Behaviour change communication to improve complementary feeding practices in Ethiopia: Couples' beliefs concerning paternal involvement in childcare

An important cause of stunting is limited consumption of complementary foods, in terms of both quantities and nutrients. Although existing studies show a positive association between fathers' engagement and children's diet, programmes designed to improve complementary feeding practices often only target mothers. In response to this, maternal behaviour change communication (BCC), paternal BCC and food voucher programmes were designed and implemented in Ethiopia using a clustered randomized controlled trial design. The paternal BCC programme included gender-equal messages to increase fathers' participation in childcare, household labour and decision making. The research reported in this paper is an examination of the BCC programmes, characterizing the behavioural, normative and control beliefs of both mothers and fathers in BCC households compared to those in control households. In this study, a total of 40 participants were included, with 13 mother-father pairs in the BCC + food voucher group, and seven pairs in the control group. Each participant was interviewed separately. We found that BCC mothers showed more gender-equal tendencies than the control mothers despite being more rural in location. By contrast, the beliefs of BCC and control fathers were similar overall, suggesting men are more resistant to gender-equal BCC. More work is needed to develop and test effective methods for changing fathers' beliefs and practices.

Effects of Behaviour Change Communication on Knowledge and Prevention of Malaria Among Women in Ghana

Behaviour change communication (BCC) remains a central component of the interventions used in the fight against malaria in Ghana. However, there is limited evidence of its effectiveness. This study evaluated the effects of BCC strategies on knowledge (symptoms, causes and prevention) and overall knowledge of malaria among Ghanaian women aged 15-49 years. The propensity score matching (PSM) approach and logistic regression were used to analyse data from the 2016 edition of the Malaria Indicator Survey (MIS). Women who participated in community-level education or heard/saw media messages on malaria, or both, had significantly more knowledge of the disease than women who lacked access to any of these mediums of communication. The effect of these strategies on women's overall knowledge of malaria is about 2% to 4% and is higher on their knowledge of the symptoms (3% to 6%) and prevention (2% to 4%) than the causes (2%). The combined effects of both mediums of communication are relatively higher than the effect of either of them as a single medium of communication. Further analysis showed that improved knowledge of the disease is associated with higher preventive measures taken by women for themselves and for their children. The results are more significant in rural and poor households than in urban and non-poor households. These findings underscore the need for the Ministry of Health and its partner institutions to adopt an innovative approach which combines the two strategies in intensively educating Ghanaians, and women in particular, on the symptoms and prevention of malaria, giving due cognisance to households' socioeconomic status and geographical location.

Effect of Behavior Change Communication on Self-Care Practices Among Adult Type-2 Diabetic Patients in a Semi-urban Community of South India: A Quasi-Experimental Study

BACKGROUND

Diabetes mellitus is often termed the modern epidemic, and India ranks second after China in the global disease burden. Practice and adherence to essential self-care behaviors, positively correlated with good glycemic control and reduced complications in people with diabetes, have been inadequately understood, especially in a semi-urban setting.

METHODS

This community-based interventional study was done among 269 known adult type 2 diabetic patients from a semi-urban community in South India for three months. By simple random sampling, known diabetics identified in the health survey by the tertiary care teaching institute were considered for the study. Self-care practices in diabetes were recorded in the pre-test using a validated semi-structured questionnaire. Two health education sessions, each for 30 minutes, were conducted with 15-20 subjects in a group. Health education materials on self-care in diabetes, such as charts, handouts, video clippings, and PowerPoint presentations in the local language, were used. The self-care practices were re-recorded in the post-test after two months. Inferential statistics were carried out with a t-test, analysis of variance (ANOVA), and Pearson correlation coefficient, and a p-value less than 0.05 was considered statistically significant.  Results: A total of 253 diabetic subjects were included in the final analysis, with an attrition rate of 6%. The mean age of participants was 56.5 ± 11.9 years. The mean score of self-care practices among diabetic subjects at the baseline was 14.6 ± 13.2. Illiteracy and smoking habit were significantly associated with lower self-care scores in the pre-test. In the post-test, after health education, there was a significant improvement in the mean self-care practices score and a reduction in the mean fasting blood sugar level. Also, a significant mild negative correlation between the self-care scores and blood sugar levels was seen (Pearson correlation coefficient = -0.21, p < 0.001).

