formative research to examine perceptions and behaviors ... · perceptions on maternal nutrition...

2012

Rolf D.W. Klemm, Jennifer Burns,

Kimberly Amundson

Johns Hopkins University

6/6/2012

Formative Research to Examine Perceptions and Behaviors about Maternal, Infant and Young Child Feeding—JENGA JAMAA ll,

Democratic Republic Congo

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Acknowledgments

The success of the formative research could not have been accomplished without the generous time, support, and thoughtfulness of many individuals. It is in this light that Johns Hopkins humbly gives thanks for the extra efforts of those individuals that not only made the process more smooth, complete, and possible, but also made the research experience enjoyable. We would like to thank both ADRA and World Vision for their support in the administrative process to make sure that this formative research was carried out. Specifically we thank Joseph Menakuntuala and Connie Smith for their direction and guidance throughout the entire process. We would also like to thank all the of the ADRA Headquarters staff that were an essential component of ensuring thorough research in helping with the questionnaire. We would like to specifically thank Laura Brye at ADRA Headquarters for diligently approving the structured interviews and providing thorough feedback and ideas to improve the data collection instruments. Also, we wish to thank Milton McHenry, Program Manager for the JENGA ll Project, who provided encouragement and support for this study.

We would like to thank all of the ADRA staff that helped coordinate vehicles, transportation, water, lodging, and all of the village visits. We want to thank those staff that kept us secure and provided direction as to what villages were safe to travel. Specifically we give thanks to Benjamin Babunga for his efforts in helping plan the schedule of village visits and Janvier Musaya Idombe for his help in preparing the villages ahead of time for our visits. Finally, we wish to thank and acknowledge the competent and diligent team of interviewers, notetakers, and focus group leaders-- Chantal Baciyunjuze Kongolo, Miki Milinganyo K. Hassang, Arsene Bonene Sanvura, Coco Alima Molisho, Patrick Bahati Mulonda, Junior Kazadi, Solage Bantu Chiza, Mado Mabulay Mbula, André Lumona Sadiki --for their hard work, long hours, patience, and perseverance to collect quality data at each and every village site. Special thanks goes to Arsene Bonene Sanvura for going above and beyond and adopting a leadership role for the team for travel coordination and printing. Finally, we wish to thank Moses for facilitating the printing process to make sure all of the copies were ready and prepared in a timely manner.

Table of Contents

Background ............................................................................................................................................. 6

Purpose ................................................................................................................................................... 8

Methods .................................................................................................................................................. 9

Selection of Study Villages ................................................................................................................ 11

Sample Size and Justification ............................................................................................................. 11

Data Analysis .................................................................................................................................... 12

Formative Research Findings ................................................................................................................ 12

Maternal Nutrition ........................................................................................................................... 12

Food Availability ........................................................................................................................... 13

Dietary Practices of Women of Reproductive Age ..................................................................... 13

General Perception of Good Health Among Women of Reproductive Age .............................. 14

Pregnancy .......................................................................................................................................... 16

Kinds and Amounts of Foods Eaten During Pregnancy ............................................................... 16

Willingness to Try New Foods During Pregnancy ...................................................................... 16

Rest During Pregnancy ................................................................................................................. 17

Prenatal Care ................................................................................................................................ 17

Iron and Folic Acid Supplementation ........................................................................................... 17

Lactation ........................................................................................................................................... 19

Kinds and Amounts of Foods Eaten During Lactation ................................................................. 19

Infant and Young Child Feeding and Caring Practices ..................................................................... 21

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General Perception of Good Health Among Infants & Young Children ..................................... 21

Breastfeeding ................................................................................................................................ 22

Complementary Feeding .............................................................................................................. 26

Knowledge of Infant and Child Feeding Behaviors ....................................................................... 33

Attitudes about Selected Infant Feeding Practices ....................................................................... 34

Mothers' Decision Making Authority ............................................................................................... 34

Sources of Advice and their Credibility ........................................................................................... 34

Health Worker Contact and Credibility .......................................................................................... 34

Leisure and Media Habits ................................................................................................................. 35

Leader Mothers and Health Workers ............................................................................................. 35

Current Knowledge of Leader Mothers ...................................................................................... 35

Training Needs of Leader Mothers .............................................................................................. 37

Functions and Knowledge of Health Workers ............................................................................ 38

Community Channels and Influence ............................................................................................. 39

Conclusion ............................................................................................................................................ 41

Communication Task ....................................................................................................................... 44

Target Groups: ................................................................................................................................. 44

Pregnant Women...................................................................................................................... 44

Nursing Women ....................................................................................................................... 45

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Mothers of infants 0-5 months of age ...................................................................................... 46

Mothers of infants 6-23 months of age .................................................................................... 48

Communication Channels ................................................................................................................ 50

General Recommendations .............................................................................................................. 51

References ............................................................................................................................................ 52

Appendix 1: Tables from Structured Interviews .................................................................................. 53

Appendix 2: List of Interviewers .......................................................................................................... 82

Appendix 3: Forms ............................................................................................................................... 83

FGD Guide on Infant and Young Child Feeding Behaviors .............................................................. 84

FGD Guide on Maternal Nutrition .................................................................................................. 89

In-depth Interview Guide for Leader Mothers ................................................................................ 94

In-depth Interview Guide for Health Workers .............................................................................. 103

Structured Interview for Mothers of Children 0-23 months ......................................................... 112

Background Childhood stunting and growth faltering

is highly prevalent in the Democratic Republic of Congo (DRC), especially in the rural district of South Kivu (1). High rates of childhood stunting are common across most regions of the DRC (46%), but particularly high in rural regions (52%), and especially high in South Kivu (56%) (1). Stunting dramatically increases from early infancy (<6 m) where it is <15% to early childhood (24-35 m) where it affects 55% of 2-3 yr olds (1). Growth stunting in childhood is a sign of “chronic undernutrition” representing an accumulation of stress episodes that have disrupted linear growth over time (2). Wasting prevalence is also exceedingly high at the youngest ages (1). Almost 1 in 5 children is abnormally thin in their first year of life, and 1 in 8 is thin through 18 months of age (1). Wasting is a sign of an acute period of stress that result in lost body mass (3). One or both forms of undernutrition are associated with increased mortality (4), higher incidence and greater severity of diarrhea (5), suppressed immuno-competence (6) and delayed motor (7) and cognitive development (8,9). Sub-optimal nutrition in early life often leads to permanent stunting in adulthood (10), and increases a woman’s risk of complications during child birth and delivering an intra-uterine growth retarded baby (11, 12), thus perpetuating stunting into the next generation.

Undernutrition in childhood is caused by a set of contributing factors that vary with intensity, duration, specific and proximity to the undernourished child. Wasting can result, for example, from being fed a diet chronically lacking sufficient energy and nutrient density, intensified by frequent episodes of diarrhea (13). Improving either of these conditions could prevent or lessen the severity of

undernutrition. Both proximal conditions, however, arise from impoverished, food-insecure, and unhygienic conditions in the home or poor access to quality treatment, stemming from lack of family resources, due to poor education and underemployment, or of community resources (13). Improving these more distal causes could lower exposure to diarrhea or improve quality of diet (13). From a prevention point of view, it is important to identify and characterize the major causes of child undernutrition that can be modified through appropriate interventions.

Photo: Local villagers gather to check out the survey team

Data from the Demographic and Health Survey conducted in the Democratic Republic of the Congo point to several potential key causes of poor child growth for which effective interventions can be designed and implemented (1):

• While breastfeeding is virtually universal, there is delayed initiation (only 48% initiated within an hour of birth), common feeding of prelacteals (18%), and low exclusive breastfeeding under 6 months of age (only 36%).

• While 82% of 6-9 month old children receive supplemental foods, only 18% of breastfed 6-23 month old children are fed the recommended diversity of food

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groups (≥3) with the recommended frequency (2-4 times a day).

• Infant size at birth and through the first few months of age are mostly determined by maternal factors, including pre-pregnancy weight and height, weight gain during pregnancy and gestational age (14). Few maternal nutrition data exist, however, the DHS reports that 1 in 5 women are too thin (BMI<18.5), and

• ~18% of women in South Kivu are stunted (<145 cm).

• The negative association between infection, especially if accompanied by diarrhea, and weight and length gain is clear from scientific evidence (15, 16). The DHS findings report high two-week prevalence rates of fever, diarrhea and acute respiratory infections among children under five years of age, with a high concentration of fever (~40%) among children 6-23 months, and high rates of diarrhea (30%) and respiratory infections (23%) among children 6-11 months.

Underlying the immediate causes of poor infant growth are factors rooted in the socioeconomic and cultural environment in which infants are raised and fed (13). These refer to food insecurity, maternal knowledge and attitudes, and the many factors present in the socioeconomic and cultural environment in which infants grow and in which caregivers make infant feeding decisions. Based on the available proxy indicators of provincial-level food deficits (measures of household poverty, household food consumption, and chronic under-nutrition in children under five), and DHS data on levels of maternal education

(21% reproductive age women have no formal schooling), health service utilization (less than 1 in 3 children receive all recommended vaccinations), access to improved water sources (<25% of rural households have access), and access to improved toilet facility (83% have no access), there are important underlying causes of poor infant growth that need to be addressed.

