AG1: Should we count local media sources within the scoring?
- Local media sources can be included in the scoring of this benchmark if they led to national level media attention.
AG1: How does the BBF country committee judge the quality of major events to determine what to include?
- Major events are conferences, gatherings, reports, photos, TV ads, or any other planned event that galvanizes public attention towards advocating for breastfeeding. The BBF Country committee will need to judge the quality of each event to see if it meets this criteria.
AG1: How do we consider negative media attention to breastfeeding in the scoring?
- Negative media attention can be considered as long as it galvanizes public attention towards advocating for breastfeeding. For example, a breastfeeding promotion campaign in Mexico featured celebrities with their backs to the camera and a banner reading "Don't turn your backs on them, give them your breasts". This elicited strong negative media attention because it did not emphasize the benefits of breastfeeding but rather shamed women who do not breastfeed. The public was spurred into action and advocated for a campaign that encouraged breastfeeding, emphasized the benefits, and included "everyday moms".
AG2: Can a highly influential individual who posts on social media with a breastfeeding picture but no advocacy message be considered a "champion"?
The benchmark description provides a good definition of the term “champion”. Champions are non-governmental, high-level advocates or influential individuals. These are people who are well known, easily recognized and whose opinions are both respected and generate advocacy. They must have been seen at least 3 times within the year promoting breastfeeding.
Champions need to meet the criteria specified in the description and their level of influence should be considered by the BBF country committees.
For example, if someone uses hashtags and/or messages attached to photos at least 3 times in a year, that person would be considered a champion promoting breastfeeding. Alternatively, if someone posts photos 20 times a year but with no messages, that would also be considered a champion. However, if someone posts 3 photos a year without any hashtags or messages, this person would not be considered. On the rare occasion where there is a major symbolic gesture made by an extremely significant, influential person, then that person can be considered a champion. An example of this is Pope Francis' vocal support of breastfeeding.
AG2: Can there be a champion within the government?
- There can be a government champion but that person should be considered under the Political Will gear. Please ensure to document the consideration/discussion the BBF committee has about this.
AG2: Can we consider influential individuals who are not visible?
- No, advocates must be visible (on websites, Facebook or other social media, TV, radio, podcasts) and promoting breastfeeding. The BBF committee needs to agree and define who are high level visible advocates, document their decision, and provide a rationale for it.
AG3: Does the National Advocacy Strategy have to be for breastfeeding specifically, or can breastfeeding be included in a broader advocacy strategy, like child health?
- Breastfeeding can certainly be included in a broader advocacy strategy. Ghana found breastfeeding advocacy strategies in multiple documents, including the Newborn Strategic Plan and the Newborn and Child Health Advocacy and Communication Strategy.
AG3: Given that effectiveness is a component of the scoring, does there need to be an evaluation component to the national advocacy strategy?
“Effective” means the strategy is operational: it was strategically implemented and has generated support for breastfeeding protection, promotion and support. To meet major progress (3), the strategy must be operational.
Mexico defined effective to mean that at least one of the advocacy goals was accomplished. Effectiveness can be measured this way or most likely the BBF country committee will need to define it themselves. To determine effectiveness, annual reports from advocacy groups can be evaluated.
AG4: Can individual advocates be considered within the national network of advocates?
- A network of advocates is formed by two or more advocacy organizations and is considered cohesive when they work collectively together. Individual members of a network might meet the definition of an advocacy champion.
Political Will Gear
PWG1: What if a high-level political leader has spoken about nutrition in general but not specifically about breastfeeding?
- This benchmark is specific to breastfeeding. To determine if a high-level political leader has spoken about breastfeeding, conduct a media search covering social media (Facebook, Twitter, Instagram), newspaper articles, radio or TV stories, transcripts, etc.
Legislation and Policies
LPG1 & 2: What is the difference between National policy and National policy on action (action plan)? We have laws on the protection of breastfeeding and maternity leave but does that qualify?
- A policy is a "high level overall plan embracing the general goals and acceptable procedures of a governmental body" (Merriam Webster). An action plan is a series of steps that need to be taken to implement the policy. The action plan should include step-by-step actions including targets and time frames. Having a policy does not necessarily mean there is funding or that there is an implementation plan, unless there is a law and funding has been allocated. Not all policies go through the full government process but instead may have gone through a institution (i.e. Ministry of Health). Consider whether there is a national policy, if funding has been allocated, or if any plans have been enacted towards implementing a breastfeeding policy. All implementation, coverage and quality is assessed in the scoring of the LPG2 benchmark.
