Social Franchising and a Nationwide Mass Media Campaign Increased the Prevalence of Adequate Complementary Feeding in Vietnam: A Cluster-Randomized Program Evaluation

The Alive & Thrive (A&T) initiative, carried out in Bangladesh, Ethiopia, and Vietnam, applied principles of social franchising within the government health system in Vietnam to improve the quality of interpersonal counseling (IPC) for infant and young child feeding (IYCF), combined with a national mass media (MM) campaign and community mobilisation (CM). (See Related Summaries, below.) Studies in a variety of contexts have reviewed strategies to improve child growth and development through investments in improving breastfeeding practices and complementary feeding (CF) knowledge and practices. At the time of planning this study, programmatic examples of CF interventions delivered within the context of large-scale programmes, or national health systems, with rigorous evaluation designs were limited. This study examines the role of social franchising to address IYCF practices and offers an example of the potential of the approach to address nutrition-related issues.

Social franchising applies commercial franchising concepts so that a brand identity is equated with quality services (in this case, through standardised operating procedures, support, and training) that help achieve social and health benefits. In Vietnam, A&T, through Save the Children, worked with the government to establish a total of 781 social franchises within government health facilities in 15 of 63 provinces at the province, district, and commune levels, using social franchising principles to deliver facility-based individual and group IYCF counseling under the brand name Mặt Trời Bé Thơ, or MTBT ("The Little Sun" in English). Referrals, CM, promotional print materials, and television advertising were used to generate demand for preventive IYCF counseling services. The MM component consisted of a national broadcast campaign that used television and digital media (internet and mobile phone applications); 1 of 4 television spots focused on promoting iron-rich food consumption beginning at 6 months of age, and another television spot promoted the use of franchise services. In intensive areas, the MM campaign also included additional out-of-home advertising on optimal IYCF practices through billboards and broadcasts on village loud-speakers. In intensive areas, CM was operated by village health workers who visited households of women with children younger than 24 months to deliver invitation cards, encourage mothers to attend MTBT counseling services, and provide women with basic IYCF messages.

Thus, A&T used 3 different components (i.e., enhanced IPC, CM, and MM) to deliver interventions. The "intensive" group was exposed to all 3 interventions; the "nonintensive" group was exposed to standard IPC and less-intensive MM and CM. Standard IPC consisted of messages and information on IYCF delivered by doctors or midwives as part of routine child health care contacts at the health facilities. In nonintensive areas, the MM component did not include community airing of loudspeaker announcements and posters promoting breastfeeding in commune health centres. In nonintensive areas, CM was less structured and covered general health care topics, such as family planning, pregnancy registration, and antenatal care, and did not include the distribution of invitation cards to attend IYCF-related counseling.

During the 4-year intervention period, nearly 5,000 frontline workers and health providers were trained, and the IPC reached an estimated 340,000 mothers of children younger than 2 years of age in the 15. The MM intervention operated at a national level, reaching greater than 11 million women aged 15-35 years.

The study used a cluster-randomised, nonblinded evaluation design with cross-sectional surveys (n=~500 children aged 6–23.9 mo and ~1000 children aged 24-59.9 mo/group) implemented at baseline (2010) and endline (2014). Difference-in-difference estimates (DDEs) of impact were calculated for intent-to-treat (ITT) analyses (includes every subject who is randomised according to randomised treatment assignment, ignoring noncompliance, protocol deviations, withdrawal, and anything that happens after randomisation) and modified per-protocol analyses (MPAs; mothers who attended the social franchising at least once: 62%. There were not enough children who adhered to the recommended number of visits to an MTBT facility, as specified in the IPC package for CF, to conduct a usual per-protocol impact analysis).

Groups were similar at baseline. In ITT analyses, there were no significant differences between groups in changes in CF practices over time. (Five CF indicators were examined: 1) minimum dietary diversity (defined as children who consumed foods from greater than or equal to 4 food groups out of 7 food groups in the previous 24 hours), 2) minimum meal frequency as appropriate for age, 3) minimum acceptable diet (defined as children who were breastfed and who also achieved the minimum dietary diversity and age-appropriate minimum meal frequency), 4) consumption of iron-rich or iron-fortified foods, and 5) timely introduction of solid, semisolid, or soft foods. Mothers or caregivers were asked about all liquids, solids, and semisolid foods consumed by the child during the previous day.) In the MPAs, greater improvements in the intensive than in the nonintensive group were seen for minimum dietary diversity [DDE: 6.4 percentage points (pps); P< 0.05] and minimum acceptable diet (8.0 pps; P< 0.05). Significant stunting declines occurred in both intensive (7.1 pps) and nonintensive (5.4 pps) groups among children aged 24-59.9 months, with no differential decline.

This means that, when combined with MM and CM, "an at-scale social franchising approach to improve IPC, delivered through the existing health care system, significantly improved CF practices, but not child growth, among mothers who used counseling services at least once." The researchers note that gap between the recommended number of visits (as per the design of the programme) and actual visits - which is what led them to conduct an MPA - was widest among children greater than or equal to 6 months of age. They say that an important consideration influencing utilisation of MTBT for CF advice in the context of Vietnam is that mothers tend to re-enter the workforce when their children are between 4 and 6 months of age. Thus, designing and using effective targeted demand-generation activities for facility-based preventive health care services services are of critical importance to ensure that more women receive counseling. "[I]t is important to address challenges to improve service utilization in order to achieve full program impact."

The researchers reflect in the discussion section: "The scale of this program and its primary focus on social behavior change communication (SBCC) distinguish it appreciably from previous studies and evaluations...that examined feeding behavior and/or growth in relatively controlled settings (efficacy trials) primarily among families or children with confirmed receipt of an education- or food-based intervention and with high adherence rates." They point to several lessons learned from this social franchise approach to deliver high-quality IPC at scale and to improve CF practices, all within a government health system. "The franchise start-up involved implementation steps to advance the model in 15 provinces simultaneously, ensuring that lessons learned could be broadly applied to other geographic areas. Extensive formative research was used to develop the behavior change interventions, including the IPC service package, the franchise brand, educational materials, and MM. The roll-out and scale-up of the franchise operations were carried out in conjunction with routine monitoring of quality and coverage, supervisory, and management approaches that supported implementation."