Effectiveness of Social and Behavior

Change Communications (SBCC) to

Improve Infant and Young Child Feeding
Practices in Ethiopia: A Rapid Review.

© UNICEF Ethiopia/2019/Mulugeta

May 2020
 Effectiveness of Social and Behavior Change
Communications (SBCC) to Improve Infant and Young
Child Feeding Practices in Ethiopia: A Rapid Review.

The Ethiopian Public Health Institute

National Information Platform for Nutrition (NIPN)

AUTHORS

Meron Girma1, Alemnesh Petros2, Dawit Alemayehu1, Aregash Samuel1

1 Ethiopian Public Health Institute, National Information Platform for Nutrition (NIPN)

This report was prepared by the NIPN in Ethiopia, hosted by the Ethiopian Public Health Institute
(EPHI). The NIPN is a global initiative funded by the European Union (EU), with support from the
Foreign, Commonwealth and Development Office and the Bill and Melinda Gates Foundation.

For communication on this report, please address any queries to NIPN Ethiopia at
ephi.nipn@gmail.com

Disclaimer: This report was produced by the NIPN in Ethiopia with the financial support of the EU
Delegation for Ethiopia. The publication has not been peer reviewed, and the opinions and contents
contained herein are the sole responsibility of the authors and do not reflect the views of the EU, the
International Food Policy Research Institute (IFPRI), nor those of EPHI.

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Table of Contents
List of acronyms 3
Executive Summary 4
Background 6
Objective of the Review 7
Methods 7
Criteria for studies included in the review 7
Search Methods and Selection of Studies 8
Data Collection and Quality Appraisal 8
Limitations of the Review 8
Results 9
Description of the Studies 9
Qualitative Analysis 9
Early initiation of breastfeeding 9
Exclusive breastfeeding under six months 9
Continued breastfeeding at one year 9
Introduction of solid, semi-solid or soft foods 10
Minimum Diet Diversity (MDD) 10
Minimum Meal Frequency (MMF) 10
Minimum Acceptable Diet (MAD) 10
Consumption of Iron-rich or Iron-fortified Foods 10
Conclusion and Recommendations 15
References 16
Annexes 18
Annex 1: Search Strategy and Search Log 18
Annex 2: PRISMA Flow Diagram 19
Annex 3: Summary of the Findings 20
Annex 4: Quality of Evidence Assessment Criteria 22
Annex 5: MOH Request Letter and Questions 23

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LIST OF ACRONYMS

BF Breastfeeding

CMAM Community Management of Acute Malnutrition

CF Complementary Feeding

EBF Exclusive Breastfeeding

ENA Essential Nutrition Actions

GRADE Grading of Recommendations, Assessment, Development and Evaluation

HDTL Health Development Team Leader

HDA Health Development Army

HEW Health Extension Worker

JBI Joanne Briggs Institute

MAD Minimum Acceptable Diet

MDD Minimum Diet Diversity

MDD Minimum Meal Frequency

IYCF Infant and Young Child Feeding

PICO Population, Intervention, Control and Outcome

SBCC Social and Behavior Change Communication

WDA Women’s Development Army

WHO World Health Organization

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EXECUTIVE SUMMARY

Appropriate infant and young child feeding (IYCF) practices are critical for optimal child growth and
development. Despite some progress, the implementation of IYCF practices are still sub-optimal in
Ethiopia. A key component of a strong, synergistic approach for improving the health and nutritional
wellbeing of children is the use of social and behavior change communication (SBCC) interventions.

The purpose of this review was to identify the types of SBCC approaches that are used in Ethiopia
and to assess their effectiveness to improve IYCF practices.

We conducted a rapid review to synthesize local evidence and included studies that were conducted
in children aged 0-23.9 months, that included a SBCC or nutrition education intervention, and that
reported on IYCF outcome indicators. Seven studies met these criteria, were critically appraised, and
the quality of their evidence rated. The eight core IYCF indicators recommended by the World Health
Organization (WHO) were selected as outcomes.

