title: Promotion of exclusive breast-feeding at scale within routine health services: impact of breast-feeding counselling training for community health workers in Recife, Brazil.
abstract: OBJECTIVE
  Breast-feeding counselling has been identified as the intervention with the greatest potential for reducing child deaths, but there is little experience in delivering breast-feeding counselling at scale within routine health systems. The study aim was to compare rates of exclusive breast-feeding associated with a breast-feeding counselling intervention in which community health agents (CHA) received 20 h of training directed at counselling and practical skills with rates pre-intervention when CHA received 4 h of didactic teaching.
  
  
  METHODS
  Cross-sectional surveys of breast-feeding practices were conducted pre- and post-intervention in random samples of 1266 and 1245 infants aged 0-5.9 months, respectively.
  
  
  METHODS
  Recife, Brazil, with a population of 2 million.
  
  
  METHODS
  CHA (n 1449) of Brazil's Family Health Programme were trained to provide breast-feeding counselling at home visits.
  
  
  RESULTS
  Rates of exclusive breast-feeding improved when CHA were trained to provide breast-feeding counselling and were significantly higher by 10-13 percentage points at age 3-5.9 months when compared with pre-intervention rates (P < 0.05). Post-intervention point prevalence of exclusive breast-feeding for infants aged <4 months was 63% and for those aged <6 months was 50%.
  
  
  CONCLUSIONS
  Multifunctional CHA were able to deliver breast-feeding counselling at scale within a routine health service and this was associated with a significant increase in rates of exclusive breast-feeding. The study reinforces the need to focus training on counselling and practical skills; a key component was an interactive style that utilized the knowledge and experience of CHA. The findings are relevant to the call by international organizations to scale up breast-feeding counselling.
authors.affiliation: 1 Department of Maternal and Child Health, Federal University of Pernambuco, Recife, Brazil.
authors.forename: Sonia B
authors.initials: SB
authors.lastname: Coutinho
authors.affiliation: 2 Department of Nutrition, Federal University of Pernambuco, Recife, Brazil.
authors.forename: Pedro Ic
authors.initials: PI
authors.lastname: Lira
authors.affiliation: 1 Department of Maternal and Child Health, Federal University of Pernambuco, Recife, Brazil.
authors.forename: Marilia C
authors.initials: MC
authors.lastname: Lima
authors.affiliation: 3 Municipal Health Secretariat, Recife, Brazil.
authors.forename: Paulo G
authors.initials: PG
authors.lastname: Frias
authors.affiliation: 1 Department of Maternal and Child Health, Federal University of Pernambuco, Recife, Brazil.
authors.forename: Sophie H
authors.initials: SH
authors.lastname: Eickmann
authors.affiliation: 4 Department of Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
authors.forename: Ann
authors.initials: A
authors.lastname: Ashworth
mesh_terms: D001938:Brazil; D001942:Breast Feeding; D003150:Community Health Workers / Q000193:education*; D003430:Cross-Sectional Studies; D005260:Female; D006293:Health Promotion / Q000379:methods*; D006801:Humans; D007223:Infant; D009035:Mothers / Q000193:education