Baby-Friendly Community Initiative Research Articles

Influence of Project Champions on Sustainability of Early Childhood Development Projects: Case of Baby-Friendly Community Initiative in Dagoretti North Constituency Nairobi County Kenya

<span>The aim of the study was to find out the influence of project champions on the sustainability of Early Childhood Development (ECD) projects, a case of the Baby-Friendly Community Initiative (BFCI) project in Dagoretti North Constituency Nairobi County, Kenya. The study was guided by the system approach theory. The study adopted a descriptive survey design. The target population was made up of 507 BFCI project stakeholders while the sample size was 211. The researchers used self-administered questionnaires to collect quantitative data while an interview guide was used to collect qualitative data in the research. Descriptive and inferential statistics were used. Data collected from the study was analyzed with the help of the Statistical Package for Social Sciences (SPSS Version 23.0). Triangulated qualitative data was analyzed through themes and content analysis. The study found that </span><span lang="EN-GB">project champions determine the sustainability of ECD projects with a high correlation value. Indicators like commitment, confidence level, influence on the community, and the connections a project champion has in the community play a significant role in the sustainability of projects. In-depth discussions with the key informants indicated the importance of project champions. </span><span>Regression analysis indicated that project champions were significant in predicting the sustainability of ECD Projects. The study recommends that </span><span lang="EN-GB">project champions should be appreciated through tokens to motivate them to champion community projects and be involved in planning projects to ensure to take into account the cultural contexts.</span>

Implementation of the Baby-Friendly Hospital & Community Initiatives in Europe: a scoping review

Abstract Background Promotion of and support for breastfeeding is essential for public health, to improve nutrition globally and save the lives of over 800,000 children annually. Since its launch in 1991, the Baby-Friendly Hospital Initiative (BFHI) has been implemented in 150 countries, to promote the ‘ten steps to successful breastfeeding', with the Baby-Friendly Community Initiative (BFCI), arising from the 10th step. Aim To synthesise evidence about BFHI and BFCI implementation in European countries. Methods This scoping review was conducted according to the Joanna Briggs Institute methodology for scoping reviews. Data were charted by country, study design, setting, study population, BFHI steps, study aim and objectives, intervention, results, barriers and enablers to implementation, evidence gaps, and recommendations. Qualitative and quantitative descriptive analyses were undertaken. Results A total of 278 articles were included in the review, of which 60 studies covered the implementation of the BFHI or BFCI in 18 European countries. Most studies were found from the UK (n = 11) Italy (n = 9) and Switzerland, Spain and Turkey (n = 6 each). Most were hospital-only based (n = 48) and most covered all ten steps of the BFHI (n = 44) and fewer BFCI (n = 4). Studies were carried out with health workers (n = 17), mothers (n = 34) and policy makers. Most studies were quantitative (n = 39) with many others designs used. Our charting of results highlights that effective implementation required political commitment, legislative and regulatory underpinning; support at organisational level; ongoing multi-professional leadership, education, training and teamwork, and effective education for women. Conclusions While contextual country-level factors are seen, there are clear patterns underpinning successful BFHI/ BFCI implementation, which can guide effective implementation. Funded by the Irish Research Council and Department of Foreign Affairs Ireland, grant number: COALESCE/2019/89 Key messages • Strong political and professional leadership is required to support the effective implementation of public health initiatives to support breastfeeding. • Ongoing, effective multi-professional education and training is required to support breastfeeding.

Actions for the protection and prevention of sustainable healthy complementary feeding in nurseries