CONCLUSION

Self-care practices, which were not satisfactory in most diabetic participants, were found to be significantly impacted by the small group education. This stresses the need for effective health education sessions as envisaged under the national program.

Can nutrition education mitigate the impacts of COVID-19 on dietary quality? Cluster-randomised controlled trial evidence in Myanmar's Central Dry Zone

We evaluate the immediate impact of a nutrition and gender behaviour change communication on dietary quality in rural communities in Myanmar and assess whether the communication helped mitigate the effect of the COVID‐19 crisis on dietary quality. The intervention was designed and implemented as a cluster‐randomised controlled trial in which 15 villages received the intervention and 15 control villages did not. The intervention was implemented from June to October 2020. This paper provides an assessment of the intervention's impact on dietary quality based on the results of two phone surveys conducted in August and October 2020. Immediate impacts of the intervention indicate an improvement in women's dietary diversity scores by half a food group out of 10. At baseline, 44% of women were likely to have consumed inadequately diverse diets; results indicate that 6% (p‐value: 0.003, SE: 0.02) fewer sample women were likely to have consumed inadequately diverse diets. More women in treatment villages consumed pulses, nuts, eggs and Vitamin A‐rich foods daily than in control villages. In response to economic shocks related to COVID‐19, households in the treatment villages were less likely to reduce the quantity of meat and fish consumption than in control villages. The long‐term impacts of the intervention need to be continuously evaluated.

Effect of complementary feeding behaviour change communication delivered through community-level actors on infant growth and morbidity in rural communities of West Gojjam Zone, Northwest Ethiopia: A cluster-randomized controlled trial

Attaining the recommended level of adequacy of the infants' diet remains a serious challenge in developing countries. On the other hand, the incidence of growth faltering and morbidity increases significantly at 6 months of age when complementary foods are being introduced. This trial aimed to evaluate the effect of complementary feeding behaviour change communication delivered through community-level actors on infant growth and morbidity. We conducted a cluster-randomized controlled trial in rural communities of Ethiopia. Trial participants in the intervention clusters (eight clusters) received complementary feeding behaviour change communication for 9 months, whereas those in the control clusters (eight clusters) received only the usual care. A pre-tested, structured interviewer-administered questionnaire was used for data collection. Generalized estimating equations regression analyses adjusted for baseline covariates and clustering were used to test the effects of the intervention on infant growth and morbidity. Infants in the intervention group had significantly higher weight gain (MD: 0.46 kg; 95% CI: 0.36-0.56) and length gain (MD: 0.96 cm; 95% CI: 0.56-1.36) as compared with those in the control group. The intervention also significantly reduced the rate of infant stunting by 7.5 percentage points (26.5% vs. 34%, RR = 0.68; 95% CI: 0.47-0.98) and underweight by 8.2 percentage points (17% vs. 25.2%; RR = 0.55; 95% CI: 0.35-0.87). Complementary feeding behaviour change communication delivered through community-level actors significantly improved infant weight and length gains and reduced the rate of stunting and underweight.

A complementary feeding and play intervention improves the home environment and mental development among toddlers in rural India

