Documenting large-scale programs to improve infant and young child feeding is key to facilitating progress in child nutrition
Ellen Piwoz, Jean Baker, and Edward A. Frongillo Key words: Africa, Asia, breastfeeding, complementary feeding, IYCF, nutrition, scaling up nutrition
This Supplement to the Food and Nutrition Bulletin presents field-tested design and implementation frameworks for rapid scale-up of programs to prevent stunting during the “window of opportunity.” It documents how infant and young child feeding (IYCF) programs were designed and successfully scaled up in Bangladesh, Ethiopia, and Vietnam from 2009 to 2013. An understanding of how to strengthen delivery systems to programmatically achieve scale in distinct country contexts and how to motivate behavior change in different populations, from decision makers to mothers, is critical for realizing the full public health impact of nutrition interventions. Effective and affordable nutrition interventions have been known for several years [1, 2], but experience with large-scale implementation has been uneven. While vitamin A supplementation, salt iodization, and, in some countries, breastfeeding promotion achieved expanded scale [1], interventions necessary to reduce stunting, wasting, and underweight have lagged behind. Gaps still remain in implementing programs for exclusive breastfeeding, although it is proven to be the number one preventive child survival intervention [2]. According to the Lancet [3], suboptimal breastfeeding accounts for more than 800,000 child deaths annually. Inadequate complementary feeding contributes to a broad range of problems, including micronutrient deficiencies, underweight, stunting, and cognitive and developmental issues, worsening the global burden of disease [4]. Ellen Piwoz is affiliated with the Bill & Melinda Gates Foundation; Jean Baker is affiliated with FHI 360, Washington, DC; Edward Frongillo is affiliated with the Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA. Please direct queries to the corresponding author: Jean Baker, Alive & Thrive, FHI 360, 1825 Connecticut Ave. NW, Washington, DC 20009, USA; e-mail: [email protected].
Why has progress in implementing large-scale breastfeeding and complementary feeding programs been delayed? Among the multiple reasons are lack of scale strategies and resources to support them, incomplete understanding of economic and cultural barriers, and incorrect assumptions about determinants of poor feeding practices, such as assuming that food insecurity or poverty is the underlying cause of poor complementary feeding. Other reasons include the absence of creative behavior change communication strategies, such as social marketing, that are employed by the private sector and lack of clarity on program approaches due to insufficient documentation of different ways to deliver results. Inadequately documented experiences and results have led to the lack of practical, field-tested frameworks, processes, and tools that can be applied in diverse contexts, delaying investments and action. To accelerate progress across countries, field-tested approaches urgently need to be documented and disseminated. This collection of papers on Alive & Thrive’s* experience in designing and implementing programs in three countries aims to contribute to filling this need. National indicators illustrate the different contexts where Alive & Thrive programs were scaled up (table 1). Despite the differences between Bangladesh, Ethiopia, and Vietnam, the critical period of stunting development was similar and occurred before 24 months of age, [9, 10, 11], which is the time period influenced by IYCF interventions. The country programs documented here constitute one of the earliest experiences of scaled up comprehensive IYCF programs that include complementary feeding. The breastfeeding components of Alive & Thrive programs are built upon past global efforts such as the Baby-Friendly Hospital Initiative, the International * Alive & Thrive is a multicountry, multiyear initiative aimed at developing large-scale program models for reducing child mortality and stunting through improved infant and young child feeding practices. It is managed by FHI 360 in partnership with BRAC, GMMB, the International Food Policy Research Institute (IFPRI), Save the Children, the University of California-Davis, and World Vision.
Food and Nutrition Bulletin, vol. 34, no. 3 © 2013 (supplement), The United Nations University.
