Exploring an aggregate longitudinal model to evaluate a mass media campaign to promote exclusive

breastfeeding in Viet NamDanielle NaugleRobert Hornik

Intervention• National mass media campaign• Development of a franchise network

of health centers providing quality counseling and care for infant and young child feeding (IYCF) • Trained service providers at 800 health

facilities in 15 provinces

• Advocacy and policy change• Extend maternity leave to six months• Instate a ban on marketing of

breastmilk substitutes for children under 1 year

Research Questions• Were there population-level increases in EBF over the course of the

campaign?• If so, can we link increases in EBF to the mass media campaign?• Can mass media alone impact EBF rates?

National Mass Media Campaign

“Nurse More” “No Water”

“Iron-rich Foods” “Little Sun Franchise Promotion”

Timing of Media Bursts and Data Collection

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Data Col-lection

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Data• 4 provinces: Hai Phong, Quang Nam, Dak Lak,

Tien Giang• Three-stage cluster sampling• Within each province, 4 districts purposefully

selected (2 franchise districts; 2 mass media only districts)• Primary sampling unit, villages, selected based on

population proportionate to size• Mothers were selected via systematic random

sampling

• 5 independent cross-sectional samples between August 2011 and April 2014 • At each wave, face-to-face surveys with

approximately 2,000 mothers of children under 6 months

Measures• Exclusive Breastfeeding (primary dependent variable)• WHO definition: Giving only breastmilk, and no other food, water, or infant

formula to a baby under the age of 6 months• “Thinking about the time period from when (name of infant) woke up

yesterday morning until the time she woke up this morning, was she given any plain water [infant formula, other liquids, or semi-solid or solid foods]?”• Dichotomous: 0 = not exclusively breastfeeding, 1 = exclusively breastfeeding

• Exposure (primary independent variable)• Aided recall: “Have you ever seen a video clip with these snapshots below?” • Confirmed recall: “What are the key messages you could recall after watching

the video clips?” • Ordinal: 0 = not exposed, 1 = exposed, but recalled no messages, 2 = exposed

and recalled 1-2 message, 3 = exposed and recalled 3 or more messages

Analyses• Four types of analyses• Secular change• Individual-level association between self-reported exposure and EBF• Commune-level over-time analyses• Differences between franchise communes and mass media only

communes

• Multivariate logistic and linear regressions using a robust variance estimator to adjust for commune-level clustering • Covariates: mother’s ethnicity, age, education, occupation, whether she is a first-

time mother, whether she had a cesarean section, whether or not the mother went back to work, the infant’s age, and the presence of the franchise.

Results: Descriptive Statistics• 11,277 participants from 118 communes• Ethnicity: Kinh (90%)• Mother’s age: 27.8• Education: 70% had some secondary schooling• Occupation: 1/3 farmers, 1/3 salaried non-government employees,

1/3 housewives, self-employed or salaried government employees• First-time mothers: 68%• Gave birth in a medical facility: 98%• Cesarean section: 25% (increased from 21% at wave 1 to 30% at wave 5)

• Back to work: 10%

Results: Secular Change

1 2 3 4 5Wave

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

29.20%

44.52% 45.75%49.93%

37.01%

Trends in Comune-Level EBF Rates over Time

Overall

EBF

Results: Secular Change

1 2 3 4 5Wave

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

29.20%

44.52% 45.75%49.93%

37.01%33.77%

34.81% 35.36%39.06%

29.15%

23.79%

55.09% 56.85%61.67%

45.66%

Trends in Comune-Level EBF Rates over Time

Overall MM Only Communes Franchise Communes

EBF

Results: Individual-Level Analyses

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

27.72%

20.90%

14.75%

10.62%

32.76% 33.94%

24.77%

34.54% Mass Media Only Communes

Franchise Communes

Not Exposed Exposed, but no message recall

Exposed, and recalled 1-2 messages

Exposed, and recalled 3+ messages

Levels of Exposure

Results: Individual-Level Analyses

0 1 2 3Exposure

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

39.13% 37.46%

44.49%

55.56%

EBF

Association between Individual Exposure and EBF

• The secular change over time suggests that EBF rates only increased significantly in franchise communes• However, the individual-level cross-sectional association between self-

reported exposure and EBF suggests that higher levels of exposure were associated with higher levels of EBF in both mass media only and franchise communes• Threated by causal order and self-selection

Conclusions: Secular and Individual-Level Analyses

Commune Level Analyses

Before After0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00% High Exposure Communes

