

% v

s. 87

.6%

p<0.

05

p<0.

05

NS

p<0.

05

p<0.

05

NS

p<0.

05

p<0.

05

NS

p<0.

05

p<0.

05

NS

p<0.

001


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

ST

UD

YA

PP

RO

AC

HE

S

US

ED

S

CA

LE

/SC

OP

EE

VA

LU

AT

ION

M

ET

HO

DS

OU

CO

ME

(S)

ME

AS

-U

RE

DR

ES

ULT

S51

P-V

AL

UE

s / C

Is 5

2

% o

f chi

ldre

n fe

d ca

rrot

(b

asel

ine

vs. 3

rd fo

llow

-up)

% o

f chi

ldre

n fe

d to

mat

o (b

asel

ine

vs. 3

rd fo

llow

-up)

% o

f chi

ldre

n fe

d vi

tam

in c

/be

ta-c

arot

ene-

rich

frui

ts

(bas

elin

e vs

. 3rd

follo

w-u

p)

% o

f chi

ldre

n fe

d ot

her

frui

ts (

base

line

vs. 3

rd

follo

w-u

p)

8.3%

vs.

52.1

%

52.0

% v

s. 81

.3%

25.8

% v

s. 50

.5%

62

.5%

vs.

85.4

%

p<0.

001

p<0.

001

p<0.

05

Not

rep

orte

d

% o

f chi

ldre

n fe

d da

l of

thic

k co

nsis

tenc

y (1

:2-3

)

- Ba

selin

e vs

. 1st

follo

w-

up

- 1s

t fo

llow

-up

vs. 2

nd

follo

w-u

p

- 2n

d fo

llow

-up

vs. 3

rd

follo

w-u

p

4.2%

vs.

34%

34%

vs.

37.5

%

37.5

% v

s. 39

.5%

Not

rep

orte

d

Parv

anta

et

al. (

2007

); Ba

ngla

desh

Trad

ition

al m

edia

; Mid

-si

zed

med

ia; S

mal

l med

ia;

Cou

nsel

ing

in h

omes

by

peer

s; Su

ppor

t gr

oup

in

com

mun

ities

by

peer

s

nort

hwes

t Ba

ngla

desh

Rep

eate

d cr

oss-

sect

iona

l –

428

wom

en w

ith

child

ren

6-24

mon

ths

old

(IG1=

144,

IG2=

141,

C

ontr

ol g

roup

=14

3)

Base

d on

48-

hour

rec

all

IG1

vs. I

G258

vs.

CG

% o

f wom

en fe

edin

g th

eir

child

ren

any

vege

tabl

es

duri

ng t

he 4

8-hr

rec

all

% o

f wom

en fe

edin

g t

heir

ch

ildre

n re

com

men

ded

port

ion

of g

reen

veg

etab

les

Med

ian

quan

tity

of g

reen

ve

geta

bles

(g)

fed

to

child

ren

Med

ian

quan

tity

of y

ello

w

vege

tabl

es (

g) fe

d to

ch

ildre

n

74%

vs.

75%

vs.

58%

33%

vs.

52%

vs.

17%

42.5

g vs

. 40g

vs.

30g

25g

vs. 2

5g. v

s. 20

g

p=0.

003

p=0.

001

p=0.

001

p=0.

00459


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

ST

UD

YA

PP

RO

AC

HE

S

US

ED

S

CA

LE

/SC

OP

EE

VA

LU

AT

ION

M

ET

HO

DS

OU

CO

ME

(S)

ME

AS

-U

RE

DR

ES

ULT

S51

P-V

AL

UE

s / C

Is 5

2

Penn

y et

al.

(200

5); P

eru

Cou

nsel

ing

in fa

cilit

ies

by

prov

ider

s; Sm

all m

edia

1 ci

ty (

Truj

illo)

with

a

popu

latio

n of

60

0,00

0

RC

T –

377

new

born

s (1

87 in

terv

entio

n, 1

90

cont

rol)

% o

f chi

ldre

n ea

ting

thic

k fo

od a

s fir

st m

ain

mea

l at

mea

l tim

es (

i.e.,

not

just

gi

ving

sou

p) a

t…

- 6

mon

ths

- 8

mon

ths

- 9

mon

ths

- 12

mon

ths

- 15

mon

ths

- 18

mon

ths

31%

vs.