LPG5: How do we determine whether the penalties and sanctions imposed are proportional to the Code violation?
- The BBF committee will need to come to an agreement about what is proportional and document their decision.
Training and Program Delivery
TPDG general: In the training benchmarks, what does the word “counseling” mean?
- Counseling is a communication method which seeks to improve self-efficacy and confidence by both listening to women and providing practical advice on breastfeeding.
TPDG general: How should we differentiate between community-based and facility- based health care settings?
- This is a country contextual issue. The BBF committee will need to define and categorize the different levels of health care delivery and document the decision.
TPDG general: How do we include health care for pregnant women?
- Pregnant women fall under the "mothers, infants and young children" umbrella.
TPDG general: What will happen with the scoring for TPDG if we have programs in place, but the coverage is not nationwide?
- Where specified, coverage means all relevant locations/programs:TPDG1-8, Integration into existing programs means ALL programs and this is reflected in the scoring.TPDG9 -11 -Coverage is reflected in the scoringTPDG12-13 - Not measuring coverage,TPDG 14 assesses coverage of deliveriesTPDG15-17 - Coverage is reflected in the scoring
TPDG1: Do we need to analyze the curricula of all the health professional schools or can we look into a sample of them? Do we look across all disciplines as well or only a sample of them (i.e. training for nurses, midwives, nutritionists, doctors, etc.)?
- Other countries have administered online surveys to the relevant university administrators to determine curricula content. Ensure that the sample of schools is representative of the national picture. For example, Mexico reviewed a statistical Yearbook Population School in Higher Education (ANUIES) 2014-2015 and selected the top 10 universities with the highest number of students of Medicine, Nutrition, Nursing, and Midwifery to survey. They also conducted an internet search to identify and review available curricula.
TPDG10: Apart from maternal/child health and IMCI, what other training programs might include breastfeeding?
- This is country specific and requires looking into the current programs within the country. Consider using questionnaires sent to training programs and curricula review to assess. Examples of related training programs are BFHI/Ten Steps and the Supplemental Nutrition Program for Women, Infants, and Children (USA).
TPDG16: We have a program targeting teen mothers that reaches national coverage, but it is the only one. Is that enough to achieve major progress? How many community-based organizations should we be including?
- If a country has government run primary health care breastfeeding support programs (e.g. baby friendly community initiative) run through primary health care units, map these activities and assess the level of coverage. Is the initiative(s) national? If a country has no government-run primary health care breastfeeding programs or similar community- based programs, map all community-based breastfeeding support activities run by NGOs/community groups/private medical practices and assess level of national coverage. The numbers of programs included is dependent on level of coverage; i.e. if 1 program provides 100% coverage, then only that program is needed to score. With non-government run programs, issues with coordination of NGOs/community groups can be a recommendation for action.
Coordination, Goals and Monitoring Gear
CGMG1: How do we score a breastfeeding sub-committee within a national nutrition working group/coordinating body?
- The BBF committee should look at the functioning of the subcommittee and evaluate its objectives and activities to promote breastfeeding. The committee should assess whether the subcommittee is focused on breastfeeding and follows the criteria set out in CGMG1 and CGMG2 (meets regularly, includes strong representation from civil organizations and sectors beyond health and nutrition, and sets specific time bound breastfeeding objectives.)
The Promotion Gear is weighted higher than the Training and Program Delivery Gear even though there are a different number of benchmarks. So if we have a stronger Promotion Gear and a weaker Training Gear, they will weigh the same in the final score. Should this be the case?
- The gear scores should be the focus rather than the total country score. For country comparison and reassessment purposes, we need to keep the scoring algorithms the same.
The word "progress" denotes that there is a baseline measure. Can we consider alternative wording for the scoring: such as not achieved, minimally achieved, partially achieved, fully achieved?
- The BBF is an ongoing process, so we use the word "progress". We agree that "achieved" is the correct terminology for the first assessment and the country committee can certainly use it. Please document the discussion and decision. For BBF reassessments, the wording will need to be revised to "no progress, minimal progress, partial progress, and major progress".