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TABLE 1. National population, health, and economic indicators for Bangladesh, Ethiopia, and Vietnam Indicator Population (millions) Per capita GDP (US$) Stunted children < 5 yr (%) Infant mortality rate per 1,000 live births
Bangladesh Ethiopia Vietnam 150 743 41 37
86 357 44 52
89 1,407 29 17
Sources: Per capita GDP, total population, and infant mortality rates are from the World Bank data base for 2011 [5]; stunting prevalence is from ICF/MACRO DHS reports from Bangladesh [6] and Ethiopia [7] and Vietnam’s National Institute of Nutrition 2010 [8]
Code of Marketing of Breast-Milk Substitutes, and maternity leave legislation [12]. Lessons from fieldbased breastfeeding programs [13] implemented by UNICEF and the US Agency for International Development (USAID-funded projects such as LINKAGES [14], BASICS, and NGO Child Survival Grants) provided valuable building blocks for Alive & Thrive. Guidelines for complementary feeding were developed much later than those for breastfeeding and were issued by the World Health Organization (WHO) in 2003 [15]. Complementary feeding indicators for assessing status and tracking progress and consensus on what constitutes adequate complementary feeding were still being developed up to 2009 [16]. Complementary feeding has received greater attention now that there are global guidance and indicators, sufficient new scientific evidence on how to improve complementary feeding behaviors [17], new products to enrich
children’s diets [18], and evidence on the use of family foods to reduce stunting [19]. Alive & Thrive programs were based on these guidelines and recommendations. The experiences reported in this set of papers are timely, as awareness about the urgency of scaling up has been created by the Scaling Up Nutrition (SUN) movement [20] and national commitments made at the June 2013 Nutrition for Growth Summit in London. The SUN movement was launched in 2010 to accelerate actions to address undernutrition in the 1000 day “window of opportunity” from pregnancy through the first two years of life. As of June 1, 2013, 40 countries had joined the SUN, committing to delivering improved nutrition outcomes and operational guidance on best practices to accelerate effective scale-up. The papers in this Supplement systematically examine the rationale used to design the Alive & Thrive programs in three countries, drawing on best practices across several domains, including implementation science, behavior change theories, policy, systems strengthening, and process and impact evaluation science. The Supplement provides innovative and tested approaches that other countries can adapt, thereby enabling accelerated design and implementation of large-scale programs to improve infant and young child feeding and nutrition in the first 2 years of life.
Acknowledgment The Bill & Melinda Gates Foundation provided funding for Alive & Thrive, managed by FHI 360.
References 1. Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K, Giugliani E, Haider BA, Kirkwood B, Morris SS, Sachdev HPS, Shekar M, for the Maternal and Child Undernutrition Study Group. What works? Interventions for maternal and child undernutrition and survival. Lancet 2008;371:417–40. 2. Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS, and the Bellagio Child Survival Study Group. How many child deaths can we prevent this year? Lancet 2003;362:65–71. 3. Black R, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M, Ezzati M, Grantham-McGregor S, Katz J, Martorell R, Uauy R, and the Maternal and Child Study Group. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet 2013. Published online June 6. http://dx.doi.org/ 10.1016/s0140-6736(13)60937-x 4. Lutter CK, Daelmans BM, de Onis M, Kothari MT, Ruel MT, Arimond M, Deitchler M, Dewey KG, Blössner M, Borghi E. Undernutrition, poor feeding practices, and low coverage of key nutrition interventions. Pediatrics 2011;128: e1–e10. 5. World Bank. Available at: http://data.worldbank.org/
6.
7.
8. 9. 10. 11.
indicator/NY.GDP.PCAP.CD for GDP; http://data .worldbank.org/indicator/SP.POP.TOTL for total population; and http://data.worldbank.org/indicator/SP.DYN .IMRT.IN for infant mortality rates. Accessed 4 June 2013. National Institute of Population Research and Training (NIPORT)/Mitra and Associates/ICF International. Bangladesh demographic and health survey 2011. Dhaka and Calverton, Md, USA: NIPORT/Mitra and Associates/ICF International, 2013. Central Statistical Agency [Ethiopia]/ICF International. Ethiopia demographic and health survey 2011. Addis Ababa and Calverton, Md, USA: Central Statistical Agency/ICF International, 2012. National Institute of Nutrition. Nutrition surveillance 2010: Viet Nam nutrition profile. Hanoi: Alive & Thrive, National Institute of Nutrition, UNICEF, 2012. Saha KK, Bamezai A, Khaled A, Subandoro A, Rawat R, Menon P. Alive & Thrive baseline survey report: Bangladesh. Washington, DC: Alive & Thrive, 2011. Ali D, Tedla M, Subandoro A, Bamezai A, Rawat R, Menon P. Alive & Thrive baseline survey report: Ethiopia. Washington, DC: Alive & Thrive, 2011. Nguyen P, Manohar S, Mai L, Subandoro A, Rawat R,
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12.