Key Findings

• SBCC interventions were found to be effective in improving IYCF practices in Ethiopia. These
interventions were more effective compared to traditional nutrition education interventions
that only focus on individual behavior change.
• SBCC interventions that were the most effective used multiple platforms, segmented the
audience, had multiple contact points, and were multisectoral.
• Improvements in several IYCF indicators were seen with SBCC interventions. Early initiation
of breastfeeding, exclusive breastfeeding, timely introduction of complementary feeding,
minimum diet diversity (MDD), minimum meal frequency (MMF), and minimum acceptable
diet (MAD) all showed some improvement. A large-scale SBCC intervention study reported a
differential increase of 6% in MDD in the group that received SBCC intervention compared to
the control group who received standard routine nutrition services through the health
system.

Conclusion and Recommendations

SBCC interventions were effective in improving some IYCF indicators when implemented at scale.
The use of multiple SBCC approaches, communication channels, and more intense exposure to
interventions, showed the largest effect on IYCF practices. However, only a limited number of
studies were found that reported the effect of SBCC and nutrition education interventions
implemented at scale on IYCF practices in Ethiopia. Among the studies that were reviewed, there
were notable differences in how IYCF indicators were assessed. Some studies did not use the WHO
recommended indicators to assess IYCF practices. This reduced available data and limited the
amount of information used to synthesize evidence on the eight core IYCF indicators.

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Based on the findings, we recommend the following:

• Reinforcing messages by using multiple communication channels is critical.

• SBCC interventions alone cannot lead to a large improvement in IYCF. These interventions
should be coupled with other interventions to improve availability, accessibility, and
affordability of food.
• Large-scale SBCC intervention implementation should be coupled with implementation
science to facilitate systematic uptake of research findings and evidence-based practices into
routine practice and to improve the quality and effectiveness of nutrition service delivery.

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BACKGROUND

Good nutrition during the first two years of life is essential for survival, physical growth, and mental
development1. Since foundations for lifelong health are laid during this time, malnutrition in children
under two years of age can have dire consequences across the entire lifespan1,2. The WHO
recommends that infants be exclusively breastfed for the first six months of life as breast milk is
sufficient to meet the infant's nutritional needs3. The mother is advised to continue breastfeeding
her baby for up to two years and to begin nutritionally adequate and safe complementary feeding at
six months to meet her baby’s evolving nutritional needs 3. If complementary foods are not
introduced at the recommended time, or if they are given inappropriately, an infant’s growth may
falter3. Hence, complementary feeding should be timely, adequate, safe, and responsive to the child’s
feeding cues4.

Sub-optimal complementary feeding practices sometimes occur due to caretakers’ limited

knowledge about the type and amount of complementary foods the baby needs and traditional
beliefs that affect food choices5. Hence, effective educational interventions such as group training,
individual counseling, feeding demonstrations, and community mobilization are needed to improve
IYCF practices6. A key component of a strong, synergistic approach for improving the health and
nutritional wellbeing of children is the use of SBCC interventions7. These interventions target
audiences beyond the individual level and include the community and societal levels8. SBCC is
interactive, contextual, theory-based, and uses multiple channels of communication. Commonly used
SBCC approaches include interpersonal communication at the individual level which is reinforced
through community mobilization and mass media messages7-10. SBCC can serve as a stand-alone
intervention but is increasingly used in combination with other behavior change strategies to
improve maternal and infant nutritional status11.

SBCC interventions have been shown to be effective in IYCF practices globally. A systematic review
of 91 studies found that SBCC improved dietary practices during pregnancy, early initiation of
breastfeeding, exclusive breastfeeding, continued breastfeeding, dietary diversity, and meal
frequency in infants and young children8. Another systematic review that looked at the use of mass
media interventions along with nutrition education, reported improvement in breastfeeding practice
and dietary diversity12. A more recent systematic review that assessed the effect of individual-
focused educational interventions on complementary feeding practices found improvements in the
age of introduction of complementary foods and hygiene practices13.