Low Exposure Communes

EBF

Results: Commune Level Analyses - Time

Before After0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

31.11%34.74%

21.05%

56.06%

Before-After EBF

Mass Media Only Communes Franchise Communes

EBF

EBF

Results: Commune Level Analyses - Exposure

Before After0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

21.00%

50.93%

21.05%

56.05%

21.10%

61.17%

Franchise

Exposure 1.568 (-1SD) Exposure 1.843 (mean)Exposure 2.1 (+1SD)

Before After0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

24.38%

30.73%31.12%34.74%

37.85% 38.76%

Mass media

Exposure 1.242 (-1SD) Exposure 1.553 (mean)Exposure 1.864 (+1SD)

Conclusions: Commune Level Analyses• The mass media campaign only had an effect on commune level EBF

rates in franchise communes, not in mass media only communes• How did the mass media campaign have an effect in franchise

communes?

Did exposure drive franchise attendance?Att

enda

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Before After0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

0.83%

19.73%

1.30%

26.21%

1.77%

32.68%

Exposure 1.568 (-1SD) Exposure 1.843 (mean) Exposure 2.1 (+1SD)

Did franchise attendance drive increases in EBF?

EBF

Before After0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

15.51%

43.50%

21.04%

56.04%

26.58%

68.59%

Franchise Attendance 9.20% (-1SD) Franchise Attendance 26.20% (mean)Franchise Attendance 43.20% (+1SD)

Did exposure affect EBF above and beyond the effect through franchise attendance?• Drop all individuals who attended “Little Sun” franchise from

construction of commune level EBF variable• Interaction between time and exposure on EBF• “Little Sun” clients included: 0.191; p = 0.048)• “Little Sun” clients excluded: 0.180; p = 0.052

Conclusions• Mass media alone did not improve population EBF rates• Mass media -> franchise attendance -> EBF• Mass media -> EBF (in franchise communes)

Significance• To change a complex behavior like EBF, multiple intervention

strategies may be valuable• Mass media can play a role in scaling up interventions • In intervention-settings where there is an interpersonal support

structure in place, mass media can contribute to population-level changes in EBF

Thank you!

Danielle Naugle, PhD CandidateAnnenberg School for CommunicationUniversity of Pennsylvaniadnaugle@asc.upenn.edu

Individual-Level Analyses

Model 1 Model 2 Model 3 EBF EBF EBFexposure 1 (vs. no exposure) -0.131 -0.079 0.034exposure 2 (vs. no exposure) 0.218** 0.246*** 0.249*

exposure 3 (vs. no exposure) 0.659*** 0.745*** 0.699***

ethnicity (kinh vs. other) -0.289** -0.288**

mother’s age (years) 0.032*** 0.032***

no school (vs. > 12 years) -0.286 -0.2861-5 years (vs. 6-9 years) -0.394** -0.395**

6-9 years (vs. > 12 years) -0.024 -0.02610-12 years (vs. > 12 years) 0.017 0.017farmer (vs. housewife) 0.215* 0.217*

government (vs. housewife) -0.005 -0.001salaried (vs. housewife) 0.155 0.156self-employed (vs. housewife) -0.057 -0.055primipara -0.106* -0.105*

cesarean -0.355*** -0.354***

month 0 (vs. month 5) 1.355*** 1.353***

month 1 (vs. month 5) 1.290*** 1.293***

month 2 (vs. month 5) 1.246*** 1.244***

month 3 (vs. month 5) 0.876*** 0.879***

month 4 (vs. month 5) 0.462*** 0.464***

back to work -0.380*** -0.384***

franchise (vs. mass media only) 0.827*** 0.835***

exposure 1#franchise (vs. no exposure#franchise) -0.247exposure 2#franchise (vs. no exposure#franchise) -0.005exposure 3#franchise (vs. no exposure#franchise) 0.080_cons -0.432*** -2.194*** -2.201***

N 9040 9009 9009* p < 0.05, ** p < 0.01, *** p < 0.001

* p < 0.05, ** p < 0.01, *** p < 0.001

Results: Commune Level Analyses Model 1

EBFModel 2

EBFModel 3

EBFModel 4

EBFModel 5

EBFafter (vs. before) 0.188*** 0.188*** 0.0363 0.303** 0.172franchise (vs. mass media only) 0.150*** -0.101** -0.137*** 0.0607after#franchise 0.314*** -0.307*** 0.172exposure 0.129* 0.217*

after#exposure 0.0257 -0.0875franchise#exposure -0.215after#franchise#exposure 0.278*

_cons 0.263*** 0.190*** 0.311*** 0.111 -0.0252N 590 590 590 590 590

• Is there a significant before-after effect of being in a higher exposure franchise commune compared to being in a lower exposure franchise commune?• How about in mass media only communes?