Photo: Women help prepare a meal in Katala after church

Among other strategies, the promotion of adequate infant and young child feeding practices and the provision of appropriate food rations to pregnant and lactating women and children <24 months in food insecure areas may be an important means to reduce the burden of undernutrition and related morbidity and mortality. However, there remains a relative dearth of evidence on the impact of dietary counseling in the prevention and management of moderately malnourished children. Programs that have had success in improving feeding behaviors have followed a staged approach to the development of a behavior change communication strategy including (17):

• a review of pre-existing information on feeding practices and diet

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• ethnographic study of health and nutrition beliefs and practices of the health providers, community members, and mothers, and their sources of information

• nutritional assessment of existing diets and practices, their potential for enrichment or improvement, and possible resistances or obstacles to improving diet quality and feeding practices

• individual and group trials of new feeding practices, foods, and recipes to determine the most feasible alternatives for improving dietary intake and people’s reactions to new products and behaviors; and

• development of a strategy for improving child feeding in the population, based on the findings from the previous four steps.

In July 2011, the Adventist Development and Relief Agency (ADRA) International was awarded a cooperative agreement from the United States Agency for International Development (USAID) to finance its second Multi Year Assistance Program (MYAP) in Fizi, Kalehe and Uvira territories in South Kivu province of eastern Democratic Republic of Congo (DRC). While the program aims to provide a broad range of agricultural development, health and nutrition and women’s empowerment programs, Johns Hopkins School of Public Health has been tasked to undertake formative research to assess beliefs and perceptions on maternal and infant and young child feeding practices, the results of which will inform the development of social and behavior change communication (SBCC) training materials and guide components of ADRA’s Care Group intervention model.

Purpose

The purpose of this study was to gain insights from mothers and key community informants regarding their beliefs and perceptions on maternal nutrition and infant and young child feeding behaviors. The study was intended to assist ADRA to prioritize and conceptualize appropriate behavior change communication messages related to nutrition, provide appropriate support to Care Groups, and anticipate challenges in the implementation of the nutrition-related behavior change component of the JENGA JAMAA-II project in South Kivu, Democratic Republic of Congo.

Specifically, the study aimed to: • Examine the barriers and constraints

to the uptake of recommended maternal nutrition and infant and young child feeding and caring practices.

• Learn more about the types and amounts of foods consumed during

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pregnancy and given during complementary feeding, and the age at which the child is introduced to these foods.

• Identify feasible and effective channels for promoting recommended maternal nutrition, and infant and young child feeding practices.

Methods This was a qualitative study which aimed

to assess beliefs and perceptions on maternal and infant and young child feeding practices, the results of which will inform the development of social and behavior change communication (SBCC) training materials and guide components of ADRA’s Care Group intervention model. In each study site, the following research methods were used: (1) structured interviews among mothers with children <24 months of age, (2) in-depth individual interviews among health workers and Leader Mothers and (3) focus groups with mothers of children <24 months of age and women of reproductive age.

Photo: Focus group of women with young children Focus Groups. Focus groups were

conducted among two separate, but related, respondent groups—mothers of infants <24 months of age and women of reproductive

age (18-45 years). One FGD per respondent group was conducted for each of the ten study sites for a total of 20 FGDs. Oral informed consent was obtained from each participant prior to initiation of the FGD. FGDs were conducted using standard procedures for FGD facilitation (see Appendix 3: Forms). Discussants were first told about the purpose and general domains of the FGD and then they were invited to discuss the topic. The facilitator allowed the group to lead the discussion so that flow of the conversation was natural and topics of particular salience to the group were explored in depth. The order of topics followed the group’s discussion; however the facilitator ensured coverage of all topic areas listed in the FGD guide (Appendix 3: Forms). FGDs were conducted in Swahili and lasted ~ 2 hours. FGDs were audio recorded and a note taker was also present. Notes from the FGD note-taker and key elements of the audio recordings were translated into English.

Information Collected from Mothers of Children <24 Months of Age

• general perception of good health among infants

• breastfeeding practices and perceptions

• complementary feeding practices and perceptions

• whether and how mothers change their feeding behaviors as the infant grows older

• perceptions of different foods for infants

• perceptions about the functions of different types of food

• perceived ways to improve complementary foods

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• perceptions of rations/commodities provided by agencies; and

• receptivity to recommended behaviors.

Information Collected from Women of Reproductive Age

• perceptions of good health among women

• kinds and amounts of food eaten during pregnancy and lactation

• changes in amounts and kinds of foods consumed during lactation

• perceptions about the link between food intake and pregnancy outcomes

• perceptions about good/bad foods during pregnancy and lactation

• perceptions about food functions; and

• receptivity to recommended behaviors.

Structured interviews. Structured interviews among mothers with infants <24 months were used to gain a more quantitative understanding of infant and young child feeding knowledge, attitude and practices related to infant and young child feeding, and to triangulate findings with those from the FGDs (see Appendix 3: Forms: Structured Interviews). Interviewers received training prior to data collection. Oral informed consent was obtained from each mother, after which the interviews were conducted. The interviews were ~60 minutes in duration.

Information Collected from Mothers of Children <24 months of age

• Socioeconomic and demographic data

• Infant and young child feeding practices including:

o breastfeeding initiation o giving of colostrum o exclusive breastfeeding o timing of introduction of

complementary foods o quality, timing and

quantity of complementary foods; and

o feeding a sick and recovering child

• Child feeding knowledge and attitudes

• Prenatal and postnatal care • Mother’s decision-making

authority • Sources of advice and their

credibility • Health worker contact and

credibility • Leisure and media habits

Photo: Structured Interview of a women in a lakeside village

In-depth Interviews (IDI): IDIs were conducted among government health workers and Leader Mothers. For each respondent group, the interview was described and oral informed consent was obtained prior to conducting the interview.

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A note-taker was present to record responses and interviews were also audio-recorded. In-depth interviews with health workers and Leader Mothers were used to understand their roles in providing health and nutrition information, and their own knowledge and perceptions of practices related to nutrition and care in pregnancy and infant and young child feeding.

Information Collected from Leader Mothers and Health Workers

• Description of their job • Nature of health and nutrition

components of their job, specifically related to concerns of pregnant/lactating women and feeding of their young infants

• Teaching aids and materials • Advice given to

pregnant/lactating women and mothers of young infants

• Frequency and nature of home visits

• Food habits in the area • Perceptions of infant and young

child feeding behaviors • Food perceptions • Food functions • Ways to improve

complementary foods • Commodities and rations • Receptivity to proposed

behaviors Selection of Study Villages

Because food availability, affordability and access are often influenced by agri-ecological zone, the study sought to include villages from the three major zones—highland, lowland and lakeside. No attempt was made to construct a representative picture of the South Kivu, but villages in the predominant agri- and geo-ecological zones

were studied. All villages were rural, and no attempt was made to include urban areas because of the few urban areas in S Kivu and because ADRA’s JENGA JAMAA-II project’s activities are focused on rural areas. Table 1 lists the villages studied and their respective ecozone. Table 1 List of Villages Studies

Territory Ecozone Village

Uvira

Highlands Lemera Katala Ndolera

Lowlands Ndunda Katogota Kigurwe

Fizi Lakeside

Ake Kenya-Plage Sebele Swima

Sample Size and Justification

The research was qualitative in nature and thus sample size calculations were not warranted. The primary considerations in determining sample size included time, logistical and financial constraints of conducting research in South Kivu, and in partnership with an implementing organization such as ADRA. The actual number of respondents for each study component is summarized in Table 2. Twelve structured interviews with mothers of infants <24 months of age were required per site to obtain adequate variation in household composition and responses, and to ensure inclusion of several children per age intervals from 0-5 m, 6-11 m and 12-23 m. A total of two focus groups discussions were conducted in each village- one with

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mothers of children <24 months of age, and one with women of reproductive age. Each FGD had ~10 participants. In addition, two in-depth interviews among government

health workers and ~3 in-depth interviews among Leader Mothers per village were conducted.

Table 2. Actual number of respondents per study component

Study Component Mothers of infants 0-24 mo.

Women of Reproductive Age

Health Workers

Leader Mothers Total

Structured Interviews 120 0 0 0 120 In-depth Individual Interviews 0 0 20 23 43

Focus Group Discussions 92 96 0 0 188

Overall Sample 212 96 20 23 351

Data Analysis Standard analytic methods were used for each

qualitative component. • Focus Group Discussions: The note taker for

each FGD listened to the taped discussion and completed notes for each group discussion. A co-investigator also participated in note-taking during the FGDs. Notes were organized on a form containing the major topic headings of the FGD guide and a report was completed for each FGD. Direct statements of respondents were written verbatim when they were describing their perceptions and feelings about specific behaviors. Upon completion of each FGD report, responses were consolidated across all FGDs according to major and sub-headings of the FGD guide. Responses were reviewed for patterns and trends.

• Structured interviews of mothers of infants <24 months of age: Quantitative analysis methods were used for the structured interviews and frequency distributions were examined (see Appendix 1: Tables 1-13). Feeding practices

were analyzed based on the following age-categories of infants: 0-5 months, 6-11 months and 12-23 months.

• In-depth interviews: Each interviewer listened to the tape of the interview and completed their interview notes. A co-investigator met regularly with the interviewers to discuss the data and address any challenges encountered during the interviews. Notes were organized by each of the major headings of the in-depth interview guide and a report was completed for each in-depth interview. Upon completion of each in-depth interview report, responses were consolidated across all interviews. Responses were reviewed for patterns and trends.

Formative Research Findings Maternal Nutrition

The women participating in the focus group discussions ranged between 18 and 45 years of age with the majority in their 20’s (Appendix 1: Table 1). A wide variety of ethnic groups were

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present, including Mufulero, Mushi, Bafulairu, Mubembe, Muviro, and Murundi. Women had anywhere from 1- 10 children, with the average having 3-5.

