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BackgroundDespite recommendations supporting optimal breastfeeding, the number of women practicing exclusive breastfeeding (EBF) remains low, and few interventions have demonstrated implementation and impact at scale. Alive & Thrive was implemented over a period of 6 y (2009–2014) and aimed to improve breastfeeding practices through intensified interpersonal counseling (IPC), mass media (MM), and community mobilization (CM) intervention components delivered at scale in the context of policy advocacy (PA) in Bangladesh and Viet Nam. In Bangladesh, IPC was delivered through a large non-governmental health program; in Viet Nam, it was integrated into government health facilities. This study evaluated the population-level impact of intensified IPC, MM, CM, and PA (intensive) compared to standard nutrition counseling and less intensive MM, CM, and PA (non-intensive) on breastfeeding practices in these two countries.Methods and FindingsA cluster-randomized evaluation design was employed in each country. For the evaluation sample, 20 sub-districts in Bangladesh and 40 communes in Viet Nam were randomized to either the intensive or the non-intensive group. Cross-sectional surveys (n ~ 500 children 0–5.9 mo old per group per country) were implemented at baseline (June 7–August 29, 2010, in Viet Nam; April 28–June 26, 2010, in Bangladesh) and endline (June 16–August 30, 2014, in Viet Nam; April 20–June 23, 2014, in Bangladesh). Difference-in-differences estimates (DDEs) of impact were calculated, adjusting for clustering. In Bangladesh, improvements were significantly greater in the intensive compared to the non-intensive group for the proportion of women who reported practicing EBF in the previous 24 h (DDE 36.2 percentage points [pp], 95% CI 21.0–51.5, p < 0.001; prevalence in intensive group rose from 48.5% to 87.6%) and engaging in early initiation of breastfeeding (EIBF) (16.7 pp, 95% CI 2.8–30.6, p = 0.021; 63.7% to 94.2%). In Viet Nam, EBF increases were greater in the intensive group (27.9 pp, 95% CI 17.7–38.1, p < 0.001; 18.9% to 57.8%); EIBF declined (60.0% to 53.2%) in the intensive group, but less than in the non-intensive group (57.4% to 40.6%; DDE 10.0 pp, 95% CI −1.3 to 21.4, p = 0.072). Our impact estimates may underestimate the full potential of such a multipronged intervention because the evaluation lacked a “pure control” area with no MM or national/provincial PA.ConclusionsAt-scale interventions combining intensive IPC with MM, CM, and PA had greater positive impacts on breastfeeding practices in Bangladesh and Viet Nam than standard counseling with less intensive MM, CM, and PA. To our knowledge, this study is the first to document implementation and impacts of breastfeeding promotion at scale using rigorous evaluation designs. Strategies to design and deliver similar programs could improve breastfeeding practices in other contexts.Trial registrationClinicalTrials.gov NCT01678716 (Bangladesh) and NCT01676623 (Viet Nam)

This theory-driven and country- and component-specific approach, centered on careful analysis of PIPs, is intended to generate information on implementation and utilization pathways of Alive & Thrive's interventions, thereby answering the questions of how impacts are achieved, or why not. This evaluation approach is not without challenges, and we highlight some of these key challenges.

BackgroundAlthough husbands may provide support during pregnancy, limited evidence exists on how to promote husbands’ engagement and what impact it has. Alive & Thrive integrated nutrition-focused interventions, targeting both wives and husbands, through an existing Maternal, Neonatal, and Child Health (MNCH) platform in Bangladesh.ObjectivesWe evaluated 1) the impact of a nutrition-focused MNCH program, compared with the standard MNCH program, on husbands’ behavioral determinants (i.e., awareness, knowledge, self-efficacy) and support to wives to adopt optimal nutrition practices and 2) how much of the previously documented impact on women's supplement intake and dietary diversity was explained by husbands’ behavioral determinants and support.MethodsWe used a cluster-randomized design with cross-sectional surveys at baseline (2015) and endline (2016) (n = ∼1000 women and ∼700 husbands/survey). We used mixed linear regression accounting for clustering to estimate difference-in-differences (DIDs) for impact on husbands’ behavioral determinants and path analysis to examine how much these determinants explained the impact on women's nutrition behaviors.ResultsOf husbands in the nutrition-focused MNCH group, 62% were counseled by health workers, 66% attended a husbands’ forum, and 34% saw video shows. The nutrition-focused MNCH, compared with the standard MNCH group, resulted in greater husbands’ awareness (DID: 2.74 of 10 points), knowledge (DID: 1.31), self-efficacy and social norms with regard to optimal nutrition practices (difference: 1.08), and support to their wives (DID: 1.86). Husbands’ behavioral determinants and support explained nearly half of the program impact for maternal supplement intake and one-quarter for dietary diversity.ConclusionsA nutrition-focused MNCH program that promoted and facilitated husbands’ engagement during their wives’ pregnancies significantly improved husbands’ awareness, knowledge, self-efficacy, and support. These improvements substantially explained the program's impact on women's intake of micronutrient supplements and dietary diversity. Targeting wives and husbands and designing activities to engage men in maternal nutrition programs are important to maximize impact. This trial was registered at www.clinicaltrials.gov as NCT02745249.

The pathways through which behavior change interventions impact breastfeeding practices have not been well studied. This study aimed to examine: (1) the effects of exposure to mass media and interpersonal counseling on exclusive breastfeeding (EBF) and hypothesized psychosocial determinants (i.e. knowledge, intention, beliefs, social norms, and self‐efficacy); and (2) the pathways through which exposure to mass media and interpersonal counseling are associated with EBF. We used survey data from mothers with children < 2 year (n = 2045) from the 2013 process evaluation of Alive & Thrive's program in Viet Nam. Multiple linear regression analyses and structural equation modeling were used to estimate effects. Exposure to mass media only, interpersonal counseling only, both or neither was 51%, 5%, 19% and 25%, respectively. Exposure to both mass media and interpersonal counseling had additive effects on EBF as well as on related psychosocial factors, compared with no exposure. For example, EBF prevalence was 26.1 percentage points (pp) higher in the group that received interpersonal counseling only, 3.9 pp higher in the mass media group and 31.8 pp higher in the group that received both interventions. As hypothesized, more than 90% of the total effect of the two interventions on EBF was explained by the psychosocial factors measured. Our findings suggest that combining different behavior change interventions leads to greater changes in psychosocial factors, which in turn positively affects breastfeeding behaviors.