Additional Commune-Level Analyses

* p < 0.05, ** p < 0.01, *** p < 0.001

Franchise Communes Mass Media Only Communes Model 1A Model 1B Model 2A Model 2B EBF EBF EBF EBF after (vs. before) 0.350*** 0.000444 0.0363 0.172exposure 0.00185 0.217*

after#exposure 0.191* -0.088_cons 0.210*** 0.207 0.311*** -0.0252N 285 285 305 305

* p < 0.05, ** p < 0.01, *** p < 0.001

Mediation Pathway: Exposure-Franchise Attendance-EBF Model 1A Model 1B Model 2A Model 2B Franchise

Attendance[95% CI]

Franchise Attendance

[95% CI]

EBF[95% CI]

EBF[95% CI]

after 0.249*** -0.165 0.350*** 0.242***

[0.206,0.293] [-0.418,0.0880] [0.300,0.400] [0.158,0.325]exposure 0.198*** 0.0177 [0.0870,0.310] [-0.0149,0.0503] after#exposure 0.226** [0.0846,0.367] franchise attendance 0.656*** 0.326**

[0.482,0.829] [0.105,0.546]after#franchise attendance 0.412**

[0.171,0.653]_cons -0.351** -0.0195 0.0386 0.125***

[-0.554,-0.147] [-0.0735,0.0345] [-0.0246,0.102] [0.0590,0.191]N 285 285 285 285

Why did EBF rates decrease so sharply at wave 5 in franchise communes?

1 2 3 4 5Wave

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

23.79%

55.09% 56.85%61.67%

45.66%

Trends in Comune-Level EBF Rates over Time

Franchise Communes

Why did EBF rates decrease so sharply at wave 5?

Wave 1 Wave 2 Wave 3 Wave 4 Wave 5Franchise Attendance 1.30% 25.72% 28.57% 30.13% 20.45%N 57 57 57 57 57

Why did EBF rates decrease so sharply at wave 5?

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Mechanisms of Effect and Failure• Reasoned Action Model• Attitudes• Perceived social norms• Perceived behavioral control (self-efficacy)• [Knowledge]

Knowledge (α = .65)• Which is better for an infant under 6 months, breast milk alone or a

combination of breast milk and infant formula?• Until what month should a mother give her infant only breast milk

and no other foods, water or infant formula?• In what month do you think an infant should start receiving plain

water in addition to breast milk?• In what month do you think an infant should first start to receive

liquids other than water in addition to breast milk?• After completing what month should an infant first start to receive

semi-solid foods?

Attitudes Scale (α = .84)• *If I am breastfeeding, but do not give my infant water until s/he completes 6 months, my

infant will be thirsty. • If I feed my infant only breast milk and no other food, water or infant formula, until s/he

completes 6 months, I am giving my infant all the nutrients s/he needs to be healthy.• *If I feed my infant a combination of breast milk and infant formula until s/he completes 6

months, I am giving him/her the best possible nutrition.• * If do not clean my infant’s mouth out with water after breastfeeding, my infant will get

thrush.• *If I am breastfeeding my 5 month old infant, but do not give my infant water, s/he will be

too hot.• *If I feed my infant a combination of breast milk and other foods when s/he is between 4

and 6 months of age, I am giving my infant the best possible nutrition.• If I feed my infant only breast milk and no other food, water, or infant formula until he

completes 6 months, I am giving my infant all the nutrients s/he needs for optimal brain development.

Perceived social norms (α = .72)• Most people who are important to me (e.g. family members,

friends…) think that I should feed my infant only breast milk, and no other food, water, or infant formula for the first 6 months (injunctive norms)• Most women who have infants like me feed their infant only breast

milk, and no other food, water or infant formula for the first 6 months (descriptive norms)

Self-efficacy (α=.69)• My breast milk is of good enough quality to nourish my infant so that

the infant does not need any other food, water, or infant formula until s/he has completed 6 months.• The more I breastfeed my infant, the more breast milk my body will

produce.• My body can produce enough colostrum to feed my newborn within

one hour an infant after birth.• My body can produce enough breast milk to feed my newborn only

breast milk and no water or infant formula in the first 24 hours. • The “first milk” produced by my body is all my newborn needs in the

24 hours after birth.