A cluster randomized trial design was used to test the efficacy of a behaviour change communication intervention on the quality of the home environment and infant development at 15 months of age. Children (n = 600) in rural South India were followed from 3 through 15 months of age. The control group (C group) received the standard of care, the complementary feeding group (CF group) received recommendations on complementary foods and the responsive complementary feeding and play group (RCF&P group) received recommendations on complementary foods plus skills on responsive feeding and play. The intervention was delivered in biweekly home visits to caregivers using flip charts. At postintervention, infants (n = 521) were assessed for development (Bayley-II scales) and their home environment was assessed (Home Observation for Measurement of the Environment [HOME] scale). Cluster adjusted analysis of variance showed no significant differences at baseline. The HOME score at 15 months differed by group, F(2, 38) = 6.41, P = 0.004; the CF and RCF&P groups had higher scores than the C group. Scores on subscales 'Opportunities for Variety in Daily Stimulation' and 'Caregiver Promotion of Child Development' (CPCD) were higher for the RCF&P group than for the C and CF groups. Mental development index (MDI) scores differed by group, F(2, 37) = 3.31, P = 0.04, with the RCF&P group showing higher scores than the C group (P < 0.04); no differences were noted in psychomotor development index (PDI) scores (P = 0.48). The subscales of HOME associated with MDI at 15 months were 'CPCD' and 'Cleanliness of Child' (R2 = 0.076). 'CPCD' was also associated with PDI (R2 = 0.039). A responsive complementary feeding and play intervention delivered through home visits benefitted children's mental development and caregiving environment at 15 months.

Nutritional training in a humanitarian context: Evidence from a cluster randomized trial

Behavioural change communication interventions have been shown to be effective at improving infant and young child nutrition knowledge and practices. However, evidence in humanitarian response contexts is scarce. Using data on secondary outcomes of breastfeeding, water treatment, and knowledge from a cluster randomized control trial of the Yemen Cash for Nutrition programme's impact on child nutritional status, this paper shows that the programme significantly improved knowledge and practices for poor women with young children in the pilot districts. The intervention consisted of cash transfers and monthly group nutrition education sessions led by locally recruited community health volunteers. Data are based on self‐reports by participants. Estimating impacts among all 1,945 women in 190 clusters randomly assigned to treatment versus control and controlling for baseline levels and community characteristic and adjusting for noncompliance with randomization, the programme increased the probability of breastfeeding initiation within the first hour after delivery by 15.6% points (p < .05; control = 74.4% and treatment = 83.6%), the probability of exclusive breastfeeding during the first 6 months by 14.4% points (control = 13.5% and treatment = 25.3%), the probability of households treating water consumed by adults by 16.7% points (p < .01; control = 13.9% and treatment = 23.4%), and treating water consumed by children under two by 10.3% points (p < .10; control = 31.2% and treatment = 37.9%). Impacts on knowledge and breastfeeding are similar for both literate and illiterate women, and water treatment impacts are significantly larger for literate women. This study was registered at 3ie (RIDIE‐STUDY‐ID‐5b4eff881b29a) and funded by the Nordic Trust Fund and Consultative Group on International Agricultural Research programme on Policies, Institutions, and Markets.

Infant and young child feeding learning sessions during savings groups are feasible and acceptable for HIV-positive and HIV-negative women in Malawi

Based on formative research, HIV-positive women in Lilongwe District, Malawi receive little infant and young child feeding (IYCF) counselling postpartum and want more support for IYCF from their husbands. To address these gaps, we implemented a behaviour change communication intervention promoting IYCF in village savings and loan associations (VSLAs) that included HIV-positive and HIV-negative women. The intervention consisted of 15 IYCF learning sessions facilitated by VSLA volunteers during regular VSLA meetings and included four sessions to which husbands were invited. We assessed the feasibility and acceptability of the intervention through learning session participation logs, structured observations of learning sessions, and in-depth interviews with HIV-positive and HIV-negative VSLA members, husbands of members, and VSLA volunteers. Nine VSLA volunteers conducted learning sessions with approximately 300-400 women, about one quarter of whom were lactating, and 25-35 men. VSLA volunteers consistently communicated technical information correctly, followed the learning session steps, and used visual aids. Sessions averaged 46 min, with <20% of observed sessions completed within the recommended time (20-25 min). Key themes from interviews were the following: (a) learning sessions were useful; (b) including HIV-positive and HIV-negative women in the sessions was acceptable; (c) information learned during sessions encouraged families to change IYCF practices; (d) IYCF messages were shared with others in the community; and (e) male participation was low because men considered VSLAs and IYCF to be women's activities. In conclusion, integrating IYCF learning sessions into VLSAs was feasible and acceptable for mixed groups of HIV-positive and HIV-negative women. Future research should test other strategies for involving men in IYCF.

