Prepared by: Jenny Moberg
Date: 2 September2012
Health system and public health evidence to recommendations framework
Should lay health workers (LHW) promote and counsel exclusive breastfeeding to 6 months?
Problem: Low uptake of exclusive breastfeeding
Option: LHW promoting/counselling exclusive breastfeeding
Comparison: Usual care (probably no promotion)
Setting: Community/primary health care settings in low
income countries
P RO B LE M
CRITERIA
Is the
problem a
priority?
Are a large
number of
people
affected?
JUDGEMENTS
No
Probably
No
Uncertain
Probably
Yes
Yes
Varies*
X
No
Probably
No
Uncertain
Probably
Yes
Yes
Background: The neonatal mortality rate in low income countries (LIC) is 33 per 1000 livebirths.1 It is estimated that optimal breastfeeding
could reduce all-cause neonatal mortality or morbidity by 55 to 87% in the world’s 75 poorest countries. 2 Exclusive breastfeeding for 6 months,
with initiation within the first hour of life, is the optimal way of feeding infants and is strongly recommended by WHO. It protects infants from
diarrhoea and acute respiratory infections – two of the major causes of infant mortality in the developing world – and improves their responses
to vaccination. Particularly in unhygienic conditions, breast milk substitutes carry a high risk of infection and can be fatal in infants.
Breastfeeding also contributes to the health of mothers; it helps to space children, increases family resources, and is a secure way of feeding.3
It is estimated that an average of 36% of babies in LIC are exclusively breastfed, with as few as 20% in some West and Central African
countries.4 Breastfeeding promotion and counseling have been shown to be effective in increasing exclusive breastfeeding rates.3 To expand
access for mother-infant pairs to breastfeeding promotion and counseling lay health workers (LHW) can be used. Lay health worker is a broad
term describing paid or voluntary healthcare providers who have not undergone formal or paraprofessional higher education but have usually
received job-related training. Included in this group are community health workers, village health workers, treatment supporters, and birth
attendants. LHWs may be one way to extend effective neonatal interventions, such as the promotion and counseling of breastfeeding.
RESEARCH EVIDENCE
ADDITIONAL INFORMATION
The neonatal mortality rate in LIC is 33 per 1000 livebirths.1 Optimal breastfeeding could reduce allcause neonatal mortality or morbidity by 55-87%, saving the lives of 1.5 million children under five
globally every year2
*Promotion of exclusive breast feeding might
not be a priority in settings where there is
already a high proportion of exclusively
breastfed babies or low neonatal mortality
rates.
On average, only roughly 1 in 3 infants 0 to 6 months old are exclusively breastfed in LICs4
*In some settings a large proportion of babies
may already be exclusively breastfed.
Varies*
X
HSPH EtR framework (Version 2): Increasing rural access to healthcare workers Option A1
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Problem: Low uptake of exclusive breastfeeding
CRITERIA
B E NE F IT S & HA RM S O F T HE O P T IO NS
Are the
desirable
anticipated
effects large?
Are the
undesirable
anticipated
effects small?
Option: LHW promoting/counselling exclusive breastfeeding
JUDGEMENTS
No
Probably
No
Uncertain
RESEARCH EVIDENCE
Probably
Yes
Yes
Varies
X
ADDITIONAL INFORMATION
Summary of findings: LHW promoting exclusive breastfeeding vs no promotion
No
Probably
No
Uncertain
Probably
Yes
X
Yes
Varies
No
included
studies
Very low
Low
Moderate
X
High
Setting: Community/primary health care settings in low
income countries
A systematic review identified 15 trials, 8 from low and middle income countries and 7 from high income
countries. Some trials assessed the effectiveness in increasing exclusive breastfeeding rates of LHWs
promoting, others assessed the effectiveness of LHW counselling, and others assess the effectiveness of
LHW doing both activities. The trials showed that:
 LHW-based promotion/counselling activities probably increase the number of mothers who breastfeed
exclusively for up to six months compared to usual care (moderate certainty of this evidence)
Outcome
Exclusive
breastfeeding
What Is the
overall
certainty of
this evidence?
Comparison: Usual care (probably no promotion)
No promotion
(per 1000
women)
LHW
promotion
(per 1000
women)
Difference
(per 1000
women)
Relative effect
(RR)
(95%CI)
Certainty of
the evidence
(GRADE)
360
965
605 more
RR 2.68
(1.86 to 3.87)
Moderate
Increased
access to
breastfeeding
counselling
No evidence included in this review.
