Evidence of Effective Approaches to Social and Behavior Change Communication for Preventing and Reducing Stunting and AnemiaFindings from a Systematic Literature Review
August 2014
{Photo to come}
ABOUT SPRING The Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) project is a five-year USAID-funded Cooperative Agreement to strengthen global and country efforts to scale up high impact nutrition practices and policies and improve maternal and child nutrition outcomes. SPRING provides state-of-the-art technical support and focuses on the prevention of stunting and maternal and child anemia in the first 1,000 days. The project is managed by JSI Research & Training Institute, Inc., with partners Helen Keller International, The Manoff Group, Save the Children, and the International Food Policy Research Institute.
RECOMMENDED CITATION Lamstein, S., T. Stillman, P. Koniz-Booher, A. Aakesson, B. Collaiezzi, T. Williams, K. Beall, and M. Anson. 2014. Evidence of Effective Approaches to Social and Behavior Change Communication for Preventing and Reducing Stunting and Anemia: Report from a Systematic Literature Review. Arlington, VA: USAID/ Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) Project.
ACKNOWLEDGMENTSThe authors wish to express our profound gratitude to the many individuals who contributed to this review. Anuradha Narayan, Joy Del Rosso and Marcia Griffiths contributed to the development of the protocol, prioritization of practices and categorization of behaviors and approaches. Marcia Griffiths, Michael Manske, and Agnes Guyon provided very thoughtful feedback on earlier drafts of this document. In ad-dition, Vicky Santoso contributed tremendously to the analysis of data extracted; Allison Smith-Estelle expertly edited the entire document cover to cover; Tammy Loverdos provided the beautiful graphic design; and Daniel Cothran shared this on SPRING’s website in a user-friendly interactive format. Thank you all so much!
DISCLAIMERThe contents of this report are the responsibility of the authors, and do not necessarily reflect the views of USAID or the U.S. Government.
SPRING
JSI Research & Training Institute, Inc.1616 Fort Myer Drive16th FloorArlington, VA 22209 USAPhone: 703-528-7474Fax: 703-528-7480Email: [email protected] Internet: www.spring-nutrition.org
Cover photos: left photo, John Nicholson, SPRING; right photos, Peggy Koniz-Booher, SPRING
I EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
TABLE OF CONTENTS
Table of Contents .....................................................................................................................................................................................I
List of Tables .........................................................................................................................................................................................III
Acronyms .........................................................................................................................................................................................IV
Executive Summary ............................................................................................................................................................................... V
1. INTRODUCTION ..................................................................................................................................................................... 1
A. Background ............................................................................................................................................................................ 1
B. Objectives ............................................................................................................................................................................... 1
2. METHODS .................................................................................................................................................................................. 3
A. Search Procedures ................................................................................................................................................................. 3
B. Organization of Findings .................................................................................................................................................... 4
Priority practices ................................................................................................................................................................... 4
Study design .......................................................................................................................................................................... 5
SBCC approaches ................................................................................................................................................................ 5
Implementation processes .................................................................................................................................................. 5
C. Limitations ............................................................................................................................................................................. 6
D. Works Cited and Literature Reviewed ............................................................................................................................... 7
3. FINDINGS .................................................................................................................................................................................. 8
3.1 PRACTICES DURING PREGNANCY AND LACTATION .......................................................................................... 8
A. Background ........................................................................................................................................................................... 8
B. Search Results ........................................................................................................................................................................ 9
C. Overview of the Evidence, by Practice ............................................................................................................................. 9
Increased energy and protein intake during pregnancy and lactation ......................................................................... 9
Enhanced quality of diet during pregnancy and lactation ........................................................................................... 10
Micronutrientsupplementationorfortification ............................................................................................................ 12
Increased rest and decreased work during pregnancy .................................................................................................. 12
D. Summary of the Evidence ................................................................................................................................................. 12
SBCC approaches utilized ................................................................................................................................................. 12
Implementation processes followed ................................................................................................................................ 14
E. Conclusions ..........................................................................................................................................................................15
F. Works Cited and Literature Reviewed ............................................................................................................................. 20
II EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
3.2. EVIDENCE OF EFFECTIVE SBCC APPROACHES TO PROMOTE BREASTFEEDING PRACTICES ..... 22
A. Background ..........................................................................................................................................................................22
B. Search Results ......................................................................................................................................................................22
C. Overview of the Evidence, by Practice ........................................................................................................................... 23
Early initiation of breastfeeding ...................................................................................................................................... 23
Exclusive breastfeeding ..................................................................................................................................................... 26
Continued breastfeeding ................................................................................................................................................... 32
D. Summary of the Evidence ................................................................................................................................................. 34
SBCC approaches utilized ................................................................................................................................................. 34
Implementation processes followed ................................................................................................................................ 35
E. Conclusions ..........................................................................................................................................................................36
F. Works Cited and Literature Reviewed ............................................................................................................................. 55
3.3. EVIDENCE OF EFFECTIVE SBCC APPROACHES TO IMPROVE COMPLEMENTARY FEEDING PRACTICES ........................................................................................................................................................ 61
A. Background ..........................................................................................................................................................................61
B. Search Results ......................................................................................................................................................................62
C. Overview of the Evidence, by Practice ........................................................................................................................... 63
Timely introduction of appropriate complementary foods ......................................................................................... 63
Dietary diversity .................................................................................................................................................................. 63
Micronutrientsupplementationorfortification ............................................................................................................. 68
Responsive and active feeding........................................................................................................................................... 72
Feeding during and after illness ........................................................................................................................................ 72
D. Summary of the Evidence ................................................................................................................................................. 72
E. Conclusions ........................................................................................................................................................................77
F. Works Cited and Literature Reviewed ...........................................................................................................................102
APPENDIX: SBCC LITERATURE REVIEW SEARCHING SETS ......................................................................................106
III EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
LIST OF TABLES
Table 2.1: High impact nutrition practices reviewed, by intervention area ......................................................................................3
Table 2.2: Number of studies by intervention area and study design ..............................................................................................4
Table 2.3: Categorization of SBCC approaches and activities ...........................................................................................................4
Table 3.1.1: Number of studies reviewed (with number of studies reporting statistically significantresultsinparentheses),byrecommendedpracticeandstudydesign .............................................................................8
Table 3.1.2: Number of studies reviewed (with number of studies reporting statistically significantresultsinparentheses),bySBCCapproachandstudydesign .......................................................................................11
Table 3.1.3: Number of studies reviewed (with number of studies reporting statistically significantresultsinparentheses),bySBCCapproach,practice,andstudydesign ......................................................................13
Table 3.1.4: Studies reporting on maternal dietary practices during pregnancy and lactation ...................................................16
Table 3.2.1: Number of studies reviewed (with number of studies reporting statistically significantresultsinparentheses),byrecommendedpracticeandstudydesign ...........................................................................23
Table 3.2.2: Number of studies reviewed (with number of studies reporting statistically significantresultsinparentheses),bySBCCapproachandstudydesign .......................................................................................33
Table 3.2.3: Number of studies reviewed (with number of studies reporting statistically significantresultsinparentheses),bySBCCapproachandstudydesign .......................................................................................37
Table 3.2.4: Studies reporting on breastfeeding practices .................................................................................................................39
Table 3.3.1: WHO Guiding Principles for complementary feeding of the breastfed child. .......................................................61
Table 3.3.2: Number of studies reviewed (with number of studies reporting statistically significantresultsinparentheses),byrecommendedpracticeandstudydesign ...........................................................................62
Table 3.3.3: Number of studies reviewed (with number of studies reporting statistically significantresultsinparentheses),bySBCCapproachandstudydesign ......................................................................................73
Table 3.3.4: Number of studies reviewed (with number of studies reporting statistically significantresultsinparentheses),bySBCCapproachandstudydesign .......................................................................................75
Table 3.3.5: Studies reporting on complementary feeding practices ..............................................................................................79
IV EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
ACRONYMS
ANC antenatal care
AOR adjusted odds ratio
BCC behavior change communication
BFH baby-friendly hospital
BFHI Baby-friendly Hospital Initiative
BINP Bangladesh Integrated Nutrition Project
CFG complementary feeding group
CHW Community Health Worker
CI confidenceinterval
DALY disability-adjusted life year
DISH Delivery of Improved Services for Health
EBF exclusive breastfeeding
ENA essential nutrition actions
FeSS iron-fortifiedsoysauce
GMP Growth monitoring and promotion
HKI Helen Keller International
ICFI Infant and Child Feeding Index
IEC Information, Education and Communication
IFA iron-folic acid
IFPRI International Food Policy Research Institute
IG Intervention group
IMCI Integrated Management of Childhood Illness
INE Intensive nutrition education
INE+SF Intensive nutrition education plus supplementary feeding
IPC Interpersonal communication
IYCF infant and young child feeding
IYCN infant and young child nutrition
KAP Knowledge, Attitudes, and Practices
KCAL kilocalories
KJ kilojoule
KSPES Knowledge Sharing Practices with Empowerment Strategies
LAM lactational amenorrhea method
LBW low birthweight
LHW Lay or Lady Health Workers
MAD minimum acceptable diet
MCHIP Maternal and Child Health Integrated Program
MICAH Micronutrient and Health Program
MIYCN maternal, infant, and young child nutrition
NCD noncommunicable disease
NE nutrition education
NEC nutrition, education, and counseling
NGO nongovernmental organization
NLM National Library of Medicine
NRC Nutrition Rehabilitation Center
OR odds ratio
p p-value
PAHO Pan-American Health Organization
PD positive deviance
PROBIT Promotion of Breastfeeding Intervention Trial
RCF&PG Responsive Complementary Feeding and Play Group
RCT randomized controlled trial
RR relative risk
SBCC social and behavior change communication
SC Save the Children
SGA Small for gestational age
SP Sulfadoxine/Pyrimethamine
SPRING Strengthening Partnerships, Results, and Innovations in Nutrition Globally
SUN Scaling Up Nutrition
TIP trials of improved practices
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
WASH water, sanitation, and hygiene
WHO World Health Organization
WRA women of reproductive age
YYB Ying Yang Bao (a Chinese multiple micronutrientpowder)
ZVITAMBO Zimbabwe Vitamin A for Mother and Babies Trial
V EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
FIN
DIN
GS
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
EXECUTIVE SUMMARY
Evidence suggests that simply increasing knowledge and awareness of good nutrition practices rarely leads to sus-tained behavior change, nor is sustained change in nutri-tion behavior likely to be achieved through a single activity. Severalspecificbehaviorsorpracticesimpactnutritionalstatusduringthecriticalfirst1,000days(pregnancytoagetwo),whilecomplex,contextualdeterminantsalsoinfluenceindividual decisions to consider, test, adopt and sustain a givenbehaviororpractice.Thefieldof SocialandBe-haviorChangeCommunication(SBCC)isacollectionof approaches and tools informed by behavioral theories and used to design public health interventions.
This review, part of a broader effort by SPRING to sup-port governments and other stakeholders in their delivery of high impact nutrition practices, provides a summary of peer-reviewed evidence regarding the effectiveness of SBCC approaches to increase the uptake of three key nutri-tion behaviors: women’s dietary practices during pregnancy and lactation, breastfeeding practices, and complementary feeding practices. SBCC interventions have been broadly categorized into three areas: interpersonal communication; use of media; and community/social mobilization. This reviewalsoidentifiesgapsintheevidenceandrecommen-dations for further areas of study.
Thisreviewincludesatotalof91studiesidentifiedusingthe Ovid MEDLINE database. Recognizing the potential valueofabroadarrayofstudydesigns,resultsfromfivestudytypesareincluded:reviews(includingmeta-analysis),randomized controlled trials, longitudinal studies, repeated cross-sectional studies, and cross-sectional studies. Ex-cluded studies include those with data from high income countries, those published prior to 2000, those written in a language other than English, and those that focused ex-clusivelyonrefinementofaresearchmethodology.Otherexclusions are noted in the text.
Findings related to women’s dietary practices during pregnancy and lactation
Undernutrition during pregnancy and lactation is a critical determinant of maternal, neonatal, and child health out-comes. Improving dietary adequacy during pregnancy and
lactation is important to help women accommodate their nutritional requirements as well as their children’s require-ments during intrauterine development and while breast-feeding(Haileslassie,etal.,2013).
The body of literature on the effectiveness of SBCC to improve women’s dietary practices during pregnancy and lactation is still small (only 15 peer-reviewed studies met theinclusioncriteria),butindicatesthatSBCCapproachescan and do succeed in improving uptake of the behaviors promoted. The greatest gap in the literature was in evidence of effectiveness of SBCC in improving rest and work-load during pregnancy. Given the importance of women’s dietary practices during pregnancy and lactation, the dearth of evidence is notable.
Findings related to breastfeeding practices
Breastfeeding is widely recognized as one of the most cost-effective investments to improve child survival (UNICEF, 2013),aswellascognitiveandmotordevelopmentandaca-demicperformance(Hortaetal,2013).Breastfeedingalsoimpartscriticalbenefitstothewoman,includingnaturalpostnatal infertility. Despite the promise of optimal breast-feeding practices, rates for WHO recommended breastfeed-ingpracticesremainlow(UNICEF,2013).
The body of literature on the effectiveness of SBCC ap-proaches in improving breastfeeding practices is strong and broad(62peer-reviewedstudiesmettheinclusioncriteria)and supports the claim that SBCC approaches can and do succeed in improving uptake of the behaviors promoted.
Evidence from several studies strongly suggests that increasing the number of contacts increases the positive effect of SBCC on breastfeeding practices. Greater con-sistency in how breastfeeding practices are measured – the definitionsof indicatorsandthemethodsof datacollec-tion – exists for breastfeeding practices when compared to women’s dietary practices and complementary feeding practices, but even with globally-recognized indicators and measurement guidance, considerable variation remains.
Findings related to complementary feeding practices
Timely appropriate complementary feeding are critical to a child’s growth and development and could avert millions of
VI EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
disability-adjusted life years, but global coverage of optimal complementary feeding practices remains low.
The evidence of the effect of SBCC on complementary feeding practices is quite broad (30 studies met the inclu-sioncriteria)andclearlyindicatesthatSBCCinterventionscan improve a wide range of complementary feeding practices. However, measures of optimal complementary feeding are so varied that it is particularly challenging to draw conclusions regarding the effectiveness of particular SBCC approaches.
Common findings
The SBCC approach most used, and the only one used without other communication interventions, was inter-personal communication. While media and community/social mobilization were used, they were always used with at least one other communication approach.
Studies included in this review employed a wide range of implementation strategies with variations in the interactions or combinations with other interventions, target groups, content, messages, scale and coverage, length and intensity, as well as context. Very little has been done to compare the effect of differences in the delivery science, particularly when implemented at scale.
The majority of the studies were implemented on a small scale, typically with fewer than 500 people per group.
Additionally, there was considerable variation in how wom-en’s dietary practices and complementary feeding practices weredefinedandmeasured.
Conclusions
Evidence suggests that using multiple SBCC approaches and channels to change behaviors is more effective than using one, that targeting multiple contacts has a greater effect than targeting only the woman herself, and that more visits or contacts results in greater change. However, such comparisons are not well-tested in the literature. Very few
comparisons have been made between the effect of timing of communications and what little has been done presents contradictory evidence. Unfortunately, it can be challenging to conduct such studies that compare differences in deliv-ery and/or disaggregate single approaches within a multi-approach intervention. SBCC practitioners and researchers must assess whether that line of research is useful.
Differences in local context (including social norms, cul-ture,andenvironmentalfactors)aswellasdifferencesintheimplementation and scale of implementation also affect the success of interventions. This underscores the importance of proper context assessments, formative research and/or ethnographic study prior to SBCC implementation.
Finally, if practices and indicators are not standardized, a projectmayimprovebehaviorsbutitwillbedifficulttoattribute changes in outcomes. This underscores the impor-tance of developing practices and indicators that are globally recognized, accepted, and used by the research and program communities. At the same time, many nutrition interven-tions are suited to iterative programming for incremental change toward the optimal, evidence-based behaviors. This means that more easily achieved indicators (components of standardizedindicatorsorshortertimeperiods)mayalsobe needed to measure progress toward the ultimate goal of changes in the standardized indicators of behaviors.
Other areas particularly important for future evaluations and operations research include:n the effect of targeting multiple audiences
orinfluencersof thebehaviorsbeing promoted, rather than focusing on one target population;
n the effect of the same SBCC intervention implemented in different contexts (social and environmental);
n the effectiveness of different approaches (including intensityandtargeting)fordifferentbehaviors;
n the cost and cost effectiveness of various SBCC approaches(particularlyasitrelatestoscalability);and
n the effectiveness and sustainability of these approaches when implemented at scale.
1 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
1. INTRODUCTION
A. Background
Evidence suggests that simply increasing knowledge and awareness of good nutrition practices rarely leads to sus-tained behavior change, nor is sustained change in nutri-tion behavior likely to be achieved through a single activity targetingasinglesubsetof thepopulation.Severalspecificbehaviors or practices greatly impact nutritional status duringthecriticalfirst1,000days(pregnancytoagetwo),andmanycomplex,contextualdeterminantsalsoinfluenceindividual decisions to actually consider, test, adopt and sustain a given behavior or practice.
Realizing this, public health practitioners for decades have applied theories from social psychology and marketing about behavior change to improve the potential of inter-ventions to change key practices. These theories address how and why people practice certain behaviors, why they makeandsustainchangesintheirbehaviors(ordon’t),and the way that social and environmental structures af-fect both their current practices and the likelihood they willchangepracticesandsustainthosechanges.Thefieldof SocialandBehaviorChangeCommunication(SBCC)isa collection of approaches and tools informed by behav-ioral theories and used to design public health and nutri-tion interventions.
SBCC theories, approaches, and tools have been widely ac-cepted and integrated into public health, water, sanitation, andhygiene(WASH),disasterpreventionandresponse,as well as maternal, infant, and young child nutrition (MIYCN).Sectorssuchasagricultureandeducationhavealso increased the impact of their interventions by utiliz-ing SBCC, while the private sector, where much of SBCC theory and practice originated, continues to use SBCC to sell existing products and services and develop new ones, andremainsakeyplayerintheevolutionof thefield.
SBCC is at an interesting crossroads. Technology is rapidly increasing access to information, even among remote populations, and the types of, and channels for, commu-nication are ever expanding. New technologies have the potential to democratize SBCC, giving those most affected by health and nutrition problems a greater voice in address-
ing them, and creating a platform for mutual accountability among social actors. While many programs and projects have impacted health and nutrition outcomes using SBCC, including campaigns to reduce tobacco use or increase use of seatbelts or re-usable shopping bags, there is a sense that SBCCmaynotbefulfillingitsfullpotentialtobringaboutsocial and individual changes for improved health and nutrition outcomes.
Under and over-nutrition, cancer and other NCDs, pre-ventable childhood diseases, and maternal and infant/young child mortality remain key global health issues. Some of theseissues,likechronicmalnutrition(stunting)amongchildren, have been surprisingly resistant to improvement, highlighting the need for more evidence about the potential of SBCC.Specificareasof focusincludehowsingleorcombined SBCC interventions change certain types of be-haviorsamongcertaingroupsinspecificcontexts,howtheycan be designed and implemented to ensure cost-effective-ness, scalability and sustainability, and how investments in SBCC can be targeted to take proven interventions to scale and to foster continual innovation.
SPRING seeks to strengthen the SBCC evidence base for stunting and anemia globally. SPRING conducted a system-atic literature review to assess the state of SBCC evidence related to three key areas of nutrition behavior: maternal diet during pregnancy and lactation; breastfeeding; and comple-mentary feeding. The review focused on communication interventions, categorized into three broad areas: interper-sonalcommunication(IPC);useof media;andcommunity/social mobilization. This report summarizes the evidence for the different SBCC approaches related to these three key behavioralorinterventionareas,andfindingsarepresentedfirstbyinterventionarea,thenbySBCCapproach,thenbytype of evidence.
WehopethatSBCCpractitionersandresearcherswillfindthis report a valuable reference tool, and a place from which to start when looking for current evidence regard-ingspecificSBCCapproachesand/orkeyinterventionareas within MIYCN.
B. Objectives
To be effective, SBCC approaches should be grounded in behavioral and social science theories, a deep understand-
2 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ing of the local context, as well as evidence. This literature review is part of a broader effort by SPRING to docu-ment and disseminate evidence related to effective SBCC approaches, and to develop program guidance to support governments and other stakeholders in the delivery of high impact nutrition practices at the facility, community, and household levels.
This review provides a comprehensive summary of peer-reviewed evidence regarding the effectiveness of SBCC
approaches in increasing the uptake of high impact MIYCN practices, seeking to answer the following questions:
1. What is the state of peer-reviewed evidence regarding the application of SBCC approaches to increase the uptake of high impact nutrition practices?
2. Where are the gaps in the evidence? What SBCC ap-proaches or activities lack evidence of effectiveness in improving nutrition-related practices?
3 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
2. METHODS
A. Search Procedures
The authors searched the United States National Library of Medicine biomedical database (NLM®)OvidMEDLINEbetween May-December 2012. The Ovid MEDLINE da-tabase contains bibliographic citations and author abstracts from more than 4,600 biomedical journals published in the United States and 70 other countries. The database con-tains over 13 million citations dating back to 1950, includ-ing more than 130,000 population-related journal citations (unique to the former POPLINE®database)thatwereadded to MEDLINE in 2002.
The following primary search parameters were used: the practices or behaviors promoted, the SBCC approach uti-lized, and the study design. A complete list of search terms is included as Appendix A.
Excluded from this review are studies with data from high income countries,1 those published prior to 2000, and those
1 The authors used the World Bank’s categorization and list of high income countries. See: http://data.worldbank.org/about/country-classifications/country-and-lending-groups#High_income.
written in a language other than English. Furthermore, articlesfocusedexclusivelyontherefinementof aresearchmethodology, those without a clear description of the prac-tices promoted or the SBCC approach utilized, and those thatdidnotspecificallyquantifyordisaggregatetheeffectof SBCC on behavioral outcomes, were also excluded. Out of 15,847 hits, 91 studies were extracted for detailed review.
Using a standardized procedure, researchers conducted an in-depth review of each of the selected studies and extract-ed the following information:
n location
n objective
n practice(s)promoted
n SBCCapproach(es)utilized
n interventiondesignprocess(e.g.formativere search)
n scale of implementation
n durationof theintervention(whereavailable)
n frequency of contact or of potential exposure (where available)
n population targeted
n study design
n study results and p-values
Table 2.1: High impact nutrition practices reviewed, by intervention area Intervention area Specific practicesWomen’s dietary practices during pregnancy and lactation
n Increased energy and protein intake during pregnancy and lactationn Enhanced quality of diet during pregnancy and lactationn Micronutrient supplementation or fortificationn Increased rest and decreased work during pregnancy
Breastfeeding practices n Early initiation of breastfeeding n Exclusive breastfeedingn Continued breastfeeding
Complementary feeding practices
n Timely introduction of complementary foodsn Dietary diversity
- Feeding children animal source foods- Feeding children fruits and vegetables- Feeding children a minimum number of food groups (dietary diversity)
n Micronutrient supplementation or fortificationn Increased meal frequency and/or density
- Increasing frequency of feeding children- Adding fats or oils to children’s foods- Enhancing the consistency of children’s foods- Increasing the quantity fed to children at each meal
n Responsive/active feedingn Feeding during and after illness
4 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
B. Organization of Findings
The literature review focuses on evidence of effectiveness around three primary intervention areas: women’s dietary practices during pregnancy and lactation, breastfeeding practices, and complementary feeding practices. These intervention areas focus on actions by mothers or other caretakersduringthe“first1000days”–theperiodbetweenconception and a child’s second birthday. The vast majority of stunting occurs during this period, and there is generally little potential for recovery thereafter.
This review is divided into three chapters corresponding to each of these three intervention areas. The chapters can be read together as one document, or read separately as independent documents. With each of these chapters, thefindingsareorganizedbyprioritypractices,SBCCapproach(es)utilized,andstudydesign.Thisorganizationenables the reader to derive an independent judgment re-
gardingfindingsfromdifferentstudydesigns.Inaddition,implementation processes followed are also discussed.
Priority practices
Within each chapter, we identify high impact nutrition practiceswithprovenefficacywithrespecttochildnutri-tion outcomes. This list of practices is consistent with those prioritized in The Lancet’s Maternal and Child Nutri-tionSeries(Bhuttaetal.,2008a;Bhuttaetal.,2013),theWorld Health Organization’s “Essential Nutrition Actions: Improving Maternal, Newborn, Infant and Young Child HealthandNutrition”(WHO,2013),theWHOe-Libraryof Evidence for Nutrition Actions, and the United Nations Children’sFund’s(UNICEF)“ImprovingChildNutrition:TheAchievableImperativeforGlobalProgress”(UNICEF,2013).Wherenormativerecommendationsexist,thechap-ter is organized accordingly. Where such recommendations
Table 2.2: Number of studies by intervention area and study design
Intervention areaReviews
with meta-analysis
RCTLongitudinal
studies
Repeated cross-
sectional studies
Cross-sectional studies
Total
Women’s dietary practices during pregnancy and lactation
1 4 2 8 0 15
Breastfeeding practices 6 27 14 13 2 62
Complementary feeding practices 0 11 9 10 0 30
Table 2.3: Categorization of SBCC approaches and activities
SBCC approaches Specific activities*Interpersonal Communication The following activities can be conducted in facilities, communities, or homes and by health care
providers, lay health workers, or peers:n One-on-one counseling n Group education n Support groups
Media n Mass median Mid-sized media (community radio / video, local billboards)n Small media (posters, flyers, calendars, reminder stickers)n Traditional media (songs, drama)n Social media (Twitter, Facebook, etc.)
Community/Social Mobilization n Campaigns, events, special “days”, ralliesn Issue groups
5 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
do not exist, we review practices with widely acknowledged potential for impact. See Table 1.1.
There was considerable variation in indicators used to measure these practices. This is partly due to the wide range of practices included within each intervention area, but is also because not all studies reviewed used standardized or recommended indicators to measure behavioral outcomes. Any difference in indicators is clearly indicated in the sum-maries associated with each practice.
Finally, because the review is organized around the effec-tivenessof SBCCactivitiesonspecificpractices,studieslooking at the effectiveness of SBCC on more than one of the prioritized practice are cited and discussed multi-ple times. Where this occurs, we have provided a detailed descriptionof thestudyinthefirstreference,andonlydiscuss results in subsequent references.
Study design
Studydesigninfluencesthevalidityandcomparabilityof outcomes. The Grades of Recommendation, Assess-ment,Development,andEvaluation(GRADE)WorkingGroup2 focuses on four key elements to assess the validity of studyfindings:studydesign,studyquality,consistency,anddirectness(GRADEWorkingGroup,2004).Habichtetal.(1999)alsoprovideguidanceonevaluationdesignfor public health program performance based on “type of inference to be made, whether this is a statement of adequacy,plausibility,orprobability”regardingattributionof change to an intervention.
Recognizing the value of a broad array of study designs, resultsfromfiveprimarystudydesignsareincluded:reviews(includingmeta-analysis),randomizedcontrolledtrials(RCT),longitudinal studies, repeated cross-sectional studies, and cross-sectional studies. Additional aspects of study design are noted within each chapter. Table 1.2 summarizes the number of studies reviewed, by intervention area and study design.
We included detailed information and analysis of all studies reportingstatisticallysignificantfindingsrelatedtoprior-ity practices. All studies are included in the summary tables at the back of each chapter. Seventy-four of the studies (includingthesevenliteraturereviewswithmeta-analyses)
2 See: http://www.gradeworkinggroup.org/intro.htm.
reviewedreportedstatisticallysignificantresultsrelevanttothis literature review. Readers may wish to use caution in interpretingstatisticallysignificantfindingsasthequalityand design of studies differ considerably.
SBCC approaches
While the importance of structural, environmental, and systems-related interventions in achieving sustainable social andbehaviorchange(SBC)shouldnotbeunderestimated,thisreviewwasconfinedtotheeffectivenessof communi-cation-related interventions in affecting behavior change. We focused on evidence around three broad SBCC ap-proaches: interpersonal communication, the use of media, and community/social mobilization. Within each approach, furtheridentifiedsub-approachesoractivitieswereidenti-fied.SeeTable1.3.
The SBCC approaches and activities outlined are con-sistent with those referenced in the C-Change/FHI360 Learning Package for Social and Behavior Change Com-munication(2010),theBillandMelindaGatesFoundation“Social & Behavior Change Interventions Landscaping Study:AGlobalReview”(Storeyetal.,2011),theUSAIDInfantandYoungChildNutrition(IYCN)Project“IYCNSocialandBehaviorChangeCommunicationApproach”(2011),theUSAID“CommunityInterventionstoPromoteOptimal Breastfeeding: Evidence on Early Initiation, Any Breastfeeding, Exclusive Breastfeeding, and Continued Breastfeeding”(2012),theUSAID“BehaviorChangeInterventions and Child Nutritional Status: Evidence from the Promotion of Improved Complementary Feeding Prac-tices”(2011)andtheUSAIDMaternalandChildHealthIntegratedProgram(MCHIP)publication“TechnicalRefer-enceMaterials:BehaviorChangeInterventions”(2010).
Most studies used more than one SBCC activity and many used more than one approach.
Implementation processes
There is consensus that delivery systems for nutrition inter-ventions are currently suboptimal (Black et al., 2008; Chopra etal.,2012;LeroyandMenon,2008;Menonetal.,2014).The World Bank’s report on how to improve health service delivery in developing countries reviewed the evidence and concluded that “the evidence base is weak for claiming suc-
6 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
cess of any particular health services strengthening strategy across LMICs3,”notingthat“howastrategyisimplementedisasimportantasthetypeof strategyimplemented”(Ovret-veitetal.,2009).Implementationprocessesinclude,butarenot limited to, the overall program design, intensity and tim-ingof contacts;typeandtrainingof person(s)communicat-ingmessages,supervisionof fieldworkers,andaudience(s)targeted. Acknowledging the importance of how services are delivered, information on targeted audiences, the scale, as well as the timing and intensity of interventions is provided whenever possible in the chapters that follow.
A particularly important aspect of the delivery of SBCC interventions is the target audience. Many people can influencewhetheranindividualadoptsorfailstoadoptapromoted behavior. Successful SBCC strategies target vari-ous audiences and often more than one audience or sphere of influence,including:4
n self/caregivers, such as pregnant and lactating women, as well as other immediate caregivers of children under two;
n directinfluencers,includingpartners/fathers,mothers-in-law, siblings, other family members, and peers;
n actors within the local community, including community members, leaders, social groups, and providers; and
n actors within the enabling environment, including the government (national, sub-regional, district and/or municipal),business,faithandmovementleaders.
3 LMIC stands for Low and Middle Income Countries 4 See the C-Change Social Ecological Model for Change.
C. Limitations
The authors limited this literature review to peer-reviewed studiesandthoseidentifiedintheOvidMEDLINE® database. While use of a second peer-reviewed journal database, Web of Science®, was considered, the high degree of overlap between the two databases made this unnecessary. Since not all projects, programs and national strategies publish in peer-reviewed journals, some relevant SBCC information, experiences, and evidence may have been omitted.
We limited the review to studies published on or after Janu-ary 1, 2000. Studies published prior to 2000 may also in-cludevaluablefindingsthatarenotcapturedinthisreview.
The review excluded research conducted in high income countries. We acknowledge that experience from other coun-try contexts, including the United States, may be valuable to assess the relative success of different SBCC approaches.
Despite comprehensive search terms that included the full rangeof activitiesincludedinthetermSBCC,reviewfind-ings are limited to communication-based approaches. This is consistent with the types of SBCC delivery strategies and in-terventions currently being utilized by the SBCC community.
Differences in local context (including social norms, cul-ture,andenvironmentalfactors)aswellasdifferencesintheimplementation and scale of implementation can impact the success of interventions and may affect generalizability of findingsincludedinthisreview.
7 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ACC/SCN.2001.WhatWorks?AReviewof theEfficacyandEffectivenessof NutritionInterventions,AllenLHandGillespieSR. ACC/SCN: Geneva in collaboration with the Asian Development Bank, Manila.
Bhutta,ZulfiqarA,JaiKDas,ArjumandRizvi,MichelleFGaffey,Neff Walker,SusanHorton,PatrickWebb,AnnaLartey,andRobert E Black. 2013. “Evidence-based Interventions for Improvement of Maternal and Child Nutrition: What Can Be DoneandatWhatCost?”TheLancet382(9890)(August):452–477.
Bhutta,ZulfiqarA,TahmeedAhmed,RobertEBlack,SimonCousens,KathrynDewey,ElsaGiugliani,BatoolAHaider,BettyKirkwood, Saul S Morris, H P S Sachdev, Meera Shekar, for the Maternal and Child Undernutrition Study Group. 2008a. “WhatWorks?InterventionsforMaternalandChildUndernutritionandSurvival.”TheLancet371(9610)(February):417–440.
Black,RobertE,LindsayHAllen,ZulfiqarABhutta,LauraECaulfield,MercedesdeOnis,MajidEzzati,ColinMathers,andJuanRivera.2008.“MaternalandChildUndernutrition:GlobalandRegionalExposuresandHealthConsequences.”TheLancet371(9608)(January):243–260.
C-Change.CModules:ALearningPackageforSocialandBehaviorChangeCommunication(SBCC).Washington,DC:C-Change/FHI 360.
GRADEWorkingGroup.“GradingQualityof EvidenceandStrengthof Recommendations.”2004.BMJ328(7454):1490–0.Habicht, J P, C G Victora, and J P Vaughan. 1999. “Evaluation Designs for Adequacy, Plausibility and Probability of Public
HealthProgrammePerformanceandImpact.”InternationalJournalof Epidemiology28(1):10–18.LeroyJ.andPurnimaMenon.2008.“FromEfficacytoPublicHealthImpact:ACallforResearchonProgramDeliveryand
UtilizationinNutrition.”TheJournal of Nutrition.138(3):628-629.MaternalandChildHealthIntegratedProgram(MCHIP).2010.TechnicalReferenceMaterials:BehaviorChangeInterventions.
Washington, DC: USAID. Menon, Purnima, NM Covic, PB. Harrigan, SE Horton, NM Kazi, S Lamstein, L Neufeld, E Oakley, and D Pelletier. 2014.
“Strengthening Implementation and Utilization of Nutrition Interventions through Research: A Framework and Research Agenda:NutritionImplementationFrameworkandResearchAgenda.”Annalsof theNewYorkAcademyof Sciencesdoi:10.1111/nyas.12447.
Chopra M, A Sharkey, N Dalmiya , D Anthony , N Binkin, on behalf of the UNICEF Equity in Child Survival, Health and Nu-trition Analysis Team. 2012. “Strategies to improve health coverage and narrow the equity gap in child survival, health, andnutrition.”TheLancet380(9850):1331–1340.
Ota, Erika, R Tobe-Gai, R Mori, and D Farrar. Antenatal Dietary Advice and Supplementation to Increase Energy and Protein Intake. In Cochrane Database of Systematic Reviews 2012, edited by The Cochrane Collaboration and Erika Ota. Chich-ester, United Kingdom: John Wiley & Sons, Ltd.
Ovretveit J, B Siadat, DH Peters, A Thota, and S El-Saharty. 2009. “Chapter 1: Review of Strategies to Strengthen Health Ser-vices.”InImprovingHealthServiceDeliveryinDevelopingCountries:FromEvidencetoAction,editedbyD.H.Peters,Sameh El-Saharty, Bafsheh Siadat, Katja Janovsky and Marko Vujicic, Washington DC: World Bank, 2009.
Storey D, K Lee, C Blake, P Lee, YL Lee, and N Depasquale. “Social & Behavior Change Interventions Landscaping Study: A GlobalReview”Seattle:TheBillandMelindaGatesFoundation,2011.
UNICEF. Improving Child Nutrition: The achievable imperative for global progress. New York: UNICEF, 2013. USAIDInfantandYoungChildNutrition(IYCN)Project.BehaviorChangeInterventionsandChildNutritionalStatus:Evi-
dence from the Promotion of Improved Complementary Feeding Practices. Washington, DC: UNICEF, 2011a.USAIDInfantandYoungChildNutrition(IYCN)Project.IYCNSocialandBehaviorChangeCommunicationApproach.
Washington, DC: USAID, 2011. USAIDInfantandYoungChildNutrition(IYCN)Project.CommunityInterventionstoPromoteOptimalBreastfeeding:
Evidence on Early Initiation, Any Breastfeeding, Exclusive Breastfeeding, and Continued Breastfeeding. Washington, DC: USAID, 2012.
World Health Organization. Essential Nutrition Actions: Improving maternal, newborn, infant, and young child health and nutrition. Geneva: World Health Organization, 2013.
WHO. E-Library of Evidence for Nutrition Actions. Geneva: World Health Organization.
D. Works Cited and Literature Reviewed
8 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
3. FINDINGS
3.1. Evidence of Effective SBCC Approaches to Improve Women’s Dietary Practices during Pregnancy and Lactation
A. Background
Undernutrition during pregnancy and lactation is a criti-cal determinant of maternal, neonatal, and child health outcomes. Maternal undernutrition is associated with an increasedriskof maternalmortality(Christianetal.,2008),and both maternal stunting and wasting are associated with term and preterm births of children small for gestational age (SGA)(Blacketal.,2013)andlowbirthweight(ACC/SCN,2001,amongothers).ChildrenbornSGAaremorelikelyto become stunted children and adults, which, for women, can place them at increased risk for delivery complications, morbidity, and mortality over time (Bhutta, 2013; Mason et al.,2012).Lowbirthweighthasbeenshowntocostsocietyinincreasedinfantmortality(Katzetal2013),lostwagesand productivity in adulthood, increased stunting and related illness, and increased rates of noncommunicable disease (NCDs)inadulthood(AldermanandBehrman,2006).
Maternal anemia is associated with an increased risk of maternal death, and there is a strong causal link between irondeficiencyanemiaandbothlowbirthweight(LBW)andperinatalmortality(RasmussanandStolzfus,2003).MaternalvitaminAdeficiencyisassociatedwithvisual
impairmentamongwomen(Blacketal.,2013)aswellasincreasedriskof infantsbeingLBW(Tielshetal.,2008)andinfantmortality(Christianetal.,2001).Deficienciesof zinc, iodine, folate, and calcium are also implicated in adverse maternal and child health outcomes.
Improving dietary adequacy during pregnancy and lactation is critical to helping women accommodate their nutritional requirements as well as their children’s requirements during intrauterine development and while breastfeeding (Haile-slassie,etal.,2013).
There is limited evidence regarding the effectiveness of protein and energy-related interventions to address mater-nal wasting and SGA. The strongest evidence comes from a Cochrane Review which concluded that balanced energy protein supplementation reduced the incidence of SGA by 32%. A subsequent meta-analysis found that balanced en-ergy protein supplementation increased birth weight by 73g andreducedtheriskof SGAby34%(Bhuttaetal.,2013).
Evidencesupportingthebenefitsof maternalmicronutri-entsupplementationandfortificationismorerobust.Ironfolic acid supplementation during pregnancy is associated with improved mean birth weight and a 79% reduction in megaloblasticanemia(Lassietal.,2013).Multiplemicro-nutrient supplementation in pregnant women is associated with a 10% reduction in SGA and 11% reduction in LBW babies(HaiderandBhutta,2012).Theconsumptionof micronutrient and iron-rich foods can also contribute to improved maternal nutritional status. Increasing the con-
Table 3.1.1: Number of studies reviewed (with number of studies reporting statistically significant results in parentheses), by recommended practice and study design
Reviews with meta-
analysisRCT
Longitudinal studies
Repeated cross-
sectional studies
Cross-sectional studies
Total
Increased energy and protein intake during pregnancy and lactation
1 (1) 0 1 (0) 3 (2) 0 5 (3)
Enhanced quality of diet during pregnancy and lactation 1 (0) 1 (1) 0 4 (3) 0 6 (4)
Micronutrient supplementation or fortification 0 3 (2) 0 3 (1) 0 6 (3)
Increased rest and decreased work during pregnancy 0 0 0 1 (0) 1 (1) 2 (1)
*Notethatcolumnsdonotsumtothe“total”sincesomearticlesreportedonmultiplepractices.
9 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
sumption of certain plant-based foods (such as green leafy vegetables)ormeatandfishcanhaveaconsiderableimpactonanindividual’sironstatus(Allenetal.,2001).
This chapter focuses on the effectiveness of Social and BehaviorChangeCommunication(SBCC)approachestoincrease the quantity and quality of women’s dietary intake during pregnancy and lactation.
B. Search Results
Fifteen peer-reviewed studies on women’s dietary prac-tices met the review’s inclusion criteria.5 A complete list of the studies reviewed, including a summary of the SBCC approach(es)utilized,thestudydesign,practicesmeasured,andlevelsof significanceispresentedinTable3.1.4attheend of this chapter.
Tenstudiesreportedastatisticallysignificantchangeinatleast one of the priority practices. Each of those articles is described in greater detail below. Studies reporting a statisti-callysignificantchangeinmorethanoneof theprioritizedpractices and/or utilizing more than one SBCC approach are cited and discussed multiple times. Where this occurs, we haveprovidedadetaileddescriptionof thestudyinthefirstreference, and only discuss results in subsequent references.
Thefindingsareorganizedbypracticestargeted,SBCCapproach(es)utilized,andstudydesign.Thisorganizationenables the reader to derive an independent judgment re-gardingfindingsfromeachstudy.Inaddition,implementa-tion processes followed are also discussed.
Of the 15 studies reviewed for this chapter, one was a literature review including a meta-analysis, four were rand-omizedcontrolledtrials(RCT),onewasalongitudinalstudy(includingacontrolgroup),eightwererepeatedcross-sectionalstudies(fiveof whichincludedcontrolgroupsandthreethatdidnot)andwasacross-sectionalstudyimple-mented only at one point in time. See Table 3.1.1.
C. Overview of the Evidence, by Practice
The evidence focuses on four key maternal nutrition prac-tices: increased energy and protein intake during pregnancy, enhanced quality of diet during pregnancy and lactation,
5 See the introductory chapter of this literature review for a full description of search procedures and inclusion/ exclusion criteria.
consumption of micronutrient supplements, and reduced work during pregnancy and lactation. While health status is also an important determinant of women’s nutritional sta-tus, practices associated with improved health status were not explored in this review.
Of thestudiesreviewed,fiveexploredenergyandproteinintake among pregnant and lactating women, six assessed enhanced quality of diet among pregnant and lactating women, six reported on the intake of micronutrient supple-ments, and two looked at increased rest and reduced work during pregnancy. See Table 3.1.1.
Increased energy and protein intake during pregnancy and lactation
Of thefivestudiesthatdiscussedincreasedenergyandprotein intake, two measured the proportion of women consuming more food during pregnancy, one measured the proportion of women consuming more food during lacta-tion, two measured caloric intake and two measured protein intake.Threeof thefivestudiesreportedstatisticallysignifi-cant results.
Literature Reviews with meta-analysis
Otaetal.(2012)conductedameta-analysisof fourRCTslooking at energy and protein intake among pregnant women. The authors included three studies in each of the analyses comparing intake among women who received nutritional advice during pregnancy and those who did not. Following a pooled analysis, the authors concluded that “advice to increase protein intake seems to be successful in achieving its goal [mean difference of +6.99 g/day], but therewasnosignificantincreaseinenergyintake.”
Cross-sectional studies
GargandKashyap(2006)conductedarepeatedcross-sectional study looking at mean daily energy and protein intake among pregnant women in one village in India. The nutrition education intervention included facility-based counseling, weekly home visits to pregnant women, and six group meetings for pregnant women over a period of two to four months. Following baseline data collection, the intervention was delivered to 50 pregnant women having completed 5-7 months of gestation. Another 50 women in month 8-9 of pregnancy were considered to be the control
10 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
group. By the time women in the intervention group had reached 8-9 months of gestation they consumed 686 kcal more per day than those in the control group.
Guyonetal.(2009)lookedatdietaryintakeduringlacta-tion in two highland provinces in Madagascar. The inter-vention included training of health workers, interpersonal communication including small and large group activities, one-to-one counseling in homes and at local health facili-ties, community/social mobilization events such as festivals celebrating breastfeeding and child health days, and the use of mass media to air breastfeeding promotion songs. The authors found that women in intervention communities were 12% more likely to report increased food intake dur-ing lactation than women in control communities.
Enhanced quality of diet during pregnancy and lactation
Of the six studies explored the effectiveness of SBCC interventionsontheconsumptionof specificnutrient-richfoods,includingfortifiedfoods,duringpregnancy,fourreportedstatisticallysignificantresults.
Randomized controlled trials
Sunetal.(2007)conductedanRCTexploringthe“effec-tivenessof socialmarketing(SM)ontheimprovementof women’sknowledge,attitudes,andbehaviors”regardingconsumptionof ironfortifiedsoysauce(FeSS)inGuidzhouProvince, China. The intervention included the use of mass media and “social marketing strategies using an integrated 6 Ps approach (product, price, place, promotion, policy, and partnership).”TheSMstrategyincludedphysician-ledcoun-selingof patientsonthebenefitsof consumingFeSS,aswellas the distribution of FeSS samples and calendars with FeSS information at the community level. The authors reported an increase in eating and purchasing behaviors in rural and urban interven-tion site as well as in control sites. In rural sites there was a net increase in FeSS purchase in intervention sites of 35 percentage points compared with rural control sites. Likewise, the net increase in was 29.5 percent-age points in urban intervention sites compared with urban control sites. With regard to the consumption of FeSS, the authors reported a net increase of 21.1 percentage points in rural intervention sites compared with rural control sites and a net increase of 25.6 percentage points in the proportion of urban women consuming FeSS.
Repeated cross-sectional studies
GargandKashyap(2006)conductedarepeatedcross-sectional study looking at mean daily intake of green leafy vegetables. By the time women in the intervention group had reached 8-9 months of gestation they consumed 49.3g of green leafy vegetables daily compared with only 12.9g among women in the control group.
Ndiayeetal.(2009)lookedattheintakeof animalprod-ucts among pregnant women in rural Senegal. The study compared two intervention packages within the Micronutri-entandHealthProgram(MICAH).Controlcommunitiesreceived the standard MICAH intervention package which included basic nutrition education and a supply of iron sup-plements and other products through health centers. Inter-vention communities received the standard MICAH package alongwithapositivedeviance(PD)/Hearth6 intervention, exposure to mid-sized media (such as community radio/video,localbillboards),homecounselingbypeers,andgroupeducation. After eight months, the percent of pregnant womenconsumingmeatorfishincreasedfrom49.4%to70.7% in PD/Hearth intervention communities while it had declined from 41.5% to 32.0% in control communities.
Finally,Wangetal.(2009)conductedastudytolookat“theeffectiveness of social mobilization and social marketing in improvingknowledge,attitudesandpractices(KAP)andFestatusinanFe-deficientpopulation.”Theinterventionincluded a kick-off meeting with key stakeholders as well as the training of community health workers, community heads and store owners/market managers. In addition, “schoolchildren were mobilized to distribute information, educationandcommunication(IEC)materialstothewholefamily after they learned the relevant knowledge through speciallydesignedclasses”and“trainedvolunteerswererecruited to disseminate IEC materials in public areas like hospitals,cultureandsportscentres.”Afteroneyear,thepercentage of women in the intervention area who had ever purchased FeSS increased from 8.9% to 36.6%.
6 According to the CORE Group’s Resource Guide for Sustainably Rehabili-tating Malnourished Children, “a Positive Deviance/Hearth Nutrition Pro-gram is a home- and neighborhood-based nutrition program for children who are at risk for protein-energy malnutrition in developing countries. The programusesthe“positivedeviance”approachtoidentifythosebehaviorspracticed by the mothers or caretakers of well-nourished children from poor families and to transfer such positive practices to others in the com-munitywithmalnourishedchildren.The“Hearth”orhomeisthelocationforthenutritioneducationandrehabilitationsessions.”(McNulty,2005).
11 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
Table 3.1.2: Number of studies reviewed (with number of studies reporting statistically significant results in parentheses), by SBCC approach and study design
SBCC approachReviews
with meta-analysis
RCTsLongitudinal
studies
Repeated cross-
sectional studies
Cross-sectional studies
TOTAL
Interpersonal Communication 1 (1) 4 (3) 1 (0) 8 (5) 1 (1) 15 (10)
One-on-One Counseling 1 (1) 3 (2) 1 (0) 6 (4) 1 (1) 12 (8)
Counseling in facilities 0 1 (1) 1 (0) 1 (1) 0 3 (2)
Counseling in communities 0 1 (1) 0 0 0 1 (1)
Counseling in homes (home visits) 0 2 (1) 0 5 (3) 1 (1) 8 (5)
Counseling in other settings 1 (1) 0 0 1 (1) 0 2 (2)
Group Education 1 (1) 1 (1) 1 (0) 6 (2) 0 9 (4)
Education in facilities 0 0 1 (0) 2 (1) 0 3 (1)
Education in communities 0 1 (1) 0 3 (0) 0 4 (1)
Education in other settings 1 (1) 0 0 1 (0) 0 2 (1)
Support Group 0 0 0 2 (1) 0 2 (1)
Support group in facilities 0 0 0 1 (0) 0 1
Support group in communities 0 0 0 0 0 0
Support group in other settings 0 0 0 1 (0) 0 1
Media 0 3 (3) 0 3 (3) 1 (1) 7 (7)
Mass media 0 1 (1) 0 1 (1) 0 2 (2)
Mid-sized media (community radio / video, local billboards) 0 1 (1) 0 1 (0) 0 2 (1)
Small media (posters, flyers, calendars, reminder stickers) 0 3 (3) 0 1 (0) 0 4 (3)
Traditional media (songs, drama) 0 0 0 0 1 (1) 1 (1)
Social media (Twitter, Facebook, etc.) 0 0 0 1 (0) 0 1
Community/Social Mobilization 0 0 0 3 (2) 0 3 (2)
Campaign, event, special “days” 0 0 0 1 (1) 0 1 (1)
Issue groups 0 0 0 2 (1) 0 1 (1)
Other 0 0 0 1 (1) 0 1 (1)
12 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
Micronutrient supplementation or fortification
Although many studies reported on micronutrient sup-plementationorfortificationamongpregnantandlactatingwomen, just six presented results in a way that allowed for examination of the distinct effect of SBCC approaches on uptake, and all of these were associated with iron supplemen-tation.Threeof thesereportedstatisticallysignificantresults.
