"Stronger with Breastmilk Only Initiative" in 5 African Countries: Case Study on the Implementation Process and Contribution to the Enabling Environment for Breastfeeding

"[T]here is an evidence gap on the implementation process to better understand how various integrated interventions to address nutrition problems can be implemented together..."

The practice of giving water before 6 months of age is the biggest barrier to exclusive breastfeeding (EBF) in West and Central Africa. To address this challenge, a social and behaviour change communication (SBCC) initiative, "Stronger with Breastmilk Only" (SWBO), was rolled out in several countries of the region. This paper presents insights from the SWBO regional initiative in 5 African countries and the contribution of its advocacy component to a more supportive environment for breastfeeding policies and programmes.

The underpinnings of the initiative, which is described in more detail at Related Summaries, below, were based on a recognition that changes must occur at multiple levels in order to tackle BF determinants. To that end, SWBO was designed with a package of interventions that combined various communication activities employing multiple channels to influence people at all levels of the socio-ecological model. The initiative included policy advocacy, health systems strengthening (with a focus on provider behaviour change), and mass media campaigns for social change and community engagement. Messaging emphasised the need for greater attention to the protection, promotion, and support of EBF. Governments and partners in the region were invited to adapt the initiative to their own national context and to integrate it into existing nutrition programmes and platforms to facilitate scaling up and sustainability.

This study was based on 2 assessments at the national level carried out in 5 countries (Burkina Faso, Chad, Democratic Republic of the Congo (DRC), Senegal, and Sierra Leone) using qualitative methods. The researchers combined 2 evaluative approaches (contribution analysis and outcome harvesting) and applied 2 theoretical lenses to examine the implementation process and the enabling environment for breastfeeding: (i) the Breastfeeding Gear Model (BFGM), which consists of 8 gears and is based on the premise that strong advocacy is needed to generate political will and enable the adoption of laws and policies that protect, promote, and support BF, and (ii) the implementation process domain of the updated Consolidated Framework for Implementation Research (CFIR), which involves 9 constructs (teaming, assessing needs, assessing context, planning, tailoring strategies, engaging, doing, reflecting & evaluating, and adapting). Data sources included about 300 documents related to the initiative and 43 key informant interviews collected between early 2021 and mid 2022.

First, by applying part of the updated CIFR lens to the SWBO initiative, the researchers show how this broad initiative composed of a set of combined interventions targeting multiple levels of determinants of breastfeeding was set up and implemented. All countries went through a similar pattern of activities for the implementation process; in all cases, the process was inclusive in the sense that a number of actors from various levels were engaged along the way. For example, in the CIFR construct "doing", the 5 countries initiated multiple activities, including: (i) sensitising policymakers, updating the decrees of the International Code of marketing of Breast-milk Substitutes (The Code), and conducting awareness-raising for parliamentarians; (ii) building the capacity of health providers on EBF and early initiation of BF, integrating SWBO messages into job aids, and offering training of trainers; or (iii) mobilising community or religious leaders, training journalists and reporters, diffusing messages through mass media, and mobilising champions.

Second, by applying the lens of the BFGM, the researchers illustrate that SWBO was able to foster an enabling environment for BF. Each of the 8 gears of an enabling environment for BF were influenced by the initiative, but progress was achieved notably on legislation and policies, coordination, funding, training and programme delivery, and research and evaluation. For example, the initiative engaged policymakers in various activities that helped raised awareness of the importance of EBF. High-level actors expressed their commitment actively by participating in public events such as launches at national or regional levels or by speaking in favour of the initiative in press conferences, TV and radio shows, and other forums. The initiative has gained a lot of visibility and political capital and thus delivered high-level commitment to BF. The researchers note that the strength of this initiative is that it does not target just a few aspects but, rather, a cohesive set of gears that work harmoniously and, together, contribute to the achievement of an enabling environment for BF.

Third, by outlining a theory of change (ToC) and applying a contribution analysis - in the form of a detailed case study of Burkina Faso - the researchers illustrate more specifically how the initiative (specifically, its advocacy component) contributed to this progress.

• Linkage 1: Activities/ouputs to proximal outcomes: In Burkina Faso, the SWBO initiative was set up and implemented with the efforts of a working group that included the Ministry of Health's Directorate of Nutrition (DN), Alive and Thrive (A&T), and UNICEF. The engagement of key stakeholders was achieved through the development of a national SWBO strategy, the organisation of advocacy meetings, and some training, as described in the paper.
• Linkage 2: Proximal outcomes to distal outcomes: Once mobilised, the various actors worked together to make progress on BF. This resulted in: increased resources allocated to BF; an improved coordination of BF efforts; the advancement of the agenda around BF promotion, support, and protection; the strengthening of BF norms; and a reinforcement of the monitoring of BF programmes.

The evidence presented here leads the researchers to affirm (i) that the advocacy and partnership activities contributed significantly to the commitment of the various stakeholders that was achieved throughout the implementation of the SWBO and (ii) that their subsequent mobilisation contributed to strengthening the policy and programmatic environment for EBF in Burkina Faso. They stress that advocacy and partnership activities were carried out multiple times throughout the initiative and preceded progress for almost each of the BFGM's gears. This finding highlights the importance of advocacy and partnership activities to progress towards an enabling environment for BF.

Thus, this study has shed light on how an initiative combining a set of interventions to address determinants of BF at multiple levels can be implemented regionally and contributes to fostering an enabling environment for BF at scale. "The SWBO initiative has acted as an umbrella for a set of effective interventions for BF, which has given a new impetus to EBF and caught the attention of many actors in the countries. This initiative provided an opportunity to repackage and rebrand EBF and send messages in a new unified way at the regional level."

In concluding, the researchers urge more countries to engage "increasingly and explicitly in such complex and multi-levels interventions to be more effective in protecting, supporting and promoting BF. This is critical to overcome the challenges brought by an aggressive formula milk industry for which the value has skyrocketed globally....Unethical marketing practices have been effective in increasing the use of formula, to a point at which we are experiencing an unprecedented and worrying...transition towards diets higher in infant formula that is expected to continue to rise..."