Photo: Women gather for a focus group discussion

Food Availability To capture ecologic variability and the effects

such variability might have on food availability, behaviors and beliefs, the study sites were distributed across three ecologic zones- highlands, lakeside and lowlands. With respect to food availability, corn, beans, and bananas were commonly grown in the highlands. Palm oil, bananas and fish were widely available in lakeside communities. In the plains or lowlands, a variety of cereals (sorghum, maize, rice), tubers (cassava, sweet potato), legumes (peanuts, beans), vegetables (cabbage, eggplant, tomatoes, onions) and fruits (bananas) were grown.

While a variety of foods were grown across the three ecological zones, the typical diet consisted of cassava fufu (starchy ball made of cassava flour and water) and a sauce (sombé)

made from cooked cassava leaves prepared at a minimum with salt and water- fufu au sombé. Households that either cultivated land or had an income were more likely to add peanuts, palm oil, onion, tomato, eggplant, green pepper, beans, rice, meat or fish to their diet, yet the average household does not have the “means” to consume these daily. Mangos, bananas, plantains, avocados, papaya, pineapple, oranges and passion fruit were some of the fruits grown throughout the South Kivu province but the ability to eat them daily is challenging. Dietary Practices of Women of Reproductive Age

Women of reproductive age (WRA) consumed the traditional dish fufu au sombé one to three times per day depending on their socioeconomic status. Sombé was often described as being “well-prepared” when it included oil, salt, ground peanuts, onion and fish. While cassava leaves are consumed most frequently, other green leaves are used as a substitute: amaranth, bean leaves, squash leaves and sweet potato leaves. The household’s livelihood, access to markets, land and water, and the season influenced what they consume. Most women were consuming what they produced, selling a portion of their harvest, and if they had the financial means they would buy other food from the market. In the research location, the women were principally farmers of cassava. Depending on the geographical zone, some grew beans, squash, sweet potatoes, peanuts, bananas, sugarcane, maize, sorghum and rice. Yet many of the households sold a large bulk of their harvest in order to have an income. One woman explained that she sold all of her sweet potatoes because they did not have any ingredients with which to prepare it. Some raised livestock but the more common practice was to sell the meat and milk rather than reserve it for household consumption.

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Meat and fish were considered too expensive to be consumed regularly. For the average family, meat (goat, beef, pork) was added to the traditional sauce on average once a week. Households closer to Lake Tanganyika consumed fish more frequently, but the price for ordinary families limited consumption to once a week. As one woman explained, “we have a desire to eat eggs and meat but don’t have money to buy it.”

Photo: Different types of cassava leaves

General Perception of Good Health Among Women of Reproductive Age

In all the research locations, women considered themselves to be in good health when they “eat well.” Table 3 lists the wide variety of foods associated with women’s good health. Eating well was most commonly defined as eating cassava, oil, peanuts, fish, beans, eggs, meat, green leaves, avocado, bananas and milk. Green leaves included those from cassava, bean, amaranth and squash plants, but cassava leaves prepared with a variety of ingredients (oil, peanuts, tomato, onion and salt) was mentioned the most frequently. When consuming these leaves, how well

someone eats appears to be determined by the number of ingredients used. Meats, including beef, goat and pork, were not ranked in importance. As one woman stated- “if I find even a small quantity of meat I feel in good health.” Fish could include the smaller, more affordable dried “fretin” or larger more expensive fresh-water fish. Fruits included banana, avocado, pineapple, mango and passion fruit, with banana and avocado being mentioned the most often. Bananas and avocados were said to make a “balanced” diet. Many of these foods were described as foods that “will improve the health of the mom and baby.”

Eating foods from the “three food groups” was mentioned several times as an indicator of good health. In one case, cane sugar and oranges were described as “energy foods,” beans, fish, avocado, green leaves, soybean, and honey as “building foods,” and eggs, meat, and banana as “protection foods.”

Apart from dietary intake, several women said in order to have good health they need to: be clean, seek prenatal care and take medicines, see their weight increase over time, and feel the baby move in-utero. Less frequently mentioned was having a mosquito net, “not having any concerns,” having money, being well dressed, and having energy.

In Table 3, the checkmarks indicate foods mentioned as “eating well foods” in the respective research location. Blank columns indicate areas where this information was not gathered.

In contrast, several ways of eating were described as not being in good health. In almost all the research locations, squash leaves prepared without “ingredients” (other than water and salt) was associated with not being in good health. Several times, women said they ate only cassava leaves and cassava fufu because this is “what they have,” and this is not considered to be eating well. Having lots of children, thereby increasing a mother’s workload, was seen as a woman in poor

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health, because she spends all day in the field without eating.

Many desire to have good health but are unable to because of lack of availability and/or access to these foods. Much of the availability and access depends on their livelihoods. For women who do not grow crops, raise livestock or catch fish, many of these foods are either not available in markets or, more commonly, they do not have the money to purchase them. Those that grow these foods are more likely to consume them during harvest season and not store them for consumption outside of these few months per year. It is common practice for households to produce staple and cash crops or raise livestock (cows, goats, chickens), and sell much of their harvest and by-products (milk, meat, palm oil), in order to have an income. It was frequently described that they eat what they grow, but even then much of this is being sold. They had the

“desire” to eat certain foods (rice, meat) but lacked the “means” to get it.

Photo: Villagers working in the cassava field

Table 3. Foods Defined as Eating Well (Among Women) Eating Well Foods (Among Women) Katala Lemera Ndolera Ake Kenya

Sebele Swima Ndunda Katogota Kigurwe Cassava

√ √ √ √ √ Porridge √ Rice √ √ Oil √ √ √ √ Peanuts √ √ √ Fish √ √ √ √ Beans √ √ √ √ √ √ Eggs √ √ √ √ √ Meat √ √ √ √ Green

√ √ √ √ √ Sweet

√ √ Fruits √ √ √ √ √ Tomato √ Onion √ √ Salt √ Tea √ √ √ Milk √ √ √

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Pregnancy Kinds and Amounts of Foods Eaten During Pregnancy

In general, there is no significant difference between the diet of a pregnant and a non-pregnant woman. Women eat their traditional dish of cassava and sauce made of a variety of green leaves. They eat what they can find even if it is not what they “desire.” According to one pregnant woman-

“I have a desire to eat tea and beignet or

bread but normally I just eat fufu with sombé or amaranth and no meat because we don’t have it.” There appears to be a strong perception of an

association between the mother’s diet and the fetus’s health, as explained by three mothers:

“when I eat well I know the baby I’m carrying is

eating well”

“[We] need to eat well during pregnancy to permit weight gain, give good health to the baby and to give the mom strength to push the baby out”

“eating poorly can give a weak child” The only difference expressed by some

women was how they reduce their dietary intake during pregnancy due to lack of appetite. One woman stated that a lack of “good things to accompany the fufu” was the reason she does not eat much.

The common unit of measurement, the ‘gigoze,’ is a tin can used at the market for selling flour. One gigoze equates to approximately four cups. Some women can eat, on average, one to two gigoze of flour per meal. It is hard to determine if this is solely what they consume or if that would be shared with other family members. One woman explained that she would use 9

gigozes of flour to prepare the family meal. Many said they could increase their intake by consuming an additional serving of staple food (cassava fufu), or half of a gigoze of flour. This depends, of course, on the yield of their harvest- “if we produce a lot in the fields we can increase our intake.” It was felt that gaining at least one kilogram per month in the second and third trimesters of pregnancy is possible if they “don’t fall sick,” “eat from the three food groups” and “don’t have concerns.”

Photo: “Gigoze” measurement tool Willingness to Try New Foods During Pregnancy

Women did express a willingness to try new foods during their next pregnancy. Avocados and bananas were most frequently mentioned as foods they could add to their diet as they tend to be most affordable, though daily consumption would be difficult. Additional suggestions varied across the geographic areas: maize porridge, cow’s milk, tea, passion fruit, mango, orange, beans, peanuts, fish, mixing soybean, maize and cassava flours and diversifying greens. These foods would be added during pregnancy to “improve the health of the mom and baby” or to “have a balanced

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diet.” The two biggest hindrances are lack of money to buy these foods and seasonal availability. However, a comment was made that should be considered- “meat is reserved for men and beans are for mothers and children.” Rest During Pregnancy and Lactation

In terms of getting more rest during pregnancy and lactation, there was a strong consensus across all research communities that this was not possible. The women explained that their workload is immense. They leave the house early in the morning to go to the field, return in the early afternoon to gather water, prepare food, bathe the children and then their husbands expect their time at night. The feeling of being “occupied” by the husband was frequently expressed. Another said a woman is treated like “an instrument.” One woman shared her personal experience-

“I could go to bed at 10 and at 12, I am not even

sleeping. I’m occupied by my husband or my thoughts are fixed on how tomorrow will be.”

Another woman shared-

“I work in the field in the morning, bring sombé home, cook it, look for water, prepare the fufu, go to bed because tomorrow I am up early to go to the market or field again”… her husband tells her not to sleep because he needs her…“to avoid problems, I accept” … “if I refuse my husband I will get slapped”….”and [then] it’s 1 [AM] and I rest [before getting up] early to go to the field.”

Another woman talked about feeling

“cornered” because of all the work she has to do and she is “obligated” to respond to her husband’s demands. When asked who could help with work at home so they could rest many responded that there is no one, unless they have older children.