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OBJECTIVE OF THE REVIEW

In Ethiopia, interventions that address nutrition during the first two years of life are provided as
part of routine nutrition services. However, despite some improvement, IYCF practices are still sub-
optimal. To aid the design and delivery of high-impact interventions, it is important to identify SBCC
approaches that work in the local context. SBCC interventions are multi-faceted by design and need
to be context-specific, and evidence-based to be effective. Therefore, the purpose of this review was
to identify the types of SBCC approaches that are being used in Ethiopia and assess the effectiveness
of these interventions to improve IYCF practices.

METHODS

We employed a rapid review methodology to synthesize evidence to address the review question:
“Can SBCC interventions effectively improve infant and young child feeding practices in Ethiopia?”

Methods used to identify, screen, select and rate certainty of evidence are outlined below.

Criteria for Studies Included in the Review

We used the PICO (Population, Intervention, Control, and Outcome) framework to break concepts
into components to facilitate the search. The criteria listed below were used to include the studies.

Type of studies. We included quantitative studies that evaluated programs providing some form of
SBCC or nutrition education intervention. Study designs included randomized controlled trials,
cluster-randomized trials, quasi-experimental studies, and repeated cross-sectional project
evaluations. The review was limited to peer-reviewed studies done in Ethiopia that were published
in English.

Types of participants: We included studies that were conducted on mother and child pairs with the
age of the child ranging between 0 to 23.9 months.

Types of interventions: The main interventions of interest for this review were those targeting
SBCC. We defined SBCC interventions as a set of interventions that are focused at the individual,
community and societal levels and that are implemented using multiple communication channels.
However, since very limited studies have been conducted on SBCC interventions in Ethiopia, we also
included nutrition education or counseling interventions that targeted individuals.

Type of outcome measures: The primary outcome of interest was IYCF practices. For the purpose
of this review, we selected the following eight core IYCF practice indicators recommended by the
WHO3.

1. Early initiation of breastfeeding within one hour after birth.

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 2. Exclusive breastfeeding for the first six months.
3. Continued breastfeeding at one year.
4. Introduction of solid semi-solid or soft foods at 6-8 months.
5. Minimum diet diversity (MDD): four or more food groups.
6. Minimum meal frequency (MMF): two times for breastfed infants 6-8 months, three times for
breastfed children 9-23 months, and four times for non-breasted children 6-23 months.
7. Minimum acceptable diet (MAD): met both MDD and MMF recommendations.
8. Consumption of iron-rich or iron-fortified foods.

Search Methods and Selection of Studies

We used PubMed to search for terms for each component in the PICO framework. The search
strategy is shown in the Annex 1, Tables 2 and 3. We did not apply design-related filters to ensure
that our search was broad and that we did not miss any studies. We exported the search results
Endnotes to keep a log of the studies and to facilitate their screening.

We screened the titles and abstracts of the studies based on the pre-defined inclusion criteria. We
reviewed the full-text of eligible studies to make a decision on their inclusion. The PRISMA flow
diagram (Annex 2, Figure 1.) provide an overview of the selection process.

Data Collection and Quality Appraisal

Once the studies were selected, we appraised their quality using the Joanna Briggs Institute (JBI)
critical appraisal tools14-16. We assessed the certainty of evidence using the Grading of
Recommendations, Assessment, Development and Evaluation (GRADE) working group guidelines17
and qualitatively synthesized the effect of interventions on outcomes. For more details on the quality
appraisal see Annex 3, Tables 4 and 5, and Annex 4, Table 6.

Limitations of the Review

The rapid nature of the review limited the scope of our evidence synthesis. For this review, we only
included peer-reviewed studies, not gray literature, our search was limited to PubMed and to studies
carried out in Ethiopia. Ideally the screening of studies and the assessment of their eligibility would
be done in pairs (two investigators assessing eligibility of a study simultaneously). However, due to
the time limit, we did not carry out a dual screening for this review.