Randomized controlled trials
Adhikarietal.(2009)assessedtheeffectof an“educationprogram and/or pill count on the change in hemoglobin levelsandtheprevalenceof anemiainpregnantwomen”among 320 pregnant women receiving prenatal care at the Tribhuvan University Teaching Hospital in Nepal. Women were randomly assigned to one of four groups (education, pillcount,educationwithpillcount,andcontrol).Bytheend of the intervention, women in the education with pill countgroupweresignificantlymorelikelytocomplywithiron supplementation recommendations than women in the pillcountalonegroup(88%and73%,respectively).
Risonaretal.(2008)assesseda“redesignedFesupple-mentationdeliverysystem”ontheislandof NegrosintheSouthern Philippines. The project included providing iron tablets to all pregnant women in two provinces (one inter-ventionandonecontrol).Intheinterventiongroup,villagehealth workers and traditional birth attendants also identi-fiedandregisteredpregnantwomenforantenatalcare,andusedIECmaterialssuchaspostersandflyerstopromoteiron supplementation. After six months, the percentage of women in the intervention group taking iron tablets had in-creased from 57.4% to 79.2%, an increase nearly four times greaterthaninthecontrolgroup(OR=3.79).
Repeated cross-sectional studies
Baquietal.(2008b)conductedarepeatedcross-sectionalstudyfocusedonironfolicacid(IFA)supplementationforpregnant women in two districts in India. Both interven-tion and control groups received counseling on preventive care, nutrition, preparedness for child birth, and health-care utilization for complications during home visits by health care providers. In intervention communities, community health workers recruited additional community volunteers (“changeagents”)tofurtherthereachof theprogramthrough additional counseling. The authors report a net increase
of 14.7 percentage points in the number of women consum-ing≥100IFAtabletsduringpregnancyin intervention sites compared with control sites.
Increased rest and decreased work during pregnancy
Two studies reported on rest and work during pregnancy. Oneof thosetworeportedstatisticallysignificantresults.Omeretal.(2008)conductedacross-sectionalstudyfocused on reducing heavy workload during pregnancy (suchaslifting),attendingprenatalcheck-ups,andfeedingcolostrum to newborns in the Sindh province of Pakistan. Theinterventiontrainedladyhealthworkers(LHW)topre-sent and discuss an embroidered cloth panel portraying key messages during routine home visits with pregnant women. Following the intervention, the authors found no difference in overall workload practices between the intervention and controlgroups,butdidfindthatwomenintheinterventiongroup were 50% more likely to reduce routine heavy work comparedwiththoseinthecontrolgroup(OR=1.48).Nobaseline data were collected.
D. Summary of the Evidence
SBCC approaches utilized
SBCC approaches are organized SBCC activities into three primary categories or approaches: interpersonal communi-cation, media, and community/social mobilization. These approachesandthespecificactivitiesassociatedwitheachare described in further detail in the introductory chapter.
The studies reviewed in this chapter included a broad range of approaches to promote optimal dietary intake among pregnant and lactating women. Most included morethanonespecificSBCCactivityandmanyutilizedmore than one approach.
ThereviewconductedbyOtaetal.(2012)includedseveralstudiesinvolvinginterpersonalcommunication(IPC)ap-proaches–specificallyindividualcounselingandgroupeduca-tion for the promotion of women’s energy and protein intake.
Amongthenineotherstudiesreportingstatisticallysignifi-cant results, all included IPC approaches, seven included some form of media, and two included community/social mobilization.One-on-onecounseling(inthehome)wasthe
13 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
Table 3.1.3: Number of studies reviewed (with number of studies reporting statistically significant results in parentheses), by SBCC approach, practice, and study design
SBCC ap-proach
Increased energy and protein intake during pregnancy and lacta-
tion
Enhanced quality of diet during pregnancy and
lactation
Micronutrient sup-plementation or
fortification
Increased rest and decreased work
during pregnancy
Interpersonal Communication
5, 3 reporting statistical significance:
1 Review with meta-analysis
(intake of protein)
2 Repeated cross-sectional
(1 intake of protein & energy; 1 food intake)
6, 4 reporting statistical significance:
1 RCT
(intake of iron-fortified soy sauce)
3 Repeated cross-sectional
(1 intake of green leafy vegetables; 1 intake of animal products; 1 purchase of iron-
fortified soy sauce)
6, 3 reporting statistical significance:
2 RCTs
(2 iron supplementation - 1 compliance, 1 likelihood of
consumption)
1 Repeated cross-sectional
(intake of ≥100 IFA tablets)
2, 1 reporting statistical significance:
1 Cross-sectional
(workload)
Media 1, 1 reporting statistical significance:
1 Repeated cross-sectional
(food intake )
3, 3 reporting statistical significance:
1 RCT
(intake of iron-fortified soy sauce)
2 Repeated cross-sectional
(1 intake of animal products ; 1 purchase of iron-fortified soy
sauce)
2, 2 reporting statistical significance:
2 RCTs
(iron supplementation compliance; likelihood of
taking iron tablets)
1, 1 reporting statistical significance:
1 Cross-sectional (workload)
Community/ Social Mobilization
1, 1 reporting statistical significance:
1 Repeated cross-sectional
(food intake )
1, 1 reporting statistical significance:
1 Repeated cross-sectional
(purchase of iron-fortified soy sauce)
1, none reporting statistical significance
No studies
most commonly used IPC approach, and small media (such asposters,flyers,stickers)wasthemostcommonlyusedmedia approach. See Table 3.1.2.
The breadth of evidence regarding the effectiveness of SBCC in changing dietary practices during pregnancy and lactation varies greatly by type approach. Table 3.1.3 pro-videsasummaryof thesefindings.
Interpersonal communication
There is some evidence of the effectiveness of IPC approach-es in increasing protein/energy intake, enhancing the quality of diet, and increasing intake of micronutrient supplements.
Themeta-analysisconductedbyOtaetal.(2012)foundastatisticallysignificantincreaseinwomen’sproteinintake
as a result of individual counseling and group education (pooledmeandifferenceof 6.99gperday),butnoincreasein energy intake.
In addition to the meta-analysis, two other studies reported significantoutcomesrelatedtotheeffectof IPCapproachesonprotein/energyconsumption,fourreportedsignificantoutcomes related to enhanced quality of diet, three report significantoutcomeswithrespecttoironintake,andonereportedasignificanteffectonworkloadduringpregnancy.
Among these studies, two reported on the effectiveness of IPC, even after controlling for other SBCC approaches. In a repeatedcross-sectionalstudy,Baquietal.(2008b)docu-mented an increase from 5% to 21.3% in the percentage of women consuming <100 IFA tables as a result of an IPC
14 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
intervention,whileGargandKashyap(2006)reportedanincrease from 13.9g to 49.3g in the daily intake of green leafy vegetables as a result of an IPC intervention.
We found no evidence to support the effectiveness of IPC approaches on the intake of other micronutrients during pregnancy and lactation, or related to decreasing work load or increasing rest during pregnancy.
Media
Weidentifiedsixprimaryresearchstudiesthatreportedpositive outcomes associated with interventions that in-cluded media-based SBCC approaches. One study reported positive outcomes related to protein/energy consump-tion, three reported positive outcomes related to enhanced quality of diet, two reported positive outcomes related to iron intake, and one reported a positive effect on workload during pregnancy.
None of these media-based interventions was delivered in isolation. All included some form of IPC, one included both IPC and community/social mobilization approaches, and the independent effect of media-based approaches was notassessed.Itisthereforedifficulttoderiveconclusionsregarding the independent, net effective of these media-basedapproaches.Weidentifiednoevidencerelatedtointake of micronutrients other than iron.
Community/social mobilization
Weidentifiedtwoprimaryresearchstudieslookingattheeffect of community/social mobilization approaches on the uptake of optimal dietary practices during pregnancy and lactation. Both studies, however, included IPC and media ap-proaches in addition to community/social mobilization, and the independent effect of community/social mobilization approaches on maternal dietary practices was not assessed.
Multiple SBCC approaches
Weidentifiednineprimaryresearchstudiesthatassessedthe effectiveness of multiple SBCC approaches to improve maternal dietary practices, and seven of the nine reported statisticallysignificantresults.Guyonetal.(2009)reporteda difference of 12 percentage points between intervention andcontrolcommunities,whileNdiayeetal.(2009)re-ported a difference of 21 percentage points in the intake of animalproducts.Sunetal.(2007)reportedadifferenceof
21-26percentagepointsinintakeof ironfortifiedsoysaucebetween intervention and control communities in rural and urbanareas,andAdhikarietal.(2009)andRisonaretal.(2008),bothRCTs,reporteddifferencesinmicronutrientintake of 15 and 22 percentage points respectively. Finally, Omeretal.(2008)reportedapositive,statisticallysignifi-cant effect with respect to reduction in workload during pregnancy(OR=1.48);however,nobaselinedatawerecol-lected,makingattributiontotheinterventiondifficult.
Justonestudy,Adhikarietal.(2009),comparedtheef-fect of more than one SBCC approach to a single SBCC approach. The authors found higher compliance rates with iron supplementation recommendations in an intervention that combined education with pill counting (88% compli-ance)comparedwithaninterventionthatincludedpillcountingalone(73%compliance).Ironsupplementationcompliance was not reported for the control group.
Implementation processes followed
Noneof thestudiesreviewedinthischapterspecificallyassessed the effect of implementation processes (e.g. inten-sity and timing of communications; type and training of personcommunicatingmessages,ortargetaudience)ontheeffectiveness of the SBCC approach on women’s dietary practices during pregnancy or lactation, nor did they con-sistently report all aspects of the implementation processes.
The intensity of communications ranged between one and four visits/sessions or weekly to monthly visits/sessions for various lengths of time. None of the studies com-pared the effect of timing or frequency.
In terms of target audiences, the studies reviewed primarily targeted the potential or actual breastfeeding woman. The literaturereviewbyOtaetal.(2012)conductedameta-analysis of studies of interventions targeting the woman alone, and among nine primary research studies reporting atleastonestatisticallysignificantdifference,eighttargetedthewomanherself,threetargeteddirectinfluencers,fourtargeted local community actors, and two targeted actors of the enabling environment. Six targeted more than one targetaudienceorbehavioralinfluencer,butnonecom-pared the effect of targeting one vs. multiple audiences or of targeting different audiences.
15 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
E. Conclusions
The body of literature on the effectiveness of SBCC to improve women’s dietary practices during pregnancy and lactation is small, but indicates that SBCC approaches can and do succeed in improving uptake of those practic-es.Whiletheliteraturemayreflectabiastopublishpositiveresults, it also underscores the important role of SBCC approaches to improve nutrition practices – practices which have been shown to have an impact on nutritional status of women, infants, and children.
What stands out from this review is the lack of evidence (orattention)thathasbeengiventoimprovingwomen’sdi-etary practices during pregnancy and lactation. The greatest gap was in evidence of effectiveness of SBCC approaches in improving rest and workload during pregnancy.
In addition, there is considerable variation in the descrip-tion of SBCC interventions, interactions or combinations with other interventions, target groups, content, messages, scale and coverage, length and intensity, as well as context.
There is also variation in how nutrition practices are definedandmeasured.Of thefivestudiesthatdiscussedenergy and protein intake during pregnancy and lactation, four different indicators were measured and no one indica-tor was measured more than twice. Of the six studies that looked at the quality of diet during pregnancy and lacta-tion,fourreportedstatisticallysignificantresultsrelatedtodistinct indicators. Each of the three studies reporting on micronutrientsupplementationorfortificationmeasuredaslightly different indicator. This underscores the impor-tance of developing indicators related to women’s dietary practices during pregnancy and lactation that are globally recognized, accepted, and used by the research and program communities alike.
The SBCC approach most used, and the only one used without other communication interventions, was IPC. While media and community/social mobilization were used, they were always used with at least one other communica-tion approach. Evidence suggests that using multiple SBCC approaches and channels to change behaviors is more effective than using one, but this is not tested in the literature. It is difficult and expensive to disag-gregate the contribution of single channels within a multi-channel intervention, and an important question
for SBCC practitioners and researchers is whether that line of research is useful.
All but one of the studies reviewed targeted the pregnant or lactating woman herself. More than half targeted other audiencesorinfluencersaswell.
The majority of the studies were implemented on a relatively smallscale(e.g.,inonehospitalorcommunity)andtypicallywith between 50 and 350 people per group. The small scale of research on this topic constrains the generalizability of findings and raises important questions about the scalability and sustainability of approaches used.
Differences in local context (including social norms, cul-ture,andenvironmentalfactors)aswellasdifferencesinthe implementation and scale of implementation affect the success of interventions. This underscores the importance of proper context assessments, formative research and/or ethnographic study prior to SBCC implementation.
Because of the relatively limited body of evidence on this topic and due to the lack of standardization in the way research related to SBCC is designed and described, it is chal-lenging to make conclusions beyond the fact that projects with SBCC result in uptake of promoted practices. While there is much to be learned from this body of literature to aid us in developing future programs, there are also many questions generated from reviewing this literature that can and hopefully will guide future evaluations and operations research. These include questions related to:
n globally recognized indicators related to women’s dietary practices during pregnancy and lactation;
n the generalizability of research in this area;n thepositive(ornegative)effectof usingmultipleSBCC
approaches compared with focusing on only one;n thepositive(ornegative)effectof targetingmultiple
audiencesorinfluencersof thebehaviorsbeingpromoted, rather than focusing on just one target population;
n the role of context, in other words, the effect of the same SBCC intervention implemented in different contexts;
n the effectiveness of different approaches (including intensityandtargeting)fordifferentbehaviors;
n the cost and cost effectiveness of various SBCC approaches(particularlyasitrelatestoscalability);and
n the effectiveness and sustainability of these approaches when implemented at scale.
16 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
Tabl
e 3.
1.4:
Stu
dies
rep
ortin
g on
mat
erna
l die
tary
pra
ctic
es d
urin
g pr
egna
ncy
and
lact
atio
n C
olor
cod
ing
key
Incr
ease
d en
ergy
and
pro
tein
inta
ke d
urin
g pr
egna
ncy
and
lact
atio
n In
take
of m
icro
nutr
ient
and
iron
sup
plem
ents
Enha
nced
qua
lity
of d
iet
duri
ng p
regn
ancy
and
lact
atio
nR
est
and
wor
k du
ring
pre
gnan
cy
ST
UD
YA
PP
RO
AC
HE
S
US
ED
SC
AL
E /
SC
OP
EE
VA
LU
AT
ION
DE
SIG
NO
UT
CO
ME
(S)
ME
AS
UR
ED
RE
SU
LTS
7P
-VA
LU
Es
/ CIs
8
Adh
ikar
i et
al (
2009
); N
epal
Cou
nsel
ing
in fa
cilit
ies
by p
rovi
ders
; Sm
all
med
ia
1 ho
spita
lR
CT
– p
regn
ant
wom
en r
ecei
ving
pr
enat
al c
are:
71
in e
duca
tion
grou
p, 7
0 in
pill
cou
nt g
roup
, 73
educ
atio
n +
pill
cou
nt g
roup
, 70
in
cont
rol g
roup
Iron
sup
plem
enta
tion
com
plia
nce
Educ
atio
n +
Pill
cou
nt
vs. P
ill c
ount
alo
ne: 8
8%
vs. 7
3%
p <
0.0
01
Ahr
ari e
t al
. (20
06);
Egyp
tG
roup
edu
catio
n in
fa
cilit
ies
by p
rovi
ders
; Su
ppor
t gr
oup
in
faci
litie
s by
pro
vide
rs
and/
or la
y vo
lunt
eers
; C
ouns
elin
g in
hom
es
by la
y vo
lunt
eers
2 la
rge
com
mun
ities
R
epea
ted
cros
s-se
ctio
nal –
519
w
omen
(34
4 in
terv
entio
n, 1
75
cont
rol)
% o
f wom
en w
ho r
epor
ted
cons
umpt
ion
of m
ore
food
du
ring
pre
gnan
cy
54.9
% v
s. 10
.6%
Not
cle
ar in
ar
ticle
% o
f wom
en w
ho r
epor
ted
cons
umpt
ion
of m
ore
mea
t du
ring
pre
gnan
cy
% o
f wom
en w
ho r
epor
ted
cons
umpt
ion
of m
ore
vege
tabl
es d
urin
g pr
egna
ncy
57.1
% v
s. 4.
2%
66.9
% v
s. 5.
3%
Not
cle
ar in
ar
ticle
% o
f pre
gnan
t w
omen
who
re
port
ed t
akin
g IF
A
% o
f pre
gnan
t w
omen
who
re
port
ed t
akin
g 7
or m
ore
IFA
tab
lets
per
wee
k
97.5
% v
s. 80
.6%
86.2
% v
s. 0.
0%
NS9
NS
% o
f wom
en w
ho r
epor
ted
an in
crea
se in
day
time
rest
du
ring
pre
gnan
cy
64.1
% v
s. 11
.7%
Not
cle
ar in
ar
ticle
Akt
er e
t al
. (20
12);
Bang
lade
shC
ouns
elin
g in
faci
litie
s by
pro
vide
rs; G
roup
ed
ucat
ion
in fa
cilit
ies
by p
rovi
ders
1 ho
spita
l Lo
ngitu
dina
l – 1
15 w
omen
(57
in
terv
entio
n, 5
8 co
ntro
l)%
of p
regn
ant
wom
en w
ho
incr
ease
d fr
eque
ncy
of m
eals
fr
om t
hree
to
five
times
a d
ay
34%
mor
e N
ot r
epor
ted
7 C
ompa
rison
is in
terv
entio
n vs
. con
trol g
roup
, unl
ess i
ndic
ated
oth
erw
ise.
8Differencesreportedasnotsignificantlydifferentatthe0.05levelareindicatedby“NS”.Differencesforwhichstatisticalsignificancewasnotreportedareindicatedby“--“.
9NS=notsignificanteitheraccordingtowhatisreportedintheoriginalarticleorp<0.05.
17 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ST
UD
YA
PP
RO
AC
HE
S
US
ED
SC
AL
E /
SC
OP
EE
VA
LU
AT
ION
DE
SIG
NO
UT
CO
ME
(S)
ME
AS
UR
ED
RE
SU
LTS
7P
-VA
LU
Es
/ CIs
8
Baqu
i et
al. (
2008
b);
Indi
aC
ouns
elin
g in
hom
es
by la
y vo
lunt
eers
; C
ouns
elin
g in
hom
es
by p
rovi
ders
2 di
stri
cts
Rep
eate
d cr
oss-
sect
iona
l –
base
line:
14,
952
rece
ntly
del
iver
ed
wom
en (
8,75
6 in
terv
entio
n,
6,19
6 co
ntro
l); e
ndlin
e: 1
3,82
6 re
cent
ly d
eliv
ered
wom
en (
7,81
2
inte
rven
tion,
6,0
14 c
ontr
ol)
endl
ine
vs. b
asel
ine
% o
f w
omen
who
con
sum
ed
equa
l to
or m
ore
than
100
IFA
tabl
ets d
urin
g pr
egna
ncy
Inte
rven
tion
grou
p: 2
1.3%
vs. 5
%
Con
trol g
roup
: 8.3
% v
s.
6.7%
p<
0.00
110
Bort
olin
i and
Vito
lo
(201
2); B
razi
lC
ouns
elin
g in
hom
es
by p
rovi
ders
1 ho
spita
lR
CT
– 3
97 (
163
inte
rven
tion,
234
co
ntro
l)%
of w
omen
who
use
fo
rtifi
ed fl
our
% o
f wom
en w
ho c
onsu
me
diet
ary
iron
tha
t is
hig
hly
bioa
vaila
ble
% o
f wom
en w
ith d
aily
iron
in
take
≥ 3
mg/
day
Base
d on
a 2
4 ho
ur d
ieta
ry
reca
ll am
ong
child
ren
12-1
6 m
onth
s ol
d, m
ean
inta
ke o
f…
- m
eat
(g)
- ir
on (
mg)
- he
me
iron
(m
g)
45.2
% v
s. 44
.2%
18.1
% v
s. 9.
8%
83.2
% v
s. 82
.8%
54.3
vs.
47.3
5.1
vs. 5
.4
1.5
vs. 1
.2
NS
NS
NS
p=0.
024
NS
p=0.
003
Cas
ey e
t al
. (20
10);
Vie
tnam
Mob
iliza
tion
of is
sue
grou
ps; C
ouns
elin
g in
ho
mes
by
peer
s
2 di
stri
cts
Rep
eate
d cr
oss-
sect
iona
l –
base
line
(Nov
200
5): 3
89 w
omen
of
rep
rodu
ctiv
e ag
e (W
RA
); 1st
fo
llow
-up
(July
200
6): 2
53 W
RA
; 2nd
fo
llow
-up
(Sep
t 20
07):
276
WR
A;
3rd fo
llow
-up
(Apr
200
9): 3
22 W
RA
3rd f
ollo
w-u
p vs
. 2nd
fo
llow
-up
vs. 1
st fo
llow
-up
% o
f wom
en w
ho t
ook
at
leas
t 75
% o
f tab
lets
rec
eive
d du
ring
pre
gnan
cy
87%
vs.
90%
vs.
51%
95
% C
Is: (
80%
-
93%
) vs
. (8
4% -
95%
) vs
. (37
% v
s. 65
%)
Gar
g an
d K
ashy
ap
(200
6); I
ndia
Cou
nsel
ing
in
faci
litie
s by
pro
vide
rs;
Gro
up e
duca
tion
in c
omm
uniti
es b
y pr
ovid
ers;
Cou
nsel
ing
in h
omes
by
prov
ider
s
1 vi
llage
Rep
eate
d cr
oss-
sect
iona
l – 1
00
wom
en (
50 in
terv
entio
n, 5
0
cont
rol)
Ener
gy (
kcal
) in
take
dur
ing
preg
nanc
y
Prot
ein
(g)
inta
ke d
urin
g pr
egna
ncy
1521
.23
vs. 8
35.1
4
48.0
5 vs
. 25.
00
p<0.
001
p<0.
001
Mea
n da
ily in
take
of g
reen
le
afy
vege
tabl
es (
g) d
urin
g pr
egna
ncy
49.3
vs.
13.9
p<0.
001
10
P-v
alue
for d
iffer
ence
-in-d
iffer
ence
test
adj
uste
d fo
r age
, edu
catio
n, p
arity
, rel
igio
n an
d st
anda
rd-o
f-liv
ing
scor
e.
18 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ST
UD
YA
PP
RO
AC
HE
S
US
ED
SC
AL
E /
SC
OP
EE
VA
LU
AT
ION
DE
SIG
NO
UT
CO
ME
(S)
ME
AS
UR
ED
RE
SU
LTS
7P
-VA
LU
Es
/ CIs
8
Guy
on e
t al
. (20
09);
Mad
agas
car
Mob
iliza
tion
of is
sue
grou
ps; M
obili
zatio
n of
cam
paig
ns, e
vent
s, or
spe
cial
day
s; M
ass
med
ia
2 hi
ghla
nd
prov
ince
s; ta
rget
ed
popu
latio
n va
ried
th
roug
hout
pro
ject
fr
om 1
.4 m
illio
n in
6 d
istr
icts
to
6 m
illio
n in
23
dist
rict
s
Rep
eate
d cr
oss-
sect
iona
l –
base
line
(200
0): 1
,200
chi
ldre
n un
der
two
year
s ol
d; e
ndlin
e (2
005)
: 1,7
60 c
hild
ren
unde
r tw
o ye
ars
old
endl
ine
vs. b
asel
ine
% o
f mot
hers
of i
nfan
ts <
6
mon
ths
who
rep
orte
d in
crea
sed
food
inta
ke d
urin
g pr
egna
ncy
% o
f mot
hers
of i
nfan
ts <
6
mon
ths
who
rep
orte
d in
crea
sed
food
inta
ke d
urin
g la
ctat
ion
55%
vs.
51%
74
% v
s. 62
%
NS
p<0.
001
Ndi
aye
et a
l. (2
009)
; Se
nega
lM
id-s
ized
med
ia;
Cou
nsel
ing
in
hom
es b
y pe
ers;
Gro
up e
duca
tion
in
com
mun
ities
by
lay
volu
ntee
rs
2 co
mm
uniti
es
Rep
eate
d cr
oss-
sect
iona
l –
base
line:
171
pre
gnan
t w
omen
(89
in
terv
entio
n, 8
2 co
ntro
l); e
ndlin
e:
200
(100
inte
rven
tion,
100
con
trol
)
endl
ine
vs. b
asel
ine
% o
f pre
gnan
t w
omen
who
re
port
ed e
atin
g m
eat
or fi
sh
at le
ast
once
a w
eek
Inte
rven
tion:
70
.7%
vs.
49.4
%
Con
trol
: 32
.0%
vs.
41.5
%
p ≤
0.00
3
p ≤
0.01
9 (d
iffer
ence
-in
- di
ffere
nces
: p=
0.00
01)
Om
er e
t al
. (20
08);
Paki
stan
Trad
ition
al m
edia
; C
ouns
elin
g in
hom
es
by p
eers
10 c
omm
uniti
es
from
thr
ee d
istr
icts
(5
inte
rven
tion
and
5 co
ntro
l)
Cro
ss-s
ectio
nal s
tudy
– 1
,070
w
omen
wer
e pr
egna
nt o
r ha
d de
liver
ed d
urin
g th
e pr
eced
ing
thre
e ye
ars
(529
inte
rven
tion,
541
co
ntro
l; 31
0 w
omen
adv
ised
by
an L
HW
, 79
9 w
omen
adv
ised
by
othe
rs o
r no
-one
)
Wom
en in
inte
rven
tion
grou
p ad
vise
d by
LH
W
vs. w
omen
adv
ised
by
othe
rs o
r no
one
11
% o
f wom
en w
ho r
epor
ted
a re
duct
ion
in r
outin
e he
avy
wor
k du
ring
pre
gnan
cy
77.1
% v
s. 58
.9%
OR
= 1
.48
(95%
CI:
1.01
–2.1
6)
Ota
et
al. (
2012
); va
riou
sIn
divi
dual
cou
nsel
ing;
Gro
up e
duca
tion
Vari
edLi
tera
ture
rev
iew
– 1
5 R
CT
s re
view
ed, f
our
rela
ted
to d
ieta
ry
advi
ce t
o in
crea
se e
nerg
y an
d pr
otei
n in
take
Prot
ein
inta
ke (
g/da
y) d
urin
g pr
egna
ncy
Ener
gy in
take
dur
ing
preg
nanc
y
Pool
ed m
ean
diffe
renc
es:
6.99
g/da
y
105.
61 k
cal/d
ay
p =
0.0
0057
NS
Ris
onar
et
al. (
2008
); Ph
ilipp
ines
Cou
nsel
ing
in
com
mun
ities
by
lay
volu
ntee
rs; S
mal
l m
edia
; Cou
nsel
ing
in h
omes
by
lay
volu
ntee
rs
6 m
unic
ipal
ities
/ vi
llage
s fr
om t
wo
prov
ince
s
RC
T –
1,1
80 p
regn
ant
wom
en
(596
inte
rven
tion,
584
con
trol
) Li
kelih
ood
of t
akin
g Fe
tab
lets
in
the
inte
rven
tion
area
s
- ba
selin
e
- en
dlin
e
OR
=3.
79
8.5%
vs.
74.3
%
79.2
% v
s. 57
.4%
p=0.
001
(95%
CI:
2.22
-6.
49)
NS
p<0.
001
11Notethattherewerenosignificantsocio-demographicdifferencesbetweeninterventionandcontrolcommunities.
19 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ST
UD
YA
PP
RO
AC
HE
S
US
ED
SC
AL
E /
SC
OP
EE
VA
LU
AT
ION
DE
SIG
NO
UT
CO
ME
(S)
ME
AS
UR
ED
RE
SU
LTS
7P
-VA
LU
Es
/ CIs
8
Sena
naya
ke e
t al
. (2
010)
; Sri
Lan
kaG
roup
edu
catio
n in
fa
cilit
ies
by p
rovi
ders
1 ho
spita
lR
epea
ted
cros
s-se
ctio
nal –
218
w
omen
bet
wee
n 16
-20
wee
ks o
f ge
stat
ion
(107
inte
rven
tion,
111
co
ntro
l)
% o
f pre
gnan
t w
omen
who
to
ok ir
on t
able
ts c
orre
ctly
at
34 w
eeks
ges
tatio
n
86.9
% v
s. 32
.4%
Not
rep
orte
d
Sun
et a
l. (2
007)
; C
hina
Mas
s m
edia
; Mid
-siz
ed
med
ia; S
mal
l med
ia;
Gro
up e
duca
tion
in
com
mun
ities
2 ur
ban
dist
rict
s an
d 2
rura
l vill
ages
R
CT
– 3
73 w
omen
19
to 7
0 ye
ars
old
(113
rur
al in
terv
entio
n, 8
0 ru
ral c
ontr
ol, 9
7urb
an in
terv
entio
n,
83 u
rban
con
trol
)
% o
f wom
en w
ho r
epor
ted
buyi
ng F
eSS
- R
ural
are
as
- U
rban
are
as
% o
f wom
en w
ho b
ough
t Fe
SS w
ho r
epor
ted
eatin
g Fe
SS - R
ural
are
as
- U
rban
are
as
53.6
% v
s. 19
%
43.3
% v
s. 11
%
85.7
% v
s. 65
%
49.5
% v
s. 11
.0%
p<0.
001
p<0.
001
p<0.
001
p<0.
001
Wan
g et
al.
(200
9);
Chi
naC
omm
unity
/soc
ial
mob
iliza
tion;
Sm
all
med
ia; G
roup
ed
ucat
ion
in
com
mun
ities
; Soc
ial
med
ia m
arke
ting;
Mee
tings
tar
getin
g po
licy
mak
ers
and
regu
lato
rs
3 co
untie
s (o
ne
urba
n an
d tw
o ru
ral)
Rep
eate
d cr
oss-
sect
iona
l –
base
line:
801
adu
lt no
n-pr
egna
nt
wom
en o
lder
tha
n 20
yea
rs o
f age
; en
dlin
e: 7
16; s
urve
y 3:
787
endl
ine
vs. b
asel
ine
% o
f wom
en w
ho h
ave
ever
pu
rcha
sed
(FeS
S)36
.6%
vs.
8.9%
p<
0.00
1
20 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ACC/SCN. 2001. What Works? A Review of the Efficacy and Effectiveness of Nutrition Interventions, Allen LH and Gillespie SR. ACC/SCN: Geneva in collaboration with the Asian Development Bank, Manila.
Adhikari, Kamala, Tippawan Liabsuetrakul, and Neelam Pradhan. 2009. “Effect of Education and Pill Count on Hemoglobin StatusDuringPrenatalCareinNepaleseWomen:aRandomizedControlledTrial.”The Journal of Obstetrics and Gynaecology Research35(3)(June):459–466.
Ahrari, Mahshid, Robert F Houser, Siham Yassin, Mona Mogheez, Y Hussaini, Patrick Crump, Gary L Darmstadt, David Marsh, and F James Levinson. 2006. “A Positive Deviance-based Antenatal Nutrition Project Improves Birth-weight in Upper Egypt.”Journal of Health, Population, and Nutrition24(4)(December):498–507.
Akter, S.M., S.K. Roy, S.K. Thakur, M. Sultana, W. Khatun, R. Rahman, S.S. Saliheen, and N. Alam. 2012. “Effects of Third Trimester Counselling on Pregnancy Weight Gain, Birthweight, and Breastfeeding Among Urban Poor Women in Bangla-desh.”Food & Nutrition Bulletin33(3)(September):194–201.
Alderman, H, and JR Behrman. 2006. “Reducing the Incidence of Low Birth Weight in Low-Income Countries Has Substantial EconomicBenefits.”The World Bank Research Observer21(1):25–48.
Allen,LindsayH.2005.“MultipleMicronutrientsinPregnancyandLactation:AnOverview.”The American Journal of Clinical Nutrition81(5)(May):1206S–1212S.
Baqui, Abdullahh, Emma K Williams, Amanda M Rosecrans, Praween K Agrawal, Saifuddin Ahmed, Gary L Darmstadt, Vish-wajeet Kumar, Usha Kiran, Dharmendra Panwar, Ramesh C Ahuja, Vinod K Srivastava, Robert E Black, and Manthuram Santoshama. 2008. “Impact of an Integrated Nutrition and Health Programme on Neonatal Mortality in Rural Northern India.”Bulletin of the World Health Organization86(10)(October):796–804.
Bhutta,ZulfiqarA,JaiKDas,ArjumandRizvi,MichelleFGaffey,Neff Walker,SusanHorton,PatrickWebb,AnnaLartey,andRobert E Black. 2013. “Evidence-based Interventions for Improvement of Maternal and Child Nutrition: What Can Be DoneandatWhatCost?”The Lancet382(9890)(August):452–477.
Black,RobertE,CesarGVictora,SusanPWalker,ZulfiqarABhutta,ParulChristian,MercedesdeOnis,MajidEzzati,SallyGrantham-McGregor, Joanne Katz, Reynaldo Martorell, Ricardo Uauy, and the Maternal and Child Nutrition Study Group.2013.“MaternalandChildUndernutritionandOverweightinLow-incomeandMiddle-incomeCountries.”The Lancet382(9890)(August):427–451.
Bortolini, Gisele Ane, and Márcia Regina Vitolo. 2012. “The Impact of Systematic Dietary Counselling During the First Year of LifeonPrevalenceRatesof AnemiaandIronDeficiencyat12-16Months.”Jornal de Pediatria88(1)(February):33–39.
Casey, Gerard J, Damien Jolley, Tran Q Phuc, Ta T Tinh, Dang H Tho, Antonio Montresor, and Beverley-Ann Biggs. 2010. “Long-term Weekly Iron-folic Acid and De-worming Is Associated with Stabilised Haemoglobin and Increasing Iron StoresinNon-pregnantWomeninVietnam.”PloS One5(12):e15691.
Cochrane Database of Systematic Reviews.
De-Regil,LuzMaria,ParminderSSuchdev,GunnEVist,SilkeWalleser,andJuanPabloPeña-Rosas.2011.“HomeFortificationof FoodswithMultipleMicronutrientPowdersforHealthandNutritioninChildrenUnderTwoYearsof Age.”Cochrane Database of Systematic Reviews 2011, edited by The Cochrane Collaboration and Luz Maria De-Regil. Chichester, United Kingdom: John Wiley & Sons, Ltd.
F. Works Cited and Literature Reviewed
21 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
Dewey, K G, R J Cohen, K H Brown, and L L Rivera. 2001. “Effects of Exclusive Breastfeeding for Four Versus Six Months on MaternalNutritionalStatusandInfantMotorDevelopment:Resultsof TwoRandomizedTrialsinHonduras.”The Journal of Nutrition131(2)(February):262–267.
Garg,Aashima,andSushmaKashyap.2006.“Effectof CounsellingonNutritionalStatusDuringPregnancy.”Indian Journal of Pediatrics73(8)(August):687–692.
Guyon, Agnès B, Victoria J Quinn, Michael Hainsworth, Priscilla Ravonimanantsoa, Voahirana Ravelojoana, Zo Rambeloson, and Luann Martin. 2009. “Implementing an Integrated Nutrition Package at Large Scale in Madagascar: The Essential NutritionActionsFramework.”Food and Nutrition Bulletin30(3)(September):233–244.
Haider,BA,andZABhutta.2012.“Multiple-MicronutrientSupplementationforWomenDuringPregnancy.”
Haileslassie, Kiday, Afework Mulugeta, and Meron Girma. 2013. “Feeding Practices, Nutritional Status and Associated Factors of LactatingWomeninSamreWoreda,SouthEasternZoneof Tigray,Ethiopia.”Nutrition Journal12(1):28
Katz, Joanne, Anne CC Lee, Naoko Kozuki, Joy E Lawn, Simon Cousens, Hannah Blencowe, Majid Ezzati, et al. 2013. “Mor-tality Risk in Preterm and Small-for-Gestational-Age Infants in Low-Income and Middle-Income Countries: A Pooled CountryAnalysis.”The Lancet382(9890):417–25.
Mason, John B, Lisa S Saldanha, and Reynaldo Martorell. 2012. “The Importance of Maternal Undernutrition for Maternal, Neonatal,andChildHealthOutcomes:AnEditorial.”Food and Nutrition Bulletin33(2Suppl)(June):S3–5.
McNulty J. and CORE Group. Positive Deviance / Hearth Essential Elements: A Resource Guide for Sustainably Rehabilitating Malnourished Children (Addendum), Washington, D.C.: CORE Group, 2005.
Ndiaye, Mamadou, Kendra Siekmans, Slim Haddad, and Olivier Receveur. 2009. “Impact of a Positive Deviance Approach to Improve the Effectiveness of an Iron-supplementation Program to Control Nutritional Anemia among Rural Senegalese PregnantWomen.”Food and Nutrition Bulletin30(2)(June):128–136.
Omer, Khalid, Sharmila Mhatre, Noor Ansari, Jorge Laucirica, and Neil Andersson. 2008. “Evidence-based Training of Front-line Health Workers for Door-to-door Health Promotion: a Pilot Randomized Controlled Cluster Trial with Lady Health WorkersinSindhProvince,Pakistan.”Patient Education and Counselling72(2)(August):178–185.
Ota, Erika, Ruoyan Tobe-Gai, Rintaro Mori, and Diane Farrar. Antenatal Dietary Advice and Supplementation to Increase En-ergy and Protein Intake. In Cochrane Database of Systematic Reviews 2012, edited by The Cochrane Collaboration and Erika Ota. Chichester, United Kingdom: John Wiley & Sons, Ltd.
Risonar, Maria Grace D, Pura Rayco-Solon, Lorena W Tengco, Jesus N Sarol, Lourdes S Paulino, and Florentino S Solon. 2008. “Effectiveness of a Redesigned Iron Supplementation Delivery System for Pregnant Women in Negros Occidental, Phil-ippines.”Public Health Nutrition12(07)(August27)
Senanayake, Hemantha M, Samanthi P Premaratne, Thilina Palihawadana, and Sumeda Wijeratne. 2010. “Simple Educational InterventionWillImprovetheEfficacyof RoutineAntenatalIronSupplementation.”The Journal of Obstetrics and Gynaecol-ogy Research36(3)(June):646–650.
Sun,Xinying,YanGuo,SisunWang,andJingSun.2007.“SocialMarketingImprovedtheConsumptionof Iron-fortifiedSoySauceAmongWomeninChina.”Journal of Nutrition Education and Behavior39(6)(December):302–310.
Wang, Bo, Siyan Zhan, Jing Sun, and Liming Lee. 2009. “Social Mobilization and Social Marketing to Promote NaFeEDTA-fortifiedSoyaSauceinanIron-deficientPopulationthroughaPublic-privatePartnership.”Public Health Nutrition12(10)(October):1751–1759.
22 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
3.2. Evidence of Effective SBCC Approaches to Promote Breastfeeding Practices
A. Background
Breastfeeding is widely recognized as one of the most cost-effective investments to improve child survival (UNICEF, 2013).AccordingtoTheLancetSeriesonMaternalandChild Under Nutrition, the adoption of exclusive breast-feeding through six months of age and continued breast-feeding through age two in 36 high burden countries could avert 11.6% of all deaths in children under the age of one, and nearly 10% of all deaths in children under the age of two(Bhuttaetal.,2008a).Thebenefitsof breastfeedingstretch beyond a child’s survival. Breastfed children do bet-ter on cognitive and motor development tests, and gener-ally achieve better academic outcomes than non-breastfed children(Hortaetal.,2013).
Additionally,breastfeedingimpartscriticalbenefitstothewoman. When practiced exclusively, breastfeeding is as-sociated with lactational amenorrhea, the natural postnatal infertility that occurs when a woman is amenorrheic (not menstruating).Thelactationalamenorrheamethod(LAM)is considered a modern method of contraception that prevents a second pregnancy within six months of giving birth, and helps to conserve maternal iron stores (Dewey etal.,2001).Increasedbirthspacingimprovesboththehealth of the woman and her infant’s chances of survival, while suboptimal pregnancy intervals are associated with an increased risk of adverse perinatal and infant/child out-comes including preterm birth, low birth weight, small for gestationalage(SGA),stunting,andunderweightinfants/children (Bhutta et al, 2013; Conde-Agudelo, 2006; Conde-Agudeloetal.,2012;Rutstein,2008).
TheWorldHealthOrganization(WHO)recommendsthree primary breastfeeding practices: initiation of breast-feeding within one hour after birth (also referred to as immediatebreastfeeding),exclusivebreastfeeding(EBF)through six months of age, and continued breastfeeding until24monthsof age(Dysonetal.,2005;WHO,2008).Evidence associated with the recommendation for imme-diate breastfeeding is limited and likely operates through theeffectof exclusivebreastfeeding(Bhuttaetal.,2013).The Lancet, therefore, includes only EBF and continued
breastfeeding in the modeling of optimal breastfeeding practices cited above.
Despite the promise of optimal breastfeeding practices, rates for the three WHO recommended breastfeeding practices remain low, and negligible progress has been made to increase these rates over the past two decades (UNICEF, 2013).Accordingtoananalysisof datafrom78lowandmiddle income countries, rates of immediate breastfeed-ing range from a mean of 36% in Eastern Europe to a mean of 58% in Latin America, and the rate of exclusive breastfeedinginchildrenonetofivemonthsof ageisjust30%(Blacketal,2013).AccordingtotheUNICEFglobaldatabase of national surveys from 2007-2011, the current rate of breastfeeding at one year is 76%, while the rate of breastfeeding at age two years is 58%.12
This chapter reviews the effectiveness of social and behav-iorchangecommunication(SBCC)approachesonimprov-ing breastfeeding practices.
B. Search Results
Sixty-two peer-reviewed studies met the literature review’s inclusion criteria.2 A complete list of the studies reviewed, includingasummaryof theSBCCapproach(es)utilized,thestudydesign,practicesmeasured,andlevelsof signifi-cance is presented in Table 3.2.4 at the end of this chapter.
Forty-eightreportedastatisticallysignificantchangeinatleast one of the priority breastfeeding practices. Each of those articles is described in greater detail below. Studies reportingastatisticallysignificantchangeinmorethanoneof the prioritized practices and/or utilizing more than one SBCC approach are cited and discussed multiple times. Where this occurs, we have provided a detailed description of thestudyinthefirstreference,andonlydiscussresultsin subsequent references.
Thefindingsareorganizedbypracticestargeted,SBCCapproach(es)utilized,andstudydesign.Thisorganizationenables the reader to derive an independent judgment re-gardingfindingsfromeachstudy.Inaddition,implementa-tion processes followed are also discussed.
12 See: http://www.childinfo.org/breastfeeding_status.html.13 See the introductory chapter of this literature review for a full description
of search procedures and inclusion/exclusion criteria.
23 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
Of the 62 studies reviewed for this chapter, six were literature reviews that included meta-analysis, 27 were randomizedcontrolledtrials(RCT),14werelongitudinalstudies, 13 were repeated cross-sectional studies, and two were cross-sectional studies. See Table 3.2.1.
The literature reviews were published between 2010 and 2012. Twenty-one of the 56 studies included in the previ-ously published reviews met the inclusion criteria for the present review, and these studies are included in the sum-maries below.
C. Overview of the Evidence, by Practice
This chapter is organized around the three WHO recom-mended breastfeeding practices: early initiation of breast-feeding, EBF through six months of age, and continued breastfeeding until 24 months of age. The feeding of colostrumisincludedintheearlyinitiationsection.Specificindicators used to measure these practices varied consider-ably among studies.
Of thestudiesreviewed,22reportedfindingsrelatedtoearly initiation of breastfeeding (including six which report-edonfeedingcolostrum),41reportedonfindingsrelatedtoEBF,and16reportedonfindingsrelatedtocontinuedbreastfeeding. See Table 3.2.1.
Early initiation of breastfeeding
Of the 22 studies that measured breastfeeding initiation, 17reportedstatisticallysignificantresults.Fifteenof thoselookedatearlyinitiationof breastfeeding(definedasinitiatingbreastfeedingwithinonehourof birth)andthree
reportedstatisticallysignificantresultsrelatedtothefeedingof colostrum to infants.
Literature reviews with meta-analysis
GogiaandSachdev(2010)conductedaliteraturereviewand meta-analysis to “determine whether home visits forneonatalcarebycommunityhealthworkers(CHW)canreduceinfantandneonataldeathsandstillbirths.”The review included four studies that assessed breast-feeding counseling provided during home visits.14 All of these studies have been included and are described in the present review. The authors found that women in the in-tervention group were more than three times more likely to initiate breastfeeding compared with women in control groups(pooledRR3.35).
Lassietal.(2010)conductedareviewof 18cluster-RCTs/quasi-RCTs of community-based interventions that in-volved training outreach workers in maternal care during pregnancy, delivery and in the postpartum period as well as newborn care. Six of the 18 studies assessed the impact of these interventions on initiation of breastfeeding within one hour after birth. The meta-analysis from these studies revealed that following community-based interventions, thepracticenearlydoubled(RelativeRisk(RR)=1.94).All but one of the six studies included in the meta-analysis matched the inclusion criteria for the present review. These studies are included in the summaries that follow.15
14 Theseinclude:Baquietal.(2008a);Baquietal.(2008b);Bhuttaetal.(2008b);andKumaretal.(2008).
15 Theseincludethetwoarmsof Baquietal.(2008a);Kumaretal.(2008);Manandharetal.(2004);Syedetal.(2006).
Table 3.2.1: Number of studies reviewed (with number of studies reporting statistically significant results in parentheses), by recommended practice and study design
Practice
Literature reviews
with meta-analysis
RCTLongitudinal
studies
Repeated cross-
sectional studies
Cross-sectional studies
Total
Early initiation of breastfeeding 2 (2) 8 (6) 2 (1) 10 (8) 0 22 (17)
Exclusive breastfeeding 4 (4) 20 (14) 12 (8) 7 (5) 2 (2) 41 (32)
Continued breastfeeding 2 (1) 7 (6) 3 (1) 4 (1) 0 16 (9)
*Notethatcolumnsdonotsumtothe“total”sincesomearticlesreportedonmultiplepractices.
24 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
Randomized controlled trials
Sixstudiesreportingstatisticallysignificantchangesinearlyinitiation of breastfeeding were RCTs. Two of these were included in the meta-analyses described above.16 Bang et al. (2005)lookedatearlyinitiationof breastfeedingasanout-come associated with delivery of a home-based neonatal care package in Gadchiroli District of India. The intervention in-cludedthetrainingof femalevillagehealthworkers(VHWs)andtraditionalbirthattendants(TBAs)toprovidehealtheducation to mothers and grandmothers about care of preg-nant women and of neonates through advice, demonstration, and assistance. Messaging addressed traditional beliefs and practicesaswellasbarrierstocareidentifiedduringthefirsttwo years of the program, and was delivered during group meetings conducted once every four months, during home visits in the eighth and ninth months of pregnancy, and on thefirstdayafterdelivery.Bytheendof theinterventionpe-riod, the percentage of women initiating breastfeeding within six hours of birth had increased from 47.5% to 89.7%. The authors did not report on the standard indicator of initiation of breastfeeding within one hour of birth.
Baquietal.(2008a)conductedalarge-scaleRCTinSylhetDistrict, Bangladesh. Twenty-four clusters, each with a population of approximately 20,000 people, were randomly assigned to one of three study groups – a community-care (CC)group,ahome-care(HC)group,oracontrolgroup.Inbothinterventiongroups(CCandHC),“maleandfemalecommunity mobilisers were recruited to hold group meet-ings for the dissemination of birth and newborn-care pre-parednessmessages…”Eachfemalecommunitymobilizerheld community meetings once every four months, while each male community mobilizer did so every 10 months. In theCCarm,femalevolunteersidentifiedpregnantwomenand encouraged them to attend community meetings organ-ized by the community mobilizers, receive routine antenatal care, and seek care for signs of serious illness in mothers or newborns. In the HC arm, CHWs “promoted birth and newborn care preparedness through two scheduled ante-natalandthreeearlypostnatalhomevisits.”Furthermore,female community mobilizers conducted group meetings with women in the HC group once every eight months. After nearly three years, breastfeeding initiation within one hour of birth was dramatically higher in both interven-
16 Theseinclude:Baquietal.(2008a)andKumaretal.(2008).
tion arms compared with the control group. While a total of71% of women in the CC group and 81% in the HC group reported initiating breastfeeding within one hour of birth, only 57% in the control group reported the same. Differences between both intervention groups and the controlgroupwerestatisticallysignificant.
Guldanetal.(2000)lookedatInfantandYoungChildFeeding(IYCF)practicesinruralSichuan,China.Thestudyincluded two intervention and two control groups. The intervention included counseling by CHWs during monthly growth monitoring and promotion sessions, and visits to the homes of pregnant women and women with children under the age of one. At the conclusion of the one year intervention, the percentage of women reporting feeding newborns colostrum was higher in the intervention group thaninthecontrolgroup(91%vs.80%).However,theauthors explained that complete randomization in group selection was not possible as the “[intervention] and control group townships could not be contiguous and needed to be roughlyequalgeographicallyandsocioeconomically”andthere were important differences between the women in the intervention and control groups in terms of mean years of educationandmainincomesource,makingitdifficultto draw conclusions about the effect of the intervention or thegeneralizabilityof thefindings.
Haideretal(2000)lookedatearlyinitiationandEBFinDha-ka, Bangladesh. The intervention included home-based peer counselingoveraperiodof fivemonths.Trainedcounselorsconductedatotalof 15homevisitsinthefivemonthstudyperiod:twointhelasttrimesterof pregnancy,fourinthefirstmonth postpartum, and every fortnight afterward until the completionof fivemonths.Attheconclusionof thestudyperiod, the percentage of women initiating breastfeeding withinthefirsthourafterbirthwas64%intheinterventiongroup, compared with 15% in the control group.
Kumaretal.(2008)conductedacluster-RCTlookingatearlyinitiation of breastfeeding in the context of a neonatal mor-tality intervention in Uttar Pradesh, India. The intervention included training CHWs to hold community meetings with folk songs and conduct home visits targeting community leaders,priests,teachers,birthattendants,unqualifiedmedicalcare providers, healthcare workers, fathers-in-law, husbands, mothers-in-law, pregnant women or mothers, neighbors, and relatives. After 16 months of implementation, the rate of
25 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
breastfeeding within one hour of birth was 70.6% among women in intervention areas compared with 15.5% among women in non-intervention areas.
