Using cognitive-behavioural techniques to improve exclusive breastfeeding in a low-literacy disadvantaged population

Development of a Digital Platform to Promote Mother and Child Health in Underserved Areas of a Lower-Middle-Income Country: Mixed Methods Formative Study

Background

Primary health care (PHC) is the backbone of universal health coverage, with community health workers (CHWs) being one of its critical pillars in lower-middle-income countries. Most CHW functions require them to be an efficient communicator, but their program development has been deficient in this area. Can IT provide some solutions? Moreover, can some IT-based CHW-delivered innovations help mothers and children in areas not covered by PHC services? We explored these questions during the development and feasibility testing of a digital application designed to improve the communication capacity of CHWs in two underserved areas of Islamabad.

Objective

This study aims to explore the perceptions, practices, and related gaps about mother and child health, and child development in an underserved area; develop and deploy a behavior change communication program to address the gaps; and assess the feasibility of the program.

Methods

We carried out a mixed methods study with three steps. First, we conducted 13 in-depth interviews and two focus group discussions with stakeholders to explore the issues faced by mothers living in these underserved areas. To address these barriers, we developed Sehat Ghar, a video-based health education application to demonstrate practices mothers and families needed to adopt. Second, we trained 10 volunteer CHWs from the same community to deliver health education using the application and assessed their pre-post knowledge and skills. Third, these CHWs visited pregnant and lactating mothers in the community with random observation of their work by a supporting supervisor.

Results

Initial exploration revealed a need for health-related knowledge among mothers and suboptimal utilization of public health care. Sehat Ghar used behavior change techniques, including knowledge transfer, enhancing mothers' self-efficacy, and improving family involvement in mother and child care. Volunteer CHWs were identified from the community, who after the training, showed a significant improvement in mean knowledge score (before: mean 8.00, SD 1.49; after: mean 11.40, SD 1.43; P<.001) about health. During supportive supervision, these CHWs were rated as excellent in their interaction with mothers and excellent or very good in using the application. The CHW and her community reported their satisfaction with the application and wanted its delivery regularly.

Conclusions

Sehat Ghar is a simple, easy-to-use digital application for CHWs and is acceptable to the community. Mothers appreciate the content and presentation and are ready to incorporate its messages into their daily practices. The real-world effectiveness of the innovation tested on 250 mother-infant pairs will be important for its proof of effectiveness. With its usefulness and adaptability, and the rapidly spreading use of mobile phones and internet technology, this cost-effective innovation can help in delivering health communications at a large scale in a minimum amount of time.

Lessons for the UK on implementation and evaluation of breastfeeding support: evidence syntheses and stakeholder engagement

Background

Breastfeeding impacts positively on multiple health outcomes, but < 50% of UK women breastfeed at 8 weeks. Women with long-term conditions face additional challenges in breastfeeding.

Objectives

To synthesise global and UK evidence to co-create an implementation and evaluation toolkit for cost-effective breastfeeding support in the NHS.

Design

Evidence syntheses with stakeholder engagement.

Review methods

Systematic reviews examined effectiveness of breastfeeding support for (1) healthy women and (2) women with long-term conditions using Cochrane Pregnancy and Childbirth Group methods. Mixed-methods systematic reviews synthesised process evaluations of effective breastfeeding support interventions for healthy women and experiences of receiving/providing support for breastfeeding women with long-term conditions. Cross-study synthesis integrated qualitative and quantitative findings. Systematic reviews synthesised evidence on the incremental costs and cost-effectiveness of breastfeeding support following National Institute for Health and Care Excellence guidance. All searches were conducted from May 2021 to October 2022. Stakeholder engagement and toolkit development comprised online discussions, a modified Delphi study, focus groups and four workshops. Participants were 23 stakeholders, 16 parents in the parents' panels, 15 women in the focus groups and 87 stakeholders who attended the workshops.

Results

We found considerably more interventions designed for healthy women (review 1) than aimed at women with long-term conditions (reviews 1 and 4); approximately half of the studies were targeted at groups at higher risk of poor breastfeeding outcomes, and the impact of support may be different in these populations. Despite this, studies from review 2 found that women perceived the provision of support as positive, important and needed. Studies from review 5 echoed a range of suggestions from participants regarding potential strategies to improve breastfeeding support, with the most widely reported being the need to acknowledge the role and influence of other sources of support (e.g. partners, family, friends, peers, external professionals, web-based resources) and involving these sources in the provision of breastfeeding support for women with long-term conditions. In reviews 3 and 6, there was uncertainty about the cost-effectiveness of breastfeeding support interventions due to the limited number of studies and lack of good-quality evidence.

Limitations

There was a lack of evidence for the effectiveness and cost-effectiveness of breastfeeding interventions in the UK. There was often insufficient information reported about intervention characteristics.

Conclusions

'Breastfeeding only' support probably reduces the number of women stopping any or exclusive breastfeeding. The evidence for 'breastfeeding plus' interventions is less consistent, but these may reduce the number of women stopping exclusive breastfeeding at 4-6 weeks and at 6 months. We found no evidence of differential intervention effects regarding mode of provision or provider. Cost-effectiveness is uncertain due to the lack of good-quality evidence. Key enablers of successful implementation were responsiveness and tailoring of interventions to both women's and supporters' needs. Breastfeeding support as delivered in the included studies probably has little to no effect on breastfeeding outcomes for women with long-term conditions. The mixed-methods synthesis and stakeholder work identified that existing interventions may not address the complex needs of these women. The main study output is a co-produced toolkit to guide implementation and evaluation of breastfeeding support services in the UK.