20%

21%

vs.

27%

35%

vs.

17%

42%

vs.

26%

42%

vs.

34%

44%

vs.

38%

p=0.

03

NS

p=0.

000

p=0.

003

NS

NS

% o

f chi

ldre

n co

nsum

ing

egg,

chic

ken

liver

, or

fish

at… -

6 m

onth

s

- 8

mon

ths

% o

f chi

ldre

n co

nsum

ing

brea

st m

ilk +

2 t

hick

pr

epar

atio

ns +

ani

mal

so

urce

food

at

9 m

onth

s

65%

vs.

51%

61%

vs.

49%

34%

vs.

23%

p=0.

009

p=0.

019

NS

at 9

, 12,

15,

or

18

mon

ths

p=0.

029

NS

at 6

, 8,

12, 1

5, o

r 18

m

onth

s

% o

f chi

ldre

n fe

d br

east

m

ilk +

2 t

hick

pre

para

tions

+

ani

mal

sou

rce

food

at

9 m

onth

s

34%

vs.

23%

p=0.

029

NS

at m

onth

s 6,

8, 1

2, 1

5,

or 1

8


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

58IG1includedhome-basedcounseling(onceinathree-monthperiod)byhealtheducatorstopregnantwomenandmothersofchildren6–24monthsold.IG2includeddiscussionofrolemodelingstoriesfacilitated

by p

eer g

roup

lead

ers d

urin

g ga

rden

ing

grou

p or

cre

dit g

roup

mee

tings

.59Itisnotclearforwhichcomparisonthisisthep-value.Theauthors’interpretationwasasfollows:“Mothersintheinterventiongroups(1and2)weremorelikelytoreportfeedinganyvegetables,andreportedfeed

-ingalargerportionofvegetablesusingafoodmodel,thanmothersinthecontrolgroup(3).Theserelationshipswerestatisticallysignificant…Thisresultalsoindicatestheseasonalavailabilityofgreenvegetables

andlackofyellowvegetables.Onthislevel,itappearsasiftheinterventionsperformedbygroups1and2werenearlyequalintheirimpact.”

ST

UD

YA

PP

RO

AC

HE

S

US

ED

S

CA

LE

/SC

OP

EE

VA

LU

AT

ION

M

ET

HO

DS

OU

CO

ME

(S)

ME

AS

-U

RE

DR

ES

ULT

S51

P-V

AL

UE

s / C

Is 5

2

Roy

et

al. (

2005

); Ba

ngla

desh

Gro

up e

duca

tion

in

com

mun

ities

by

lay

volu

ntee

rs; S

mal

l med

ia

rura

l Ban

glad

esh

RC

T –

282

mod

erat

ely

mal

nour

ishe

d ch

ildre

n 6-

23 m

onth

s (9

3 in

INE

grou

p, 9

9 in

INE-

SF g

roup

, an

d 90

in c

ontr

ol g

roup

)

INE

vs. I

NE-

SF

vs. C

ontr

ol

Use

of f

eedi

ng p

ots

by

mot

hers

- At

base

line

- Aft

er 3

mon

th

inte

rven

tion

- Aft

er 6

mon

th

obse

rvat

ion

Chi

ldre

n fe

d >

3 t

imes

/day

- At

base

line

- Aft

er 3

mon

th

inte

rven

tion

- Aft

er 6

mon

th

obse

rvat

ion

43%

vs.

66%

vs.

43%

99%

vs.

100%

vs.

47%

100%

vs.

100%

vs

. 48%

3% v

s. 13

% v

s. 15

%

98%

vs.

99%

vs.

54%

97%

vs.

100%

vs.

58%

NS

p<0.