Finally,Omeretal.(2008)conductedanRCTfocusedonreducingheavyworkload(suchaslifting)duringpregnancy,attending prenatal check-ups, and feeding colostrum to newborns in Sindh Province of Pakistan. The intervention trainedladyhealthworkers(LHW)topresentanddiscussan embroidered cloth panel portraying key messages dur-ing routine home visits with pregnant women. Following the interventions, the authors found that women advised by a LHW were more likely to feed their newborn colos-trum than those who were not advised by a LHW to do so (79.2%vs.65.3%).
Longitudinal studies
Akteretal.(2012)lookedatbreastfeedinginitiationinalongitudinal study conducted in one hospital in Bangladesh. The intervention involved four group counseling ses-sions during the last trimester of pregnancy. Following the intervention, 75.4% of women in the intervention group reported initiating breastfeeding within one hour of birth, compared with 34.4% of women in the control group.
Repeated cross-sectional studies
Eightof the15studiesreportingstatisticallysignificantresults were repeated cross-sectional studies. Baqui et al.(2008b)lookedattheimpactof aninterventionthatincluded counseling during home visits on preventive care practices for mothers, newborn care practices, and the use of health care services in India. In intervention areas, CHWs recruited additional community volunteers (“change agents”)toexpandthereachof theprogram.Followingintervention, the number of women initiating breastfeeding within one hour of birth increased by 31.2%.
Crookstonetal.(2007)lookedatbreastfeedingbehaviorsin rural Cambodia. The intervention “assess[ed] the impact of Buddhistnunsandwat(pagoda)granniesonoptimalbreastfeedingbehaviours.”Youngnunsweretrainedtopro-motebreastfeedingintheirvillagesusingleaflets,visualaidsand home visits. In addition, the nuns mobilized communi-ty groups, provided one-on-one counseling, and conducted educational sessions with groups of 6-10 women. After one year, women in the intervention group were 62% more
likely to initiate breastfeeding within one hour after birth than those in the control group.
Quinnetal.(2005)conductedarepeatedcross-sectionalstudy looking at timely initiation and EBF in three coun-tries: Madagascar, Bolivia, and Ghana. The interventions varied slightly by country, but all were implemented at scale as part of the USAID-funded Linkages project. In all three countries, “women were reached through small- and large-group activities, one-on-one counseling in homes and at local health posts, breastfeeding promo-tion songs performed by women’s groups and musical troupes, and community mobilization events such as local theater, health fairs, and festivals celebrating breastfeeding andchildhealthdays.”Massmediawasusedtocomple-ment this community-based work. After four years of implementation, rates of early initiation of breastfeeding increased from 34% to 78% in Madagascar, from 56% to 74% in Bolivia, and from 32% to 50% in Ghana. All changeswerestatisticallysignificant.
Guyonetal.(2009)reportedonthesameinterventioninMadagascarafterfiveyearsof implementation,findinganincrease from 33% to 68% in rates of early initiation of breastfeeding.NeitherQuinnetal.(2005)norGuyonetal.(2009)includedacontrolgroup.
Saowakonthaetal.(2000)lookedatthefeedingof colos-trum to newborns in three districts in northeastern Thai-land.Theinterventionincludedtraininghealthofficials,health care workers, and villagers, and disseminating mes-saging through broadcasting systems, events and exhibi-tions, and bulletin boards. By the end of the study period, the percentage of women reporting feeding colostrum to their newborns increased from 63.5% to 97.2%. There was no control group in this study.
Sunetal.(2011)lookedatinfantandyoungchildfeedingpractices as part of an intervention to promote consumption of YingYangBao(YYB),amultiplemicronutrientpow-der, in Shan’xi Province, China. The intervention included formative research and message testing as well as behavior changecommunication(BCC)targetinghealthworkersandfamily members. BCC materials included handbooks about IYCF for parents, booklets about YYB for health work-ers, and television spots for the public. After 20 months of project implementation, the percentage of women reporting
26 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
early initiation of breastfeeding had increased from 8.6% to 16.8%.17 There was no control group in this study.
Syedetal(2006)lookedattheprovisionof newborncarein10upazilas(sub-districts)inBangladesh.Theinterven-tion involved “increasing the coverage of health workers and community-based caregivers trained and competent in providing essential newborn care and promoting positive maternalandnewborn-carepractices.”Activitiestargetedpregnant mothers as well as family decision-makers, such as husbands, mothers-in-law, and village leaders. After less than two years of the intervention, the percentage of women initiating breastfeeding within one hour of birth had increased from 38.6% to 76.2%. Though this dif-ferencewasstatisticallysignificant,thelackof acontrolgroupmakesitdifficulttoconclusivelyattributethechange to the intervention.
Finally,ThompsonandHarutyunyan(2009)lookedatEBFthrough six months of age in Martuni region in northeastern Armenia. The intervention was delivered through a com-munity-based Integrated Management of Childhood Illness (IMCI)platform,andincludedhomevisitsforpregnantandlactating women, group education classes for new parents, and a local mass media campaign. By the end of the study period, the number of women initiating breastfeeding within one hour of birth was 16.2% greater among women exposed to the IMCI campaign compared with those who were not exposed(72.5%.and56.3%,respectively).
Exclusive breastfeeding
Of the 45 studies reporting on EBF practices, 33 reported statisticallysignificantresults.Fiveof thesestudiesreportedon duration of EBF, 14 reported on EBF for six months, fivereportedonEBFamongthoseundersixmonthsof age, 19 reported on EBF at other ages, and two reported on EBFatunspecifiedages.
Literature reviews with meta-analysis
Hall(2011)conductedameta-analysisof fourRCTsto“as-sess the effectiveness of community-based interventions to improve the rates of exclusive breastfeeding at four to six months in infants in low- and low-to-middle income coun-
17 Notethatthestudyauthorsdidnotdefineearlyinitiation;however,giventhat the authors used many globally recognized indicators, it is assumed thatthiswasdefinedtobewithinonehourof birth.
tries.”Community-basedinterventionsweredefinedasinter-ventions accessible locally to the woman (whether in her own homeoralocalbuildingsuchasaclinicorschool);deliveredby a health professional or trained lay person; and provided either individually or in a group. Interventions could be provided antenatally, postnatally or both, and participants were limited to women who were pregnant or currently breastfeeding an infant less than six months of age. The meta-analysisfoundasignificanteffectof community-basedinterventionsonratesof EBF(pooledOR=5.9).Threeof the four studies reviewed by Hall met the inclusion criteria of the present review and these studies are summarized below.18
Imdadetal.(2011)conductedameta-analysisof atotalof 53 RCTs and quasi-RCTs looking at the impact of educa-tion and support strategies on breastfeeding outcomes. Fourteen of those studies were conducted in developing countries.Theinterventionsweredefinedas“breastfeed-ing education and/or additional support given to mothers through counselors (be they doctors, nurses, midwives, lactationconsultantsorpeercounselors)inindividualorgroupsessions.”Theauthorsfoundasix-foldincreaseinrates of EBF at six months of age and an 89% increase in rates of EBF at 4-6 weeks of age following interventions in developing countries. In sub-group analyses, the au-thors found that changes in prenatal counseling, postnatal counseling and a combination of both were statistically significant,with“thehighestimpactbeingthatof prena-talcounselling.”Furthermore,“groupcounsellinghadagreaterimpact(67%increaseinEBFrateat4-6weeks),comparedwithindividualcounselling(38%increase).Theresultswerestatisticallysignificantatalllevelsof care(com-munity,facilityandbothcombined).”Fiveof thefourteenstudiesincludedintheImdadetal.(2011)reviewmettheinclusion criteria of the present review and these studies are included in the summaries below.19
Jollyetal.(2012)conductedasystematicliteraturereviewand meta-regression analysis of RCTs conducted in high-, middle- and low-income countries “to examine the effect of setting, intensity, and timing of peer support on breast-feedingpractices.”Thereviewincluded17RCTs;however,only six were conducted in low income countries. In a
18 TheseincludeBashouretal.(2008);Bhandarietal.(2003);andHaideretal.(2000).
19 TheseincludeAidametal.(2005);Aksuetal.(2011);Bhandarietal.(2003);Haideretal.(2000);andKrameretal.(2001).
27 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
sub-analysis of low income countries, those who received peersupportweresignificantlylesslikelytohavestoppedEBFatthelaststudyfollowup(RR=0.63).Fourof thesixlow-income country studies included in this meta-analysis met the inclusion criteria for the present review and are included in the summaries below.20
Finally,Renfrewetal.(2012)conductedaCochraneReviewlooking at the effect of extra support for women on EBF at sixmonthsof age.Extrasupportwasdefinedasreassurance,praise, information, and the opportunity to discuss questions with professionals, trained lay people or both during home visits or facility-based counseling sessions. This meta-analysis used data from 52 RCTs or quasi-RCTs, 16 of which were conducted in middle- to low-income countries. Extra support led to a lower risk of having stopped EBF at 4-6 weeks (aver-ageRR=0.74)aswellasalowerriskof havingstoppedEBFatsixmonths(averageRR=0.86).Inasub-groupanalysis,theauthors found a greater treatment effect on EBF cessation at six months “in settings where there were high background ratesof breastfeedinginitiation(averageRR=0.83)comparedwithareaswheretherewasintermediate(averageRR=0.89)orlowbackgroundinitiationrates(averageRR=1.00),[…]Re-sults were even more pronounced for cessation of exclusive breastfeeding at up to four to six weeks with interventions seeming to be most effective for women living in areas with highbackgroundinitiationrates(averageRR=0.61)comparedwithareaswithintermediate(averageRR=0.81)orlowrates(averageRR=0.97)”(Renfrewetal.,2012).Fourteenof the16 middle- to low-income studies included in Renfrew et al. (2012)mettheinclusioncriteriaforthepresentreviewandthese studies are included in the summaries below.21
Randomized controlled trials
Fifteenof the33studiesreportingstatisticallysignificantresults were RCTs. Thirteen of these were included in the meta-analyses described previously.22 Agrasada et
20 TheseincludeAgrasadaetal.(2005);Coutinhoetal.(2005);Leiteetal.(2005);andTylleskäretal.(2011).
21 TheseincludeAidametal.(2005);Aksuetal.(2011);Albernazetal.(2003);Bashouretal.(2008);Bhandarietal.(2003);Bhandarietal.(2005);Coutinhoetal.(2005);deOliveiraetal.(2006);Haideretal.(2000);Khreshehetal.(2011);Krameretal.(2001);Leiteetal.(2005);Santiagoetal.(2003);andTylleskäretal.(2011).
22 TheseincludeAgrasadaetal.(2005);Aidametal.(2005);Aksuetal.(2011);Bashouretal.(2008);Bhandarietal.(2003);Bhandarietal.(2005);Coutinhoetal.(2005);Haideretal.(2000);Krameretal.(2001);Kupra-takuletal.(2010);Leiteetal.(2005);Santiagoetal.(2003);andTripathyetal.(2010).
al.(2005)lookedattheefficacyof postnatalpeercoun-seling conducted in a hospital in Manila, Philippines. The study included two intervention groups – one in which peer counselors were trained to provide breastfeeding counseling and the other in which peer counselors were trained to provide general childcare counseling. Women in the control group did not receive any counseling. Both intervention groups included eight counseling sessions conducted at home at the following child ages: 3-5 days, 7-10 days, 21 days, and 1.5 months. Women then received counseling monthly until their children reached the age of 5.5 months. Data on breastfeeding practices were col-lected during well-child hospital visits at child age two and four weeks and monthly until the child was six months old. The authors found that women in the breastfeeding counseling intervention group were more likely to report EBF in the previous seven days at six months of age (44%)thanthoseinthechildcarecounselinggroup(7%)orthecontrolgroup(0%).Statisticalmodelingrevealedthat women in the breastfeeding counseling group were 6.3 times more likely to EBF in the previous seven days at six months than those in the other groups.
Aidametal.(2005)conductedanRCTlookingatEBFatsix months of age in Thema Township, Ghana. The inter-vention involved provider counseling and home visits, and includedtwointerventiongroups:thefirstinterventiongroup(IG1)includedtwoprenatalcounselingsessions,onecounseling session 48 hours postpartum, and six postpartum homevisits.Thesecondgroup(IG2)excludedtheprenatalcounseling, but included the rest. Following the intervention, the rate of EBF at 6 months of age was 90% in IG1, 79.5% in IG2, and 54.5% in the control group.23 The differences werestatisticallysignificantforbothinterventiongroups.
Aksuetal.(2011)lookedatbreastfeedingpracticesamongwomen who gave birth in a hospital following a Baby-friend-lyHospitalInitiative(BFHI)interventioninAydın,Turkey.Inadditiontoeducationinthefirstfewhoursafterdelivery,which was provided to all women in the hospital, women in the intervention group received breastfeeding education at home three days after delivery and were then monitored for six months. At each time point, women in the intervention group were more likely to exclusively breastfeed than women
23 Aidam et al. measured EBF at 6 months through both monthly recall and 24hourrecall.Wesitefiguresfromthe24hourrecall.
28 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
in the control group – 67% vs. 40% at two weeks, 60% vs. 33% at six weeks, and 43% vs. 23% at six months. At six months postpartum, women in the intervention group exclu-sively breastfed an average of 0.8 months longer more than womeninthecontrolgroup(4.7vs.3.9months).
Bashouretal.(2008)exploredtheimpactof homevisitsonEBF in Damascus, Syria. Women who had recently given birth at the Maternity Teaching Hospital in Damascus, Syria were randomly assigned to one of two intervention groups – women in IG1 received four home visits (on days 1, 3, 7, and30followingdelivery),whilewomeninIG2receivedonehome visit on the third day after delivery. Registered midwives were trained to provide information, education, and support to women during the home visits. Following the intervention, EBFatfourmonthswassignificantlyhigheramongwomeninboth intervention groups – 28.5% among women in IG1 and 30.1% among those in IG2 compared with those who received nohomevisits(20.2%).Followingasub-analysisof find-ings, the authors found that “the effect was major among the groups of women who had normal vaginal delivery but not thewomenwhohadac-sectionorwereprimigravidae,”andsuggested that other factors such as hospital policy regarding the practice of rooming-in (the practice of mothers and babies stayingtogetherafterbirth)mayplayaroleandthatsuchsub-groupsmay“requireaspecialpackageof intervention.”
Bhandarietal.(2003)lookedatmediandurationof EBF,andEBFatthree,four,five,andsixmonthsof ageinHaryana, India. The intervention included counseling by traditional birth attendants at birth, monthly home visits bycommunity-basedhealthworkersduringthechild’sfirstyear of life, and counseling during weighing sessions every three months. By the end of the study period, median durationof EBFwassignificantlyhigherintheinterven-tion group compared with the control group (122 days vs. 41days),theproportionof womenreportingEBFatfourmonths was 69% in the intervention group compared with 12% in the control group, and EBF at six months was 42% in the intervention group compared with 4% in the control group.Inafollow-uparticle,Bhandarietal.(2005)reportedthat women exposed to three or more communication channels were more likely to be practicing EBF at three months than those exposed to just one or two communica-tionchannelsornoneatall(≥3channels:93.6%,1-2chan-nels:81.3%,nochannels:70.8%).
BortoliniandVitolo(2012)lookedatEBFpracticesamong infants born in one hospital in Brazil. The inter-vention group received home visits during the children’s firstyearof lifeonamonthlybasisupto6months,andat8, 10 and 12 months. Results showed that children in the intervention group were more likely to be EBF for four or more months than those in the control group (45.1% vs. 28.6%)andatsixmonths(19.1%vs.8.2%).
Coutinhoetal.(2005)lookedatEBFatsixmonthsof agein Pernambuco, Brazil. Following the training for health care providers on the BFHI,24 the proportion of infants exclusively breastfed during the hospital stay increased sig-nificantly,butEBFwasnotsustainedbeyondthehospitalstay. In an effort to increase the length of EBF, researchers randomly assigned women who gave birth in two BFHI hospitals to the intervention group, which received ten postnatal home visits by trained community health agents, or to the control group, which did not receive home visits but still received the breastfeeding support provided during the hospital stay. At six months post-partum, rates of EBF among women in the intervention group was 45% com-pared with 13% among women in the control group.
Haideretal(2000)lookedatbreastfeedingpracticesinDhaka,Bangladesh.Followingafivemonthpeercounselingintervention, the proportion of children exclusively breast-fedatfivemonthsof agewas70%intheinterventiongroup compared with 6% in the control group.
Krameretal.(2001)lookedatbreastfeedingpracticesin31hospitals in Belarus. The objective of the Promotion of BreastfeedingInterventionTrial(PROBIT)wasto“assessthe effects of breastfeeding promotion on breastfeeding duration and exclusivity and gastrointestinal and respiratory infectionandatopiceczemaamonginfants.”Theinterven-tion was “modeled on the Baby-Friendly Hospital Initiative
24 According to the WHO website: “The Baby-friendly Hospital Initiative (BFHI)waslaunchedbyWHOandUNICEFin1991,followingtheIn-nocenti Declaration of 1990. The initiative is a global effort to implement practices that protect, promote and support breastfeeding. To help in the implementation of the initiative, different tools and materials were devel-oped,field-testedandprovided,includingacourseformaternitystaff,aself-appraisaltoolandanexternalassessmenttool.”TherevisedBFHIpackage includes background and implementation; material for training/raising the awareness of policy and decision-makers in relation of BFHI and IYCF in general; materials for a 20-hour course for training facility staff (clinicalandnon-clinical);self-appraisalandmonitoringtools;andassessment and re-assessment tools. See: http://www.who.int/nutrition/topics/bfhi/en/
29 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
of the World Health Organization and United Nations Chil-dren’s Fund, which emphasizes health care worker assistance with initiating and maintaining breastfeeding and lactation and postnatal breastfeeding support, or a control interven-tion of continuing usual infant feeding practices and poli-cies.”Attheendof thestudyperiod,ratesof EBFatthreemonths were 43.3% in the intervention group and 6.4% in the control group. Rates of EBF at six months were 7.9% in the intervention group and 0.6% in the control group.
Kupratakuletal.(2010)lookedatEBFinthecontextof an intervention aimed at improving antenatal and postnatal support in Bangkok, Thailand. The intervention included Knowledge Sharing Practices with Empowerment Strategies (KSPES)duringantenataleducation(storytelling,demonstra-tion,andpractice)aswellaspostnatalsupport.Attheendof the six month intervention period, 20% of the women in the intervention group reported EBF through six months, while none in the control group reported EBF through six months.
Leiteetal.(2005)assessed“theeffectivenessof home-based peer counselling on breastfeeding rates for unfavour-ablylowbirthweightbabies”inBrazil.Womenandtheirnewbornbabiesidentifiedinthematernityservicesthatmetthe inclusion criteria were randomly assigned to the inter-vention or control group. The intervention group received six home visits from trained lay counselors at 5, 15, 30, 60, 90 and 120 days following birth. In addition to counseling, home visits included “interviews with the mother; observa-tion of the home environment; observation of all aspects involved with the breastfeeding, including technical ones, as wellasthemother-childrelationship;andidentificationof thedifficultiesfacedbythemotherduringbreastfeeding.”Following the intervention, rates of EBF at four months weresignificantlyhigheramongtheinterventiongroupthanthecontrolgroup(24.7%vs.19.4%).
MorrowandGuerrero(2001)conductedanRCTtodeter-mine the effectiveness of three vs. six home visits by peer counselors on EBF rates among women in a peri-urban area of Mexico. The intervention was informed by an eth-nographic study identifying maternal beliefs, practices, and needs. Lay counselors were recruited from each interven-tion community and trained by La Leche League. Women were enrolled during pregnancy and randomly assigned to one of two intervention groups –women in IG1 received six home visits and women in IG2 received three home
visits. In IG1, “mothers were visited by [peer counselors] twiceduringpregnancy(midandlatepregnancy),imme-diatelypostpartum,andatweeks2,4,and6postpartum.”In IG2, women were visited once late in pregnancy, once immediately postpartum, and once two weeks after delivery. The authors found that women in IG1 who received six home visits had higher rates of EBF than women in IG2 whoreceivedthreevisits(67%vs.52%)ornovisits(12%).
Santiagoetal.(2003)exploredtheroleof pediatriciansinimproving EBF rates at four months in Brazil. Healthy, full term infants born at the pediatrics outpatient clinic in the Triângulo Mineiro teaching hospital in Minas Gerais were randomly divided into three groups. Women in IG1 received advice from a multidisciplinary breastfeeding support team (including a pediatrician trained in breastfeeding, a social worker,apsychologist,adentistandanurse)duringwhichtimebreastfeedingdifficultieswerediscussedandpotentialsolutions were offered as a group. Women in IG2 received advice from the same trained pediatrician, but in individual consultations, while those in the control group received ad-vice from a pediatrician with no breastfeeding training. Fol-lowing the intervention, 82.9% of women in IG1, 66.7% of women in IG2, and 30.3% of women in the control group reported EBF at four months. The difference between IG1 andIG2wasnotstatisticallysignificant;however,thediffer-encebetweenIG1andthecontrolwasstatisticallysignificant.
Finally,Tripathyetal.(2010)conductedanRCTlookingatEBF in Orissa and Jharkhand, India. In intervention areas, female facilitators conducted monthly meetings with new mothers for a period of 20 months. The meetings revolved around participatory learning and action, and led to the development and implementation of strategies to address maternal and newborn health problems. Following adjusted analysis of surveillance data from years one and three, the authors reported that the proportion of infants exclusively breastfed at six weeks was higher in intervention areas than incontrolareas(OR=1.82).25
Longitudinal studies
Eightof the33studiesreportingstatisticallysignificantresultswerelongitudinalstudies.Akteretal.(2012)studiedan intervention which involved four group counseling ses-
25 Theseinclude:Baquietal.(2008a);Baquietal.(2008b);Bhuttaetal.(2008b);andKumaretal.(2008).
30 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
sions during the last trimester of pregnancy. Following the intervention, 64.9% of women in the intervention group reported EBF at one month after birth, compared with 37.9% of women in the control group.
Balalukaetal.(2012)conductedalongitudinalstudylookingatmediandurationof EBF,andEBFatfour,five,andsixmonths in two health districts in the Democratic Republic of Congo. The intervention involved a combination of home visits, community based counseling, and community mobiliza-tion,includingmonthlycommunity“weighingsessions.”Afterapproximately three years of implementation, the authors compared EBF practices in the intervention health district with another health district that resembled the intervention district. They found that median duration of EBF was two months longer in the intervention district than in the control district(sixvs.fourmonths).Likewise,theprevalenceof EBFwas higher in the intervention district compared with the control district at all of the following points in time: at four months(91.8%vs.50.7%),atfivemonths(81.3%vs.9.6%),andatsixmonths(57.7%vs.2.7%).Alldifferenceswerestatis-ticallysignificant;however,thelackof baselinevaluesmakesitdifficulttoattributethesedifferencestotheintervention.
Braunetal.(2003)lookedattheeffectof theBFHIonEBF by following two cohorts of babies born at a hospital in Porto Alegre, Brazil – one cohort of babies born before the BFHI initiative had been introduced and the other born after the BFHI initiative had been introduced. Mothers wereinterviewedattheendof thefirst,second,fourth,and sixth months after birth. The authors found that the median duration of EBF increased from one month to two months after BFHI had been introduced.
Alametal.(2002)conductedalongitudinalstudycompar-ing EBF rates in two hospitals in Dhaka, Bangladesh. The interventionhospitalwascertified“baby-friendly,”whilethe control hospital was not. The authors assessed EBF practices at 30, 60, 90, 120, and 150 days postpartum. At each time point, EBF rates were higher among women who delivered in the baby-friendly hospital compared with those who delivered in the control hospital, but the sta-tisticalsignificanceof thesedifferenceswasnotreported.Thelikelihoodof EBFformorethanfivemonthswasstatistically greater in the intervention hospital compared withthecontrolhospital(8.1%vs.6.5%)aswastheme-diandurationof EBF(69.74daysvs.48.4days).
Piwozetal.(2005)conductedalongitudinalstudywithinthe Zimbabwe Vitamin A for Mother and Babies Trail (ZVITAMBO),inwhich14,110mother-babypairswereenrolled within 96 hours of delivery. “Formative research was undertaken to guide the design of the program that included group education, individual counselling, videos, and brochures. Exclusive breast-feeding was recommend-ed for mothers of unknown or negative HIV status, and forHIV+motherswhochosetobreast-feed.”Com-parisons were made between women who were enrolled in the trial before, during, and after the education and counseling program was implemented. The authors found that women who enrolled in ZVITAMBO while the coun-seling and education program was being fully implement-ed were 8.4 times more likely to EBF at three months compared with those who enrolled in ZVITAMBO before the program began and, therefore, only partially partici-pated in the program.
Inafollow-uparticle,Piwozetal.(2007)assessedtheas-sociation between exposure to the counseling and educa-tion program described directly above and postnatal HIV transmission among a subset of 437 HIV+ women, 365 of whom did not know their HIV status. They found that EBF was higher in the intervention group at six weeks and three months, but no such effect was found at six months.
Saludetal.(2009)evaluatedapeercounselinginterven-tion aimed at increasing EBF rates in the Philippines. The intervention targeted 312 “mothers with infants less than 2 months of age who were not exclusively breastfeeding or haddifficultybreastfeeding.”Eachwomanthenreceivedthree peer counseling visits: one at baseline, another after one week, and the third after two weeks. Following inter-vention, EBF had increased from 1% to 53.5%.
Finally,Suleetal.(2009)evaluatedtheimpactof nutritionaleducationonIYCFknowledge,attitudeandpractices(KAP)of women in southwest Nigeria. The intervention included group-based nutrition education and demonstrations of complementary food once every two weeks for a period of six months. Participating women were also visited in their homes monthly for six months to monitor their EBF practices. After six months, women with children six months orolderintheinterventioncommunityweresignificantlymore likely to report EBF for six months than women in the controlcommunity(66.7%and52.0%,respectively).
31 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
Repeated cross-sectional studies
Crookstonetal.(2007)lookedatbreastfeedingbehaviorsina repeated cross-sectional study conducted in rural Cambo-dia. At baseline, women in program communities were 54% more likely than women in control communities to have breastfed exclusively in the previous 24 hours. At follow-up, they were 81% more likely to do so. After one year, the RR associated with EBF through six months of age had increased from 1.54 to 1.81.
Harkinsetal.(2008)evaluatedtheeffectivenessof IMCIinterventions on EBF for six months in San Luis, Hondu-ras. The authors described the community IMCI approach asusingthe“social-actormethodology”tocreateandpromote “linkages between partners that create syner-giesinlocalandregionalsocialmobilizations.”Teachersand Red Cross volunteers trained in community IMCI conducted home visits to promote prenatal care, exclusive breastfeeding, vaccinations, and the healthy growth and developmentof infantsandchildren.”Afteroneyear,the percentage of women reporting EBF for six months increased from 11% to 19%.
ThompsonandHarutyunyan(2009)lookedatEBFthrough six months of age in Martuni region in northeast-ern Armenia. The intervention was delivered through a community-based IMCI platform, and included home visits for pregnant and lactating women, group education classes for new parents, and a local mass media campaign. By the end of the study period, rates of EBF through six months increasedfrom16.7%to48.1%.Thefindingwasstatisti-callysignificant;however,thelackof datafromacontrolgroup limits claims of attribution.
Quinnetal.(2005)lookedatEBFinthreecountries:Madagascar, Bolivia, and Ghana. Following a four year multi-channel behavior change program, rates of exclusive breastfeeding among children under six months of age increased from 46% to 68% in Madagascar, from 54% to 65% in Bolivia, and from 68% to 79% in Ghana.
Inafollow-upanalysistotheQuinnetal.(2005)article,Guyonetal.(2009)reportedanincreaseinEBFfrom42%to70%afterfiveyearsof implementationinMadagascar.NeitherQuinnetal.(2005)orGuyonetal.(2009)includedcontrol communities.
Cross-sectional studies
Guptaetal.(2004)“evaluatedtheextenttowhichexpo-sure to BCC messages in the media determined improve-ments in exclusive breastfeeding knowledge and practices in areas targeted by the Delivery of Improved Services for Health(DISH)Projectof Uganda.”TheDISHProjectdeveloped and disseminated materials that targeted both men and women of reproductive age and promoted EBF forthefirstsixmonthsandappropriatecomplementaryfeeding practices. The intervention used radio, television, video, posters, and print materials (newspapers, magazines, orleaflets).Multiplelogisticregressionanalysisshowedthat women exposed to multiple BCC messages were more likely to exclusively breastfeed their infant for six months than women exposed to just one message. How-ever, women with no exposure were more likely to EBF than those with exposure to any one message. The authors cautioned that “even the positive effects of self-reported BCC exposure on the outcomes of interest do not neces-sarily imply a direct causation, since precise information on the timing of changes in knowledge and practices of individuals with respect to exposure to the mass media was lacking.”Theyalsodiscussedconfoundingfactorswhichmay be related both to exposure and to EBF practices, including age of respondent, marital status, parity and other socio-demographic factors, and suggested that the effects of media on breastfeeding practices “were less conclusive possibly because of the short interval between the launch of theBCCcampaignandsurveyimplementation.”
Matovuetal.(2008)conductedaretrospectivestudycomparing adherence to EBF recommendations among HIV+ Ugandan women attending individual client-provider counseling at a health facility and receiving education with those who only received group counseling or education. At enrollment all women opted to EBF. At the conclusion of the study period, women who had received individual counseling were more likely to EBF at six months than those who had received only group counseling or educa-tion(OR=3.43).Furthermore,thosewhohadattendedatleastfourantenatalcare(ANC)visitswereevenmorelikely to EBF at 6 months (OR=5.95, Adjusted Odds Ratio(AOR)=3.86),whilethosewhoattendedatleastsixpostnatal counseling sessions were more likely to EBF at six months than those who received less (OR=3.34,
32 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
AOR=12.52).Finally,thosewhoconsultedahealthworkerregarding breastfeeding problems were also more likely to EBFatsixmonths(OR=4.97,AOR=13.11).However,theretrospective nature and the lack of randomization make it impossible to attribute these differences to the intervention.
Continued breastfeeding
Of the 16 studies reporting on continued breastfeed-ingpractices,ninereportedstatisticallysignificantresults.Continued breastfeeding was measured at six months (two studies),at12months(fourstudies),andat24months(onestudy).Statisticallysignificantresultswithregardtotheduration of any breastfeeding were reported in two studies.
Literature reviews with meta-analysis
Imdadetal.(2011)conductedameta-analysisof 53RCTsandquasi-RCTs looking at the impact of education and support strategies on breastfeeding outcomes. The authors reviewed twenty studies which reported on breastfeeding at six months, two of which were from developing countries. They found a 12%increaseinanybreastfeedingatsixmonths(RR=1.12).
Randomized controlled trials
Sixof theninestudiesreportingstatisticallysignificantresultswereRCTs.Aksuetal.(2011)lookedattheimpactof both facility and home-based counseling on continued breastfeeding rates in Turkey. Following the intervention, women in the intervention group breastfed for an average of three months longer than those in the control group (15.1vs.12.1months).
Bhandarietal.(2001)conductedanRCTinwhichwomenwererandomizedtooneof fourgroups:thefirstreceivedamicronutrient-fortifiedfoodsupplementalongwithmonthly nutrition counseling, the second received monthly nutrition counseling alone, the third received a twice-weekly home visit, and the fourth received no intervention. Following intervention, breastfeeding at 12 months was actually lower among those who received the supplement and counseling compared with those who received no inter-vention(83.9%vs.96.7%).Theauthorsreportednootherstatisticallysignificantfindings.
BortoliniandVitolo(2012)conductedastudyof infantsborn in Rio Grande do Sul, Brazil. Newborns and their
mothers were randomly assigned to the intervention or control group. Women in the intervention group received homevisitsduringthechildren’sfirstyearof lifeonceamonth through the age of six months, and then every other month until the child reached 12 months. Following the in-tervention, the proportion of children breastfed at both six and 12 months was higher in the intervention group than the control group (66.3% vs. 55.6% at 6 months and 52.8% vs.41.9%at12months).
Guldanetal.(2000)lookedattheimpactof home-basedpeer counseling on continued breastfeeding practices. Fol-lowing a year-long intervention, the percentage of women reporting breastfeeding infants between the ages of 4-12 months was higher in the intervention group than in the controlgroup(83%and75%,respectively).Thefindingswerestatisticallysignificant;however,asnotedbefore,thelack of baseline and/or randomization of the interven-tion and control groups makes attribution of change to the intervention challenging.
Krameretal.(2001)lookedattheimpactof facilityandlay counseling and small media on continued breastfeeding practices in Belarus. Following the intervention, breast-feeding rates at 12 months were 19.7% in the intervention group compared with 11.4% in the control group (adjusted OR=0.47).
Kupratakuletal.(2010)foundthattheproportionof womenpracticing“predominant”breastfeedingat6months,definedas “infants … fed with the mothers’ breast milk and water, sweetenedwaterandjuiceswithoutformula”wassignificant-ly higher among women in the intervention group compared withthoseincontrolgroup(40.0%vs.5.3%).
Longitudinal studies
DuyanCamurdanetal.(2007)conductedalongitudinalstudylooking at the impact of the BFHI initiative on breastfeeding practices in Gazi University Hospital in Turkey. All women delivering in the hospital were invited to participate in peri-odic well-child visits. During each visit, providers reinforced thebenefitsof breastfeedingandprovidedcounseling.Theaverage duration of breastfeeding was 21.17 months among women giving birth after the introduction of BFHI, com-pared with 17.83 months among those giving birth prior to the introduction of BFHI. Following regression analysis
33 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
Table 3.2.2: Number of studies reviewed (with number of studies reporting statistically significant results in parentheses), by SBCC approach and study design
SBCC approaches and activities
Reviews with meta-
analysisRCTs
Longitudinal studies
Repeated cross-
sectional studies
Cross-sectional studies
TOTAL
Interpersonal Communication 6 (6) 27 (21) 14 (9) 11 (9) 1 (1) 59 (46)
One-on-One Counseling 6 (5) 25 (20) 12 (9) 10 (9) 1 (1) 48 44)
Counseling in facilities 0 8 (5) 9 (6) 2 (2) 1 (1) 20 (14)
Counseling in communities 2 (2) 0 2 (2) 2 (2) 0 6 (6)
Counseling in homes (home visits) 4 (4) 23 (18) 4 (3) 5 (3) 0 32 (28)
Counseling in other settings 2 (2) 0 0 2 (2) 0 4 (4)
Group Education 3 (3) 6 (5) 6 (3) 4 (4) 1 (1) 17 (16)
Education in facilities 0 1 (1) 3 (3) 0 1 (1) 5 (4)
Education in communities 1 (1) 5 (4) 4 (2) 3 (3) 0 12 (10)
Education in other settings 2 (0) 0 0 1 (0) 0 3(0)
Support Group 1 (1) 4 (3) 5 (3) 5 (3) 0 14 (10)
Support group in facilities 0 2 (2) 4 (3) 1 (1) 0 7 (6)
Support group in communities 1 (1) 2 (1) 1 (0) 2 (0) 0 5 (2)
Support group in other settings 0 0 0 2 (0) 0 2 (0)
Media 0 5 (5) 8 (6) 9 (6) 2 (2) 24 (19)
Mass media 0 0 0 4 (3) 1 (1) 5 (4)
Mid-sized media (community radio / video, local billboards)
0 0 2 (2) 5 (3) 1 (1) 8 (6)
Small media (posters, flyers, calendars, reminder stickers) 0 4 (4) 7 (5) 7 (5) 1 (1) 19 (15)
Traditional media (songs, drama) 0 3 (3) 0 0 0 3 (3)
Social media (Twitter, Facebook, etc.) 0 0 0 0 0 0
Community/Social Mobilization 1 (1) 4 (3) 2 (1) 9 (6) 0 16 (11)
Campaign, event, special “days” 0 0 0 2 (2) 0 2 (2)
Issue groups 1 (1) 3 (2) 2 (1) 5 (2) 0 11 (7)
Other 0 1 (1) 0 3 (3) 0 4 (4)
34 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
that controlled for variables that might affect breastfeeding practices (mother’s occupation, educational status, age, way of birth,parity,durationof pregnancy,birthweight)thebreastfeeding rate was 1.5 times higher among women giving birth after the introduction of BFHI, compared with those giving birth prior to the introduction of BFHI.
Repeated cross-sectional studies
Guyonetal.(2009)conductedarepeatedcross-sectionalstudy looking at breastfeeding practices in Madagascar. Fol-lowing an intervention that included community mobiliza-tion, campaign events, and mass media, rates of breastfeed-ing among children 12-15 months of age increased from 89% to 94%, and among children 20-23 months of age the rate increased from 43% to 73%.
D. Summary of the Evidence
SBCC approaches utilized
For the purposes of analysis, we organized SBCC activi-ties into three primary categories or approaches: inter-personal communication, media, and community/social mobilization.Theseapproachesandthespecificactivitiesassociated with each are described in further detail in the introductory chapter.
The studies reviewed included a broad range of approaches to promote optimal breastfeeding practices. Most included morethanonespecificSBCCactivityandmanyutilizedmore than one approach.
All six literature reviews focused on interpersonal commu-nication(IPC)approaches.Onereviewincludedfindingsrelated to community/social mobilization.
Amongthe42otherstudiesreportingstatisticallysignifi-cant results, 40 included interpersonal communication (IPC)approaches,19includedsomeformof media,and10 included community/social mobilization. One-on-one counseling in the home was the most commonly used IPC approach, small media was the most commonly used media approach and the gathering of issues groups was the most commonly used community/social mobilization approach (seeTable3.2.2).
Nine of the reviewed studies explored the impact of the BFHI on breastfeeding practices. In some cases an SBCC
intervention was added to the standard BFHI package, while in other cases, facilities implementing BFHI were compared with those who were not doing so.
There is a wide breadth of evidence regarding the effective-ness of various SBCC approaches in changing breastfeeding practices.Table3.2.3providesasummaryof thesefindings.
Interpersonal communication
Six reviews with meta-analysis establish the effectiveness of IPC approaches with respect to uptake of optimal breastfeeding practices. All but one looked solely at IPC interventions.GogiaandSachdev(2010)reportedapositiveeffect of IPC with respect to early initiation of breastfeed-ing(RR=3.35),whileImdadetal.(2011)reportedasix-foldincrease in EBF rates at six months following breastfeed-ingpromotionindevelopingcountries(RR=1.37overall).Renfrewetal.(2012)foundthatextrasupportledtoalowerriskof havingstoppedEBFatsixmonths(RR=0.86),Hall(2011)andJollyetal.(2012)reportedsimilareffectrelatedtoEBFatothertimes,andImdadetal.(2011)reportedaposi-tive effect of IPC on continued breastfeeding at six months (RR=1.12).Lassietal.(2010)reportedanRRof 1.94withrespect to early initiation of breastfeeding, but the inter-vention package included both IPC and community/social mobilization,makingattributiontoIPCdifficult.Noneof thereviewsreportedfindingsassociatedwithbreastfeedingattwo years of age, the universally recommended practice.
In addition to the reviews, 41 primary research studies re-portedstatisticallysignificantoutcomesrelatedtotheeffectof IPC interventions on breastfeeding initiation, 14 reported significantoutcomeswithrespecttobreastfeedinginitiation,27reportedonEBF,andninereportedsignificantoutcomeswith respect to continued breastfeeding rates.
Eighteen studies measured the effectiveness of IPC inde-pendent of other SBCC approaches, including six which were not included in the previously described reviews: three RCTs, two longitudinal studies, and one repeated cross-sec-tionalstudy.AmongtheRCTs,BortoliniandVitollo(2012)reportedthemostcompellingfindings,adifferencebetweenintervention and control communities of 10.7 percentage points with respect to breastfeeding at six months and 10.9 percentage points with respect to breastfeeding at 12 months.
In the only study looking at continued breastfeeding at two
35 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
yearsof age,Guyonetal.(2009)reportedanincreaseof 30percentage points in their repeated cross-sectional study.
Indicators and study design varied considerably among studies,makingconsolidationof findingsfromstudiesnotincludedinpreviousliteraturereviewsdifficult.
Media
We did not identify any reviews documenting the effective-ness of media-related interventions on breastfeeding out-comes, but did identify 19 primary research studies report-ingsignificantoutcomesassociatedwithinterventionsthatincluded media-based SBCC approaches. Nine reported a significanteffectwithrespecttobreastfeedinginitiation,13reportedasignificanteffectwithrespecttouptakeof EBF,andthreereportedasignificanteffectwithrespecttocontinued breastfeeding practices.
Onlyoneof thesestudies,Guptaetal.(2004),presentedfindingsregardingtheeffectof media-basedapproachesindependent of other SBCC approaches. Researchers measured the impact of exposure to messaging through four different media channels: radio, television, posters, and print materials. They reported a greater likelihood of EBF for six months among those exposed to messages through these forms of media two or more times.
Community/Social mobilization
Lassietal.,(2010)includedfindingsrelatedtocommunity/social mobilization. The review, however, looked at both community/social mobilization and IPC, and did not disag-gregate results between the two approaches. It is therefore not possible to assess the effect of IPC independent of other SBCC approaches.
Eightprimaryresearchstudiesreportedasignificanteffectof interventions including community/social mobiliza-tion with respect to breastfeeding initiation, six reported a significanteffectwithrespecttoEBF,andonereportedasignificanteffectwithrespecttocontinuedbreastfeeding.
None of these studies reported on the effect of com-munity/social mobilization in isolation from other SBCC approaches,soitisdifficulttoderiveconclusionsregardingthe singular effectiveness of community/social mobiliza-tion in changing breastfeeding practices.
Multiple SBCC approaches
One review documented the effect of multiple SBCC ap-proaches on the uptake of breastfeeding practices. Lassi et al.(2010)reportedanRRof 1.94amongstudiesemployingIPC and/or community/social mobilization to improve uptake of early initiation of breastfeeding. They did not, however, distinguish among studies employing IPC, com-munity/social mobilization, or both.
InadditiontothereviewbyLassietal.(2010),weidenti-fiedtwenty-threeprimaryresearchstudiesreportingposi-tive outcomes associated with interventions that included more than one SBCC approach. Eleven reported a posi-tive effect with respect to early initiation of breastfeed-ing, 15 report a positive effect with respect to EBF, and three reported a positive effect with respect to continued breastfeeding at six months or older. Among the most no-tablearethreeRCTsnotincludedintheLassietal.(2010)review:Bangetal.(2005);MorrowandGuerrero(2001);andOmeretal.(2008).
None of these studies measured the effect of the utiliza-tion of more than one SBCC approach compared with the utilization of just one approach. One must use caution, therefore, in drawing conclusions about the effectiveness of interventions employing multiple approaches versus those employing just one approach.
Implementation processes followed
Few of the studies reviewed in this chapter assessed the effect of implementation processes (e.g. intensity and timing of communications; type and training of person communicatingmessages,ortargetaudience)ontheeffectiveness of the SBCC approach on breastfeeding practices, nor did they consistently report all aspects of the implementation processes.
Little work has been done to compare the effect of timing orfrequencyof interventions.Imdadetal.(2011)con-ducted a sub-analysis which showed that “prenatal counsel-ling had greater impacts on breastfeeding rates at 4-6 weeks, while combined prenatal and postnatal promotion were im-portantforbreastfeedingratesat6months.”Renfrewetal.(2012)foundnoeffectof thetimingof thesupport(duringtheantenatalorpostnatalvisit),whileJollyetal.(2012)found that “combined antenatal and postnatal peer support
36 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
wasnotassociatedwithasignificantimprovementinnotbreast feeding at last study follow-up, whereas postnatal onlyinterventionsdidsignificantlyreducenotbreastfeed-ing.”Likewise,Aidametal.(2005)foundthatwomenwhoreceived two prenatal counselling sessions, one counseling session 48 hours postpartum, and six postpartum home visits were just as likely to EBF at six months as those who received only postpartum counselling.
The intensity of communications ranged between one and twenty visits or sessions, and several meta-analyses and studies did make comparisons between the effectiveness of interven-tionswithvariedintensities.Jollyetal.(2012)foundthatwom-eninthemoreintensiveinterventions(≥5contactsplanned)were more likely to report breastfeeding at last follow-up com-paredwithusualcare.Similarly,Renfrewetal.(2012)foundthat “studies with four to eight visits seemed to be associated withamorepronouncedtreatmenteffect.”However,theau-thors warned that “care is needed in the interpretation of this findingasthereisinconsistentreportingduetovariationsinthe timing of outcome assessments, and the settings of studies and the population groups included in studies with more face-to-face visits also varied. It is likely that support will be most effectivewhenitreflectsthelocalneedsof thepopulation.”Renfrew et al. also found a greater treatment effect on EBF at six months when the “intervention was delivered by non-professionals(averageRR=0.74)comparedwithprofessionals(averageRR=0.93)orboth(averageRR=0.76).”Likewise,women who received face-to-face support were 19% less likely to have given up EBF at six months compared with those who didnot(averageRR=0.81).
Piwozetal.(2007)conductedanRCTcomparingthosewho received no visits, one visit, two visits or three visits when counselling on HIV and infant feeding was provided. They found that EBF at six weeks and three months was incrementally higher with each additional visit. Statistical significanceof thedifferencesbetweenthegroupswerenotreported, but the authors did conclude that “frequency of intervention contact was associated with safer breastfeeding knowledgeandexclusivebreastfeedingpractices.”
Finally,MorrowandGuerrero(2001)conductedanRCTinwhich they compared EBF at three months between those who received six home visits and those who received three home visits. While those receiving six home visits appeared to be more likely to EBF at three months than their counter-
partswhoreceivedonlythreehomevisits(a15%difference),thestatisticalsignificanceof thedifferencewasnotreported.Both were effective when compared with a control group.
In terms of target audiences, the majority of the studies reviewed focused attention on the mother or caregiver. Among the 48 studies (literature reviews and primary re-search)reportingstatisticallysignificantresults,alltargetedthe mother of the child herself. Twenty-six targeted only the mother of the child herself. Fourteen also targeted directinfluencers,18targetedlocalcommunityactors,andthree targeted actors of the enabling environment in addi-tion to pregnant or lactating women.
OnlyLassietal.(2010)comparedtheeffectof targetingonevs. multiple audiences or of targeting different audiences. The authors found that “the most successful packages were those that emphasized involving family members through community support and advocacy groups and community/social mobilization and education strategies, provision of care through trained CHWs via home visitation, and strengthened properreferralsforsickmothersandnewborns.”
E. Conclusions
The body of literature focusing on SBCC approaches be-ing used to improve breastfeeding practices is strong and broad, supporting the claim that SBCC approaches can and do succeed in improving uptake of the behaviors promot-ed.Whiletheliteraturemayreflectabiastopublishpositiveresults, it also underscores the important role of SBCC ap-proaches in improving nutrition practices – practices which have been shown to have an impact on the nutritional status of women, infants, and children.
There is more consistency in how breastfeeding practices aredefinedandmeasuredthanintheotherchaptersof thisreview. This is particularly so in the case of early initiation of breastfeeding. However, even with globally-recognized indica-tors and measurement guidance from the WHO, consider-able variation remains. For example, while fourteen studies re-portedstatisticallysignificantfindingsrelatedtoEBFchildrensix months old, 19 reported on EBF at a range of other ages.
There is considerable variation in the SBCC interven-tions designed to improve breastfeeding practices – in the interactions or combinations with other interven-tions, target groups, content, messages, scale and
37 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
Table 3.2.3: Number of studies reviewed (with number of studies reporting statistically significant results in parentheses), by SBCC approach and study design
SBCC approachInitiating
breastfeeding earlyExclusive
breastfeeding Continued
breastfeeding Interpersonal Communication
20, 16 reporting statistical significance:
2 Review with meta-analysis (within one hour)
6 RCTs (3 within one hour; 1 within 6
hours; 2 colostrum, 2 included in previous meta-analysis)
1 Longitudinal (within one hour)
7 Repeated cross-sectional (6 within one hour; 1 “early
initiation”; 1 colostrum, 1 included in previous meta-analysis)
40, 31 reporting statistical significance:
4 Review with meta-analysis (2 any EBF; 2 at 4-6 weeks;
2 at 6 months)
14 RCTs (8 at 6 months; 1 at 5 months; 8 at 4 months; 5 at 3 months; 1 at 2 months; 1 at 6 weeks; 2 at 30 days; 1 at 15 days;
1 at 7 days; 13 included in previous meta-analysis)
8 Longitudinal (1 at 1 month, 1 at 6 weeks, 3 at 3
months, 1 at 4 months, 1 at 5 months, 3 at 6 months, 2 duration)
5 Repeated cross-sectional (1 at 6 months; 4 among children < 6
months)
1 Cross-sectional (at 6 months among HIV+ women)
16, 10 reporting statistical significance:
1 Review with meta-analysis (at 6 months)
7 RCTs (3 at 6 months; 2 at 12 months; 1 among those 4-12 months; 1 duration; 4 included in previous
meta-analysis)
1 Longitudinal (duration)
1 Repeated cross-sectional (at 24 months)
Media 10, 9 reporting statistical significance:
3 RCTs (1 within 1 hour; 1 within 6 hours; colostrum; 1 included in previous
meta-analysis)
7 Repeated cross-sectional (4 within one hour; 1 within 30
minutes, 1 “early initiation”; 1 colostrum)
17, 13 reporting statistical significance:
2 RCTs (2 at 3 months; 1 at 6 months)
5 Longitudinal (2 at 3 months; 1 at 5 months; 1 at 6 months; among children < 6 months;
duration)
4 Repeated cross-sectional (among children < 6 months)
2 Cross-sectional (2 at 6 months, 1 among
HIV+ women)
6, 3 reporting statistical significance:
1 RCTs (1 at 12 months)
1 Longitudinal (duration)
1 Repeated cross-sectional (at 24 months)
Community/social mobilization
11, 8 reporting statistical significance:
1 Review with meta-analysis (within one hour)
1 RCT (initiation within one hour; 1 within 6 hours, included in previous meta-
analysis)
7 Repeated cross-sectional (5 within one hour; 1 within 30
minutes, 2 colostrum, 1 included in previous meta-analysis)
8, 6 reporting statistical significance:
1 RCT (at 4 months; at 6 months, included in
previous meta-analysis)
1 Longitudinal (at 3 months; at 4 months)
4 Repeated cross-sectional (1 at 6 months; 3 among children < 6
months)
2, 1 reporting statistical significance:
1 Repeated cross-sectional (at 24 months)
38 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
coverage, length and intensity, as well as context.