Educational interventions to improve menstrual health: approaches and challenges

BACKGROUND

Inappropriate menstrual care practices result in adverse health consequences among girls. Developing and implementing interventions that minimize these adverse consequences and facilitate development of healthy menstrual behavior are a priority for any nation.

OBJECTIVES

This study aimed at collating, summarizing and reviewing evidence to assess the effectiveness of interventions to improve menstrual health and the challenges faced in doing the same.

METHODS

A systematic review of studies published in peer-reviewed journals and project reports was conducted. Intervention studies related to menstrual health management conducted from 2007 to 2018 were analyzed. A total of 27 interventions conducted among young girls in different countries were identified and study characteristics and outcomes were reviewed.

RESULTS

Different intervention studies used a variety of methods like lectures, discussions, demonstrations using multiple audio-visual aids and provision of resources like menstrual cups, sanitary pads and washing soap to spread awareness about menstrual hygiene. Most of the interventions reported a positive impact on the awareness and menstrual practices of girls. However, in a few studies no significant change was observed in the attitude regarding regular bathing, practices related to self-medication for dysmenorrhea and socio-cultural taboos.

CONCLUSION

This review of literature has offered insights into the scope and development of future interventions so that apart from increasing awareness and knowledge on menstrual health issues, sustained behavior change can be brought about among girls to improve their health.

An mHealth voice messaging intervention to improve infant and young child feeding practices in Senegal

Mobile health (mHealth) interventions have the potential to improve infant and young child feeding (IYCF) practices; however, gaps in the literature remain regarding their design, implementation, and effectiveness. The aims of this study were to design an mHealth voice messaging intervention delivered to mothers and fathers targeting IYCF practices and examine its implementation and impact in households with children 6-23 months in three rural villages in Senegal. We conducted focus groups (n = 6) to inform the intervention development. We then conducted a pilot study (n = 47 households) to examine the impact of the intervention on IYCF practices of children 6-23 months. Voice messages were sent to the children's mothers and fathers over a period of 4 weeks (two messages per week; eight messages in total), and 24-hr dietary recalls and food frequency questionnaires (FFQs) were conducted before and immediately after the implementation of the mHealth intervention to examine its impact on IYCF practices. Overall, three of the eight behaviours increased and one decreased. There was a significant increase in the number of children that consumed fish (60% vs. 94%; p = .008) as measured by the 24-hr recall after the completion of the intervention. We also found significantly higher frequency of egg (p = .026), fish (p = .004), and thick porridge (p = .002) consumption in the previous 7 days measured by the FFQ. Our findings suggest that voice messaging IYCF interventions in Senegal have the potential to improve IYCF behaviours among young children in the short term. Future research should entail scaling-up the intervention and examining its sustainability over the long-term.

The potential role of micronutrient powders to improve complementary feeding practices

Micronutrient powder (MNP) interventions are often integrated within infant and young child feeding (IYCF) programmes to improve micronutrient intake from complementary foods. This review aims to describe country experiences with MNP interventions and their impact on IYCF practices and develop a framework for how MNP may strengthen complementary feeding practices. A literature review and key informant interviews were used to gather data on complementary feeding practices in MNP programme design, implementation, and evaluation. Findings from 11 MNP programmes in different geographic regions reinforced the potential of MNP interventions to add renewed focus and resources to existing IYCF programmes. MNP plays an important role in ensuring adequate micronutrient intake and reducing anaemia in young children. In some programmes, MNP users had improved IYCF practices, such as breastfeeding to 24 months and children receiving complementary foods with adequate consistency, frequency, and diversity. Our framework highlights how behaviour change communication is an essential component for influencing household actions, not only to generate demand and promote correct and sustained MNP use but also raise awareness of IYCF practices. The actions at MNP policy, delivery, and behaviour change communication levels collectively influence household IYCF practices, and formative research and monitoring and evaluation serve to inform programme design and optimize impact. In conclusion, a limited but growing body of evidence suggests that MNP interventions can contribute to improve complementary feeding practices. However, there is scope for improvement even among integrated MNP and IYCF programmes in order to realize the full potential of MNP interventions for IYCF practices.

