title: Impacts on Breastfeeding Practices of At-Scale Strategies That Combine Intensive Interpersonal Counseling, Mass Media, and Community Mobilization: Results of Cluster-Randomized Program Evaluations in Bangladesh and Viet Nam.
abstract: BACKGROUND
  Despite recommendations supporting optimal breastfeeding, the number of women practicing exclusive breastfeeding (EBF) remains low, and few interventions have demonstrated implementation and impact at scale. Alive & Thrive was implemented over a period of 6 y (2009-2014) and aimed to improve breastfeeding practices through intensified interpersonal counseling (IPC), mass media (MM), and community mobilization (CM) intervention components delivered at scale in the context of policy advocacy (PA) in Bangladesh and Viet Nam. In Bangladesh, IPC was delivered through a large non-governmental health program; in Viet Nam, it was integrated into government health facilities. This study evaluated the population-level impact of intensified IPC, MM, CM, and PA (intensive) compared to standard nutrition counseling and less intensive MM, CM, and PA (non-intensive) on breastfeeding practices in these two countries.
  
  
  RESULTS
  A cluster-randomized evaluation design was employed in each country. For the evaluation sample, 20 sub-districts in Bangladesh and 40 communes in Viet Nam were randomized to either the intensive or the non-intensive group. Cross-sectional surveys (n ~ 500 children 0-5.9 mo old per group per country) were implemented at baseline (June 7-August 29, 2010, in Viet Nam; April 28-June 26, 2010, in Bangladesh) and endline (June 16-August 30, 2014, in Viet Nam; April 20-June 23, 2014, in Bangladesh). Difference-in-differences estimates (DDEs) of impact were calculated, adjusting for clustering. In Bangladesh, improvements were significantly greater in the intensive compared to the non-intensive group for the proportion of women who reported practicing EBF in the previous 24 h (DDE 36.2 percentage points [pp], 95% CI 21.0-51.5, p < 0.001; prevalence in intensive group rose from 48.5% to 87.6%) and engaging in early initiation of breastfeeding (EIBF) (16.7 pp, 95% CI 2.8-30.6, p = 0.021; 63.7% to 94.2%). In Viet Nam, EBF increases were greater in the intensive group (27.9 pp, 95% CI 17.7-38.1, p < 0.001; 18.9% to 57.8%); EIBF declined (60.0% to 53.2%) in the intensive group, but less than in the non-intensive group (57.4% to 40.6%; DDE 10.0 pp, 95% CI -1.3 to 21.4, p = 0.072). Our impact estimates may underestimate the full potential of such a multipronged intervention because the evaluation lacked a "pure control" area with no MM or national/provincial PA.
  
  
  CONCLUSIONS
  At-scale interventions combining intensive IPC with MM, CM, and PA had greater positive impacts on breastfeeding practices in Bangladesh and Viet Nam than standard counseling with less intensive MM, CM, and PA. To our knowledge, this study is the first to document implementation and impacts of breastfeeding promotion at scale using rigorous evaluation designs. Strategies to design and deliver similar programs could improve breastfeeding practices in other contexts.
  
  
  BACKGROUND
  ClinicalTrials.gov NCT01678716 (Bangladesh) and NCT01676623 (Viet Nam).
authors: Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, District of Columbia, United States of America.
authors: Purnima
authors: P
authors: Menon
authors: Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, District of Columbia, United States of America.
authors: Phuong Hong
authors: PH
authors: Nguyen
authors: Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, District of Columbia, United States of America.
authors: Kuntal Kumar
authors: KK
authors: Saha
authors: Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, District of Columbia, United States of America.
authors: Adiba
authors: http://orcid.org/0000-0001-8381-9959
authors: A
authors: Khaled
authors: Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, District of Columbia, United States of America.
authors: Andrew
authors: http://orcid.org/0000-0002-7211-9233
authors: A
authors: Kennedy
authors: Alive & Thrive, FHI360, Washington, District of Columbia, United States of America.
authors: Lan Mai
authors: LM
authors: Tran
authors: Alive & Thrive, FHI360, Washington, District of Columbia, United States of America.
authors: Tina
authors: T
authors: Sanghvi
authors: Alive & Thrive, FHI360, Washington, District of Columbia, United States of America.
authors: Nemat
authors: N
authors: Hajeebhoy
authors: Alive & Thrive, FHI360, Washington, District of Columbia, United States of America.
authors: Jean
authors: http://orcid.org/0000-0001-6360-0028
authors: J
authors: Baker
authors: Save the Children, Washington, District of Columbia, United States of America.
authors: Silvia
authors: http://orcid.org/0000-0002-8023-5023
authors: S
authors: Alayon
authors: BRAC, Dhaka, Bangladesh.
authors: Kaosar
authors: K
authors: Afsana
authors: BRAC, Dhaka, Bangladesh.
authors: Raisul
authors: R
authors: Haque
authors: University of South Carolina, Columbia, South Carolina, United States of America.
authors: Edward A
authors: EA
authors: Frongillo
authors: Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, District of Columbia, United States of America.
authors: Marie T
authors: MT
authors: Ruel
authors: Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, District of Columbia, United States of America.
authors: Rahul
authors: R
authors: Rawat
mesh_terms: D000293:Adolescent; D000328:Adult; D001459:Bangladesh; D001942:Breast Feeding / Q000706:statistics & numerical data*; D016000:Cluster Analysis; D003256:Community Participation; D003376:Counseling; D003430:Cross-Sectional Studies; D058015:Health Communication / Q000592:standards*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D033181:Information Dissemination; D008402:Mass Media; D015397:Program Evaluation; D014744:Vietnam; D055815:Young Adult