Interpersonal communication was the most prevalent SBCC approach found to be effective at improving breastfeeding practices in both implementation and research. While media and community/social mobilization were used, they were almost always used with at least one other communication approach.Theevidenceincludedinthereviewalsoreaffirmsthe importance of peer support for improving breastfeeding practices, whether one-on-one or in groups. The question remains as to whether many projects use IPC because it is more effective than other approaches at improving breast-feeding practices, or whether it has become the default ap-proach. Given the complex and personal nature of the suite of behaviors making up optimal breastfeeding, it is likely the former. Unfortunately it is both difficult and expensive to disaggregate the contribution of single channels or specific activities within a multi-channel intervention, and an important question for SBCC practitioners and researchers is whether that line of research is useful.
SBCC interventions to promote breastfeeding practices are suited to iterative programming, because even if standards for behaviors aren’t met, there can be signifi-cant movement toward the standard. In a hypothetical ex-ample, the target number of women exclusively breastfeeding at six months might not be met, but many women may have continued EBF for a month or two more than they would have had the intervention not happened. In this example, the intervention may not have succeeded in achieving the stand-ardized indicator, but moved the EBF duration in the right di-rection. Iterative interventions can learn what supported that move in the right direction, and build on them.
Allof thestudiesreportingstatisticallysignificantresultstargeted the woman herself. Nearly half targeted other audiencesorinfluencersaswell.Littlehasbeendonetocompare the effect of targeting one vs. multiple audiences or of targeting different audiences, but what was done suggested that targeting multiple contacts has a greater effect than targeting only the woman herself, given the important role of husbands, mothers-in-law, and community leaders. With regard to timing, few compari-sons were made between the effect of different timings and
what little was done presents contradictory evidence.
Thereissomeevidencethatintensity(numberof contacts)influencestheeffectivenessof SBCCinterventionsinpro-moting adoption of optimal breastfeeding practices. The in-tensity of communications ranged between one and twenty visits or sessions. While some studies reported statistically significantimprovementsinbreastfeedingpracticesafteronly one or a few contacts, evidence from several meta-analyses and primary research studies strongly suggests that increasing the number of contacts increases the positive effect of SBCC interventions on breastfeeding practices.
The majority of studies were implemented on a relatively small scale, within a few health facilities or communities and typically with fewer than 500 study participants per group. Because of these limitation and due to the lack of standardization in the way research related to SBCC is designed and described, it is challenging to make conclu-sions beyond the fact that projects with SBCC will result in uptake of promoted practices.
The evidence for SBCC and breastfeeding suggests the effect of context (including social norms, culture, and envi-ronmentalfactors)aswellasexistingnationalbreastfeedingrates. This underscores the importance of proper context assessments, formative research and/or ethnographic study prior to SBCC implementation.
While there is much to be learned from this large body of literature to aid us in developing future programs, a number of questions remain. These include questions related to:
n thepositive(ornegative)effectof usingmultipleSBCCapproaches compared with focusing on only one;
n thepositive(ornegative)effectof targetingmultipleaudiencesorinfluencersof thebehaviorsbeingpromoted,rather than focusing on just one target population;
n the role of context, in other words, the effect of the same SBCC intervention implemented in different contexts;
n the effectiveness of different approaches (including intensityandtargeting)fordifferentbehaviors;
n the cost and cost effectiveness of various SBCC approaches(particularlyasitrelatestoscalability);and
n the effectiveness and sustainability of these approaches when implemented at scale.
39 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
Tabl
e 3.
2.4:
Stu
dies
rep
ortin
g on
bre
astfe
edin
g pr
actic
esC
olor
cod
ing
key
Brea
stfe
edin
g in
itiat
ion
Excl
usiv
e br
east
feed
ing
Con
tinue
d br
east
feed
ing
ST
UD
YA
PP
RO
AC
HE
S
US
ED
SC
OP
E /
SC
AL
EE
VA
LU
AT
ION
D
ES
IGN
OU
TC
OM
E(S
) M
EA
SU
RE
DR
ES
ULT
S26
P-V
AL
UE
s /
CIs
27
Abo
lyan
(20
06);
Rus
sia
Cou
nsel
ing
in fa
cilit
ies
by
prov
ider
s; Su
ppor
t gr
oup
in fa
cilit
ies
by p
rovi
ders
an
d/or
lay
volu
ntee
rs; S
mal
l m
edia
8 m
ater
nity
hos
pita
ls
Long
itudi
nal –
741
hea
lthy
post
part
um w
omen
(38
3 in
terv
entio
n, 3
58 c
ontr
ol)
Med
ian
time
until
initi
atio
n of
bre
astfe
edin
g 2
hrs.
vs. 1
2 hr
s.N
S28
% E
BF fr
om b
irth
unt
il di
scha
rge
from
hos
pita
l88
.9%
vs.
32.6
%N
S
Agr
asad
a et
al.
(200
5); P
hilip
pine
sC
ouns
elin
g in
hom
es b
y la
y vo
lunt
eers
1 ho
spita
l R
CT
– 1
79 p
ostp
artu
m
wom
en (
60 IG
1, 6
0 IG
2,
59 c
ontr
ol)
coun
selin
g gr
oup
vs. “
othe
r gr
oups
”29
% E
BF d
urin
g pr
evio
us 7
da
ys a
t 6
mon
ths
Like
lihoo
d of
EBF
44%
vs.
0%
OR
=6.
3 (b
ased
on
gen
eral
ized
es
timat
ing
equa
tion
mod
els)
--
p<0.
001
(95%
CI:
3.53
-11
.3)
Aid
am e
t al
. (20
05);
Gha
naC
ouns
elin
g in
faci
litie
s by
pr
ovid
ers;
Cou
nsel
ing
in
hom
es b
y pr
ovid
ers
2 ho
spita
lsR
CT
– 1
23 p
regn
ant
wom
en a
tten
ding
pre
nata
l cl
inic
s: 40
IG1,
39
IG2,
44
cont
rol)30
IG1
vs. I
G2
vs.
cont
rol
% E
BF d
urin
g pr
evio
us
mon
th a
t 6
mon
ths
% E
BF d
urin
g pr
evio
us 2
4 ho
urs
at 6
mon
ths
% E
BF “
sinc
e bi
rth”
at
6 m
onth
s
90.0
% v
s. 74
.4%
vs
. 47.
7%
90.0
% v
s. 79
.5%
vs
. 54.
5%
Pool
ed
inte
rven
tion
vs.
cont
rol
39.5
% v
s. 19
.6%
p=0.
008
p=0.
001
p=0.
02
26
Com
paris
on is
inte
rven
tion
vs. c
ontro
l gro
up, u
nles
s ind
icat
ed o
ther
wise
.27Differencesreportedasnotsignificantlydifferentareindicatedby“NS”.Differencesforwhichstatisticalsignificancewasnotreportedareindicatedby“--“.
28NS=notsignificanteitheraccordingtowhatisreportedintheoriginalarticleorp<0.05.
29
The
aut
hors
com
pare
d E
BF ra
tes a
mon
g th
e br
east
feed
ing
coun
selin
g gr
oup
with
rate
s fou
nd a
mon
g th
ose
in th
e gr
oup
whe
re p
eer c
ouns
elor
s wer
e tra
ined
to p
rovi
de g
ener
al c
hild
care
cou
nsel
ing,
and
the
cont
rol
arm
who
did
not
rece
ive
any
coun
selin
g.30Interventiongroup1(IG1)includedtwoprenatalcounselingsessions,onecounselingsession48hourspostpartum,andsixpostpartumhomevisits.IG2excludedtheprenatalcounseling,butincludedtheother
inte
rven
tions
.
40 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ST
UD
YA
PP
RO
AC
HE
S
US
ED
SC
OP
E /
SC
AL
EE
VA
LU
AT
ION
D
ES
IGN
OU
TC
OM
E(S
) M
EA
SU
RE
DR
ES
ULT
S26
P-V
AL
UE
s /
CIs
27
Akt
er e
t al
. (20
12);
Bang
lade
shC
ouns
elin
g in
faci
litie
s by
pro
vide
rs; G
roup
ed
ucat
ion
in fa
cilit
ies
by
prov
ider
s
1 ho
spita
l Lo
ngitu
dina
l – 1
15 w
omen
at
six
mon
ths
gest
atio
n (5
7 in
terv
entio
n, 5
8 co
ntro
l)
% b
reas
tfeed
ing
initi
atio
n w
ithin
one
hou
r of
bir
th
% E
BF a
t 1
mon
th
75.4
% v
s. 34
.5%
64.9
% v
s. 37
.9%
p=0.
001
p=0.
003
Aks
u et
al.
(201
1); T
urke
yC
ouns
elin
g in
hom
es
by p
eers
; Cou
nsel
ing
in
faci
litie
s by
pro
vide
rs
(BH
FI a
nd in
faci
lity
coun
selin
g al
so g
iven
to
cont
rol g
roup
)
1 ho
spita
lR
CT
– 6
0 w
omen
who
ga
ve b
irth
in s
tudy
hos
pita
l (3
0 in
terv
entio
n, 3
0 co
ntro
l)
% E
BF a
t 2
wee
ks
% E
BF a
t 6
wee
ks
% E
BF a
t 6
mon
ths
Dur
atio
n of
EBF
(m
onth
s)
Mea
n du
ratio
n of
br
east
feed
ing
(mon
ths)
67%
vs.
40%
60%
vs.
33%
43%
vs.
23%
4.7
vs. 3
.9
15.1
vs.
12.1
p=0.
0038
p=0.
038
p=0.
04
p=0.
014
p=0.
001
Ala
m e
t al
. (20
02);
Bang
lade
shC
ouns
elin
g in
faci
litie
s by
pr
ovid
ers;
Supp
ort
grou
p in
faci
litie
s by
pro
vide
rs
and/
or la
y vo
lunt
eer;
Smal
l m
edia
2 ho
spita
ls (
1 in
terv
entio
n, 1
co
ntro
l)
Long
itudi
nal –
209
wom
en
who
gav
e bi
rth
in s
tudy
ho
spita
l (10
5 in
terv
entio
n,
104
cont
rol)
% E
BF a
t 1
mon
th
(30
days
)
% E
BF a
t 2
mon
ths
(6
0 da
ys)
% E
BF a
t 3
mon
ths
(9
0 da
ys)
% E
BF a
t 4
mon
ths
(1
20 d
ays)
% E
BF a
t 5
mon
ths
(1
50 d
ays)
% E
BF >
5 m
onth
s
Med
ian
dura
tion
of E
BF
82.3
% v
s. 50
.0%
63.2
% v
s. 40
.0%
34.7
% v
s. 21
.5%
20.8
% v
s.11
.4%
16.2
% v
s. 6.
5%
8.1%
vs.
6.5%
69.7
4 vs
. 48.
4 da
ys
--
--
--
--
--
p<0.
001
p<0.
001
Alb
erna
z et
al.
(200
3); B
razi
lSm
all m
edia
; Cou
nsel
ing
in fa
cilit
ies
by p
rovi
ders
; C
ouns
elin
g in
hom
es u
sing
H
otlin
e
1 ci
ty
RC
T –
157
new
born
s (8
2 in
terv
entio
n, 7
5 co
ntro
l)%
EBF
at
4 m
onth
s40
% v
s. 31
%N
S
% b
reas
tfeed
ing
at 4
m
onth
s (o
ther
food
or
milk
in a
dditi
on t
o br
east
m
ilk)
Like
lihoo
d of
hav
ing
stop
ped
brea
stfe
edin
g at
4
mon
ths
32%
vs.
28%
Pr
eval
ence
ra
tio::
1.85
NS
p=0.
04
(95%
CI:
1.01
-3.
41)
41 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ST
UD
YA
PP
RO
AC
HE
S
US
ED
SC
OP
E /
SC
AL
EE
VA
LU
AT
ION
D
ES
IGN
OU
TC
OM
E(S
) M
EA
SU
RE
DR
ES
ULT
S26
P-V
AL
UE
s /
CIs
27
Alb
erna
z et
al.
(200
8); B
razi
lSm
all M
edia
; Cou
nsel
ing
in fa
cilit
ies
by p
rovi
ders
; C
ouns
elin
g in
hom
es u
sing
H
otlin
e
1 ci
ty
Long
itudi
nal –
421
from
19
82 c
ohor
t, 56
1 fr
om
1993
coh
ort,
310
from
19
97-1
998
coho
rt, 3
17
from
200
4 co
hort
Post
vs.
imm
edia
tely
pr
ior
to
inte
rven
tion31
% E
BF a
t 1
mon
th
% E
BF a
t 3
mon
ths
% E
BF a
t 6
mon
ths
40%
vs.
26%
19%
vs.
16%
no d
iffer
ence
-- -- --
% b
reas
tfeed
ing
at 6
m
onth
s
% b
reas
tfeed
ing
at 2
4 m
onth
s
% b
reas
tfeed
ing
at 2
4 m
onth
s
64%
vs.
46%
33%
vs.
22%
11%
vs.
14%
--
--
--
Ald
erm
an (
2007
); U
gand
aG
roup
edu
catio
n in
co
mm
uniti
es b
y la
y vo
lunt
eers
; Mob
iliza
tion
of is
sue
grou
ps; S
uppo
rt
grou
p in
com
mun
ities
by
peer
s
34 d
istr
icts
Lo
ngitu
dina
l – 2
,250
ho
useh
olds
with
a c
hild
un
der
6 (7
50 IG
1, 7
50 IG
2,
750
cont
rol)
% o
f inf
ants
wea
ned
befo
re 6
mon
ths
(~BF
at
6 m
onth
s)
“sig
nific
ant
decl
ine”
--
Aza
d et
al.
(201
0); B
angl
ades
hG
roup
edu
catio
n in
co
mm
uniti
es b
y la
y vo
lunt
eers
18 c
lust
ers
from
th
ree
rura
l dis
tric
ts
(9 in
terv
entio
n, 9
co
ntro
l)
RC
T –
36,
113
birt
hs
(17,
514
inte
rven
tion,
18
,599
con
trol
)
% E
BF fo
r si
x w
eeks
68·0
% v
s. 61
·5%
RR
: 1·1
0 (0
·98–
1·24
)
Adj
uste
d R
R:
1·10
(0·
98–
1·23
)
Bala
luka
et
al. (
2012
); D
emoc
ratic
R
epub
lic o
f Con
goM
obili
zatio
n of
issu
e gr
oups
; Cou
nsel
ing
in
com
mun
ities
by
peer
s; C
ouns
elin
g in
hom
es b
y pe
ers
2 di
stri
cts
(1
inte
rven
tion,
1
cont
rol)
Long
itudi
nal –
385
ne
wbo
rns
(208
in
terv
entio
n, 1
78 c
ontr
ol)
Med
ian
dura
tion
of E
BF
% E
BF a
t 4
mon
ths
% E
BF a
t 5
mon
ths
% E
BF a
t 6
mon
ths
6 vs
. 4 m
onth
s
91.8
% v
s. 50
.7%
81.3
% v
s. 9.
6%
57.7
% v
s. 2.
7%
p<0.
001
p<0.
001
p<0.
001
p<0.
001
Bang
et
al. (
2005
); In
dia
Mob
iliza
tion
of is
sue
grou
ps; C
ouns
elin
g in
co
mm
uniti
es b
y pe
ers;
Cou
nsel
ing
in h
omes
by
peer
s
86 v
illag
es (
39
inte
rven
tion
villa
ges,
popu
latio
n: 3
8,99
8;
47 c
ontr
ol v
illag
es,
popu
latio
n: 4
2,14
9)
RC
T –
2,3
61 n
eona
tes;
base
line
(199
5-19
96):
763;
1st fo
llow
-up
(199
6–19
97):
685;
2nd
follo
w-u
p (1
997–
1998
): 91
3
2nd fo
llow
-up
vs.
1st fo
llow
-up
vs.
base
line
% b
reas
tfeed
ing
initi
atio
n w
ithin
six
hou
rs o
f bir
th89
.7%
vs.
81.9
%
vs. 4
7.5%
Sign
ifica
nce
of
tren
d p
<0.
001
Baqu
i et
al. (
2008
a); B
angl
ades
hC
ouns
elin
g in
hom
es
by la
y vo
lunt
eers
; Ev
ents
tar
getin
g po
licy
mak
ers
and
regu
lato
rs;
Mob
iliza
tion
of c
ampa
ign,
ev
ent,
or s
peci
al “
days
”
24 u
nion
s (p
opul
atio
n:
appr
oxim
atel
y 20
,000
eac
h) fr
om
thre
e ru
ral upazilas
of S
ylhe
t di
stri
ct (
8 un
ions
per
gro
up)
RC
T –
14,
769
live
birt
hs fr
om h
ome
care
in
terv
entio
n, 1
6,32
5 liv
e bi
rths
from
com
mun
ity
care
inte
rven
tion,
15,
350
from
con
trol
% b
reas
tfeed
ing
initi
atio
n w
ithin
one
hou
r of
bir
th
Hom
e ca
re v
s. co
ntro
l
Com
mun
ity c
are
vs.
cont
rol
81%
vs.
57%
71%
vs.
57%
p<0.
0001
p=0.
0158
31
Not
e th
at a
utho
rs a
lso re
port
ed a
dditi
onal
tim
e po
ints.
42 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ST
UD
YA
PP
RO
AC
HE
S
US
ED
SC
OP
E /
SC
AL
EE
VA
LU
AT
ION
D
ES
IGN
OU
TC
OM
E(S
) M
EA
SU
RE
DR
ES
ULT
S26
P-V
AL
UE
s /
CIs
27
Baqu
i et
al. (
2008
b); I
ndia
Cou
nsel
ing
in h
omes
by
lay
volu
ntee
rs; C
ouns
elin
g in
hom
es b
y pr
ovid
ers;
man
y ot
her
inte
rven
tions
to
impr
ove
curr
ent
heal
th
care
2 di
stri
cts
in U
ttar
Pr
ades
h st
ate
(1
inte
rven
tion,
1
cont
rol)
Rep
eate
d cr
oss-
sect
iona
l –
base
line:
14,
952
wom
en
who
had
had
a li
ve b
irth
or
stil
lbir
th w
ithin
the
re
fere
nce
peri
od (
8,75
6 in
terv
entio
n, 6
,196
co
ntro
l); e
ndlin
e:13
,826
w
omen
who
had
had
a li
ve
birt
h or
stil
lbir
th w
ithin
th
e re
fere
nce
peri
od
(7,8
12 in
terv
entio
n, 6
,014
co
ntro
l)
%br
east
feed
ing
initi
atio
n w
ithin
one
hou
r of
bir
thA
t ba
selin
e:
3.1%
vs.
2.4%
At
endl
ine:
37
.7%
vs.
5.8%
Diff
eren
ce in
di
ffere
nces
: p<
0.00
132
Bash
our
et a
l. (2
008)
; Syr
iaC
ouns
elin
g in
hom
es b
y pr
ovid
ers
1 ho
spita
l in
Dam
ascu
sR
CT
– 8
76 w
omen
who
ha
d re
cent
ly g
iven
bir
th
(285
in IG
1, 2
94 in
IG2,
29
7 in
con
trol
)
IG1
vs. I
G2
vs.
CG
33
% E
BF a
t 4
mon
ths
(usi
ng
no o
ther
flui
ds e
xcep
t br
east
milk
for
the
baby
)
28.5
% v
s. 30
.1%
vs
. 20.
2%
p=0.
023
Bert
i et
al. (
2010
); Et
hiop
ia, G
hana
, M
alaw
i and
Tan
zani
aM
eetin
gs t
arge
ting
polic
y m
aker
s an
d re
gula
tors
; Ev
ents
tar
getin
g po
licy
mak
ers
and
regu
lato
rs;
Supp
ort
grou
p in
co
mm
uniti
es; M
obili
zatio
n of
issu
e gr
oups
; Mas
s m
edia
4 co
untr
ies,
4 m
illio
n be
nefic
iari
es
Rep
eate
d cr
oss-
sect
iona
l –
seco
ndar
y da
ta fr
om
2-3
time
poin
ts fr
om
prog
ram
eva
luat
ions
of
mod
erat
e or
hig
h qu
ality
an
d D
emog
raph
ic H
ealth
Su
rvey
s (D
HS)
; pro
gram
su
rvey
sam
ple
size
s pe
r co
untr
y w
ere
betw
een
900
and
4801
ran
dom
ly
sele
cted
hou
seho
lds
per
surv
ey
endl
ine
vs.
mid
line
vs.
base
line
% E
BF fo
r 6
mon
ths
Ethi
opia
Gha
na
Mal
awi
Tanz
ania
49%
vs.
38%
vs.
25%
49%
vs.
27%
vs.
17%
70%
vs.
47%
vs.
15%
21%
vs.
15%
vs
. ---
--
--
--
--
32
P-va
lue
for d
iffer
ence
-in-d
iffer
ence
test
adj
uste
d fo
r age
, edu
catio
n, p
arity
, rel
igio
n an
d st
anda
rd-o
f-liv
ing
scor
e.33
IG
1 re
ceiv
ed fo
ur h
ome
visit
s on
days
one
, thr
ee, s
even
, and
30
follo
win
g de
liver
y. IG
2 re
ceiv
ed o
ne h
ome
visit
on
day
thre
e. T
he c
ontro
l gro
up re
ceiv
ed c
urre
nt st
anda
rd o
f ca
re in
Syr
ia, w
hich
incl
uded
no
hom
e vi
sits f
ollo
win
g ho
spita
l disc
harg
e
43 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ST
UD
YA
PP
RO
AC
HE
S
US
ED
SC
OP
E /
SC
AL
EE
VA
LU
AT
ION
D
ES
IGN
OU
TC
OM
E(S
) M
EA
SU
RE
DR
ES
ULT
S26
P-V
AL
UE
s /
CIs
27
Bhan
dari
et
al. (
2001
); In
dia
Cou
nsel
ing
in h
omes
by
prov
ider
s1
com
mun
ity in
D
elhi
RC
T –
418
infa
nts
four
m
onth
s of
age
(96
in fo
od
supp
lem
ent
grou
p; 9
5 in
nut
ritio
nal c
ouns
elin
g gr
oup;
and
96
in v
isita
tion
grou
p; 1
00 in
con
trol
gr
oup)
; dat
a co
llect
ed
whe
n in
fant
s w
ere
6, 9
and
12
mon
ths
of a
ge
Supp
lem
ent
+ c
ouns
elin
g vs
. cou
nsel
ing
alon
e vs
. vi
sita
tion
vs.
cont
rol
Com
pari
sons
w
ith fi
nal g
roup
(v
isita
tion)
% b
reas
tfeed
ing…
at 6
mon
ths
at
9 m
onth
s
at 1
2 m
onth
s
93.8
% v
s. 97
.9%
vs
. 99.
0% v
s. 93
.0%
,
92.0
% v
s. 95
.5%
vs
. 97.
9% v
s. 91
.4%
83.9
% v
s. 96
.9%
vs
. 96.
7% v
s. 89
.2%
NS,
NS,
NS
N
S, N
S, N
S p<
0.05
, NS,
NS
Bhan
dari
et
al. (
2003
); In
dia
Gro
up e
duca
tion
in
com
mun
ities
by
prov
ider
s; C
ouns
elin
g in
hom
es b
y pe
ers
8 co
mm
uniti
es
(4 in
terv
entio
n, 4
co
ntro
l)
RC
T –
1,1
15 in
fant
s bo
rn w
ithin
9 m
onth
s of
st
art
of in
terv
entio
n; 3
m
onth
ass
essm
ent:
895
infa
nts
(483
inte
rven
tion,
41
2 co
ntro
l); 6
mon
th
asse
ssm
ent:
880
infa
nts
(468
inte
rven
tion,
412
co
ntro
l)
% E
BF a
t 3
mon
ths
% E
BF a
t 4
mon
ths
% E
BF a
t 5
mon
ths
% E
BF a
t 6
mon
ths
Med
ian
dura
tion
of E
BF
EBF
amon
g lo
w-b
irth
w
eigh
t ba
bies
79%
vs.
48%
69%
vs.
12%
49%
vs.
6%
42%
vs.
4%
122
days
vs.
41
days
high
er r
ates
at
eve
ry t
ime
poin
t
p-<
0.00
01
p-<
0.00
01
p-<
0.00
01
p-<
0.00
01
p-<
0.00
01
p<0.
001
Bhan
dari
et
al. (
2005
); In
dia
Cou
nsel
ing
in fa
cilit
ies
by p
rovi
ders
; Cou
nsel
ing
in h
omes
by
peer
s; M
obili
zatio
n of
issu
e gr
oups
8 co
mm
uniti
es
(4 in
terv
entio
n, 4
co
ntro
l)
RC
T –
102
5 ne
wbo
rns
0 vs
. 1-2
vs.
3+
chan
nels
% E
BF a
t 3
mon
ths
% E
BF a
t 4
mon
ths
Mea
n du
ratio
n of
EBF
(d
ays)
70.8
% v
s. 81
.3%
vs
. 93.
6%
data
not
re
port
ed
114.
1 vs
. 127
.3
vs. 1
28.7
day
s
p=0.
0002
ad
j. p=
0.00
2
p=0.
001
p=0.
090
adj.
p= 0
.064
44 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ST
UD
YA
PP
RO
AC
HE
S
US
ED
SC
OP
E /
SC
AL
EE
VA
LU
AT
ION
D
ES
IGN
OU
TC
OM
E(S
) M
EA
SU
RE
DR
ES
ULT
S26
P-V
AL
UE
s /
CIs
27
Bhut
ta e
t al
. (20
08b)
; Pak
ista
nG
roup
edu
catio
n in
co
mm
uniti
es b
y pr
ovid
ers;
Cou
nsel
ing
in h
omes
by
lay
volu
ntee
rs; M
obili
zatio
n of
is
sue
grou
ps; S
mal
l med
ia;
Mid
-siz
ed m
edia
8 vi
llage
clu
ster
s fr
om 2
sub
-dis
tric
ts
in S
indh
pro
vinc
e (4
in
terv
entio
n w
ith a
to
tal p
opul
atio
n of
13
8,60
0, 4
con
trol
)
Rep
eate
d cr
oss-
sect
iona
l –
data
wer
e co
llect
ed a
t ba
selin
e (Ju
n-A
ug 2
003)
an
d th
ree
othe
r tim
e po
ints
; End
line
data
(Se
pt
2005
) re
port
ed a
re fr
om
395
and
375
wom
en
from
the
inte
rven
tion
and
cont
rol v
illag
e cl
uste
rs
% b
reas
tfeed
ing
initi
atio
n w
ithin
one
hou
r of
bir
th66
.1%
vs.
21.1
%
Not
rep
orte
d
% E
BF fo
r fir
st 4
mon
ths
64.6
% v
s. 18
.1%
Not
rep
orte
d
Bort
olin
i and
Vito
lo (
2012
); Br
azil
Cou
nsel
ing
in h
omes
by
prov
ider
s1
hosp
ital
RC
T –
397
new
born
s (1
63in
terv
entio
n, 2
34
cont
rol)
% E
BF a
t…
< 1
mon
th
= o
r >
4 m
onth
s
= o
r >
6 m
onth
s
33.3
% v
s. 48
%
45.1
% v
s. 28
.6%
19.1
% v
s. 8.
2%
p=0.
004
p=0.
001
p=0.
001
% b
reas
tfeed
ing
at…
- at
6 m
onth
s
- at
12
mon
ths
66.3
% v
s. 55
.6%
52.8
% v
s. 41
.9%
p=0.
04
p=0.
04
Brau
n et
al.
(200
3); B
razi
lC
ouns
elin
g in
faci
litie
s by
pr
ovid
ers;
Supp
ort
grou
p in
faci
litie
s by
pro
vide
rs
and/
or la
y vo
lunt
eers
; Sm
all
med
ia
1 ho
spita
lLo
ngitu
dina
l – 4
37
new
born
s (in
terv
entio
n:
250
born
in 1
999,
2 y
ears
af
ter
BFH
I im
plem
enta
tion;
co
ntro
l: 18
7 bo
rn in
199
4)
Dur
atio
n of
EBF
2
vs. 1
mon
thp=
0.01
Cou
tinho
et
al. (
2005
); Br
azil
Cou
nsel
ing
in h
omes
by
lay
volu
ntee
rs2
hosp
itals
R
CT
– 3
50 w
omen
w
ho g
ave
birt
h in
ta
rget
hos
pita
ls (
175
inte
rven
tion,
175
con
trol
)
% E
BF a
t 6
mon
ths
45%
vs.
13%
p<0.
0001
% b
reas
tfeed
ing
at 6
m
onth
s 78
% v
s. 62
%p<
0.00
01
Cro
okst
on e
t al
. (20
07);
Cam
bodi
aC
omm
unity
/soc
ial
mob
iliza
tion;
Gro
up
educ
atio
n in
com
mun
ities
by
lay
volu
ntee
rs;
Cou
nsel
ing
in c
omm
uniti
es
by la
y vo
lunt
eers
; Sm
all
med
ia; S
uppo
rt g
roup
in
faci
litie
s by
pro
vide
rs a
nd/
or la
y vo
lunt
eers
4 di
stri
cts
(3
inte
rven
tion,
1
cont
rol)
Rep
eate
d cr
oss-
sect
iona
l –
base
line
(sum
mer
of
2004
): 44
0 w
omen
with
a
child
less
tha
n 6
mon
ths
of
age
(206
inte
rven
tion,
234
co
ntro
l); 1
yea
r fo
llow
-up
: 467
wom
en (
222
inte
rven
tion,
245
con
trol
)
% b
reas
tfeed
ing
initi
atio
n w
ithin
one
hou
r of
bir
thA
t ba
selin
e:
RR
=1.
1
At
follo
w-u
p:
RR
=1.
62
(95%
CI:
0.74
–1.6
8)
(95%
CI:
1.30
–2.0
1)
EBF
in t
he p
revi
ous
24
hour
s am
ong
infa
nts
< 6
m
onth
s of
age
At
base
line:
R
R=
1.54
At
follo
w-u
p:
RR
=1.
81
(95%
CI:
1.21
–1.9
6)
(95%
CI:
1.49
–2.2
1)
de O
livei
ra e
t al
. (20
06);
Braz
ilC
ouns
elin
g in
faci
litie
s by
pr
ovid
ers;
Cou
nsel
ing
in
hom
es b
y pr
ovid
ers
1 ho
spita
lR
CT
– 2
11 m
othe
r-in
fant
pa
irs
(74
inte
rven
tion,
137
co
ntro
l)
% E
BF a
t 7
days
po
stpa
rtum
% E
BF a
t 30
day
s po
stpa
rtum
79.7
% v
s. 82
.5%
60.8
% v
s. 53
.3%
NS
NS
45 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ST
UD
YA
PP
RO
AC
HE
S
US
ED
SC
OP
E /
SC
AL
EE
VA
LU
AT
ION
D
ES
IGN
OU
TC
OM
E(S
) M
EA
SU
RE
DR
ES
ULT
S26
P-V
AL
UE
s /
CIs
27
Duy
an C
amur
dan
et a
l. (2
007)
; Tu
rkey
Cou
nsel
ing
in fa
cilit
ies
by
prov
ider
s; Su
ppor
t gr
oup
in fa
cilit
ies
by p
rovi
ders
an
d/or
lay
volu
ntee
rs; S
mal
l m
edia
1 ho
spita
l C
ross
-sec
tiona
l – 2
97
babi
es b
orn
in t
he fo
ur
mon
ths
afte
r BF
HI
(Nov
embe
r 20
02-F
ebru
ary
2003
) (in
terv
entio
n)
and
258
babi
es b
orn
befo
re B
FHI (
Nov
embe
r 20
01-F
ebru
ary
2002
) (c
ontr
ol)
af
ter-
BFH
I gr
oup
vs.
befo
re-B
FHI
% E
BF a
t 15
day
s ol
d
% E
BF a
t 2
mon
ths
% E
BF-a
t 4
mon
ths
% E
BF a
t 6
mon
ths
97.4
% v
s. 93
.1%
76.1
% v
s. 67
.2%
53.7
% v
s. 45
.6%
9.3%
vs.
9.8%
NS
NS
NS
NS
Mea
n du
ratio
n of
br
east
feed
ing
(mon
ths)
21.1
7 vs
. 17.
83
mon
ths
O
R=
1.5
p=0.
0036
(9
5% C
I: 1.
16–2
.03)
Gog
ia a
nd S
achd
ev (
2010
); In
dia,
Paki
stan
, Ban
glad
esh
Cou
nsel
ing
in h
omes
by
lay
volu
ntee
rsva
ried
Lite
ratu
re r
evie
w –
four
R
CT
s Br
east
feed
ing
initi
atio
n w
ithin
one
hou
r of
bir
thPo
oled
RR
:
3.35
p=
0.01
2 (9
5% C
I: 1.
31-
8.59
)
Gul
dan
et a
l. (2
000)
; Chi
naC
ouns
elin
g in
hom
es b
y pe
ers
4 to
wns
hips
(2
inte
rven
tion,
2
cont
rol)
RC
T –
new
born
s w
ere
enro
lled
thro
ugho
ut
the
year
of p
roje
ct
impl
emen
tatio
n, a
t co
mpl
etio
n of
the
ye
ar in
fant
s ha
d be
en
mon
itore
d fo
r 4-
12
mon
ths;
495
infa
nts
born
du
ring
stu
dy p
erio
d an
alyz
ed (
250
inte
rven
tion,
24
5 co
ntro
l); in
fant
s 4-
6 m
onth
s ol
d: 5
7 in
terv
entio
n, 6
9 co
ntro
l; in
fant
s 7-
9 m
onth
s ol
d: 8
5 in
terv
entio
n, 7
6 co
ntro
l; in
fant
s 10
-12
mon
ths
old:
10
8 in
terv
entio
n, 1
00
cont
rol
% b
reas
tfeed
ing
initi
atio
n w
ithin
one
hou
r of
bir
th
% b
reas
tfeed
ing
initi
atio
n w
ithin
24
hour
or
mor
e of
bir
th
% g
ave
colo
stru
m t
o in
fant
23%
vs.
18%
23%
vs.
35%
91
% v
s. 80
%
NS
p=0.
031
p<0.
004
% b
reas
tfeed
ing
at 4
-12
mon
ths
83%
vs.
75%
p=0.
034
Gup
ta e
t al
. (20
04);
Uga
nda
Mas
s m
edia
12 d
istr
icts
C
ross
-sec
tiona
l – 2
12
wom
en a
ged
15-4
9 ye
ars
who
se y
oung
est
child
was
un
der
six
mon
ths
of a
ge
EBF
for
6 m
onth
s
No
BCC
m
essa
ge
expo
sure
: O
R=
2.32
Expo
sure
to
1 BC
C t
ype:
O
R=
1.00
Expo
sure
to
>1
BCC
typ
e:
OR
=2.
79
p<0.
05
NS
p<
0.05
46 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ST
UD
YA
PP
RO
AC
HE
S
US
ED
SC
OP
E /
SC
AL
EE
VA
LU
AT
ION
D
ES
IGN
OU
TC
OM
E(S
) M
EA
SU
RE
DR
ES
ULT
S26
P-V
AL
UE
s /
CIs
27
Guy
on e
t al
. (20
09);
Mad
agas
car
Mob
iliza
tion
of is
sue
grou
ps; M
obili
zatio
n of
ca
mpa
ign,
eve
nt, o
r sp
ecia
l “d
ays”
; Mas
s m
edia
2 hi
ghla
nd p
rovi
nces
; ta
rget
ed p
opul
atio
n va
ried
thr
ough
out
proj
ect
from
1.4
m
illio
n in
6 d
istr
icts
to
6 m
illio
n in
23
dist
rict
s
Rep
eate
d cr
oss-
sect
iona
l –
base
line
(200
0): 1
,200
ch
ildre
n un
der
two
year
s ol
d; e
ndlin
e (2
005)
: 1,7
60
child
ren
unde
r tw
o ye
ars
old
endl
ine
vs.
base
line
% b
reas
tfeed
ing
initi
atio
n w
ithin
one
hou
r of
bir
th68
% v
s. 33
%p<
0.00
1
% E
BF o
f inf
ants
< 6
m
onth
s ol
d70
% v
s. 42
%p<
0.00
1
% b
reas
tfeed
ing
of
child
ren
12-1
5 m
onth
s of
age
% b
reas
tfeed
ing
of
child
ren
20-2
3 m
onth
s of
age
94%
vs.
89%
73
% v
s. 43
%
p<0.
05
p<0.
001
Hai
der
et a
l. (2
000)
; Ban
glad
esh
Cou
nsel
ing
in h
omes
by
peer
s40
zon
es in
Dha
ka
(20
inte
rven
tion,
20
cont
rol)
RC
T –
573
wom
en in
last
tr
imes
ter
of p
regn
ancy
w
ho c
ompl
eted
all
five
mon
ths
of s
tudy
(28
8 in
terv
entio
n, 2
85 c
ontr
ol)
% b
reas
tfeed
ing
initi
atio
n w
ithin
one
hou
r of
bir
th64
% v
s. 15
%
p<0.
001
% E
BF a
t 5
mon
ths
70%
vs.
6%p<
0.00
01
Hal
l (20
11);
Indi
a, Sy
ria,
Paki
stan
, and
Ba
ngla
desh
Cou
nsel
ing
in c
omm
uniti
es;
Cou
nsel
ing
in h
omes
by
peer
s; G
roup
edu
catio
n in
co
mm
uniti
es
vari
edLi
tera
ture
rev
iew
– fo
ur
RC
Ts
EBF
in lo
w a
nd m
iddl
e-in
com
e co
untr
ies
(effe
ct
of c
omm
unity
-bas
ed
inte
rven
tions
)
pool
ed O
R=
5.9
(9
5% C
I: 1.
81-
18.6
)
Haq
ue e
t al
. (20
02);
Bang
lade
shC
ouns
elin
g in
faci
litie
s by
pr
ovid
ers
3 co
unse
ling
cent
ers
Long
itudi
nal –
114
m
othe
r-ch
ild p
airs
co
mpl
eted
one
-yea
r fo
llow
-up
(59
inte
rven
tion,
55
con
trol
)
% g
ave
colo
stru
m t
o in
fant
10
0% v
s. 98
.9%
--
% E
BF fo
r 5
mon
ths
54.2
% v
s. 36
.4%
NS
Har
kins
et
al. (
2008
); H
ondu
ras
Mob
iliza
tion
of is
sue
grou
ps; C
ouns
elin
g in
ho
mes
1 co
mm
unity
R
epea
ted
cros
s-se
ctio
nal34
–H
ondu
ras:
300
hous
ehol
ds w
ith
child
ren
unde
r tw
o ye
ars
old
inte
rvie
wed
in A
ugus
t 20
04 a
nd D
ecem
ber
2005
(p
ost-
inte
rven
tion)
en
dlin
e vs
. ba
selin
e
EBF
for
6 m
onth
s 19
% v
s. 11
%p<
0.05
47 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ST
UD
YA
PP
RO
AC
HE
S
US
ED
SC
OP
E /
SC
AL
EE
VA
LU
AT
ION
D
ES
IGN
OU
TC
OM
E(S
) M
EA
SU
RE
DR
ES
ULT
S26
P-V
AL
UE
s /
CIs
27
Imda
d et
al.
(201
1); v
ario
usC
ouns
elin
g; G
roup
ed
ucat
ion/
coun
selin
gva
ried
Lite
ratu
re r
evie
w –
53
RC
Ts
and
quas
i-RC
Ts
EBF
at 4
-6 w
eeks
- in
dev
elop
ed a
nd
deve
lopi
ng c
ount
ries
- in
dev
elop
ing
coun
trie
s
EBF
at 6
mon
ths
- in
dev
elop
ed a
nd
deve
lopi
ng c
ount
ries
- in
dev
elop
ing
coun
trie
s
RR
=2.
37
RR
= 1
.89
RR
=1.
43
RR
= 6
.32
(95%
CI:
1.33
-4.
24)
p<0.
001
(95%
CI:
1.50
-2.
37)
p<0.
001
(95%
CI:
1.28
-1.
60)
p<0.
001
(95%
CI:
3.35
-11
.93)
p<
0.00
1
Brea
stfe
edin
g at
6 m
onth
s
- in
dev
elop
ed a
nd
deve
lopi
ng c
ount
ries
RR
= 1
.12
(95%
CI:
1.01
-1
.24)
Jolly
et
al. (
2012
); va
riou
sC
ouns
elin
g in
hom
es
by p
eers
; Cou
nsel
ing
in c
omm
uniti
es b
y pe
ers;
Sup
port
gro
up in
co
mm
uniti
es b
y pe
ers
vari
edLi
tera
ture
rev
iew
– 1
7 R
CT
s R
isk
of n
ot E
BF a
t la
st
stud
y fo
llow
-up
in lo
w
inco
me
coun
trie
s (P
eer
supp
ort
vs. n
one)
RR
= 0
.63
(95%
CI:
0.52
-
0.78
)
Ris
k of
not
bre
astfe
edin
g at
last
stu
dy fo
llow
-up
in lo
w in
com
e co
untr
ies
(Pee
r su
ppor
t vs
. non
e)
RR
= 0
.70
(95%
CI:
0.60
-
0.82
)
Khr
eshe
h et
al.
(201
1); J
orda
nC
ouns
elin
g in
faci
litie
s by
pr
ovid
ers;
Cou
nsel
ing
in
hom
es b
y pr
ovid
ers
(vi
a ph
one)
2 ho
spita
lsR
CT
– 9
0 po
stpa
rtum
w
omen
(45
inte
rven
tion,
45
con
trol
)
% E
BF a
t 6
mon
ths
39%
vs.
27%
NS
34
It n
ot c
lear
from
the
artic
le if
this
was
a lo
ngitu
dina
l or r
epea
ted
cros
s-se
ctio
nal s
tudy
. Giv
en th
e in
dica
tor r
epor
ted,
it is
ass
umed
to b
e re
peat
ed c
ross
-sec
tiona
l.
48 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ST
UD
YA
PP
RO
AC
HE
S
US
ED
SC
OP
E /
SC
AL
EE
VA
LU
AT
ION
D
ES
IGN
OU
TC
OM
E(S
) M
EA
SU
RE
DR
ES
ULT
S26
P-V
AL
UE
s /
CIs
27
Kra
mer
et
al. (
2001
); R
epub
lic o
f Be
laru
sC
ouns
elin
g in
faci
litie
s by
pr
ovid
ers;
Supp
ort
grou
p in
faci
litie
s by
pro
vide
rs
and/
or la
y vo
lunt
eers
; Sm
all
med
ia
31 m
ater
nity
ho
spita
ls a
nd
poly
clin
ics
(16
inte
rven
tion,
15
cont
rol)
RC
T –
16,
442
mot
her-
infa
nt p
airs
(8,
547
inte
rven
tion,
7,8
95
cont
rol)
% E
BF a
t 3
mon
ths
% E
BF a
t 6
mon
ths
43.3
% v
s. 6.
4%
AO
R=
0.47
7.9%
vs.
0.6%
p<0.
001
(95%
CI:
0.32
-0.
69)
p= 0
.01
% b
reas
tfeed
ing
at 1
2 m
onth
s19
.7%
vs.
11.4
%
AO
R=
0.47
(9
5% C
I: 0.
32-
0.69
)
Kum
ar e
t al
. (20
08);
Indi
aG
roup
Edu
catio
n in
co
mm
uniti
es b
y la
y vo
lunt
eers
; Cou
nsel
ing
in
hom
es b
y la
y vo
lunt
eers
; Sm
all m
edia
; Tra
ditio
nal
med
ia
39 v
illag
es
(pop
ulat
ion:
10
4,12
3) (
13 v
illag
es
in e
ach
grou
ps)35
RC
T –
2,6
01 li
ve b
irth
s (1
,522
inte
rven
tion,
1,0
79
cont
rol)
% p
re-la
ctea
l fee
d
% b
reas
tfeed
ing
initi
atio
n w
ithin
one
hou
r of
bir
th
38·4
% v
s. 79
·9%
70
·6%
vs.
15·5
%
Rat
e ra
tio: 0
·49
(0·4
2–0·
57)
p<0·
0001
Rat
e ra
tio: 4
·57
(3·3
8–6·
15)
p<0·
0001
Kup
rata
kul e
t al
. (20
10);
Tha
iland
Supp
ort
grou
p in
faci
litie
s by
pro
vide
rs a
nd/o
r la
y vo
lunt
eer;
Cou
nsel
ing
in h
omes
by
prov
ider
s; C
ouns
elin
g in
hom
es b
y pr
ovid
ers
(vi
a ph
one)
5 ho
spita
lsR
CT
– 8
0 pr
egna
nt
wom
en o
f mor
e th
an
32 w
eeks
’ ges
tatio
n (4
0 in
terv
entio
n; 4
0 co
ntro
l)
% E
BF a
t …
-
14 d
ays
- 1
mon
th
- 2
mon
ths
- 4
mon
ths
- 5
mon
ths
- 6
mon
ths
82.5
% v
s. 52
.6%
77
.5%
vs.
52.6
%
62.5
% v
s. 36
.8%
35
.0%
vs.
7.9%
25
.0%
vs.
2.6%
20
.0%
vs.
0%
p =
0.0
05
p =
0.0
21
p =
0.0
23
p =
0.0
08
p =
0.0
12
p =
0.0
05
% p
redo
min
ant
brea
stfe
edin
g at
6 m
onth
s %
par
tial b
reas
tfeed
ing
at
6 m
onth
s
40.0
% v
s. 5.
3%
15.0
% v
s. 15
.8%
p =
0.0
002
p =
0.9
23
Lass
i et
al. (
2010
); va
riou
sEv
ents
tar
getin
g po
licy
mak
ers
and
regu
lato
rs;
Mob
iliza
tion
of is
sue
grou
ps; C
ouns
elin
g in
ho
mes
by
peer
s
vari
edLi
tera
ture
rev
iew
– 1
8 R
CT
s an
d qu
asi-R
CT
s BF
initi
atio
n w
ithin
one
ho
ur o
f bir
thR
R =
1.9
4 p<
0.00
1
(95%
CI:
1.56
-
2.42
)
Leite
et
al. (
2005
); Br
azil
Cou
nsel
ing
in h
omes
by
peer
s8
heal
th c
ente
rs
RC
T –
1,0
03 w
omen
an
d th
eir
new
born
s (5
03
inte
rven
tion,
500
con
trol
)
% E
BF a
t 4
mon
ths
24.7
% v
s. 19
.4%
p =
0.0
44
35
The
focu
s her
e is
on th
e co
ntro
l gro
up, w
hich
“re
ceiv
ed th
e us
ual s
ervi
ces o
f go
vern
men
tal a
nd n
on-g
over
nmen
tal o
rgan
izat
ions
in th
e ar
ea; a
n in
terv
entio
n gr
oup,
whi
ch re
ceiv
ed a
pre
vent
ive
pack
age
of in
terv
entio
ns fo
r ess
entia
l new
born
car
e (b
irth
prep
ared
ness
, cle
an d
eliv
ery
and
cord
car
e, th
erm
al c
are
[incl
udin
g skin-to-skincare],breastfeedingpromotion,anddangersignrecognition)”(Kumaretal.,2008).
49 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ST
UD
YA
PP
RO
AC
HE
S
US
ED
SC
OP
E /
SC
AL
EE
VA
LU
AT
ION
D
ES
IGN
OU
TC
OM
E(S
) M
EA
SU
RE
DR
ES
ULT
S26
P-V
AL
UE
s /
CIs
27
Li e
t al
. (20
07);
Chi
naM
obili
zatio
n of
issu
e gr
oups
; Mid
-siz
ed m
edia
; Sm
all m
edia
10 v
illag
es (
2 fr
om
each
of fi
ve s
ampl
ed
tow
nshi
ps in
Lux
i ci
ty (
popu
latio
n of
app
roxi
mat
ely
321,
000)
Rep
eate
d cr
oss-
sect
iona
l –
352
infa
nts
born
dur
ing
refe
renc
e pe
riod
endl
ine
vs.
base
line
Ave
rage
tim
e un
til
initi
atio
n of
bre
astfe
edin
g (h
ours
)
- M
ale
child
- Fe
mal
e ch
ild
- Tot
al
% b
reas
tfeed
ing
initi
atio
n w
ithin
30
min
utes
- M
ale
child
- Fe
mal
e ch
ild
- Tot
al
17.7
vs.
27.8
20.3
vs.
29.8
19.0
vs.
28.5
47.4
% v
s. 37
.6%
42.4
% v
s. 36
.8%
44.9
% v
s. 37
.2%
-- -- -- -- -- --
Mea
n du
ratio
n of
br
east
feed
ing
(mon
ths)
- M
ale
child
- Fe
mal
e ch
ild
- Tot
al
12.0
vs.
12.6
12.9
vs.
12.9
12.5
vs.
12.8
-- -- --
Mac
kint
osh
et a
l. (2
002)
; Vie
tnam
Cou
nsel
ing
in h
omes
by
peer
s; G
roup
edu
catio
n in
com
mun
ities
by
lay
volu
ntee
rs
5 co
mm
unes
(4
inte
rven
tion,
1
cont
rol)
Rep
eate
d cr
oss-
sect
iona
l –
46 h
ouse
hold
s in
in
terv
entio
n (fa
mily
had
on
e ch
ild w
ho p
revi
ousl
y pa
rtic
ipat
ed in
the
pro
ject
an
d on
e yo
unge
r ch
ild
who
had
not
par
ticip
ated
), 25
hou
seho
lds
in c
ontr
ol
(had
no
prev
ious
exp
osur
e to
pro
gram
act
iviti
es a
nd
incl
uded
an
olde
r an
d yo
unge
r si
blin
g in
the
age
ra
nge
of t
he in
terv
entio
n ho
useh
olds
)
% c
urre
ntly
bre
ast-
feed
ing36
“yo
unge
r” c
hild
Mea
n du
ratio
n of
br
east
feed
ing
(mon
ths)
41.3
% v
s. 20
%
16.8
vs.