Future work

Evaluation of breastfeeding support for all women, particularly those at risk of poor breastfeeding outcomes (e.g. long-term conditions, deprivation). This could involve tailoring the toolkit to local contexts via implementation and effectiveness studies or using quality improvement studies.

Study registration

This study is registered as PROSPERO CRD42022337239, CRD42021229769 and CRD42022374509. The reviews of economic evidence were not registered; however, the review protocol can be accessed via the repository held by Queen's University Belfast Research Portal (https://pure.qub.ac.uk/).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR130995) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 20. See the NIHR Funding and Awards website for further award information.

The effect of counseling with cognitive behavior approach on self-esteem and body image in lactating mothers: randomized clinical trial

BACKGROUND

Some of the women experience low self-esteem and negative body image in pregnancy and postpartum. These two factors along with other factors can reduce the rate of exclusive breastfeeding among women. Cognitive-behavior therapy (CBT) is one of the psychological approaches that is effective on the betterment of many of the psychological and personality disorders such as body image disorders as well as improvement of self-esteem. The aim of this randomized control trial is to recognize the effects of CBT during pregnancy period on self-esteem, body image (primary outcome) and exclusive breastfeeding (secondary outcome).

METHOD

In this randomized controlled trial, 70 eligible pregnant women referring to health centers of Tabriz- Iran were assigned to two groups of 35 as intervention and control groups using randomized blocking method. For intervention group, 8 sessions of CBT based on Cash and Strachan's body image protocol and Michael Free's for self-esteem were performed. Control group was received routine pregnancy care by their health provider. Rosenberg self-esteem scale and multidimensional body self-relation questionnaire (MBSRQ) were completed before intervention, immediately after intervention and 4 weeks after delivery. Likewise, exclusive breastfeeding questionnaire was completed 4 weeks after childbirth. Independent t-test, chi square and repeated measures ANOVA tests were used to analyze the data.

RESULTS

According to repeated measures ANOVA test and with controlling baseline score, the mean scores on self-esteem (AMD): 7.18; 95%confidence interval (CI): 4.43 to 9.94; p < 0.001)) and body image (AMD: 49.74; 95%CI = 28.57 to 70.91; p < 0.001) in the intervention group were significantly higher than the control group. Also, after intervention, the mean score of body image subscales including appearance evaluation (p = 0.010), appearance orientation (p = 0.001), fitness evaluation (p = 0.004), fitness orientation (p = 0.001), health evaluation (p = 0.001), health orientation (p = 0.018), and illness orientation (p = 0.002) was significantly higher in the intervention group than the control group.

CONCLUSIONS

CBT was effective on the improvement of self-esteem and body image and through which might lead to the increase of exclusive breastfeeding among women.

TRIAL REGISTRATION NUMBER

IRCT20110524006582N33. First Date of registration: 17/10/2022. Submission ID 4ca86cd4-8459-4b86-9fe5-63f6a8184956.

Promising trends and influencing factors of complementary feeding practices in Côte d'Ivoire: An analysis of nationally representative survey data between 1994 and 2016

Poor complementary feeding (CF) challenges early childhood growth. We examined the trends and influencing factors of CF practices among children aged 6-23 months in Côte d'Ivoire. Using data from Demographic and Health Surveys (DHS, 1994-2011) and Multiple Indicator Cluster Surveys (MICS, 2000-2016), the trends and predictors of World Health Organization-United Nations International Children's Emergency Fund CF indicators including the timely introduction of complementary foods (INTRO), minimum meal frequency (MMF), minimum dietary diversity (MDD) and minimum acceptable diet (MAD) were determined. Using 2016 MICS data, we applied multivariate logistic regression models to identify factors associated with CF indicators. Between 1994 and 2016, the mean proportion of children aged 6-8 months achieving INTRO was 56.9% and increased by about 25% points since 2006. Over 2011-2016, the proportion of children aged 6-23 months meeting MMF, MDD and MAD increased from 40.2% to 47.7%, 11.3% to 26.0% and 4.6% to 12.5%, respectively. Older children and those from urban households had higher odds of meeting MDD and MAD. Maternal TV watching was associated with higher odds of meeting MDD. The secondary or higher education levels of mothers significantly predicted higher odds of meeting INTRO and MDD. Currently, breastfeeding was also positively associated with odds of meeting MMF and MAD. Children from poorer households had lower odds of meeting MMF, MDD and MAD. Despite the improvements, CF practices remain suboptimal in Côte d'Ivoire. Influencing factors associated with CF were distributed across individual, household and community levels, calling for future programmes and policies to implement multi-level strategies to improve young children's diet in Côte d'Ivoire.

A mixed-methods study on the dietary practices of early postpartum women during the summer rainy season in Belgaum, Karnataka, India

The current mixed-method study uses Food Frequency Questionnaires and 24-hour dietary recalls (n = 41) to assess the food/nutrient intake; and qualitative interviews to identify local perceptions of food among 41 early postpartum women in Belgaum, India. The results show that total energy, protein, and most micronutrient intake were significantly lower than the Recommended Dietary Allowance of India (p < .05 individually); ninety percent of mothers restricted the consumption of some specific fruits, vegetables, and other foods during postpartum due to their perceptions of foods, folk medicines, and health beliefs. Culturally sensitive programs relevant to postpartum diet practices for women should be implemented.