Abstract Background The WHO and UNICEF in the Global Strategy for infant and young children feeding (GS), indicate that the principle actors of society play significant roles in protecting, promoting and supporting safe and adequate complementary feeding for infants and young children. The WHO and FAO in The Sustainable Healthy Diet, guiding principles (SHD) moreover underline synergies among foods, nutrients present in dietary patterns and their bioavailability, degree of food processing, and subsequent health impact. COVID-19's (C) social economic impact has changed food supply costs. The UNICEF Baby-Friendly Community Initiative, involving 41 nurseries with 1600 enrolled children and a coverage rate of 38% (EU objective 35%) has operated in the municipality of Trieste, since 2015. Beginning August 2022 the project aims were to verify the application of food safety regulations (FSR), recommendation of the GS, SHD and regional nutritional guidelines (RNG) in nursery catering services. Methods 13 nurseries have been verified. 78 food samples (FS) of oven-cooked vegetables (V), meat and fish (MF) were taken from 10 nursery kitchens, with a total production of 1150 meals per day. The University of Trieste has performed over 400 analyses. The outcomes were compared with FSR, literature references and pre C research results carried out in 2015. Results Relevant and systemic corrective actions indicated by FSR, GS and RNG have been implemented to overcome non-compliance. The analyses performed on FS have shown that the protective compounds have remained similar, and in some cases improved, in V foods. However, in the MF-based oven-cooked preparations, a significant content of Maillard products was highlighted and only some of them showed values above the acceptable limit. Conclusions The evidence of the project will be able to orient public actors for future integrated actions of protection, promotion and support of a healthy and sustainable complementary diet after C. Key messages • After the social economic impact of the Covid-19 pandemic it is determinant to support public actors in continuing to protect, promote and support safe and adequate complementary feeding in nurseries. • It is crucial to program systemic and coordinated actions to ensure adequate resilient food systems in nursery catering services in adherence with the WHO, FAO and UNICEF recommendations.

Improving breastfeeding support through the implementation of the baby friendly hospital and community initiatives: a scoping review protocol.

Background: Improved breastfeeding practices have the potential to save the lives of over 823,000 children under 5 years old globally every year. Exclusively breastfeeding infants for the first six months would lead to the largest infant mortality reduction. The Baby-Friendly Hospital Initiative (BFHI) is a global campaign by the World Health Organization and the United Nations Children's Fund (UNICEF), which promotes best practice to support breastfeeding in maternity services. The Baby-Friendly Community Initiative (BFCI) is an extension of the BHFI's 10 th step of the Ten Steps to Successful Breastfeeding and of the BFHI overall. Its focus is on community-based breastfeeding supports for women. There have been no known attempts to synthesise the overall body of evidence on the BFHI in recent years, and no synthesis of empirical research on the BFCI. This scoping review asks the question: what is known about the implementation of the BFHI and the BFCI globally? Methods and analysis: This scoping review will be conducted according to the Joanna Briggs Institute methodology for scoping reviews. Inclusion criteria will follow the Population, Concepts, Contexts approach. A data charting form will be developed and applied to all the included articles. Qualitative and quantitative descriptive analysis will be undertaken. The PAGER (Patterns, Advances, Gaps, Evidence for practice and Research recommendations) methodological framework will be used to analyse and report review findings. Conclusion: This review will establish gaps in current evidence which will inform areas for future research in relation to this global initiative.

Improving breastfeeding support through the implementation of the baby friendly hospital and community initiatives: a scoping review protocol

Background: Improved breastfeeding practices have the potential to save the lives of over 823,000 children under 5 years old globally every year. Exclusively breastfeeding infants for the first six months would lead to the largest infant mortality reduction. The Baby-Friendly Hospital Initiative (BFHI) is a global campaign by the World Health Organization and the United Nations Children's Fund (UNICEF), which promotes best practice to support breastfeeding in maternity services. The Baby-Friendly Community Initiative (BFCI) is an extension of the BHFI’s 10 th step of the Ten Steps to Successful Breastfeeding and of the BFHI overall. Its focus is on community-based breastfeeding supports for women. There have been no known attempts to synthesise the overall body of evidence on the BFHI in recent years, and no synthesis of empirical research on the BFCI. This scoping review asks the question: what is known about the implementation of the BFHI and the BFCI globally? Methods and analysis: This scoping review will be conducted according to the Joanna Briggs Institute methodology for scoping reviews. Inclusion criteria will follow the Population, Concepts, Contexts approach. A data charting form will be developed and applied to all the included articles. Qualitative and quantitative descriptive analysis will be undertaken. The PAGER (Patterns, Advances, Gaps, Evidence for practice and Research recommendations) methodological framework will be used to analyse and report review findings. Conclusion: This review will establish gaps in current evidence which will inform areas for future research in relation to this global initiative.

Effectiveness of the baby-friendly community initiative on exclusive breastfeeding in Kenya.