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RESULTS

Description of the Studies

We identified seven relevant studies for this review18-24. Only two of the studies, Kim et.al, 201920
and Kim et. al, 201621, evaluated the effect of a large-scale SBCC interventions on IYCF practices.
Both studies were evaluations of programs implemented by Alive & Thrive Ethiopia. The 2019 study
had a control group20 while the older study (2016) used a pre- and post-evaluation design with no
control group21. Both SBCC intervention studies used a multi-channel communication approach
which included interpersonal communication with mothers, community mobilization, and mass
media messages20,21. The remaining five studies18,19,22-24 all provided nutrition education
interventions that were only targeted to mothers for individual behavior change. One of the studies
Kang, 201719, was an evaluation of a large-scale community-based nutrition intervention program.
The rest were small studies of programs that were not implemented at a large scale18,22-24. The
results of each study and methodological details are summarized in Table 1. The qualitative analysis
of the results by outcomes is presented below.

Qualitative Analysis

Early initiation of breastfeeding

An increase in early initiation of breastfeeding were observed in three studies. Two of these
evaluated programs that used an SBCC approach 20,21 and one focused on a nutrition education
approach18. Out of these three studies, only one20 had a control group that received standard
nutrition services as part of the healthcare system. In this study, early initiation of breastfeeding
increased in the control group as well as in the SBCC group. Even though more improvement was
seen in the SBCC group (7%), this difference was not statistically significant.

Exclusive breastfeeding under six months

The pre- and post-intervention evaluation21 of a large-scale SBCC program implemented for 24
months, showed a significant increase in exclusive breastfeeding by 9%.

Continued breastfeeding at one year

Despite the increase in exclusive breastfeeding, no impact was seen on continued breastfeeding at
one year in neither of the large-scale SBCC intervention studies20,21, nor did it show an improvement
in the control group that received standard nutrition services20.

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 Introduction of solid, semi-solid or soft foods
Although the difference in increase was not statistically significant, SBCC interventions contributed
to the increase in the timely introduction of complemetary foods at 6-8 months (3%), while timely
introduction decreased (13%) in the control group who received standard nutrition services20. In a
pre- and post-intervention evaluation, timely introduction of complementary foods increased
significantly in those who received SBCC interventions21.

Minimum Diet Diversity (MDD)

The study by Kim et.al, 2019, found that SBCC interventions significantly improved MDD by 6% in
the SBCC intervention group compared to control group20. MDD also increased by 3% in a pre- and
post-SBCC intervention evaluation21. A study that provided nutrition education also reported an
improvement in MDD in the intervention group compared to the control group24.

Minimum Meal Frequency (MMF)

In the same study by Kim et.al, 2019, the MMF improved in both the SBCC intervention group (6%
increase)20 and in the control group (1% increase). Although the increase was higher in the SBCC
group, it was not statistically significant. Large improvement in MMF was seen in a pre- and post-
SBCC intervention evaluation (26% increase)21. A large scale-community nutrition education
program also improved meal frequency19.

Minimum Acceptable Diet (MAD)

Kim et.al, 2019, also found that the MAD was marginally higher in the SBCC intervention group (5%
differential increase) compared to the control group20. MAD also improved in the group who
received standard nutrition services, and significantly increased (by 3%) in the pre- and post-SBCC
intervention evaluation21.

Consumption of Iron-rich or Iron-fortified Foods

SBCC interventions did not signifcanlty improve consumption of iron-rich or iron-fortified foods20,21.