Adverse effects
No evidence included in this review. See additional information*.
This review did not report any adverse effect
caused by LHW promoting or counselling
breastfeeding.
*HIV is known to be transmitted through
breastfeeding. However, in low and middle
income countries WHO still recommends
exclusive breastfeeding for 6 months with
antiretroviral treatment for the mother and /or
infant6
Based on Lewin 20125 Link to detailed evidence profile
HSPH EtR framework (Version 2): Lay health workers – breastfeeding promotion/counseling
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Problem: Low uptake of exclusive breastfeeding
CRITERIA
Option: LHW promoting/counselling exclusive breastfeeding
JUDGEMENTS
Comparison: Usual care (probably no promotion)
RESEARCH EVIDENCE
Setting: Community/primary health care settings in low
income countries
ADDITIONAL INFORMATION
The relative importance or values of the main outcomes of interest:
How certain
is the relative
importance of
the desirable
and
undesirable
outcomes?
Important
uncertainty
or
variability
Possibly
important
uncertainty
or
variability
Probably
no
No
important important
uncertainty uncertainty No known
or
or
undesirable
variability variability outcomes
X
Outcome
Relative importance
Certainty of the evidence
Exclusive breast feeding
No evidence
-
Increased access to
breastfeeding
counselling
No evidence
-
Adverse effects
No evidence*
-
Exclusive breastfeeding for 6 months protects infants
from diarrhoea and acute respiratory infections and
improves their responses to vaccination. Where clean
water is sparse breast milk substitutes carry a high
risk of infection and can be fatal in infants.
Breastfeeding also contributes to the health of
mothers; it helps to space children, increases family
resources, and is a secure way of feeding
V A LUE S
*See additional information above regarding HIV.
Are the
desirable
effects large
relative to
undesirable
effects?
No
Probably
No
Uncertain
Probably
Yes
X
Yes
Varies
See the summary of findings and relative importance of the main outcomes above.
HSPH EtR framework (Version 2): Lay health workers – breastfeeding promotion/counseling
Both exclusive breastfeeding and access to
counselilng are considered important and there are
no reported adverse effects of LHW delivering
breastfeeding promotion and counselling in the
review
3
Problem: Low uptake of exclusive breastfeeding
CRITERIA
Option: LHW promoting/counselling exclusive breastfeeding
JUDGEMENTS
Comparison: Usual care (probably no promotion)
RESEARCH EVIDENCE
Setting: Community/primary health care settings in low
income countries
ADDITIONAL INFORMATION
RE S O URCE US E
Main resource requirements
Are the resources
required small?
Probably
No
Uncertain
Probably
Yes
X
Yes
Varies*
X
Settings in which LHW programmes already exist
Training
1-2 weeks of practice-based training in health
promotion and communication
Supervision
and monitoring
Regular supervision by midwife or nurse
Supplies
Promotional materials for mothers and other
caregivers
*Both the ‘probably yes’ and the ‘varies’ boxes have been ticked as
thereis wide variation in the resources required depending on factors
such as the strength of existing LHW programmes and the intensity of
the counselling programme proposed. However the resources required
are likely to be small relative to other interventions in most settings.
Is the incremental
cost small relative
to the net
benefits?
E Q UIT Y
No
Resource
What would be
the impact
on health
inequities?
No
Probably
No
Uncertain
Probably
Yes
X
Yes
Varies
The resources required are relatively small and the impacts on breastfeeding are
large. The cost effectiveness is increased if the promotion of breast feeding is done
as part of a family care package2
Increased Probably Uncertain Probably Reduced Varies
increased
reduced
X
HSPH EtR framework (Version 2): Lay health workers – breastfeeding promotion/counseling
May reduce inequities in infant morbidity and mortality
4
Problem: Low uptake of exclusive breastfeeding
A CCE P T A B ILIT Y
CRITERIA
Is the option
acceptable
to key
stakeholders?
Option: LHW promoting/counselling exclusive breastfeeding
JUDGEMENTS
No
Probably
No
Uncertain
Comparison: Usual care (probably no promotion)
RESEARCH EVIDENCE
Probably
Yes
X
Yes
Varies
Setting: Community/primary health care settings in low
income countries
ADDITIONAL INFORMATION
A systematic review of LHW programmes (Glenton 2012) suggests that recipients
are generally very positive to LHW programmes, including programmes offering
promotion and support (moderate certainty of this evidence). Recipients expressed
confidence in the knowledge and skills of the LHWs and saw them as a useful
source of information. They also appreciated the nature of the LHW-recipient
relationship, emphasising the similarities they saw between themselves and the
LHWs and the importance of trust, respect, kindness and empathy (moderate
certainty of this evidence).