0001

p<

0.00

01

NS

NS

NS


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

ST

UD

YA

PP

RO

AC

HE

S

US

ED

S

CA

LE

/SC

OP

EE

VA

LU

AT

ION

M

ET

HO

DS

OU

CO

ME

(S)

ME

AS

-U

RE

DR

ES

ULT

S51

P-V

AL

UE

s / C

Is 5

2

Roy

et

al. (

2007

); Ba

ngla

desh

Gro

up e

duca

tion

in

com

mun

ities

by

lay

volu

ntee

rs; S

mal

l med

ia

121

Com

mun

ity

Nut

ritio

n C

ente

rs

(CN

Cs)

of t

he

Bang

lade

sh

Inte

grat

ed N

utri

tion

Proj

ect

(BIN

P) in

fo

ur r

egio

ns

RC

T –

576

nor

mal

and

m

ildly

mal

nour

ishe

d ch

ildre

n 6-

9 m

onth

s ol

d (2

94 in

terv

entio

n, 2

82

cont

rol)

% o

f chi

ldre

n fe

d <

3 e

ggs

per

wee

k

- ba

selin

e

- en

dlin

e (6

mon

ths)

- fo

llow

-up

(12

mon

ths)

% o

f chi

ldre

n fe

d 3

or

mor

e eg

gs p

er w

eek

- ba

selin

e

- en

dlin

e (6

mon

ths)

- fo

llow

-up

(12

mon

ths)

89.3

% v

s. 90

%

51.5

% v

s. 83

.7%

70.3

% v

s. 88

.1%

11.3

% v

s. 10

%

38.5

% v

s. 16

.2%

29.8

% v

s. 11

.9%

NS

p<0.

01

p<0.

01

NS

NS

p<0.

01

% o

f wom

en w

ho r

epor

ted

addi

ng e

xtra

oil

to t

heir

ch

ildre

n’s

food

- ba

selin

e

- en

dlin

e (6

mon

ths)

- fo

llow

-up

(12

mon

ths)

CF

fed

to in

fant

= o

r >

3

times

/day

- ba

selin

e

- en

dlin

e (6

mon

ths)

- fo

llow

-up

(12

mon

ths

Sepa

rate

pot

for

child

- ba

selin

e

- en

dlin

e (6

mon

ths)

- fo

llow

-up

(12

mon

ths)

1.6%

vs.

22.8

%

69.8

% v

s. 20

.9%

61.3

% v

s. 21

.5%

30.4

% v

s. 31

.0%

83.8

% v

s. 19

.4%

88.5

% v

s. 24

.5%

52.5

% v

s. 52

.3%

91.6

% v

s. 76

.8%

91.8

% v

s. 76

.8%

NS

p<0.

0001

p<0.

0001

NS

p<0.

0001

p<0.

0001

N

S

p<0.

0001

p<0.

0001

Sant

os e

t al

. (20

01);

Braz

il Sm

all m

edia

; Cou

nsel

ing

in

faci

litie

s by

pro

vide

rs28

gov

ernm

ent

heal

th c

ente

rs in

a

Sout

hern

Bra

zil c

ity

(14

inte

rven

tion

and

14 c

ontr

ol)

RC

T –

424

chi

ldre

n le

ss

than

18

mon

ths

old

(218

in

terv

entio

n, 2

06 c

ontr

ol)

endl

ine

vs.

base

line

Mea

n nu

trie

nt in

take

(kJ

) at

2nd

follo

w-u

p (4

5-da

ys

post

con

sulta

tion)

am

ong

infa

nts

3827

.5 v

s. 35

46.8

NS


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

ST

UD

YA

PP

RO

AC

HE

S

US

ED

S

CA

LE

/SC

OP

EE

VA

LU

AT

ION

M

ET

HO

DS

OU

CO

ME

(S)

ME

AS

-U

RE

DR

ES

ULT

S51

P-V

AL

UE

s / C

Is 5

2

Sun

et a

l. (2

011)

; Chi

naSm

all m

edia

; Mas

s m

edia

; Mid

-siz

ed m

edia

; C

ouns

elin

g in

faci

litie

s by

pr

ovid

ers

2 co

untie

s in

Sh

an’x

i pro

vinc

e (a

ppro

xim

atel

y 6,

000

child

ren

6-24

m

onth

s of

age

)

Rep

eate

d cr

oss-

sect

iona

l –

base

line

(June

200

8):

226

care

give

rs a

nd t

heir

ch

ildre

n 6-

24 m

onth

-old

; en

dlin

e (Ja

nuar

y 20

10):

221

care

give

rs a

nd t

heir

ch

ildre

n 6-

24 m

onth

-old

endl

ine

vs.

base

line

% o

f car

egiv

ers

who

in

trod

uced

sol

id, s

emi-

solid

or

soft

food

s af

ter

6 m

onth

s

71.1

% v

s. 92

.9%

NS

% o

f bre

astfe

d ch

ildre

n fe

d m

inim

al d

ieta

ry d

iver

sity

>

4 gr

oups

% o

f non

-bre

astfe

d ch

ildre

n fe

d m

inim

al

diet

ary

dive

rsity

>4

grou

ps

74.1

% v

s. 57

.5%

53

.9%

vs.

