A LINKAGES Applied Research Update

Gaps and Guidance March 2000

Current Issues gram strategies that are most effective in bring- ing about positive behavior change and im- While a great deal is known about the health proved health of and women of and spacing benefits of , con- reproductive age. They focus on breastfeeding, siderably less is known about how best to pro- complementary feeding, and maternal nutrition. mote breastfeeding. Public and private Behavior change strategies being tested include organizations have used a variety of strategies to -to-mother support groups, home visits, promote such key breastfeeding behaviors as informal contacts, counseling, modified trials of early initiation and exclusive breastfeeding. Of improved practices, “positive deviance,” and so- the few rigorous studies that document the im- cial marketing. pact of breastfeeding promotion, most are clinic- based. Rigorous assessments of the impact of The studies will: community-based, non-clinical interventions are rare, leaving program planners and policymakers s document program impact, with little scientific guidance about “what works s test alternative program approaches to im- best.” proving and maternal nutrition, An extensive review of the literature on the s impact of breastfeeding interventions1 identifies provide on-going guidance to program staff the following seven major research gaps: based on research results, and

1. Audience analysis to identify most s promote critical consciousness among in need of breastfeeding education, policymakers, program implementers, re- searchers, and others about how inquiry can 2. Effectiveness of mothers’ support groups in be used to improve programs. promoting exclusive and continued breastfeeding, LINKAGES’ research partners include leading PVOs ( International, CARE, 3. Influence of peer counselors on Save the Children), universities (Johns Hopkins breastfeeding behaviors, University, Emory University, and Eastern Vir- ginia Medical School), Cooperating Agencies 4. Role of mass media in changing (Population Services International), and research breastfeeding behaviors and sustaining be- institutes. havior change, Study 1: Testing the La Leche League model in 5. Influence on others of individuals who al- Guatemala: Does mother-to-mother ready practice optimal behaviors, breastfeeding support work? 6. Cost-effectiveness of programs, and This is the first study to rigorously test the most well-known and widespread strategy for 7. Impact of changing national policies on the promoting breastfeeding: mother-to-mother sup- quality of services, breastfeeding behaviors, port groups pioneered by La Leche League Inter- and providers’ knowledge, attitudes, and national. For the past ten years, La Leche League practices. Guatemala has trained and supported more than 200 volunteer breastfeeding counselors in low- LINKAGES’ Response income, peri-urban areas of Guatemala. Breastfeeding &... LINKAGES is addressing several of these This study tests the hypothesis that La Leche gaps through four applied research studies. League breastfeeding support (including mother- These studies are designed to identify the pro- to-mother support groups and household visits) improves breastfeeding practices at the commu- nity level. A second hypothesis tests whether in- 1Green, C.P. (1999) Improving breastfeeding behaviors: Evidence from creasing the ratio of breastfeeding counselors to two decades of intervention research. LINKAGES/Academy for Educa- tional Development. Washington DC. women of reproductive age results in signifi-

LINKAGES s AED s 1825 Connecticut Avenue, NW Washington, DC 20009 s (202) 884-8000 s Fax: (202) 884-8977 cantly higher rates of exclusive breastfeeding and lower best to counsel women about infant feeding in the context of rates of bottle usage among children less than six months high HIV prevalence. Timeline: 2/99-2/01 old. Study 3: Improving breastfeeding and complementary The Guatemala study uses a pre-/post cross-sectional feeding practices in Vietnam: How does a positive deviance design to compare 650 infants less than six months of approach work? age and includes a census, a survey of mothers, and in- terviews with breastfeeding counselors. One hundred ad- Vietnam has one of the highest rates of childhood malnu- ditional breastfeeding counselors will be trained as part trition in the world. Since 1990, Save the Children/US has of the study. Findings from the research will enable pro- used “positive deviance” to reduce severe childhood malnutri- gram planners at La Leche League and elsewhere to bet- tion in program areas by approximately 75 percent. “Positive ter allocate resources and design effective, efficient deviants” are resource-poor, well-nourished children. Save the programs to increase the prevalence of exclusive Children’s program helps parents of poorly nourished chil- breastfeeding. Timeline: 9/99-9/01 dren learn how the parents of positive deviant children are able to keep their children well nourished, in spite of tremen- Study 2: Informing Zimbabwean women about HIV dous poverty. transmission through breastfeeding: Does counseling A large part of this study on positive deviance focuses on affect infant feeding decisions, skills, and behaviors? complementary feeding of children 6-24 months of age. Sev- HIV can be transmitted from infected mothers to eral sub-studies focus on the breastfeeding practices of moth- their babies during breastfeeding. UN policy recommends ers of infants 0-6 months of age and the impact of their labor that HIV-positive women be fully informed about various outside of the household on breastfeeding practices. Save the infant feeding options, including replacement feeding, Children’s experience in using a positive deviance approach and supported in their individual decisions about how to to improve breastfeeding practices will inform program man- feed their babies. LINKAGES is conducting research to un- agers of its potential as a vehicle for breastfeeding behavior derstand the context within which women make infant change in other settings. Timeline: 4/99-4/01 feeding decisions. Study 4: Improving micronutrient status of women of The ZVITAMBO (Zimbabwe Vitamin A for Mothers reproductive age in Bolivia: Does social marketing of a and Babies) Project includes a qualitative and a quantita- micronutrient supplement work? tive component. The qualitative research, completed in 1999, included market surveys, focus groups, and in- This research tests whether increasing the availability of a depth interviews (among known HIV positives, known commercial, low-cost multiple vitamin and mineral supple- HIV negatives, and women with unknown HIV status). In- ment (VitalDía) affects use of the supplement by women of formation was gathered to assess costs associated with reproductive age in the Department of Santa Cruz, Bolivia. each feeding option; the availability of replacement VitalDía is being promoted through the media, workshops, foods; potential stigmatization of women who choose not seminars, and point of sale materials. The overall social mar- to breastfeed; and caregivers’ ability to properly keting strategy also includes an information campaign to breastfeed, express and heat-treat breastmilk, and pre- raise awareness among women, particularly focusing on pare commercial . This information was pregnant and lactating women, about the importance of nu- used in developing an intervention to inform women of trition to their health. This media campaign will emphasize infant feeding options. the consumption of fruits and vegetables.

The quantitative study, currently underway, will as- Among the instruments used in the study were a baseline sess the impact of information and counseling about HIV survey of knowledge, attitudes, practices, and beliefs (KAPB) transmission on women’s knowledge, skills, and actual of 1,704 women of reproductive age; focus groups; distribu- feeding practices. Results from both the qualitative and tion surveys; and cost analyses. A follow-up KAPB survey will quantitative studies will provide guidance to the Govern- be administered approximately nine months after product ment of Zimbabwe and to other agencies regarding how launch. Timeline: 7/98-6/00

Contact the Information Resource Center of the LINKAGES Project for detailed summaries of each applied research study and a list of available reports.

E-mail: [email protected] Fax: (202) 884-8977 Phone: (202) 884-8822 Website: www.linkagesproject.org

Breastfeeding &... is a publication of LINKAGES: Breastfeeding, LAM, Complementary Feeding, and Maternal Nutrition Program. LINKAGES is supported by G/PHN/HN, Global, the United States Agency for International Development (USAID) under the terms of Grant No. HRN-A-00-97-00007-00 and is managed by the Academy for Educational Develop- ment. The opinions expressed herein are those of the authors and do not necessarily reflect the views of USAID.