Prenatal Care All women interviewed had consulted a health professional during their previous pregnancy, with 74% having consulted with a doctor and 26% with a nurse (Appendix 1: Table 9). Most women had their first prenatal consultation during their 2nd trimester of pregnancy (Figure 1) and half of the women had 4 or more prenatal consultations (Figure 2).

Photo: Woman working hard to provide for her family

Iron and Folic Acid Supplementation The women’s receptivity to taking iron and

folic acid supplements daily during pregnancy was overall positive. Ninety-two percent of women interviewed said they took iron-folic acid supplements during their last pregnancy, with ~40% taking the pills for 100 days or more (Figure 3 and Appendix 1: Table 9). Most receive them for free from the health clinic during antenatal care visits, though many said they don’t start their care until their fourth or fifth month of pregnancy (Appendix 1: Table 9). Several reasons for taking them included “to increase the blood,” “protects the mothers against blood lost during

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delivery,” “to protect the health of the child,” to give the mother energy to “push the baby out,” and to

prevent “dizziness” and “anemia.”

Figure 1

Figure 2

01020304050607080

0-3 m0 4-6 mo 7-9 mo

Percent

Months pregnant

Number of months pregnant when women first consulted a health professional during last pregnancy

05

1015202530

1 time 2 times 3 times 4 times 5 times 6 ormoretimes

Percent

Times Consulted Health Professional

Number of times women consulted a health professional during their last pregnancy

19

Figure 3

Lactation Kinds and Amounts of Foods Eaten During Lactation

It was generally expressed that while women maintain their same diet of cassava fufu and dark green leafy vegetables during lactation, they perceived that not eating well and specific foods hinder milk production, while other foods enhance production. Among the foods considered to be good for lactating women, the common factor across all research locations is peanuts. Among foods perceived to be bad for lactation, how squash leaves are prepared is paramount. Table 4 contains the various combinations of foods that help or hinder milk production.

In almost every research community, how squash leaves are prepared came up as an inhibiting or enhancing factor. If they are prepared without “ingredients” (peanuts, tomato, oil, and fish) and only salt, this is seen to hinder milk production. Two women from different communities

described this simple dish as tasting sour. However, when squash leaves are prepared with these “ingredients” milk production is enhanced. A couple of mothers explained that when prepared this way it tastes good or “gives an appetite,” thereby helping the mother to eat more and resulting in increased milk production. Squash leaves can “make a woman become malnourished because squash leaves don’t contain any nutrients,” reported one woman. When asked why mothers eat squash leaves if they know it hinders milk production, one explained that – “squash leaves will hinder milk production but if we have hunger and this is available we’ll eat it; we’re tired of eating sombé all the time.” Lack of purchasing ability or seasonal availability came up in several communities as hindrances to being able to regularly prepare their meals the preferred way.

On several occasions it was said that peanuts, alone or in combination with other foods, help to increase milk production. Moreover, cooking with a variety of

0 5 10 15 20 25 30 35 40 45

less than 10 days10 to 19 days20 to 29 days30 to 39 days40 to 49 days50 to 59 days60 to 69 days70 to 79 days80 to 89 days90 to 99 days

100 days or more

Percent

Number of days women took iron syrup or supplement during last pregnancy

20

ingredients appears to support the perception of improved milk production. A woman explained that if she is lucky she adds meat to sombé. If she has access to beans or eggplant she will add them. Another said that by adding peanuts, tomatoes and onion this gives a woman an appetite, so she eats more and therefore produces more milk. But because of lack of financial means they only eat the leaves. Some explained that several of the food products were rich in protein, energy or vitamins but there was no pattern to this reasoning. The temperature of drink and food came up several times. Hot tea is thought to make the mother sweat therefore lactation is “working.” Another said hot sombé prepared with peanuts aids lactation. It appears as though the taste of food- enhanced by using more ingredients- helps the lactating woman to eat more, therefore increasing milk production.

The quantity of food consumed also seems to influence whether or not a mother thinks she produces enough milk. As one mother described-

“Fretin [small dried fish] doesn’t increase milk production as much as other

foods. We cannot eat enough fish to help the production. [However] we can eat a sufficient amount of greens to satisfy and produce milk.” After suggesting these foods that are

good for milk production, women would often say that they could not eat these regularly because of “lack of means.” Those that produce peanuts do not store peanuts following harvest because they have to sell them in order to have money. A woman further elaborated by saying sickness is prevalent here and it consumes a lot of their money.

In comparison to pregnancy, the quantity of food consumed appears to be greater, due to an increased appetite. One woman explained that she has more room for food and needs more food to produce milk. Some said they could eat double the measure of cassava flour than they would during pregnancy. Another felt that “the woman has the right” to eat more of the traditional food because she needs to recuperate after pregnancy and produce milk.” Their receptivity to being able to eat an extra meal during lactation wasn’t clear. One felt she could add peanuts to her dishes but not regularly.

Table 4: Combinations of Foods Perceived to Enhance/Hinder Lactation and Milk ProductionFoods Perceived to HINDER Breast Milk Production:

Squash leaves prepared only with salt Foods Perceived to ENHANCE Breast Milk Production:

Hot tea (w/o milk or sugar) or Extra water Beans, fish, cassava leaves Extra staple foods (beans, rice, corn, cassava) Peanuts and hot sombé Cassava leaves, oil and fish Fish, peanuts, tomatoes, onion) Peanuts Tomato, onion, green pepper, peanuts Soy flour, tomato, onion, green pepper, peanuts Squash leaves with peanuts, oil and fish

Squash leaves with peanuts and tomato Porridge Peanuts, beans and maize fufu Peanuts, beans, soybeans and porridge Cassava fufu and meat Amaranth and fresh fish Cassava fufu and fish Peanuts, tomatoes, onion Cassava leaves and peanuts Squash leaves with peanuts, oil and fish and tomato

Infant and Young Child Feeding and Caring Practices

The women participating in the focus group discussions ranged between 18 and 45 years of age with the majority in there 20’s (Appeddix 1: Table 1). A wide variety of ethnic groups were present, including Mufulero, Mushi, Bafulairu, Mubembe, Muviro, Bazoba, Munyindu and Murundi. Women had anywhere from 1-8 children, with the average woman having 2-5 (Appendix 1: Table 1). General Perception of Good Health Among Infants & Young Children

A child in good health was most commonly described as a child who breastfeeds and eats well. A child that does not “fall sick” was the next most common explanation. There were several mentions of a child having a good weight or being “fat” as indicators of good health, and the inverse- skinny- indicates poor health. Mothers talked about taking the child to the health center to see improvements in their weight as assurance of good health. Others considered children to be in good health when: a child does not cry often; a child has hair that is black and thick, not yellow and thin; a child without swollen feet; and a child who comes from a family with sufficient food and money. Finally, several references were made about waiting to introduce foods until six months coupled with a child not falling sick to be signs of a child in good health.

With regard to the breastfed child, there was a frequent association made between a mother’s health and/or her eating habits and the child’s health. Several mothers shared their perspective on this:

“when milk is plentiful the child will eat well

[and for this] the mom needs to eat well to feel satisfied”

“if a woman doesn’t eat well, the child will

take a long time to breastfeed because the milk won’t be sufficient”

“mom has lots of milk in her breast as a

result of eating well” “Eating fufu and sombé we are only satisfied.

Adding ingredients like oil, peanuts, green onion, salt are what they we wish to add to the sombé and this means we are eating well”

Photo: Mother works hard to takes care of her children

A pattern emerged with most mothers saying they cannot afford to eat this way regularly. While they would like to be able to eat three times a day, the reality is most are eating only one to two times per day.

For a child to be eating well and therefore have good health, several meals were described (Table 5). Having the ability to eat cassava fufu, sombé and fish was most frequently mentioned as what would give a child good health- “When I prepare fufu and sombé and fish I know both me and my child are eating well”….“if I eat fish at each moment that I desire to….if I need fish at noon and I can have fish at noon.” On the contrary, eating poorly was described as eating cassava fufu with only sombé or other dark green leafy vegetables or eating foods prepared without oil.

Table 5: Foods defined as “Eating Well” (among children) Cassava fufu and meat Cassava fufu, amaranth and beans

Cassava fufu and fresh fish Biscuits, banana, avocado plus breast milk

Cassava fufu and dried fish Cassava fufu and sombé or amaranth with oil and peanuts

Cassava fufu, porridge, cow’s milk Amaranth prepared with oil, peanuts, soy flour, salt and tomatoes

Breastfeeding It is very clear that women breastfeed

their children so they will grow well and have good health. Several mothers claimed that “it is their right” -of the child- to be breastfed when they ask. In fact, most mothers said they feed on demand, or “each time the child asks”- often described as when the child cries. Day and night feeding takes place though some women did say that their children nurse so frequently at night that they have nothing left in their breasts in the morning.

Initiation of Breastfeeding The majority of women reported

initiating breastfeeding within an hour of childbirth and over 80% of women reported initiating within the first 5 hrs of birth

(Figure 4 and Appendix 1: Table 3). “Mohondo,” or colostrum, in commonly given to children within one hour of birth, after the mother bathes. Various reasons were shared for why they give it: cleans the stomach, gives intelligence to the child, gives energy, contains vitamins and protein, protects the child from disease, and helps the white milk to come in. Although their grandparents would throw out colostrum, many claim this is the advice coming from the health center. “At the health center they tell us to give the milk right away because it helps the child to grow. Before [health center counseling] we used to throw out the first milk.” The few that said they gave sugar water or asked another woman to breastfeed for her said they did so because they think there is nothing in there since they cannot see milk “running out.”