27.6

%

p=0.

007

p=0.

008

% o

f car

egiv

ers

that

kne

w

abou

t YY

B

Of t

hose

tha

t kn

ew a

bout

Y

YB,

the

% w

ho e

ver

purc

hase

d it

Of t

hose

who

eve

r pu

rcha

sed

YY

B, %

of

child

ren

cons

umed

it…

- ev

ery

day

- ev

ery

othe

r da

y

59.6

% (

endl

ine)

13.5

% (

endl

ine)

55

.6%

(en

dlin

e)

40.7

% (

endl

ine)

Not

rep

orte

d

Not

rep

orte

d N

ot r

epor

ted

Not

rep

orte

d

% o

f bre

astfe

d ch

ildre

n fe

d m

inim

al m

eal f

requ

ency

% o

f non

-bre

astfe

d ch

ildre

n fe

d m

inim

al m

eal

freq

uenc

y

% o

f bre

astfe

d ch

ildre

n fe

d m

inim

al a

ccep

tabl

e di

et

% o

f non

-bre

astfe

d ch

ildre

n fe

d m

inim

al

acce

ptab

le d

iet

51.0

% v

s. 53

.7%

53.4

% v

s. 47

.1%

73.5

% v

s. 42

.1%

45%

vs.

25.0

%

NS

NS

p <

0.0

1

p =

0.0

25


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

ST

UD

YA

PP

RO

AC

HE

S

US

ED

S

CA

LE

/SC

OP

EE

VA

LU

AT

ION

M

ET

HO

DS

OU

CO

ME

(S)

ME

AS

-U

RE

DR

ES

ULT

S51

P-V

AL

UE

s / C

Is 5

2

Tho

mps

on a

nd H

arut

yuny

an

(200

9); A

rmen

iaC

ouns

elin

g in

hom

es b

y pe

ers;

Supp

ort

grou

p in

co

mm

uniti

es b

y pe

ers;

Smal

l med

ia; M

id-s

ized

m

edia

16 v

illag

es

Rep

eate

d cr

oss-

sect

iona

l –

300

wom

en w

ith a

t le

ast

one

child

age

d 24

mon

ths

and

youn

ger

at p

re-

and

post

-inte

rven

tion

endl

ine

vs.

base

line

% o

f inf

ants

age

d 6-

9 m

onth

s re

ceiv

ing

brea

stm

ilk a

nd C

Fs

48.1

% v

s. 16

.7%

NS

Vazi

r et

al.

(201

3); I

ndia

Cou

nsel

ing

in h

omes

by

lay

volu

ntee

rs; S

mal

l med

ia60

vill

ages

from

th

ree

Inte

grat

ed

Chi

ld D

evel

opm

ent

Serv

ices

(IC

DS)

Pr

ojec

t ar

eas

in

And

hra

Prad

esh

(20

villa

ges

per

grou

p)

RC

T –

600

wom

en

enro

lled

in t

hird

tri

mes

ter

of p

regn

ancy

and

follo

wed

th

roug

h ch

ild’s

15 m

onth

s of

age

(17

0 in

CFG

, 145

in

RC

F&PG

, 16

8 in

CG

)60

CFG

vs.

CG

, R

CF&

PG v

s. C

G

% o

f chi

ldre

n co

nsum

ing

goat

/ chi

cken

live

r61

- 9

mon

ths

- 15

mon

ths

% o

f chi

ldre

n co

nsum

ing

goat

mea

t

- 9

mon

ths

- 15

mon

ths

% o

f chi

ldre

n co

nsum

ing

poul

try

- 9

mon

ths

- 15

mon

ths

% o

f chi

ldre

n co

nsum

ing

buffa

lo m

ilk

- 9

mon

ths

- 15

mon

ths

% o

f chi

ldre

n co

nsum

ing

egg -

9 m

onth

s

- 15

mon

ths

30.7

% v

s. 2.

3%,

25.6

% v

s. 2.