The baby‐friendly hospital initiative (BFHI) promotes exclusive breastfeeding (EBF) in hospitals, but this is not accessible in rural settings where mothers give birth at home, hence the need for a community intervention. We tested the effectiveness of the baby‐friendly community initiative (BFCI) on EBF in rural Kenya. This cluster randomized study was conducted in 13 community units in Koibatek sub‐county. Pregnant women aged 15–49 years were recruited and followed up until their children were 6 months old. Mothers in the intervention group received standard maternal, infant and young child nutrition counselling, support from trained community health volunteers, health professionals and community and mother support groups, whereas those in the control group received standard counselling only. Data on breastfeeding practices were collected longitudinally. The probability of EBF up to 6 months of age and the restricted mean survival time difference were estimated. A total of 823 (intervention group n = 351) pregnant women were recruited. Compared with children in the control group, children in the intervention group were more likely to exclusively breastfeed for 6 months (79.2% vs. 54.5%; P < .05). Children in the intervention group were also exclusively breastfed for a longer time, mean difference (95% confidence interval [CI]) 0.62 months (0.38, 0.85; P < .001). The BFCI implemented within the existing health system and including community and mother support groups led to a significant increase in EBF in a rural Kenyan setting. This intervention has the potential to improve EBF rates in similar settings.

Improving breastfeeding support through the implementation of the baby friendly hospital and community initiatives: a scoping review protocol

Background: Improved breastfeeding practices have the potential to save the lives of over 823,000 children under 5 years old globally every year. Exclusively breastfeeding infants for the first six months would lead to the largest infant mortality reduction. The Baby-Friendly Hospital Initiative (BFHI) is a global campaign by the World Health Organization and the United Nations Children's Fund (UNICEF), which promotes best practice to support breastfeeding in maternity services. The Baby-Friendly Community Initiative (BFCI) is an extension of the BHFI’s 10th step of the Ten Steps to Successful Breastfeeding and of the BFHI overall. Its focus is on community-based breastfeeding supports for women. There have been no known attempts to synthesise the overall body of evidence on the BFHI in recent years, and no synthesis of empirical research on the BFCI. This scoping review asks the question: what is known about the implementation of the BFHI and the BFCI globally? Methods and analysis: This scoping review will be conducted according to the Joanna Briggs Institute methodology for scoping reviews. Inclusion criteria will follow the Population, Concepts, Contexts approach. A data charting form will be developed and applied to all the included studies. Qualitative and quantitative descriptive analysis will be undertaken. In order to address equity of access to the BFHI/BFCI, the Levesque et al. (2013) access to health care framework will be used as a lens to analyse the charted data in relation to this aspect of the review. An already established group of stakeholders with experience of infant feeding policy and implementation in Malawi will be consulted, to obtain expert views on the findings of the scoping review. Conclusion: This review will establish gaps in current evidence which will inform areas for future research in relation to this global initiative.

Effectiveness of the baby-friendly community initiative in promoting exclusive breastfeeding among HIV negative and positive mothers: a randomized controlled trial in Koibatek Sub-County, Baringo, Kenya

BackgroundAlthough the baby-friendly community initiative (BFCI) has been proposed as a community-level approach to improve infant feeding practices, there is little data on its variation in effectiveness by HIV status. We conducted a study to determine the effectiveness of BFCI in changing knowledge and attitudes towards exclusive breastfeeding (EBF) and increasing the rates among HIV negative and HIV positive women in rural Kenya.MethodsA community-based cluster-randomized controlled trial was implemented from April 2015 to December 2016 among 901 women enrolled across 13 clusters. The intervention groups received a minimum of 12 personalized home-based counselling sessions on infant feeding by trained community health volunteers from their first or second trimester of pregnancy until 6 months postpartum. Other interventions included education sessions at maternal child clinics, mother-to-mother support group meetings and bi-monthly baby-friendly gatherings targeting influencers. The control group received standard health education at the facility and during monthly routine home visits by community health volunteers not trained on BFCI. Primary outcome measures were the rates of EBF at week 1, months 2, 4 and 6 postpartum. Secondary outcomes included knowledge and attitudes regarding breastfeeding for HIV-exposed infants. Statistical methods included analysis of covariance and logistic regression.ResultsAt 6 months, EBF rates among HIV negative mothers were significantly higher in the BFCI intervention arm compared to the control arm (81.7% versus 42.2% p = 0.001). HIV positive mothers in the intervention arm had higher EBF rates at 6 months than the control but the difference was not statistically significant (81.8% versus 58.4%; p = 0.504). In HIV negative group, there was greater knowledge regarding EBF for HIV-exposed infants in the intervention arm than in the control (92.1% versus 60.7% p = 0.001). Among HIV positive mothers, such knowledge was high among both the intervention and control groups (96% versus 100%, p > 0.1). HIV negative and positive mothers in the intervention arm had more favourable attitudes regarding EBF for HIV-exposed infants than the control (84.5% versus 62.1%, p = 0.001) and (94.6% versus 53.8% to p = 0.001) respectively.ConclusionsBFCI interventions can complement facility-based interventions to improve exclusive and continued breastfeeding knowledge, attitudes, and behaviours among HIV negative and positive women.