16.6
NS
NS
Man
andh
ar e
t al
. (20
04);
Nep
alSu
ppor
t gr
oup
in
com
mun
ities
by
peer
s; M
obili
zatio
n of
issu
e gr
oups
; Cou
nsel
ing
in
hom
es b
y pe
ers
42 r
ural
vill
age
deve
lopm
ent
com
mitt
ees
from
on
e di
stri
ct (
21
inte
rven
tion,
21
cont
rol)
RC
T –
6,7
14 (
3,19
0 in
terv
entio
n, 3
,524
co
ntro
l)
% b
reas
tfeed
ing
initi
atio
n w
ithin
one
hou
r of
bir
th
% d
isca
rded
col
ostr
um
62%
vs.
54%
, A
OR
37 =
1.4
0
29%
vs.
42%
, A
OR
=0.
55
(95%
CI:
0.52
–3.7
9)
(95%
CI:
0.27
–1.1
0)
36Womenwereaskedaboutcurrentbreastfeedingpracticesofthe“younger”child.Themeanageofthe“younger”childwas26monthsininterventioncommunitiesand29monthsincontrolcommunities.The
differencewasnotstatisticallysignificant.
50 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ST
UD
YA
PP
RO
AC
HE
S
US
ED
SC
OP
E /
SC
AL
EE
VA
LU
AT
ION
D
ES
IGN
OU
TC
OM
E(S
) M
EA
SU
RE
DR
ES
ULT
S26
P-V
AL
UE
s /
CIs
27
Mat
ovu
et a
l. (2
008)
; Uga
nda
Cou
nsel
ing
in fa
cilit
ies
by p
rovi
ders
; Gro
up
educ
atio
n in
faci
litie
s by
pr
ovid
ers;
Smal
l med
ia;
Mid
-siz
ed m
edia
3 he
alth
faci
litie
s (2
ho
spita
ls, 1
cen
ter)
R
etro
spec
tive
cros
s-se
ctio
nal s
tudy
– 1
39
HIV
infe
cted
wom
en w
ith
child
ren
6-12
mon
ths
old
who
adh
ered
to
EBF
for
six
mon
ths,
139
HIV
in
fect
ed w
omen
who
did
no
t ad
here
to
EBF
for
six
mon
ths
EBF
for
6 m
onth
s am
ong
HIV
+ w
omen
(in
divi
dual
vs
. gro
up c
ouns
elin
g)
EBF
for
6 m
onth
s am
ong
HIV
+ w
omen
(at
leas
t 4
AN
C s
essi
ons
atte
nded
vs.
few
er t
han
4)
% E
BF fo
r 6
mon
ths
amon
g H
IV+
wom
en
(att
ende
d at
leas
t 6
post
nata
l cou
nsel
ing
sess
ions
vs.
few
er t
han
6)
EBF
for
6 m
onth
s am
ong
HIV
+ w
omen
(di
scus
sed
with
hea
lth w
orke
r de
cisi
on r
egar
ding
EBF
vs.
did
not)
OR
=3.
43
OR
=5.
95
OR
=3.
34
OR
= 4
.97
p<0.
05
p<0.
05
p<0.
05
p<0.
05
Mor
row
and
Gue
rrer
o (2
001)
; M
exic
oC
ouns
elin
g in
hom
es b
y pe
ers;
Smal
l med
ia1
com
mun
ity
(pop
ulat
ion
of
appr
oxim
atel
y 30
,000
)
RC
T –
130
wom
en 3
m
onth
s po
stpa
rtum
(44
IG
1, 5
2 IG
2, 3
4 co
ntro
l)
IG
1 vs
. IG
2 vs
. co
ntro
l gro
up
% E
BF a
t 3
mon
ths
67%
vs.
52%
vs.
12%
p <
0.0
01, l
og
rank
tes
t
Om
er e
t al
. (20
08);
Paki
stan
Trad
ition
al m
edia
; C
ouns
elin
g in
hom
es b
y pe
ers
10 c
omm
uniti
es
from
3 d
istr
icts
(5
inte
rven
tion,
5
cont
rol),
8 o
f whi
ch
wer
e ru
ral
RC
T –
1,0
70 w
omen
w
ho h
ad b
een
preg
nant
an
d de
liver
ed d
urin
g th
e th
ree
year
s pr
ior
to
the
inte
rven
tion
(529
in
terv
entio
n, 5
41 c
ontr
ol)
% g
ave
colo
stru
m t
o in
fant
79
.2%
vs.
65.3
%
OR
=1.
60
(95%
CI:
1.17
–2.1
8)
Pach
ón e
t al
. (20
02); V
ietn
amG
roup
edu
catio
n in
co
mm
uniti
es b
y la
y vo
lunt
eers
12 c
omm
unes
from
on
e ru
ral V
ietn
am
(6 in
terv
entio
n, 6
co
ntro
l)
Long
itudi
nal –
238
ch
ildre
n 5-
25 m
onth
s ol
d (1
19 in
terv
entio
n, 1
19
cont
rol)
% b
reas
tfeed
ing
prev
ious
da
y at
mon
th 0
% b
reas
tfeed
ing
prev
ious
da
y at
mon
th 1
2
72.3
% v
s. 65
.5%
13.4
% v
s. 13
.9%
NS
NS
37
Adj
uste
d od
ds ra
tio
51 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ST
UD
YA
PP
RO
AC
HE
S
US
ED
SC
OP
E /
SC
AL
EE
VA
LU
AT
ION
D
ES
IGN
OU
TC
OM
E(S
) M
EA
SU
RE
DR
ES
ULT
S26
P-V
AL
UE
s /
CIs
27
Piw
oz e
t al
. (20
05);
Zim
babw
eC
ouns
elin
g in
faci
litie
s by
pr
ovid
ers;
Cou
nsel
ing
in
com
mun
ities
by
prov
ider
s; G
roup
edu
catio
n in
fa
cilit
ies;
Gro
up e
duca
tion
in c
omm
uniti
es; M
id-s
ized
m
edia
14 m
ater
nity
clin
ics
from
gre
ater
H
arar
e
RC
T –
14,
110
wom
en
from
the
Zim
babw
e V
itam
in A
for
Mot
hers
an
d Ba
bies
Pro
ject
clin
ical
(Z
VIT
AM
BO)
clin
ical
tri
al;
11,3
62, 1
311,
and
143
7 w
ere
enro
lled
duri
ng
the
pre,
par
tial,
and
full
inte
rven
tion
peri
od; d
ata
wer
e co
llect
ed a
t m
ultip
le
time
poin
ts
% E
BF fo
r at
leas
t 3
mon
ths
Part
ial
part
icip
atio
n:
AO
R=
1.75
Full
part
icip
atio
n:
AO
R=
8.43
No
part
icip
atio
n vs
. gro
up o
nly
vs. i
ndiv
idua
l co
unse
ling
only
vs
. gro
up +
in
divi
dual
5.
5% v
s. 13
.4%
vs
. 15.
9% v
s. 23
.7%
p<0.
001
(95%
CI:
1.31
-2.
35)
p<0.
0001
(9
5% C
I: 6.
13–1
1.59
) p<
0.00
01
Piw
oz e
t al
. (20
07);
Zim
babw
eG
roup
edu
catio
n in
fa
cilit
ies
by p
rovi
ders
; Sm
all
med
ia; M
id-s
ized
med
ia;
Cou
nsel
ing
in fa
cilit
ies
by
prov
ider
s
14 m
ater
nity
clin
ics
from
gre
ater
H
arar
e
RC
T –
437
HIV
+ p
ost-
inte
rven
tion
wom
en fr
om
the
ZV
ITA
MBO
clin
ical
tr
ial (
20 r
ecei
ved
3 vi
sits
, 10
8 re
ceiv
ed 2
vis
its,
234
rece
ived
1 v
isit,
75
rece
ived
no
visi
ts);
used
da
ta c
olle
cted
at
6 w
eeks
po
stpa
rtum
, 3 m
onth
s po
stpa
rtum
, and
eve
ry 3
m
onth
s th
erea
fter
for
up
to 2
4 m
onth
s
Dos
e re
spon
se:
0 vs
. 1 v
s. 2
vs. 3
vi
sits
% E
BF a
t 6
wee
ks
% E
BF a
t 3
mon
ths
%
EBF
at
6 m
onth
s
8% v
s. 15
% v
s. 14
.8%
vs.
30%
6.7%
vs.
12.8
%
vs. 1
7.6%
vs.
25%
4.0%
vs.
6.0%
vs.
4.6%
vs.
5.0%
p=0.
02
p=0.
005
p=0.
48
Qui
nn e
t al
. (20
05);
Boliv
ia,
Mad
agas
car
and
Gha
naIn
divi
dual
cou
nsel
ing;
Supp
ort
grou
p; M
ass
med
ia; S
mal
l med
ia;
Mob
iliza
tion
Boliv
ia -
3
ecor
egio
ns i
n ru
ral
and
urba
n ar
eas
(1
mill
ion
peop
le)
G
hana
– 3
0 di
stri
cts
(3.5
mill
ion
peop
le)
Mad
agas
car
- 10
fo
cus
dist
rict
s of
2
high
land
pro
vinc
es
(exp
ande
d an
d co
ntra
cted
due
to
polit
ical
cri
ses)
Rep
eate
d cr
oss-
sect
iona
l –
larg
e re
peat
ed s
urve
ys in
ea
ch c
ount
ry
% t
imel
y in
itiat
ion
of
brea
stfe
edin
g
Boliv
ia
Mad
agas
car
Gha
na
74%
vs.
56%
78%
vs.
34%
50%
vs.
32%
p<0.
001
p<0.
001
p<0.
05
% E
BF o
f inf
ants
< 6
m
onth
s ol
d
Boliv
ia
Mad
agas
car
Gha
na
65%
vs.
54%
68%
vs.
46%
79%
vs.
68%
p<0.
001
p<0.
001
p<0.
001
52 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ST
UD
YA
PP
RO
AC
HE
S
US
ED
SC
OP
E /
SC
AL
EE
VA
LU
AT
ION
D
ES
IGN
OU
TC
OM
E(S
) M
EA
SU
RE
DR
ES
ULT
S26
P-V
AL
UE
s /
CIs
27
Ren
frew
et
al. (
2012
); va
riou
sIn
divi
dual
cou
nsel
ing;
Gro
up e
duca
tion
/ co
unse
ling
vari
edLi
tera
ture
rev
iew
– 5
2 R
CT
s or
qua
si-R
CT
s; 37
in
hig
h-in
com
e co
untr
ies,
12 in
upp
er-m
iddl
e-in
com
e co
untr
ies,
2 in
low
-mid
dle-
inco
me
coun
trie
s, an
d 2
in
low
-inco
me
coun
trie
s38
risk
rat
ios
follo
win
g al
l for
ms
of
extr
a su
ppor
t to
geth
er
Ris
k of
hav
ing
stop
ped
EBF
at s
ix m
onth
s (a
ll co
untr
ies)
Ris
k of
hav
ing
stop
ped
EBF
at 4
-6 w
eeks
(al
l co
untr
ies)
RR
= 0
.86
R
R =
0.7
4
(95%
CI:
0.82
-
0.91
)
(95%
CI:
0.61
-
0.89
)
Dur
atio
n of
bre
astfe
edin
g (a
ll co
untr
ies)
Ris
k of
sto
ppin
g br
east
feed
ing
befo
re s
ix
mon
ths
(all
coun
trie
s)
posi
tive
effe
ct
RR
= 0
.91
--
(95%
CI:
0.88
-
0.96
)
Salu
d et
al.
(200
9); P
hilip
pine
sC
ouns
elin
g in
hom
es b
y pe
ers;
15 z
ones
from
one
ci
ty (
popu
latio
n 25
,499
)
Long
itudi
nal –
312
wom
en
with
infa
nts
less
tha
n 2
mon
ths
old
who
wer
e no
t ex
clus
ivel
y br
east
feed
ing
at b
asel
ine
endl
ine
vs.
base
line
% E
BF o
f inf
ants
< 3
m
onth
s ol
d53
.5%
vs.
1%
Not
e: b
asel
ine
= in
fant
< 2
m
onth
s, en
dlin
e =
3 w
eeks
late
r
p<0.
001
Sant
iago
et
al. (
2003
); Br
azil
Cou
nsel
ing
in fa
cilit
ies
by
prov
ider
s; C
ouns
elin
g in
fa
cilit
ies
by la
y vo
lunt
eers
; G
roup
edu
catio
n in
fa
cilit
ies
by p
rovi
ders
1 cl
inic
RC
T –
101
bab
ies
(35
in
IG1,
33
in IG
2, a
nd 3
3 in
co
ntro
l) 39
IG1
vs. I
G2
vs.
cont
rol
% E
BF o
f inf
ants
4 m
onth
s ol
d82
.9%
vs.
66.7
%
vs. 3
0.3%
OR
=1.
00 v
s. O
R=
0.39
vs.
O
R=
0.11
p<0.
001
(95%
CI:
0.12
-1.
36)
vs. (
95%
C
I: 0.
03-
0.39
)
Saow
akon
tha
et a
l. (2
000)
; Tha
iland
Mob
iliza
tion
of c
ampa
ign,
ev
ent,
or s
peci
al “
days
”; M
id-s
ized
med
ia; S
mal
l m
edia
90 v
illag
es (
targ
et
popu
latio
n w
as
appr
oxim
atel
y 33
,000
wom
en o
f re
prod
uctiv
e ag
e)
Rep
eate
d cr
oss-
sect
iona
l –
700
endl
ine
vs.
base
line
% g
ave
colo
stru
m t
o in
fant
97
.2%
vs.
65.3
%p=
0.00
0
Sule
et
al. (
2009
); N
iger
iaSm
all m
edia
; Gro
up
educ
atio
n in
com
mun
ities
by
pro
vide
rs; C
ouns
elin
g in
ho
mes
by
prov
ider
s
2 ru
ral c
omm
uniti
es
(1 in
terv
entio
n w
ith a
pop
ulat
ion
of 5
,202
, 1 c
ontr
ol
with
a p
opul
atio
n of
8,
121)
Long
itudi
nal –
300
m
othe
rs o
f chi
ldre
n ag
ed 0
-18
mon
ths
(150
in
terv
entio
n, 1
50 c
ontr
ol)
% E
BF fo
r 6
mon
ths
amon
g in
fant
s w
ere
≥ 6
mon
ths
base
line:
59.0
%
vs. 4
7.9%
endl
ine
(6
mon
ths
late
r):
66.7
% v
s. 52
%
NS
p=0.
01
38
Not
e th
at o
ne st
udy
was
con
duct
ed in
two
coun
tries
.
53 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ST
UD
YA
PP
RO
AC
HE
S
US
ED
SC
OP
E /
SC
AL
EE
VA
LU
AT
ION
D
ES
IGN
OU
TC
OM
E(S
) M
EA
SU
RE
DR
ES
ULT
S26
P-V
AL
UE
s /
CIs
27
Sun
et a
l. (2
011)
; Chi
naSm
all m
edia
; Mas
s m
edia
; Mid
-siz
ed m
edia
; C
ouns
elin
g in
faci
litie
s by
pr
ovid
ers
2 co
untie
s in
Sh
an’x
i pro
vinc
e (a
ppro
xim
atel
y 6,
000
child
ren
6-24
m
onth
s of
age
)
Rep
eate
d cr
oss-
sect
iona
l –
bas
elin
e (Ju
ne 2
008)
: 22
6 ca
regi
vers
and
the
ir
child
ren
6-24
mon
th-o
ld;
endl
ine
(Janu
ary
2010
): 22
1 ca
regi
vers
and
the
ir
child
ren
6-24
mon
th-o
ld
endl
ine
vs.
base
line
% e
arly
initi
atio
n of
br
east
feed
ing
16.8
% v
s. 8.
6%
p=0.
01
% b
reas
tfeed
ing
at 1
2 m
onth
s
% b
reas
tfeed
ing
at 2
4 m
onth
s
66.7
% v
s. 76
%
37.0
% v
s. 42
.3%
NS
NS
Syed
et
al. (
2006
); Ba
ngla
desh
Cou
nsel
ing
in fa
cilit
ies
by p
rovi
ders
; Soc
ial
and
com
mun
ity
mob
iliza
tion/
eng
agem
ent/
em
pow
erm
ent;
Cou
nsel
ing
in h
omes
by
prov
ider
s
11 upazilas
(sub
-di
stri
cts)
(10
in
terv
entio
n, 1
co
ntro
l)
Rep
eate
d cr
oss-
sect
iona
l –
base
line:
3,3
25 w
omen
w
ith c
hild
ren
aged
less
th
an o
ne y
ear
(2,9
89
inte
rven
tion,
336
con
trol
); en
dlin
e: 3
,110
wom
en w
ith
child
ren
aged
less
tha
n on
e ye
ar (
2,78
2 in
terv
entio
n,
323
cont
rol)
% b
reas
tfeed
ing
initi
atio
n w
ithin
one
hou
r of
bir
th
% g
ave
colo
stru
m t
o in
fant
base
line:
38.
6%
vs. 3
2.7%
endl
ine:
76.
2%
vs. 4
6.7%
Diff
eren
ce in
di
ffere
nces
: 23.
6
base
line:
86.
3%
vs. 9
1.7%
endl
ine:
96.
5%
vs. 9
3.5%
Diff
eren
ce in
di
ffere
nces
: 8.4
p=0.
01
--
Tho
mps
on a
nd H
arut
yuny
an (
2009
); A
rmen
iaC
ouns
elin
g in
hom
es b
y pe
ers;
Supp
ort
grou
p in
co
mm
uniti
es b
y pe
ers;
Smal
l med
ia; M
id-s
ized
m
edia
16 v
illag
es a
cros
s M
artu
ni r
egio
n of
G
egha
rkun
ik m
arz
Rep
eate
d cr
oss-
sect
iona
l –
600
with
at
leas
t on
e ch
ild a
ged
24 m
onth
s or
you
nger
(30
0 pr
e-in
terv
entio
n; 3
00 p
ost-
inte
rven
tion)
endl
ine
vs.
base
line
% b
reas
tfeed
ing
initi
atio
n w
ithin
one
hou
r of
bir
th
endl
ine
vs.
base
line:
66.
9%
vs. 7
0.4%
expo
sed
vs.
unex
pose
d:
72.5
% v
s. 56
.3%
p<0.
05
p<0.
05
% E
BF in
the
pas
t 24
ho
urs
amon
g in
fant
s <
6
mon
ths
old
endl
ine
vs.
base
line:
48.
1%
vs. 1
6.7%
expo
sed
vs.
unex
pose
d:
58.1
% 3
7.5%
p<0.
05
p<0.
05
39
Wom
en in
IG1
rece
ived
adv
ice
from
a m
ulti-
prof
essio
nal b
reas
tfeed
ing
team
; wom
en in
IG2
rece
ived
adv
ice
from
a p
edia
trici
an tr
aine
d in
bre
astfe
edin
g; a
nd w
omen
in th
e co
ntro
l gro
up re
ceiv
ed a
dvic
e fr
om a
pe
diat
ricia
n w
ith n
o br
east
feed
ing
train
ing.
54 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ST
UD
YA
PP
RO
AC
HE
S
US
ED
SC
OP
E /
SC
AL
EE
VA
LU
AT
ION
D
ES
IGN
OU
TC
OM
E(S
) M
EA
SU
RE
DR
ES
ULT
S26
P-V
AL
UE
s /
CIs
27
Trip
athy
et
al. (
2010
); In
dia
Supp
ort
grou
p in
co
mm
uniti
es b
y pe
ers
36 c
lust
ers
(18
inte
rven
tion,
18
cont
rol)
with
a
popu
latio
n of
ap
prox
imat
ely
228,
186
RC
T –
liv
e bi
rths
id
entifi
ed o
ver
stud
y pe
riod
; ana
lysi
s of
br
east
feed
ing
indi
cato
rs
was
lim
ited
to 1
6,92
6 in
fant
s al
ive
at 1
mon
th
(8,8
07 in
terv
entio
n; 8
,119
co
ntro
l)
% b
reas
tfeed
ing
initi
atio
n w
ithin
four
hou
rs o
f bir
th61
% v
s. 61
%
OR
= 1
.0140
(95%
CI:
0·38
– 3·
11)
% E
BF fo
r 6
wee
ks80
% v
s. 69
%
OR
=1·
82(9
5% C
I: 1.
14–2
.92)
Tylle
skar
et
al. (
2011
); Bu
rkin
a Fa
so,
Uga
nda,
Sout
h A
fric
aC
ouns
elin
g in
hom
es b
y pe
ers
24 c
omm
uniti
es in
Bu
rkin
a Fa
so, 2
4 in
U
gand
a, an
d 34
in
Sout
h A
fric
a (v
illag
es
rand
omly
ass
igne
d in
a
1:1
ratio
to
cont
rol
or in
terv
entio
n cl
uste
rs)
RC
T –
2,5
79 m
othe
r-in
fant
pai
rs
Burk
ina
Faso
: 392
in
terv
entio
n, 4
02 c
ontr
ol
Uga
nda:
396
inte
rven
tion,
36
9 co
ntro
l
Sout
h A
fric
a: 53
5 in
terv
entio
n, 4
85 c
ontr
ol
% E
BF d
urin
g pr
evio
us
7 da
ys a
t 3
mon
ths
(12
wee
ks)
Burk
ina
Faso
Uga
nda
Sout
h A
fric
a
% E
BF d
urin
g pr
evio
us
7 da
ys a
t 6
mon
ths
(24
wee
ks)
Burk
ina
Faso
Uga
nda
Sout
h A
fric
a
77%
vs.
23%
77%
vs.
34%
8% v
s. 4%
71%
vs.
9%
OR
=3.
27
51%
vs.
11%
O
R=
2.30
2% v
s. <
1%
OR
=1.
98
-- -- -- (95%
CI:
2.13
–5.0
3)
(95%
CI:
2.00
–2.6
5)
(95%
CI:
1.30
-3.
02)
40Oddsratiosareadjustedforclustering,stratification,maternaleducation,assets,andanytribalaffiliation.
55 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
Abolyan, Lyubov V. 2006. “The Breastfeeding Support and Promotion in Baby-Friendly Maternity Hospitals and Not-as-Yet Baby-FriendlyHospitalsinRussia.”Breastfeeding Medicine1(2)(June):71–78.
Agrasada, Grace V, Jan Gustafsson, Elisabeth Kylberg, and Uwe Ewald. 2005. “Postnatal Peer Counselling on Exclusive Breast-feedingof Low-birthweightInfants:aRandomized,ControlledTrial.”Acta Paediatrica (94(8):1109–1115.
Aidam, Bridget A, Rafael Pérez-Escamilla, and Anna Lartey. 2005. “Lactation Counselling Increases Exclusive Breast-feeding RatesinGhana.”The Journal of Nutrition135(7)(July):1691–1695.
Aksu, Hilmiye, Mert Küçük, and Gülergün Düzgün. 2011. “The Effect of Postnatal Breastfeeding Education/support Offered atHome3DaysafterDeliveryonBreastfeedingDurationandKnowledge:aRandomizedTrial.”The Journal of Maternal-fetal & Neonatal Medicine: The Official Journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians24(2)(February):354–361.
Akter, S.M., S.K. Roy, S.K. Thakur, M. Sultana, W. Khatun, R. Rahman, S.S. Saliheen, and N. Alam. 2012. “Effects of Third Trimester Counselling on Pregnancy Weight Gain, Birthweight, and Breastfeeding Among Urban Poor Women in Bangla-desh.”Food & Nutrition Bulletin33(3)(September):194–201.
Alam, M U L, M Rahman, and F Rahman. 2002. “Effectiveness of Baby Friendly Hospital Initiative on the Promotion of ExclusiveBreastfeedingAmongtheDhakaCityDwellersinBangladesh.”Mymensingh Medical Journal:MMJ11(2)(July):94–99.
Albernaz, Elaine, Cesar G Victora, Hinke Haisma, Antony Wright, and William A Coward. 2003. “Lactation Counselling In-creasesBreast-feedingDurationbutNotBreastMilkIntakeasMeasuredbyIsotopicMethods.”The Journal of Nutrition 133(1)(January):205–210.
Albernaz, Elaine, Cora L Araújo, Elaine Tomasi, Gicele Mintem, Elsa Giugliani, Alicia Matijasevich, Mercedes de Onis, Fernan-doCBarros,andCesarGVictora.2008.“Influenceof BreastfeedingSupportontheTendenciesof BreastfeedingRatesintheCityof Pelotas(RS),Brazil,from1982to2004.”Jornal de Pediatria84(6)(December):560–564.
Alderman, H. 2007. “Improving Nutrition through Community Growth Promotion: Longitudinal Study of the Nutrition and EarlyChildDevelopmentPrograminUganda.”World Development35(8):1376–1389.
Azad, Kishwar, Sarah Barnett, Biplob Banerjee, Sanjit Shaha, Kasmin Khan, Arati Roselyn Rego, Shampa Barua, Dorothy Flat-man, Christina Pagel, Audrey Prost, Matthew Ellis, Anthony Costello. 2010. “Effect of Scaling up Women’s Groups on BirthOutcomesinThreeRuralDistrictsinBangladesh:ACluster-RandomisedControlledTrial.”The Lancet375(9721)(April):1193–1202.
Balaluka, Ghislain B, Pépin S Nabugobe, Prudence N Mitangala, Nickel B Cobohwa, Carole Schirvel, Michèle W Dramaix, and Philippe Donnen. 2012. “Community Volunteers Can Improve Breastfeeding Among Children Under Six Months of Age intheDemocraticRepublicof CongoCrisis.”International Breastfeeding Journal 7.
Bang, Abhay T, Rani A Bang, Hanimi M Reddy, Mahesh D Deshmukh, and Sanjay B Baitule. 2005. “Reduced Incidence of NeonatalMorbidities:Effectof Home-BasedNeonatalCareinRuralGadchiroli,India.”Journal of Perinatology25(March):S51–S61.
Baqui, Abdullah H, Shams El-Arifeen, Gary L Darmstadt, Saifuddin Ahmed, Emma K Williams, Habibur R Seraji, Ishtiaq Mannan, Syed M Rahman, Rasheduzzaman Shah, Samir K Saha, Uzma Syed, Peter J Winch, Amnesty Lefevre, Ma-thuram Santosham, Robert E Black, for the Projahnmo Study Group. 2008. “Effect of Community-based Newborn-care Intervention Package Implemented through Two Service-delivery Strategies in Sylhet District, Bangladesh: a Cluster-randomizedControlledTrial.”The Lancet371(9628)(June7):1936–1944.
F. Works Cited and Literature Reviewed
56 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
Baqui, Abdullahh, Emma K Williams, Amanda M Rosecrans, Praween K Agrawal, Saifuddin Ahmed, Gary L Darmstadt, Vish-wajeet Kumar, Usha Kiran, Dharmendra Panwar, Ramesh C Ahuja, Vinod K Srivastava, Robert E Black, and Manthuram Santoshama. 2008. “Impact of an Integrated Nutrition and Health Programme on Neonatal Mortality in Rural Northern India.”Bulletin of the World Health Organization86(10)(October):796–804,A.
Bashour, Hyam N, Mayada H Kharouf, Asma A Abdulsalam, Khalil El Asmar, Mohammed A Tabbaa, and Salah A Cheikha. 2008.“Effectof PostnatalHomeVisitsonMaternal/infantOutcomesinSyria:aRandomizedControlledTrial.”Public Health Nursing 25(2)(April):115–125.
Berti, Peter R, Alison Mildon, Kendra Siekmans, Barbara Main, and Carolyn Macdonald. 2010. “An Adequacy Evaluation of a 10-year,Four-countryNutritionandHealthProgramme.”International Journal of Epidemiology39(2)(April):613–629.
Bhandari, N, R Bahl, B Nayyar, P Khokhar, J E Rohde, and M K Bhan. 2001. “Food Supplementation with Encouragement toFeedIttoInfantsfrom4to12Monthsof AgeHasaSmallImpactonWeightGain.”The Journal of Nutrition131(7)(July):1946–1951.
Bhandari, Nita, Rajiv Bahl, Sarmila Mazumdar, Jose Martines, Robert E Black, and Maharaj K Bhan. 2003. “Effect of Commu-nity-based Promotion of Exclusive Breastfeeding on Diarrhoeal Illness and Growth: a Cluster Randomised Controlled Trial.”TheLancet361(9367)(April26):1418–1423.
Bhandari, Nita, Sarmila Mazumder, Rajiv Bahl, José Martines, Robert E Black, and Maharaj K Bhan. 2005. “Use of Multiple Op-portunitiesforImprovingFeedingPracticesinUnder-twosWithinChildHealthProgrammes.”Health Policy and Planning 20(5)(September):328–336.
Bhutta,ZulfiqarA,JaiKDas,ArjumandRizvi,MichelleFGaffey,Neff Walker,SusanHorton,PatrickWebb,AnnaLartey,andRobert E Black. 2013. “Evidence-based Interventions for Improvement of Maternal and Child Nutrition: What Can Be DoneandatWhatCost?”The Lancet382(9890)(August):452–477.
Bhutta,ZulfiqarA,TahmeedAhmed,RobertEBlack,SimonCousens,KathrynDewey,ElsaGiugliani,BatoolAHaider,BettyKirkwood, Saul S Morris, H P S Sachdev, Meera Shekar, for the Maternal and Child Undernutrition Study Group. 2008a. “WhatWorks?InterventionsforMaternalandChildUndernutritionandSurvival.”The Lancet371(9610)(February):417–440.
Bhutta,ZulfiqarA,ZahidAMemon,SajidSoofi,MuhammadSuhailSalat,SimonCousens,andJoseMartines.2008b.“Im-plementingCommunity-BasedPerinatalCare:ResultsfromaPilotStudyinRuralPakistan.”Bulletin of the World Health Organization86(6)(June):452–459.
Black,RobertE,CesarGVictora,SusanPWalker,ZulfiqarABhutta,ParulChristian,MercedesdeOnis,MajidEzzati,SallyGrantham-McGregor, Joanne Katz, Reynaldo Martorell, Ricardo Uauy, and the Maternal and Child Nutrition Study Group.2013.“MaternalandChildUndernutritionandOverweightinLow-incomeandMiddle-incomeCountries.”The Lancet382(9890):427–451.
Black,RobertE,LindsayHAllen,ZulfiqarABhutta,LauraECaulfield,MercedesdeOnis,MajidEzzati,ColinMathers,andJuanRivera.2008.“MaternalandChildUndernutrition:GlobalandRegionalExposuresandHealthConsequences.”The Lancet371(9608)(January):243–260.
Bortolini, Gisele Ane, and Márcia Regina Vitolo. 2012. “The Impact of Systematic Dietary Counselling During the First Year of LifeonPrevalenceRatesof AnemiaandIronDeficiencyat12-16Months.”Jornal de Pediatria88(1)(February):33–39.
Braun, Maria Luiza G., Elsa R. J. Giugliani, Maria Emília Mattos Soares, Camila Giugliani, Andréa Proenço de Oliveira, and Claudia Maria Machado Danelon. 2003. “Evaluation of the Impact of the Baby-Friendly Hospital Initiative on Rates of Breastfeeding.”American Journal of Public Health93(8)(August):1277–1279.
Conde-Agudelo A, A Rosas-Bermudez , F Castano, MH Norton. 2012. “Effects of birth spacing on maternal, perinatal, infant, andchildhealth:asystematicreviewof causalmechanisms.”Studies in Family Planning 43: 93–114.
57 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
Conde-Agudelo A, A Rosas-Bermudez, AC Kafury-Goeta. 2006. “Birth spacing and risk of adverse perinatal outcomes: a meta-analysis.”The Journal of the American Medical Association 295: 1809.
Conde-Agudelo, A. 2006. Birth Spacing and Risk of Adverse Perinatal Outcomes: A Meta-analysis. The Journal of the American Medical Association295(15):1809–1823.
Conde-Agudelo, A., and José M Belizán. 2000. “Maternal Morbidity and Mortality Associated with Interpregnancy Interval: Cross-sectionalStudy.”BMJ321(7271)(November18):1255–1259.
Conde-Agudelo, Agustín, Anyeli Rosas-Bermudez, Fabio Castaño, and Maureen H Norton. 2012. “Effects of Birth Spacing on Maternal,Perinatal,Infant,andChildHealth:aSystematicReviewof CausalMechanisms.”Studies in Family Planning43(2)(June):93–114.
Conde-Agudelo,Agustin.2006.“BirthSpacingandRiskof AdversePerinatalOutcomes:AMeta-analysis.”The Journal of the American Medical Association295(15)(April19):1809.
Coutinho, Sonia Bechara, Pedro Israel Cabral de Lira, Marilia de Carvalho Lima, and Ann Ashworth. 2005. “Comparison of the Effectof TwoSystemsforthePromotionof ExclusiveBreastfeeding.”The Lancet366(9491)(September24):1094–1100.
Crookston, Benjamin T, Kirk A Dearden, Ketsana Chan, Theary Chan, and David D Stoker. 2007. “Buddhist Nuns on the Move:AnInnovativeApproachtoImprovingBreastfeedingPracticesinCambodia.”Maternal & Child Nutrition3(1)(January):10–24.
De Oliveira, Luciana Dias, Elsa Regina Justo Giugliani, Lilian Córdova do Espírito Santo, and Leandro Meirelles Nunes. 2012. “Impact of a Strategy to Prevent the Introduction of Non-breast Milk and Complementary Foods During the First 6 Months of Life: a RandomizedClinicalTrialwithAdolescentMothersandGrandmothers.”Early Human Development88(6)(June):357–361.
De Oliveira, Luciana Dias, Elsa Regina Justo Giugliani, Lílian Córdova do Espírito Santo, Maristela Cavalheiro Tamborindeguy França, Enilda Maria Lara Weigert, Celina Valderez Feijó Kohler, and Ana Lúcia de Lourenzi Bonilha. 2006. “Effect of Intervention to Improve Breastfeeding Technique on the Frequency of Exclusive Breastfeeding and Lactation-related Prob-lems.”Journal of Human Lactation: Official Journal of International Lactation Consultant Association22(3)(August):315–321.
Debes, Amanda K, Anjalee Kohli, Neff Walker, Karen Edmond, and Luke C Mullany. 2013. “Time to Initiation of Breastfeed-ingandNeonatalMortalityandMorbidity:aSystematicReview.”BMC Public Health13(Suppl3):S19.
Dewey, Kathryn. 2003. Guiding Principles for Complementary Feeding of the Breastfed Child. Washington, DC, USA: PAHO/WHO, Division of Health Promotion and Protection/Food and Nutrition Program.
Dewey, K G, R J Cohen, K H Brown, and L L Rivera. 2001. “Effects of Exclusive Breastfeeding for Four Versus Six Months on MaternalNutritionalStatusandInfantMotorDevelopment:Resultsof TwoRandomizedTrialsinHonduras.”The Journal of Nutrition131(2)(February):262–267.
Duyan Camurdan, A, S Ozkan, D Yüksel, F Pasli, F Sahin, and U Beyazova. 2007. “The Effect of the Baby-friendly Hospital InitiativeonLong-termBreastfeeding.”International Journal of Clinical Practice61(8)(August):1251–1255.
Ghosh, Shanti, Asha Kilaru, and Saraswathy Ganapathy. 2002. “Nutrition Education and Infant Growth in Rural Indian Infants: NarrowingtheGenderGap?”Journal of the Indian Medical Association100(8)(August):483–484,486–488,490.
Gogia, Siddhartha, and Harshpal Singh Sachdev. 2010. “Home Visits by Community Health Workers to Prevent Neonatal DeathsinDevelopingCountries:aSystematicReview.”Bulletin of the World Health Organization88(9)(September1):658–666B.
Guldan, G S, H C Fan, X Ma, Z Z Ni, X Xiang, and M Z Tang. 2000. “Culturally Appropriate Nutrition Education Improves InfantFeedingandGrowthinRuralSichuan,China.”The Journal of Nutrition130(5)(May):1204–1211.
58 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
Gupta, Neeru, Charles Katende, and Ruth Bessinger. 2004. “An Evaluation of Post-campaign Knowledge and Practices of Ex-clusiveBreastfeedinginUganda.”Journal of Health, Population, and Nutrition22(4)(December):429–439.
Guyon, Agnès B, Victoria J Quinn, Michael Hainsworth, Priscilla Ravonimanantsoa, Voahirana Ravelojoana, Zo Rambeloson, and Luann Martin. 2009. “Implementing an Integrated Nutrition Package at Large Scale in Madagascar: The Essential NutritionActionsFramework.”Food and Nutrition Bulletin30(3)(September):233–244.
Haider, R, A Ashworth, I Kabir, and S R Huttly. 2000. “Effect of Community-based Peer Counsellors on Exclusive Breastfeed-ingPracticesinDhaka,Bangladesh:aRandomisedControlledTrial.”The Lancet356(9242)(November11):1643–1647.
Hall, Jennifer. 2011. “Effective Community-based Interventions to Improve Exclusive Breastfeeding at Four to Six Months in Low-andLow-middle-incomeCountries:aSystematicReviewof RandomisedControlledTrials.”Midwifery27(4)(Au-gust):497–502.
Haque, M F, M Hussain, A Sarkar, M M Hoque, Fakir Anjuman Ara, and S Sultana. 2002. “Breast-feeding Counselling and ItsEffectonthePrevalenceof ExclusiveBreast-feeding.”Journal of Health, Population, and Nutrition20(4)(December):312–316.
Harkins,Thomas,ChristopherDrasbek,JuanArroyo,andMichaelMcQuestion.2008.“TheHealthBenefitsof SocialMobiliza-tion: Experiences with Community-based Integrated Management of Childhood Illness in Chao, Peru and San Luis, Hon-duras.”Promotion & Education15(2)(June):15–20.
Horta,B,RBahl,JMartines,CVictora.“Evidenceonthelong-termeffectsof breastfeeding.”Geneva:WorldHealthOrganiza-tion, 2007.
Imdad,Aamer,MohammadYawarYakoob,andZulfiqarABhutta.2011.“Effectof BreastfeedingPromotionInterventionsonBreastfeedingRates,withSpecialFocusonDevelopingCountries.”BMC Public Health11(Suppl3):S24.
Jolly, Kate, Lucy Ingram, Khalid S Khan, Jonathan J Deeks, Nick Freemantle, and Christine MacArthur. 2012. “Systematic Review of Peer Support for Breastfeeding Continuation: Metaregression Analysis of the Effect of Setting, Intensity, and Timing.”BMJ (Clinical Research Ed.) 344: d8287.
Khresheh, Reham, Aida Suhaimat, Fawzia Jalamdeh, and Lesley Barclay. 2011. “The Effect of a Postnatal Education and Sup-portProgramonBreastfeedingAmongPrimiparousWomen:ARandomizedControlledTrial.”International Journal of Nursing Studies48(9)(September):1058–1065.
Kramer, M S, B Chalmers, E D Hodnett, Z Sevkovskaya, I Dzikovich, S Shapiro, J P Collet, I Vanilovich, I Mezen, T Ducruet, G Shishko, V Zubovich, D Mknuik, E Gluchanina, V Dombrovskiy, A Ustinovitch, T Kot, N Bogdanovich, L Ovchinikova, EHelsing;andPROBITStudyGroup.2001.“Promotionof BreastfeedingInterventionTrial(PROBIT):aRandomizedTrialintheRepublicof Belarus.” The Journal of the American Medical Association285(4):413–420.
Kramer,MichaelS,andRitsukoKakuma.2004.“TheOptimalDurationof ExclusiveBreastfeeding:aSystematicReview.”Ad-vances in Experimental Medicine and Biology 554: 63–77.
Kumar, Vishwajeet, Saroj Mohanty, Aarti Kumar, Rajendra P Misra, Mathuram Santosham, Shally Awasthi, Abdullah H Baqui, Pramod Singh, Vivek Singh, Ramesh C Ahuja, Jai Vir Singh, Gyanendra Kumar Malik, Saifuddin Ahmed, Robert E Black, Mahendra Bhandari, Gary L Darmstadt, for the Saksham Study Group. 2008. “Effect of Community-Based Behaviour ChangeManagementonNeonatalMortalityinShivgarh,UttarPradesh,India:ACluster-RandomisedControlledTrial.”The Lancet372(9644):1151–1162.
Kupratakul, Jutamart, Surasak Taneepanichskul, Nipunporn Voramongkol, and Vorapong Phupong. 2010. “A Randomized Controlled Trial of Knowledge Sharing Practice with Empowerment Strategies in Pregnant Women to Improve Exclusive BreastfeedingduringtheFirstSixMonthsPostpartum.”Journal of the Medical Association of Thailand = Chotmaihet Thang-phaet93(9)(September):1009–1018.
59 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
Lassi,ZohraS,BatoolAHaider,andZulfiqarABhutta.“Community-BasedInterventionPackagesforReducingMaternalandNeonatalMorbidityandMortalityandImprovingNeonatalOutcomes.”InCochrane Database of Systematic Reviews 2010, editedbyTheCochraneCollaborationandZulfiqarABhutta.Chichester,UK:JohnWiley&Sons,Ltd.
Leite, Alvaro J Madeiro, Rosana Fiorini Puccini, Alvaro N Atalah, Antonio L Alves Da Cunha, and Márcia Tavares Machado. 2005. “Effectiveness of Home-based Peer Counselling to Promote Breastfeeding in the Northeast of Brazil: a Rand-omizedClinicalTrial.”Acta Paediatrica94(6):741–746.
Li, Yan, Masanaka Hotta, Anping Shi, Zhi Li, Jianzhing Yin, Guangping Guo, Kimiko Kawata, and Hiroshi Ushijima. 2007. “MalnutritionImprovementforInfantsUnder18MonthsOldof DaiMinorityinLuxi,China.”Pediatrics International 49 (2)(April):273–279.
Mackintosh, U Agnes Trinh, David R Marsh, and Dirk G Schroeder. 2002. “Sustained Positive Deviant Child Care Practices and TheirEffectsonChildGrowthinVietNam.”Food and Nutrition Bulletin23(4Suppl)(December):18–27.
Manandhar, Dharma S, David Osrin, Bhim Prasad Shrestha, Natasha Mesko, Joanna Morrison, Kirti Man Tumbahangphe, Suresh Tamang, Sushma Thapa, Dej Shrestha, Bidur Thapa, Jyoti Raj Shrestha, Angie Wade, Josephine Borghi, Hilary Standing, Madan Manandhar, Anthony M de L Costello, and members of the MIRA Makwanpur trial team. 2004. “Ef-fect of a Participatory Intervention with Women’s Groups on Birth Outcomes in Nepal: Cluster-randomized Controlled Trial.”The Lancet364(9438):970–979.
Matovu,A,BKirunda,GRugamba-Kabagambe,NMTumwesigye,andFNuwaha.2008.“FactorsInfluencingAdherencetoExclusiveBreastFeedingamongHIVPositiveMothersinKabaroleDistrict,Uganda.”East African Medical Journal85(4):162–70.
Morrow,AL,andMLGuerrero.2001.“FromBioactiveSubstancestoResearchonBreast-feedingPromotion.”Advances in Experimental Medicine and Biology 501: 447–455.
Nunes, Leandro Meirelles, Elsa Regina Justo Giugliani, Lilian Cordova do Espírito Santo, and Luciana Dias de Oliveira. 2011. “Reduction of Unnecessary Intake of Water and Herbal Teas on Breast-fed Infants: a Randomized Clinical Trial with AdolescentMothersandGrandmothers.”The Journal of Adolescent Health: Official Publication of the Society for Adolescent Medi-cine49(3)(September):258–264.
Omer, Khalid, Sharmila Mhatre, Noor Ansari, Jorge Laucirica, and Neil Andersson. 2008. “Evidence-based Training of Front-line Health Workers for Door-to-door Health Promotion: a Pilot Randomized Controlled Cluster Trial with Lady Health WorkersinSindhProvince,Pakistan.”Patient Education and Counselling72(2)(August):178–185.
Pachón, Helena, Dirk G Schroeder, David R Marsh, Kirk A Dearden, Tran Thu Ha, and Tran Thi Lang. 2002. “Effect of an In-tegratedChildNutritionInterventionontheComplementaryFoodIntakeof YoungChildreninRuralNorthVietNam.”Food and Nutrition Bulletin23(4Suppl)(December):62–69.
Piwoz, Ellen G, Peter J Iliff, Naume Tavengwa, Lorrie Gavin, Edmore Marinda, Kevin Lunney, Clare Zunguza, Kusum J Nathoo, and Jean H Humphrey. 2005. “An Education and Counseling Program for Preventing Breast-Feeding-Associated HIV TransmissioninZimbabwe:DesignandImpactonMaternalKnowledgeandBehavior.”The Journal of Nutrition135(4):950–55.
Piwoz, Ellen G., Jean H. Humphrey, Naume V. Tavengwa, Peter J. Iliff, Edmore T. Marinda, Clare D. Zunguza, Kusum J. Na-thoo, Kuda Mutasa, Lawrence H. Moulton, and Brian J. Ward. 2007. “The Impact of Safer Breastfeeding Practices on PostnatalHIV-1TransmissioninZimbabwe.”American Journal of Public Health97(7):1249–54.
Quinn, Victoria J, Agnès B Guyon, Joan W Schubert, Maryanne Stone-Jiménez, Michael D Hainsworth, and Luann H Martin. 2005. “Improving Breastfeeding Practices on a Broad Scale at the Community Level: Success Stories from Africa and LatinAmerica.”Journal of Human Lactation: Official Journal of International Lactation Consultant Association21(3)(August):345–354.
60 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
Renfrew, Mary J, Felicia M McCormick, Angela Wade, Beverley Quinn, and Therese Dowswell. “Support for Healthy Breastfeed-ingMotherswithHealthyTermBabies.”InCochrane Database of Systematic Reviews 2012, edited by The Cochrane Collabo-ration and Felicia M McCormick. Chichester, UK: John Wiley & Sons, Ltd.
Rutstein, Shea O., and Macro International Inc. “Further Evidence of the Effects of Preceding Birth Intervals on Neonatal, Infant, and Under-Five-Years Mortality and Nutritional Status in Developing Countries: Evidence from the Demographic andHealthSurveys.”41.DHS Working Papers. Calverton, Maryland, USA: USAID, 2008.
Salud, M. A. L. B., J. I. Gallardo, J. A. Dineros, A. F. Gammad, J. Basilio, V. Borja, A. Iellamo, L. Worobec, H. Sobel, and J.-M. Olive. 2009. “People’s Initiative to Counteract Misinformation and Marketing Practices: The Pembo, Philippines, Breast-feedingExperience,2006.”Journal of Human Lactation25(3):341–49.doi:10.1177/0890334409334605.
Santiago, Luciano B, Heloisa Bettiol, Marco A Barbieri, Manoel R P Guttierrez, and Luiz A Del Ciampo. 2003. “Promotion of Breastfeeding:TheImportanceof PediatricianswithSpecificTraining.”Jornal de Pediatria79(6)(December):504–512.
Saowakontha, S, P Pongpaew, N Vudhivai, R Tungtrongchitr, P Sanchaisuriya, U Mahaweerawat, W Laohasiriwong, C Intara-khao, P Leelapanmetha, K Chaisiri, V Vatanasapt, A Merkle, and FP Schlep. 2000. “Promotion of the Health of Rural WomenTowardsSafeMotherhood--anInterventionProjectinNortheastThailand.”The Southeast Asian Journal of Tropical Medicine and Public Health 31 Suppl 2: 5–21.
SinghK,PSrivastava.1992.“Theeffectof colostrumoninfantmortality:Urbanruraldifferentials.”Health and Population 15 (3&4):94–100
Sule, S, A Onayade, T C Abiona, A O Fatusi, E O Ojofeitimi, O A Esimai, and K T Ijadunola. 2009. “Impact of Nutritional EducationonNutritionalStatusof Under-fiveChildreninTwoRuralCommunitiesof South-westNigeria.”The Nigerian Postgraduate Medical Journal16(2)(June):115–125.
Sun, Jing, Yaohua Dai, Shuaiming Zhang, Jian Huang, Zhenyu Yang, Junsheng Huo, and Chunming Chen. 2011. “Implemen-tationof aProgrammetoMarketaComplementaryFoodSupplement(YingYangBao)andImpactsonAnaemiaandFeedingPracticesinShanxi,China.”Maternal & Child Nutrition7Suppl3(October):96–111.
Syed, Uzma, S K Asiruddin, M S I Helal, Imteaz I Mannan, and John Murray. 2006. “Immediate and Early Postnatal Care for MothersandNewbornsinRuralBangladesh.”Journal of Health, Population, and Nutrition24(4)(December):508–518.
Thompson, Michael E, and Tsovinar L Harutyunyan. 2009. “Impact of a Community-based Integrated Management of Child-hoodIllnesses(IMCI)ProgrammeinGegharkunik,Armenia.”Health Policy and Planning24(2)(March):101–107.
Tripathy, Prasanta, Nirmala Nair, Sarah Barnett, Rajendra Mahapatra, Josephine Borghi, Shibanand Rath, Suchitra Rath, et al. 2010. “Effect of a Participatory Intervention with Women’s Groups on Birth Outcomes and Maternal Depression in JharkhandandOrissa,India:ACluster-RandomisedControlledTrial.”The Lancet375(9721)(April):1182–1192.
Tylleskär,Thorkild,DebraJackson,NicolasMeda,IngunnMarieSEngebretsen,MickeyChopra,AbdoulayeHamaDiallo,TanyaDoherty, Eva-Charlotte Ekström, Lars T Fadnes, Ameena Goga, Chipepo Kankasa, Jørn I Klungsøyr, Carl Lombard, Victoria Nankabirwa, Jolly K Nankunda, Philippe Van de Perre, David Sanders, Rebecca Shanmugam, Halvor Sommer-felt, Henry Wamani, James K Tumwine, for the PROMISE-EBF Study Group. 2011. “Exclusive Breastfeeding Promotion byPeerCounsellorsinsub-SaharanAfrica(PROMISE-EBF):aCluster-randomizedTrial.”The Lancet378(9789)(July30):420–427.
Uruakpa,FO,MAHIsmond,ENTAkobundu.2002.“Colostrumanditsbenefits:areview”Nutrition Research, Volume 22, Issue 6, June 2002, Pages: 755-767.
USAIDInfantandYoungChildNutrition(IYCN)Project.Community Interventions to Promote Optimal Breastfeeding: Evidence on Early Initiation, Any Breastfeeding, Exclusive Breastfeeding, and Continued Breastfeeding. Washington, DC: USAID, 2012.
World Health Organization. Indicators for assessing infant and young child feeding practices: conclusions of a consensus meeting held 6–8 Novem-ber 2007 in Washington D.C., USA. Geneva: World Health Organization Press, 2008.