Barriers and facilitators to exclusive breastfeeding in rural Pakistan: a qualitative exploratory study

Background

Exclusive breastfeeding (EBF) of children until six months of age is considered one of the most critical interventions in tackling childhood undernutrition. EBF rates are suboptimal in Pakistan, particularly in rural areas where child undernutrition is most prevalent. This study aimed to explore barriers to EBF in a rural context of Pakistan.

Methods

The study was conducted in the rural district Matiari of Sindh, Pakistan, during Jan-March 2020. We used a qualitative exploratory study design and conducted 36 focus group discussions (FGDs). Participants were purposively selected mothers who had not practiced EBF during their previous childbirth, their spouses and mothers-in-law, and lady health workers (LHWs) serving in the study catchment. FGDs were audio-recorded, transcribed, and translated into English from the local language and analysed using thematic content analysis.

Results

Barriers to EBF included low awareness and cultural practices of prelacteal feeds, insufficient breast milk production, undernutrition of mothers, mothers’ occupation as fieldworkers, less birth spacing, low awareness about the correct technique of breastfeeding, maternal and child ailments, abnormal breasts, and influence of in-laws to start top-up feeds. Several facilitators were identified: family support, appropriate maternal diet, maternal awareness, and support in the neighborhood.

Conclusion

Barriers to EBF are multifaceted in rural areas, and interventions aiming to improve adherence to EBFshould be multipronged. Awareness-raising alone might not be sufficient, and other interventions should be designed to address the barriers of maternal malnutrition, insufficient milk production, and socio-cultural practices. In addition, safe alternatives to breast milk may be necessary if breastfeeding is truly not feasible. Lack of breast milk substitutes is particularly challenging for poor rural women who cannot afford infant formula milk.

The effect of electronic job aid assisted one‐to‐one counselling to support exclusive breastfeeding among 0–5‐month‐old infants in rural Bangladesh

Exclusive breastfeeding (EBF) for the first 6 months has established benefits, yet had slow improvements globally. Little is known about electronic job aid‐assisted counselling to support EBF. As a secondary outcome of a cluster randomized controlled trial in Bangladesh, we assessed the effect of electronic job aid‐supported nutrition counselling and practical demonstration on EBF. We randomized pregnant women to one of five study arms in the trial and followed mother–child dyads until 2 years of age. Community health workers (CHWs) provided breastfeeding counselling with or without prenatal and complementary nutrient supplements in all four intervention arms. The comparison arm continued with the usual practice where mothers could receive nutrition counselling at routine antenatal and postnatal care, and during careseeking for childhood illnesses. We assessed breastfeeding indicators at birth and monthly until the child was 6 months old, in both intervention and comparison arms. To evaluate the effect of nutrition counselling on breastfeeding, we combined all four intervention arms and compared them with the comparison arm. Intervention newborns had half the risk (relative risk [RR]: 0.54, 95% confidence interval [CI]: 0.39, 0.76) of receiving prelacteal feeds than those in the comparison arm. EBF declined steeply in the comparison arm after 3 months of age. EBF was 16% higher in the intervention than the comparison arm at 4 months (RR: 1.16, 95% CI: 1.08, 1.23) and 22% higher at 5 months of age (RR: 1.22, 95% CI: 1.12, 1.33). Maternal background and household characteristics did not modify the intervention effect, and we observed no difference in EBF among caesarean versus vaginal births. Breastfeeding counselling and practical demonstration using an electronic job aid by CHWs are promising interventions to improve EBF and are scalable into existing community‐based programmes.

Using an electronic job aid, repeated, one‐to‐one counselling and practical demonstration to mothers by locally recruited CHWs reduced prelacteal feeding and improved EBF practice by delaying the early introduction of complementary food.

The positive effect of counselling on EBF remains similar with or without nutrient supplementation.

Electronic job aid supported counselling to promote breastfeeding should be integrated into existing community‐based maternal and child health programmes.

Feasibility of a birth-cohort in Pakistan: evidence for better lives study

Background

Evidence for Better Lives Study Foundational Research (EBLS-FR) is a preliminary endeavor to establish the feasibility of a global birth cohort, and within this feasibility study, piloting the research instrument, with participants from eight lower middle-income countries across the globe. It aims to investigate mediators and moderators of child development and wellbeing; it envisages informing policy and practice change to promote child health and wellbeing globally. Pakistan is one of the resource poor lower middle-income country (LMIC) taking part in this global birth cohort; we report the feasibility of establishing such a birth cohort in Pakistan.

Method

From March 2019 to July 2019, 153 third trimester pregnant women were identified, using community health worker registers, and approached for baseline demographics and a number of maternal wellbeing, mental health, support-related information, and stress-related biomarkers from bio-samples in a peri-urban area of Islamabad Capital Territory. One hundred fifty of these women gave consent and participated in the study. From October 2019 to December 2019, we re-contacted and were able to follow 121 of these women in the 8–24 weeks postnatal period. All interviews were done after obtaining informed consent and data were collected electronically.

