Dear all:

 I know there was some research in Niger on the "hot knife" test for colostrum.  Mother's would 
test their colostrum on a hot knife and if it rolled one way it would be discarded and if it roller the 
other mom would nurse.  They had a Nutrition Communication Project that I think developed 
messages for this.  I know the use of colostrum did improve, but I have absolutely no specifics on 
how they did it.  

I'm not a social marketer, but I know that they do have techniques for working on resistances in 
the population.  Good solid exploratory research is important.  I think that's what we do on a daily 
basis with every client we see - ask all those detailed questions to find out why mom is resistant. 
Then they do focus groups with clearly definied groups of people who have similar beliefs.  These 
use these groups to help figure out what messages might change the practice.  

The other approach is the Trials of Improved Practices.  Giving options to the moms, not 
necessarily the ones we would deem the best, but several doable options for the moms that will 
get them closer to what we feel would be best practices.  For instance, if you were trying to get 
more vitamin A into children, you'd give them several different options and recipes for foods and 
suggestions of when and how much to give.  Maybe some would try the dried mangos while others 
would try the sweet potato pancakes.  Moms would pick one of the options.  You go back and then 
interview mom about the implementation process.  Find out what worked and what didn't.  On a 
public health scale, you do this with many women and document and develop messages for 
different groups.  Maybe you'd find out that the dried mangos got bugs, while the sweet potato 
recipe was too difficult and you'd start over only to find that adding palm nut oil to the fried 
cassava leaves was a hit.  Then pick the best combination of behavioral changes that worked for 
most of the mothers and use their own words to help "Market" the practice.  Maybe you'd get 
some message like, "Try palm nut oil in your cassava leaves, your family will think you're the best 
cook in town and you'll know you're protecting them from chicken eyes"  (Chicken eyes is a 
common term for night blindness).  Or if moms complained that their husbands weren't giving 
them enough money for palm oil - maybe, the message would be "Dads, buy palm oil for your 
wives.  Your cassava leaves will taste better and your children won't get chicken eyes."  

I think we unconciously do this all the time with our own respective practices.  We all see slightly 
different subgroups of the population, observe how they respond to our recommendations, and 
gradually modify our recommendations accordingly.  

That's why I'm not surprised when I hear that Pam Hirsch has lots of pump-abusing moms who set 
the stage for mastitis and this year in my population I am seeing more plugged ducts in my 
pump-abusing mothers.  I am sure there is some subtle difference in our populations that 
produces this difference either in their practices or their exposure to pathogens or who they seek 
help from.  Maybe I'm not gettng the mastitis cases because women have found out about the 
breastfeeding medicine specialist here in Manhattan and she's taking care of the more serious 
consequences of pump abus.

The devil is always in the details - that's why we get studies showing that pacifiers reduce SIDS 
when it defies all logic for anyone who works with normally fed infants.  We all know that there 
must be some asynchrony between what babies need and what babies are actually provided in a 
small subsegment of the total population of babies that are in those studies that creates a 
situation where an artificial device seems necessary to reduce the risk of SIDS.  Nailing down what 
is different about those babies that seemed to have needed the pacifiers would be quite difficult 
but very important for providing much more sensible public health recommendations.  Ditto for 
applying the evidence we have at hand in the different cultural settings in which we work.

Best, Susan Burger

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