Changing Breastfeeding Behavior

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• Changing Breastfeeding Behavior
• at Community Level
• LINKAGES Results in
• Bolivia, Ghana Madagascar

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Presented by Nancy Keith

• Regional Director Europe/Eurasia
• Health Communication Partnership

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LINKAGES Mandate

• to improve breastfeeding and related
  complementary feeding and maternal nutrition
  practices, and to increase the uptake of the
  lactational amenorrhea method (LAM)

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The challenge for LINKAGES was...

• Could breastfeeding behaviors be changed?
• Could they be changed at scale?
• What works at the community level?

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LINKAGES Strategy

• ... at end of 1999, decision to focus on
  improving breastfeeding practices at a large
  scale in three countries Bolivia, Ghana
  Madagascar

Bolivia
Bolivia
Ghana
Madagascar
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LINKAGESBolivia, Ghana Madagascar

• Emphasis on BCM/LAM
• Rapid Results
• Broad coverage
• Sustainability

Bolivia
Bolivia
Ghana
Madagascar
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Rapid Results Bolivia, Ghana Madagascar
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Rapid Assessment Key Indicators

• Initiation of breastfeeding within 1 hour of
  birth
  
• Exclusive breastfeeding (0-
• LAM up-take

UNICEF/90-033/Sprague
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Madagascar, Ghana, and Bolivia
Timely initiation of breastfeeding
(within 1 hour of birth)
100
69
69
80
62
56
60
Percent
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32
40
20
0
Madagascar
Ghana
Bolivia
n14327 n22580
n1454 n2377
n1699 n2199
p
p
p
2000
2001
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Madagascar, Ghana, and BoliviaExclusive
breastfeeding of infants 0 11
Madagascar and BoliviaLAM rate(women with
infants 0- 12
Broad Coverage

• How do we do it?

Bolivia
Bolivia
Ghana
Madagascar
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How we do it...

• Work with many different partners to mainstream
  our community interventions into their
  
• nutrition programs
• child survival programs
• reproductive health programs
• food security programs
• other activities

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Partners in Ghana
Other partners District Health Teams
Action Aid ACDEP WFP New Energy
Radio Stations University World Vision
Freedom from Hunger

• Yr 2003 Coverage
• 3.0 million total population in 3 northern
  regions

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Partners in Madagascar

• Yr 2002 Coverage
• 6 million total population in 23 districts

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Partners in Bolivia

• Yr 2003 Coverage
• 1 million total population in all 3 eco-regions

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2000 Coverage...
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2001Onwards Expansion...
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Rapid Results

• How did we do it?

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What we do...
Multi-level Strategy

• Nutrition policy analysis advocacy at all
  levels
  
• Pre-service curricula reform and in-service
  training
  
• Community level nutrition behavior change
  interventions
  

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LINKAGES BEHAVIOR CHANGE MODEL
Advocacy for policy change
Policy
Training, advocacy
Health Care Providers - Services Provision
Groups to change community norms
Norms of Surrounding Society
Secondary Target Audience
Groups to create support
Primary Target Audience
Individual Behavior Change
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LINKAGES BEHAVIOR CHANGE MODEL
Policy
Health Care Providers - Services Provision
Norms of Surrounding Society
Secondary Target Audience
Mother
Individual Behavior Change
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LINKAGES BEHAVIOR CHANGE MODEL
Policy
Health Care Providers - Services Provision
Norms of Surrounding Society
Father Grandmother
Support for the mother
Mother
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LINKAGES BEHAVIOR CHANGE MODEL
Policy
Health Care Providers - Services Provision
Groups to change community norms
CBOs, Leaders Community
Father Grandmother
Mother
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LINKAGES BEHAVIOR CHANGE MODEL
Policy
Training, advocacy
HWs MOH, NGOs, Volunteers
CBOs, Leaders Community
Father Grandmother
Mother
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LINKAGES BEHAVIOR CHANGE MODEL
Advocacy for policy change
Policy Makers
HWs MOH, NGOs, Volunteers
CBOs, Leaders Community
Father Grandmother
Mother
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LINKAGES BEHAVIOR CHANGE MODEL
Advocacy for policy change
Policy
Training, advocacy
Health Care Providers - Services Provision
Groups to change community norms
Norms of Surrounding Society
Secondary Target Audience
Groups to create support
Primary Target Audience
Individual Behavior Change
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LINKAGES Theoretical Underpinning
Combination of theories and approaches

• Individual behavior change - Stages of Change
• Normative change through critical mass
• Peer to peer/shared experiences through support
  groups
  