Results

One hundred fifty (98.0%) third trimester pregnant women consented and were successfully interviewed, 111 (74.0%) provided bio-samples and 121 (80.6%) were followed up postnatally. Their mean age and years of schooling was 27.29 (SD = 5.18) and 7.77 (SD = 4.79) respectively. A majority (82.3%) of the participants were housewives. Nearly a tenth were first time mothers. Ninety-two (61.3%) of the women reported current pregnancy to have been unplanned. Overall wellbeing and mental health were reported to be poor (WHO-5 mean scores 49.41 (SD = 32.20) and PHQ-9 mean scores 8.23 (SD = 7.0)). Thirty-eight (21.8%) of the women reported four or more adverse childhood experiences; 46 (31.3%) reported intimate partner violence during their current pregnancy. During the postnatal follow up visits, 72 (58.0%) of the women reported breastfeeding their infants.

Conclusion

The foundational research demonstrated that Pakistan site could identify, approach, interview, and follow up women and children postnatally, with a high response rates for both the follow up visits and bio-samples. Therefore, a future larger-scale pregnancy birth cohort study in Pakistan is feasible.

Health Literacy and Associated Outcomes in the Postpartum Period at Grady Memorial Hospital

OBJECTIVES

Many studies correlate lower health literacy with poorer health outcomes and inferior provider-patient communication. Little is known about how impaired health literacy among women receiving prenatal care at inner city public hospitals may impact reproductive health behaviors and outcomes. The objective of this study was to assess health literacy among postpartum women receiving care at a public tertiary care center and to explore the association of impaired health literacy with prenatal care attendance and postpartum outcomes.

METHODS

Written consent was obtained before completing the 7-item REALM-SF study tool to assess health literacy. A score of zero to three indicated low health literacy, four to six moderately low health literacy, and seven adequate health literacy. Patients completed a 25-item demographic questionnaire, and medical outcomes were obtained via this questionnaire and chart review. Descriptive statistics were generated, and bivariate and multivariate analyses evaluated the association between REALM-SF score and study outcomes.

RESULTS

We recruited 300 adult English-speaking postpartum women and 293 were included in the final analysis. The majority of participants (53.9%) experienced impaired health literacy (score zero to six). Most respondents completed high school or higher education (77.1%), 17.8% had no prenatal care, and 83.6% reported that this pregnancy was unplanned. After adjusting for age, race, and education, women in the lowest health literacy group were less likely to indicate a plan to exclusively breastfeed (aRR = 0.54, p = 0.03).

CONCLUSIONS FOR PRACTICE

Impaired health literacy affects a majority of our patients and is associated with reproductive health outcomes, including exclusive breastfeeding. Health care providers should attempt to overcome differences in health literacy through strong breastfeeding promotion. Verbal and written patient education materials should be tailored to the needs of patients with impaired health literacy.

A mixed-methods systematic review on barriers to exclusive breastfeeding

INTRODUCTION

The World Health Organization recommends exclusive breastfeeding for every newborn during the first 6 months of life, yet women come across various challenges to continuing it.

AIM

This systematic review was intended to identify barriers to exclusive breastfeeding among mothers.

METHODS

MEDLINE, Cumulative Index to Nursing and Allied health literature, ProQuest, Web of Science and Scopus databases were searched from January 1990 to October 2017. The systematic review included quantitative, qualitative and mixed-methods studies to identify barriers to exclusive breastfeeding among mothers of reproductive age with an infant aged between 0 and 12 months. All studies were screened based on titles, abstracts and full text by two reviewers independently. The methodological quality of included studies was assessed using appropriate tools. Of the 9737 eligible records, 44 studies were included for analysis. Classification of barriers to exclusive breastfeeding was adopted from the conceptual framework of factors affecting breastfeeding practices given by Hector and colleagues.

RESULTS

In total 32 barriers were grouped under individual, group and society level factors. Meta-analysis indicated that mothers who smoked had 2.49 times more odds of not exclusively breastfeeding than non-smoking mothers and mothers who had undergone caesarean section had 1.69 times more risk of cessation of exclusive breastfeeding than mothers who have had a vaginal childbirth.

CONCLUSION

The systematic review revealed a complex interplay of various barriers related to exclusive breastfeeding. It is recommended that context-specific strategies should be designed in accordance with barriers existing in a region or country.

Promoting self-management of breast and nipple pain in breastfeeding women: Protocol of a pilot randomized controlled trial

The majority of women experience pain during breastfeeding initiation with few strategies to manage breast and nipple pain. In fact, women cite breast and nipple pain as among the most common reasons for breastfeeding cessation. To address this important issue, we developed a breastfeeding self-management (BSM) intervention, based on the Individual and Family Self-Management Theory Framework. In this framework, self-management is conceptualized as a process in which women use knowledge, beliefs, and social facilitation to achieve breastfeeding goals. The purpose of this longitudinal pilot randomized controlled trial was to test the feasibility, acceptability, and preliminary efficacy of the BSM intervention with women initiating breastfeeding. Recruitment of 60 women intending to breastfeed occurred within 48 hr of delivery and women were randomized to either the intervention or usual care group. The BSM intervention group received BSM education modules that included information of how to manage breast and nipple pain and self-management support through biweekly texting from the study nurse, and were asked to complete a daily breastfeeding journal. Primary outcomes measured at baseline, 1, 2, and 6 weeks will be used to (a) evaluate feasibility, acceptability, and preliminary efficacy of the BSM intervention, and (b) assess the influence of protective and risk factors of breastfeeding pain (including individual genetic polymorphisms related to pain sensitivity) on process variables for self-management of breastfeeding and breastfeeding pain, and on proximal (breastfeeding pain severity and interference, breastfeeding frequency) and distal outcomes (breastfeeding exclusivity and duration and general well-being).