61 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
3.3. Evidence of Effective SBCC Approaches to Improve Complementary Feeding Practices
A. Background
At the age of six months, breast milk alone is no longer sufficienttomeetthenutritionalrequirementsof agrowingchild(WorldHealthOrganization(WHO)/UNICEF,1998).Timely and appropriate complementary feeding is critical to a child’s growth and development. According to the 2008 maternal and child undernutrition series in The Lancet, the adoption of optimal complementary feeding practices and other supportive strategies at scale could result in a 17% relative reduction in the prevalence of stunting at 24 months, andavert5.5milliondisability-adjustedlifeyears(DALY)(Bhutta,2008a).Inasimilarseriesin2013,TheLancetreiter-ated the association between appropriate complementary feeding and nutritional outcomes, citing a study by Ruel and Menon(2002)thatfoundapositive,statisticallysignificantassociation between feeding practices and height-for-age infiveLatinAmericancountries.Finally,inananalysisof datasetsfrom14lowincomecountries,Marriottetal.(2012)reported that “consumption of a minimum acceptable diet
with dietary diversity reduced the risk of both stunting and underweight whereas minimum meal frequency was associ-atedwithlowerriskof underweightonly.”
Despite the promise of timely appropriate complementary feeding, global coverage of optimal complementary feeding practices remains low. According to an analysis of 2002-2008 data on complementary feeding practices in 46 coun-tries, just one-third of children aged 6-23 months received the recommended dietary diversity,41 approximately half received the recommended number of feeds, and only 20% receivedtheminimumacceptablediet(Lutter,2012).42
This chapter focuses on the effectiveness of Social and BehaviorChangeCommunication(SBCC)approachestoimproving complementary feeding practices of children 6-24 months of age. The chapter focuses on the WHO guiding
principles for complementary feeding for the breastfed
41 This refers to the number of food groups consumed over a given period indicating variety as stated in the guidance. Household level dietary diver-sity is an indicator for household food security (though this indicator is moreaccuratewhenaggregatedtoreflectthefoodsecurityof thesurveyarea),whileindividualdietarydiversityisanindicatorof dietaryqualityforanindividual(usuallymeasuredforwomenoryoungchildren).
42 Minimal acceptable diet is a composite of dietary diversity and meal frequency.
Table 3.3.1: WHO Guiding Principles for complementary feeding of the breastfed child 1 What When How
Timely introduction of appropriate complementary foods
Start at six months of age
Start with small amounts of food, increase quantity as child gets older. At six months, infants can eat pureed, mashed or semi-solid foods; at eight months, most can eat “finger foods;” by 12 months, most can eat “family foods.”
Dietary diversity After six months, daily
Feed a variety of foods: meat, poultry, fish or eggs; vitamin A-rich fruits and vegetables; diets with adequate fat content.43
Supplementation or fortification
After six months of age, as needed
Use fortified complementary foods or vitamin-mineral supplements for the infant, preferably mixed with or fed with food.
Increased meal frequency and/or energy density
Gradual age-dependent increase
Increase the number of times that a child is fed as he or she gets older: for the “average” child, 2-3 times/day at 6-8 months; 3-4 times/day at 9-23 months. Additional nutritious snacks may be offered 1-2 times per day.
Active and responsive feeding Always Feed infants directly; assist older children in feeding themselves; minimize distractions during meals; talk to children during feeding with eye-to-eye contact.
Safe food preparation and storage practices
Always Store foods safely and serve immediately after preparation; use clean utensils, cups and bowls; avoid using baby bottles.
Feeding during and after illness Always Increase fluid intake during illness; including more frequent breastfeeding; and encourage the child to eat soft, varied, appetizing, favorite foods. After illness, give food more often than usual and encourage the child to eat more.
AdaptedfromPAHO/WHO(2003).
43 The dietary diversity of complementary foods helps to ensure that the nutrient needs of infants and young children are met. For example, evidence shows that the adequate consumption of fruits and dark green, leafy vegetables alone can meet the vitamin A requirements for infants and young children (ACC/SCN, 2001).However,plant-basedcomplementaryfoodsalonearenotsufficienttomeetthebreadthof nutrientrequirementsof infantsandyoungchildren,unlessfortifiedfoodsorsupplementsarealsoconsumed.Animalproducts,includingmeat,poultry,fishandeggs,shouldbeconsumedonadailybasis(Dewey,2003).Meatandfishprovidemoreabsorbableironandincreasetheabsorptionof non-haemiron(ACC/SCN,2001).
62 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
child(Pan-AmericanHealthOrganization(PAHO)/WHO,2003).SeeTable3.3.1.
B. Search Results
Thirty peer-reviewed studies met the literature review inclu-sion criteria.443A complete list of the studies reviewed, in-cludingasummaryof theSBCCapproach(es)utilized,thestudydesign,practicesmeasured,andlevelsof significanceis provided in Table 3.3.5 at the end of this chapter.
Twenty-fivestudiesreportedastatisticallysignificantchange in at least one of the recommended complementary
44 See the introductory chapter of this literature review for a full description of search procedures and inclusion/exclusion criteria.
feeding practices. Each of those articles is described in
greaterdetailbelow.Studiesreportingastatisticallysignifi-
cant change in more than one of the prioritized practices
and/or utilizing more than one SBCC approach are cited
and discussed multiple times. Where this occurs, we have
providedadetaileddescriptionof thestudyinthefirstref-
erence, and only discuss results in subsequent references.
Thefindingsareorganizedbypracticestargeted,SBCC
approach(es)utilized,andstudydesign.Thisorganization
enables the reader to derive an independent judgment re-
gardingfindingsfromeachstudy.Inaddition,implementa-
tion processes followed are discussed.
Table 3.3.2: Number of studies reviewed (with number of studies reporting statistically significant results in parentheses), by recommended practice and study design
Practice Sub-practice
Literature reviews
with meta-analysis
RCTsLongi- tudinal studies
Repeated cross-
sectional studies
Cross-sectional studies
Total
Timely introduction of complementary foods
0 1 (1) 1 (0) 3 (1) 0 5 (2)
Dietary diversity
Feeding children animal source foods 0 7 (7) 4 (3) 2 (2) 1 (1) 14 (13)
Feeding children fruits and vegetables 0 3 (3) 3 (2) 3 (3) 1 (1) 10 (9)
Feeding children a minimum number of food groups
0 2 (0) 0 2 (1) 2 (1) 6 (2)
Micronutrient supplementation or fortification
0 4 (1) 0 1 (1) 0 5 (2)
Increased meal frequency and/or density
Increasing frequency of feeding children 0 3 (2) 2 (2) 3 (2) 2 (1) 10 (7)
Adding fats or oils to children’s foods 0 5 (4) 0 0 0 5 (4)
Enhancing the consistency of children’s foods
0 2 (2) 1 (0) 0 0 3 (2)
Increasing the quantity fed to children at each meal
0 3 (2) 1 (1) 0 0 4 (3)
Responsive/active feeding 0 2 (2) 1 (0) 0 0 (0) 3 (2)
Feeding during and after illness 0 1 (1) 0 2 (0) 0 3 (1)
*Notethatcolumnsdonotsumtothe“total”sincesomearticlesreportedonmultiplepractices.
63 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
Of the 30 studies reviewed for this chapter, eleven were rand-omizedcontrolledtrials(RCT),ninewerelongitudinalstudies(fivewithcontrolgroupsandfourwithnocontrolgroup),andtenwererepeatedcross-sectionalstudies(fivewithcon-trolgroupsandfivewithnocontrolgroup).SeeTable3.3.2.
C. Overview of the Evidence, by Practice
With the release of the PAHO/ WHO’s Guiding Principles for Complementary Feeding of Breastfed Children(2003),theneedtodevelop standardized indicators to capture the breadth of recommended complementary feeding practices was estab-lished.Thisrecognitionresultedinthedevelopmentof fivestandardized indicators of complementary feeding: intro-duction of solid, semi-solid or soft foods, minimum dietary diversity, minimum meal frequency, minimum acceptable diet(MAD),andconsumptionof iron-richoriron-fortifiedfoods(WHO,2008).
The studies reviewed in this chapter, however, revealed very little consistency in how complementary feeding prac-tices were measured, and few employed the standardized indicators described above. The review is therefore focused on the WHO Guiding Principles rather than the “recom-mended”indicators.SeeTable3.3.1.Theguidingprinciplerelated to the safe preparation and storage of food was considered beyond the scope of this review.
Ofthe30studiesreviewed,fivemeasuredtheintroductionof complementary foods (mean age at or the frequency of intro-ductionof foodsatspecifiedages);20exploredthenutrientcontentof foods;fivestudiedtheuseorconsumptionof for-tifiedproductsorsupplements;16measuredmealfrequency,energy density, or energy intake; three looked at how children werefed(responsivelyoractively),andthreemeasuredfeed-ing practices during and after illness. See Table 3.3.2.
Timely introduction of appropriate complementary foods
Of thefivestudieslookingattheintroductionof comple-mentary foods or particular food types, two reported at leastonestatisticallysignificantresult.Eachof thestudiesmeasured the practice differently, and neither reported on the recommended standard indicator, namely the “propor-
tion of infants 6-8 months of age who receive solid, semi-solidorsoftfoods”(WHO,2008).
DeOliveiraetal.(2012)conductedanRCTmeasuringthemean age of introduction of complementary foods in a hospital in Brazil. The intervention included client-provider counseling in the facility and follow-up home visits. At the conclusion of the study period, the mean age at introduction of complementary foods was 153 days in the intervention group, compared with 95 days in the control group. Similarly, 22.8% of children were introduced to complementary foods at four months of age in the intervention group, compared with 41% in the control group. However, the authors found that “at 6 months, the prevalence of infants receiving com-plementary foods was similar for the two groups: 87.1% for theinterventiongroupand88.4%forthecontrolgroup.”
Lietal.(2007)conductedarepeatedcross-sectionalstudylooking at the mean age of introduction of seven wean-ingfoodsinfivetownshipsinYunanProvince,China.Theintervention included one-on-one counseling, food prepa-ration demonstrations, peer education, growth monitoring from birth through 17 months, and dissemination of a maternal and child nutrition video and pamphlet. The pro-ject also supported the strengthening of integrated man-agementof childhoodillness(IMCI)-relatedservices,andprovided thiamine to women just before or after delivery. Following the intervention, the age of introduction of all food groups except cow’s milk had increased.
Dietary diversity
Of the 20 studies that looked at the nutrient content of complementaryfoods,15reportedstatisticallysignificantresults.Of thosereportingstatisticallysignificantfindings,13 reported on the feeding of animal source foods, nine reported on the feeding of fruits and vegetables, and three reported on dietary diversity. Just one article (Sun et al., 2011)reportedontherecommendedstandardindicator,“proportion of children 6-23 months of age who receive foodsfrom4ormorefoodgroups.”(WHO,2008)
Feeding children animal source foods
Of the 14 studies that measured the feeding or consump-tion of animal source foods, all but one reported statisti-
64 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
callysignificantresults.Theoutcomesmeasured,however,varied considerably among studies. There was little con-sistency among studies with respect to the meat product promoted (meat, cow’s milk, buffalo milk, eggs, positive deviance(PD)foodsincludinganimalsourcefoods,and/or“iron-richfoods”),themeasurementof milkintake(quantityconsumedandfrequencyof consumption),andmeasurement of egg consumption (mean number of times consumed and percentage of children fed three or more eggs).Furthermore,referenceperiodsandagerangesvariedconsiderably among studies.
Randomized controlled trials
Sevenof thestudiesreportingstatisticallysignificantresultswereRCTs.Bhandarietal.(2004)lookedattheconsump-tion of milk, fruit, and vegetables in India. The intervention involved “monthly home visits for new births until aged 12 months and weighing once every 3 months for children under 2 years of age conducted by Anganwadi workers, immuniza-tion clinics run by the auxiliary nurse midwives and sick child contactswithhealthcareproviders.”Additionally,auxiliarynurse midwives discussed key messages during monthly meet-ings with community representatives who, in turn, shared them during monthly neighborhood meetings. Following the intervention, the percentage of children nine months of age consuming any type of milk was 91.8% in the interven-tion group, compared with 82.6% in the control group. This findingwasstatisticallysignificant.Whilethedifferenceat18monthsof agewasnotstatisticallysignificant,differencesinmean energy intake from milk between the intervention and controlgroupwerestatisticallysignificantatboth9monthand 18 months – 837kcal vs. 607kcal at 9 months of age and 2021kcal vs. 1289kcal at 18 months of age.
BortoliniandVitolo(2012)lookedatmeanintakeof cow’smilk and meat among children 12 to 16 months of age in Rio Grande do Sul, Brazil. Women in the intervention group received monthly home visits during their child’s firstsixmonthsof life,andfollowupvisitswhenthechildren reached 8, 10 and 12 months of age. Following the intervention, the proportion of women postponing the introduction of cow’s milk was higher in the intervention group(50.9%)thanthecontrolgroup(36.6%).Further-more, mean intake of cow’s milk and meat in children 6-12 months of age was higher in the intervention group (588.1
mland54.3g,respectively)thaninthecontrolgroup(501.6mland47.3g,respectively).
Guldanetal.(2000)lookedatthefrequencyof feedingchildreneggs,meat,andfishormeatbrothinruralSichuan,China. The intervention included counseling by community healthworkers(CHW)duringmonthlygrowthmonitoringsessions, and visits to the homes of pregnant women and women with children under the age of one. During the home visits “nutrition educators disseminated a feeding guidebook and growth chart to each family, [provided] age-appropriate breastfeeding and complementary feeding suggestions and advice, answered questions and weighed each infant, marking theinfant’sweightonthegrowthchart.”Followingtheinter-vention, the percentage of children ages 4-6 months and 7-9 months that were fed eggs was 37% and 66% respectively in the intervention group, compared with 16% and 41% respec-tively in the control group. The percentage of children ages 7-9monthsand10-12monthsthatwerefedfishormeatbroth on a daily basis was 9% and 13% respectively in the intervention group, compared with 1% and 3% respectively in the control group, while the proportion of children ages 7-9 months and 10-12 months that were fed meat was 19% and 23% respectively in the intervention group, compared with 8% and 9% in the control group.
Pennyetal.(2005)lookedattheconsumptionof egg,chick-enliver,orfishinTrujillo,Peru.Theinterventionaimedto“enhance the quality of nutrition counseling through training and provision of simple, standardized, age-appropriate mes-sages to be used at all points of contact with young children [ortheircaregivers]inthefacility.”Datawerecollectedonacohort of children from intervention and control facilities from birth to age 18 months. Following the intervention, a higher proportion of women in the intervention group reportedfeedingegg,chicken,liver,orfishacrossthesixmeasurement points (at 6, 8, 9, 12, 15, and 18 months of age)thanwomeninthecontrolgroup;however,resultswereonlysignificantatsixandeightmonthsof age.Thepracticeof feeding animal foods improved in the immediate period following counseling; but diminished over time.
Royetal.(2007)lookedatthefeedingof eggs,theadditionof oil to children’s food, the feeding of energy and protein
65 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
rich local complementary foods rich in micronutrients,45 and the feeding of children from a separate pot in Bangladesh. The intervention included the delivery of nutrition education sessions to small groups of women through trained commu-nityhealthworkers.Thegroupsmetweeklyforthefirstthreemonths and biweekly for the second three months. Forma-tive research guided development of messages, and the ses-sions included food preparation demonstrations. In addition to the mothers groups, men and older family members were targeted through monthly community/social mobilization ef-forts. Following the intervention, the percentage of children receiving three or more eggs increased from 11.3% to 29.8% in the intervention group and from 10% to 11.9% in the control group. Furthermore, the percentage of caregivers reporting feeding an animal-based complementary food in-creased from 30.4% to 88.5% in the intervention group and declined from 31% to 24.5% in the control group.
Vaziretal.(2013)lookedatconsumptionof iron-richfoods among children 9-15 months of age in 60 villages in India. The intervention, implemented over a period of 12 months, included regular home visits by trained village women (twice a month or four times a month depend-ingontheageof theinfant).Thecomplementaryfeedinggroup(CFG),receivedelevennutritioneducationmessageson sustained breastfeeding and complementary feeding, while the responsive complementary feeding and play group(RCF&PG),receivedthesesamemessagesaswellaseight messages on responsive feeding and eight messages ondevelopmentalstimulationusingfivesimpletoys.Thecontrol group received routine services provided under India’s Integrated Child Development Services program.
At nine months of age, 30.7% of children in the CFG and 25.6% of children in the RCF&PG consumed goat or chicken liver during the previous week compared with 2.3%
45 This complementary food is called kitchuri in Bangladesh. According to the authors, “Khichuri is a home-based transitional complementary food made with locally available inexpensive items in which rice and lentils complement each other to provide limiting amino acids (lysine and methionine,respectively),andtheadditionof aneggfurtherincreasedtheprotein quality. Moreover, egg yolk and vegetables increased the vitamin A, carotene, and other micronutrient contents of khichuri. Although animal-origin foods are a rich source of iron, they were not affordable to a large proportion of the families in our study population. During the intervention, there was a sharp increase in the use of khichuri as the main complementary food, but subsequently the practice decreased to some extent, largely due to the increase in age of the study children, when they werealreadyhabituatedtothefamilyfoods.”(Royetal.,2007)
of children in the control group. In addition, 22.3% of chil-dren in the CFG and 11.3% of children in the RCF&PG consumed goat meat during the previous week compared with 4.5% of children in the control group. At 15 months of age, 43.5% of children in the CFG group and 44% in the RCF&PG group consumed liver compared with 13.1% of children in the control group, while 37.5% of children in the CFG group and 45.2% of children in the RCF&PG group had consumed poultry in the previous week com-paredwith18.9%inthecontrolgroup.Thefindingswerestatisticallysignificant.Theauthorsfoundnostatisticaldifference with respect to intake of eggs.
Finally,Zamanetal.(2008)lookedatthefeedingof eggs,meat, and liver, the addition of ghee or butter to children’s foods,andfeedingof afortifiedcomplementaryfoodinLahore, Pakistan. The intervention was introduced as part of an IMCI program, and included counseling of sick women and children seeking care at a local health center. The counseling was provided by trained health workers equipped with counseling cards that had been adapted to the local culture and language. Eight to 14 days after re-cruitment, the proportion of women offering their children eggs was 16 percentage points higher among children in the intervention compared with those in the control group. Six months after recruitment, the difference was 21 percent-age points. The proportion of women offering children chicken, beef, or mutton 8-14 days after recruitment was approximately 18 percentage points higher in the interven-tiongroupthanthecontrolgroup.Thesefindingswerestatisticallysignificant.Theauthorsfoundnostatisticallysignificantdifferencesinthefeedingof chicken,beef ormutton six months after recruitment, or in the feeding of liver during any period of follow up.
Longitudinal studies
Pachónetal.(2002)conductedalongitudinalrandomizedstudy looking at the consumption of locally available PD foods in rural Vietnam.46 The intervention was based on
46 PDfoodsincluded:crab,fish,fruit,peanut,sesameseed,vegetables,eggs, shrimp, tofu, beans, cassava, meat, potatoes, rice, snail, clams, corn, sweet potatoes, bananas, green vegetables, oranges, papaya, starches, and tangerines.
66 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
the PD/Hearth approach.47 Theauthorsidentifiedseverallocally available highly nutritious foods, which were then promoted in intensive nutrition rehabilitation sessions for mothers of malnourished children. Women attended the sessions for two weeks each month for up to nine months. Duringtheintensiveinterventionperiod(months2-6)chil-dren under the age of three in the intervention group were fed PD foods an average of 4.1 times per day compared with an average of 3.6 times per day among children in the control group.
Palwalaetal.(2009)conductedalongitudinalstudywithoutcontrols looking at mean intake of cow’s milk, eggs, meat, legumes, fruits, and vegetables in Mumbai, India. Trained fieldworkersworkedwithgroupsof 8-10mothersusingwhat the authors describe as “innovative modules and dem-onstrations.”Theworkersthenfollowedupweeklyusing“a simple checklist … to assess impact, identify practices notadopted,andprovidefurtherinputs.”Bytheendof the study period, mean intake of milk among children 6-36 months of age had increased from 134 mL to 202 mL, while mean intake of egg had increased from 20 g to 29 g,andmeanintakeof meat(mutton,chicken,orfish)hadincreased from 4 g to 9 g.
Repeated cross-sectional studies
Aboudetal.(2008)lookedatmeanegg,fish,andcow’smilk consumption among children in Sripur, Bangladesh. Both intervention and control groups received 12 education sessionsonchilddevelopment,includingfiveoncomple-mentary feeding. The intervention group received an ad-ditional six sessions on responsive feeding. Although both the intervention and control groups participated in sessions oncomplementaryfeeding,atthefivemonthfollowupchildren in the intervention group consumed a mean of 0.28 eggs during the previous 24 hours, while children in the control group consumed just 0.09 eggs in the previous 24hours.Thedifferencewasstatisticallysignificant.Differ-
47 According to the CORE Group’s Resource Guide for Sustainably Rehabili-tating Malnourished Children, “a Positive Deviance/Hearth Nutrition Pro-gram is a home- and neighborhood-based nutrition program for children who are at risk for protein-energy malnutrition in developing countries. The programusesthe“positivedeviance”approachtoidentifythosebehaviorspracticed by the mothers or caretakers of well-nourished children from poor families and to transfer such positive practices to others in the com-munitywithmalnourishedchildren.The“Hearth”orhomeisthelocationforthenutritioneducationandrehabilitationsessions”(McNulty,2005).
encesintheconsumptionof fishandcow’smilkwerenotsignificantlydifferent.
Mackintoshetal.(2002)conductedarepeatedcross-sectional study with controls looking at consumption of specificfoods,48 hygiene, and health practices in Tan Hoah, Vietnam. The intervention included growth monitoring andpromotion(GMP)forallchildrenunderthreeyearsof age, and a PD/Hearth nutrition rehabilitation program for malnourished children that involved education and dem-onstration with their caretakers. At the conclusion of the study period, 93.3% of children in the intervention group had consumed shrimp in the previous week compared with 76% of children in the control group, and 97.8% of children in the intervention group had consumed eggs in the past week, compared with 72% in the control group. Thesefindingswerestatisticallysignificant.Similarly,themean frequency of shrimp and egg consumption in the in-terventiongroup(3.2and4.0,respectively)wassignificantlygreater than consumption in the control group (1.0 and 1.5, respectively).Differencesintheconsumptionof meatandfreshfishwerenotstatisticallysignificant.
Sunetal.(2011)measuredthepercentageof childrenfediron-richfoods(definedhereasmeat,fish,poultry,liverandironsupplements)beforeandafteraneightmonthbehaviorchangecommunication(BCC)interventioninShan’xi, China. The program, which was primarily aimed at increasing children’s consumption of a multiple micro-nutrient powder, included formative research and develop-ment of messaging and materials. The BCC materials in-cludedinfantandyoungchildfeeding(IYCF)handbooksfor parents, booklets for health workers, and television spots. Caregivers “were educated about [IYCF] (includ-ingtheuseof YYB)duringtheirchildren’sregularvillagedoctor visits. Brochures were also distributed by pediatri-cians to families with infants and young children during sick and well child visits at maternal and child health care hospitals.”Datafromtheendlinesurveyrevealedthatthepercentage of children fed iron-rich foods had increased from19.2% to 56.8%; however, the lack of baseline values oracontrolgroupmakesitdifficulttoattributethesedif-ferences to the intervention.
48 FoodsincludedlocallyidentifiedPDfoods(peanuts,sesame,driedfish,snails,shrimp,crab,andgreens)andotherfoods(sweetpotatoes,soybeans,eggs,freshfish,meat,fruit,andoil/fat).
67 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
Cross-sectional studies
Ghoshetal.(2002)lookedattheconsumptionof animalmilk, the number of food groups consumed, and feeding fre-quency among children in a cross-sectional study conducted in 13 villages in India. The intervention included monthly home visits by trained workers for a period of four to six months. Comparisons were made between infants included in the baseline study who reached 12 months of age before the interventionbegan(controlgroup)andthosewhowerelessthan six months old at the start of the intervention and con-tinued to participate until the child reached 12 months of age (interventiongroup).Bytheendof thestudyperiod,53.2%of children between six and 10 months of age in the inter-vention group had been fed animal milk in the previous 24 hours compared with 31.9% of children in the control group.
Feeding children fruits and vegetables
Of the ten studies that measured fruit and vegetable intake, ninereportedstatisticallysignificantresults.Theindica-tors measured varied considerably between studies, making comparisonsacrossstudiesdifficult.
Randomized controlled trials
Bhandarietal.(2004)conductedanRCTlookingatvegeta-ble and fruit consumption among children in India. At the end of the study period, the percentage of children nine months of age consuming any type of vegetables was 6.7% in the intervention group, compared with 2% in the control group.Thisdifferencewasstatisticallysignificant.Theau-thorsfoundnostatisticallysignificantdifferencesbetweenthe intervention group and control group with respect to fruit consumption, or children’s consumption of vegetables at 18 months of age.
Guldanetal.(2000)lookedattheconsumptionof fruitsand vegetables in rural Sichuan, China. Following a peer counseling intervention, the percentage of children in the intervention group consuming fruit exceeded the percent-age among controls in all age groups (26% vs. 10% at 4-6 months of age, 68% vs. 42% at 7-9 months of age, and 79%vs.52%at10-12monthsof age).Thesefindingswerestatisticallysignificant.Vegetableconsumptionamongchil-drenintheinterventiongroupwassignificantlygreaterthan
the control group in children 7-9 months of age (79% vs. 65%),butnotinchildren4-6or10-12monthsof age.
Finally,Vaziretal.(2013)lookedattheconsumptionof bananas and spinach by children in India. The study included two different intervention groups: a CFG and an RCF&PG. At nine months of age, 60.9% of children in the CFG and 59.4% of children in the RCF&PG consumed bananas dur-ing the previous week, compared with 38.6% of children in the control group, while 20.1% of children in the CFG and 14.4% of children in the RCF&PG consumed spinach during the previous week, compared with 5.1% of children inthecontrolgroup.Bothfindingswerestatisticallysignifi-cant. At 15 months of age, 79.3% of children in the CFG group and 78.3% in the RCF&PG group consumed bananas, compared with 61.9% of children in the control group, while 42.4% of children in the CFG group and 45.2% of children in the RCF&PG group had consumed spinach in the previ-ous week, compared with 29.5% in the control group.
Longitudinal studies
Pachónetal.(2002)childrenunderthreeintheinterven-tion group were fed PD foods,49 including vegetables, green vegetables, sweet potatoes, bananas, oranges, papayas, and tangerines, an average of 4.1 times per day compared with only 3.6 times per day among children in the control group. Thisfindingwasstatisticallysignificant.
Palwalaetal.(2009)measuredchildren’smeanconsumptionof fruits and the proportion of children consuming veg-etables in Mumbai, India. By the end of the study period, mean intake of fruit in children between six and 36 months of age had increased from 41g to 82g, the percentage of children consuming green leafy vegetables had increased from 16.7% to 87.6%, and the percentage of children consuming carrots had increased from 8.3% to 52.1%. The resultswerestatisticallysignificant.
Repeated cross-sectional studies
Aboudetal.(2008)conductedarepeatedcross-sectionalstudy looking at mean fruit and vegetable intake among chil-
49 PDfoodsidentifiedthroughaPDinquiryincluded:crab,fish,fruit,peanut, sesame seed, vegetables, eggs, shrimp, tofu, beans, cassava, meat, potatoes, rice, snail, clams, corn, sweet potatoes, bananas, green vegeta-bles, oranges, papaya, starches, and tangerines.
68 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
dren in Sripur, Bangladesh. Five months after the responsive feeding intervention, the mean number of times children consumed fruit and vegetables during the previous day was .6 and1.37(respectively)intheinterventiongroup,comparedwith.32and.8(respectively)inthecontrolgroup.
Mackintoshetal.(2002)lookedatconsumptionof greens,sweet potatoes, and fruit in Thanh Hoa, Vietnam. At the conclusion of a GMP and PD/Hearth intervention, 100% of children in the intervention group consumed fruit in the previous week, compared with 88% in the control group. Similarly, the mean frequency of fruit consumption in the previous week was 5.4 in the intervention group, compared with1.5inthecontrolgroup.Thesefindingswerestatisti-callysignificant.Differencesintheconsumptionof greensandsweetpotatoeswerenotstatisticallysignificant,althoughthe authors did report an increase in the mean frequency of sweet potato consumption (6.7 times/week in the interven-tiongroupvs.3.2times/weekinthecontrolgroup).
Parvantaetal.(2007)lookedatchildfeedingpractices,particularly associated with iron-rich foods, in northwest Bangladesh.Interventiongroup1(IG1)includedhome-basedcounseling(onceinathreemonthperiod)byhealtheducators to pregnant women and mothers of children 6–24 monthsold.Interventiongroup2(IG2)includeddiscussionof role modeling stories facilitated by peer group leaders dur-ing gardening group or credit group meetings. Participants were asked to share these stories with related women who fell into the eligibility categories mentioned above. Following the intervention, 52% of women in IG2 reported feeding children 6-24 months of age the recommended portion of green leafy vegetables, compared with 33% of women in IG1, and 17% of women in the control group.
Cross-sectional studies
Finally,Kilaruetal.(2005)lookedattheconsumptionof bananas and dietary diversity in rural Karnataka, India. The intervention included monthly counseling (referred to as “education”inthearticle)forcaregiversof infantsfrombirth through a child’s second birthday. The nutrition edu-cationwasprovidedinthehomebytrainedfieldresearchstaff (highschoolorcollegeeducatedfieldworkerswholiveincloseproximitytothestudyvillages).“Afteradminister-ingthemonthlyquestionnaire,thefieldstaff woulddiscuss
reported feeding practices with the primary caregiver. The total time for the questionnaire and counseling was about 1½ hours. Field staff would review dietary information from the questionnaires and talk about ways of improving the quality and quantity of the diet through questions and probesaskedinafriendlymanner.Thefieldstaff wouldoften provide personal examples of how to overcome challenges in feeding young children, including the kind of communication skills needed to coax young children to eat.”Followingtheintervention,33%of caregiversintheintervention group reported feeding children 7-11 months of age bananas, compared with 4% in the control group.
Feeding children a minimum number of food groups (dietary diversity)
Two of six studies that measured dietary diversity reported statisticallysignificantresults.Sunetal.(2011)conductedarepeated cross-sectional study looking at dietary diversity in Shan’xi, China. Following a provider counseling and media intervention, the percentage of women reporting that they fed their six to 24 month old children more than four food groups50 had increased from 57.5% to 74.1% among breastfed children, and from 27.6% to 53.9% among non-breastfed children. Furthermore, the percentage of children fed a minimal acceptable diet had increased from 42.1% to 73.5% among breastfed children and from 25.0% to 45.0% among non-breastfed children. There was no control group included in the study.
Kilaruetal.(2005)conductedacross-sectionalanalysislooking at dietary diversity in Karnakaka, India. Following a home-based counseling intervention, the percentage of children11monthsof ageconsumingatleastfivedifferentfood groups was 42% in the intervention group, compared with 19% in the control group.
Micronutrient supplementation or fortification
Althoughweidentifiedmanystudiesreportingontheconsumptionof micronutrientsupplementsorfortifiedproducts,onlyfivepresentedresultsinawaythatenabledanexaminationof thedistincteffectof specificSBCC
50 The authors did not explain if dietary data were based on a food recall and, if so, the recall period.
69 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
approaches on uptake. Two of these reported statistically significantresults.
Bonvecchioetal.(2007)conductedanRCTlookingatthe impact of a behavior change intervention designed to improve the utilization of a multi-micronutrient nutritional supplement (papilla)amongchildren6-23monthsof agein Mexico. Papilla was provided as part of the Oportunidades Program free of charge, but conditional upon mothers’ participation in monthly education sessions on health and nutrition in all study communities. In intervention communi-ties, these education sessions were complemented by home visits in which volunteers conveyed four key messages related to the preparation and use of papilla, and demonstrated its preparation. Health care service providers conveyed similar messaging during consultations, and videos on these top-ics were screened in health facility waiting rooms. Posters were mounted in multiple sites, including health centers, stores, community centers, and churches, while megaphones mounted on trucks broadcast messages and announcements. At follow up, the authors reported a net increase of 43.5 percentage points in proper preparation of papilla in inter-vention communities compared with control communities, a net increase of 64.4 percentage points in daily provision of papilla, and a net increase of 61.5 percentage points in those providing papilla between breakfast and dinner.
Dongreetal.(2011)conductedarepeatedcross-sectionalstudy with controls focused on increasing coverage of iron supplementation among children under the age of three in 23 villages in India. The intervention included nutritional education sessions conducted during the Bal Suraksha Diwas (childhealthday)celebrationandduringhomevisits,freedistribution of iron syrup, and monthly village-level commu-nity/social mobilization meetings. Furthermore, “a photo-graph of locally available iron-rich foods and citrus fruits was shown to mothers to increase their awareness of sources of iron.[…]”Afterthreemonths,thepercentageof childrenunder the age of three who took iron supplementation in-creased from 8.8% to 41.6%. It is important to note that this intervention distributed the iron syrup free of charge.
Increased meal frequency and/or energy density
Sixteen studies measured meal frequency and energy den-sityand12of themreportedstatisticallysignificantresults.Four broad categories of practices were reported: seven studies reported on frequency of feeding, four reported on the addition of fats or oils to children’s foods, two reported on enhancing the energy density of children’s foods (i.e. decreasingwatercontent),andthreereportedonincreasingquantity fed to children at each meal.
Increasing frequency of feeding children
Seven of eleven studies that looked at the frequency or numberof mealsfedtochildrenoveraspecifiedperiodof timereportedstatisticallysignificantresults.
Randomized controlled trials
Bhandarietal.(2004)lookedatmealfrequencyamongchildren at nine and 18 months of age in India. At the conclusion of the facility and home based counseling intervention, children nine months of age in the interven-tion group consumed a mean of 4.4 meals in the previ-ous 24 hours, compared with a mean of 3.9 meals in the control group, while children 18 months of age in the intervention group consumed a mean of 5.9 meals in the previous 24 hours, compared with a mean of 5.4 among children in the control group. Both differences were statisticallysignificant.Meanenergyintakeintheprevious24 hours was higher among children in the intervention groupthaninthecontrolgroup(1556kilojoule(kJ)of energy vs. 1025 kJ among 9 month olds, and 3807 kJ vs. 2577kJamong18montholds).
Royetal.(2007)lookedatchildrenfedthreeormoretimesper day in Bangladesh. At the conclusion of the group education and small media intervention, 83.8% of children in the intervention group were fed three or more times per day compared with 19.4% of children in the control group. Thesedifferencesremainedstatisticallysignificantatfollowupsixmonthslater(88.5%vs.24.5%respectively).
70 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
Longitudinal studies
Pachónetal.(2002)lookedatmealfrequencyamongchil-dren under the age of three in rural Vietnam. After two to six months of a PD/Hearth group education intervention, children in the intervention group were fed a mean of 4.6 times per day compared with a mean of 4.2 times per day among children in the control group. After 12 months of the intervention, children in the intervention group consumed a mean of 4.9 meals per day compared with a mean of 4.6 meals per day among children in the control group. Further-more, during the intensive intervention period (months two tosix)childrenintheinterventiongroupweremorelikelytomeetenergyintakerequirements(kcal/kg)thanthoseinthecontrolgroup(49.0%vs.35.1%).Thisdifferencewasstatisti-callysignificant.Atthe12monthfollow-upperiod,however,the difference in the percentage of children meeting the recommendedintakewasnotstatisticallysignificant.
Repeated cross-sectional studies
Guyonetal.(2009)lookedattheimpactof interventionsdesigned to increase food intake during pregnancy and lacta-tion and feeding frequency in children in two highland prov-inces in Madagascar. The intervention included training of health workers, interpersonal communication, community/social mobilization, and the use of mass media. At the end of the study period, “the proportion of breastfed children 6-23 months of age fed the recommended number of times increased from 87% to 92%. There was no increase in the rate of feeding the recommended times per day among chil-dren6-8monthsof age,buttherewasasignificantincreaseamongchildren9to23monthsof age(from85%to93%).”
Kimmonsetal.(2004)reportedonseveralstudiesassess-ing the feasibility of different approaches for improving complementary feeding practices in rural Bangladesh. Each study was conducted for seven days among approximately 30 women. One tested the feasibility and effectiveness of educational messages to increase the frequency of meals fed to children. Women were asked to feed at least three meals per day, and more if possible. They were advised that snackfoods(amountslessthan10g)werenottobeconsid-ered meals, and they were encouraged to continue to give snacks as usual. By the end of the seven day trial, the num-ber of meals provided to children in the previous 24 hours
had increased from a mean of 2.2 to a mean of 4.1. The second study focused on increasing the quantity of food offered to, and consumed by, infants at each meal. This trial did not have an effect on meal frequency, but did improve the quantity of food consumed by children (see below in discussionof quantityfedtochildrenateachmeal).Inthethird small study, women were taught to decrease viscosity of children’s food (and therefore increase food or energy consumption)by“changingtherecipeoraddingamylase,increasing energy density by adding sugar or oil, or chang-ingthefood’sorganolepticcharacteristics.”
Mackintoshetal.(2002)conductedarepeatedcross-sectionalstudy looking at feeding frequency among children in Tan Hoa, Vietnam. Following a PD/Hearth intervention, children in the intervention group consumed a mean of 2.9 full meals per day compared with a mean of 2.2 meals per day among children in the control group, and children in the intervention group consumed a mean of 2.5 snacks per day compared with a mean of 1.6 snacks per day in the control group.
Cross-sectional studies
Kilaruetal.(2005)lookedatthefrequencyof feedingintwo age groups in India. Following a provider counseling intervention, the percentage of children 7 to 11 months of age that were fed at least four times in addition to breast milk in the previous 24 hours was 78% in the intervention group and 51% in the control group.
Adding fats or oils to children’s foods
Five studies looked at the addition of oil, butter, or other fat to children’s diets to increase energy density, and all but one reportedstatisticallysignificantresults.Bhandarietal.(2004)conducted an RCT looking at the addition of oil or butter to infant foods in India. Following an intervention that included home visits and counseling at the facility level, the percentage of children nine months of age consuming foods with added oil or butter was 8.6% in the intervention group compared with 0.5% in the control group, and the percentage of chil-dren 18 months of age consuming foods with added oil or butter was 24.1% in the intervention group compared with 5.8% in the control group. The researchers found a corre-spondingchangeinenergyintakefromoil(kJper24hours)among children nine months and 18 months of age.
71 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
InasecondRCT,Mackintoshetal.(2002)conductedare-peated cross-sectional study in Tan Hoa, Vietnam. Among other foods, they looked at the consumption of oil/fat by children between 7-9 months of age. Following a PD/Hearth intervention, children in the intervention group were fed oil/fat 6.6 times per week on average compared with 2.8 times among children in the control group.
Royetal.(2007)lookedattheadditionof oiltochildren’sfood in Bangladesh. Following the intervention, the per-centage of children at six months of age that received food with added oil was 69.8% in the intervention group com-pared with 20.9% in the control group, and the percentage of children at 12 months of age that received food with added oil was 61.3% in the intervention group compared with 21.5% in the control group.
Finally,Vaziretal.(2013)lookedattheadditionof fattocomplementary foods and the energy intake of children in India. The study included two different intervention groups: a CFG and an RCF&PG. At nine months of age, 51.4% of children in the CFG and 44.4% of children in the RCF&PG consumed added fat during the previous week compared with 24.4% of children in the control group. At 15 months of age, 42.4% of children in the CFG and 52.5% of children in the RCF&PG consumed added fat during the previous week compared with 29.5% of children in the control group. Similar differences in median energy intake following intervention were also reported. At nine months of age, median energy intake among children in the CFG group was 348 kcal and 331kcal in the RCF&PG group, compared with 209 kcal in the control group. At 15 months of age, median energy intake among children in both intervention groups was 569 kcal compared with 460 kcal among children in the control group.
Enhancing the consistency of children’s foods
Four studies evaluated the effect of an SBCC intervention on energy density of complementary food by enhancing theconsistencyof foods.Tworeportedstatisticallysignifi-cantresults.Zamanetal.(2008)conductedanRCTlookingat the feeding of kitchuri, a thick complementary food in Lahore, Pakistan. At 8 to 14 days after recruitment, 61.6% of women in the intervention group had offered their chil-dren kitchuri compared with 45% of women in the control
group, and at 180 days after recruitment, 65.9% of women had offered their children kitchuri compared with 44.3% in the control group. Findings 8 to 14 days after recruitment werenotstatisticallysignificant,whilefindingsfrom180daysafterrecruitmentwerestatisticallysignificant.
Pennyetal.(2005)conductedanRCTlookingatthefeed-ing of thick consistency foods among six age groups in Trujillo,Peru.Asignificantlyhigherpercentageof caregiv-ers in the intervention group compared with the control group fed food of a thick consistency to their children at measurementstakenatsixmonthsof age(31%vs.20%),atninemonthsof age(35%vs.17%),andat12monthsof age(42%vs.26%).Differencesattheagesof 8,15,and18monthswerenotstatisticallysignificant.
Increasing the quantity fed to children at each meal
While several studies measured energy intake among children,onlythreereportedstatisticallysignificantresultsspecificallyrelatingtoincreasingthequantityof foodfedto children at each meal. Two studies reported on the use of a separate feeding pot, and one article reported on an increase in the quantity of food offered and time allocated for feeding children.
Royetal.(2005)conductedanRCTlookingattheuseof a separate feeding pot for malnourished children 6 to 24 months of age in rural Chandpur, Bangladesh. The inter-vention took place within the Bangladesh Integrated Nutri-tionProject(BINP),andincludedtwointerventiongroupsof mothers.Inthefirstgroup,womenreceivedintensivenutritioneducation(INEgroup)twiceeachweekforthreemonths. In the second group, women received the same nu-trition education as well as supplementary feeding (INE+SF group).ThecontrolgroupreceivedstandardBINPservicesof twice-monthly nutrition education. After three months, 99% of women in the INE group and 100% of women in the INE+SF group reported the use of a separate pot for children, compared with 47% in the control group. At the end of six months of observation, 100% of women in both intervention groups reported use of separate pots for chil-dren, compared with 48% in the control group.
72 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
Royetal.(2007)alsolookedattheuseof aseparatefeed-ing pot for children 6 to 9 months of age in four upazilas (administrativeunitswithindistricts)infourgeographicregions of Bangladesh. Following the intervention, the authors reported an increase of 14.3% in the proportion of children served from their own pots.
Finally,Kimmonsetal.(2004)conductedalongitudinalstudy looking at the quantity of food and duration of feed-inginBangladesh.Followinganinterventioninwhichfieldworkers encouraged women to increase the quantity of food fed to their children and allocate more time for meals, theresearchersobservednostatisticallysignificantdiffer-ence in the amount of food offered. However, they did observeastatisticallysignificantdifferenceinthequantityof foodconsumedbetweendayoneof thestudy(40g)andday7(64g),andinthedurationof themeal–fromsixto13 minutes.
Responsive and active feeding
Three studies looked at responsive or active feeding and two(bothRCTs)reportedstatisticallysignificantresults.Bhandarietal.(2004)lookedatseveralactivefeedingprac-tices in Indian children at nine and 18 months of age. The intervention included provider counseling, peer counseling, and group education to mothers. At nine months of age, 34.8% of women in the intervention group reported active encouragement, compared with 7.7% in the control group. At 18 months of age, 89.7% of women in the interven-tion group reported active encouragement, compared with 49.0% in the control group. Differences between the intervention group and control group held across a series of specificpractices,includingfeedingwithloveandaffec-tion(41%vs.11%),tryingrepeatedlyif thechilddidnoteat(15.4%vs.1%),womanfeedingherchildherself (34.9%vs.26.4%),womanmakingthechildsitinherlap(18.2%vs.6.6%),andfeedingthechildwithotherfamilymembers(12.4%vs.2.5%).
Zhangetal.(2013)lookedatactivefeedingandfeed-ing during illness among infants in rural Lasihui, China. Children were enrolled at two to four months of age and were assessed at 6, 9, 12, 15 and 18 months of age. The intervention included group training sessions conducted
by trained township doctors for mothers, grandmothers, and fathers, and home visits by trained providers every three months “with the purpose of identifying possible feedingproblemsandprovidingindividualcounselling.”The project disseminated child feeding booklets, and con-ducted demonstrations of food preparation using locally available, affordable, acceptable and nutrient-dense foods. After 18 months of the intervention, 88.0% of women in the intervention group encouraged their children to eat when they refused food, compared with 53.9% in the control group.
Feeding during and after illness
Three studies measured practices related to complementary feeding of sick or malnourished children, but only one reportedstatisticallysignificantresults.Zhangetal.(2013)conducted an RCT looking at feeding of breast milk and easy-to-digest foods to sick children in rural Laishui, China. Following the intervention, 88.8% of women reported feeding breast milk and easy-to-digest foods to their chil-dren with diarrhea, compared with 65% of women in the control group, while 67.3% of women in the intervention group reported preparing easy-to-digest food separately for their children with diarrhea, compared with 32.8% in the control group.
D. Summary of the Evidence
SBCC approaches utilized
For the purposes of analysis, we organized SBCC activi-ties into three primary categories or approaches: inter-personal communication, media, and community/social mobilization.Theseapproachesandthespecificactivitiesassociated with each are described in further detail in the introductory chapter.
The studies reviewed included a broad range of approaches to promote optimal complementary feeding practices. Most includedmorethanonespecificSBCCactivityandmanyutilized more than one approach.
Of the25studiesreportingstatisticallysignificantfindings,24utilizedinterpersonalcommunication(IPC)approaches,
73 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
Table 3.3.3: Number of studies reviewed (with number of studies reporting statistically significant results in parentheses), by SBCC approach and study design
SBCC approaches and activities
Literature reviews with meta-anal-
ysis
RCTsLongitudinal
studies
Repeated cross-sec-
tional studies
Cross-sec-tional studies
TOTAL
Interpersonal Communication 0 12 (12) 8 (7) 7 (4) 2 (2) 29 (25)
One-on-One Counseling 0 10 (6) 4 (0) 5 (1) 2 (2) 21 (9)
Counseling in facilities 0 5 (3) 1 (0) 0 2 (2) 8 (5)
Counseling in communities 0 0 0 1 (1) 0 1 (1)
Counseling in homes (home visits) 0 7 (3) 3 (2) 3 (1) 0 13 (6)
Counseling in other settings 0 0 0 1 (0) 0 1
Group Education 0 4 (3) 5 (5) 4 (3) 0 13 (11)
Education in facilities 0 0 1 (1) 0 0 1 (1)
Education in communities 0 4 (3) 4 (4) 3 (2) 0 11 (9)
Education in other settings 0 0 0 1 (0) 0 1
Support Group 0 0 0 3 (2) 0 3 (2)
Support group in facilities 0 0 0 0 0 0
Support group in communities 0 0 0 2 (1) 0 2 (1)
Support group in other settings 0 0 0 1 (0) 0 1
Media 0 7 (7) 2 (2) 5 (4) 0 14 (13)
Mass media 0 0 0 2 (2) 0 2 (2)
Mid-sized media (community radio / video, local billboards)
0 0 0 4 (3) 0 4 (3)
Small media (posters, flyers, calendars, reminder stickers)
0 7 (7) 2 (2) 4 (3) 0 13 (12)
Traditional media (songs, drama) 0 0 0 1 (1) 0 1 (1)
Social media (Twitter, Facebook, etc.) 0 0 0 0 0 0
Community/Social Mobilization 0 2 (2) 0 4 (3) 0 6 (5)
Campaign, event, special “days” 0 0 0 2 (2) 0 2 (2)
Issue groups 0 0 0 4 (3) 0 4 (3)
Other 0 2 (2) 0 0 0 2 (2)
74 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
12utilizedsomeformof media,andfiveemployedcom-munity/social mobilization. Group education in commu-nities was the most commonly used IPC approach; small media was the most commonly used media approach; and issue groups were the most commonly used forms of com-munity/social mobilization. See Table 3.3.3.
The breadth of evidence regarding the effectiveness of SBCC in changing complementary feeding practices varies by type approach. Below, we discuss the evidence associ-ated with each of the primary SBCC approaches utilized to promoted complementary feeding practices. Table 3.3.4 providesaconsolidatedsummaryof thesefindings.
Interpersonal communication
Weidentifiednopreviousreviewslookingattheeffective-ness of IPC on uptake of optimal complementary feeding practices, but did identify 24 primary research studies reportingstatisticallysignificantoutcomesassociatedwithinterventions that included IPC. One study reported a positive effect with respect to the timely introduction of complementary foods, 15 reported a positive effect with respect to dietary diversity, two documented a positive effectwithrespecttosupplementationorfortification,12reported a positive effect with respect to meal frequency or density, two reported a positive effect with respect to responsive or active feeding, and one reported a posi-tive effect with respect to feeding during or after illness. Twelve of these studies measured the effectiveness of IPC independent of other SBCC approaches, including four RCTs. Indicators and study design varied consider-ablybetweenstudies,makingconsolidationof findingsdifficult.Intheonlystudycomparingtheeffectivenessof different IPC approaches in changing complemen-taryfeedingpractices,Parvantaetal.(2007)comparedindividual stage-based counseling by a trained agent and education through storytelling led by a group leader. They found that “twice as many women who met with the trained agent (in contrast to those who met with the groupleaders)demonstratedfeedingaportionof greenvegetables equal to or surpassing the recommended quan-tity.”Thoughstatisticalsignificanceof thisdifferencewasnot reported, it was suggested in the authors’ analysis.
Media
Weidentifiednopreviousreviewsdocumentingtheeffec-tiveness of media-related interventions on complementary feeding outcomes, but did identify 13 primary research studies that reported positive outcomes associated with interventions including media-based SBCC approaches. One study reported a positive effect with respect to the timely introduction of complementary foods, nine studies reported a positive effect with respect to dietary diversity, one study documented a positive effect with respect to supplementationorfortification,sevenreportedapositiveeffect with respect to meal frequency or density, one study reported a positive effect with respect to responsive or ac-tive feeding, and one study reported a positive effect with respect to feeding during or after illness.
None of these studies, however, measured the effect of media interventions independent of other SBCC ap-proaches,makingitdifficulttomakedefinitiveconclusionsregarding the effectiveness of media related interventions on complementary feeding outcomes.