3%

38%

vs.

13.1

%,

33.7

% v

s. 13

.1%

22.3

% v

s. 4.

5%,

11.3

% v

s. 4.

5%

43.5

% v

s. 33

%,

44%

vs.

33%

4.5%

vs.

1.7%

, 4.

4% v

s. 1.

7%

37.5

% v

s. 18

.9%

, 45

.2%

vs.

18.9

%

98.6

% v

s. 10

0%,

99.2

% v

s. 10

0%

81.5

% v

s. 72

.7%

, 78

.9%

vs.

72.7

%

55.3

% v

s. 17

.6%

, 51

.9%

vs.

17.6

%

73.9

% v

s. 54

%,

77.7

% v

s. 54

%

p<0.

05, p

<0.

05

p<0.

05, p

<0.

05

p<0.

05, p

<0.

05

NS,

NS

NS,

NS

p<0.

05, p

<0.

05

NS,

NS

NS,

NS

p<0.

05, p

<0.

05

p<0.

05, p

<0.

05


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

ST

UD

YA

PP

RO

AC

HE

S

US

ED

S

CA

LE

/SC

OP

EE

VA

LU

AT

ION

M

ET

HO

DS

OU

CO

ME

(S)

ME

AS

-U

RE

DR

ES

ULT

S51

P-V

AL

UE

s / C

Is 5

2

% o

f chi

ldre

n co

nsum

ing

any

bana

na

- at

9 m

onth

s

- at

15

mon

ths

% o

f chi

ldre

n co

nsum

ing

any

spin

ach

- at

9 m

onth

s

- at

15

mon

ths

60.9

% v

s. 38

.6%

, 59

.4%

vs.

38.6

%

79.3

% v

s. 61

.9%

, 78

.3%

vs.

61.9

%

20.1

% v

s. 5.

1%,

14.4

% v

s. 5.

1%

42.4

% v

s. 29

.5%

, 45

.2%

vs.

29.5

%

p<0.

05, p

<0.

05

p<0.

05, p

<0.

05

p<0.

05, p

<0.

05

p<0.

05, p

<0.

05

Med

ian

ener

gy in

take

(kc

al)

amon

g ch

ildre

n

- at

9 m

onth

s

- at

15

mon

ths

% o

f chi

ldre

n co

nsum

ing

adde

d fa

t

- at

9 m

onth

s

- at

15

mon

ths

348

vs. 2

09, 3

31

vs. 2

09

569

vs. 4

60, 5

69

vs. 4

60

51.4

% v

s. 24

.4%

, 44

.4%

vs.

24.4

%

42.4

% v

s. 29

.5%

, 52

.5%

vs.

29.5

%

p<0.

05, p

<0.

05

p<0.

05, p

<0.

05

p<0.

05, p

<0.

05

p<0.

05, p

<0.

05


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

60

CFG

= C

ompl

emen

tary

feed

ing;

RC

F&PG

= R

espo

nsiv

e co

mpl

emen

tary

feed

ing

& p

lay g

roup

; CG

= C

ontro

l gro

up61

C

onsu

mpt

ion

is ba

sed

on a

Foo

d Fr

eque

ncy

Que

stio

nnai

re u

sed

to a

sses

s the

freq

uenc

y of

mic

ronu

trien

t-ric

h ve

geta

ble

and

anim

al fo

ods c

onsu

med

by

infa

nts d

urin

g th

e pr

evio

us w

eek.

ST

UD

YA

PP

RO

AC

HE

S

US

ED

S

CA

LE

/SC

OP

EE

VA

LU

AT

ION

M

ET

HO

DS

OU

CO

ME

(S)

ME

AS

-U

RE

DR

ES

ULT

S51

P-V

AL

UE

s / C

Is 5

2

Zam

an e

t al

. (20

08);

Paki

stan

Cou

nsel

ing

in fa

cilit

ies

by

prov

ider

s; co

mm

unity

/so

cial

mob

iliza

tion

36 h

ealth

cen

ters

(1

8 pe

r gr

oup)

RC

T –

375

mot

hers

and

th

eir

child

ren

aged

6-2

4 m

onth

s re

crui

ted8

-14

days

aft

er r

ecru

itmen

t: 32

0 m

othe

r-ch

ild p

airs

(1

51 in

terv

entio

n,16

9 co

ntro

l); 1

80 d

ays

afte

r re

crui

tmen

t: 26

6 m

othe

r-ch

ild p

airs

(12

9 in

terv

entio

n, 1

37 c

ontr

ol)