The use of computer mediated communication in providing patient support: A review of the research literature

OBJECTIVES

The aim of this study is to explore how computer mediated communication has been used by a variety of healthcare,professionals to support their patients and discuss the implication that this may have for future practice.

DESIGN

A systematized review of the literature.

DATA SOURCES

A review of empirical studies within the literature was carried out in April 2016 in CINAHL, MEDLINE, ASSIA, BNI, Psychinfo, and Web of Science databases.

REVIEW METHODS

The databases searched produced 2930 titles, of which 190 publications were considered relevant to the objectives. Titles and abstracts were then reviewed and duplicates removed producing 67 publications. Exclusion and inclusion criteria were applied. The inclusion criteria were (1) interventions that facilitate two-way communication between any healthcare professional and their patients via a computer; (2) Interventions aimed at providing any type of support e.g. emotional, tangible, informational, or esteem support; (3) English language; (4) Primary empirical studies. Data quality was assessed and thematic analysis applied.

RESULTS

Thirty-one publications were included in this study. Intervention types included Email (n = 8), Videoconferencing (n = 7), Online Social Support Groups (n = 9) and multifaceted interventions (n = 7). Three themes emerged from the data including increasing access to healthcare, adding value to healthcare delivery and improving patient outcomes. Twenty-five (81%) of the studies found that computer mediated communication could produce positive effects.

CONCLUSIONS

Computer mediated communication could be both what patients want and a way of delivering support to patients in a resource tight environment. This has implications for a range of health support needs and professionals including nurses, midwives and allied healthcare professionals. Reviewing the lessons learnt will ensure future interventions are tailored to the support needs of the patients, carefully planned and mindful of the risks.

Therapeutic Relationship and Study Adherence in a Community Health Worker-Led Intervention

Community health workers (CHWs) are increasingly utilized to reach low-resource communities. A critical domain influencing success is the CHWs' ability to create and maintain a therapeutic relationship with the participants they serve. A limited evidence base exists detailing this construct, and evaluating CHW-participant relationships in the context of CHW-led programs. In a longitudinal study design, data on this therapeutic relationship were collected [as captured using The Scale to Assess the Therapeutic Relationship in Community Mental Health Care (STAR)] on 141 participants who had been assigned to a CHW during their perinatal period. Results indicate that therapeutic relationship was associated with the participant's psychosocial health, and independently predicted study adherence in the longitudinal intervention. Changes in therapeutic relationship over the months following birth were strongly associated with changes in anxiety and depression symptoms. A trustful relationship is critical in ensuring CHWs can effectively reach the population they serve. The findings offer additional psychometric evidence of the uses and benefits of STAR outside of the traditional clinical setting in the context of public health research.

Interventions Designed to Promote Exclusive Breastfeeding in High-Income Countries: A Systematic Review Update

BACKGROUND

Worldwide, women seldom reach the recommended target of exclusive breastfeeding up to 6 months postpartum. The aim of the current study was to update a previously published review that presented a conceptual and methodological synthesis of interventions designed to promote exclusive breastfeeding up to 6 months in high-income countries.

MATERIALS AND METHODS

A systematic search of leading databases was conducted for scholarly, peer-reviewed, randomized controlled trials published from June 2013 to December 2016. Twelve new articles were identified as relevant; all were published in English and assessed exclusive breastfeeding with a follow-up period extending beyond 4 months postpartum. Articles were analyzed for overall quality of evidence in regard to duration of exclusive breastfeeding, using the Grading and Recommendations Assessment, Development, and Evaluation approach.

RESULTS

A significant increase in the duration of exclusive breastfeeding was found in 4 of the 12 studies. All four successful interventions had long-duration postpartum programs, implemented by telephone, text message, or through a website. Some of the successful interventions also included prenatal education or in-hospital breastfeeding support.

CONCLUSIONS

Results from this review update correspond closely with previous findings, in that all of the successful interventions had lengthy postnatal support or an education component. More studies assessed intervention fidelity than in the previous review; however, there was little discussion of maternal body-mass index. While a pattern of successful interventions is beginning to emerge, further research is needed to provide a robust evidence base to inform future interventions, particularly with overweight and obese women.

Systematic review of infant and young child complementary feeding practices in South Asian families: the Pakistan perspective

Objective

Suboptimal nutrition among children remains a problem among South Asian (SA) families. Appropriate complementary feeding (CF) practices can greatly reduce this risk. Thus, we undertook a systematic review of studies assessing CF (timing, dietary diversity, meal frequency and influencing factors) in children aged <2 years in Pakistan.

Design

Searches between January 2000 and June 2016 in MEDLINE, EMBASE, Global Health, Web of Science, OVID Maternity & Infant Care, CINAHL, Cochrane Library, BanglaJOL, POPLINE and WHO Global Health Library. Eligibility criteria: primary research on CF practices in SA children aged 0–2 years and/or their families. Search terms: ‘children’, ‘feeding’ and ‘Asians’ with their derivatives. Two researchers undertook study selection, data extraction and quality appraisal (EPPI-Centre Weight of Evidence).

