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

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

Why does nutrition deteriorate rapidly among children under 2 years of age? Using qualitative methods to understand community perspectives on complementary feeding practices in Bangladesh.

BACKGROUND: Child undernutrition remains high in South Asian and sub-Saharan African countries. Rapid declines in nutritional status occur before the age of 2 years, particularly during the period of complementary feeding. Improving complementary feeding practices is a neglected area in nutrition programs. OBJECTIVE: To understand community perspectives on complementary feeding practices in order to inform the design of future interventions for improved complementary feeding. METHODS: From May through August 2009, data were collected in two rural locations and one urban location in Bangladesh through semistructured interviews, food attributes exercises, 24-hour dietary recalls, opportunistic observations, and trials of improved practices (TIPs). Key informant interviews and focus group discussions were also carried out among family members and community opinion leaders. RESULTS: Lay perceptions about complementary feeding differ substantially from international complementary feeding recommendations. A large proportion of children do not consume sufficient amounts of complementary foods to meet their energy and micronutrient needs. There was a gap in knowledge about appropriate complementary foods in terms of quality and quantity and strategies to convert family foods to make them suitable for children. Complementary feeding advice from family members, peers, and health workers, the importance given to feeding young children, and time spent by caregivers in feeding influenced the timing, frequency, types of food given, and ways in which complementary feeding occurred. CONCLUSIONS: Perceptions and practices related to complementary feeding need to be effectively addressed to improve the levels of child undernutrition. Lack of understanding of children's nutritional needs and insufficient time for feeding children are key barriers to complementary feeding.

Breastfeeding in infancy: identifying the program-relevant issues in Bangladesh.

BACKGROUND: In Bangladesh, many programs and projects have been promoting breastfeeding since the late 1980 s. Breastfeeding practices, however, have not improved accordingly. METHODS: For identifying program-relevant issues to improve breastfeeding in infancy, quantitative data were collected through visits to households (n = 356) in rural Chittagong and urban slums in Dhaka, and qualitative data from sub-samples by applying semi-structured in-depth interviews (n = 42), focus group discussions (n = 28), and opportunistic observations (n = 21). Trials of Improved Practices (TIPs) (n = 26) were conducted in the above sites and rural Sylhet to determine how best to design further interventions. Our analysis focused on five breastfeeding practices recommended by the World Health Organization: putting baby to the breast within the first hour of birth, feeding colostrum and not giving fluids, food or other substances in the first days of life, breastfeeding on demand, not feeding anything by bottle, and exclusive breastfeeding for the first six months. RESULTS: The biggest gaps were found to be in putting baby to the breast within the first hour of birth (76% gap), feeding colostrum and not giving other fluids, foods or substances within the first three days (54% gap), and exclusive breastfeeding from birth through 180 days (90% gap). Lack of knowledge about dangers of delaying initiation beyond the first hour and giving other fluids, foods or substances, and the common perception of "insufficient milk" were main reasons given by mothers for these practices. Health workers had talked to only 8% of mothers about infant feeding during antenatal and immunization visits, and to 34% of mothers during sick child visits. The major providers of infant feeding information were grandmothers (28%). CONCLUSIONS: The findings showed that huge gaps continue to exist in breastfeeding behaviors, mostly due to lack of awareness as to why the recommended breastfeeding practices are beneficial, the risks of not practicing them, as well as how to practice them. Health workers' interactions for promoting and supporting optimal breastfeeding are extremely low. Counseling techniques should be used to reinforce specific, priority messages by health facility staff and community-based workers at all contact points with mothers of young infants.