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Table 1. Summary of intervention and findings of the reviewed studies

Author, Study setting Population Intervention vs Control Outcomes Findings Authors’ conclusions and
Year and design studied recommendations
Kim, et. Western Mother-child Intervention group: 1. Early initiation Early initiation of BF: Delivering SBCC
al., 2019 Amhara pairs Health extension workers (HEW): IYCF of breastfeeding - Intervention group: 15.58% interventions in first or
(6-23.9 mo.) counseling and food demonstrations. (BF) increase second level agriculturally
Impact 2. Continued - Control group: 8.43% increase productive areas, using
evaluation: Intervention: Health development team leaders breastfeeding at Continued breastfeeding at multiple platforms and
repeated Baseline (HDTL): IYCF counseling. one year. one year: involving different sectors,
cross-sectional n=1328, End- 3. Timely - Intervention group: 0.14% achieved improvements in
studies line n=1360 Development Agents: promoted introduction of decrease. MDD.
agricultural activities. solid, semi-solid, - Control group: 0.04% decrease
Control: or soft foods at Introduction of solid and Despite improvements
Baseline Ethiopian Orthodox church leaders: 6–8.9 months semi-solid foods: complementary feeding
n=1318 Community mobilization. 4. MMD - Intervention group: 2.62% practice remained poor at
End-line 5. MMF increase, end-line and although the
n=1360 Community-based Organizations: 6. MAD - Control group: 3.08% decrease intervention was delivered
Community conversations on IYCF. 7. Consumption of MMD: through multiple platforms,
iron-rich or - Intervention group: 19.7% exposure to interventions
Mass media: 12-episode radio drama. iron-fortified increase was still moderate. Thus,
Broadcast was supplemented with foods - Control group: 8.4% increase. A there is need for continued
mobile vans and live re-enactment. significant difference in efforts to improve
difference 6.2% complementary feeding
Control group: MMF: practices and expand
HEWs and HDTLs: provided standard - Intervention group: 5.7% intervention coverage.
nutrition counseling and food increase,
demonstrations. - Control group: 1.21% decrease
Development Agents: provided MAD:
standard agricultural services. Little or - Intervention group: 14.1%
no IYCF community mobilization. increase
- Control group: 8.58% increase

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 Mass media: 12-episode radio drama. Consumption of iron-rich or
iron-fortified foods:
Duration of intervention: 36 months - Intervention group: 1.03%
increase
- Control group: 2.1% increase
Kang Habro and Mother and Intervention group: 1. MMF - MMF score was higher among A community-based
et.al., Melka Bello child pairs Cooking demonstration followed by a 2. MDD the intervention group than the nutrition intervention, that
2017 districts, (6-12 months) 12-day IYCF promotion session. control group over the 12- was implemented
Eastern One to two follow up visits within the month follow-up period. concurrently with existing
Ethiopia. two weeks following the session. - MDD was higher in the routine interventions,
intervention group but was not improved meal frequency in
Cluster Control group: significant. the intervention group.
randomized Standard of care (Routine IYCF practice
trial provide through the health system) Longer exposure is needed
n=2064 (1032 to increase diet diversity in
per group) resource limited settings.
Kim, et. Southern Mother and Intervention group: 1. Early initiation - Early initiation of BF increased SBCC interventions were
al., 2016 Nations, child pairs Large-scale SBCC intervention. of BF by 13.7% associated with large
Nationalities (0-59.9 2. Exclusive - EBF increased by 9.4 % improvements. Despite
and Peoples’ months) HEW/women’s development army breastfeeding - Timely introduction of improvements,
Region (WDA): Counseling of women on seven (EBF) for six complementary foods increased complementary feeding
(SNNP), Tigray key messages on IYCF. months by 22.2% practices are still very poor
3. Continued BF at - MDD increased by 3.3% in Ethiopia.
Pre- and post- Community mobilization: community one year - MMF increased by 26.2%
evaluation: conversations on IYCF. 4. Timely - MAD increased by 3.5% Overall exposure to
Repeated cross introduction of - Consumption of iron-rich foods intervention was low. Larger
sectional Mass media: six radio messages, two on solid, semi-solid, increased by 2.7% effects might have been
studies (2010, breastfeeding and four on or soft foods at achieved with greater
n=1481 and complementary feeding. 6–8.9 months coverage and higher
2014, n=1475) 5. MDD intensity.
Control group: No control group 6. MMF
7. MAD