13.
14.
15.
16.
Menon P. Alive & Thrive baseline survey report: Viet Nam. Washington, DC: Alive & Thrive, 2011. Mangasaryan N, Martin L, Brownlee A, Ogunlade A, Rudert C, Cai X. Breastfeeding promotion, support and protection: review of six country programmes. Nutrients 2012;4:990–1014. World Health Organization/UNICEF/Academy for Educational Development/US Agency for International Development. Learning from large-scale communitybased programmes to improve breastfeeding practices. Geneva: WHO, 2008. Quinn VJ, Guyon AB, Schubert JW, Stone-Jiménez M, Hainsworth MD, Martin LH. Improving breastfeeding practices on a broad scale at the community level: Success stories from Africa and Latin America. J Hum Lact 2005;21:345–54. World Health Organization/Pan American Health Organization. Guiding principles for complementary feeding of the breastfed child. Washington, DC: PAHO, 2003. World Health Organization. Indicators for assessing
17.
18.
19.
20.
infant and young child feeding practices. Part 2: Measurement. Geneva: WHO, 2010. Available at: http:// whqlibdoc.who.int/publications/2010/9789241599290_ eng.pdf. Accessed 11 June 2013. Dewey KG, Adu-Afarwuah S. Systematic review of the efficacy and effectiveness of complementary feeding interventions in developing countries. Matern Child Nutr 2008;4(suppl 1):24–85. Zlotkin S, Arthur P, Antwi KY, Yeung G. Treatment of anemia with microencapsulated ferrous fumarate plus ascorbic acid supplied as sprinkles to complementary (weaning) foods. Am J Clin Nutr 2001;74:791–5. Penny ME, Creed-Kanashiro HM, Robert RC, Narro MR, Caulfield LE, Black RE. Effectiveness of an educational intervention delivered through the health services to improve nutrition in young children: a cluster-randomized controlled trial. Lancet 2005;365:1863–72. SUN. Scaling up Nutrition: a framework for action. September 2010. Available at: http://scalingupnutrition. org/wpcontent/uploads/2013/05/SUN_Framework.pdf. Accessed 20 June 2013.
Ellen Piwoz, Jean Baker, and Edward A. Frongillo Key words: Africa, Asia, breastfeeding, complementary feeding, IYCF, nutrition, scaling up nutrition
This Supplement to the Food and Nutrition Bulletin presents field-tested design and implementation frameworks for rapid scale-up of programs to prevent stunting during the “window of opportunity.” It documents how infant and young child feeding (IYCF) programs were designed and successfully scaled up in Bangladesh, Ethiopia, and Vietnam from 2009 to 2013. An understanding of how to strengthen delivery systems to programmatically achieve scale in distinct country contexts and how to motivate behavior change in different populations, from decision makers to mothers, is critical for realizing the full public health impact of nutrition interventions. Effective and affordable nutrition interventions have been known for several years [1, 2], but experience with large-scale implementation has been uneven. While vitamin A supplementation, salt iodization, and, in some countries, breastfeeding promotion achieved expanded scale [1], interventions necessary to reduce stunting, wasting, and underweight have lagged behind. Gaps still remain in implementing programs for exclusive breastfeeding, although it is proven to be the number one preventive child survival intervention [2]. According to the Lancet [3], suboptimal breastfeeding accounts for more than 800,000 child deaths annually. Inadequate complementary feeding contributes to a broad range of problems, including micronutrient deficiencies, underweight, stunting, and cognitive and developmental issues, worsening the global burden of disease [4]. Ellen Piwoz is affiliated with the Bill & Melinda Gates Foundation; Jean Baker is affiliated with FHI 360, Washington, DC; Edward Frongillo is affiliated with the Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA. Please direct queries to the corresponding author: Jean Baker, Alive & Thrive, FHI 360, 1825 Connecticut Ave. NW, Washington, DC 20009, USA; e-mail: [email protected].