Figure 4

51%

31%

8%

4% 4% 1% 1%

Breastfeeding Initiation Time

within 1 hour

1 to 5 hours

6 to 11 hours

12 to 24 hours

1 day to 3 days

4 to 7 days

more than 1 week

Time till Breastfeeding after birth:

Exclusive Breastfeeding While not the majority, there are several

women who claimed they exclusively breastfed their infants until six months of age. They report being successful in doing so because they are encouraged by the nurses at the health center who have counseled them since their antenatal care visits. One woman explained that she started giving porridge to her younger child at three months and he developed diarrhea so she took him to the hospital. They told her to stop giving porridge. So with her second child, she gave only breast milk until six months. Several of the other women who reported to exclusively breastfeed stated that it is possible because of what they eat. Although a combination of foods was described, the majority said their diets consisted of hot tea, sombé prepared with oil, peanuts and/or fish.

Almost forty percent of women interviewed said they had some difficulty

initiating breastfeeding (Appendix 1: Table 3). Reasons for the difficult initiation included experiencing breast pain, having plugged milk ducts or cracks, feeling they did not have enough breast milk, claiming the infant was sick, or they did not have enough time to feed the child or the child did not suckle well (Figure 5). Three to four months after birth, a sizeable number of women (20%) had difficulty in breastfeeding (Figure 6, Appendix 1: Table 3). Main reasons included feeling there was not enough breast milk, not having the time to feed the infant, experiencing pain, plugged milk duct and mother or baby becoming ill. Forty-one percent of mothers of infants 0-5 months of age had fed their child water on the previous day of the survey, and 27% had fed baby formula. (Figure 7, Appendix 1: Table 4).

Figure 5

0 5 10 15 20 25 30 35 40

Inverted nipple

Breast engorgement

Child did not suck well

Not enough time to feed child

Sick baby

Cracked nipples

Felt not enough breast milk

Plugged milk duct

Problems with breast (pain)

Percent

Type

of D

iffic

ulty

Type of difficulty in initiating breastfeeding

24

Figure 6

Figure 7

Duration of Breastfeeding

It is very common for children to be breastfed well into their second or third year of life. “I have six [children]. This is my ninth born. I let my child continue until they decide they are done breastfeeding.” For those who stop before then, a

common reason is becoming pregnant again. Fifty percent of women interviewed who terminated breastfeeding between six and eleven months did so because of becoming pregnant again (Appendix 1: Table 4). Women believe that in continuing to breastfeed when pregnant, the milk will hurt the

0 5 10 15 20 25 30 35

Inverted nippleChild did not suck well

Cracked nipplesBreast engorgement

Mother became illSick baby

Not enough time to feed childProblems with breast (pain)

Plugged milk ductFelt not enough breast milk

Percent

Type

of D

iffic

ulty

Type of difficulty in breastfeeding when child is 3-4 months of age

0 5 10 15 20 25 30 35 40 45

Water

Baby formula

Any other milk

Fruit juice (home-made)

Percent

Type

of F

ood/

Drin

k

Children 0-5months fed in the last 24 hours

25

health of the older child. One mother explained that she stopped breastfeeding her older child upon becoming pregnant for fear of “spoiling” the skin of her child. Two women from different communities explained that they found the color of their milk changed from yellow to a clear color indicating bad milk and feared this would hurt their children. Another woman said her child will become “bwaki” (malnourished) if she continues to breastfeed when pregnant. One woman who is currently pregnant and continues to breastfeed her nine-month-old said she is planning to wean her older child soon because “there isn’t much milk. It doesn’t flow.” When asked why she has continued to breastfeed through her first five months of pregnancy, she said “I do it so my child doesn’t suffer.” When asked what suffering was, she said “swollen face, hair changing color from black to yellow and a child who stops crawling and moving around.”

Photo: Children curious about the camera

Barriers and Potential Solutions Several major barriers appear to prevent

women from being able to practice exclusive

breastfeeding. First, their workload requires them to either tend to crops they cultivate or gather food from fields most days. Often, they will leave their children for hours in the care of nannies, neighbors or family members. Although not a widely adopted practice, there were a few women across the research sites that carry their child with them to the field. Most of these women do not have anyone with whom they can leave their children. In carrying the child on their back and produce on their head they are still able to carry an umbrella to shield them from sun and rain. One woman explained that if her child is awake she ties him to her back and breastfeeds when needed; otherwise if her child is sleeping she puts him in the shade to sleep. Another woman expressed concern for her child crawling around and putting dirt in his mouth. There were mixed responses from women as to whether this would be possible for them. Some said they have too much to carry and no room for their child. Others said it would be possible for those whose fields are close to home. Those with fields close by return home every two hours to breastfeed.

Second, the majority of women talked about their child crying during or after feeding and this leading them to think that their milk production is insufficient. Others describe how those watching the child often give them porridge to soothe them from crying. Even the mother, thinking that her milk is insufficient gives porridge to stop a child from crying- “if they cry a lot I give porridge at two or three months [of age].” “I breastfeed but he cries a lot and that makes me think it isn’t satisfying.” However, one woman explained that she was successful in exclusively breastfeeding until six months because the child “didn’t cry after breastfeeding” and she “breastfed the child every time he asked.”

When exploring if expressing breast milk would be a possible solution to the challenge of exclusive breastfeeding, most women said they are not familiar with the practice though there

26

was uniform interest in learning to do so. Two women claimed to be currently expressing breast milk. The first learned at a refugee camp in Tanzania and continues to receive support from a midwife at a hospital not far from her village. Her motivation to continue the practice is so her child doesn’t cry and she knows that he has her milk when she is away. The second learned from her community health worker and at the district hospital during her antenatal care visits. A few concerns were raised regarding expressing breast milk. Chief among them is contamination of milk by flies and their child becoming sick. In one case, the group responded with strong resistance explaining they would be chased out of the community by their father-in-laws or husbands if they were caught expressing milk. Others said they would be viewed as cows or witches. In one village, the women got very defense and reacted strongly when it was suggested that the traditional chief and husbands could be sensitized on the technique of expressing breast milk. The challenge of eating well enough to be able to produce enough milk to express surfaced again. A final point of resistance was in regard to their ability to boil water and sanitize feeding utensils as some appeared to be hesitant.

Complementary Feeding

Timing of Introduction of Complementary Foods

Children commonly receive porridge and other semi-solid foods before six months of age in the research area. From the structured interviews, water and other non-breast milk liquids were first given to a child at a median age of four months and porridge at five months (Figure 7; Appendix 1: Table 5). In FGDs, women explained that a child’s cry indicating they aren’t satisfied during or after breastfeeding coupled with women’s perceived inability to produce enough milk lend mothers to introduce

foods generally within two to three months of life. Finding that the child stops crying after giving food encourages the mother to think this is what they need.

Photo: Structured Interview of a woman with a child less than 12 months of age

A mother explained how after introducing

porridge her child became “calm” so she continued to give it to him. “When the child cries the child is hungry” was frequently voiced. Several moms shared their frustration-

“he cries, he cries, you give milk and he

isn’t satisfied” “ if you give the porridge his eyes follow

the porridge and he takes it and is satisfied” “I take tea at 6 [AM], arrive at the field

at 8. When I return home, I find that he has cried all day so I am obligated to give porridge.”

Mothers’ inability to produce enough milk because of not eating well was expressed in nearly every village. They explained that with not eating all day- just taking some water and a piece of cassava- they cannot produce enough milk.

27

Another common reason women begin introducing foods early on is because of their workload in the field requiring them to leave their children at home for two to five hours, on average. Many women say they don’t leave food at home but that grandmothers, nannies or older children watching the children give porridge to calm them from crying. The few women claiming they wait to introduce porridge until six months are able to because they return home every two hours to breastfeed. They also talked about how this is what they were “instructed” to do by the nurses and midwives at the health center. A few mothers said they waited until 10 months to introduce foods because their child refused fufu earlier on and seemed satisfied with milk.

In general, porridge is introduced first, followed by family food between seven and twelve months. A few mothers started giving porridge at two months and cassava fufu and sombé by five months. Similar to breastfeeding, women allow the child’s cry to indicate when they are ready for change. As one woman

explained, she started porridge at six months. At seven months, she started giving fufu because her child cried a lot with just porridge and so she assumed he wasn’t “satisfied.” Other women let the point at which the child refused to take porridge any longer indicate when to introduce family food. Another woman said she is planning on skipping porridge and instead introducing fufu at nine months because her child doesn’t cry which indicates that her milk is sufficient.

Based on the structured interviews, over half of the children 6-23 months of age had not yet been given eggs, yellow fruits or vegetables, or meat (Appendix 1: Table 4). More than 40% had not yet been fed legumes or fish. Among the infants who had already been introduced to the foods, the median age when meat was introduced was 9 months, and 8-8.5 months for yellow fruits and vegetables, green vegetables, legumes, eggs, and solid food. Fish and semi-solid foods were first introduced at a median age of 7 months; while porridge was introduced at about 6 months of age.

Figure 8

0 10 20 30 40 50 60 70 80 90

WaterPorridge, rice gruel, maize grueletc.

Solid foods (rice, fufu/casava, wheat, other)Other Non breast milk liquids (sugar/glucose water, tea, fruit juice etc.)

FishLegumes (pulse, peas, etc)

Semi-solid foods (soft or mashed maize/casava/potato, ripe banana,…Meat (chicken, mutton, beef, etc., khichuri with meat)

Yellow fruits or vegetablesEggs

Cow/Goat milk

Percent

Type

of F

ood

Not

Yet

Giv

en

Proportion of infants 6-23 months who had not yet been given the listed foods

Figure 9

Figure 10

0 2 4 6 8 10 12 14

WaterOther non breast milk liquids

Cow/Goat milkPorridge, rice gruel, maize grueletc.