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 Duration of interventions: 48 months 8. Consumption of Household food insecurity
iron-rich or and other constraints should
iron-fortified be addressed to enable
foods conditions for adoption of
recommended practices
promoted by effective SBCC
strategies in Ethiopia.
Muluale Wolayita Zone, 80 mother- Intervention group: 1. MMF - MMF: Significant increase in the A recipe-based group
m et.al., SNNPR child pairs Nutrition education focused on 2. Incorporating intervention group and some nutrition education
2016 A quasi- (6-18 months) incorporating pulses into legumes into increase in the control group intervention increased
experimental complementary foods, delivered every complementary - More mothers in the addition of locally grown
study two weeks for six months to mothers. foods intervention group pulsed to complementary
incorporated legumes in foods.
Control group: Standard of care complementary foods
compared to the control
Callagha Tigray, 215 mothers Intervention group: 1. Early initiation - Breastfeeding within the first Promotion of skin to skin
n-Koru, Oromia, Facility-based Kangaroo Mother Care. of BF hour increased. contact and exclusive
et.al., Amhara and Community-based promotion of breastfeeding by community
2016 SNNP exclusive breastfeeding and skin to skin health workers, coupled
Pre and post contact by HEW and health with strengthened newborn
intervention development army (HDA) during 3 care at local health facilities,
design home visits after delivery. likely contributed to
significant increases in
Control group: No control group newborn care practices.
Tariku, Dore Bafano 166 mother- Intervention group: 1. MDD - MDD increased in both An educational intervention
et.al., district, Sidama child pairs Group 1: Community health volunteers 2. MMF intervention groups and did not based on the health belief
2015 Zone, SNNPR (6–18 months) delivered messages on complementary show an improvement in the model, improved minimum
feeding using the Health Belief Model control group. diet diversity. Meal
Cluster- every two weeks for three months. frequency were improved in
randomized Group 2: HEW provided nutrition all groups.
trial education using traditional (didactic)

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 method on complementary feeding This study demonstrated
practices every two weeks for three that mode of delivery of
months. messages is important to
achieve desired
Control group: Standard of care improvements in
complementary feeding
practices.
Negash, Hula Woreda, 197 mother- Intervention group: 1. MDD - Improvement in MDD seen in A recipe-based nutrition
et. al., SNNPR child pairs Nutrition education on young child 2. MMF the intervention group. education intervention
2014 (6 to 23 feeding and complementary food - MMF improved in both the increased minimum diet
Cluster months) cooking demonstration every two intervention and control diversity and minimum meal
randomized weeks for six months. groups. frequency.
trial
Control group: Standard of care

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CONCLUSION AND RECOMMENDATIONS

Despite limited evidence in the Ethiopian context, SBCC interventions were effective in
improving some IYCF indicators when implemented at scale. Dietary diversity and meal
frequency were two indicators that were consistently improved through SBCC interventions.
The evidence also showed that using multiple SBCC approaches and channels to improve IYCF
practices was more effective. Large-scale SBCC interventions that showed the largest and
reliable effect on feeding practices used multiple SBCC approaches, and in one instance, the
intervention was multisectoral. The evidence also showed more contacts and exposure to
messages resulted in greater improvement in feeding practices. Using multiple approaches to
deliver SBCC intervention such as interpersonal communications, community mobilization, and
mass media reinforced messages and created a conducive environment for behavior change. It
is also important to note that in addition to the delivery of SBCC interventions, other enabling
factors such as food security, are important to facilitate behavior change.

Among the studies that were reviewed, there were notable differences in how IYCF indicators
were assessed. Some studies did not use the WHO recommended indicators to assess IYCF
practices. This reduced available data and limited the amount of information used to synthesize
evidence on the eight core IYCF indicators. Furthermore, there were only a limited number of
studies that have reported the effect of SBCC and nutrition education interventions
implemented at scale on feeding practices. In the future, large-scale SBCC intervention
implementation should be coupled with implementation science to facilitate systematic uptake
of research findings and evidence-based practices into routine practice and to improve the
quality and effectiveness of nutrition service delivery.