Why has progress in implementing large-scale breastfeeding and complementary feeding programs been delayed? Among the multiple reasons are lack of scale strategies and resources to support them, incomplete understanding of economic and cultural barriers, and incorrect assumptions about determinants of poor feeding practices, such as assuming that food insecurity or poverty is the underlying cause of poor complementary feeding. Other reasons include the absence of creative behavior change communication strategies, such as social marketing, that are employed by the private sector and lack of clarity on program approaches due to insufficient documentation of different ways to deliver results. Inadequately documented experiences and results have led to the lack of practical, field-tested frameworks, processes, and tools that can be applied in diverse contexts, delaying investments and action. To accelerate progress across countries, field-tested approaches urgently need to be documented and disseminated. This collection of papers on Alive & Thrive’s* experience in designing and implementing programs in three countries aims to contribute to filling this need. National indicators illustrate the different contexts where Alive & Thrive programs were scaled up (table 1). Despite the differences between Bangladesh, Ethiopia, and Vietnam, the critical period of stunting development was similar and occurred before 24 months of age, [9, 10, 11], which is the time period influenced by IYCF interventions. The country programs documented here constitute one of the earliest experiences of scaled up comprehensive IYCF programs that include complementary feeding. The breastfeeding components of Alive & Thrive programs are built upon past global efforts such as the Baby-Friendly Hospital Initiative, the International * Alive & Thrive is a multicountry, multiyear initiative aimed at developing large-scale program models for reducing child mortality and stunting through improved infant and young child feeding practices. It is managed by FHI 360 in partnership with BRAC, GMMB, the International Food Policy Research Institute (IFPRI), Save the Children, the University of California-Davis, and World Vision.
Food and Nutrition Bulletin, vol. 34, no. 3 © 2013 (supplement), The United Nations University.
S143
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E. Piwoz et al.
TABLE 1. National population, health, and economic indicators for Bangladesh, Ethiopia, and Vietnam Indicator Population (millions) Per capita GDP (US$) Stunted children < 5 yr (%) Infant mortality rate per 1,000 live births
Bangladesh Ethiopia Vietnam 150 743 41 37
86 357 44 52
89 1,407 29 17
Sources: Per capita GDP, total population, and infant mortality rates are from the World Bank data base for 2011 [5]; stunting prevalence is from ICF/MACRO DHS reports from Bangladesh [6] and Ethiopia [7] and Vietnam’s National Institute of Nutrition 2010 [8]
Code of Marketing of Breast-Milk Substitutes, and maternity leave legislation [12]. Lessons from fieldbased breastfeeding programs [13] implemented by UNICEF and the US Agency for International Development (USAID-funded projects such as LINKAGES [14], BASICS, and NGO Child Survival Grants) provided valuable building blocks for Alive & Thrive. Guidelines for complementary feeding were developed much later than those for breastfeeding and were issued by the World Health Organization (WHO) in 2003 [15]. Complementary feeding indicators for assessing status and tracking progress and consensus on what constitutes adequate complementary feeding were still being developed up to 2009 [16]. Complementary feeding has received greater attention now that there are global guidance and indicators, sufficient new scientific evidence on how to improve complementary feeding behaviors [17], new products to enrich
children’s diets [18], and evidence on the use of family foods to reduce stunting [19]. Alive & Thrive programs were based on these guidelines and recommendations. The experiences reported in this set of papers are timely, as awareness about the urgency of scaling up has been created by the Scaling Up Nutrition (SUN) movement [20] and national commitments made at the June 2013 Nutrition for Growth Summit in London. The SUN movement was launched in 2010 to accelerate actions to address undernutrition in the 1000 day “window of opportunity” from pregnancy through the first two years of life. As of June 1, 2013, 40 countries had joined the SUN, committing to delivering improved nutrition outcomes and operational guidance on best practices to accelerate effective scale-up. The papers in this Supplement systematically examine the rationale used to design the Alive & Thrive programs in three countries, drawing on best practices across several domains, including implementation science, behavior change theories, policy, systems strengthening, and process and impact evaluation science. The Supplement provides innovative and tested approaches that other countries can adapt, thereby enabling accelerated design and implementation of large-scale programs to improve infant and young child feeding and nutrition in the first 2 years of life.
Acknowledgment The Bill & Melinda Gates Foundation provided funding for Alive & Thrive, managed by FHI 360.