Semi-solid foodsFish

Solid foods (rice, fufu/casava, wheat, other)Eggs

Legumes (pulse, peas, etc)Green vegetables

Yellow fruits or vegetablesMeat (chicken, mutton, beef, etc., khichuri with meat)

Age, months

Type

of F

ood

Intr

oduc

ed

Figure 9 Age when foods were first introduced to infants among infants 6-23 months of age

0 20 40 60 80 100

RiceLiver, heart, kidneys

EggsRipe papaya and mango

Milk products (yogurt, rice pudding etc)Purchased baby cereals

Starchy vegetablesMeat such as beef, mutton

Chicken, duck, pigeonNon-human milkAny other fruits

Orange and yellow fruits and vegetablesBeans

Syrup or table that "increases the blood" (iron-containing)Bread or buns or donuts

Green leafy vegetablesPeanuts, groundnuts, other nuts

Pumpkin, orange yam, sweet potatoe, carrots, tomato…Other fruits-bananas, oranges

FishFat (oil, butter, ghee)

Casava or maize porridgeFufu

Percent

Type

of F

ood

Cons

umed

Figure 10 Percent of infants who consumed the foods listed on the day before the survey by age category

12-23 6-11

Kinds and Amounts of Complementary Foods Porridge generally consists of only cassava

flour and water but access to flours vary depending on the location. In the lowlands, sorghum, maize, cassava, soybean and rice flours exist and several are mixed when preparing porridge, but this is not found elsewhere. Porridge made from green plantain flour is found in the highlands. The technique involves drying sliced green plantains in the sun followed by grinding them into flour. Porridge made from cassava flour is made by cutting manioc into pieces and soaking it in water for at least 24 hours to reduce the cyanide. Then, it is dried in the sun and pounded into flour. One mother said she prepares porridge from maize flour and adds peanut flour because it tastes good. If anything was being added to porridge, most often it was sugar.

When porridge is introduced to a child, it is generally served using a spoon and a “gobelet” (cup). In visiting a home of a mother with a six-month old, the research team was able to observe the preparation and feeding of porridge. The following is the description:

The porridge was made of four tablespoons of a blend of maize, sorghum and cassava flours mixed with a half cup of water. It was cooked in a pot over hot coals for about 10 minutes, and then cooled slightly in a plastic cup. Washing of the cup was not observed but described as using only lake water and soap. The mother sat on the ground with her child sitting across her lap leaning against the crook of her other arm, partially facing her. The child eagerly consumed three teaspoons of porridge of medium-consistency. The mother frequently tasted the porridge to gauge the temperature before serving it. She said she didn’t have the means to add anything to the porridge, but in talking with her it was apparent that she did

not know that she could add palm oil, avocado, mashed banana, mango, beans or pounded peanuts to the porridge. She claimed she was unable to produce much milk but still offers her breast to her child several times a day. She asked when the project would come to teach her how to make different porridges and expressed interest in receiving support so she could continue to breastfeed.

Children eat what the family eats- “we give children what we have.” Family food generally consists of cassava fufu and sombé or other dark green leafy vegetables, prepared with water and salt. In terms of the quality of food, meat and fish might be added to sombé once per week, on average. Depending on the means of the household, sombé may be prepared with peanuts, tomatoes, onion, oil and other ingredients, but the average household does not do this regularly. Families with livestock do not appear to be giving their children the meat and milk of the cows and goat, yet there was no explanation for this. The meat they eat is generally purchased. Milk was not reported as a food commonly given to children, though it is being sold in plastic water bottles along the road in towns. Children also tend to eat- porridge or family foods- according to the family schedule of twice a day. The meal is fed to the child by hand. Once the children are capable of feeding themselves, they are given their own plastic bowl, although this was not confirmed through observation.

Figure 10 shows the foods mothers said they fed their infants the day before the survey based on infant age categories. “Fufu” was the predominant complementary food fed to both 6-11 and 12-23 month old infants with 44% and 86%, respectively (Appendix 1: Table 4 and 5). Green vegetables, beans and orange vegetables/fruits were the next most common foods fed to infants 12-23 months. Only ~37% of infants 6-23 months of age ate any animal source foods on the previous day (Appendix 1: Table 4).

Barriers and Potential Solutions Poverty, or lack of purchasing power, inhibits

a mother’s ability to diversity the child’s diet. One woman explained that if she had the ability, she would add fish, peanut flour, sugar, salt but explained that she rarely has the means- “ we can go one month without putting other things in porridge.” Ninety-four percent of mothers interviewed felt meat, milk, eggs, fruit and vegetables are beneficial for children, while eighty- seven said the cost makes it hard for them to provide these foods to children (Appendix 1: Table 7).

There appears to be recognition of the difference in the way a child eats depending on the ingredients used - “when I give fufu with meat my child eats with an appetite.” “When I put condiments in the sauce my child eats well, my child eats more.” The “condiments” she refers to are oil, onion, soy flour, salt, peanut powder, cassava leaves or amaranth. “If we give porridge we need to add sugar as that will improve the taste and the child will eat with strength.”

Lack of knowledge of how to enrich the child’s dishes also appears to be a barrier. Many mothers claimed they did not know they could add palm oil, avocados, bananas, mangos, mashed beans and pounded peanuts to porridge. On one occasion, a woman said she adds pounded dried fish to porridge made of banana flour. However, there was strong interest expressed by them to learn how to prepare a variety of porridges and snack foods for the children. Availability of and access to food influence what exists in the various locations. In areas where livestock are raised, children may not be regularly drinking milk or eating the meat from their herds. This is an area for further exploration to know how they perceive these foods for children.

Lack of time due to a mother’s busy workload may also be a significant barrier to child feeding. Forty percent of women interviewed said their housework makes it hard for them to spend enough time encouraging their child to eat

(Appendix 1: Table 8). Nearly half the women interviewed felt it took too much time to reheat leftover food.

In exploring some of the locally available options, mothers felt that on occasion, and more regularly during harvest season, they could improve complementary foods by adding some foods to either the porridge or giving them as a snack. Table 6 lists the foods that mothers thought they could add to their children’s diets. Of all the foods mentioned, palm oil, avocado and banana came up the most frequently as foods that could be added to porridge. In one case, a few mothers said they give fruits to children because they were told it helps with defecation and preventing constipation. Table 6. Potential Foods to be Added To Children’s Diets

Food Functions Rarely, would mothers talk about the

functions of foods. One group explained that they do not give yellow bananas, eggs, milk, beans, corn, peanuts, and beignets to children because they do not have the “means,” but they believe these foods “fortify and give vitamins to the body.” On a whole, there did not appear to be any bad foods for children, though one area to further explore is the belief of which bananas are suitable for children. One woman explained that they give only small yellow bananas to children as opposed to large ones because the large ones are

Foods Mothers Felt They Could Add to Children’s Diets

Sweet potato Soybean flour Guava

Beans Maize flour Papaya

Palm Oil Sorghum flour Orange

Peanut flour Frétin (dried fish) Avocado

Banana Mango

31

too sweet and “risk producing worms in the bellies of children.”

Changes in Feeding Behaviors as Infants Grow Older

According to the women in the focus group discussions, there are few changes made to the diet of children as they grow older. However, a slightly different picture emerges from the data gathered during structured interviews with mothers. In comparison to those 6-11 months, children 12-23 months are given less porridge and more fufu, green leafy vegetables, vitamin-A rich fruits and vegetables, starchy vegetables and beans (Appendix 1: Table 4 and 5). The other categories more or less remain the same. The majority of children are not receiving cow and goat’s milk, which emphasizes the importance of them continuing to breastfeed.

Amount of food fed to children The concept of quantity of food consumed is

obscure. Apart from the tin can (guigoz) used to measure flour at the market, measuring when preparing food is not common practice. Several described how they take flour by the handful and put it in the cooking pot with water. One mother thought she uses about a handful of flour when preparing porridge. On one occasion, a mother explained that she measures flour using a spoon when preparing porridge. When describing the amount consumed, spoonfuls and “tartine” (oval shaped ball of fufu) are commonly used. Several talked about giving 2-3 spoonfuls of porridge when they first introduced food. When serving family food, or fufu, they talk about giving a child a “tartine.” which is created by loosely using a plastic bowl and shaping the fufu against the side of the pan. Less concrete still is the quantity of food given to a child once they start on family foods. Overall, it is difficult to measure as children are left to eat until they are satisfied or refuse to eat anymore -“we don’t have quantities of food. We put the food there in front of them [children] and they eat until they are satisfied.”

From the structured interviews, mothers were shown a small 200 ml plastic bowl and asked how many platefuls of cooked food they fed to their child during the previous day. Figure 11 shows that the majority of children 12-23 months of age were getting about ½ a bowl of food per day (Appendix 1: Table 5).

Photo: Bananas are an option to add to porridge

32

Figure 11

Feeding During and Following Sickness When a child is sick there are no special

foods that are given to them. Many said if they are still breastfeeding that they continue to breastfeed when the child is sick as opposed to giving other liquids. About half of the women say their child breastfeeds the same amount while the other half said they consume less (Appendix 1: Table 7). If their child has already started eating foods, the majority mothers said they are giving less semi-solid and solid foods than usual and some reported not giving any, most likely because the child refused. Some explained that if their child refuses to eat or vomits and they let them be until they are willing to take porridge or family food again in small amounts. Many will take

their child to the health center when they have diarrhea or will not eat.