Maternal knowledge in complementary feeding following Baby Friendly Community Initiative in Koibatek, Kenya.

The Kenyan Ministry of Health has developed a National Strategy on Infant and Young Child Feeding with the goal of improving feeding practices for infants and children. In order to promote appropriate infant feeding, the government has explored implementation of the Baby Friendly Community Initiative (BFCI). This study assessed maternal knowledge of attributes of complementary feeding following implementation of BFCI in Koibatek, Kenya. A randomized control study composed of 270 mother–infant pairs previously enrolled in a BFCI programme in Koibatek was conducted. The study found that a significantly greater number of mothers in the intervention group were more knowledgeable about proper breastfeeding and complementary feeding aspects compared with controls (P ≤ 0.001). About half (53%) of mothers in the intervention group had high knowledge scores in comparison with 20% of mothers in the control group. When the relationship between mothers' knowledge and complementary feeding practices (minimum meal frequency, minimum dietary diversity and minimum acceptable diet) was assessed, significant associations were observed (P = 0.010, P ≤ 0.001 and P ≤ 0.001, respectively). The odds of having a high knowledge score regarding complementary feeding practices were significantly higher for the intervention group compared with the control group (odds ratio [OR]: 25.98, 95% confidence interval [CI] 13.62–49.55, P ≤ 0.001). The BFCI intervention effectively improved mothers' knowledge on complementary feeding and correlated with improved feeding practices.

Baby-Friendly Community Initiative-From national guidelines to implementation: A multisectoral platform for improving infant and young child feeding practices and integrated health services.

The Baby‐Friendly Community Initiative (BFCI) is an extension of the 10th step of the Ten Steps of Successful Breastfeeding and the Baby‐Friendly Hospital Initiative (BFHI) and provides continued breastfeeding support to communities upon facility discharge after birth. BFCI creates a comprehensive support system at the community level through the establishment of mother‐to‐mother and community support groups to improve breastfeeding. The Government of Kenya has prioritized community‐based programming in the country, including the development of the first national BFCI guidelines, which inform national and subnational level implementation. This paper describes the process of BFCI implementation within the Kenyan health system, as well as successes, challenges, and opportunities for integration of BFCI into health and other sectors. In Maternal and Child Survival Program (MCSP) and UNICEF areas, 685 community leaders were oriented to BFCI, 475 health providers trained, 249 support groups established, and 3,065 children 0–12 months of age reached (MCSP only). Though difficult to attribute to our programme, improvements in infant and young child feeding practices were observed from routine health data following the programme, with dramatic declines in prelacteal feeding (19% to 11%) in Kisumu County and (37.6% to 5.1%) in Migori County from 2016 to 2017. Improvements in initiation and exclusive breastfeeding in Migori were also noted—from 85.9% to 89.3% and 75.2% to 92.3%, respectively. Large gains in consumption of iron‐rich complementary foods were also seen (69.6% to 90.0% in Migori, 78% to 90.9% in Kisumu) as well as introduction of complementary foods (42.0–83.3% in Migori). Coverage for BFCI activities varied across counties, from 20% to 60% throughout programme implementation and were largely sustained 3 months postimplementation in Migori, whereas coverage declined in Kisumu. BFCI is a promising platform to integrate into other sectors, such as early child development, agriculture, and water, sanitation, and hygiene.

