Evaluating Programmatic Effectiveness and Implementation: An Assessment of Factors Affecting Change in the Practice of Exclusive Breastfeeding in Ethiopia and Mali

Abstract

Exclusive breastfeeding (EBF) to six months of age is one of the most effective interventions to ensure the survival of newborns and children, yet programmatic activities implemented to increase EBF rates are only variably successful. With funding from the Canadian government's Muskoka Initiative Partnership Program, two NGOs (CARE and Save the Children) implemented programs in Ethiopia and Mali to improve maternal, newborn, and child health outcomes, including EBF. Programmatic activities were diverse, including the development of educational material, community‐based counselling, radio messaging, and mother‐to‐mother support groups. This study aimed to quantitatively assess the observed change in EBF coverage from cross‐sectional survey data, and qualitatively determine contextual factors that influenced the implementation of EBF programmes from focus group discussions (n=15; included mothers and community leaders) and key informant interviews (n=17; included government officials and NGO personnel). Baseline and endline data showed a net increase in the EBF rate in both countries (Mali: 27.3% [95% CI: 19.2 to 35.3] to 66.3% [95% CI: 57.0 to 75.7], P<0.05; Ethiopia: 69.4% [95% CI: 62.4 to 76.3] to 75.1% [95% CI: 69.9 to 80.3], not significant). When analyzed inductively (themes identified from the qualitative data) and deductively (categories assigned to the qualitative data from an existing framework), some of the most influential factors that emerged for EBF adoption were engaging influential community members as ‘champions’ for change; repeated exposure to information about EBF practice and benefits; exposure to community members’ EBF testimonials; and community recognition of a strong need for change to improve infant health outcomes. Traditional beliefs, knowledge, and practices regarding infant feeding and gender role‐related expectations were also found to be important factors for EBF behavioural change. Ultimately, the identified factors for successful implementation and uptake of EBF activities will help to guide and refine existing implementation frameworks, as well as programmatic approaches to increase the number of mothers who practice EBF.Support or Funding InformationFinancial support was provided by the Government of Canada through Foreign Affairs, Trade, and Development Canada (DFATD).