When a child recovers from sickness the women in the focus group said they let them eat until they are satisfied. There was no real indication if this amount increases or not.

During the structured interviews mothers were asked whether they fed more, less, the same as usual or did not give certain food types to sick or recovering children (Appendix 1: Table 7). Figure 12 shows that infants are fed the same or less breast milk during illness, and only about 40% are fed more breast milk during recovery. Forty-to-sixty percent of mothers reported not giving semi-solid and solid foods to their infants during illness, and only 4%-6% reported increasing the amount of these foods recovery.

0 10 20 30 40 50 60 70 80 90

none

half

one

two

three

Percentage of children

Num

ber o

f Pla

tefu

ls

Number of platefuls (250mL) of cooked food fed to child yesterday

6-8 months 9-11 months 12-17 months 18-23 months

33

Figure 12

Knowledge of Infant and Child Feeding Behaviors

Several questions were asked during the structured interview to gauge mothers’ knowledge of key infant and young child feeding behaviors (Appendix 1: Table 7). Knowledge of the following behaviors was high: early (<1 hr after birth) initiation of breastfeeding (73.1%); feeding colustrum to the infant (84%); on-demand breastfeeding (85%); frequency of breastfeeding an infant <6 months of age; continued breastfeeding when the mother is ill (84%).

Problematic knowledge areas were related to giving water to young children, ways to make porridge more nutritious for the child, and the variety of foods that

should be in a 6-12 month old child’s diet. About half of the women felt that water should be given to infants<6 months of age when the weather is hot (54%) (Appendix 1: Table 7). Forty percent felt that breastfeeding should be terminated when the mother becomes pregnant again. A small proportion of mothers mentioned adding meat/fish (20%) or eggs (19%) to enrich porridge. A slightly higher proportion of mothers mentioned adding colored fruits and vegetables (24%), milk (26%), soy flour (30%) and sugar (23%) to make the porridge more nutritious. Similarly, when asked what variety of foods should be in a 6-12 month old child’s diet, far less than half the mothers mentioned

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Sick Recovering Sick Recovering Sick Recovering Sick Recovering

Breast milk Non-breastmilk liquids Semi-solid food Solid food

Perc

ent

Feeding practices for sick or recovering child

Does not give Less than usual Same as usual More than usual

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fish (20%), egg (42%), yellow vegetables (38%), meat (41%) or green leafy vegetables

(40%).

Attitudes about selected infant feeding practices

During the structured interview mothers were asked whether they agreed, disagreed or neither agreed nor disagreed to 13 statements related to infant and young child feeding (Appendix 1: Table 8). The results suggest that mothers (i) are very favorably disposed to continuing breastfeeding until 24 month of age, (ii) are confident that they can exclusively breastfeeding their infant through 6 months of age, (iii) think it is beneficial to add foods such as meat, milk, eggs, fruits and vegetables to their baby’s diet; (iv) willing to continue breastfeeding when the mother or baby is sick; (v) are confident that they can recognize and respond appropriately when her baby refuses to eat; (vi) recognize the importance of washing both hands with soap after defecating is important for her baby’s health. However, despite the favorable attitude toward adding nutrient dense foods to their child’s diet, 87% of mothers felt the high cost of these foods makes it hard for her to prepare these foods for her baby, and 40% felt that a lot of housework made it difficult for her to spend enough time encouraging her baby to eat.

Mothers Decision Making Authority The structured interview explored the

mothers’ decision-making authority in matters of feeding decisions and spending money (Appendix 1: Table 10). Over half the mothers (53%) said they she decides what to cook on a daily basis, but 37% said their husband makes this decision. With respect to what a child gets fed, this decision rests mostly with the mother (61%), but in 27% of households, the husband is the decision maker. The majority of women feel they have to consult their husbands about what to do with even a small amount of savings, and over 70% of

women consult their husbands when it comes to money decisions.

Sources of Advice and their Credibility Based on the structured interviews, husbands

(64%), followed by mothers (16%) are the major sources of advice within the home about matters relating to child feeding and health (Appendix 1: Table 11). Outside of the home, the major source of advice is the staff of the medical clinic (48%), followed by the community health worker (14%), and by friends or relatives. Mothers really like to take advice about child feeding from the staff of the medical clinic (37%), husbands (31%) and mothers (11%), and have the greatest trust in the advice provided by their husband (38%) and health staff (35%). Mothers recognize that health workers are the most knowledgeable source of child advice and that they have been trained about child health and feeding.

Health Worker Contact and Credibility Almost all (87%) of mothers interviewed

knew the health worker by name, and claimed to meet the health worker at least once per month (Appendix 1: Table 12). Important to note is that many of the study sites were located near a health clinic and this may add a bias as to the potential contact that the women have with their health worker. About a third of women mentioned that the health worker visited their homes once a month, but 55% said they had never met the health worker at home. Almost all (94%) of mothers said they trusted the health worker’s advice about child health and feeding because the health worker is perceived as “caring” (37%), as having received training on child feeding (26%) or is highly intelligent (23%).

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Leisure and Media Habits About 64% of women claimed to have “free

time” after finishing their work. Most had 1-2 hours of free time which they used predominantly for resting/sleeping (54%) and playing with their children (28%) (Appendix 1: Table 13). During the FGDs women suggested that they don’t have time for rest, showing a variation in responses regarding thoughts about free time. Among the activities that women said they would ideally like to do with their free time, resting/sleeping (35%) was cited most commonly, followed by playing with children (20%), watching TV (13%), reading (10%), and listening to the radio (9%).

Almost half of the women claimed to meet with other mothers in their respective villages at least every two weeks or more frequently, although 25% said they never get together with other mothers (Appendix 1: Table 13). Among those who do meet other mothers, the most common activities during the meetings are discussing family life (56%) and discussing local news (25%). Most (58%) of women reported being members in a women’s group. About 65% of women listen to the radio, and among those who do, 71% listen on a daily basis, and listen mostly to news (37%) or music (30%) programs. Only 13% of women reported watching TV.

Leader Mothers and Health Workers During the study period, Leader Mothers had

not yet been trained and but they were eagerly waiting for the JENGA JAMAA II training to start. Leader mothers interviewed had a wide range of backgrounds. They ranged in age from 18-60, with most being 20-30 years of age. Most farmed and/or sold produce like the average women in their communities. In addition, many previously held or continue to hold esteemed positions within their communities, which may be one of the reasons they were selected as Leader Mothers. Several have previously worked for NGOs in the area of health and nutrition,

agriculture, water and sanitation, reintegration of child soldiers, education and community mobilization. A few obtained secondary degrees in school.

Photo: Women working in the field

Current Knowledge of Leader Mothers Most Leader Mothers have a basic knowledge

of identifying sick and malnourished children. Signs they look for include fever (hot-to-touch); a lethargic child who doesn’t play; a child who cries but tears do not flow; discolored, thin and dry hair; dry and loose skin; thinness; swollen face, belly and feet; a child who does not eat or breastfeed often; a child who cries constantly; and a child who vomits or has diarrhea. A few were familiar with the terms Marasmus and Kwashiokor. Most referred to the three food groups that they either learned at school or through their own experience during antenatal care counseling at the health center. A few

36

expressed confidence in being able to counsel mothers on feeding practices. One even

mentioned knowing about active feeding approaches. All the women said that while they

could identify these various signs the best way to identify the health and nutritional status of the child is through a consultation at the health center.

Photo: A breastfeeding woman in a structured interview

In their role as Leader Mothers, they feel they could provide support to pregnant women by encouraging those who miss their period to confirm at the health center. Other areas they feel they could be supportive in is in following up to ensure the women are attending their antenatal care visits and confirm that they not only received their vaccines and medications but that they continue to take them as directed. One even suggested she would confirm during home visits that pregnant women use their mosquito nets and if the women didn’t, then she encouraged them and their children to use it.

Overall, the Leader Mothers said they would promote exclusive breastfeeding and acknowledge that this is the message coming from health centers. However, they feel that it will be quite difficult given the current practices in the community. Some even admitted that they themselves were unable to exclusively breastfeed for similar reasons. Current practices include women giving sugar water as prelacteals because “they think there is no milk in their breasts and

their child will die from hunger.” Secondly, women’s workload hinders them from having the time to breastfeed – “[women] leave the bed for the field and return completely tired and then have to prepare food.” Another factor is a cultural practice of the Bafulero where if a mother thinks she cannot breastfeed right away, a mother is physically unable to breastfeed or if a mother dies during delivery, the community will provide a child with “muondo” the first milk of a cow who birthed a calf that same day. Several shared the advice they would give to encourage mothers to breastfeed exclusively from the beginning -

“[It’s] the first milk that contains the

medicine.” “as a Leader Mother, I would tell her

[neighbor] that that [porridge before six months] will spoil the growth of her child….that the child is exposed to many illnesses …. that it will slow growth.”

One Leader Mother said her church

encourages giving porridge at three months. Similar to explanations coming from mothers, Leader Mothers confirmed that it is common practice in the community to give porridge to soothe a child’s cry because women think their children are not satisfied from their milk. In response to whether they think the women in the community would be willing to express breast milk, there were mixed feelings. Some felt the cultural taboos are too strong to convince a woman to even consider it. Others felt that if women were taught in a comfortable setting to express and hygienically prepare and preserve breast milk they felt it would be possible.