% o

f wom

en w

ho r

epor

ted

incr

easi

ng t

he a

mou

nt o

f m

ilk o

ffere

d to

chi

ldre

n62

- At

8-14

day

s af

ter

recr

uitm

ent

- At

180

days

aft

er

recr

uitm

ent

% o

f chi

ldre

n of

fere

d eg

gs

- At

8-14

day

s af

ter

recr

uitm

ent

- At

180

days

aft

er

recr

uitm

ent

% o

f chi

ldre

n of

fere

d ch

icke

n/ b

eef /

mut

ton

- At

8-14

day

s af

ter

recr

uitm

ent

- At

180

days

aft

er

recr

uitm

ent

% o

f chi

ldre

n of

fere

d liv

er

- At

8-14

day

s af

ter

recr

uitm

ent

- At

180

days

aft

er

recr

uitm

ent

38.4

1% v

s. 24

.26%

48.0

% v

s. 29

.2%

49.6

7% v

s. 31

.95%

60.3

2% v

s. 39

.69%

49.6

7% v

s. 31

.95%

60.3

2% v

s. 39

.69%

17.2

2% v

s. 9.

47%

30.9

5% v

s. 19

.85%

p= 0

.035

2

p= 0

.032

4

p= 0

.036

8

p= 0

.042

8

p= 0

.015

5

p= 0

.050

8

p= 0

.093

4

p= 0

.158

9


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

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CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

ST

UD

YA

PP

RO

AC

HE

S

US

ED

S

CA

LE

/SC

OP

EE

VA

LU

AT

ION

M

ET

HO

DS

OU

CO

ME

(S)

ME

AS

-U

RE

DR

ES

ULT

S51

P-V

AL

UE

s / C

Is 5

2

% o

f wom

en w

ho r

epor

ted

addi

ng g

hee/

but

ter/

oil t

o ch

ildre

n’s

food

- At

8-14

day

s af

ter

recr

uitm

ent

- At

180

days

aft

er

recr

uitm

ent

% o

f wom

en w

ho r

epor

ted

offe

ring

chi

ldre

n th

ick

kitc

huri

- At

8-14

day

s af

ter

recr

uitm

ent

- At

180

days

aft

er

recr

uitm

ent

30.4

6% v

s. 24

.85%

53.9

7% v

s. 38

.17%

61.5

9% v

s. 44

.97%

65.8

7% v

s. 44

.27%

p= 0

.561

6

p= 0

.173

6

p= 0

.068

2

p=0.

0441

Zha

ng e

t al

. (20

13);

Chi

naG

roup

edu

catio

n in

co

mm

uniti

es b

y pr

ovid

ers;

Cou

nsel

ing

in h

omes

by

prov

ider

s; co

mm

unity

/so

cial

mob

iliza

tion;

Sm

all

med

ia

8 to

wns

hips

(4

inte

rven

tion,

4

cont

rol)

in L

aish

ui

coun

ty

RC

T –

at

base

line:

599

in

fant

s ag

ed 2

-4 m

onth

s ol

d (2

94 in

terv

entio

n,

305

cont

rol);

492

at

18 m

onth

s of

age

(25

1 in

terv

entio

n, 2

41 c

ontr

ol);

data

col

lect

ed a

t ba

selin

e,

6, 9

, 12,

15

and

18 m

onth

s of

age

% o

f wom

en w

ho

enco

urag

ed c

hild

ren

to e

at

whe

n th

ey r

efus

ed fo

od63

88.0

% v

s. 53

.9%

p<0.

05

% o

f w

omen

who

fed

brea

st m

ilk a

nd e

asy-

to-

dige

st fo

ods

for

child

ren

with

dia

rrhe

a

% o

f wom

en w

ho

cook

ed e

asy-

to-d

iges

t fo

od s

epar

atel

y fo

r th

eir

child

ren

with

dia

rrhe

a

88.8

% v

s. 65

.0%

67

.3%

vs.

32.8

%

p<0.

05

p<0.