However, some recipients regarded promotional activities as not relevant to their
needs (moderate certainty of this evidence). LHWs who primarily offered
promotional and counselling services sometimes expressed a need to offer "real
healthcare" such as curative care in order to better respond to the expressed
needs of the community (moderate certainty of this evidence).
F E A S IB ILIT Y
Based on Glenton 20127 Link to detailed evidence summary
Is the option
feasible to
implement?
No
Probably
No
Uncertain
Probably
Yes
X
Yes
Varies*
X
Some training and supervision is needed. However, a systematic review (Glenton
2012) suggests that ongoing support, training and supervision were often
insufficient in LHW programmes (moderate certainty of this evidence). The review
suggests that the involvement of family members, including husbands, in
promotional and other activities may be important (moderate certainty of this
evidence). However, counselling and communication, either to mothers, their
husbands and other family members about breastfeeding, family planning and
other issues was perceived by LHWs as a complex task for which they sometimes
felt unprepared and for which they requested specific training (moderate certainty
of this evidence). In addition, trainers were not necessarily competent to train them
in these skills (low certainty of this evidence).
The intervention is unlikely to require changes to norms or
regulations.
*Both the ‘probably yes’ and the ‘varies’ boxes have been ticked as
thereis wide variation in the feasibility of implementing counseling
exclusive breastfeeding by LHWs depending on factors such as the
skills, responsibilities and training of LHWs in existing LHW
programmes. However counselling exclusive breastfeeding by
LHWs is likely to be feasible in most settings.
Based on Glenton 20127 Link to detailed evidence summary
HSPH EtR framework (Version 2): Lay health workers – breastfeeding promotion/counseling
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Problem: Low uptake of exclusive breastfeeding
Balance of consequences
Undesirable consequences
clearly outweigh
desirable consequences
in most settings
Option: LHW promoting/counselling exclusive breastfeeding
Undesirable consequences
probably outweigh
desirable consequences
in most settings
Comparison: Usual care (probably no promotion)
The balance between
desirable and undesirable
consequences
is closely balanced or uncertain
Setting: Community/primary health care settings in low
income countries
Desirable consequences
probably outweigh
undesirable consequences
in most settings
Desirable consequences
clearly outweigh
undesirable consequences
in most settings
X
Type of recommendation
We recommend against the option
We suggest considering the option
Only in the context of rigorous research
Only with targeted monitoring and evaluation
Only in specific contexts
Recommendation (text)
We recommend the option
X
We recommend LHW promote and counsel exclusive breastfeeding to 6 months in settings where there is a low rate of exclusive breastfeeding and where a well-functioning LHW
programme already exists. Where a well-functioning programme does not exist, the intervention could be incorporated into a new programme, but appropriate attention must be
paid to communication skills training for LHWs, and to providing any necessary resources.
Justification
The effects of using LHWs to promote and counsel exclusive breastfeeding probably have important benefits and may be cost effective. In addition, it is probably an acceptable and
feasible intervention and may also reduce inequities by extending care to underserved populations.
Implementation
The following should be considered when using LHWs to promote and counsel exclusive breastfeeding:
 Promotional and counselling activities need to be perceived by both LHWs and recipients as relevant and meaningful. LHWs and recipients should be involved in the planning
and implementation of the intervention. Local beliefs and practical circumstances related to breastfeeding should be addressed within the programme design and the promotional
services should be designed in such a way that they are not perceived as offensive to recipients
 LHWs from the same community may be acceptable to recipients and selection processes should consider this
 LHWs, trainers and supervisors need initial and ongoing training, not only in information content but also in counselling and communication skills. Communication tools and
techniques that may be helpful include visual tools, the use of a variety of venues and opportunities to deliver promotional information, and mass media campaigns that repeat
the LHWs' promotional messages. Programmes should also consider whether and how to involve husbands and other family members in promotional activities in their particular
setting
 Financing of training and communication tools must be considered
 Changes in incentives may be necessary to reflect any changes in LHWs’ scope of practice, although giving incentives for certain tasks but not for others may negatively affect
the work that is carried out
 Responsibility for supervision of workers needs to be clear, and supervision needs to be regular and supportive
considerations
Monitoring and evaluation Consideration should be given to monitoring LHW counselling and communication skills, service delivery and resource use.