15
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 ANNEXES

Annex 1: Search Strategy and Search Log

Table 2. Search strategy

PICO elements Search term

Children under 2 Infant [tiab] OR young children [tiab] OR Children under 2 [tiab] OR Neonate
[tiab] OR Infant [Mesh] OR Infant, Newborn (Mesh]
AND
Social behavior Social behavior change communication [tiab] OR Nutrition counseling [tiab]
change OR
communication Nutrition education [tiab] OR
Health education [Mesh] OR
Counseling [Mesh] OR
Education [Mesh]
AND
Feeding practices IYCF [tiab] OR Breastfeeding [tiab] OR Complementary feeding [tiab] OR
Feeding behavior [Mesh] OR Diet [Mesh] OR
Breast Feeding [Mesh] OR Weaning [Mesh]
AND
Ethiopia Ethiopia

Table 3. Search log March 13, 2020

# Search string (PubMed) # Results

Infant and young child feeding [tiab] 1
1 Infant [tiab] OR young children [tiab] OR Children under 2 [tiab] OR Neonate [tiab] OR 1,211,983
Infant [Mesh] OR Infant, Newborn (Mesh]
2 Social behavior change communication [tiab] OR Nutrition counseling [tiab] OR 868,787
Nutrition education [tiab] OR Health education [Mesh] OR Counseling [Mesh] OR
Education [Mesh]
3 IYCF [tiab] OR Breastfeeding [tiab] OR Complementary feeding [tiab] OR Feeding 401,058
behavior [Mesh] OR Diet [Mesh] OR Breast Feeding [Mesh] OR Weaning [Mesh]
4 Ethiopia [tiab] OR Ethiopia [Mesh] 17,048
5 #1 AND #2 AND #3 AND #4 592

18
Annex 2: PRISMA Flow Diagram

Figure 1: PRISMA flow diagram

Records identified through Additional records identified

database searching through other sources
(n = 592) (n = 2)

Records after duplicates removed

(n = 594)

Records screened Records excluded

(n = 594) (n = 584)

Full-text articles assessed Full-text articles excluded,

for eligibility with reasons
(n = 11) (n = 3)

Full-text articles critically

appraised Full-text articles excluded,
(n = 7) with reasons
(n = 0)

Studies included in
qualitative synthesis
(n = 7)

Studies included in quantitative

synthesis (meta-analysis)
(n = 0)

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 Annex 3: Summary of the Findings

Table 4: Summary of the findings for SBCC interventions

SBCC intervention compared with standard of care

Patients or population: Children of complementary feeding age (6-23.9 months)

Settings: Community
Intervention: SBCC intervention
Comparison: Standard of care /Pre- and post- intervention evaluation
Outcomes Impact Number of Quality of the
participants evidence
(Studies) (GRADE)*
Early initiation of Early initiation of BF increased in both SBCC 4153 ⊕⊕⊕⊖
breastfeeding and standard of care groups. Increase was (2 studies) Moderate
higher in SBCC group by 7% although not
statistically significant. In a pre- and post-
intervention evaluation, SBCC significantly
increased early initiation of breastfeeding by
14%.
Exclusive breastfeeding In a pre- and post-intervention evaluation, SBCC 1472 ⊕⊕⊕⊖
under 6 months significantly increased exclusive breastfeeding (1 study) Moderate
by 9%.
Continued breastfeeding SBCC intervention had no impact on continued 4153 ⊕⊕⊕⊖
at one year breastfeeding at one year. (2 studies) Moderate
Introduction of solid SBCC intervention increased timely 4153 ⊕⊕⊕⊖
semi-solid or soft foods introduction of CF, while it decreased in (2 studies) Moderate
standard of care group. In a pre- and post-
intervention evaluation timely introduction of
CF increased significantly in those who received
SBCC.
Minimum diet diversity SBCC intervention significantly improved MDD 4153 ⊕⊕⊕⊖
compared to standard of care (6% increase). (2 studies) Moderate
MDD significantly increased by 3% in a pre- and
post-SBCC intervention evaluation.
Minimum meal MMF improved in both SBCC and standard of 4153 ⊕⊕⊕⊖
frequency care. Although increase was higher in the SBCC (2 studies) Moderate
group, it was not statistically significant. Large