05

63Theauthorsalsoreportedstatisticallysignificantdifferencesbetweeninterventionandcontrolgroupsateachtimepointintheinfantandchildfeedingindex(ICFI)whichincludedbreastfeeding,bottle-feeding,di-

etar

y di

vers

ity, f

ood

freq

uenc

y, va

riety

of

food

gro

ups a

nd fr

eque

ncy

of c

onsu

mpt

ion

of d

iffer

ent f

ood

grou

ps. H

owev

er, s

ince

no

othe

r art

icle

s rep

orte

d on

this

indi

cato

r, th

is ha

s not

bee

n em

phas

ized

in th

is re

view

.


INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

E SU

MM

ARY

FIN

DIN

GS

CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

62

Not

e th

at p

-val

ues a

re o

f re

port

ed o

dds r

atio

and

acc

ount

for c

lust

er ra

ndom

izat

ion.

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GS

CO

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EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

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CO

MPL

EMEN

TARY

FE

EDIN

GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

CTA

TIO

N

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INTR

OD

UC

TIO

NM

ETH

OD

SEX

ECU

TIV

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ARY

FIN

DIN

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MPL

EMEN

TARY

FE

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GBR

EAST

FEED

ING

PREG

NA

NC

Y A

ND

LA

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TIO

N

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APPENDIX: SBCC LITERATURE REVIEW SEARCHING SETS

The following search terms were used for this review. They are organized according to the original conceptu-alization of categories of nutrition practices and SBCC approaches. Over time, these search terms evolved, so they do not precisely align with the current chapters but they do provide evidence of all terms that were searched. Notethattheasterisk(“*”)wasusedtocallupvariationsin word endings.

A. PRACTICES

1. Optimal maternal nutrition practices((pregnancyORlactation)AND((dietORconsumption)OR(energyintake)OR(energyexpenditure)OR(micro-nutrientintake)OR(ironsupplement*)OR(diet*diversity)OR(nutritionpractice))

2. Optimal infant and young child nutrition practices

a) Breastfeeding ((breastfeed*)OR(infantfeeding)OR(rooming-incare)OR(rooming-in)OR(earlyinitiationof breastfeed*)OR(initiationof breastfeed*)OR(timelyinitiationof breastfeed*)OR(exclusivebreastfeed*)OR(breastmilksub-stitute)OR(lengthof feeding)OR(breastfeed*onbothbreast)OR(feed*ondemand)OR(breastfeed*frequency)OR(durationof breastfeed*))

NOTE: Our interest in breast milk substitutes is limited to circumstances where breast feeding is not possible.

b) Complementary feeding((child)OR(infant))AND((complementaryfood*)OR(complementaryfeeding)OR(introductionof comple-mentaryfood)OR((frequency)AND(feeding))OR(activefeeding)OR(dietarydiversity)OR(protein)OR(energy)OR(food-basedintervention)OR((food*)AND((liquid)OR(soft)OR(semi-solid)OR(solid)OR(amount)OR(quantity)OR(quality)OR(consistency)OR(density))))

3. IYCF of the sick and/or malnourished and/or HIV+ child

((child*)OR(infant*))AND((illness)OR(malaria)OR(pneumonia)OR(HIV)or(diarrhea)OR(malnutrition)OR(stunt*)OR(wast*)OR(underweight))AND((breastfeed*)OR(feeding)OR(rooming-incare)OR(breastmilksubstitute)OR(complementaryfood*)OR(complemen-taryfeeding)OR(food-basedintervention)OR(IMCIfoodbox)OR(recuperativefeeding)OR(Ready-to-useThera-peuticFood)OR(Ready-to-useSupplementaryFood))

4. Control and prevention of MN deficiencies

((childORwom*n)AND((intakeORconsumption)AND(food)AND((vitaminArich)OR(vitaminAfortified)OR(animalsource)OR(ironrich)))OR(Purchaseof forti-fiedfood)OR(micronutrientpowder)OR(sprinkles)OR(ironintake)OR(zincintake)OR(anemia)OR(fortifiedcomplementaryfood)OR(micronutrientpowder)OR(ITN)OR(insecticide-treatednets)OR(lipid-basednutri-entsupplement)OR(ready-to-usefood)OR(de-worm*)OR(deworm*)OR(helminth*)OR(malariaprophylaxis)OR(intermittentpreventivetherapy)OR(IPT)OR(Lacta-tionalamenorrheamethod)OR(Lactationalamenorrhoeamethod)OR(LAM)))