Factors influencing the uptake of a mass media intervention to improve child feeding in Bangladesh

Mass media are increasingly used to deliver health messages to promote social and behaviour change, but there has been little evidence of mass media use for improving a set of child feeding practices, other than campaigns to promote breastfeeding. This study aimed to examine the factors influencing the uptake of infant and young child feeding messages promoted in TV spots that were launched and aired nationwide in Bangladesh. We conducted a mixed‐methods study, using household surveys (n = 2,000) and semistructured interviews (n = 251) with mothers of children 0–23.9 months and other household members. Factors associated with TV spot viewing and comprehension were analysed using multivariable logistic regression models, and interview transcripts were analysed by systematic coding and iterative summaries. Exposure ranged from 36% to 62% across 6 TV spots, with comprehension ranging from 33% to 96% among those who viewed the spots. Factors associated with comprehension of TV spot messages included younger maternal age and receipt of home visits by frontline health workers. Three direct narrative spots showed correct message recall and strong believability, identification, and feasibility of practicing the recommended behaviours. Two spots that used a metaphorical and indirect narrative style were not well understood by respondents. Understanding the differences in the uptake factors may help to explain variability of impacts and ways to improve the design and implementation of mass media strategies.

Nutrition behaviour change communication causes sustained effects on IYCN knowledge in two cluster-randomised trials in Bangladesh

Behaviour change communication (BCC) can improve infant and young child nutrition (IYCN) knowledge, practices, and health outcomes. However, few studies have examined whether the improved knowledge persists after BCC activities end. This paper assesses the effect of nutrition sensitive social protection interventions on IYCN knowledge in rural Bangladesh, both during and after intervention activities. We use data from two, 2‐year, cluster randomised control trials that included nutrition BCC in some treatment arms. These data were collected at intervention baseline, midline, and endline, and 6–10 months after the intervention ended. We analyse data on IYCN knowledge from the same 2,341 women over these 4 survey rounds. We construct a number correct score on 18 IYCN knowledge questions and assess whether the impact of the BCC changes over time for the different treatment groups. Effects are estimated using ordinary least squares accounting for the clustered design of the study. There are 3 main findings: First, the BCC improves IYCN knowledge substantially in the 1st year of the intervention; participants correctly answer 3.0–3.2 more questions (36% more) compared to the non‐BCC groups. Second, the increase in knowledge between the 1st and 2nd year was smaller, an additional 0.7–0.9 correct answers. Third, knowledge persists; there are no significant decreases in IYCN knowledge 6–10 months after nutrition BCC activities ended.

WHO guideline for brief sexuality-related communication: implications for STI/HIV policy and practice

Brief sexuality-related communication (BSC) aims to identify current and potential sexual concerns and motivate those at risk to change their sexual behaviour or maintain safe sexual behaviour. BSC in primary health care can range from 5 to 60 minutes and takes into account biological, psychological and social dimensions of sexual health and wellbeing. It focuses on opportunistic rather than systematic or continuous communication and can be used in conjunction with already established prevention programs. The informational and motivational techniques of BSC enable health care providers to communicate more effectively with their patients, encouraging them to take steps to avoid HIV and sexually transmitted infections. The WHO Department of Reproductive Health and Research, following a review and assessment of existing evidence with regards to BSC, has recently published the guideline on Brief Sexuality-Related Communication: Recommendations for a Public Health Approach.