Community/social mobilization
Weidentifiednoreviewsdocumentingtheeffectivenessof community/social mobilization approaches on complemen-taryfeedingoutcomes,butdididentifyfiveprimaryresearchstudiesreportingstatisticallysignificantoutcomesthatinclud-ed community/social mobilization approaches: One study reported a positive effect with respect to the timely introduc-tion of complementary foods, one reported a positive effect with respect to dietary diversity, one documented a positive effectwithrespecttosupplementationorfortification,tworeported a positive effect with respect to meal frequency or density, one reported a positive effect with respect to respon-sive or active feeding, and one reported a positive effect with respect to feeding during or after illness.
None of these studies measured the effectiveness of com-munity/social mobilization independent of other SBCC approaches.Itisthereforedifficulttoderiveconclusionsre-garding the effectiveness of community/social mobilization with respect to uptake of complementary feeding practices.
75 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
Tabl
e 3.
3.4:
Num
ber
of s
tudi
es r
evie
wed
(w
ith n
umbe
r of
stu
dies
rep
ortin
g st
atis
tical
ly s
igni
fican
t re
sults
in p
aren
thes
es),
by S
BCC
ap
proa
ch a
nd s
tudy
des
ign
SB
CC
ap
pro
ach
Tim
ely
intr
odu
c-ti
on
of
com
ple-
men
tary
fo
ods
Die
tary
div
ersi
tyM
icro
nu-
trie
nt s
up-
plem
enta
-ti
on
or
fort
ifica
-ti
on
Incr
ease
d m
eal f
requ
ency
and
/or
dens
ity
Res
pon-
sive
/ ac
tive
fe
edin
g
Feed
ing
duri
ng
and
afte
r ill
ness
Feed
ing
child
ren
anim
al
sour
ce
foo
ds
Feed
ing
child
ren
frui
ts a
nd
vege
ta-
bles
Feed
ing
child
ren
a m
inim
um
num
ber
of f
oo
d gr
oup
s
Incr
easi
ng
freq
uenc
y o
f fee
ding
ch
ildre
n
Add
ing
fats
or
oils
to
ch
ildre
n’s
foo
ds
Enh
anci
ng
the
con-
sist
ency
of
child
ren’
s fo
ods
Incr
easi
ng
the
quan
-ti
ty fe
d to
ch
ildre
n at
eac
h m
eal
Inte
rper
-so
nal C
om
-m
unic
atio
n
4 (1
)
1 R
CT
(a
ge a
t in
tro-
duct
ion)
14 (
13)
6
RC
Ts
(5
egg
, 1
liver
, 1 fi
sh, 3
m
eat)
3 Lo
ngitu
-di
nal
(2 m
ilk, 1
eg
g, 1
mea
t, 1
PD)
3 R
epea
ted
cros
s-se
c-tio
nal
(1 e
gg, 1
fish
, 1
iron
- ri
ch)
1 C
ross
-sec
-tio
nal (
milk
)
10 (
9)
3
RC
Ts
(2
frui
ts, 2
ve
geta
bles
; ba
nana
and
sp
inac
h)
2
Long
itu-
dina
l (1
PD
, 1
vege
tabl
es)
3
Rep
eate
d cr
oss-
sec-
tiona
l (2
frui
ts, 2
ve
geta
bles
, 1
swee
t po
tato
)
1 C
ross
-se
ctio
nal
(ban
ana)
6 (2
)
1 R
epea
ted
cros
s-se
c-tio
nal
(>=
4 fo
od
grou
ps)
1 C
ross
-se
ctio
nal
(≥ 5
food
gr
oups
)
5 (2
)
1 R
CT
(fo
rtifi
ed
com
plem
en-
tary
food
)
1 Lo
ngitu
-di
nal
(iron
sup
-pl
emen
tatio
n co
vera
ge)
10 (
7)
2
RC
Ts
(≥
3 m
eals
; #
of m
eals
)
2 Lo
ngitu
-di
nal
(2 #
of
mea
ls)
2
Rep
eate
d cr
oss-
sec-
tiona
l (#
of m
eals
)
1 C
ross
-se
ctio
nal (
≥ 4
times
)
5 (4
)
4 R
CT
s
(2 a
dded
fat/
oil/b
utte
r; ve
geta
ble
oil d
aily
; lar
d da
ily; w
oman
ad
ded
fat
to
her
chil-
dren
’s fo
od)
4 (2
)
1 R
CT
(t
hick
food
s)
1
Rep
eate
d cr
oss-
sec-
tiona
l (t
hick
food
s)
4 (3
)
2 R
CT
s
(sep
arat
e
pot)
1 Lo
ngitu
-di
nal
(mea
l dur
a-tio
n)
3 (2
)
2 R
CT
s
(enc
oura
ge-
men
t)
3 (1
)
1 R
CT
(fe
edin
g du
r-in
g di
arrh
ea)
76 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
SB
CC
ap
pro
ach
Tim
ely
intr
odu
c-ti
on
of
com
ple-
men
tary
fo
ods
Die
tary
div
ersi
tyM
icro
nu-
trie
nt s
up-
plem
enta
-ti
on
or
fort
ifica
-ti
on
Incr
ease
d m
eal f
requ
ency
and
/or
dens
ity
Res
pon-
sive
/ ac
tive
fe
edin
g
Feed
ing
duri
ng
and
afte
r ill
ness
Feed
ing
child
ren
anim
al
sour
ce
foo
ds
Feed
ing
child
ren
frui
ts a
nd
vege
ta-
bles
Feed
ing
child
ren
a m
inim
um
num
ber
of f
oo
d gr
oup
s
Incr
easi
ng
freq
uenc
y o
f fee
ding
ch
ildre
n
Add
ing
fats
or
oils
to
ch
ildre
n’s
foo
ds
Enh
anci
ng
the
con-
sist
ency
of
child
ren’
s fo
ods
Incr
easi
ng
the
quan
-ti
ty fe
d to
ch
ildre
n at
eac
h m
eal
Med
ia1
(1)
1
Rep
eate
d cr
oss-
sec-
tiona
l (a
ge a
t in
tro-
duct
ion)
5 (5
)
3 R
CT
(3
egg
, 2 li
ver,
1 fis
h, 1
goa
t, 1
poul
try)
1 Lo
ngitu
di-
nal (
egg)
1 R
epea
ted
cros
s-se
c-tio
nal
(iron
-ric
h)
3 (3
)
1 R
CT
(b
anan
a an
d sp
inac
h)
1
Long
itudi
-na
l (ve
geta
-bl
es)
1
Rep
eate
d cr
oss-
sec-
tiona
l (v
eget
able
s)
2 (1
)
1 R
epea
ted
cros
s-se
c-tio
nal
(>=
4 fo
od
grou
ps)
2 (1
)
1 R
CT
(fo
rtifi
ed
com
plem
en-
tary
food
)
4 (2
)
1 R
CT
(≥
3 m
eals
)
1 R
epea
ted
cros
s-se
c-tio
nal
(# o
f mea
ls)
2 (2
)
2 R
CT
s (1
ad
ded
fat/
oil/b
utte
r; w
oman
ad
ded
fat
to
her
chil-
dren
’s fo
od)
2 (1
)
1 R
epea
ted
cros
s-se
c-tio
nal
(thi
ck fo
ods)
2 (2
)
2 R
CT
s (s
epar
ate
po
t)
1 (1
)
1 R
CT
(e
ncou
rage
-m
ent)
2 (1
)
1 R
CT
(fe
ed-
ing
duri
ng
diar
rhea
)
Co
mm
u-ni
ty/ S
oci
al
Mo
biliz
a-ti
on
1 (1
)
1 R
epea
ted
cros
s-se
c-tio
nal (
age
at
intr
oduc
tion)
1 (1
)
1 R
CT
0 (0
)0
(0)
1 (1
)
1 R
epea
ted
cros
s-se
c-tio
nal
(iron
sup
-pl
emen
tatio
n co
vera
ge)
1 (1
)
1 R
epea
ted
cros
s-se
c-tio
nal (
# o
f m
eals
)
1 (0
)1
(1)
1
RC
T
(thi
ck fo
ods)
0 (0
)1
(1)
1
RC
T
(enc
oura
ge-
men
t)
3 (1
)
1 R
CT
(fe
ed-
ing
duri
ng
diar
rhea
)
77 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
Multiple SBCC approaches
Weidentifiednoreviewsdocumentingtheeffectivenessof multiple SBCC approaches on complementary feeding outcomes. Of the 25 primary research studies reporting statisticallysignificantresultswithrespecttocomplemen-tary feeding outcomes, one study reported a positive effect with respect to timely introduction of complementary foods, seven reported a positive effect with respect to dietary diversity, two reported a positive effect with respect tomicronutrientsupplementationandfortification,sixreported a positive effect with respect to meal frequency and/or density, one reported a positive effect with respect to responsive or active feeding, and one reported a positive effect with respect to feeding during or after illness.
No studies compared the effect of different SBCC ap-proaches or measured the effect of the utilization of more than one SBCC approach compared with the utilization of just one approach. One must use caution, therefore, in deriving conclusions regarding the effectiveness of inter-ventions employing multiple approaches vis-à-vis those employing just one approach.
Implementation processes followed
None of the studies reviewed in this chapter assessed the effect of implementation processes (e.g. intensity and timing of communications; type and training of person communicatingmessages,ortargetaudience)ontheeffec-tiveness of the SBCC approach on complementary feeding practices, nor did they consistently report all aspects of the implementation processes.
The intensity of communications ranged from one to 24 visits/sessions, conducted weekly or monthly for various lengths of time. However, none of the studies compared the effect of timing or frequency.
In terms of target audiences, all of the studies reviewed in this chapter targeted the mother or primary caregiver of the child.Amongthe25studiesreportingstatisticallysignificantresults, fourteen targeted only the mother/caregiver while eleven targeted an additional audience as well. Eight also targeteddirectinfluencers,eighttargetedlocalcommunityactors, and one targeted actors of the enabling environment.
None of the studies compared the effect of targeting one vs. multiple audiences or of targeting different audiences.
E. Conclusions
The evidence of the effect of SBCC on complementary feeding practices is quite broad, and clearly indicates that SBCC interventions can improve a wide range of comple-mentaryfeedingpractices.Whiletheliteraturemayreflecta bias to publish positive results, it also underscores the important role of SBCC approaches in improving nutrition practices – practices which have been shown to have an im-pact on nutritional status of women, infants, and children.
There is very little consistency in how complementary prac-ticesaredefined,thenormativestandardsfollowedforthem,and the indicators used to measure them. This is the case, even with the existence of globally recognized indicators and measurement guidance from the WHO. An additional challengeisthatbehaviorsarehighlycontext-specificwhenit comes to complementary feeding – with different food taboos and different foods available that are appropriate for complementary feeding. If behaviors aren’t standardized, a projectmayimprovebehaviorsbutitwillbedifficulttoat-tribute changes in outcomes to those behaviors.
Similarly, there is considerable variation in the descrip-tion of SBCC interventions – the interactions or combinations with other interventions, target groups, content, messages, scale and coverage, length and intensity, as well as context.
SBCC interventions to promote complementary feed-ing practices are suited to iterative programming, be-cause even if standards for behaviors aren’t met, there can be significant movement toward the standard. In a hypothetical example, the target number of families introducing leafy green vegetables at six months might not be met, but many families may have begun introducing by eight months, whereas before the intervention they were not introducing until one year. Iterative interventions can learn what supported that move in the right direction, and build on them.
Interpersonal communication is the most prevalent SBCC approach used and researched, and is consistently effective
78 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
at improving complementary feeding practices. All but one of the studies in this chapter used IPC, and half of these measured the effectiveness of IPC independent of other SBCC approaches. While media and com-munity/social mobilization were used, they were always used with at least one other communication approach. No studies compared the effectiveness between differ-ent approaches or between one versus multiple SBCC channels or specific activities. This may be due to the difficultandcostof implementingmultiplearmsof astudy or disaggregating the contribution of single channels orspecificactivitieswithinamulti-channelintervention.Whatever the reason, it is important for SBCC practitioners and researchers to consider whether this line of research is worth the effort it will require.
Allof thestudiesreportingstatisticallysignificantresultstargeted the mother of the child herself. More than half of thosetargetedoneormoreotheraudiencesorinfluencersas well. No studies were identified that compared the effect of targeting one vs. multiple audiences or of targeting different audiences.
Little was mentioned in the articles reviewed regarding the timing of communications. The intensity of communica-tions ranged from one to 24 visits or sessions, conducted weekly or monthly for various lengths of time. None of the studies compared the effect of timing or intensity of communications.
Most studies were implemented on a relatively small scale, within only a few communities and typically having fewer than 300 study participants per group.
Finally, differences in local context (including social norms, culture,andenvironmentalfactors)aswellasdifferencesinthe implementation and scale of implementation affect the success of interventions. This underscores the importance of proper context assessments, formative research and/or ethnographic study prior to SBCC implementation.
Due to the lack of standardization in the way research re-lated to SBCC is designed and described, it is challenging to make conclusions beyond the fact that projects with SBCC will result in uptake of promoted practices. While there is much to be learned from this body of literature to aid us in developing future programs, a number of questions remain. These include questions related to:
n thepositive(ornegative)effectof usingmultipleSBCCapproaches compared with focusing on only one;
n thepositive(ornegative)effectof targetingmultipleaudiencesorinfluencersof thebehaviorsbeingpromoted, rather than focusing on just one target population;
n the role of context, in other words, the effect of the same SBCC intervention implemented in different contexts;
n the effectiveness of different approaches (including intensityandtargeting)fordifferentbehaviors;
n the cost and cost effectiveness of various SBCC approaches(particularlyasitrelatestoscalability);and
n the effectiveness and sustainability of these approaches when implemented at scale.
79 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
Tabl
e 3.
3.5:
Stu
dies
rep
ortin
g on
com
plem
enta
ry fe
edin
g pr
actic
es
Col
or c
odin
g ke
y
Intr
oduc
tion
of c
ompl
emen
tary
food
sEn
suri
ng n
utri
ent
cont
ent
of fo
ods
Prov
idin
g su
pple
men
ts o
r fo
rtifi
ed p
rodu
cts
Prov
idin
g ad
equa
te m
eal f
requ
ency
and
ene
rgy
dens
ity
Feed
ing
resp
onsi
vely
or
activ
ely
Feed
ing
duri
ng a
nd a
fter
illn
ess
ST
UD
YA
PP
RO
AC
HE
S
US
ED
S
CA
LE
/SC
OP
EE
VA
LU
AT
ION
M
ET
HO
DS
OU
CO
ME
(S)
ME
AS
-U
RE
DR
ES
ULT
S51
P-V
AL
UE
s / C
Is 5
2
Abo
ud e
t al
. (20
08);
Bang
lade
shG
roup
edu
catio
n in
co
mm
uniti
es b
y la
y vo
lunt
eers
36 v
illag
e cl
uste
rs
in a
rur
al S
ripu
r su
b-di
stri
ct (
18
inte
rven
tion,
18
cont
rol)
Rep
eate
d cr
oss-
sect
iona
l –
183
wom
en w
ith
child
ren
12 t
o 24
mon
ths
old
(91
inte
rven
tion,
92
cont
rol);
dat
a co
llect
ed
at b
asel
ine
and
5 m
onth
fo
llow
-up
Mea
n nu
mbe
r of
tim
es
food
s w
ere
eate
n by
chi
ld
yest
erda
y
-ani
mal
(fis
h)
-egg
-cow
’s m
ilk
0.86
vs.
1.01
0.28
vs.
0.09
0.85
vs.
0.73
NS53
p=0.
02
NS
Mea
n nu
mbe
r of
tim
es
frui
t w
as e
aten
by
child
ye
ster
day
Mea
n nu
mbe
r of
tim
es
vege
tabl
es w
ere
eate
n by
ch
ild y
este
rday
0.60
vs.
0.32
1.37
vs.
0.80
p=0.
04
p=0.
004
Abo
ud e
t al
. (20
09);
Bang
lade
shG
roup
edu
catio
n in
co
mm
uniti
es b
y la
y vo
lunt
eers
37 v
illag
e cl
uste
rs
in a
rur
al Ja
lakh
a su
b-di
stri
ct (
19
inte
rven
tion,
18
cont
rol)
Rep
eate
d cr
oss-
sect
iona
l –
203
wom
en w
ith
child
ren
8 to
20
mon
ths
old
(108
int
erve
ntio
n; 9
5 co
ntro
l)
Mea
n n
umbe
r of
food
ty
pes
eate
n (o
f sev
en)
by
child
ren
as r
epor
ted
by
mot
her
Mea
n n
umbe
r of
food
ty
pes
eate
n (o
f sev
en)
by
child
ren
as r
epor
ted
by
mot
her
3.25
vs.
2.93
2.22
vs.
2.26
NS
NS
Mea
n nu
mbe
r of
mou
thfu
ls
of fo
od t
aken
by
child
ren
at m
idda
y m
eal
-Pre
-tes
t
-Pos
t-te
st
-Fol
low
-up
13.7
7 v
s. 15
.10
20.7
8 v
s. 20
.11
21.2
3 vs
. 21.
62
NS
NS
NS
51
Com
paris
on is
inte
rven
tion
vs. c
ontro
l gro
up, u
nles
s ind
icat
ed o
ther
wise
.52Differencesreportedasnotsignificantlydifferentareindicatedby“NS”.Differencesforwhichstatisticalsignificancewasnotreportedareindicatedby“--“.
53NS=notsignificanteitheraccordingtowhatisreportedintheoriginalarticleorp<0.05.
80 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ST
UD
YA
PP
RO
AC
HE
S
US
ED
S
CA
LE
/SC
OP
EE
VA
LU
AT
ION
M
ET
HO
DS
OU
CO
ME
(S)
ME
AS
-U
RE
DR
ES
ULT
S51
P-V
AL
UE
s / C
Is 5
2
Bhan
dari
et
al. (
2001
); In
dia
Cou
nsel
ing
in h
omes
by
prov
ider
s1
com
mun
ity in
D
elhi
R
CT
– 4
18 in
fant
s fo
ur
mon
ths
of a
ge (
96 in
food
su
pple
men
t gr
oup;
95
in n
utri
tiona
l cou
nsel
ing
grou
p; 1
00 in
con
trol
gr
oup;
and
96
in v
isita
tion
cont
rol g
roup
); d
ata
colle
cted
whe
n in
fant
s w
ere
6, 9
and
12
mon
ths
of a
ge
Supp
lem
ent
+
coun
selin
g vs
. co
unse
ling
alon
e vs
. vis
itatio
n vs
. co
ntro
l
Com
pari
sons
w
ith fi
nal
grou
p (v
isita
tion
cont
rol)
Med
ian
ener
gy (
kJ)
inta
ke/
day
from
usu
al fo
ods
am
ong
child
ren
- at
26
wee
ks
- at
38
wee
ks
- at
52
wee
ks
Med
ian
tota
l ene
rgy
(kJ)
inta
ke/ d
ay a
mon
g ch
ildre
n
- at
26
wee
ks
- at
38
wee
ks
- at
52
wee
ks
171
vs. 4
72 v
s. 19
2 vs
. 268
476
vs. 9
78 v
s. 43
0 vs
. 577
761
vs. 1
417
vs.
665
vs. 9
24
1409
vs.
472
vs.
192
vs. 2
68
2169
vs.
978
vs.
430
vs. 5
77
2922
vs.
1417
vs
. 665
vs.
924
NS,
p<0.
05,
NS
NS,
p<0.
05,
NS
NS,
p<0.
05,
NS
--
--
--
81 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ST
UD
YA
PP
RO
AC
HE
S
US
ED
S
CA
LE
/SC
OP
EE
VA
LU
AT
ION
M
ET
HO
DS
OU
CO
ME
(S)
ME
AS
-U
RE
DR
ES
ULT
S51
P-V
AL
UE
s / C
Is 5
2
Bhan
dari
et
al. (
2004
); In
dia
Cou
nsel
ing
in fa
cilit
ies
by p
rovi
ders
; Gro
up
educ
atio
n in
com
mun
ities
by
pro
vide
rs; C
ouns
elin
g in
ho
mes
by
peer
s
8 co
mm
uniti
es
(4 in
terv
entio
n, 4
co
ntro
l)
RC
T –
1,0
25 n
ewbo
rns
(552
inte
rven
tion,
473
co
ntro
l); d
ata
colle
cted
ev
ery
3 m
onth
s fo
r 18
m
onth
s
% o
f chi
ldre
n w
ho
cons
umed
any
milk
- at
9 m
onth
s
- at
18
mon
ths
Mea
n en
ergy
inta
ke fr
om
milk
, kJ/2
4 hr
s
- at
12
mon
ths
- at
18
mon
ths
% o
f chi
ldre
n w
ho
cons
umed
veg
etab
les
- at
12
mon
ths
- at
18
mon
ths
% o
f chi
ldre
n w
ho
cons
umed
frui
ts
- at
12
mon
ths
- at
18
mon
ths
91.8
% v
s. 82
.6%
98.6
% v
s. 95
.9%
837
vs. 6
07
2021
vs.
1289
6.7%
vs.
2%
26%
vs.
24.1
%
16.2
% v
s. 11
.9%
44.8
% v
s. 40
.4%
p<0.
01
NS
p<0.
01
p<0.
001
p<0.
05
NS
NS
NS
Ener
gy in
take
(al
l foo
ds),
kJ/2
4 h
- at
9 m
onth
s
- at
18
mon
ths
Ener
gy in
take
from
oil,
kJ/2
4 h
- at
9 m
onth
s
- at
18
mon
ths
% o
f chi
ldre
n w
ho
cons
umed
add
ed o
il or
bu
tter
to
reci
pes
- at
9 m
onth
s
- at
18
mon
ths
Mea
n nu
mbe
r of
mea
ls
cons
umed
by
child
in t
he
prev
ious
24
hour
s
- at
9 m
onth
s
- at
18
mon
ths
1556
vs.
1025
3807
vs.
2577
134
vs. 5
8
335
vs. 1
84
8.6%
vs.
0.5%
24.1
% v
s. 5.
8%
4.4
vs. 3
.9
5.9
vs.
5.4
p<0.
001
p<0.
001
p<0.
001
p<0.
001
p<0.
01
p<0.
001
p<0.
01
p<0.
01
82 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ST
UD
YA
PP
RO
AC
HE
S
US
ED
S
CA
LE
/SC
OP
EE
VA
LU
AT
ION
M
ET
HO
DS
OU
CO
ME
(S)
ME
AS
-U
RE
DR
ES
ULT
S51
P-V
AL
UE
s / C
Is 5
2
% o
f wom
en t
hat
repo
rted
ac
tivel
y en
cour
agin
g th
eir
child
ren
to e
at m
ore
- at
9 m
onth
s
- at
18
mon
ths
At
18 m
onth
s…
- %
of w
omen
tha
t re
port
ed fe
edin
g th
eir
child
ren
with
love
- %
of w
omen
tha
t re
port
ed t
ryin
g re
peat
edly
if t
heir
chi
ld
did
not
eat
- %
of w
omen
tha
t re
port
ed fe
edin
g th
eir
child
her
self
- %
of w
omen
tha
t re
port
ed m
akin
g he
r ch
ild s
it in
her
lap
- %
of w
omen
tha
t re
port
ed fe
edin
g th
eir
child
with
oth
er fa
mily
m
embe
rs
34.8
% v
s. 7.
7%
89.7
vs.
49%
41%
vs.
11%
15
.4%
vs.
1%
34.9
vs.
26.4
%
18.2
% v
s. 6.
6%
12.4
% v
s. 2.
5%
p<0.
0001
p<0.
0001
p<0.
0001
p<
0.00
01
p<0.
0001
p<
0.00
01
p<0.
0001
83 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ST
UD
YA
PP
RO
AC
HE
S
US
ED
S
CA
LE
/SC
OP
EE
VA
LU
AT
ION
M
ET
HO
DS
OU
CO
ME
(S)
ME
AS
-U
RE
DR
ES
ULT
S51
P-V
AL
UE
s / C
Is 5
2
Bonv
ecch
io e
t al
. (20
07);
Mex
ico
Cou
nsel
ing
in fa
cilit
ies
by
prov
ider
s; C
ouns
elin
g in
ho
mes
by
lay
volu
ntee
rs;
Smal
l med
ia
4 co
mm
uniti
es
from
Ver
acru
z an
d C
hiap
as s
tate
s (1
in
terv
entio
n an
d 1
cont
rol c
omm
unity
fr
om e
ach
stat
e)
RC
T –
715
hou
seho
lds
part
icip
ated
in t
he
Oportunidades
pro
gram
an
d ha
d a
child
6-
23 m
onth
s of
age
pr
esen
t (V
erac
ruz:
171
inte
rven
tion,
173
con
trol
; C
hiap
as: 1
90 in
terv
entio
n,
181
cont
rol);
dat
a co
llect
ed a
t ba
selin
e an
d 5
mon
ths
late
r
Prep
ared
pap
illa
(nut
ritio
nal s
uppl
emen
t)
corr
ectly
Gav
e pa
pilla
eve
ry d
ay
Gav
e pa
pilla
bet
wee
n br
eakf
ast
and
dinn
er
Vera
cruz
: 82.
8%
vs. 1
9.3%
Chi
apas
: 80.
8%
vs. 1
5.6%
[net
incr
ease
of
42.9
per
cent
age
poin
ts in
in
terv
entio
n co
mpa
red
with
co
ntro
l]
Vera
cruz
: 78.
2%
vs. 1
7%
Chi
apas
: 71.
6%
vs. 2
2.2%
[net
incr
ease
of
64.4
per
cent
age
poin
ts in
in
terv
entio
n co
mpa
red
with
co
ntro
l]
No
data
on
Vera
cruz
an
d C
hiap
as
prov
ided
[net
incr
ease
of
61.5
per
cent
age
poin
ts in
in
terv
entio
n co
mpa
red
with
co
ntro
l]
p<0.
0554
p<
0.05
p<0.
05
84 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ST
UD
YA
PP
RO
AC
HE
S
US
ED
S
CA
LE
/SC
OP
EE
VA
LU
AT
ION
M
ET
HO
DS
OU
CO
ME
(S)
ME
AS
-U
RE
DR
ES
ULT
S51
P-V
AL
UE
s / C
Is 5
2
Bort
olin
i and
Vito
lo (
2012
); Br
azil
Cou
nsel
ing
in h
omes
by
prov
ider
s1
hosp
ital
RC
T –
397
new
born
s (1
63 in
terv
entio
n , 2
34
cont
rol)
Base
d on
a 2
4 ho
ur d
ieta
ry
reca
ll am
ong
child
ren
12-1
6 m
onth
s ol
d, m
ean
inta
ke o
f…
- co
w’s
milk
(m
L)
- m
eat
(g)
- ir
on (
mg)
- he
me
iron
(m
g)
- no
n-he
me
iron
(m
g)
501.
6 vs
. 588
.1
54.3
vs.
47.3
5.1
vs. 5
.4
1.5
vs. 1
.2
3.8
vs. 4
.5
p=0.
03
p=0.
024
p=0.
22
p=0.
003
p=0.
002
% ir
on s
uppl
emen
tatio
n of
ch
ildre
n at
0-6
mon
ths
% ir
on s
uppl
emen
tatio
n of
ch
ildre
n at
6-1
2 m
onth
s
18.2
% v
s. 19
.6%
23%
vs.
21.8
%
NS
NS
Col
ecra
ft e
t al
. (20
04);
Gha
naG
roup
edu
catio
n in
fa
cilit
ies
by p
rovi
ders
four
pri
mar
y he
alth
ca
re fa
cilit
ies
in
Acc
ra
with
a fu
nctio
ning
da
y-ca
re n
utri
tion
reha
bilit
atio
n
cent
er (
NR
C)
Long
itudi
nal –
108
ca
regi
vers
and
the
ir 1
16
child
ren
who
wer
e ne
wly
en
rolle
d in
an
NR
C
betw
een
Nov
embe
r 19
99
and
July
200
0
base
line
vs.
endl
ine
vs.
follo
w u
p
% o
f eat
ing
even
ts
cont
aini
ng fi
sh p
owde
r
% o
f eat
ing
even
ts
cont
aini
ng o
ther
ani
mal
pr
otei
n
% o
f eat
ing
even
ts
cont
aini
ng m
ilk
% o
f eat
ing
even
ts
cont
aini
ng e
ggs
% o
f eat
ing
even
ts
cont
aini
ng g
reen
leaf
y ve
geta
bles
24.1
% v
s. 23
.6%
vs
. 14.
3%
49.1
% v
s. 58
.2%
vs
. 50.
0%
39.3
% v
s. 25
.5%
vs
. 11.
9%
18.7
% v
s. 14
.6%
vs
. 4.8
%
13.4
% v
s. 23
.6%
vs
. 38.
1%
NS
NS
p=0.
007
NS
NS
85 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
54
P-va
lues
are
for m
ean
incr
emen
ts fr
om b
asel
ine
to e
ndlin
e in
inte
rven
tion
sites
com
pare
d w
ith c
ontro
l site
s.
ST
UD
YA
PP
RO
AC
HE
S
US
ED
S
CA
LE
/SC
OP
EE
VA
LU
AT
ION
M
ET
HO
DS
OU
CO
ME
(S)
ME
AS
-U
RE
DR
ES
ULT
S51
P-V
AL
UE
s / C
Is 5
2
De
Oliv
eira
et
al. (
2012
); Br
azil
Cou
nsel
ing
in fa
cilit
ies
by
prov
ider
s1
hosp
ital
RC
T –
dat
a fr
om 2
55
adol
esce
nt g
irls
del
iver
ing
in t
he h
ospi
tal a
naly
zed
(132
mot
her-
child
pai
rs
inte
rven
tion,
123
con
trol
); da
ta c
olle
cted
at
base
line
and
mon
thly
for
six
mon
ths
post
part
um
Mea
n ag
e of
intr
oduc
tion
of n
on-b
reas
t m
ilk a
nd
com
plem
enta
ry fo
ods
(day
s)
% o
f chi
ldre
n fe
d co
mpl
emen
tary
food
s at
4
mon
ths
% o
f chi
ldre
n fe
d co
mpl
emen
tary
food
s at
6
mon
ths
153
(95%
CI,
114.
6–19
1.4)
vs.
95 d
ays
(95%
CI,
8.7–
111.
3)
22.8
% (
95%
CI:
15.9
–29.
7) v
s. 41
% (
95%
CI:
32.8
–49.
2)
87.1
% (
95%
CI:
81.4
–92.
8) v
s. 88
.4%
(95
% C
I: 82
.9–9
3.9)
CIs
did
not
ov
erla
p C
Is d
id n
ot
over
lap
CIs
ove
rlap
Don
gre
et a
l. (2
011)
; Ind
iaM
obili
zatio
n of
cam
paig
n,
even
t, or
spe
cial
“da
ys”;
Mob
iliza
tion
of is
sue
grou
ps
23 v
illag
es
Rep
eate
d cr
oss
sect
iona
l –
child
ren
6 to
35
mon
ths
of a
ge (
base
line:
261
; en
dlin
e / 3
mon
ths
follo
w-
up: 3
72)
endl
ine
vs.
base
line
% ir
on s
uppl
emen
tatio
n
amon
g ch
ildre
n 6-
35
mon
ths
of a
ge
41.6
% v
s. 8.
8%p=
0.00
1
Gho
sh e
t al
. (20
02);
Indi
aC
ouns
elin
g in
hom
es b
y pr
ovid
ers
13 v
illag
es
Cro
ss s
ectio
nal –
infa
nts
aged
less
tha
n si
x m
onth
s
wer
e en
rolle
d on
an
on-g
oing
bas
is b
etw
een
1997
-199
9; 2
42 in
fant
s 5-
11 m
onth
s ol
d w
ere
incl
uded
in t
his
anal
ysis
(1
73 in
fant
s <
6 m
onth
s of
age
at
base
line
form
ed
inte
rven
tion
grou
p, 6
9 in
fant
s w
ho r
each
ed
12 m
onth
s pr
ior
to t
he
inte
rven
tion
form
ed
cont
rol g
roup
); da
ta
colle
cted
mon
thly
unt
il th
e ch
ild r
each
ed 2
4 m
onth
s of
age
% o
f chi
ldre
n 6-
10 m
onth
s of
age
fed
anim
al m
ilk
Mea
n nu
mbe
r of
diff
eren
t fo
od g
roup
s fe
d in
a 2
4-ho
ur p
erio
d
- at
9 m
onth
s
- at
10
mon
ths
- at
11
mon
ths
53.2
%
vs. 3
1.9%
3.61
vs.
2.86
3.87
vs.
3.1
4.34
vs.
3.4
p<0.
01
Not
rep
orte
d
Mea
n nu
mbe
r of
chi
ld
feed
s in
the
pre
viou
s 24
ho
urs
- at
9 m
onth
s
- at
10
mon
ths
- at
11
mon
ths
3.7
vs. 2
.71
4.17
vs.
3.03
4.28
vs.
3.09
Not
rep
orte
d
86 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ST
UD
YA
PP
RO
AC
HE
S
US
ED
S
CA
LE
/SC
OP
EE
VA
LU
AT
ION
M
ET
HO
DS
OU
CO
ME
(S)
ME
AS
-U
RE
DR
ES
ULT
S51
P-V
AL
UE
s / C
Is 5
2
Gul
dan
et a
l. (2
000)
; Chi
naC
ouns
elin
g in
hom
es b
y pe
ers
4 to
wns
hips
(2
inte
rven
tion,
2
cont
rol)
RC
T –
new
born
s w
ere
enro
lled
thro
ugho
ut
the
year
of p
roje
ct
impl
emen
tatio
n, a
t co
mpl
etio
n of
the
ye
ar in
fant
s ha
d be
en
mon
itore
d fo
r 4-
12
mon
ths;
495
infa
nts
born
dur
ing
stud
y pe
riod
ana
lyze
d (2
50
inte
rven
tion,
245
con
trol
); in
fant
s 4-
6 m
onth
s ol
d: 5
7 in
terv
entio
n, 6
9 co
ntro
l; in
fant
s 7-
9 m
onth
s ol
d: 8
5 in
terv
entio
n, 7
6 co
ntro
l; in
fant
s 10
-12
mon
ths
old:
10
8 in
terv
entio
n, 1
00
cont
rol
% o
f chi
ldre
n fe
d eg
gs d
aily
- at
4-6
mon
ths
- at
7-9
mon
ths
- at
10-
12 m
onth
s
% o
f chi
ldre
n fe
d fis
h/m
eat
brot
h da
ily
- at
4-6
mon
ths
- at
7-9
mon
ths
- at
10-
12 m
onth
s
% o
f chi
ldre
n fe
d m
eat
daily -
at 4
-6 m
onth
s
- at
7-9
mon
ths
- at
10-
12 m
onth
s
% o
f chi
ldre
n fe
d ve
geta
bles
dai
ly
- at
4-6
mon
ths
- at
7-9
mon
ths
- at
10-
12 m
onth
s
% o
f chi
ldre
n fe
d fr
uit
daily
- at
4-6
mon
ths
- at
7-9
mon
ths
- at
10-
12 m
onth
s
37%
vs.
16%
66%
vs.
41%
66%
vs.
62%
4% v
s. 0%
9% v
s. 1%
13%
vs.
3%
4% v
s. 0%
19%
vs.
8%
23%
vs.
9%
35%
vs.
32%
79%
vs.
65%
89%
vs.
89%
26%
vs.
10%
68%
vs.
42%
79%
vs.
52%
p<0.
01
p<0.
01
NS
NS
p<0.
05
p<0.
01
NS
p<0.
05
p<0.
01
NS
p<0.
05
NS
p<0.
05
p<0.
01
p<0.
001
% o
f chi
ldre
n fe
d ve
geta
ble
oil d
aily
- at
4-6
mon
ths
- at
7-9
mon
ths
- at
10-
12 m
onth
s
% o
f chi
ldre
n fe
d la
rd d
aily
- at
4-6
mon
ths
- at
7-9
mon
ths
- at
10-
12 m
onth
s
32%
vs.
29%
65%
vs.
58%
82%
vs.
82%
9% v
s. 4%
31%
vs.
9%
46%
vs.
28%
NS
NS
NS
NS
p<0.
01
p<0.
01
87 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ST
UD
YA
PP
RO
AC
HE
S
US
ED
S
CA
LE
/SC
OP
EE
VA
LU
AT
ION
M
ET
HO
DS
OU
CO
ME
(S)
ME
AS
-U
RE
DR
ES
ULT
S51
P-V
AL
UE
s / C
Is 5
2
Guy
on e
t al
. (20
09);
Mad
agas
car
Mob
iliza
tion
of is
sue
grou
ps; M
obili
zatio
n of
ca
mpa
ign,
eve
nt, o
r sp
ecia
l “d
ays”
; Mas
s m
edia
2 hi
ghla
nd p
rovi
nces
; ta
rget
ed p
opul
atio
n va
ried
thr
ough
out
proj
ect
from
1.4
m
illio
n in
6 d
istr
icts
to
6 m
illio
n in
23
dist
rict
s
Rep
eate
d cr
oss-
sect
iona
l –
base
line
(200
0): 1
,200
ch
ildre
n un
der
two
year
s ol
d; e
ndlin
e (2
005)
: 1,7
60
child
ren
unde
r tw
o ye
ars
old
endl
ine
vs.
base
line
% o
f chi
ldre
n fe
d th
e m
inim
um r
ecom
men
ded
num
ber
of m
eals
per
day
at
6-23
mon
ths
92%
vs.
87%
p<
0.00
1
% o
f chi
ldre
n (6
–8 m
onth
s)
fed
com
plem
enta
ry fo
ods
in t
he p
revi
ous
24 h
ours
96%
vs.
92%
NS
% s
ick
infa
nts
and
child
ren
(6-2
3 m
onth
s) fe
d m
ore
than
usu
al d
urin
g ill
ness
in
prev
ious
2 w
eeks
%
sic
k in
fant
s an
d ch
ildre
n (6
-23
mon
ths)
fed
mor
e th
an u
sual
aft
er il
lnes
s
5% v
s. 4%
20
% v
s. 25
%
NS
NS
Haq
ue e
t al
. (20
02);
Bang
lade
shC
ouns
elin
g in
faci
litie
s by
pr
ovid
ers
3 ce
nter
s (2
br
east
feed
ing
coun
selin
g ce
nter
s an
d 1
mai
n ce
nter
)
Long
itudi
nal –
59
child
-mot
her
pair
s in
in
terv
entio
n co
mpl
eted
on
e-ye
ar fo
llow
-up,
55
in
cont
rol
% o
f wom
en w
ho
intr
oduc
ed c
ompl
emen
tary
fo
ods
at 6
mon
ths
of a
ge
88%
vs.
53%
NS
Har
kins
et
al. (
2008
); Pe
ru
Mob
iliza
tion
of is
sue
grou
ps; C
ouns
elin
g in
ho
mes
1 co
mm
unity
(p
opul
atio
n: 2
5,00
0)R
epea
ted
cros
s-se
ctio
nal
– Pe
ru: 7
8 w
omen
55
inte
rvie
wed
in 2
002
and
in
2004
(af
ter
inte
rven
tion)
endl
ine
vs.
base
line
% o
f sic
k ch
ildre
n fe
d m
ore
freq
uent
ly a
nd in
sm
alle
r qu
antit
ies
61%
vs.
22%
Not
rep
orte
d
88 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ST
UD
YA
PP
RO
AC
HE
S
US
ED
S
CA
LE
/SC
OP
EE
VA
LU
AT
ION
M
ET
HO
DS
OU
CO
ME
(S)
ME
AS
-U
RE
DR
ES
ULT
S51
P-V
AL
UE
s / C
Is 5
2
Kila
ru e
t al
. (20
05);
Indi
aC
ouns
elin
g in
hom
es b
y pr
ovid
ers
13 v
illag
es
Cro
ss-s
ectio
nal –
infa
nts
aged
less
tha
n si
x m
onth
s w
ere
enro
lled
on a
n on
-goi
ng b
asis
bet
wee
n 19
97-1
999;
242
infa
nts
5-11
mon
ths
old
wer
e in
clud
ed in
thi
s an
alys
is
(173
infa
nts
< 6
mon
ths
of a
ge a
t ba
selin
e fo
rmed
in
terv
entio
n, 6
9 in
fant
s w
ho r
each
ed 1
2 m
onth
s pr
ior
to t
he in
terv
entio
n fo
rmed
con
trol
); da
ta
colle
cted
long
itudi
nally
, m
onth
ly u
ntil
the
child
re
ache
d 24
mon
ths
of a
ge,
how
ever
ana
lysi
s is
cro
ss-
sect
iona
l
NO
TE:
The
se a
re t
he s
ame
data
ana
lyze
d by
Gho
sh
et a
l. (2
002)
use
d he
re
to r
epor
t on
diff
eren
t in
dica
tors
.
% o
f car
egiv
ers
feed
ing
child
ren
(7-1
1 m
onth
s)
bana
nas
% o
f car
egiv
ers
feed
ing
child
ren
(11
mon
ths)
at
leas
t 5
diffe
rent
food
gr
oups
56
33%
vs.
4%
adju
sted
OR
=
3.23
42%
vs.
19%
ad
just
ed O
R =
10
.00
p<0.
001
(95%
CI:
1.28
-7
.69)
p=0.
01
(95%
CI:
2.78
-
33.3
3)
% o
f chi
ldre
n (7
-11
mon
ths)
fed
at le
ast
4 tim
es in
add
ition
to
brea
st
milk
in t
he p
revi
ous
24
hour
s
78%
vs.
51%
ad
just
ed
OR
=4.
35
p<0.
001
(95%
CI:
1.96
- 10
.00)
89 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
55
It is
not
cle
ar fr
om th
e ar
ticle
, but
bas
ed o
n th
e in
dica
tors
repo
rted
one
wou
ld a
ssum
e th
ese
are
mot
hers
of
child
ren
unde
r the
age
of
two
year
s.
ST
UD
YA
PP
RO
AC
HE
S
US
ED
S
CA
LE
/SC
OP
EE
VA
LU
AT
ION
M
ET
HO
DS
OU
CO
ME
(S)
ME
AS
-U
RE
DR
ES
ULT
S51
P-V
AL
UE
s / C
Is 5
2
Kim
mon
s et
al.
(200
4); B
angl
ades
hG
roup
edu
catio
n in
co
mm
uniti
es b
y la
y vo
lunt
eers
seve
ral s
mal
l rur
al
villa
ges
Long
itudi
nal –
30
mot
hers
w
ith in
fant
s 6-
12 m
onth
s of
age
in t
he m
eal q
uant
ity
stud
y; 30
in t
he m
eal
freq
uenc
y st
udy
Day
7 v
s. da
y 1
(bas
elin
e)
Mea
l qua
ntity
stu
dy:
- Q
uant
ity o
f foo
d of
fere
d (g
)
- Q
uant
ity o
f foo
d co
nsum
ed (
g)
- M
ean
num
ber
of m
eals
fe
d to
chi
ldre
n in
the
pr
evio
us 2
4 ho
urs
- D
urat
ion
of m
eal
(min
utes
)
- Vis
cosi
ty o
f foo
d fe
d to
ch
ildre
n57
Mea
l fre
quen
cy s
tudy
:
- M
ean
num
ber
mea
ls d
urin
g w
hich
co
mpl
emen
tary
food
w
as t
o ch
ildre
n in
the
pr
evio
us 2
4 ho
urs
95 v
s. 67
64 v
s. 40
2.9
vs. 2
.3
13 v
s. 6
3.1
vs. 3
.7
4.1
vs. 2
.2
NS
p<0.
05
NS
p<0.
05
NS
p<0.
05
Li e
t al
. (20
07);
Chi
naM
obili
zatio
n of
issu
e gr
oups
; Mid
-siz
ed m
edia
; Sm
all m
edia
10 v
illag
es (
2 fr
om
each
of fi
ve s
ampl
ed
tow
nshi
ps in
Lux
i ci
ty (
popu
latio
n of
app
roxi
mat
ely
321,
000)
Rep
eate
d cr
oss-
sect
iona
l –
352
infa
nts
(age
gro
up
not
clea
r fr
om a
rtic
le)
endl
ine
vs.
base
line
Ave
rage
age
(in
mon
ths)
of
intr
oduc
tion
for
each
w
eani
ng fo
od
-Egg
-Por
k
-Fis
h
-Ani
mal
live
r
-Milk
-Veg
etab
le
-Fru
it
9.0
vs. 6
.5
7.5
vs. 6
.2
10.6
vs.
8.3
10.1
vs.
9.5
5.9
vs. 7
.5
7.7
vs. 6
.3
8.4
vs. 6
.6
p<0.
01
p<0.
01
p<0.
01
p<0.
05
p<0.
01
p<0.
01
p<0.
01
90 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
56
Food
gro
ups e
xam
ined
wer
e da
iry, c
erea
l, pr
otei
n, fr
uit,
vege
tabl
es, o
il an
d fa
t, su
gar a
nd sa
vory
snac
ks.
ST
UD
YA
PP
RO
AC
HE
S
US
ED
S
CA
LE
/SC
OP
EE
VA
LU
AT
ION
M
ET
HO
DS
OU
CO
ME
(S)
ME
AS
-U
RE
DR
ES
ULT
S51
P-V
AL
UE
s / C
Is 5
2
Mac
kint
osh
et a
l. (2
002)
; Vie
tnam
Cou
nsel
ing
in c
omm
uniti
es
by p
eers
; Gro
up e
duca
tion
in c
omm
uniti
es b
y la
y vo
lunt
eers
5 co
mm
unes
(4
inte
rven
tion,
1
cont
rol)
Rep
eate
d cr
oss-
sect
iona
l – 4
6 ch
ildre
n in
in
terv
entio
n gr
oup
(fam
ily
had
one
child
who
pre
viou
sly
part
icip
ated
in t
he p
roje
ct
and
one
youn
ger
child
w
ho h
ad n
ot p
artic
ipat
ed),
25 h
ouse
hold
s in
con
trol
gr
oup
(had
no
prev
ious
ex
posu
re t
o pr
ogra
m
activ
ities
and
incl
uded
an
olde
r an
d yo
unge
r si
blin
g in
the
age
ran
ge o
f the
in
terv
entio
n ho
useh
olds
)
% o
f wom
en r
epor
ting
feed
ing
thei
r ch
ild…
- dr
ied
fish
- sh
rim
p
- fr
esh
fish
- m
eat
- eg
gs
- gr
eens
- sw
eet
pota
toes
- fr
uit
Mea
n #
of t
imes
/wk
wom
an r
epor
ted
feed
ing
her
child
…
- dr
ied
fish
- sh
rim
p
- fr
esh
fish
- m
eat
- eg
gs
- gr
eens
- sw
eet
pota
toes
- fr
uit
20.9
% v
s. 64
.0%
93.3
% v
s. 76
.0%
95.6
% v
s. 96
.0%
97.8
% v
s. 92
.0%
97.8
% v
s. 72
.0%
93.3
% v
s. 96
.0%
97.7
% v
s. 88
.0%
100.
0% v
s. 88
.0%
2.3
vs. 0
.8
3.2
vs. 1
.0
5.6
vs. 4
.6
2.6
vs. 0
.7
4.0
vs. 1
.5
6.9
vs. 6
.4
6.7
vs. 3
.2
5.4
vs. 1
.5
p<0.
01
p<0.
05
NS
NS
p<0.
01
NS
NS
p<0.
05
p<0.
05
p<0.
01
NS
p<0.
01
p<0.
01
NS
p<0.
01
p<0.
01
Mea
n #
of m
ain
mea
ls/d
ay
fed
to c
hild
% o
f wom
en t
hat
repo
rt
feed
ing
thei
r ch
ild s
nack
s
Mea
n #
of s
nack
s fe
d/da
y fe
d to
chi
ld
2.9
vs. 2
.2
95.7
% v
s. 52
%
2.5
vs. 1
.6
p<0.
001
p<0.
001
p<0.
001
91 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
57Scalerangesfrom1(liketea)to4(likecookedrice).
ST
UD
YA
PP
RO
AC
HE
S
US
ED
S
CA
LE
/SC
OP
EE
VA
LU
AT
ION
M
ET
HO
DS
OU
CO
ME
(S)
ME
AS
-U
RE
DR
ES
ULT
S51
P-V
AL
UE
s / C
Is 5
2
Pach
ón e
t al
. (20
02); V
ietn
amG
roup
edu
catio
n in
co
mm
uniti
es b
y la
y vo
lunt
eers
12 c
omm
unes
from
on
e ru
ral V
ietn
am
(6 in
terv
entio
n, 6
co
ntro
l)
Long
itudi
nal –
238
ch
ildre
n 5-
25 m
onth
s ol
d (1
19 i
nter
vent
ion,
119
co
ntro
l)
Freq
uenc
y of
con
sum
ing
PD fo
ods
(tim
es p
er d
ay
- ba
selin
e
- m
onth
2-6
of
inte
rven
tion
- m
onth
12
of
inte
rven
tion
4.3
vs.
4.2
4.1
vs.
3.6
3.8
vs.
3.7
NS
p<0.
05
NS
Qua
ntity
of f
ood
cons
umed
(g)
- ba
selin
e
- m
onth
2-6
of
inte
rven
tion
- m
onth
12
of
inte
rven
tion
Mea
l tim
e fr
eque
ncy
(p
er d
ay)
- ba
selin
e
- m
onth
2-6
of
inte
rven
tion
- m
onth
12
of
inte
rven
tion
Ener
gy in
take
(kc
al)
- ba
selin
e
- m
onth
2-6
of
inte
rven
tion
- m
onth
12
of
inte
rven
tion
Prop
ortio
n m
et e
nerg
y (k
cal/k
g) r
equi
rem
ents
- ba
selin
e
- m
onth
2-6
of
inte
rven
tion
- m
onth
12
of
inte
rven
tion
262.
2 v
s. 24
3.5
299.
7 v
s. 25
4.5
409.
8 v
s. 34
0.3
4.6
vs.
4.4
4.6
vs.
4.2
4.9
± 1
.5 v
s. 4.
4
629.
2 vs
. 596
.6
662.
7 vs
. 597
.4
826.
9 vs
. 718
.4
66.4
% v
s. 62
.2%
49.0
% v
s. 35
.1%
31.3
% v
s. 23
.5%
NS
p<0.
05
p<0.
01
NS
p<0.
01
p<0.