20
 improvement in MMF were seen in a pre- and
post-SBCC intervention evaluation.
Minimum acceptable MAD improved in both SBCC and standard of 4153 ⊕⊕⊕⊖
diet care. Increase was marginaly higher in the SBCC (2 studies) Moderate
group. MAD significantly increased by 3% in a
pre- and post-SBCC intervention evaluation.
Consumption of iron- SBCC intervention did not significantly improve 4153 ⊕⊕⊕⊖
rich or iron-fortified consumption of iron-rich or iron-fortified (2 studies) Moderate
foods Foods.
*GRADE Working Group grades of evidence
⊕⊕⊕⊕ High: We are confident that the true effect lies close to what was found in the research
⊕⊕⊕⊖ Moderate: The true effect is likely to be close to what was found, but there is a possibility that it is substantially
different
⊕⊕⊖⊖ Low: The true effect may be substantially different from what was found
⊕⊖⊖⊖ Very low: We are very uncertain about the effect

Table 5: Summary of finding for nutrition education interventions

Nutrition education intervention compared with standard of care

Patients or population: Children of complementary feeding age (6-23.9 months)
Settings: Community
Intervention: SBCC intervention
Comparison: Standard of care
Outcomes Impact Number of Quality of the
participants evidence
(Studies) (GRADE)*
Early initiation of Nutrition education significantly increased early 217 ⊕⊖⊖⊖
breastfeeding initiation of breastfeeding. (1 study) Very low

Minimum diet diversity Nutrition education improved dietary diversity. 363 ⊕⊖⊖⊖
(1 study) Very low
Minimum meal Nutrtion education significantly improved meal 2338 ⊕⊖⊖⊖
frequency frequency. (3 studies) Very low
*GRADE Working Group grades of evidence
⊕⊕⊕⊕ High: We are confident that the true effect lies close to what was found in the research
⊕⊕⊕⊖ Moderate: The true effect is likely to be close to what was found, but there is a possibility that it is substantially
different
⊕⊕⊖⊖ Low: The true effect may be substantially different from what was found
⊕⊖⊖⊖ Very low: We are very uncertain about the effect

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Annex 4: Quality of Evidence Assessment Criteria

Table 6: Quality of evidence assessment criteria

Quality of evidence Study design Lower if * Higher if *

High (4) Randomized trial Study limitations Strong association

-1 Serious +1 Strong, no
Moderate (3) -2 Very serious plausible
confounders
Inconsistency +2 Very strong, no
Low (2) Observational study
-1 Serious major threats to
-2 Very serious validity
Very low (1)

Indirectness Dose response

-1 Serious +1 Evidence of a
-2 Very serious gradient

Imprecision All plausible

-1 Serious confounders
-2 Very serious +1 All plausible
confounders or bias
Publication bias would decrease the
-1 Likely size of the effect if
-2 Very likely there is evidence of
an effect, or increase
it if there is evidence
of no harmful effect
(safety)
* 1 = Move up or down one grade (for example from high to intermediate), 2 = Move up or down two grades (for
example from high to low) 0.5 = Borderline. Inconsistency: in the body of evidence. Indirectness: Outcomes of interest
are not compared at the same time, impact not directly assessed and generalization. Imprecision: Small sample size
and large confidence intervals. Risk of bias: Allocation concealment, blinding, loss to follow up, intention-to-treat, all
outcomes are reported, selection bias and information bias.

22
Annex 5: MOH Request Letter and Questions

23
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