Effectiveness of Baby Friendly Community Initiative (BFCI) on complementary feeding in Koibatek, Kenya: a randomized control study

BackgroundAppropriate infant and young child nutrition is critical for proper growth and development. In order to promote optimal nutrition at an early age, the World Health Organization (WHO) and UNICEF have developed the Baby Friendly Hospital Initiative (BFHI) to address poor breastfeeding practices in maternity wards. However, impact is limited in less developed countries like Kenya, where more than half of all births are home deliveries. Therefore, Kenya has explored the adoption of Baby Friendly Community Initiative (BFCI) in its rural settings. In contrast to the BFHI, the BFCI supports breastfeeding and optimal infant feeding in community. BFCI has been implemented in Koibatek, in rural Kenya. This study aimed at assessing the effectiveness of BFCI on complementary feeding practices of children aged 6–23 months, by comparing intervention and control groups.MethodsThis was a randomized control study design that included 270 mother-infant pairs enrolled in the Baby Friendly Community Initiative (BFCI) project in Koibatek. Evaluation was carried out using structured questionnaires.ResultsA statistically significantly higher proportion of children in the intervention group compared to the control group attained minimum dietary diversity (77% vs. 58%; p = 0.001), minimum meal frequency (96% vs. 89%; p = 0.046) and minimum acceptable diet (77% vs. 61%; p = 0.005). The odds of attaining minimum dietary diversity, minimum meal frequency and minimum acceptable diet were statistically significantly higher for the intervention group compared to control group (OR: 4.95; 95%CI 2.44–10.03, p = < 0.001; OR: 14.84; 95%CI 2.75–79.9, p = 0.002; OR: 4.61; 95%CI 2.17–9.78, p = < 0.001 respectively).ConclusionThe BFCI intervention was successful in improving complementary feeding practices. Strengthening and prioritizing BFCI interventions could have a significant impact on child health outcomes in rural Kenya.Trial registrationISRCTN03467700. Registration 24 September 2014. Retrospectively registered.

Effectiveness of the Baby Friendly Community Initiative in Italy: a non-randomised controlled study

ObjectiveTo assess the effectiveness of the Baby Friendly Community Initiative (BFCI) on exclusive breast feeding at 6 months.DesignControlled, non-randomised trial.Setting18 Local Health Authorities in 9 regions of Italy.Participants5094 mother/infant dyads...

Feasibility and effectiveness of the baby friendly community initiative in rural Kenya: study protocol for a randomized controlled trial.

BackgroundInterventions promoting optimal infant and young child nutrition could prevent a fifth of under-5 deaths in countries with high mortality. Poor infant and young child feeding practices are widely documented in Kenya, with potential detrimental effects on child growth, health and survival. Effective strategies to improve these practices are needed. This study aims to pilot implementation of the Baby Friendly Community Initiative (BFCI), a global initiative aimed at promoting optimal infant and young child feeding practices, to determine its feasibility and effectiveness with regards to infant feeding practices, nutrition and health outcomes in a rural setting in Kenya.MethodsThe study, employing a cluster-randomized trial design, will be conducted in rural Kenya. A total of 12 clusters, constituting community units within the government’s Community Health Strategy, will be randomized, with half allocated to the intervention and the other half to the control arm. A total of 812 pregnant women and their respective children will be recruited into the study. The mother-child pairs will be followed up until the child is 6 months old. Recruitment will last approximately 1 year from January 2015, and the study will run for 3 years, from 2014 to 2016. The intervention will involve regular counseling and support of mothers by trained community health workers and health professionals on maternal, infant and young child nutrition. Regular assessment of knowledge, attitudes and practices on maternal, infant and young child nutrition will be done, coupled with assessment of nutritional status of the mother-child pairs and morbidity for the children. Statistical methods will include analysis of covariance, multinomial logistic regression and multilevel modeling. The study is funded by the NIH and USAID through the Program for Enhanced Research (PEER) Health.DiscussionFindings from the study outlined in this protocol will inform potential feasibility and effectiveness of a community-based intervention aimed at promoting optimal breastfeeding and other infant feeding practices. The intervention, if proved feasible and effective, will inform policy and practice in Kenya and similar settings, particularly regarding implementation of the baby friendly community initiative.Trial registrationISRCTN03467700; Date of Registration: 24 September 2014

The New Zealand/Aotearoa Baby-Friendly Hospital Initiative Implementation Journey