01
NS
NS
NS
NS
p<0.
01
NS
92 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ST
UD
YA
PP
RO
AC
HE
S
US
ED
S
CA
LE
/SC
OP
EE
VA
LU
AT
ION
M
ET
HO
DS
OU
CO
ME
(S)
ME
AS
-U
RE
DR
ES
ULT
S51
P-V
AL
UE
s / C
Is 5
2
Palw
ala
et a
l. (2
009)
; Ind
iaG
roup
edu
catio
n in
co
mm
uniti
es b
y pr
ovid
ers;
Smal
l med
ia
5 co
mm
uniti
es in
M
umba
i Lo
ngitu
dina
l – 3
98 w
omen
w
ith c
hild
ren
6-3
6 m
onth
s ol
d
Mea
n am
ount
s of
food
-st
uffs
fed
to c
hild
ren
Milk
(m
L)
- ba
selin
e vs
. 1st
follo
w-
up
- 1s
t fo
llow
-up
vs. 2
nd
follo
w-u
p
- 2n
d fo
llow
-up
vs. 3
rd
follo
w-u
p
Egg
(g)
- ba
selin
e vs
. 1st
follo
w-
up
- 1s
t fo
llow
-up
vs. 2
nd
follo
w-u
p
- 2n
d fo
llow
-up
vs. 3
rd
follo
w-u
p
Mut
ton/
chi
cken
/ fish
(g)
- ba
selin
e vs
. 1st
follo
w-
up
- 1s
t fo
llow
-up
vs. 2
nd
follo
w-u
p
- 2n
d fo
llow
-up
vs. 3
rd
follo
w-u
p
Mea
n am
ount
of f
ruit
(g)
fed
to c
hild
ren
- ba
selin
e vs
. 1st
follo
w-
up
- 1s
t fo
llow
-up
vs. 2
nd
follo
w-u
p
- 2n
d fo
llow
-up
vs. 3
rd
follo
w-u
p
% o
f chi
ldre
n fe
d gr
een
leaf
y ve
geta
bles
(ba
selin
e vs
. 3rd
follo
w-u
p)
134
vs. 1
53
153
vs. 1
96
196
vs. 2
02
20 v
s. 21
21 v
s. 26
26 v
s. 29
4 v
s. 7
7 v
s. 9
9 v
s. 9
41 v
s. 61
61 v
s. 79
79 v
s. 82
16.7
% v
s. 87
.6%
p<0.
05
p<0.
05
NS
p<0.
05
p<0.
05
NS
p<0.
05
p<0.
05
NS
p<0.
05
p<0.
05
NS
p<0.
001
93 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ST
UD
YA
PP
RO
AC
HE
S
US
ED
S
CA
LE
/SC
OP
EE
VA
LU
AT
ION
M
ET
HO
DS
OU
CO
ME
(S)
ME
AS
-U
RE
DR
ES
ULT
S51
P-V
AL
UE
s / C
Is 5
2
% o
f chi
ldre
n fe
d ca
rrot
(b
asel
ine
vs. 3
rd fo
llow
-up)
% o
f chi
ldre
n fe
d to
mat
o (b
asel
ine
vs. 3
rd fo
llow
-up)
% o
f chi
ldre
n fe
d vi
tam
in c
/be
ta-c
arot
ene-
rich
frui
ts
(bas
elin
e vs
. 3rd
follo
w-u
p)
% o
f chi
ldre
n fe
d ot
her
frui
ts (
base
line
vs. 3
rd
follo
w-u
p)
8.3%
vs.
52.1
%
52.0
% v
s. 81
.3%
25.8
% v
s. 50
.5%
62
.5%
vs.
85.4
%
p<0.
001
p<0.
001
p<0.
05
Not
rep
orte
d
% o
f chi
ldre
n fe
d da
l of
thic
k co
nsis
tenc
y (1
:2-3
)
- Ba
selin
e vs
. 1st
follo
w-
up
- 1s
t fo
llow
-up
vs. 2
nd
follo
w-u
p
- 2n
d fo
llow
-up
vs. 3
rd
follo
w-u
p
4.2%
vs.
34%
34%
vs.
37.5
%
37.5
% v
s. 39
.5%
Not
rep
orte
d
Parv
anta
et
al. (
2007
); Ba
ngla
desh
Trad
ition
al m
edia
; Mid
-si
zed
med
ia; S
mal
l med
ia;
Cou
nsel
ing
in h
omes
by
peer
s; Su
ppor
t gr
oup
in
com
mun
ities
by
peer
s
nort
hwes
t Ba
ngla
desh
Rep
eate
d cr
oss-
sect
iona
l –
428
wom
en w
ith
child
ren
6-24
mon
ths
old
(IG1=
144,
IG2=
141,
C
ontr
ol g
roup
=14
3)
Base
d on
48-
hour
rec
all
IG1
vs. I
G258
vs.
CG
% o
f wom
en fe
edin
g th
eir
child
ren
any
vege
tabl
es
duri
ng t
he 4
8-hr
rec
all
% o
f wom
en fe
edin
g t
heir
ch
ildre
n re
com
men
ded
port
ion
of g
reen
veg
etab
les
Med
ian
quan
tity
of g
reen
ve
geta
bles
(g)
fed
to
child
ren
Med
ian
quan
tity
of y
ello
w
vege
tabl
es (
g) fe
d to
ch
ildre
n
74%
vs.
75%
vs.
58%
33%
vs.
52%
vs.
17%
42.5
g vs
. 40g
vs.
30g
25g
vs. 2
5g. v
s. 20
g
p=0.
003
p=0.
001
p=0.
001
p=0.
00459
94 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ST
UD
YA
PP
RO
AC
HE
S
US
ED
S
CA
LE
/SC
OP
EE
VA
LU
AT
ION
M
ET
HO
DS
OU
CO
ME
(S)
ME
AS
-U
RE
DR
ES
ULT
S51
P-V
AL
UE
s / C
Is 5
2
Penn
y et
al.
(200
5); P
eru
Cou
nsel
ing
in fa
cilit
ies
by
prov
ider
s; Sm
all m
edia
1 ci
ty (
Truj
illo)
with
a
popu
latio
n of
60
0,00
0
RC
T –
377
new
born
s (1
87 in
terv
entio
n, 1
90
cont
rol)
% o
f chi
ldre
n ea
ting
thic
k fo
od a
s fir
st m
ain
mea
l at
mea
l tim
es (
i.e.,
not
just
gi
ving
sou
p) a
t…
- 6
mon
ths
- 8
mon
ths
- 9
mon
ths
- 12
mon
ths
- 15
mon
ths
- 18
mon
ths
31%
vs.
20%
21%
vs.
27%
35%
vs.
17%
42%
vs.
26%
42%
vs.
34%
44%
vs.
38%
p=0.
03
NS
p=0.
000
p=0.
003
NS
NS
% o
f chi
ldre
n co
nsum
ing
egg,
chic
ken
liver
, or
fish
at… -
6 m
onth
s
- 8
mon
ths
% o
f chi
ldre
n co
nsum
ing
brea
st m
ilk +
2 t
hick
pr
epar
atio
ns +
ani
mal
so
urce
food
at
9 m
onth
s
65%
vs.
51%
61%
vs.
49%
34%
vs.
23%
p=0.
009
p=0.
019
NS
at 9
, 12,
15,
or
18
mon
ths
p=0.
029
NS
at 6
, 8,
12, 1
5, o
r 18
m
onth
s
% o
f chi
ldre
n fe
d br
east
m
ilk +
2 t
hick
pre
para
tions
+
ani
mal
sou
rce
food
at
9 m
onth
s
34%
vs.
23%
p=0.
029
NS
at m
onth
s 6,
8, 1
2, 1
5,
or 1
8
95 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
58IG1includedhome-basedcounseling(onceinathree-monthperiod)byhealtheducatorstopregnantwomenandmothersofchildren6–24monthsold.IG2includeddiscussionofrolemodelingstoriesfacilitated
by p
eer g
roup
lead
ers d
urin
g ga
rden
ing
grou
p or
cre
dit g
roup
mee
tings
.59Itisnotclearforwhichcomparisonthisisthep-value.Theauthors’interpretationwasasfollows:“Mothersintheinterventiongroups(1and2)weremorelikelytoreportfeedinganyvegetables,andreportedfeed
-ingalargerportionofvegetablesusingafoodmodel,thanmothersinthecontrolgroup(3).Theserelationshipswerestatisticallysignificant…Thisresultalsoindicatestheseasonalavailabilityofgreenvegetables
andlackofyellowvegetables.Onthislevel,itappearsasiftheinterventionsperformedbygroups1and2werenearlyequalintheirimpact.”
ST
UD
YA
PP
RO
AC
HE
S
US
ED
S
CA
LE
/SC
OP
EE
VA
LU
AT
ION
M
ET
HO
DS
OU
CO
ME
(S)
ME
AS
-U
RE
DR
ES
ULT
S51
P-V
AL
UE
s / C
Is 5
2
Roy
et
al. (
2005
); Ba
ngla
desh
Gro
up e
duca
tion
in
com
mun
ities
by
lay
volu
ntee
rs; S
mal
l med
ia
rura
l Ban
glad
esh
RC
T –
282
mod
erat
ely
mal
nour
ishe
d ch
ildre
n 6-
23 m
onth
s (9
3 in
INE
grou
p, 9
9 in
INE-
SF g
roup
, an
d 90
in c
ontr
ol g
roup
)
INE
vs. I
NE-
SF
vs. C
ontr
ol
Use
of f
eedi
ng p
ots
by
mot
hers
- At
base
line
- Aft
er 3
mon
th
inte
rven
tion
- Aft
er 6
mon
th
obse
rvat
ion
Chi
ldre
n fe
d >
3 t
imes
/day
- At
base
line
- Aft
er 3
mon
th
inte
rven
tion
- Aft
er 6
mon
th
obse
rvat
ion
43%
vs.
66%
vs.
43%
99%
vs.
100%
vs.
47%
100%
vs.
100%
vs
. 48%
3% v
s. 13
% v
s. 15
%
98%
vs.
99%
vs.
54%
97%
vs.
100%
vs.
58%
NS
p<0.
0001
p<
0.00
01
NS
NS
NS
96 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ST
UD
YA
PP
RO
AC
HE
S
US
ED
S
CA
LE
/SC
OP
EE
VA
LU
AT
ION
M
ET
HO
DS
OU
CO
ME
(S)
ME
AS
-U
RE
DR
ES
ULT
S51
P-V
AL
UE
s / C
Is 5
2
Roy
et
al. (
2007
); Ba
ngla
desh
Gro
up e
duca
tion
in
com
mun
ities
by
lay
volu
ntee
rs; S
mal
l med
ia
121
Com
mun
ity
Nut
ritio
n C
ente
rs
(CN
Cs)
of t
he
Bang
lade
sh
Inte
grat
ed N
utri
tion
Proj
ect
(BIN
P) in
fo
ur r
egio
ns
RC
T –
576
nor
mal
and
m
ildly
mal
nour
ishe
d ch
ildre
n 6-
9 m
onth
s ol
d (2
94 in
terv
entio
n, 2
82
cont
rol)
% o
f chi
ldre
n fe
d <
3 e
ggs
per
wee
k
- ba
selin
e
- en
dlin
e (6
mon
ths)
- fo
llow
-up
(12
mon
ths)
% o
f chi
ldre
n fe
d 3
or
mor
e eg
gs p
er w
eek
- ba
selin
e
- en
dlin
e (6
mon
ths)
- fo
llow
-up
(12
mon
ths)
89.3
% v
s. 90
%
51.5
% v
s. 83
.7%
70.3
% v
s. 88
.1%
11.3
% v
s. 10
%
38.5
% v
s. 16
.2%
29.8
% v
s. 11
.9%
NS
p<0.
01
p<0.
01
NS
NS
p<0.
01
% o
f wom
en w
ho r
epor
ted
addi
ng e
xtra
oil
to t
heir
ch
ildre
n’s
food
- ba
selin
e
- en
dlin
e (6
mon
ths)
- fo
llow
-up
(12
mon
ths)
CF
fed
to in
fant
= o
r >
3
times
/day
- ba
selin
e
- en
dlin
e (6
mon
ths)
- fo
llow
-up
(12
mon
ths
Sepa
rate
pot
for
child
- ba
selin
e
- en
dlin
e (6
mon
ths)
- fo
llow
-up
(12
mon
ths)
1.6%
vs.
22.8
%
69.8
% v
s. 20
.9%
61.3
% v
s. 21
.5%
30.4
% v
s. 31
.0%
83.8
% v
s. 19
.4%
88.5
% v
s. 24
.5%
52.5
% v
s. 52
.3%
91.6
% v
s. 76
.8%
91.8
% v
s. 76
.8%
NS
p<0.
0001
p<0.
0001
NS
p<0.
0001
p<0.
0001
N
S
p<0.
0001
p<0.
0001
Sant
os e
t al
. (20
01);
Braz
il Sm
all m
edia
; Cou
nsel
ing
in
faci
litie
s by
pro
vide
rs28
gov
ernm
ent
heal
th c
ente
rs in
a
Sout
hern
Bra
zil c
ity
(14
inte
rven
tion
and
14 c
ontr
ol)
RC
T –
424
chi
ldre
n le
ss
than
18
mon
ths
old
(218
in
terv
entio
n, 2
06 c
ontr
ol)
endl
ine
vs.
base
line
Mea
n nu
trie
nt in
take
(kJ
) at
2nd
follo
w-u
p (4
5-da
ys
post
con
sulta
tion)
am
ong
infa
nts
3827
.5 v
s. 35
46.8
NS
97 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ST
UD
YA
PP
RO
AC
HE
S
US
ED
S
CA
LE
/SC
OP
EE
VA
LU
AT
ION
M
ET
HO
DS
OU
CO
ME
(S)
ME
AS
-U
RE
DR
ES
ULT
S51
P-V
AL
UE
s / C
Is 5
2
Sun
et a
l. (2
011)
; Chi
naSm
all m
edia
; Mas
s m
edia
; Mid
-siz
ed m
edia
; C
ouns
elin
g in
faci
litie
s by
pr
ovid
ers
2 co
untie
s in
Sh
an’x
i pro
vinc
e (a
ppro
xim
atel
y 6,
000
child
ren
6-24
m
onth
s of
age
)
Rep
eate
d cr
oss-
sect
iona
l –
base
line
(June
200
8):
226
care
give
rs a
nd t
heir
ch
ildre
n 6-
24 m
onth
-old
; en
dlin
e (Ja
nuar
y 20
10):
221
care
give
rs a
nd t
heir
ch
ildre
n 6-
24 m
onth
-old
endl
ine
vs.
base
line
% o
f car
egiv
ers
who
in
trod
uced
sol
id, s
emi-
solid
or
soft
food
s af
ter
6 m
onth
s
71.1
% v
s. 92
.9%
NS
% o
f bre
astfe
d ch
ildre
n fe
d m
inim
al d
ieta
ry d
iver
sity
>
4 gr
oups
% o
f non
-bre
astfe
d ch
ildre
n fe
d m
inim
al
diet
ary
dive
rsity
>4
grou
ps
74.1
% v
s. 57
.5%
53
.9%
vs.
27.6
%
p=0.
007
p=0.
008
% o
f car
egiv
ers
that
kne
w
abou
t YY
B
Of t
hose
tha
t kn
ew a
bout
Y
YB,
the
% w
ho e
ver
purc
hase
d it
Of t
hose
who
eve
r pu
rcha
sed
YY
B, %
of
child
ren
cons
umed
it…
- ev
ery
day
- ev
ery
othe
r da
y
59.6
% (
endl
ine)
13.5
% (
endl
ine)
55
.6%
(en
dlin
e)
40.7
% (
endl
ine)
Not
rep
orte
d
Not
rep
orte
d N
ot r
epor
ted
Not
rep
orte
d
% o
f bre
astfe
d ch
ildre
n fe
d m
inim
al m
eal f
requ
ency
% o
f non
-bre
astfe
d ch
ildre
n fe
d m
inim
al m
eal
freq
uenc
y
% o
f bre
astfe
d ch
ildre
n fe
d m
inim
al a
ccep
tabl
e di
et
% o
f non
-bre
astfe
d ch
ildre
n fe
d m
inim
al
acce
ptab
le d
iet
51.0
% v
s. 53
.7%
53.4
% v
s. 47
.1%
73.5
% v
s. 42
.1%
45%
vs.
25.0
%
NS
NS
p <
0.0
1
p =
0.0
25
98 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ST
UD
YA
PP
RO
AC
HE
S
US
ED
S
CA
LE
/SC
OP
EE
VA
LU
AT
ION
M
ET
HO
DS
OU
CO
ME
(S)
ME
AS
-U
RE
DR
ES
ULT
S51
P-V
AL
UE
s / C
Is 5
2
Tho
mps
on a
nd H
arut
yuny
an
(200
9); A
rmen
iaC
ouns
elin
g in
hom
es b
y pe
ers;
Supp
ort
grou
p in
co
mm
uniti
es b
y pe
ers;
Smal
l med
ia; M
id-s
ized
m
edia
16 v
illag
es
Rep
eate
d cr
oss-
sect
iona
l –
300
wom
en w
ith a
t le
ast
one
child
age
d 24
mon
ths
and
youn
ger
at p
re-
and
post
-inte
rven
tion
endl
ine
vs.
base
line
% o
f inf
ants
age
d 6-
9 m
onth
s re
ceiv
ing
brea
stm
ilk a
nd C
Fs
48.1
% v
s. 16
.7%
NS
Vazi
r et
al.
(201
3); I
ndia
Cou
nsel
ing
in h
omes
by
lay
volu
ntee
rs; S
mal
l med
ia60
vill
ages
from
th
ree
Inte
grat
ed
Chi
ld D
evel
opm
ent
Serv
ices
(IC
DS)
Pr
ojec
t ar
eas
in
And
hra
Prad
esh
(20
villa
ges
per
grou
p)
RC
T –
600
wom
en
enro
lled
in t
hird
tri
mes
ter
of p
regn
ancy
and
follo
wed
th
roug
h ch
ild’s
15 m
onth
s of
age
(17
0 in
CFG
, 145
in
RC
F&PG
, 16
8 in
CG
)60
CFG
vs.
CG
, R
CF&
PG v
s. C
G
% o
f chi
ldre
n co
nsum
ing
goat
/ chi
cken
live
r61
- 9
mon
ths
- 15
mon
ths
% o
f chi
ldre
n co
nsum
ing
goat
mea
t
- 9
mon
ths
- 15
mon
ths
% o
f chi
ldre
n co
nsum
ing
poul
try
- 9
mon
ths
- 15
mon
ths
% o
f chi
ldre
n co
nsum
ing
buffa
lo m
ilk
- 9
mon
ths
- 15
mon
ths
% o
f chi
ldre
n co
nsum
ing
egg -
9 m
onth
s
- 15
mon
ths
30.7
% v
s. 2.
3%,
25.6
% v
s. 2.
3%
38%
vs.
13.1
%,
33.7
% v
s. 13
.1%
22.3
% v
s. 4.
5%,
11.3
% v
s. 4.
5%
43.5
% v
s. 33
%,
44%
vs.
33%
4.5%
vs.
1.7%
, 4.
4% v
s. 1.
7%
37.5
% v
s. 18
.9%
, 45
.2%
vs.
18.9
%
98.6
% v
s. 10
0%,
99.2
% v
s. 10
0%
81.5
% v
s. 72
.7%
, 78
.9%
vs.
72.7
%
55.3
% v
s. 17
.6%
, 51
.9%
vs.
17.6
%
73.9
% v
s. 54
%,
77.7
% v
s. 54
%
p<0.
05, p
<0.
05
p<0.
05, p
<0.
05
p<0.
05, p
<0.
05
NS,
NS
NS,
NS
p<0.
05, p
<0.
05
NS,
NS
NS,
NS
p<0.
05, p
<0.
05
p<0.
05, p
<0.
05
99 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ST
UD
YA
PP
RO
AC
HE
S
US
ED
S
CA
LE
/SC
OP
EE
VA
LU
AT
ION
M
ET
HO
DS
OU
CO
ME
(S)
ME
AS
-U
RE
DR
ES
ULT
S51
P-V
AL
UE
s / C
Is 5
2
% o
f chi
ldre
n co
nsum
ing
any
bana
na
- at
9 m
onth
s
- at
15
mon
ths
% o
f chi
ldre
n co
nsum
ing
any
spin
ach
- at
9 m
onth
s
- at
15
mon
ths
60.9
% v
s. 38
.6%
, 59
.4%
vs.
38.6
%
79.3
% v
s. 61
.9%
, 78
.3%
vs.
61.9
%
20.1
% v
s. 5.
1%,
14.4
% v
s. 5.
1%
42.4
% v
s. 29
.5%
, 45
.2%
vs.
29.5
%
p<0.
05, p
<0.
05
p<0.
05, p
<0.
05
p<0.
05, p
<0.
05
p<0.
05, p
<0.
05
Med
ian
ener
gy in
take
(kc
al)
amon
g ch
ildre
n
- at
9 m
onth
s
- at
15
mon
ths
% o
f chi
ldre
n co
nsum
ing
adde
d fa
t
- at
9 m
onth
s
- at
15
mon
ths
348
vs. 2
09, 3
31
vs. 2
09
569
vs. 4
60, 5
69
vs. 4
60
51.4
% v
s. 24
.4%
, 44
.4%
vs.
24.4
%
42.4
% v
s. 29
.5%
, 52
.5%
vs.
29.5
%
p<0.
05, p
<0.
05
p<0.
05, p
<0.
05
p<0.
05, p
<0.
05
p<0.
05, p
<0.
05
100 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
60
CFG
= C
ompl
emen
tary
feed
ing;
RC
F&PG
= R
espo
nsiv
e co
mpl
emen
tary
feed
ing
& p
lay g
roup
; CG
= C
ontro
l gro
up61
C
onsu
mpt
ion
is ba
sed
on a
Foo
d Fr
eque
ncy
Que
stio
nnai
re u
sed
to a
sses
s the
freq
uenc
y of
mic
ronu
trien
t-ric
h ve
geta
ble
and
anim
al fo
ods c
onsu
med
by
infa
nts d
urin
g th
e pr
evio
us w
eek.
ST
UD
YA
PP
RO
AC
HE
S
US
ED
S
CA
LE
/SC
OP
EE
VA
LU
AT
ION
M
ET
HO
DS
OU
CO
ME
(S)
ME
AS
-U
RE
DR
ES
ULT
S51
P-V
AL
UE
s / C
Is 5
2
Zam
an e
t al
. (20
08);
Paki
stan
Cou
nsel
ing
in fa
cilit
ies
by
prov
ider
s; co
mm
unity
/so
cial
mob
iliza
tion
36 h
ealth
cen
ters
(1
8 pe
r gr
oup)
RC
T –
375
mot
hers
and
th
eir
child
ren
aged
6-2
4 m
onth
s re
crui
ted8
-14
days
aft
er r
ecru
itmen
t: 32
0 m
othe
r-ch
ild p
airs
(1
51 in
terv
entio
n,16
9 co
ntro
l); 1
80 d
ays
afte
r re
crui
tmen
t: 26
6 m
othe
r-ch
ild p
airs
(12
9 in
terv
entio
n, 1
37 c
ontr
ol)
% o
f wom
en w
ho r
epor
ted
incr
easi
ng t
he a
mou
nt o
f m
ilk o
ffere
d to
chi
ldre
n62
- At
8-14
day
s af
ter
recr
uitm
ent
- At
180
days
aft
er
recr
uitm
ent
% o
f chi
ldre
n of
fere
d eg
gs
- At
8-14
day
s af
ter
recr
uitm
ent
- At
180
days
aft
er
recr
uitm
ent
% o
f chi
ldre
n of
fere
d ch
icke
n/ b
eef /
mut
ton
- At
8-14
day
s af
ter
recr
uitm
ent
- At
180
days
aft
er
recr
uitm
ent
% o
f chi
ldre
n of
fere
d liv
er
- At
8-14
day
s af
ter
recr
uitm
ent
- At
180
days
aft
er
recr
uitm
ent
38.4
1% v
s. 24
.26%
48.0
% v
s. 29
.2%
49.6
7% v
s. 31
.95%
60.3
2% v
s. 39
.69%
49.6
7% v
s. 31
.95%
60.3
2% v
s. 39
.69%
17.2
2% v
s. 9.
47%
30.9
5% v
s. 19
.85%
p= 0
.035
2
p= 0
.032
4
p= 0
.036
8
p= 0
.042
8
p= 0
.015
5
p= 0
.050
8
p= 0
.093
4
p= 0
.158
9
101 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
ST
UD
YA
PP
RO
AC
HE
S
US
ED
S
CA
LE
/SC
OP
EE
VA
LU
AT
ION
M
ET
HO
DS
OU
CO
ME
(S)
ME
AS
-U
RE
DR
ES
ULT
S51
P-V
AL
UE
s / C
Is 5
2
% o
f wom
en w
ho r
epor
ted
addi
ng g
hee/
but
ter/
oil t
o ch
ildre
n’s
food
- At
8-14
day
s af
ter
recr
uitm
ent
- At
180
days
aft
er
recr
uitm
ent
% o
f wom
en w
ho r
epor
ted
offe
ring
chi
ldre
n th
ick
kitc
huri
- At
8-14
day
s af
ter
recr
uitm
ent
- At
180
days
aft
er
recr
uitm
ent
30.4
6% v
s. 24
.85%
53.9
7% v
s. 38
.17%
61.5
9% v
s. 44
.97%
65.8
7% v
s. 44
.27%
p= 0
.561
6
p= 0
.173
6
p= 0
.068
2
p=0.
0441
Zha
ng e
t al
. (20
13);
Chi
naG
roup
edu
catio
n in
co
mm
uniti
es b
y pr
ovid
ers;
Cou
nsel
ing
in h
omes
by
prov
ider
s; co
mm
unity
/so
cial
mob
iliza
tion;
Sm
all
med
ia
8 to
wns
hips
(4
inte
rven
tion,
4
cont
rol)
in L
aish
ui
coun
ty
RC
T –
at
base
line:
599
in
fant
s ag
ed 2
-4 m
onth
s ol
d (2
94 in
terv
entio
n,
305
cont
rol);
492
at
18 m
onth
s of
age
(25
1 in
terv
entio
n, 2
41 c
ontr
ol);
data
col
lect
ed a
t ba
selin
e,
6, 9
, 12,
15
and
18 m
onth
s of
age
% o
f wom
en w
ho
enco
urag
ed c
hild
ren
to e
at
whe
n th
ey r
efus
ed fo
od63
88.0
% v
s. 53
.9%
p<0.
05
% o
f w
omen
who
fed
brea
st m
ilk a
nd e
asy-
to-
dige
st fo
ods
for
child
ren
with
dia
rrhe
a
% o
f wom
en w
ho
cook
ed e
asy-
to-d
iges
t fo
od s
epar
atel
y fo
r th
eir
child
ren
with
dia
rrhe
a
88.8
% v
s. 65
.0%
67
.3%
vs.
32.8
%
p<0.
05
p<0.
05
63Theauthorsalsoreportedstatisticallysignificantdifferencesbetweeninterventionandcontrolgroupsateachtimepointintheinfantandchildfeedingindex(ICFI)whichincludedbreastfeeding,bottle-feeding,di-
etar
y di
vers
ity, f
ood
freq
uenc
y, va
riety
of
food
gro
ups a
nd fr
eque
ncy
of c
onsu
mpt
ion
of d
iffer
ent f
ood
grou
ps. H
owev
er, s
ince
no
othe
r art
icle
s rep
orte
d on
this
indi
cato
r, th
is ha
s not
bee
n em
phas
ized
in th
is re
view
.
102 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
62
Not
e th
at p
-val
ues a
re o
f re
port
ed o
dds r
atio
and
acc
ount
for c
lust
er ra
ndom
izat
ion.
Aboud, Frances E, Anna C Moore, and Sadika Akhter. 2008. “Effectiveness of a Community-based Responsive Feeding ProgrammeinRuralBangladesh:aClusterRandomizedFieldTrial.”Maternal & Child Nutrition4(4)(October):275–286.
Aboud,FrancesE,SohanaShafique,andSadikaAkhter.2009.“AResponsiveFeedingInterventionIncreasesChildren’sSelf-feedingandMaternalResponsivenessbutNotWeightGain.”The Journal of Nutrition139(9)(September):1738–1743.
ACC/SCN. 2001. What Works? A Review of the Efficacy and Effectiveness of Nutrition Interventions, Allen LH and Gillespie SR. ACC/SCN: Geneva in collaboration with the Asian Development Bank, Manila.
Arimond, Mary, and Marie T Ruel. 2004. “Dietary Diversity Is Associated with Child Nutritional Status: Evidence from 11 DemographicandHealthSurveys.”The Journal of Nutrition134(10)(October):2579–2585.
Atwood, Stephen J., and Karen Codling. Strategy to Reduce Maternal and Child Undernutrition. Bangkok: UNICEF, East Asia andPacificRegionalOffice,2003.
Bhandari, N, R Bahl, B Nayyar, P Khokhar, J E Rohde, and M K Bhan. 2001. “Food Supplementation with Encourage-menttoFeedIttoInfantsfrom4to12Monthsof AgeHasaSmallImpactonWeightGain.”The Journal of Nutrition 131 (7)(July):1946–1951.
Bhandari, Nita, Sarmila Mazumder, Rajiv Bahl, Jose Martines, Robert E Black, and Maharaj K Bhan. 2004. “An Educa-tional Intervention to Promote Appropriate Complementary Feeding Practices and Physical Growth in Infants and Young ChildreninRuralHaryana,India.”The Journal of Nutrition134(9)(September):2342–2348.
Bhutta,ZulfiqarA,JaiKDas,ArjumandRizvi,MichelleFGaffey,Neff Walker,SusanHorton,PatrickWebb,AnnaLartey, and Robert E Black. 2013. “Evidence-based Interventions for Improvement of Maternal and Child Nutrition: WhatCanBeDoneandatWhatCost?”The Lancet382(9890)(August):452–477.
Bhutta,ZulfiqarA,TahmeedAhmed,RobertEBlack,SimonCousens,KathrynDewey,ElsaGiugliani,BatoolAHaider,etal.2008a.“WhatWorks?InterventionsforMaternalandChildUndernutritionandSurvival.”The Lancet371(9610)(February):417–440.
Black,RobertE,CesarGVictora,SusanPWalker,ZulfiqarABhutta,ParulChristian,MercedesdeOnis,MajidEzzati,Sally Grantham-McGregor, Joanne Katz, Reynaldo Martorell, Ricardo Uauy, and the Maternal and Child Nutrition Study Group.2013.“MaternalandChildUndernutritionandOverweightinLow-incomeandMiddle-incomeCountries.”The Lancet382(9890):427–451.
Bonvecchio, Anabelle, Gretel H Pelto, Erika Escalante, Erick Monterrubio, J P Habicht, Fernanda Nava, Maria-Angeles Villanueva, Margarita Safdie, and J A Rivera. 2007. “Maternal Knowledge and Use of a Micronutrient Supplement Was ImprovedwithaProgrammaticallyFeasibleInterventioninMexico.”The Journal of Nutrition137(2)(February):440–446.
Bortolini, Gisele Ane, and Márcia Regina Vitolo. 2012. “The Impact of Systematic Dietary Counselling During the First Yearof LifeonPrevalenceRatesof AnemiaandIronDeficiencyat12-16Months.”Jornal de Pediatria88(1)(February):33–39.
Bruyeron, Olivier, Mirrdyn Denizeau, Jacques Berger, and Serge Trèche. 2010. “Marketing Complementary Foods and SupplementsinBurkinaFaso,Madagascar,andVietnam:LessonsLearnedfromtheNutridevProgram.”Food and Nutrition Bulletin31(2Suppl)(June):S154–167.
F. Works Cited and Literature Reviewed
103 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
Colecraft, Esi K, Grace S Marquis, Alfred A Bartolucci, LeaVonne Pulley, W Bruce Owusu, and H Michael Maetz. 2004. “A Longitudinal Assessment of the Diet and Growth of Malnourished Children Participating in Nutrition Rehabilitation CentresinAccra,Ghana.”Public Health Nutrition7(4)(June):487–494.
De Oliveira, Luciana Dias, Elsa Regina Justo Giugliani, Lilian Córdova do Espírito Santo, and Leandro Meirelles Nunes. 2012. “Impact of a Strategy to Prevent the Introduction of Non-breast Milk and Complementary Foods During the First 6Monthsof Life:aRandomizedClinicalTrialwithAdolescentMothersandGrandmothers.”Early Human Development 88 (6)(June):357–361.
Dewey,KathrynG.,andSethAdu-Afarwuah.2008.“SystematicReviewof theEfficacyandEffectivenessof Comple-mentaryFeedingInterventionsinDevelopingCountries.”Maternal & Child Nutrition4(s1)(April):24–85.
Dewey, Kathryn. Guiding Principles for Complementary Feeding of the Breastfed Child. Washington, DC, USA: PAHO/WHO, Division of Health Promotion and Protection/Food and Nutrition Program, 2003.
Dickey, Vanessa C, Helena Pachón, David R Marsh, Tran Thi Lang, David R Claussenius, Kirk A Dearden, Tran Thu Ha, andDirkGSchroeder.2002.“Implementationof NutritionEducationandRehabilitationPrograms(NERPs)inVietNam.”Food and Nutrition Bulletin23(4Suppl)(December):78–85.
Dongre, Amol R, Pradeep R Deshmukh, and Bishan S Garg. 2011. “Community-led Initiative for Control of Anemia AmongChildren6to35Monthsof AgeandUnmarriedAdolescentGirlsinRuralWardha,India.”Food and Nutrition Bul-letin32(4)(December):315–323.
Ghosh, Shanti, Asha Kilaru, and Saraswathy Ganapathy. 2002. “Nutrition Education and Infant Growth in Rural Indian Infants:NarrowingtheGenderGap?”Journal of the Indian Medical Association100(8)(August):483–484,486–488,490.
Gibson,RosalindS,andVictoriaPAnderson.2009.“AReviewof InterventionsBasedonDietaryDiversificationorModificationStrategieswiththePotentialtoEnhanceIntakesof TotalandAbsorbableZinc.”Food and Nutrition Bulletin 30 (1Suppl)(March):S108–143.
Guldan, G S, H C Fan, X Ma, Z Z Ni, X Xiang, and M Z Tang. 2000. “Culturally Appropriate Nutrition Education Im-provesInfantFeedingandGrowthinRuralSichuan,China.”The Journal of Nutrition130(5)(May):1204–1211.
Guyon, Agnès B, Victoria J Quinn, Michael Hainsworth, Priscilla Ravonimanantsoa, Voahirana Ravelojoana, Zo Rambelo-son, and Luann Martin. 2009. “Implementing an Integrated Nutrition Package at Large Scale in Madagascar: The Essential NutritionActionsFramework.”Food and Nutrition Bulletin30(3)(September):233–244.
Haque, M F, M Hussain, A Sarkar, M M Hoque, Fakir Anjuman Ara, and S Sultana. 2002. “Breast-feeding Counselling and Its EffectonthePrevalenceof ExclusiveBreast-feeding.”Journal of Health, Population, and Nutrition20(4)(December):312–316.
Harkins,Thomas,ChristopherDrasbek,JuanArroyo,andMichaelMcQuestion.2008.“TheHealthBenefitsof SocialMobilization: Experiences with Community-based Integrated Management of Childhood Illness in Chao, Peru and San Luis,Honduras.”Promotion & Education15(2)(June):15–20.
Imdad,Aamer,MohammadYawarYakoob,andZulfiqarABhutta.2011.“Impactof MaternalEducationAboutComple-mentaryFeedingandProvisionof ComplementaryFoodsonChildGrowthinDevelopingCountries.”BMC Public Health 11(Suppl3):S25.
Kilaru,A,PLGriffiths,SGanapathy,andShantiGhosh.2005.“Community-basedNutritionEducationforImprovingInfantGrowthinRuralKarnataka.”Indian Pediatrics42(5)(May):425–432.
104 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
Kimmons, Joel E, Kathryn G Dewey, Emdadul Haque, J Chakraborty, Saskia J M Osendarp, and Kenneth H Brown. 2004. “Behavior-change Trials to Assess the Feasibility of Improving Complementary Feeding Practices and Micronutrient In-takeof InfantsinRuralBangladesh.”Food and Nutrition Bulletin25(3)(September):228–238.
Li, Yan, Masanaka Hotta, Anping Shi, Zhi Li, Jianzhing Yin, Guangping Guo, Kimiko Kawata, and Hiroshi Ushijima. 2007.“MalnutritionImprovementforInfantsUnder18MonthsOldof DaiMinorityinLuxi,China.”Pediatrics International 49(2)(April):273–279.
Lutter, CK, B M Daelmans, M de Onis, M Kothari, M T Ruel, M Arimond, M Deitchler, K G Dewey, M Blossner, and E Borghi.(2007).“Undernutrition,poorfeedingpractices,andlowcoverageof keynutritioninterventions.”Pediatrics.128(6),e1418-1427.
Mackintosh, U Agnes Trinh, David R Marsh, and Dirk G Schroeder. 2002. “Sustained Positive Deviant Child Care Prac-ticesandTheirEffectsonChildGrowthinVietNam.”Food and Nutrition Bulletin23(4Suppl)(December):18–27.
Marriott, Bernadette P., Alan White, Louise Hadden, Jayne C. Davies, and John C. Wallingford. 2012. “World Health Organization(WHO)InfantandYoungChildFeedingIndicators:AssociationswithGrowthMeasuresin14Low-incomeCountries:WHOCoreFeedingIndicatorsandGrowth.”Maternal & Child Nutrition8(3)(July):354–370.
Mason, John B, Lisa S Saldanha, and Reynaldo Martorell. 2012. “The Importance of Maternal Undernutrition for Mater-nal,Neonatal,andChildHealthOutcomes:AnEditorial.”Food and Nutrition Bulletin33(2Suppl)(June):S3–5.
McNulty J. and CORE Group. Positive Deviance / Hearth Essential Elements: A Resource Guide for Sustainably Rehabilitating Mal-nourished Children (Addendum), Washington, D.C.: CORE Group, 2005.
Pachón, Helena, Dirk G Schroeder, David R Marsh, Kirk A Dearden, Tran Thu Ha, and Tran Thi Lang. 2002. “Effect of an Integrated Child Nutrition Intervention on the Complementary Food Intake of Young Children in Rural North Viet Nam.”Food and Nutrition Bulletin23(4Suppl)(December):62–69.
Palwala, Misba, Shweta Sharma, Shobha A Udipi, Padmini S Ghugre, Gopa Kothari, and Pradeep Sawardekar. 2009. “Nu-tritionalQualityof DietsFedtoYoungChildreninUrbanSlumsCanBeImprovedbyIntensiveNutritionEducation.”Food and Nutrition Bulletin30(4)(December):317–326.
Parvanta, C F, K K Thomas, and KS Zaman. 2007. “Changing Nutrition Behavior in Bangladesh: Successful Adaptation of NewTheoriesandAnthropologicalMethods.”Ecology of Food and Nutrition46(3/4):221–244.
Penny,MaryE,HilaryMCreed-Kanashiro,RebeccaCRobert,MRocioNarro,LauraECaulfield,andRobertEBlack.2005. “Effectiveness of an Educational Intervention Delivered through the Health Services to Improve Nutrition in YoungChildren:aCluster-RandomisedControlledTrial.”The Lancet365(9474)(June28):1863–1872.
Roy,SK,GJFuchs,ZebaMahmud,GulshanAra,SumayaIslam,SohanaShafique,SyedaSharminAkter,andBarnaliChakraborty. 2005. “Intensive Nutrition Education with or without Supplementary Feeding Improves the Nutritional Sta-tusof Moderately-MalnourishedChildreninBangladesh.”Journal of Health, Population, and Nutrition23(4):320–30.
Roy,SwapanKumar,SairaParveenJolly,SohanaShafique,GeorgeJFuchs,ZebaMahmud,BarnaliChakraborty,andSuchismita Roy. 2007. “Prevention of Malnutrition among Young Children in Rural Bangladesh by a Food-Health-Care EducationalIntervention:ARandomized,ControlledTrial.”Food and Nutrition Bulletin28(4):375–83.
Ruel, Marie T, and Purnima Menon. 2002. “Child Feeding Practices Are Associated with Child Nutritional Status in Latin America:InnovativeUsesof theDemographicandHealthSurveys.”The Journal of Nutrition132(6)(June):1180–1187.
105 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
INTR
OD
UC
TIO
NM
ETH
OD
SEX
ECU
TIV
E SU
MM
ARY
FIN
DIN
GS
CO
MPL
EMEN
TARY
FE
EDIN
GBR
EAST
FEED
ING
PREG
NA
NC
Y A
ND
LA
CTA
TIO
N
Santos, I, C G Victora, J Martines, H Gonçalves, D P Gigante, N J Valle, and G Pelto. 2001. “Nutrition Counselling In-creasesWeightGainAmongBrazilianChildren.”The Journal of Nutrition131(11)(November):2866–2873.
Sun, Jing, Yaohua Dai, Shuaiming Zhang, Jian Huang, Zhenyu Yang, Junsheng Huo, and Chunming Chen. 2011. “Imple-mentationof aProgrammetoMarketaComplementaryFoodSupplement(YingYangBao)andImpactsonAnaemiaandFeedingPracticesinShanxi,China.”Maternal & Child Nutrition7Suppl3(October):96–111.
Thompson, Michael E, and Tsovinar L Harutyunyan. 2009. “Impact of a Community-based Integrated Management of ChildhoodIllnesses(IMCI)ProgrammeinGegharkunik,Armenia.”Health Policy and Planning24(2)(March):101–107.
Vazir,Shahnaz,PatriceEngle,NagallaBalakrishna,PaulaLGriffiths,SusanLJohnson,HilaryCreed-Kanashiro,Syl-via Fernandez Rao, Monal R Shroff, and Margaret E Bentley. 2013. “Cluster-randomized Trial on Complementary and Responsive Feeding Education to Caregivers Found Improved Dietary Intake, Growth and Development Among Rural IndianToddlers.”Maternal & Child Nutrition9(1)(January):99–117.
World Health Organization. Indicators for assessing infant and young child feeding practices: conclusions of a consensus meeting held 6–8 November 2007 in Washington D.C., USA. Geneva: World Health Organization, 2008.
World Health Organization/UNICEF. Complementary feeding of young children in developing countries: a review of current scientific knowledge. Geneva: World Health Organization, 1998.
Zaman, Shakila, Rifat N Ashraf, and José Martines. 2008. “Training in Complementary Feeding Counselling of Healthcare WorkersandItsInfluenceonMaternalBehavioursandChildGrowth:aCluster-randomizedControlledTrialinLahore,Pakistan.”Journal of Health, Population, and Nutrition26(2)(June):210–222.
Zhang, Jingxu, Ling Shi, Da-Fang Chen, Jing Wang, and Yan Wang. 2013. “Effectiveness of an Educational Intervention toImproveChildFeedingPracticesandGrowthinRuralChina:UpdatedResultsat18Monthsof Age.”Maternal & Child Nutrition9(1)(January):118–129.
106 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
APPENDIX: SBCC LITERATURE REVIEW SEARCHING SETS
The following search terms were used for this review. They are organized according to the original conceptu-alization of categories of nutrition practices and SBCC approaches. Over time, these search terms evolved, so they do not precisely align with the current chapters but they do provide evidence of all terms that were searched. Notethattheasterisk(“*”)wasusedtocallupvariationsin word endings.
A. PRACTICES
1. Optimal maternal nutrition practices((pregnancyORlactation)AND((dietORconsumption)OR(energyintake)OR(energyexpenditure)OR(micro-nutrientintake)OR(ironsupplement*)OR(diet*diversity)OR(nutritionpractice))
2. Optimal infant and young child nutrition practices
a) Breastfeeding ((breastfeed*)OR(infantfeeding)OR(rooming-incare)OR(rooming-in)OR(earlyinitiationof breastfeed*)OR(initiationof breastfeed*)OR(timelyinitiationof breastfeed*)OR(exclusivebreastfeed*)OR(breastmilksub-stitute)OR(lengthof feeding)OR(breastfeed*onbothbreast)OR(feed*ondemand)OR(breastfeed*frequency)OR(durationof breastfeed*))
NOTE: Our interest in breast milk substitutes is limited to circumstances where breast feeding is not possible.
b) Complementary feeding((child)OR(infant))AND((complementaryfood*)OR(complementaryfeeding)OR(introductionof comple-mentaryfood)OR((frequency)AND(feeding))OR(activefeeding)OR(dietarydiversity)OR(protein)OR(energy)OR(food-basedintervention)OR((food*)AND((liquid)OR(soft)OR(semi-solid)OR(solid)OR(amount)OR(quantity)OR(quality)OR(consistency)OR(density))))
3. IYCF of the sick and/or malnourished and/or HIV+ child
((child*)OR(infant*))AND((illness)OR(malaria)OR(pneumonia)OR(HIV)or(diarrhea)OR(malnutrition)OR(stunt*)OR(wast*)OR(underweight))AND((breastfeed*)OR(feeding)OR(rooming-incare)OR(breastmilksubstitute)OR(complementaryfood*)OR(complemen-taryfeeding)OR(food-basedintervention)OR(IMCIfoodbox)OR(recuperativefeeding)OR(Ready-to-useThera-peuticFood)OR(Ready-to-useSupplementaryFood))
4. Control and prevention of MN deficiencies
((childORwom*n)AND((intakeORconsumption)AND(food)AND((vitaminArich)OR(vitaminAfortified)OR(animalsource)OR(ironrich)))OR(Purchaseof forti-fiedfood)OR(micronutrientpowder)OR(sprinkles)OR(ironintake)OR(zincintake)OR(anemia)OR(fortifiedcomplementaryfood)OR(micronutrientpowder)OR(ITN)OR(insecticide-treatednets)OR(lipid-basednutri-entsupplement)OR(ready-to-usefood)OR(de-worm*)OR(deworm*)OR(helminth*)OR(malariaprophylaxis)OR(intermittentpreventivetherapy)OR(IPT)OR(Lacta-tionalamenorrheamethod)OR(Lactationalamenorrhoeamethod)OR(LAM)))
5. WASH
((hygiene)OR(handwash*)OR(hand-wash*)OR(washhand*)OR(foodprepar*)OR((safehandl*)ANDfood)OR((safewater)ANDuse*)OR(boil*water)OR(chlorineANDwater)OR(use*ANDlatrine))
B. SBCC APPROACHES
1. Broad and cross-cutting approaches
((behaviorchange)OR(behavior-centered)OR(behaviourchange)OR(behaviour-centered)(communicationchan-nels)OR(communication)OR(essentialnutritionactions)OR(informationeducationandcommunication)OR(IEC)OR(socialchange)OR(socialmobiliz*)OR(socialmove-ment)OR(socialnetwork*)OR(socialnorm*)OR(socialsupport)OR(strategiccommunication))
NOTE: Search results that reference essential nutrition ac-tions must include a communications/counseling component.
107 EVIDENCE OF EFFECTIVE APPROACHES TO SOCIAL AND BEHAVIOR CHANGE COMMUNICATION FOR PREVENTING AND REDUCING STUNTING AND ANEMIA: FINDINGS FROM A SYSTEMATIC LITERATURE REVIEW
2. Community-based approaches
((babyfriendlycommunityinitiative)OR(baby-friendlycom-munityinitiative)OR(behaviorsignal*)OR(caregroup)OR(communitydefinedquality)OR(communityengagement)OR(communityintervention)OR(communityleader)OR(communitymobilization)OR(communityoutreach)OR(communityrole-play)OR(community-led)OR(counsel)OR(dance)OR(demonstration*)OR(drama)OR(groupeducation)OR(modelbreastfeedingcommunity)OR(moth-er*group)OR(music)OR(positivedeviance)OR(publicopinionleader)OR(religiousleader)OR(supportgroup)OR(trialsof improvedpractices)OR(TIPS))
NOTES:Searchresultsthatreferencecommunitydefinedqualityortrialsof improvedpractices(TIPS)mustincludeacommunications/counseling component. Supports groups may include peer, mother, mother-to-mother and other types.
3. Facility-based approaches
((communityhealthworker)OR(frontlinehealthworker)OR(midwives)OR(nurse*)OR(nutritionworker)OR(physician)OR(traditionalbirthattendant)OR(partnershipdefinedquality)OR(PDQ)OR(providerdefinedquality)OR(qualityANDcommunications)OR(qualityANDcoun-seling)OR(qualityassurance)OR(qualityimprovement)OR(babyfriendlyhospitalinitiative)OR(baby-friendlyhospitalinitiative)OR(BFHI)OR(baby-friendly)OR(nutritionas-sessmentcounselingandsupport)OR(NACS)OR(preven-tionof mothertochildtransmission)OR(PMTCT))
NOTE:SearchresultsthatreferencePartnershipDefinedQuality(PDQ),ProviderDefinedQuality,qualityassurance,quality improvement, and prevention of mother-to-child transmission(PMTCT)mustincludeacommunications/counseling component.
4. Interpersonal communication approaches
((caregivercontact)OR(client-providerinteraction)OR(patient-providerinteraction)OR(physician-patientinterac-tion)OR(provider-clientinteraction)OR(provider-patientinteraction)OR(clinictalks)OR(counsel*)OR(facilitateddiscussion)OR(growthpromot*)OR(homevisit)OR(householdoutreach)OR(outreach)OR(interpersonalcommunication)OR(jobaid)OR(negotiat*)OR(peereducat*)OR(persuas*)OR(promot*)OR(roleplay))
NOTES: Counsel* includes but is not limited to peer coun-seling. Job aid references must include a communications/counseling component.
5. Mass media and social marketing
((advocacy)OR(marketing)OR(massmedia)OR(printmedia)OR(radio)OR(SMS)OR(socialfranchising)OR(socialmarketing)OR(socialmedia)OR(television)OR(textmessag*)OR(video))
NOTE: References to social franchising and social market-ing must include a communications/counseling component.
C. ASSESSMENT / EVALUATION TERMS
((review)OR(effectiv*)OR(evaluat*)OR(evidence)OR(impact)OR(improv*)OR(meta-analysis)OR(rand-omizedcontrolledtrial)OR(RCT))
D. COUNTRY EXCLUSION
NOT(UnitedStates)
NOTE: All studies conducted in all other high income coun-tries were individually excluded during the review process.