Our findings indicate that a combined community infant and young child feeding training and a newsletter reduced the mean duration of diarrhoea by a remarkable 2.3 days at 14 weeks compared to control areas. The findings also showed that 76% of infants who had diarrhoea might have been prevented if their mothers had received both interventions at 14 weeks. No other study has measured the effect of mother- based promotion of exclusive breastfeeding intervention in Zimbabwe using a factorial design.
On the other hand, our study demonstrates that providing timely and accurate information to mothers is effective, fundamental and promotes exclusive breastfeeding. Additionally, mother-based promotion of exclusive breastfeeding results in an increase in exclusive breastfeeding rates, reduced duration of diarrhoea and pneumonia as well as significant increase in age specific immunization through the use of a newsletter.
The findings of this study are however unique in that the cue to action was achieved through an approach that is potentially replicable, sustainable and was delivered through existing routine health services in primary health care settings. The result that the newsletter works better than community infant and young child feeding training is not in accord with any previous studies as we did not find a similar approach in literature. We are also not aware of other published studies that have evaluated the effects of mother-based promotion of exclusive breastfeeding, but the approach may be similar to other studies where letters were used to increase adherence to tetanus booster vaccination among adults [23] and letters that were used in improving immunization coverage [24]. In Tanzania, a Cochrane systematic review showed that the use of letters was effective in improving male participation in the PMTCT programme [25]. Nevertheless, the design or even the context was not similar to our study.
Thus, relative to no intervention, the use of both the newsletter and cIYCF training for village health workers resulted in a more than double absolute mean decrease in the duration of diarrhoea while the newsletter remained effective even up to 20 weeks. The possible explanations for this finding is that; village health workers trained in cIYCF track mothers before and soon after delivery to record them in their registers. So during this period they are more likely to counsel mothers for exclusive breastfeeding. On the other hand, firstly, the newsletter is a marketing tool that ensures that women receive complete, accurate, timely, and consistent information on breastfeeding which is fundamental for any program promoting exclusive breastfeeding [18-20]. It demonstrates the feasibility of disseminating breastfeeding messages directly to the intended users in the developing world. Thus if the media and various communications target optimal breastfeeding, it is possible to achieve universal exclusive breastfeeding in Zimbabwe.
Secondly, a newsletter has the properties that can help women to sort the myths surrounding breastfeeding. It also helps women to understand the benefits of breastfeeding without misinformation or mixed messages while ensuring that women receive accurate, complete and consistent messages to protect, promote and support breastfeeding [26].
Thirdly, the newsletter acted as a reference material that was used by mothers at home to solve common breastfeeding problems that were highlighted in some studies as a barrier to exclusive breastfeeding [27-29]. Furthermore, since the newsletter contained information on most frequently asked questions and answers, how to overcome breastfeeding difficulties aided in improving breastfeeding practices thereby impacting on diarrhoea and pneumonia duration [30].
Our findings are consistent with other studies that evaluated the effects of community-based interventions on EBF [19,31-34]. Unanimous evidence shows that interventions that increase exclusive breastfeeding have positive effects on reducing duration of diarrhoea and pneumonia [35-39]. The reduction then impacts on severity of diarrhoea and the ultimate goal to reduce child/infant mortality can be achieved [17,20]. Another study conducted in Dhaka, Bangladesh showed that deaths from diarrhoea and pneumonia could be reduced by a third if infants were exclusively breastfed for first six months [21,33,39-41].
Nevertheless, the findings of this study also probably indicate the less effectiveness of the cIYCF training beyond 14 weeks after delivery. The possible implication of our results is that with cIYCF alone, universal exclusive breastfeeding or reaching the target of 90% EBF up to six months will not be possible in Midlands Province.
There are several explanations to our findings; the effectiveness of cIYCF training depends on the full coverage of the trainings in all facilities and their communities and thus uses a dose response relationship. In our study setting, some clusters were trained but full coverage was not achieved. This might have impacted heavily on the village health worker: mother ratio which was estimated at 1 VHW: 365 mothers, with most mothers not receiving the benefits of the trainings.
A report in The Lancet of a randomized trial comparing the effects of hospital-based system and community-based system intervention providing ten postnatal home visits found that home visits significantly increased the chances of exclusive breastfeeding [32,33,42]. Thus in our setting, it might be possible that home visits were only being conducted soon after delivery and probably up to three months while beyond 14 weeks the frequency became insignificant. This is of great concern and thus calls for other interventions that help to sustain EBF up to six months. Thus a breastfeeding newsletter bridges the gap as it is given directly to the mother. Providing consistent information is an enabling environment for sustainable EBF up to six months.
Another study have shown that the use of trained peer counsellors on the pay roll was more effective compared to volunteers [32,34]. The use of volunteers is the most likely scenario in our case and hence it is less effective. This might be because the effectiveness of cIYCF depends on motivated peer counsellors or volunteers, since the approach relies on training peer counsellors or volunteers to impart knowledge to mothers. Several studies elsewhere suggested the implementation of cIYCF at scale, intensive follow up and supportive supervision, as well as routine monthly meetings or non- financial incentives to peer counsellors as improving the effectiveness of cIYCF trainings.
In this study, the lack of association with severity of diarrhoea can be explained by the fact that, though not exclusive, over 98% of infants in all groups were being breastfed. Given that continued breastfeeding reduces dehydration, few infants developed severe diarrhoea and thus probably the sample size was not adequate to determine meaningful differences. It is also possible that treatment efficacy of Zinc Sulphate and oral rehydration solution played an important role in treatment and prevention of dehydration. Similar findings were reported in an educational intervention where village and community health workers were trained in community infant and young child feeding showed an increase in exclusive breastfeeding but no association with severe diarrhoea [22,35,36,39,43].
Cluster randomized trials are also prone to bias. We noted some differences in employment status and knowledge on exclusive breastfeeding among infants of mothers. In addition, in the cluster that received both interventions, an organization called Zvitambo was also following up breastfeeding mothers. However, we do not think that the highlighted factors can contribute to the differences noted in diarrhoea and pneumonia duration, but deserve further investigation.
It is also possible that information highlighted in the newsletter that was given to a sub-group of mothers in intervention communities contaminated intervention sites and reinforced the motive to read and understand the contents so that one stands a chance to win. In so doing, mothers understood the benefits and dangers of not breastfeeding exclusively. In tandem with the Health Belief Model, a theory widely used in preventive health behaviour; because of the perceived benefits, mothers were more likely to take action. Perceived benefits are a determinant of preventive health actions [44]. However, the role of chance could not be ruled out as a possible explanation for this finding.
The use of a breastfeeding newsletter and a newsletter plus cIYCF can be generalized to other types of preventive care, since this approach was borrowed from the promotion of healthy lifestyles in Japan through the Healthy Obihiro 21. However it would be an important area for future research. Since the intervention depended on ability to read, findings cannot be generalized to illiterate communities.
Some limitations of our study included observation bias in reporting especially mothers of infants in the intervention communities tended to over report exclusive breastfeeding and under report illnesses. This was overcome by the use of trained nutritionist and nutrition assistants.