Silvia Alayón 20 th International Congress on Nutrition Granada, Spain September 18, 2013 Alternatives to RCTs: Evaluation of A&T’s national mass media campaign, lessons from Viet Nam

Presentation Summary Viet Nam context Mass media campaign Evaluation challenges Evaluation approaches Preliminary results Lessons learned 2

Viet Nam Background Total Population (2011): 88 million in 63 provinces 31% Urban (2011) Literacy rate: 93% (2011) Total Fertility Rate (2011): 2 children/woman Infant mortality rate (2011): 17/1,000 live births Life expectancy (2011): 75 years Television ownership (2005): 85% Weekly television viewership (2011): 92% Stunting (2010): 29% Exclusive Breastfeeding (2010): 20% 3

A&T Objectives in Vietnam Increase exclusive breastfeeding to 27.5%, from 19% in A&T areas at baseline Prevent stunting in 54,000 children Reach 2.5 million families of children under 2: – 1 million through interpersonal communication delivered at 781 IYCF franchises in 15 provinces – 1.5 million through a national mass media 4

Alive & Thrive Model 5 Evaluation of Mass Media

A&T’s behavior change model

Elements of the mass media campaign Number of TV Commercials (4) 2 promoting exclusive breastfeeding for 6 months 1 promoting consumption of iron rich foods and 1 promoting the IYCF franchises Media channels usedNational & provincial television Village loud speakers (rural) Out of home advertisement (billboards, bus wraps, etc.) Video screens in supermarkets (urban) Internet (urban) Key messagesBreastfed infants (under 6m) do not need water Nursing more will ensure sufficient breast milk Feed infants and young children iron rich foods Other messagesTarget perceptions about: benefits of breastfeeding social norms self-efficacy 7

Evaluation challenges Inability to randomize, universal coverage of national TV Many interventions occurring concurrently— policy changes*, national program, etc. 8 *Poster on Building political commitment for longer ML and marketing of BMS 5-6pm, Wednesday, Screen 6.

Four Evaluation Approaches 1.Analysis of national EBF trend 2.Constructed cohort design 3.Geographic cohort design 4.Trends & associations along the causal pathway: exposure to the campaign, behavioral determinants and EBF 9

Data Sources 10 Interim 1 4 provinces Interim 2 4 provinces Interim 3 4 provinces Mass media Campaign 1

Approach #1: Analysis of National Trend (%EBF) 11

Approach #2: Constructed cohort design Using post-campaign data (e.g. TV viewership habits, etc.) to predict the likelihood of exposure among pre-campaign respondents Based on prediction, create two cohorts from the baseline data: likely exposed and likely unexposed Disaggregate baseline data by these two groups to simulate comparable groups from the baseline data 12

Approach #3: Geographic cohort design Use natural variability in exposure among geographic areas to create areas of “high” and “low” exposure Compare trends between the “high” and “low” exposure geographic areas 13

And now for the exciting results... 14

Approach #3: Geographic cohort design Exposure to EBF campaign by district (2012) 15 n=2,065

Aggregate cohort design EBF by levels of exposure (2012) 16 n=xxxx; p<X

Aggregate cohort design EBF by levels of exposure (without MTBT) (2012) 17 n=xxxx; p<X

Approach #3: Geographic cohort design EBF by levels of exposure (without IPC) (2012) 18 n(2011)=2,344; n(2012)=2,065

Approach #4: Exploring the causal pathway Measure the level of exposure to the campaign and recall Measure behavioral determinants Measure EBF Determine associations among these 19

Exposure: A&T campaign and infant formula ads 20 n=2,305 (Aug 11) n=2,065 (Oct 12) n=2,321 (May 13)

Mothers’ recall the media messages 21 n=2,065 (Oct 12) n=2,321 (May 13)

Knowledge and beliefs have improved 22 n=2,305 (Aug 11) n=2,065 (Oct 12) n=2,321 (May 13)

Mothers’ beliefs about water are changing 23 n=2,305 (Aug 11) n=2,065 (Oct 12) n=2,321 (May 13)

Differences exist in determinants between exposed and unexposed women (May 2013) 24 n=2,321; ***p<.001

% Exclusive BF% No water 25 EBF and No water n=2,305 (Aug 11) n=2,065 (Oct 12) n=2,321 (May 13)

Summary of Findings In the four evaluation provinces: – 85% of mothers have been exposed to the campaign – Only about 1 in 3 women now believe a breastfed infant needs water – EBF has increased by 20 percentage points More rigorous analysis to: – control for possible confounders and covariates – mediating effects of behavioral determinants 26

Lessons Learned: Evaluation Building the theoretical model and documenting the approaches before collecting data ensured that we had the right data to evaluate the campaign. Analyzing the relationships between determinants and behaviors using baseline data helped us prioritize which ones to continue measuring. Planning multiple approaches guarded against unexpected data limitations (e.g. our inability to predict media exposure). 27

Acknowledgements The Bill and Melinda Gates Foundation A&T Vietnam Team National Institute of nutrition Ministry of Health ISMS Media partners - TKL, OMD and Maxus Ogilvy Vietnam UNICEF and WHO in Vietnam 28