The Financial Costs of Mass Media Interventions Used for Improving Breastfeeding Practices in Bangladesh, Burkina Faso, Nigeria, and Vietnam

Round 1

Reviewer 1 Report

The article absolutely lacks any scientific interest.

It only analyzes the costs of four intervention programs on health behaviors and habits, without evaluating the results or comparing costs and benefits. In addition, these programs have been developed in different countries, with different cultures and idiosyncrasies that are never analyzed. This means that the actions included in the programs differ notably. In addition, the programs have been developed in different periods of time and have had different durations. All of this is intended to be corrected with a simple calculation of a temporary average and the updating of the monetary units to a single reference moment. However, both differences -the contents of the programs and the temporal aspects- should partly explain the more than notorious differences in costs that are obtained.

Interestingly, in the discussion the authors refer to other studies where there are measures of the results of the programs in which some of them have participated. There are differences in results between the programs. If these exist, it makes no sense to compare only the costs. Comparing costs alone only makes sense if it can be justifiably assumed that the results will be similar in different contexts.

We are aware that the data offered in the work are important for an economic evaluation of a health intervention such as the one analyzed, but the work presented fails due to the basis in the approach of this type of analysis.

Author Response

Please see the attached file.

Author Response File: Author Response.docx

Reviewer 2 Report

This study examines the costs of mass media interventions for breastfeeding practices in 4 different countries. The abstract reads well, no changes required. Overall, this is a well-written, comprehensive study of mass media costing for an important public health condition in LMICs. Only a few minor suggestions provided below.

The introduction provides a nice overview of the importance of breastfeeding, how mass media can impact on breastfeeding practices, and how proper practice may be lacking across the world. A thorough review of the type of mass media provided to the relevant countries is provided, including how such media was delivered and duration of delivery. Only a few minor comments about Intro (including checking the use of acronyms throughout the entire document). Line 45 - not sure the word 'cost' should be here or is in the right place. Line 47 - one of the 'most' frequently used...

Lines 67-76 confused me a bit. Is this text talking about the current study, or one you have done previously? If this is about the current study, it seems as though you are presenting results in the Introduction? I think this section either needs to be re-worded so it doesn't read as results and more like research questions/hypotheses, or remove it completely. 

Lines 87-89 - were these costs excluded because you could not source them, or because it was not the focus of the current study? Some justification for the removal of these apparently important costs is needed. 

Lines 102-104 - which country was not given this mass media information and why?

Lines 162-164 are repetitive of information presented in Intro. Can remove this here or in Intro so it does not repeat. There are various other areas where information is repeated throughout Methods (e.g. 198-199). Please check for repetition. Table 1 provides a very comprehensive overview of the mass media provided in each of the 4 countries. The costs included in analysis seem to be a good overview of what would have gone into the mass media campaigns - there does not seem to be anything missing. All cost calculations are well explained, with enough detail to re-run the methods if needed. Cost per beneficiary and sensitivity analyses were also well explained. 

I am not sure if this is even possible, but could you provide an indication of the proportion of beneficiaries you estimated as being reached, compared to the entire population that could have been reached? Or does your estimates of pregnant women or mothers of children aged <2 years actually capture the entire cohort in that country? Sorry for my confusion here. How many of these beneficiaries did not recall mass media content - do you know?

Discussion does a good job of restating key results, as well as comparing findings to other studies which had similar aims. In lines 509-517, while I understand why this is included, can you try to link your argument to the findings of your study? How could mass media assist with this?

Author Response

Please look for our response in the attached file. 

Author Response File: Author Response.docx

Reviewer 3 Report

The paper is a “cost-accounting” exercise to determine the costs of mass media campaigns for breastfeeding in four countries. Below is the list of my major concerns:

(1)   I am not sure to what extent these campaigns can be considered as “interventions.” Please see Fraser and Galinsky (2010) (Fraser, M. W., & Galinsky, M. J. (2010). Steps in intervention research: Designing and developing social programs. Research on Social Work Practice, 20(5), 459-466.).

(2)   Even if these campaigns are considered to be an intervention, estimating the cost of an intervention without calculating the benefits is hardly an interesting research question. It is just a cost-accounting exercise. 

Author Response

Please look for our response in the attached file. 

Author Response File: Author Response.docx

Reviewer 4 Report

Great work

Strengths:

Author Response

Point 1: Great work. Strengths: The authors did excellent work and described the study extensively. 
Response 1: We appreciate the positive feedback from the reviewer. 

Point 2: Weakness: I did not see any weakness.

Response 2: We are thankful that the article has met the reviewer’s expectations.

Round 2

Reviewer 3 Report

I thank the authors for their efforts to address my comments. 

According to me, the "cost-accounting" exercise is not an interesting research question. The methodology and literature review parts look fine. However, I am not sure whether the research question has substantial value.

Author Response

We greatly appreciate the reviewer’s acknowledgement of our methodology and literature review and are pleased to have an opportunity to respond to the remaining concern regarding the study’s contribution.

Estimates of the costs of implementing nutrition interventions are required for informing a wide range of decisions in global nutrition. While the importance of nutrition has been extensively proven and there is substantial evidence of effective interventions, the lack of scaling up proven nutrition interventions (tested in limited areas) is a major gap, and the lack of empirical cost estimates is a barrier to scale. Analyses of cost per person reached is an important consideration to inform priority setting. Costing of interventions is also needed for financial planning and management, and the formulation of resource requirements and budgets. Cost estimates provide additional detail on how interventions are implemented, which can be useful for assessing ways of streamlining service delivery. In this paper we are estimating costs to enable country planners and decision makers to assess affordability, to generate credible benchmarks for planning, and for assessing efficiency of resource use across program components for a critically important global health topic.

By discussing relevant country-specific details of mass media and their costs we offer insights for program implementers for the first time in diverse settings about the types of activities and resources needed to implement mass media interventions for breastfeeding promotion. The costs are presented separately for individual countries along with details of how they differed; the descriptive information helps implementers and decision-makers in other countries to adapt the findings to their own contexts. The health impacts of breastfeeding interventions are already well documented elsewhere (Lancet breastfeeding series 2016) and are considered adequate for program planning. We could have contributed to this literature if we could extricate impact results for mass media alone from the combined program that had synergistic impacts; we added this as a limitation of the study in Lines 574-575. What is more urgent is missing information on costs and coverage resulting from mass media specifically. To provide a comparative statistic we present coverage results and cost per beneficiary, and these are attributable exclusively to mass media and also comparable across countries.

Our study provides answers to planning and budgeting questions urgently needed for scaling up interventions. We are often asked, ‘what does it cost to implement mass media interventions and what is the coverage of mass media in LMICs.’ Our study is the first to provide urgently needed answers based on actual large- scale programs and does so for multiple country settings; we also provide the cost structures for different types of mass media interventions for the first time. Our results suggest the need for diverse strategies that are tailored for country contexts and provides a range of costs and coverage for the program planning. These are the unique contributions of our paper, and we made corrections in the text to clarify this. The main rationale for publishing these coverage and cost-related results is that they are needed by planners and decision-makers for designing and budgeting the scaling up of programs.