Constraints and opportunities for implementing nutrition-specific, agricultural and market-based approaches to improve nutrient intake adequacy among infants and young children in two regions of rural Kenya

Several types of interventions can be used to improve nutrient intake adequacy in infant and young child (IYC) diets, including fortified foods, home fortification, nutrition education and behaviour change communication (BCC) in addition to agricultural and market‐based strategies. However, the appropriate selection of interventions depends on the social, cultural, physical and economic context of the population. Derived from two rural Kenyan populations, this analysis combined information from: (1) a quantitative analysis to derive a set of food‐based recommendations (FBRs) to fill nutrient intake gaps in IYC diets and identify ‘problem nutrients’ for which intake gaps require solutions beyond currently available foods and dietary patterns, and (2) an ethnographic qualitative analysis to identify contextual factors posing opportunities or constraints to implementing the FBRs, including perceptions of cost, convenience, accessibility and appropriateness of the recommended foods for IYC diets and other social or physical factors that determine accessibility of those foods. Opportunities identified included BCC to increase the acceptability and utilisation of green leafy vegetables (GLV) and small fish and agronomic interventions to increase the productivity of GLV and millet. Value chains for millet, beans, GLV, milk and small fish should be studied for opportunities to increase their accessibility in local markets. Processor‐level interventions, such as partially cooked fortified dry porridge mixes or unfortified cereal mixes incorporating millet and beans, may increase the accessibility of foods that provide increased amounts of the problem nutrients. Multi‐sectoral actors and community stakeholders should be engaged to assess the feasibility of implementing these locally appropriate strategies.

Using formative research to design a context-specific behaviour change strategy to improve infant and young child feeding practices and nutrition in Nepal

Global recommendations on strategies to improve infant feeding, care and nutrition are clear; however, there is limited literature that explains methods for tailoring these recommendations to the local context where programmes are implemented. This paper aims to: (1) highlight the individual, cultural and environmental factors revealed by formative research to affect infant and young child feeding and care practices in Baitadi district of Far Western Nepal; and (2) outline how both quantitative and qualitative research methods were used to design a context-specific behaviour change strategy to improve child nutrition. Quantitative data on 750 children aged 12-23 months and their families were collected via surveys administered to mothers. The participants were selected using a multistage cluster sampling technique. The survey asked about knowledge, attitude and behaviours relating to infant and young child feeding. Qualitative data on breastfeeding and complementary feeding beliefs and practices were also collected from a separate sample via focus group discussions with mothers, and key informant interviews with mothers-in-law and husbands. Key findings revealed gaps in knowledge among many informants resulting in suboptimal infant and young child feeding practices - particularly with relation to duration of exclusive breastfeeding and dietary diversity of complementary foods. The findings from this research were then incorporated into a context-specific nutrition behaviour change communication strategy.

Are birth-preparedness programmes effective? Results from a field trial in Siraha district, Nepal

The birth-preparedness package (BPP) promotes active preparation and decision-making for births, including pregnancy/postpartum periods, by pregnant women and their families. This paper describes a district-wide field trial of the BPP implemented through the government health system in Siraha, Nepal, during 2003-2004. The aim of the field trial was to determine the effectiveness of the BPP to positively influence planning for births, household-level behaviours that affect the health of pregnant and postpartum women and their newborns, and their use of selected health services for maternal and newborn care. Community health workers promoted desired behaviours through inter-personal counselling with individuals and groups. Content of messages included maternal and newborn-danger signs and encouraged the use of healthcare services and preparation for emergencies. Thirty-cluster baseline and endline household surveys of mothers of infants aged less than one year were used for estimating the change in key outcome indicators. Fifty-four percent of respondents (n=162) were directly exposed to BPP materials while pregnant. A composite index of seven indicators that measure knowledge of respondents, use of health services, and preparation for emergencies increased from 33% at baseline to 54% at endline (p=0.001). Five key newborn practices increased by 19 to 29 percentage points from baseline to endline (p values ranged from 0.000 to 0.06). Certain key maternal health indicators, such as skilled birth attendance and use of emergency obstetric care, did not change. The BPP can positively influence knowledge and intermediate health outcomes, such as household practices and use of some health services. The BPP can be implemented by government health services with minimal outside assistance but should be comprehensively integrated into the safe motherhood programme rather than implemented as a separate intervention.