References 1. Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K, Giugliani E, Haider BA, Kirkwood B, Morris SS, Sachdev HPS, Shekar M, for the Maternal and Child Undernutrition Study Group. What works? Interventions for maternal and child undernutrition and survival. Lancet 2008;371:417–40. 2. Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS, and the Bellagio Child Survival Study Group. How many child deaths can we prevent this year? Lancet 2003;362:65–71. 3. Black R, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M, Ezzati M, Grantham-McGregor S, Katz J, Martorell R, Uauy R, and the Maternal and Child Study Group. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet 2013. Published online June 6. http://dx.doi.org/ 10.1016/s0140-6736(13)60937-x 4. Lutter CK, Daelmans BM, de Onis M, Kothari MT, Ruel MT, Arimond M, Deitchler M, Dewey KG, Blössner M, Borghi E. Undernutrition, poor feeding practices, and low coverage of key nutrition interventions. Pediatrics 2011;128: e1–e10. 5. World Bank. Available at: http://data.worldbank.org/
6.
7.
8. 9. 10. 11.
indicator/NY.GDP.PCAP.CD for GDP; http://data .worldbank.org/indicator/SP.POP.TOTL for total population; and http://data.worldbank.org/indicator/SP.DYN .IMRT.IN for infant mortality rates. Accessed 4 June 2013. National Institute of Population Research and Training (NIPORT)/Mitra and Associates/ICF International. Bangladesh demographic and health survey 2011. Dhaka and Calverton, Md, USA: NIPORT/Mitra and Associates/ICF International, 2013. Central Statistical Agency [Ethiopia]/ICF International. Ethiopia demographic and health survey 2011. Addis Ababa and Calverton, Md, USA: Central Statistical Agency/ICF International, 2012. National Institute of Nutrition. Nutrition surveillance 2010: Viet Nam nutrition profile. Hanoi: Alive & Thrive, National Institute of Nutrition, UNICEF, 2012. Saha KK, Bamezai A, Khaled A, Subandoro A, Rawat R, Menon P. Alive & Thrive baseline survey report: Bangladesh. Washington, DC: Alive & Thrive, 2011. Ali D, Tedla M, Subandoro A, Bamezai A, Rawat R, Menon P. Alive & Thrive baseline survey report: Ethiopia. Washington, DC: Alive & Thrive, 2011. Nguyen P, Manohar S, Mai L, Subandoro A, Rawat R,
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Documenting infant and young child feeding programs
12.
13.
14.
15.
16.
Menon P. Alive & Thrive baseline survey report: Viet Nam. Washington, DC: Alive & Thrive, 2011. Mangasaryan N, Martin L, Brownlee A, Ogunlade A, Rudert C, Cai X. Breastfeeding promotion, support and protection: review of six country programmes. Nutrients 2012;4:990–1014. World Health Organization/UNICEF/Academy for Educational Development/US Agency for International Development. Learning from large-scale communitybased programmes to improve breastfeeding practices. Geneva: WHO, 2008. Quinn VJ, Guyon AB, Schubert JW, Stone-Jiménez M, Hainsworth MD, Martin LH. Improving breastfeeding practices on a broad scale at the community level: Success stories from Africa and Latin America. J Hum Lact 2005;21:345–54. World Health Organization/Pan American Health Organization. Guiding principles for complementary feeding of the breastfed child. Washington, DC: PAHO, 2003. World Health Organization. Indicators for assessing
17.
18.
19.
20.
infant and young child feeding practices. Part 2: Measurement. Geneva: WHO, 2010. Available at: http:// whqlibdoc.who.int/publications/2010/9789241599290_ eng.pdf. Accessed 11 June 2013. Dewey KG, Adu-Afarwuah S. Systematic review of the efficacy and effectiveness of complementary feeding interventions in developing countries. Matern Child Nutr 2008;4(suppl 1):24–85. Zlotkin S, Arthur P, Antwi KY, Yeung G. Treatment of anemia with microencapsulated ferrous fumarate plus ascorbic acid supplied as sprinkles to complementary (weaning) foods. Am J Clin Nutr 2001;74:791–5. Penny ME, Creed-Kanashiro HM, Robert RC, Narro MR, Caulfield LE, Black RE. Effectiveness of an educational intervention delivered through the health services to improve nutrition in young children: a cluster-randomized controlled trial. Lancet 2005;365:1863–72. SUN. Scaling up Nutrition: a framework for action. September 2010. Available at: http://scalingupnutrition. org/wpcontent/uploads/2013/05/SUN_Framework.pdf. Accessed 20 June 2013.
