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

"The Alive & Thrive [A&T] initiative aimed to improve infant and young child feeding (IYCF) practices through large-scale implementation of social and behavior change communication interventions in four regions of Ethiopia."

A&T’s social and behaviour change (SBCC) initiative in Ethiopia, begun in 2009, has aimed to reduce undernutrition caused by suboptimal breastfeeding (BF) and complementary feeding (CF) practices. Adequate infant and young child feeding (IYCF), including exclusively breastfed (EBF) ages 0-6 months and additional solid, semi-solid, or soft foods (CF) at 6-23 months, has needed systematic scaling up. Promising SBCC approaches reviewed include individual- and group-based peer counseling and support provided by lay counselors or trained professionals. Thus, "[t]he program adopted a four-component implementation framework to achieve scale: 1) advocacy and policy dialogues at the national and sub-national levels, 2) interpersonal communication (IPC) and community mobilization, 3) mass communication, and 4) strategic use of data." This evaluation measures a number of the communication-based SBCC approaches.

The IPC focus was on seven key messages to mothers, and community mobilization and mass media interventions were directed at opinion leaders, fathers and other caregivers. "At the community level, age-appropriate IYCF messages and counseling to mothers and caregivers of children less than two years of age were delivered primarily through the Federal Ministry of Health’s flagship Health Extension Program, utilizing the large network of government-salaried female health extension workers (HEWs) and cadres of community health volunteers known as the Women’s Development Armies (WDAs) or Health Development Armies (HDAs)." Implementation partners worked in four populous regions using community actions including "counseling at the health post or during routine home visits and community mobilization activities such as village gatherings to discuss IYCF and food demonstrations (i.e., in preparation of enriched complementary foods)....Print materials, particularly the Child Nutrition Card (CNC) describing the seven recommended feeding behaviors ('Excellent Feeding Actions'), were developed for use in interpersonal and community sessions." Mass media promoted messages through radio spots, two on BF and four on CF. An estimated 960,000 women were reached by radio spots.

The evaluation used an adequacy design based on before and after comparisons in two of the four programme regions to determine whether there were changes in intended outcomes and whether objectives were met. A cross-sectional household survey was conducted at baseline (2010) and four years later (2014) to see if World Health Organization (WHO) core indicators of IYCF and reducing of stunting were met. In addition, plausibility analyses, including an analysis of changes in intermediary outcomes, such as the recall of key messages and food items promoted by the interventions, and a dose-response analysis looking at outcomes by timing and intensity of intervention exposure (number of channels and frequency of hearing messages) were applied. "The eight IYCF indicators examined were: 1) early initiation of BF, 2) EBF to six months, 3) continued BF at one year, 4) timely introduction of solid, semi-solid, or soft foods at 6–8.9 months, 5) minimum dietary diversity, 6) minimum meal frequency, 7) minimum acceptable diet, and 8) consumption of iron-rich or iron-fortified foods [24]. The IYCF indicators were constructed based on mothers' previous-day recall about BF and of specific liquids and foods consumed by the study children." Timing of exposure in terms of the age of the child was measured to try to determine "optimal timing" of exposure to messages. A second programme called Community-based Nutrition (CBN) was examined to compare outcomes and intervention exposure.

Among the results were the following:

1. Over half of the mothers had been exposed to 2–3 channels, and 19.8% had been exposed to 4 or more channels. "With the exception of exposure to the CNCs (72.6%), however, exposure to any other SBCC channels in the six months preceding the endline survey was low (ranging from 8.9% to 31.1%). "
2. Only about one-third of mothers had heard any mass media message, 14% had attended a village gathering, and only 8.9% had attended a food demonstration. Overall, contacts with the HEW at the health post and home visit, frequency of contacts, and discussion about IYCF during these contacts had increased significantly between baseline and endline."
3. Early initiation of BF increased. "The prevalence of children with minimum dietary diversity (11.8%), minimum acceptable diet (9.9%), and having consumed iron-rich foods in the past 24 hours (4.8%) remained extremely low at endline."
4. There were significant shifts in the age of introduction of various liquids and foods to a more timely introduction between 6 and 8.9 months of age among children less than two years of age.
5. There was a slight difference in stuntings and small declines in acute respiratory infections (ARI) symptoms and diarrhoea.
6. "With respect to the number of channels to which mothers were exposed, we observed a strong dose-response association between exposure to increasing SBCC channels and early initiation of BF, minimum dietary diversity, and minimum acceptable diet, no clear dose-response association between exposure to SBCC channels and child stunting or HAZ [height-for-age Z-scores]."

The document concludes that: "Exposure to the A&T’s SBCC interventions in Ethiopia was significantly and plausibly associated with improved IYCF practices. Larger effects might have been achieved with greater coverage and higher intensity." Despite improvements, the recommendations support further improving children's diets and nutritional status, "particularly in the complementary feeding period, by addressing household food insecurity and other constraints" that limit adoption of recommended practices.