The Baby-Friendly Hospital Initiative (BFHI) was launched by the World Health Organization and United Nations International Children's Emergency Fund in 1991 following the Innocenti Declaration of 1990, of which New Zealand/Aotearoa was a signatory. After a number of unsuccessful attempts to implement BFHI by breastfeeding advocates, the New Zealand Breastfeeding Authority (NZBA) was established in 1999. Successful BFHI implementation was achieved through a number of factors, including the establishment of a national body (NZBA) with oversight of BFHI facility implementation and auditing, Māori and consumer participation at all levels, the recertification requirements for midwives of breastfeeding education by the Midwifery Council, and maternity facilities having paid BFHI coordinators. Once the NZBA was established, BFHI accreditation of maternity facilities had a rapid rise from 0% in 2000 to 96.1% in 2011 (74 of 77 facilities). Data collected over this period shows a 28.8-percentage-point increase of exclusive breastfeeding at discharge from maternity facilitates between 2001 (55.6%) and 2011 (84.4%). Future strategies focus on having all relevant community providers achieve Baby-Friendly Community Initiative accreditation and on the NZBA's lobbying the government for initiatives that support, promote, and protect breastfeeding.

A Controlled Study on Baby-Friendly Communities in Italy: Methods and Baseline Data

This study reports the research methods and baseline data of a project aimed at assessing the effect of an intervention based on the 7 Steps of the Baby Friendly Community Initiative (BFCI) on the rate of exclusive breastfeeding at 6 months in Italy. In this controlled, nonrandomized study, nine Local Health Authorities were assigned to an early and nine to a late intervention group. Data on breastfeeding in infants followed up from birth to 12 months were gathered at baseline and in two subsequent rounds, after the 7 Steps were implemented in the early and late intervention groups, respectively. Step-down logistic regression analysis, corrected for the cluster effect, was used to compare breastfeeding rates between groups. At baseline, there were no significant differences in breastfeeding rates at birth (n=1,781) and at 3 (n=1,854), 6 (n=1,601), and 12 (n=1,510; loss to follow-up, 15.2%) months between groups. At birth, 96% of mothers initiated breastfeeding, 72% exclusively (recall from birth). At 3 months, 77% of infants were breastfed, 54% exclusively with 24-hour and 46% with 7-day recall. At 6 months, the rate of any breastfeeding was 62%, with 10% and 7% exclusive breastfeeding with 24-hour and 7-day recall, respectively. At 12 months, 31% of the children continued to breastfeed. The project is ongoing and will allow estimation of the effect of the BFCI.

Constructing a baby-friendly community

The Baby-Friendly Hospital Initiative (BFHI), developed by the World Health Organization and the United Nations Children's Fund to promote breastfeeding in maternity facilities worldwide, has had a global impact on breastfeeding outcomes. However, further interventions are necessary before and after hospital discharge to meet the initiative's recommended 6-month targets. The Baby-Friendly Community Initiative (BFCI), a multifaceted program for community based breastfeeding promotion designed to complement BFHI, addresses this challenge. The purpose of this paper is to introduce the origin of BFCI and its current implementation status in several countries as a reference for effective BFCI promotion in Taiwan.

Establishing the Baby-Friendly Community Initiative in Italy

The Baby-Friendly Hospital Initiative (BFHI), developed by the World Health Organization and the United Nations Children's Fund (UNICEF) to promote breastfeeding in maternity facilities worldwide, has had a global impact on breastfeeding outcomes, but other interventions are needed both before and after hospital discharge to meet the recommended targets at 6 months. The Baby-Friendly Community Initiative (BFCI), a multifaceted program for community-based breastfeeding promotion that is complementary to the BFHI, addresses this challenge. To describe the development, strategy, and implementation of the BFCI in Italy. In 2006, UNICEF Italy created a working group to develop the BFCI for the Italian health system. A review of the different BFCI models worldwide was conducted. A preliminary adaptation of tools to Italian community health care settings was developed in 2007, when the Italian BFCI Seven Steps were published. Two years later, UNICEF Italy launched the Standards for Best Practice for both hospitals and communities, based on 2009 BFHI and UNICEF UK BFCI materials. The main outcome was to promote this process in Italian regional health systems and develop tools to assess compliance with the BFCI criteria. There is now one fully accredited Baby-Friendly Community in Italy, and 17 other communities are working on the various stages. The BFCI, a complex program that involves participation, training, audits, a continuous flow of feedback, and provision of resources for health workers and families, is now a reality in Italy.