Impacts of a Social and Behavior Change Communication Program Implemented at Scale on Infant and Young Feeding Practices in Nigeria: Results of a Cluster-Randomized Evaluation

"The modest levels of early initiation of breastfeeding in both states and of exclusive breastfeeding and minimum dietary diversity, particularly in Kaduna, indicate a need for programs to further improve interpersonal communication in health facilities and during home visits and to include a sustained mass media campaign..."

Infant and young child feeding (IYCF) practices are important for child survival and healthy growth, but IYCF practices remain suboptimal in Nigeria. The objective of this cluster-randomised impact evaluation was to measure the impact of Alive & Thrive (A&T)'s IYCF social and behaviour change communication (SBCC) intervention on early initiation of breastfeeding, exclusive breastfeeding, and minimum dietary diversity in Kaduna and Lagos States.



The theory of change for the intervention in Nigeria is built on the socio-ecological model and was tested by A&T in other countries. The theory posits that interpersonal communication and mass media contacts with mothers and family members and community mobilisation through religious and community leaders, in conjunction with advocacy and strategic use of data, will lead to improved knowledge and optimal IYCF practices, better health worker capacity to deliver quality IYCF services, and improved health outcomes.

Interpersonal communication and community mobilisation activities were conducted in 16 intervention local government areass (LGAs) in Kaduna State and 10 intervention LGAs in Lagos State. In collaboration with state Ministries of Health, A&T trained 1,554 traditional birth attendants (TBAs), 4,892 health workers at public and private health facilities, and 123 master trainers who could support cascade training to other health facilities in the intervention LGAs. The 2-day training covered IYCF practices, interpersonal communication skills and counseling techniques, one-on-one communication, facilitation skills for group counseling, and data reporting. Health providers were supported with posters (15,000 Kaduna, 10,000 Lagos), leaflets (20,000 each state), and IYCF messages presented on LED screens where available in health facilities. Health providers delivered IYCF messages to pregnant women and mothers with a child 0-23 months of age through group and individual interpersonal communication at health facilities. In addition, 479 community volunteers (Kaduna 228, Lagos 251), including representatives from community-based organisations and community leaders, were trained to conduct home visits and hold community meetings to discuss IYCF with pregnant women, mothers with young children, and men.



A&T developed and produced key IYCF mass media messages in Hausa and English languages through the "Start Strong" campaign to promote early initiation of breastfeeding, exclusive breastfeeding, and dietary diversity. These were deployed through television (see example, below) and radio and were complemented with posters, leaflets, billboards, and vehicle ads. The mass media campaign was implemented for 10 months from September 2019 through June 2020. Television ads were shown on two stations in Kaduna and three in Lagos and on three cable channels available nationwide, with more than 1,500 spots in Kaduna and more than 2,000 in Lagos. Radio ads were aired on three stations in Kaduna and four in Lagos, with more than 6,000 spots in Kaduna and close to 8,000 in Lagos. Television and radio ads were aired 7-8 times per day. Television and radio call-in programmes amplified the messages.



Local government areas were randomly allocated to intervention or comparison. Cross-sectional surveys of households with children aged 0-23 months were conducted [N = 6,266 baseline (2017), N = 7,320 endline (2020)]. Logistic regression was used to calculate difference-in-differences estimates (DDEs) of impact on IYCF practices and to assess within-group changes from baseline to endline. Associations between intervention exposures and IYCF practices were tested in both study groups combined.



In Kaduna, a positive differential effect of the intervention was found for exclusive breastfeeding (adjusted DDE 8.9 percentage points (pp), P<0.099). Increases in both study groups from baseline to endline were observed in Kaduna for early initiation of breastfeeding (intervention 12.2 pp, P = 0.010; comparison 6.4 pp, P = 0.118) and minimum dietary diversity (intervention 20.0 pp, P<0.001; comparison 19.7 pp, P<0.001), which eliminated differential effects. In Lagos, no differential intervention impacts were found on IYCF practices because changes in early initiation of breastfeeding from baseline to endline were small in both study groups, and increases in both study groups from baseline to endline were observed for exclusive breastfeeding (intervention 8.9 pp, P = 0.05; comparison 6.6 pp, P<0.001) and minimum dietary diversity (intervention 18.9 pp, P<0.001; comparison 24.3 pp, P<0.001). Odds of all three IYCF practices increased with exposure to facility-based interpersonal communication in both states and with community mobilisation or mass media exposure in Kaduna.



In this evaluation, mothers' IYCF knowledge and/or awareness generally increased from baseline to endline in Kaduna in tandem with increases in IYCF practices. The picture was more mixed in Lagos. Increases in knowledge of exclusive breastfeeding aligned with increases in the practice from baseline to endline, while increases in knowledge and awareness of early initiation of breastfeeding did not translate into increases in the practice in Lagos. Early initiation of breastfeeding is influenced by many factors other than knowledge, including the woman having a caesarean section and the advice and actions of midwives and nurses present at delivery. For example, glucose water and infant formula, which are often recommended by midwives and nurses, were among the most common prelacteal feeds in Lagos. More research is needed to develop strategies to change norms related to early infant feeding among mothers and health workers in Lagos.



Thus, this evaluation found weak impacts of the A&T intervention on IYCF practices in the difference-in-differences analysis because of suspected intervention spillover to the comparison group: A substantial number of mothers in the comparison group were exposed to intervention components, especially interpersonal communication. For instance, the team suspects the state Ministries of Health may have used their resources to implement similar activities and health worker training in the comparison LGAs to keep the states overall from appearing to lag behind on IYCF. However, substantial within-group increases in IYCF practices from baseline to endline are likely attributable to the intervention, which was the major IYCF promotion activity in both states. This assertion is supported by the association between intervention exposures and IYCF practices.



In conclusion: "As the government of Nigeria continues to implement the IYCF intervention in Kaduna and Lagos and replicate the effort in other states, it should focus on training health workers to carry out facility-based interpersonal communication, as this had the strongest relationship with IYCF practices in both states, and on increasing community outreach and mobilization."