Franchise communes: Before-after changes in commune level cognitions

Knowledge Attitudes Norms Self-efficacy

M=.72, SD=.15 M=4.30, SD=.69 M=4.18, SD=.87 M=4.71, SD=.46

[95% CI] [95% CI] [95% CI] [95% CI]

after (vs. before) 0.250*** 1.232*** 1.514*** 0.693***

[0.227,0.273] [1.126,1.337] [1.364,1.664] [0.606,0.780]

_cons 0.515*** 3.318*** 2.974*** 4.156***

[0.487,0.543] [3.179,3.456] [2.814,3.133] [4.061,4.250]

N 285 285 285 285

* p < 0.05, ** p < 0.01, *** p < 0.001

Franchise communes: Cross-sectional association between commune level exposure and cognitions

Knowledge Attitudes Norms Self-efficacy

[95% CI] [95% CI] [95% CI] [95% CI]

exposure 0.140*** 0.666*** 0.857*** 0.459***

[0.0974,0.183] [0.386,0.946] [0.526,1.189] [0.215,0.704]

_cons 0.457*** 3.081*** 2.612*** 3.867***

[0.378,0.536] [2.558,3.604] [1.990,3.234] [3.406,4.328]

N 285 285 285 285

* p < 0.05, ** p < 0.01, *** p < 0.001

Franchise communes: Before-after cognitions by commune level exposure

Knowledge Attitudes Norms Self-efficacy [95% CI] [95% CI] [95% CI] [95% CI]after (vs. before) 0.129 0.798 0.537 0.754*

[-0.015,0.272] [-0.028,1.625] [-0.749,1.824] [0.0572,1.451]exposure 0.087* 0.477* 0.432 0.486**

[0.013,0.161] [0.0184,0.936] [-0.185,1.048] [0.178,0.794]after#exposure 0.066 0.236 0.532 -0.0334 [-0.008,0.141] [-0.211,0.683] [-0.140,1.205] [-0.398,0.331]_cons 0.354*** 2.442*** 2.182*** 3.264***

[0.216,0.493] [1.622,3.263] [1.033,3.331] [2.712,3.816]N 285 285 285 285

* p < 0.05, ** p < 0.01, *** p < 0.001

Mass media communes: Before-after changes in commune level cognitions

Knowledge Attitudes Norms Self-efficacy

M=.64; SD=.12 M=3.89; SD=.54 M=3.71; SD=.68 M=4.43; SD=.35

[95% CI] [95% CI] [95% CI] [95% CI]

after (vs. before) 0.110*** 0.459*** 0.507*** 0.264***

[0.0812,0.138] [0.348,0.570] [0.365,0.649] [0.182,0.346]

_cons 0.547*** 3.525*** 3.309*** 4.219***

[0.515,0.580] [3.379,3.672] [3.147,3.471] [4.117,4.321]

N 305 305 305 305

* p < 0.05, ** p < 0.01, *** p < 0.001

Mass media communes: Cross-sectional association between commune level exposure and cognitions

Knowledge Attitudes Norms Self-efficacy

[95% CI] [95% CI] [95% CI] [95% CI]

exposure 0.138** 0.628** 0.724** 0.315*

[0.047,0.228] [0.197,1.058] [0.244,1.204] [0.0778,0.552]

_cons 0.421*** 2.918*** 2.590*** 3.941***

[0.275,0.568] [2.222,3.614] [1.822,3.359] [3.552,4.330]

N 305 305 305 305

* p < 0.05, ** p < 0.01, *** p < 0.001

Mass media communes: Before-after cognitions by commune level exposure

Knowledge Attitudes Norms Self-efficacy [95% CI] [95% CI] [95% CI] [95% CI]after (vs. before) 0.0770 0.759** 0.308 0.604***

[-0.028,0.182] [0.287,1.232] [-0.310,0.927] [0.291,0.918]exposure 0.121* 0.782** 0.622* 0.490**

[0.007,0.235] [0.209,1.355] [0.020,1.223] [0.198,0.782]after#exposure 0.021 -0.193 0.128 -0.219*

[-0.048,0.090] [-0.524,0.137] [-0.287,0.543] [-0.423,-0.016]_cons 0.360*** 2.311*** 2.344*** 3.457***

[0.177,0.543] [1.409,3.212] [1.382,3.305] [2.988,3.926]N 305 305 305 305

* p < 0.05, ** p < 0.01, *** p < 0.001