Results

From 45 712 results, seventeen studies were included. Despite adopting the WHO Infant and Young Child Feeding guidelines, suboptimal CF was found in all studies. Nine of fifteen studies assessing timing recorded CF introduced between 6 and 9 months. Five of nine observed dietary diversity across four of seven food groups; and two of four, minimum meal frequency in over 50 % of participants. Influencing factors included lack of CF knowledge, low maternal education, socio-economic status and cultural beliefs.

Conclusions

This is the first systematic review to evaluate CF practices in Pakistan. Campaigns to change health and nutrition behaviour are needed to meet the substantial unmet needs of these children.

Risk factors of poor complementary feeding practices in Pakistani children aged 6-23 months: A multilevel analysis of the Demographic and Health Survey 2012-2013

Appropriate feeding practices are crucial for survival, growth, and development in childhood. This paper analyzes Pakistan's Demographic and Health Survey 2012-2013 to fill the knowledge gap in risk factors of poor complementary feeding practices in Pakistani children. Multilevel models were applied to fit the multistage cluster sample of 2,827 children aged 6-23 months from 489 communities. Introduction of solid, semi-solid, or soft foods (intro) was achieved in 67% infants aged 6-8 months. Among children aged 6-23 months, the proportion of children meeting minimum meal frequency, dietary diversity (MDD), and acceptable diet criteria were 63%, 22% and 15%, respectively. Consumption of legumes and nuts, flesh foods, and vitamin A-rich fruits and vegetables was low in all children (6-19%), even among children who met the MDD criteria (15-55%). Younger child age, especially between 6 and 11 months and delayed maternal postnatal checkup were significant individual-level risk factors that consistently increased the odds of not meeting all four criteria examined. Fewer antenatal care visits predicted the odds of achieving intro and minimum meal frequency while younger maternal age and household poverty predicted the odds of achieving MDD and minimum acceptable diet. Community-level factors included geographic region and general access to maternal and child health care services. The overall poor quality of children's complementary diets in Pakistani calls for stronger policy and program action to promote the consumption of key nutrient-dense foods while prioritizing interventions for the most vulnerable children and populations.

The effect of body and mind stress-releasing techniques on the breastfeeding of full-term babies; a critical analysis of published interventional studies

OBJECTIVE

To critically assess the effectiveness of complementary/alternative medicine modalities, comprising body/mind stress-releasing techniques, on the breastfeeding (BF) success of mothers of full-term newborns.

METHODS

Literature review in Medline and other available database sources until December 2015, and critical analysis of pooled data. The study selection included randomized-controlled trials, case-control studies, and case series.

RESULTS

The total number of analyzed studies was 9. Among them, three represented level-I, two level-II, one level-III, and three level-IV evidence. The pooled maternal population was 2135. Interventions that could influence cognition management seem effective in improving BF initiation and duration (strength of recommendation B), manual relaxation techniques in promoting BF initiation (strength of recommendation B), and auditory-mediated mind guidance in promoting BF duration (strength of recommendation C). The implementation of environmental sensory stimulations improves maternal perception about breastfeeding practice (strength of recommendation C).

CONCLUSIONS

Certain methods of complementary and alternative medicine show positive effect on breastfeeding. Further studies with good quality evidence, dedicated follow-up of the families after discharge, and strict definitions of breastfeeding and weaning are necessary to confirm the effectiveness of the identified interventions.

The global pendulum swing towards community health workers in low- and middle-income countries: a scoping review of trends, geographical distribution and programmatic orientations, 2005 to 2014

BACKGROUND

There has been a substantial increase in publications and interest in community health workers (CHWs) in low- and middle-income countries (LMIC) over the last years. This paper examines the growth, geographical distribution and programmatic orientations of the indexed literature on CHWs in LMIC over a 10-year period.

METHODS

A scoping review of publications on CHWs from 2005 to 2014 was conducted. Using an inclusive list of terms, we searched seven databases (including MEDLINE, CINAHL, Cochrane) for all English-language publications on CHWs in LMIC. Two authors independently screened titles/abstracts, downloading full-text publications meeting inclusion criteria. These were coded in an Excel spreadsheet by year, type of publication (e.g. review, empirical), country, region, programmatic orientation (e.g. maternal-child health, HIV/AIDS, comprehensive) and CHW roles (e.g. prevention, treatment) and further analysed in Stata14. Drawing principally on the subset of review articles, specific roles within programme areas were identified and grouped.

FINDINGS

Six hundred seventy-eight publications from 46 countries on CHWs were inventoried over the 10-year period. There was a sevenfold increase in annual number of publications from 23 in 2005 to 156 in 2014. Half the publications were reporting on initiatives in Africa, a third from Asia and 11 % from the Americas (mostly Brazil). The largest single focus and driver of the growth in publications was on CHW roles in meeting the Millennium Development Goals of maternal, child and neonatal survival (35 % of total), followed by HIV/AIDS (16 %), reproductive health (6 %), non-communicable diseases (4 %) and mental health (4 %). Only 17 % of the publications approached CHW roles in an integrated fashion. There were also distinct regional (and sometimes country) profiles, reflecting different histories and programme traditions.

CONCLUSIONS

The growth in literature on CHWs provides empirical evidence of ever-increasing expectations for addressing health burdens through community-based action. This literature has a strong disease- or programme-specific orientation, raising important questions for the design and sustainable delivery of integrated national programmes.

