The Association of a Large-Scale Television Campaign With Exclusive Breastfeeding Prevalence in Vietnam

"...study supports a growing literature showing that mass media can make a valuable contribution to behavioral beliefs, social norms, self-efficacy, and knowledge, which in turn prepares mothers to adopt exclusive breastfeeding behaviors."

A 2014 review identified 45 peer-reviewed studies that used social and behaviour change communication (SBCC) to address exclusive breastfeeding (EBF), 33 of which showed statistically significant results. Mass media is viewed as especially important for promoting EBF to counter the advertising and promotion of infant formula. Alive & Thrive (A&T) is an international initiative whose goal is to scale up nutrition to save lives, prevent illness, and ensure healthy growth and development through the first 1,000 days of life. In Vietnam, A&T aimed to increase EBF by implementing a behaviour change programme that included interpersonal counseling through branded social franchise services and a nationwide mass media campaign. By collecting data during 5 repeated cross-sectional surveys in a 3-year time span across 4 provinces of Vietnam, this study examined the association between exposure to A&T Vietnam's breastfeeding television spots and exclusive breastfeeding (EBF).

The A&T mass communication in Vietnam, which is detailed at Related Summaries, below, included: (i) 4 television spots, (ii) print materials (posters, booklets, leaflets, and newspaper articles), (iii) out-of-home advertising (on billboards, screens in supermarkets and hospitals, bus advertisements, and loudspeakers), and (iv) digital materials and communication (website, online forum, online counseling, a Facebook fan page, television spots online, and a mobile telephone application). Of the 4 television spots, 2 addressed EBF: one by focusing on the behaviour of not giving water (see the video below) and the other by encouraging mothers to nurse more to produce more breastmilk. This study's focus was on the 2 breastfeeding television spots. The television spots, developed through extensive formative research, concept testing, and pretesting and professionally produced, were broadcast in intensive bursts from December 2011 through January 2015 on national and provincial television channels.

The researchers performed face-to-face interviews with 11,722 mothers of infants younger than 6 months of age using 5 cross-sectional surveys 6 or more months apart between 2011 and 2014 in Vietnam. Sample sizes were 2,065 to 2,593, and approximately 50% of participants lived in areas with (A&T-intensive [I]) and approximately 50% without (A&T-nonintensive [NI]) facilities offering counseling services at social franchises. The researchers analysed data at individual and commune levels separately for A&T-I and A&T-NI areas.

Exposure to television spots was associated with higher EBF in A&T-I (odds ratio [OR] = 3.33; 95% confidence interval [CI] = 2.70, 4.12) and A&T-NI (OR = 1.31; 95% CI = 1.03, 1.67) areas. In A&T-I areas, mothers who could recall at least 1 message were more likely to report EBF. In A&T-NI areas, only recall of at least 3 messages was associated with higher EBF. In communes, 1 message recalled (mean score range = 0.3-2.4) corresponded to 17 (P = .005) and 8 (P = .1) percentage points higher EBF prevalence in A&T-I and A&T-NI communes, respectively.

The researchers offer several possible explanations for the differences between A&T-I and A&T-NI areas:

1. In A&T-NI areas, the only mass media activity was broadcasting the television spots on national and provincial stations. In A&T-I areas, the mass media campaign itself was more intensive than in A&T-NI areas because campaign messages were also echoed via television spots on screens at franchises, take-home materials (e.g., leaflets and booklets), posters, billboards, and short dramas about infant feeding broadcast on village loudspeakers. Women who had visited a franchise were more likely to remember exposure and to recall messages. It is also possible that the mass media campaign motivated women to visit franchises.
2. Exposure to the television spots and message recall were associated with shifting knowledge, behavioral beliefs, social norms, and self-efficacy in both A&T-NI and A&T-I areas. The translation from improved behavioural determinants into EBF behaviour may have been potentiated by additional support, such as interpersonal counseling services in A&T-I areas.
3. The media campaign may have enhanced the effects of the franchise counseling in 4 ways: (i) The television spots may have improved counselors' motivation or performance. (ii) The highly emotional tone of the television spots may have added a new dimension to the content of messages that were also delivered through interpersonal counseling. (iii) Mothers may have been more persuaded to adopt a behaviour when exposed to messages through more than 1 channel. (iv) The television spots may have helped to shift social norms related to EBF, meaning that mothers perceived that others like them or others who influence them support EBF.

In conclusion, the findings "may persuade practitioners to use theory-based and emotion-focused television spots for social and behavior change, especially as part of comprehensive programs" and "may aid people in fields beyond nutrition as they consider mass media for similarly complex behaviors".