Published in the Journal of Human Lactation (Vol. 21, No. 3, pps. 345-354), this article examines the strategies and successes of large-scale community-level, communication-centred programmes designed to improve breastfeeding practices in Bolivia, Ghana, and Madagascar. The case study illustrates the way in which sizeable improvements in optimal breastfeeding can be achieved at scale and within a relatively rapid time frame using a multi-faceted, communication-focused approach, tailored specifically to meet the demands of each specific country in which the approach was implemented. In short, the resource explores how and why focusing on breastfeeding practices on a large-scale level - and using communication strategies to do so - is "feasible and should be a central component of any child survival strategy."

As detailed here, in recognition of the finding that exclusive breastfeeding (EBF) in the first 6 months of life and continued breastfeeding from 6-11 months is "the single most effective preventive intervention in reducing child mortality", in 1996 the United States Agency for International Development (USAID) issued a grant to the Academy for Educational Development (AED) to design and implement a 10-year programme - the LINKAGES Project, to improve breastfeeding practices rapidly and at scale. This resource details the progress made by LINKAGES, which ended in December 2006, and its partners to increase the timely initiation of breastfeeding (TIBF) - primarily among mothers with young infants in resource-poor settings - in these 3 countries through strategies built on 4 core components: partnerships, training, behaviour change communication (BCC), and community activities.

Rather than approach breastfeeding promotion as a vertical programme, in each of the 3 countries LINKAGES set out to integrate breastfeeding in broader nutrition, child survival, and reproductive health programmes as well as in relevant non-health programmes. Key elements of this strategy, which are described in detail in the resource, include:

1. Partnership-building - From the outset, partners were involved in all aspects of programme design and implementation - e.g., reviewing and interpreting formative research, developing key messages, pre-testing materials, co-facilitating training sessions, and monitoring and evaluating activities. Specifically,
   
   
   • In Bolivia, LINKAGES worked with 16 members of the national network PROCOSI, and government health workers collaborating with partner non-governmental organisations (NGOs) got involved in training sessions and community events. Local radio stations were contracted to broadcast the programme's jingles and stories.
   • In Ghana, a variety of partners participated in the effort; in addition, early on, journalists, radio announcers from 3 stations in the north, staff from 2 universities, and members of the Food and Nutrition Security Network participated in workshops that shaped the design of the programme and its field approach.
   • In Madagascar, one of the partnering mechanisms was the Intersectoral Action Group for Nutrition (the GAIN); LINKAGES assisted the government and other local groups, including donors, to establish the GAIN to harmonise nutrition messages and field approaches and share experiences. A national female singing celebrity, local newspaper journalists, and more that 20 local radio stations also disseminated messages.

2. Capacity-building - In all 3 countries, training materials were developed to meet the specific, short-term, and practical needs of service providers and community volunteers, with an eye to fostering negotiation skills necessary to convince mothers to change their infant-feeding behaviours. The sessions engaged participants in discussions of key messages, role-plays, demonstrations, and practice in the use of materials such as counselling cards, child health booklets, cloth flipcharts, and posters during individual counselling and group sessions.
3. Behaviour change communication (BCC) - The intention in the 3 countries was to change individual behaviour while educating and engaging others, such as fathers and grandmothers, who influence the individual's (usually the mother's) choices. "Targeted, concise messages" were developed to promote "do-able" actions, and "edutainment" strategies dominated. For instance,
   
   
   • In Bolivia, a nationwide radio campaign developed to complement the programme's activities at the community level, included 6 radio spots, 4 radio dramas, and 5 songs in 3 languages (Spanish, Aymara, and Quechua).
   • In Ghana, local radio announcers who were involved in the programme's design and training activities used a variety of formats such as songs, soap operas, radio call-in shows, quizzes, dramatic comedies, panel discussions with local nutrition experts, and advice from community leaders; intensive radio campaigns were launched every year during World Breastfeeding Week.
   • In Madagascar, radio announcers from national and local stations received training in infant and young child feeding to prepare them to promote these issues during their broadcasts along with breastfeeding promotion jingles. Partner radio stations broadcast 6 to 10 spots each day during the "mass campaign months" that were held every quarter. Similar spots were played on cassettes that were distributed to bus and taxi drivers in programme
     areas.

4. Community activities - Women were reached through small- and large-group activities, one-on-one counselling in homes and at local health posts, breastfeeding promotion songs performed by women's groups and musical troupes, and community mobilisation events such as local theatre, health fairs, and festivals celebrating breastfeeding and child health days. Celebration of success through village festivals, healthy baby contests, and "nutrition certificates" for families with optimally fed babies were drawn upon to fuel enthusiasm in the communities. A key communication strategy highlighted here is the value of peer group support and interaction.

In each country programme, an overall monitoring and evaluation system was established to provide data to track progress and use in programme management. Survey methodology and sampling for each country is outlined in the case study. Results are detailed as well; in short, these programmes reached sizable populations: Bolivia, 1 million; Ghana, 3.5 million; and Madagascar, 6 million. Over 3 to 4 years, TIBF (within 1 hour of birth) increased from 56% to 74% (P < .001) in Bolivia, 32% to 40% (P < .05) in Ghana, and 34% to 78% (P < .001) in Madagascar. Marked increases in exclusive breastfeeding of infants 0 to 6 months of age were also documented: from 54% to 65% (P < .001) in Bolivia, 68% to 79% (P < .001) in Ghana, and 46% to 68% (P < .001) in Madagascar. In Ghana and Madagascar, significant results were seen within 1 year of community interventions.

The authors suggest that a mix of activities, such as interpersonal counselling, community mobilisation, and mass media, contributes to behaviour change when these activities deliver consistent messages. Linking health workers and community health promoters (particularly for referral) is one strategy endorsed here for fostering mothers' receipt of consistent messages. In addition to harmonising approaches and messages through partnership and community involvement, the authors note that advocacy is key - creating an overall positive policy environment for breastfeeding and nutrition through effective policy analysis.

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