Insert image here Good afternoon. I’m here representing Alive & Thrive and to talk about a small doable action that actually achieved an increase in an ideal behavior. International SBCC Summit| February 2016 A small doable action that achieved an increase in the “ideal” behavior: Alive & Thrive in Viet Nam

  Alive & Thrive scales up nutrition to save lives, prevent illness, and ensure healthy growth and development.   Alive & Thrive is a learning project and it was designed to answer the question: “Can we scale up nutrition?” Beginning in 2009, the Bill & Melinda Gates Foundation offered Alive & Thrive the resources and the vision to put the question to the test in 3 large countries—Bangladesh, Ethiopia, and Viet Nam. Not to keep you in suspense, the answer is a resounding “yes”—it is possible to achieve rapid, large scale behavior change. Alive & Thrive is funded by the Bill & Melinda Gates Foundation and the governments of Canada and Ireland and managed by FHI 360.

Alive & Thrive’s first 5 years Here’s a snapshot of Alive & Thrive’s first 5 years. Between 2009 and 2014, A&T applied 4 program components in 3 countries and reached an estimated 16 million mothers of children under 2 through interpersonal communication and/or mass media. Yes: A&T was able to deliver behavior change interventions at scale.

Rapid, large-scale improvements in breastfeeding are possible And, as an example of the kinds of behavior change the external evaluation of Alive & Thrive detected, in all 3 countries exclusive breastfeeding increased significantly. In Viet Nam, the orange line on this graph, where the baseline was only 19%, the rate tripled in four years of program implementation (from 2010 to 2014). And rates reached more than 80% in Bangladesh and Ethiopia.

Framework for scaling up behavior change programs 1 2 3 How did we do it? This is Alive & Thrive’s framework for scaling up infant and young child feeding, and we believe it can be adapted to other behavior change programs. The framework includes four main program components, numbered on this slide: advocacy, interpersonal communication and community mobilization, mass communication, and strategic use of data. And our program design engages not only mothers and caregivers but other members of society who are important influencers of mothers’ feeding practices: policymakers, employers, service providers, community leaders, and families. Note that mass communication reaches across all of these audiences, and that today I’ll be talking about a single TV spot. 4

Exclusive breastfeeding 5 small doable actions = the ideal behavior Give breastmilk Do not give water Do not give infant formula Do not give other liquids Do not give semisolid or solid food One of the most important practices to save babies’ lives and increase growth and development is what we refer to as “exclusive breastfeeding”—giving breastmilk and only breastmilk. WHO recommends this practice for the first 6 months. Exclusive breastfeeding is not a behavior in itself, but a cluster of behaviors—or small doable actions. To achieve this ideal “behavior,” a mother really is doing (or NOT doing) 5 things: Giving breastmilk Not giving water Not giving infant formula Not giving other liquids and Not giving semisolid or solid food Alive & Thrive’s interpersonal communication addressed many aspects of breastfeeding, but for a 45-second TV spot, we wanted to narrow things down to the most strategic choice of ONE small doable action.

Not giving water would potentially double exclusive breastfeeding Viet Nam, baseline, 2010 It turns out that of the 5 small doable actions that make up exclusive breastfeeding, there IS ONE that could have the greatest impact. Here’s a graph that shows baseline prevalence of these feeding practices over the first 6 or 7 months of babies’ lives. This is not the easiest graph to understand, so let me walk you through it. Across the bottom of the graph, you see the age, in months, of the child. The colored bands running across the graph show the percentage of babies in each month-age cohort who are fed by each method – that is, the small doable actions I just mentioned. The dark green swath at the bottom of the graph represents exclusive breastfeeding. If 100% of babies were exclusively breastfed for 6 months, the IDEAL behavior, this entire graph would be dark green. Instead, it starts out low and drops of quickly. You can see that for the youngest month-cohort, at the left-hand side of the graph, EBF was at about 40%. Moving to the right, we see that by 2-3 months that drops to about half of that, and by 4-5 months hardly any babies are given only breastmilk. Now look at the next swath up. That is babies who receive only breastmilk + plain water. At almost any point in time, the number of mothers giving only breastmilk + water is about the same as those giving only breastmilk, meaning that if we could help ALL of those mothers to stop giving water, we would double the percentage of exclusively breastfed babies. By contrast, those who are receiving breastmilk + infant formula are represented by the very narrow white band. Even if we helped ALL those mothers to stop giving formula, we’d have a pretty small impact on EBF, or exclusive breastfeeding. We were fortunate, then, to have quantitative data that showed us that ONE small doable action could have a large impact on the ideal behavior. [IN CASE OF A QUESTION ABOUT THIS: The large light green swath on the right, as babies are older—is food that’s replacing breastmilk.]

Behavior change model for “No Water” TV spot Our theory of behavior change hypothesized that if mothers (and others) were exposed to our “No water” TV spot, it would change the knowledge, beliefs, and attitudes listed here in the second column. Those changes would support the small doable action of “do not give water for 6 months,” and that change, in turn, would result in increases in the ideal behavior, exclusive breastfeeding.

“No water” TV spot, Viet Nam Take 40 seconds now to see the “No water” TV spot.

EBF and No water % Exclusive BF % No water The hypothesis was correct. Our evaluation of the mass media campaign shows that exposure to the TV spots is associated with increased exclusive breastfeeding. The green line shows changes over time among women who were exposed to the TV spots—at times 2 and 3, after the campaign was on the air. The blue line is women who were unexposed. At time 2, just after the first TV burst, you see an initial “bump” among unexposed women, but those gains were not sustained as in the exposed group. [Click to show second graph] The trend in the percentage of mothers that do not give water mimics the trend we’re seeing in EBF, so we know that increases in that particular small doable action are contributing to the exclusive breastfeeding result. Women who are exposed to the campaign are more likely to withhold water and thus more likely to exclusively breast feed. It’s rare to have the data to show what can happen if you choose the right small doable action. We’re pleased to add this example to today’s debate. n=2,305 (Aug 11) n=2,065 (Oct 12) n=2,321 (May 13)

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