The effectiveness and cost-effectiveness of the peer-delivered Thinking Healthy Programme for perinatal depression in Pakistan and India: the SHARE study protocol for randomised controlled trials

BACKGROUND

Rates of perinatal depression (antenatal and postnatal depression) in South Asia are among the highest in the world. The delivery of effective psychological treatments for perinatal depression through existing health systems is a challenge due to a lack of human resources. This paper reports on a trial protocol that aims to evaluate the effectiveness and cost-effectiveness of the Thinking Healthy Programme delivered by peers (Thinking Healthy Programme Peer-delivered; THPP), for women with moderate to severe perinatal depression in rural and urban settings in Pakistan and India.

METHODS/DESIGN

THPP is evaluated with two randomised controlled trials: a cluster trial in Rawalpindi, Pakistan, and an individually randomised trial in Goa, India. Trial participants are pregnant women who are registered with the lady health workers in the study area in Pakistan and pregnant women attending outpatient antenatal clinics in India. They will be screened using the patient health questionnaire-9 (PHQ-9) for depression symptoms and will be eligible if their PHQ-9 is equal to or greater than 10 (PHQ-9 ≥ 10). The sample size will be 560 and 280 women in Pakistan and India, respectively. Women in the intervention arm (THPP) will be offered ten individual and four group sessions (Pakistan) or 6-14 individual sessions (India) delivered by a peer (defined as a mother from the same community who is trained and supervised in delivering the intervention). Women in the control arm (enhanced usual care) will receive health care as usual, enhanced by providing the gynaecologist or primary-health facilities with adapted WHO mhGAP guidelines for depression treatment, and providing the woman with her diagnosis and information on how to seek help for herself. The primary outcomes are remission and severity of depression symptoms at the 6-month postnatal follow-up. Secondary outcomes include remission and severity of depression symptoms at the 3-month postnatal follow-up, functional disability, perceived social support, breastfeeding rates, infant height and weight, and costs of health care at the 3- and 6-month postnatal follow-ups. The primary analysis will be intention-to-treat.

DISCUSSION

The trials have the potential to strengthen the evidence on the effectiveness and cost-effectiveness of an evidence-based psychological treatment recommended by the World Health Organisation and delivered by peers for perinatal depression. The trials have the unique opportunity to overcome the shortage of human resources in global mental health and may advance our understanding about the use of peers who work in partnership with the existing health systems in low-resource settings.

TRIAL REGISTRATION

Pakistan Trial: ClinicalTrials.gov Identifier: NCT02111915 (9 April 2014) India Trial: ClinicalTrials.gov Identifier: NCT02104232 (1 April 2014).

Breastfeeding Practices, Demographic Variables, and Their Association with Morbidities in Children

Appropriate feeding practices are the key contributor to reducing morbidities and mortalities in under-five children. A cross-sectional questionnaire based survey of mothers of children aged less than 5years was conducted in 781 mothers. More than half of mothers (57.5%) started feeding within an hour of birth, 55.9% gave exclusive breastfeeding for six months, 89.1% of the mothers stopped breastfeeding before two years of age, 18.2% of the mothers bottle-fed the babies, and 15.6% had problems during breastfeeding in first 6 months. Early initiation of breastfeeding within one hour of birth promoted exclusive breastfeeding, and breastfeeding for longer duration. Exclusive breastfeeding increased frequency of feeds. Multivariable logistic regression showed that initiation of breastfeeding after an hour of birth (p = 0.035), not providing exclusive breastfeeding for 6 months (p < 0.0001), unemployed mothers (p = 0.035), having two or more kids (p = 0.001), and complementary feeds given by person other than mother (p = 0.007) increased hospitalization. Starting breastfeeding after an hour of birth (p = 0.045), severe malnutrition (p = 0.018), and breastfeeding for < two years (p = 0.026) increased rates of diarrhea. Breastfeeding practices were not optimum and interventions to improve these practices need to be strengthened.

The impact of perinatal depression on exclusive breastfeeding: a cohort study

Perinatal depression is associated with infant undernutrition. We hypothesised that perinatal depression was associated with early cessation of exclusive breastfeeding and reduced quantity of breast milk in rural Pakistan. We used a prospective cohort design to study a population-based sample of 132 depressed and 147 non-depressed women from the third trimester of pregnancy to 6 months post-natal. Current major depressive episode was measured in the third trimester and 6 months post-natal using the Structured Clinical Interview for DSM-IV Diagnosis. In a convenience sample of 24 depressed and 31 non-depressed exclusively breastfeeding mothers, breast milk quantity was assessed (mL kg(-1) infant weight per 24 h) at 4 months using the dose-to-mother deuterium dilution method. We administered also the Perception of Insufficient Milk questionnaire at 6 months post-natal. Depression was associated with fewer days of exclusive breastfeeding (91.8 (SD = 47.1) vs. 108.7 days (SD = 54.3) (95% CI: 3.4 to 30.3 P = 0.014). Women with persistent depression ceased exclusive breastfeed earliest. There was no difference in the quantity of breast milk produced by depressed and non-depressed mothers: 89.3 (SD = 38.1) vs. 83.9 (29.0) ml/kg infant wt/24 hours, P = 0.57. Depressed mothers were significantly more likely to report insufficient milk: PIM scores were 34.4 (SD = 14.3) for depressed and 39.7 (SD = 10.4) for non-depressed women (P = 0.004). In Cox regression PIM score mediated the association between depression and early cessation of breastfeeding. In this area of rural Pakistan, perinatal depression is associated with early cessation of exclusive breastfeeding and this is associated with mothers' perceptions of insufficiency of breast milk but not reduced milk production.