• Social marketing of new ideas
• HW performance improvement through self-efficacy
  (practice to feel competent)
  

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Stages of Change Model
Telling others

Steps in changing a practice
Maintenance
Adoption
Trial
Intention
Contemplation
Aware
Pre-awareness
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Stages of Change Model
Telling others
Steps in changing a practice
Maintenance
Adoption
Trial
Intention
Contemplation
Aware
Information
Pre-awareness
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Stages of Change Model
Telling others
Steps in changing a practice
Maintenance
Adoption
Trial
Intention
Persuade
Contemplation
Aware
Information
Pre-awareness
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Stages of Change Model
Telling others
Steps changing a practice
Maintenance
Adoption
Negotiate
Trial
Encourage
Intention
Persuade
Contemplation
Aware
Information
Pre-awareness
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Stages of Change Model
Telling others
Steps in changing a practice
Support
Maintenance
Discuss benefits
Adoption
Negotiate
Trial
Encourage
Intention
Persuade
Contemplation
Aware
Information
Pre-awareness
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Stages of Change Model
Telling others
Praise
Steps in changing a practice
Support
Maintenance
Discuss benefits
Adoption
Negotiate
Trial
Encourage
Intention
Persuade
Contemplation
Aware
Information
Pre-awareness
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LINKAGES Community Level Strategy Bolivia, Ghana
Madagascar

• What do we do at the community level?

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LINKAGES Community-level Behavior Change Strategy

• Strategies messages based on formative
  research and trials of improved behaviors
  (simplified TIPS)
  
• Focus on 2-3 priority breastfeeding behaviors
  that make a difference
  

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LINKAGES Community-level Behavior Change Strategy
Target - mothers

• Negotiate with her to try an improved feeding
  behavior based on her resources/preferences
  
• Educate using print
• Exchange experiences in support groups

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LINKAGES Community-level Behavior Change Strategy
Target - fathers

• Create awareness through radio, meetings for men
  
  
• Encourage support for mother
• Engage as community volunteers

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LINKAGES Community-level Behavior Change Strategy
Target - grandmothers

• Praise for passing on knowledge to daughters
• Create awareness of value of improved practices
• Enlist as volunteers

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LINKAGES Community-level Behavior Change Strategy
Changing community norms

• Work with existing groups and CBOs to create
  community support for mother
  
• Saturate community with converts
• Individual behavior change plus support
  normative change
  

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Sustainability

• How do we achieve it?

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Sustainability

• Wove strategy into programs of many different
  partners and networks inside and outside
  government
  
• Included key nutrition issues in relevant
  policies and strategies
  
• Normative change at the community level
• Pre-service Curricula Reform
• Madagascar (with IMCI)
• Ghana (Essential Nutrition Actions)

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Lessons Learned to Date
Creating a critical mass of believers leads to
norm change

• Creating consensus through policy analysis and
  advocacy (PROFILES) develops broad based support
  and agreement on issues.
  
• Working through community-based partners expands
  reach (NGOs) and leverages resources (UNICEF).
  
• Focusing on network approach broke down typical
  barriers to share package and protocols
  
• government and NGOs working together
• NGOs working with other NGOs

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Lessons Learned to Date
Behavior change can take place quickly

• Negotiating for trial of new practices eliminated
  barriers, because women saw the benefits and led
  to immediate adoption of the new practice.
  
• Women who try the new practice need to be
  supported by their family and community- they do
  not always act alone.
  
• The link needs to be strong between facility and
  community efforts to provide support for new
  behavior.
  
• Community wide saturation ensures a safe
  environment for new practices.
  

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Lessons Learned to Date
Training can lead to quick behavior change

• Training all kinds of community volunteers
  expanded the reach
  
• Using skill-based training heavy on practice
  ensures quick up-take by field workers. Guided
  practice on real people leads to feelings of
  self -efficacy.
• Short 4 hour courses at monthly staff meetings
  provide update and motivation (Madagascar)
  
• Coaching on the job is essential to motivation
  
  
• super
• short course

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Lessons Learned to Date
Reinforcing interpersonal communication with
media and print
spread the word rapidly

• Inviting media to all activities and training
  motivated them to use the material in difference
  formats
  
• Simple appropriate counseling cards could be used
  even by illiterate volunteers
  
• Singing star in Madagascar breastfed her baby and
  became poster mom for breastfeeding
  
• Community events celebrated success
• Working through the university linked
  nutritionists throughout the country

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Lessons Learned to Date
Breastfeeding
Breastfeeding is the link and Entry Point
PMTCT

• Harmonized messages
• Decrease in missed opportunities
• BFHI/community/support groups

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The End