Feasibility and Acceptability of Integrating a Multicomponent Breastfeeding Promotion Intervention into Routine Health Services in Private Health Facilities in Lagos State, Nigeria: A Mixed Methods Process Evaluation

"This study provides evidence that it is feasible and acceptable for private health providers in Lagos to include breastfeeding counseling and support as part of the antenatal and postnatal services they provide."

Many factors across multiple socio-ecological levels have been identified that promote or inhibit exclusive breastfeeding in Nigeria. Studies show that mothers who report more health service contacts are more likely to practice exclusive breastfeeding for the recommended length of time (6 months), yet most healthcare providers in Lagos State, Nigeria, are private and are not required to offer breastfeeding counseling to women. In response, from May 2019 to April 2020, Alive & Thrive (A&T) implemented a multicomponent breastfeeding promotion intervention in private health facilities in Lagos. This paper describes a mixed-methods process evaluation in 10 intervention and 10 comparison private health facilities to examine the feasibility and acceptability of integrating the intervention into routine health services.

Implemented by a Nigerian organisation, Equitable Health Access Initiative (EHAI), in collaboration with A&T, the intervention had components including: training and coaching facility owners/managers and health providers on implementing the Baby-Friendly Hospital Initiative (BFHI) and breastfeeding counseling skills; providing interpersonal communication and counseling in person and on WhatsApp by trained health providers to pregnant women and lactating mothers; and distributing behaviour change communication (BCC) materials such as posters and counseling cards to health providers and pocket-sized cards to the pregnant women and mothers. All trainings were conducted with comprehensive infant and young child feeding (IYCF) counseling training materials.

A total of 238 facility owners/managers and health providers from the 10 intervention health facilities received 3-day onsite trainings in May 2019, with the expectation that they would cascade the training to other health providers in the health facilities. The intervention also included an mHealth component in which pregnant women and lactating mothers received one breastfeeding message per day shared via bulk text messages/SMS and could participate in breastfeeding support groups on WhatsApp, led by an assigned "Breastfeeding Champion" (mothers who had practiced exclusive breastfeeding for 6 months and were recruited to provide peer support). Breastfeeding messages were also broadcast on TV screens in the waiting rooms at the health facilities, and A&T implemented a breastfeeding mass media campaign in Lagos State using radio and TV. EHAI conducted quarterly onsite coaching and supportive supervision visits to the health facilities. A&T and EHAI did not provide any programme support to the comparison health facilities.

The impact of the intervention has been documented elsewhere (see Related Summaries, below). In brief, mothers in the intervention health facilities who received breastfeeding counseling from a health provider, received a breastfeeding-related text or WhatsApp messages, or heard A&T radio spots had increased odds of practicing exclusive breastfeeding at 6 weeks. Mothers in the intervention health facilities who had participated in the WhatsApp support groups also had increased odds of practicing exclusive breastfeeding at 24 weeks. To successfully scale the multicomponent intervention to other parts of Nigeria, the present study is designed to examine and understand the effects of the intervention on service provision in the private health facilities, including factors that make implementation feasible and acceptable.

The researchers conducted in-depth interviews with 20 health facility owners/managers and providers, 179 structured observations of health providers during service provision to pregnant and lactating women, and 179 exit interviews with pregnant and lactating women. Key results:

• Feasibility of private health providers including breastfeeding counseling and support as part of their services: Almost all health facility providers, owners, and managers appreciated that the owners and managers had been included in all the intervention activities. They explained that this approach had strengthened relationships, facilitated programme activities, and fostered an environment that was conducive to providing breastfeeding counseling and support to mothers. The health providers also mentioned employing creative communication approaches such as singing songs during counseling sessions to make the breastfeeding messages simpler. The health facility owners and managers appreciated the practical support skills the health providers obtained from the training and coaching they had received (e.g., skills to help with baby positioning and latching) and were now using to support mothers to practice exclusive breastfeeding.
• Barriers and facilitators to integrating breastfeeding counseling and support into services at private health facilities: Most health facility owners/managers and providers reported enjoying the training they received from EHAI and A&T because they learned how to communicate their messages more effectively. Health providers reported that all the practical skills from the training had been helpful in providing counseling to the women and supporting them to practice exclusive breastfeeding. Some health providers mentioned that the counseling materials they had received had been helpful in communicating breastfeeding messages to the mothers. They also said reaching pregnant women and lactating mothers on WhatsApp had been helpful to continue to support, encourage, and provide positive reinforcement for mothers to practice exclusive breastfeeding. However, the health providers reported implementation barriers, including increased workload, use of personal time for counseling on WhatsApp, and some mothers' lack of access to WhatsApp support groups.
• Health providers' experiences with implementing and mothers' experiences with participating in the intervention: Most of the health providers reported improvements in the quality of services offered, which they attributed to the intervention. Other health providers reported feeling more motivated to work because of the intervention. Third-trimester exit interviews showed that 86% of women in the intervention health facilities were very confident they could carry out the breastfeeding advice they received, compared to 47% in the comparison health facilities.
• Influence of the intervention on service delivery in the private health facilities:  At 6 weeks postpartum, more mothers were asked if they were breastfeeding at the intervention facilities (63%) compared to only 36% of mothers in the comparison facilities. The benefits of exclusive breastfeeding were discussed with more mothers at the intervention (59%) compared to the comparison health facilities (36%) at 6 weeks postpartum. The third-trimester exit interviews showed that 53% of women from the intervention health facilities received breastfeeding counseling, compared with 40% of women from the comparison health facilities. The exit interviews with lactating mothers at the 6 weeks postpartum visits also showed that 61% of mothers in the intervention facilities reported receiving breastfeeding counseling compared with 30% of mothers in the comparison health facilities.

Despite more pregnant women and mothers receiving breastfeeding counseling in the intervention health facilities, there were still gaps in intervention facilities (e.g., not including counseling about giving babies water in addition to breastmilk), which need to be addressed for a successful scaling of the intervention. "Future private health facility-based breastfeeding promotion interventions in Lagos could consider including targeted messages that address...socio-cultural beliefs about water and breastfeeding."

Going forward, the researchers also recommend that:

• Health facility owners and managers employ task shifting strategies to help manage the client load;
• Health providers use the counseling materials during counseling sessions to ensure consistency in the quality of counseling provided; and
• Breastfeeding Champions offer in-person support sessions in addition to the WhatsApp support groups, at the private health facilities or at community spaces that are familiar and accessible to the mothers. (This strategy would allow mothers without smartphones to receive exclusive breastfeeding social support from the Breastfeeding Champions and other mothers.)

In conclusion, the research suggests that provision of breastfeeding counseling and support through private health facilities is feasible and acceptable, but service delivery challenges must be considered for successful scale-up.