Cognitive-behavioral counseling for exclusive breastfeeding in rural pediatrics: a cluster RCT

OBJECTIVE

To test the effectiveness of cognitive-behavioral counseling on the rate and duration of exclusive breastfeeding (EBF) during the first 6 months of an infant's life compared with routine counseling.

METHODS

A single blind cluster-randomized controlled trial was undertaken in 40 Union Councils of a rural district in the northwest province of Pakistan between May 2009 and April 2010. By simple unmatched randomization, 20 Union Councils were each allocated to intervention and control arms. Two hundred twenty-four third trimester pregnant women in the intervention and 228 third trimester pregnant women in the control arm were enrolled and followed-up biweekly until 6 months postpartum. Analyses were by intention to treat. Mothers in the intervention group received 7 sessions of cognitive-behavioral counseling from antenatal to 6 months postpartum, whereas the control group received an equal number of routine sessions. Proportion of mothers exclusively breastfeeding at 6 months postpartum and duration of EBF through these 6 months was assessed.

RESULTS

At 6 months postpartum, 59.6% of mothers in the intervention arm and 28.6% in the control arm were exclusively breastfeeding. This translates into a 60% reduced risk of stopping exclusively breastfeeding during the first 6 months (adjusted hazard ratio, 0.40 [95% confidence interval: 0.27-0.60], P < .001). Mothers in the intervention group were half as likely to use prelacteal feeds with their infants (adjusted relative risk, 0.51 [95% confidence interval: 0.34-0.78]).

CONCLUSIONS

Compared with routine counseling, cognitive-behavioral counseling significantly prolonged the duration of EBF, doubling the rates of EBF at 6 months postpartum.

Interventions designed to promote exclusive breastfeeding in high-income countries: a systematic review

BACKGROUND

Worldwide, women fail to reach the recommended exclusive breastfeeding target of 6 months postpartum. The objective of this study was to present a conceptual and methodological synthesis of interventions designed to promote exclusive breastfeeding to 6 months in high-income countries.

MATERIALS AND METHODS

A systematic search of leading databases was conducted for scholarly peer-reviewed randomized trials published between January 2000 and June 2013. Seventeen articles were identified as relevant; all were published in English and assessed exclusive breastfeeding with a follow-up period extending beyond 4 months postpartum. Articles were analyzed for overall quality of evidence, regarding duration of exclusive breastfeeding, using the Grading and Recommendations Assessment, Development, and Evaluation approach.

RESULTS

A significant increase in the duration of exclusive breastfeeding was found in eight of the 17 studies, with most interventions using supportive or educational approaches. Interventions in pregnancy focused on educating mothers on the benefits of exclusive breastfeeding. Fifteen interventions took place, at least in part, in the postnatal period and provided educational and emotional support to mothers. Of the eight successful interventions, five took part in the postnatal period in the mothers' own homes. The quality of the evidence for duration of exclusive breastfeeding was moderate.

CONCLUSIONS

The most successful interventions were conducted in the postnatal period and over a long period of time; however, the findings were inconsistent. No study assessed intervention fidelity, and only two studies noted maternal body mass index, a variable known to affect exclusive breastfeeding rates. Further research is needed to provide a robust evidence base to inform future interventions.

Understanding care and feeding practices: building blocks for a sustainable intervention in India and Pakistan

Undernutrition and inadequate stimulation both negatively influence child health and development and have a long-term impact on school attainment and income. This paper reports data from India and Pakistan looking at how families interact, play with, and feed children; their expectations of growth and development; and the perceived benefits, consequences, opportunities, and barriers of adopting recommended feeding and developmental behaviors. These data were collected as part of formative research for the Sustainable Program Incorporating Nutrition and Games (SPRING) trial. This trial aims to deliver an innovative, feasible, affordable, and sustainable intervention that can achieve delivery at a scale of known effective interventions that maximize child development, growth, and survival and improve maternal psychosocial well-being in rural India and Pakistan.

Integrating maternal psychosocial well-being into a child-development intervention: the five-pillars approach

Maternal psychosocial well-being (MPW) is a wide-ranging concept that encompasses the psychological (e.g., mental health, distress, anxiety, depression, coping, problem solving) and social (e.g., family and community support, empowerment, culture) aspects of motherhood. Evidence-based MPW interventions that can be integrated into large-scale maternal and child health programs have not been developed. Building on several years of research in Pakistan, we developed and integrated a cognitive behavioral therapy-based MPW intervention (the five-pillars approach) into a child nutrition and development program. Following formative research with community health workers (CHWs; n = 40) and families (n = 37), CHWs were trained in (1) empathic listening, (2) family engagement, (3) guided discovery using pictures, (4) behavioral activation, and (5) problem solving. A qualitative feasibility study in one area demonstrated that CHWs were able to apply these skills effectively to their work, and the approach was found to be useful by CHWs, mothers, and their families. The success of the approach can be attributed to (1) mothers being the central focus of the intervention, (2) using local CHWs whom the mothers trust, (3) simplified training and regular supervision, and (4) an approach that facilitates, not adds, to the CHWs' work.