Exploring how and why Care Groups work to improve infant feeding practices in low- and middle-income countries: a realist review protocol

Abstract

Background Within our inquiry into the implementation of breastfeeding policy in Malawi, Care Groups have been mentioned as a means to improve maternal and child health and nutrition outcomes. The ‘Care Group model’ is an approach primarily used in international development settings, whereby social and behaviour changes are promoted through supported peer-to-peer (mostly mother-to-mother) knowledge sharing. The aim of most Care Groups is to promote improved infant nutrition, improve hygiene and increase the number of children who are fully vaccinated and exclusively breastfed for the first 6 months. The behavioural changes promoted by Care Groups (such as safe infant feeding, frequent hand washing, consistent mosquito net usage, providing suitable complementary foods from 6 months old) have the potential of averting preventable deaths particularly among children under five. While a variety of approaches are used to promote improved health and nutrition for children under five, the Care Groups model was best known and frequently referenced during our discussions with key stakeholders regarding the delivery at community level of Malawi’s National Multi-Sector Nutrition Policy 2018-2022. A better understanding of how Care Groups achieve their social and behaviour change results and how community-based efforts are sustained can potentially help to ensure more effective planning and budgeting for Care Group interventions and enable greater sustainability and increased coverage of infant feeding support countrywide. This realist review is designed to improve our understanding of how, why, to what extent and under what circumstances Care Groups improve infant feeding practices in low- and middle-income countries (LMICs). Methods and analysis A realist review is a theory-driven approach to evidence synthesis. To undertake this realist review, we will gather evidence by conducting peer-reviewed and grey literature database searches in order to find peer reviewed articles, programme guidelines and evaluation reports, among other texts, associated with the implementation of Care Groups in low- and middle-income countries. Our review process has five key steps: (1) locating existing theories; (2) searching for evidence in literature; (3) selecting articles and other suitable evidence; (4) extracting data, identifying configurations of context-mechanism-outcomes; and (5) synthesising the evidence, drawing conclusions. Discussion The results of this realist review will be written up according to RAMESES guidelines and disseminated through a stakeholder workshop in Malawi, through conference presentations and peer-reviewed publications. It is intended to improve the understanding of the potential and limits of working through Care Groups globally and among relevant Malawi Ministry of Health staff and the donor and NGO community, both internationally and within Malawi. This systematic review protocol has been submitted for registration on the PROSPERO database (receipt number: 170261).

What are the mechanisms and contexts by which care groups achieve social and behavioural change in low- and middle-income countries? Group motivation findings from a realist synthesis

“…The realist synthesis we conducted followed the steps set out in our research protocol. 23 These, are comprised of: i. developing our initial programme theories (IPTs): a series of statements that describe components of the intervention under study, and how we hypothesise that each will bring about change. We started out with a small number of IPTs but added additional programme theories during the data extraction phase.…”

“…Sample search strategies and sample results can be found in supplementary file 1. As we described in the protocol for this synthesis, (23) there were challenges with the search as the terms 'Care' and 'Groups', and even 'Care Groups' are used in many different ways and contexts. As can be seen in the sample searches included, we specifically searched for articles using key terms for the intervention (Care Group, and variations), the focus of the intervention (nutrition, behaviour change, infant feeding etc.)…”

“…(22) This paper aims to answer the first question contained in our research protocol: "What are the mechanisms and contexts by which Care Groups achieve social and behavioural change?" (23) This study fills a knowledge gap in relation to understanding of why, how, and under what circumstances Care Group programmes achieve their outcomes. It provides insights into how community-based volunteers can be motivated and how this motivation can be sustained over time.…”

Improving breastfeeding support through the implementation of the baby friendly hospital and community initiatives: a scoping review protocol

“…The research aims and objectives for this scoping review were developed iteratively through discussions between the research team and were informed by the pilot search of the literature. The proposed review is situated within a wider research project, which is evaluating the implementation of evidence-based policy on infant feeding in Malawi 17 , focused on exclusive breastfeeding for the first six months. In Malawi, the BFHI has been a well-known vehicle for the improvement of exclusive breastfeeding promotion in hospitals and health facilities since 1993, and as recent as 2018, several externally funded initiatives have been implemented to revive the BFHI, provide training for healthcare staff and accreditation for baby-friendly hospitals 6 .…”

Improving breastfeeding support through the implementation of the baby friendly hospital and community initiatives: a scoping review protocol

“…The research aims and objectives for this scoping review were developed iteratively through discussions between the research team and were informed by the pilot search of the literature. The proposed review is situated within a wider research project, which is evaluating the implementation of evidence-based policy on infant feeding in Malawi 27 , focused on exclusive breastfeeding for the first six months. In Malawi, the BFHI has been a well-known vehicle for the improvement of exclusive breastfeeding promotion in hospitals and health facilities since 1993, and as recent as 2018, several externally funded initiatives have been implemented to revive the BFHI, provide training for healthcare staff and accreditation for baby-friendly hospitals 6 .…”