Research priorities
Further trials of LHWs promoting exclusive breastfeeding are no longer a high priority as a large number of trials have already been conducted.
HSPH EtR framework (Version 2): Lay health workers – breastfeeding promotion/counseling
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Problem: Low uptake of exclusive breastfeeding
Option: LHW promoting/counselling exclusive breastfeeding
Comparison: Usual care (probably no promotion)
Setting: Community/primary health care settings in low
income countries
GRADE Evidence Profile: Lay health workers promoting and counselling exclusive breastfeeding versus usual care
Author(s): JMoberg
Date: 2012-09-05
Question: Should LHW promoting and counselling vs usual care be used for exclusive breastfeeding to 6 months?
Settings: UK (4 studies); USA (4); Bangladesh (4); Brazil (2); India (2); Canada; Philippines; Mexico; Uganda; Burkina Faso
Bibliography: 5 Lewin S, Munabi-Babigumira S, Glenton C, Daniels K, Bosch-Capblanch X, van Wyk BE, Odgaard-Jensen J, Johnasen M, Aja GN, Zwarenstein M, Scheel IB. Lay health workers in primary and community health care for
maternal and child health and the management of infectious diseases 2012
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HSPH EtR framework (Version 2): Lay health workers – breastfeeding promotion/counseling
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Problem: Low uptake of exclusive breastfeeding
Option: LHW promoting/counselling exclusive breastfeeding
Comparison: Usual care (probably no promotion)
Setting: Community/primary health care settings in low
income countries
References
1
WHO World Health Statistics 2012 www.who.int/gho/publications/world_health_statistics
Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L, for the Lancet Neonatal Survival Steering Team. Evidence-based, cost-effective interventions: how many newborn
babies can we save? Lancet 2005; 365: 977-88
3 WHO 2011. Exclusive breastfeeding www.who.int/nutrition/topics/exclusive_breastfeeding/en/
2
Report card on nutrition: Number 4, May 2006 www.unicef.org/progressforchildren/2006n4/index_breastfeeding.html
Lewin S, Munabi-Babigumira S, Glenton C, Daniels K, Bosch-Capblanch X, van Wyk BE, Odgaard-Jensen J, Johansen M, Aja GN, Zwarenstein M, Scheel IB. Lay health workers in primary and
community health care for maternal and child health and the management of infectious diseases 2012
6 WHO Guidelines on HIV and Infant Feeding 2010 www.who.int/maternal_child_adolescent/documents/9789241599535/en/index.html
4
5
Glenton C, Colvin C, Carlsen B, Swartz A, Lewin S, Noyes J, Rashidian A. A systematic review of barriers and facilitators to the implementation of lay health worker programmes for maternal
and child health 2012
7
HSPH EtR framework (Version 2): Lay health workers – breastfeeding promotion/counseling
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Explanations
Definitions for ratings of the certainty of the evidence (GRADE)**
Ratings
High
Moderate
Low
Very Low
Definitions
Implications
This research provides a very good indication of the likely effect. The likelihood that the effect will
be substantially different* is low.
This evidence provides a very good basis for making a decision about whether to implement the
intervention. Impact evaluation and monitoring of the impact are unlikely to be needed if it is
implemented.
This research provides a good indication of the likely effect. The likelihood that the effect will be
substantially different4 is moderate.
This evidence provides a good basis for making a decision about whether to implement the
intervention. Monitoring of the impact is likely to be needed and impact evaluation may be
warranted if it is implemented.
This research provides some indication of the likely effect. However, the likelihood that it will be
substantially different4 is high.
This evidence provides some basis for making a decision about whether to implement the
intervention. Impact evaluation is likely to be warranted if it is implemented.
This research does not provide a reliable indication of the likely effect. The likelihood that the effect
will be substantially different4 is very high.
This evidence does not provide a good basis for making a decision about whether to implement the
intervention. Impact evaluation is very likely to be warranted if it is implemented.
*Substantially different: large enough difference that it might have an effect on a decision
**The Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group began in the year 2000 as an informal collaboration of people with an interest in addressing the shortcomings of present grading systems in health care. The
working group has developed a common, sensible and transparent approach to grading quality of evidence and strength of recommendations. Many international organizations have provided input into the development of the approach and have started using it.
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HSPH EtR framework (Version 2)
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