5. WASH

((hygiene)OR(handwash*)OR(hand-wash*)OR(washhand*)OR(foodprepar*)OR((safehandl*)ANDfood)OR((safewater)ANDuse*)OR(boil*water)OR(chlorineANDwater)OR(use*ANDlatrine))

B. SBCC APPROACHES

1. Broad and cross-cutting approaches

((behaviorchange)OR(behavior-centered)OR(behaviourchange)OR(behaviour-centered)(communicationchan-nels)OR(communication)OR(essentialnutritionactions)OR(informationeducationandcommunication)OR(IEC)OR(socialchange)OR(socialmobiliz*)OR(socialmove-ment)OR(socialnetwork*)OR(socialnorm*)OR(socialsupport)OR(strategiccommunication))

NOTE: Search results that reference essential nutrition ac-tions must include a communications/counseling component.


2. Community-based approaches

((babyfriendlycommunityinitiative)OR(baby-friendlycom-munityinitiative)OR(behaviorsignal*)OR(caregroup)OR(communitydefinedquality)OR(communityengagement)OR(communityintervention)OR(communityleader)OR(communitymobilization)OR(communityoutreach)OR(communityrole-play)OR(community-led)OR(counsel)OR(dance)OR(demonstration*)OR(drama)OR(groupeducation)OR(modelbreastfeedingcommunity)OR(moth-er*group)OR(music)OR(positivedeviance)OR(publicopinionleader)OR(religiousleader)OR(supportgroup)OR(trialsof improvedpractices)OR(TIPS))

NOTES:Searchresultsthatreferencecommunitydefinedqualityortrialsof improvedpractices(TIPS)mustincludeacommunications/counseling component. Supports groups may include peer, mother, mother-to-mother and other types.

3. Facility-based approaches

((communityhealthworker)OR(frontlinehealthworker)OR(midwives)OR(nurse*)OR(nutritionworker)OR(physician)OR(traditionalbirthattendant)OR(partnershipdefinedquality)OR(PDQ)OR(providerdefinedquality)OR(qualityANDcommunications)OR(qualityANDcoun-seling)OR(qualityassurance)OR(qualityimprovement)OR(babyfriendlyhospitalinitiative)OR(baby-friendlyhospitalinitiative)OR(BFHI)OR(baby-friendly)OR(nutritionas-sessmentcounselingandsupport)OR(NACS)OR(preven-tionof mothertochildtransmission)OR(PMTCT))

NOTE:SearchresultsthatreferencePartnershipDefinedQuality(PDQ),ProviderDefinedQuality,qualityassurance,quality improvement, and prevention of mother-to-child transmission(PMTCT)mustincludeacommunications/counseling component.

4. Interpersonal communication approaches

((caregivercontact)OR(client-providerinteraction)OR(patient-providerinteraction)OR(physician-patientinterac-tion)OR(provider-clientinteraction)OR(provider-patientinteraction)OR(clinictalks)OR(counsel*)OR(facilitateddiscussion)OR(growthpromot*)OR(homevisit)OR(householdoutreach)OR(outreach)OR(interpersonalcommunication)OR(jobaid)OR(negotiat*)OR(peereducat*)OR(persuas*)OR(promot*)OR(roleplay))

NOTES: Counsel* includes but is not limited to peer coun-seling. Job aid references must include a communications/counseling component.

5. Mass media and social marketing

((advocacy)OR(marketing)OR(massmedia)OR(printmedia)OR(radio)OR(SMS)OR(socialfranchising)OR(socialmarketing)OR(socialmedia)OR(television)OR(textmessag*)OR(video))

NOTE: References to social franchising and social market-ing must include a communications/counseling component.

C. ASSESSMENT / EVALUATION TERMS

((review)OR(effectiv*)OR(evaluat*)OR(evidence)OR(impact)OR(improv*)OR(meta-analysis)OR(rand-omizedcontrolledtrial)OR(RCT))

D. COUNTRY EXCLUSION

NOT(UnitedStates)

NOTE: All studies conducted in all other high income coun-tries were individually excluded during the review process.

evidence of effective approaches to social and …...evidence of effective approaches to social and...

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