There is a general consensus among the Leader Mothers that most people are eating what

37

they produce, and selling a sizeable amount of their harvest. People tend to sell their livestock as opposed to eat them. When a household has the money, they will add fish, meat or beans to their diet. The majority claim that porridge and even family food is being given to children before six months of age. In terms of advising mothers on complementary feeding practices, many said they would advise mothers to use what is locally available, start porridge at six (some said seven) months and start family food between nine and twelve months, while continuing to breastfeed until two to three years of age. To improve complementary foods, some believe it is possible to add pounded dried fish to porridge or use a blend of green plantain and cassava flour, as they have seen it practiced. Others felt they could recommend using the locally available palm oil, peanuts, and soybean, maize and sorghum flours, but that communities need to be sensitized and mothers encouraged to practice. Giving children fruits as snacks would also be encouraged. There was some concern that in certain areas it would be too difficult to add much to children’s food because families are too poor and their harvest is not adequate. Furthermore, they would recommend feeding children three times a day.

Photo: Palm and palm kernel are made into oil

Training Needs of Leader Mothers It is apparent that training is necessary in

order for Leader Mothers to serve as role models in their communities. Three Leader Mothers shared their feeding experiences-

“I have a habit of going to the market or

field and leaving my child at home. When I take my child he cries a lot. Before I feed him I wash my hands and my breast because I’m in contact with lots of microbes from the roots in the field. I breastfeed for 10 minutes but I am in a hurry to prepare the food for the day. I take my child off forcefully so I can do my work at home.”

“I breastfed my child since birth but

because of field work I left my child at home with porridge made from cassava, sugar, water, oil, peanuts and sometimes sorghum. After six months, I started family food.”

“I have a baby of six months that I

exclusively breastfeed. After six months I will give porridge and if I see that my child doesn’t eat a lot I will exclusively breastfeed until eight months.”

“When I breastfeed my child cries a lot

and giving water helps to satisfy him.”

Conversely, some Leader Mothers are Positive Deviants in their own communities. One Leader Mother waited three months following her delivery before returning to field work, and she continues to carry her child to the field so she can breastfeed at any moment.

Many of the Leader Mothers said they are waiting for the “food promised by ADRA” and to “teach us what to eat.” It is not clear if they see the food aid as a replacement for what they traditionally eat. They acknowledge that most people eat only cassava fufu and sombé and they

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know it is not sufficient- “we eat to satisfy ourselves but not to grow.” An interesting account was given by one Leader Mother - “we have the information but we don’t have the means to change the foods. We change [the diet] when we have some things to add but that is why there is malnutrition. MSF [Médecins Sans Frontières] can only reach so many people….they don’t give family rations, just Plumpy’nut.” Finally, one Leader Mother said “we need to change their ways of preparing foods. [We] need to teach them how to use what exists in their community that is good for the child.” All of the Leaders Mothers feel flipcharts with photos and few words is the best approach to disseminating messages amongst largely an illiterate population and easiest for conducting home visits. A few suggested passing messages through radio and church services.

Photo: A local mother demonstrates preparation of a greens and fretin

Functions and Knowledge of Health Workers In the JENGA JAMAA II program, there will

be opportunities for Leader Mothers to work with staff at health centers. The majority of health center staff interviewed during this research are males with nursing degrees, and others have university or high school degrees. Employed by the government they claim that pay is poor and they are overworked. In their work, they offer a number of services (delivering babies, prenatal consultations, immunizations, treating ill patients). Less frequently, they conduct household visits to follow up with malnourished patients and to offer support in breastfeeding and complementary feeding practices. Health workers explain that they rarely have time to do home visits to follow up to see if the advice is being practiced. Lack of transportation also prevents them from getting to homes.

When they conduct home visits they use flipcharts and brochures to teach about the three foods groups and to encourage optimal feeding practices, such as exclusively breastfeeding. However, they acknowledge the challenge of getting people to put into practice the messages they promote- “Even if they know the rules of three groups of food, they cannot respect them because they are poor.” Another shared- "We see many mothers who still give porridge to infants two or three months old even if we teach them." Almost all of the health workers confirmed women are giving colostrum within one hour of birth. This practice, and delivering at health centers, has increased over the years because of sensitizing the community. Many explained that during antenatal care visits, they counsel mothers on the importance of giving colostrum, feeding on demand and the benefits of exclusive breastfeeding. However, they further confirmed the challenge of exclusive breastfeeding when women spend a large majority of their day in the fields. Overall, they felt that mothers might not

39

accept the idea of taking their child to the field for fear that the baby could become sick from the variable weather. With regard to promoting expressing breast milk, there was concern that communities, due to cultural beliefs, would not accept the practice. Most health workers see women continuing to breastfeed until two or three years of age unless they become pregnant at which point they abruptly wean children.

Photo: A local mother shows us her home garden with root vegetables and pineapple

The health workers further confirmed that

the majority of people are eating cassava fufu with cassava leaves and beans, and fish on occasion. There is little variation in their meals and they eat two times a day, including children. One health worker said that in his health zone it is common practice for the men to eat fish and meat while children are given only the cassava leaves and small dried fish. Despite households cultivating beans, peanuts, maize, rice, potatoes, cassava and fruits (banana, orange, avocado, mango) they sell the majority rather than reserve some for consumption. Most children are given porridge in their first year and family food as of 12 months. Avocados and bananas are common snack foods for children. However the challenge of diversifying the child’s diet is great- "A lot of mothers know that they must add soybean flour,

peanuts, fish, sugar, sorghum to porridge and fruits like avocado and banana, but it is not done because many households are very poor."

The health workers see the importance of changing the diet of children as they grow older. The majority support introducing porridge enriched with fruits, fish, peanuts, beans, oil and a blend of flours starting at six months and introducing family foods by 12 months, all the while continuing to breastfeed until two or three years of age. They counsel women on preparing meals using foods from the three foods groups so there is adequate carbohydrate, fat and protein in their diet. One health worker emphasized the importance of improving community knowledge of the three food groups, training them on growing amaranth, bean and cassava leaves, and promoting reserving some of their harvest for consumption rather than selling. Another felt that training female leaders to counsel other women in the community would be an effective strategy to changing behaviors, on an individual level.

Community Channels and Influence The most credible source of advice on

matters related to pregnancy, lactation and child feeding and caring practices is the health center. Ninety-nine percent of women interviewed said they received some form of prenatal care during their last pregnancy, which included nutritional counseling during pregnancy (Appendix 1: Table 9). During the FGDs it was noted that at the health center women feel they are getting the best care available, and they feel encouraged by the health center staff to carry out optimal feeding and caring practices. One woman said she felt good that the nurse and midwife are trained, and if they cannot help her they refer her to where she can get the support she needs. Apart from advice, women feel it is a reliable place to receive medicine (for the most part, supply did not appear to be a major problem) and examinations during antenatal and postnatal

40

periods. There was some indication that women appreciated community health workers conducting home visits, though this was not covered in detail.

The second most trusted source is the mother-in-law. What was not clear was if this was out of obligation or preference, though fewer women said this is their preferred source of advice. Part of it may be related to the Bafulero tradition where newly married couples live with the husband’s parents until they have their second or third child, at which point they are free to get their own place. What is clear is that there is resistance coming from some community members and husbands in using the health center. Women are encouraged to seek advice from traditional healers, use home-prepared herbal medicines and consult advice in “prayer rooms.”

Photo: Local children gather to play It is important to recognize the role of the

husband in influencing infant and young child feeding practices. Men control the money and make decisions on how money should be spent, as well as makes decision in the house about IYCF. Among those in the house, sixty-four percent of women interviewed said it is the husband advising about matters relating to child feeding and health (Appendix 1: Table 11). So it is

clear that husbands need to be included in any sensitization efforts regarding optimal nutrition during pregnancy, lactation and child caring and feeding.

While this area was not explored in-depth,

there was some suggestion of passing messages through the radio and churches, or hosting community theater productions. Seventy-one percent of women who listen to the radio, do so everyday- Radio Lemera and Radio Burundi were the most commonly mentioned (Appendix 1: Table 13).

Women throughout all research sites expressed interest in learning to prepare new dishes for their children. It was suggested that ADRA should enlist the assistance of the health center to inform and gather together women for group sessions. Others liked the idea of receiving home visits by peers who have previous experience in an area that is new for a first time mother. In terms of materials, there was strong interest in being able to see what is being communicated- and flipcharts are what people are most familiar with. Brochures and pamphlets showing how to carry out practices and recipes on how to prepare dishes were also suggested. A final recommendation coming from the women was to involve the village chief in gathering the men in the community to attend group discussions about optimal caring and feeding practices. Sundays or in the afternoons on most days are most practical given their field and market obligations.

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Photo: The beautiful landscape in the hillside villages

Conclusion This formative study was intended to provide insights from mothers of young children, leader mothers and health workers about key maternal and infant feeding and care behaviors, and beliefs to assist ADRA to prioritize and contextualize appropriate social and behavior change communication messages for the JENGA JAMAA II Project. Before implementing programs to improve feeding and caring behaviors, it is important to understand potential constraints to adopting recommended behaviors or foods within the South Kivu context. We identified several constraints that may limit the effectiveness of a behavior change approach unless they are addressed as part the JENGA JAMAA II Project:

• Food availability: Although infants require relatively few calories compared to other members of the household, severe household food insecurity can be a limiting factor. A more common limitation is the unavailability or high cost of nutrient-dense foods, such as animal products, fruits and vegetables. Women seem to willing to try feeding a

greater variety of complementary foods, but they were afraid this was not available to them on a daily basis. While the study did not formally measure household food security or the availability and cost of nutrient-dense foods, these were major constraints raised by women in the focus groups, and also surfaced as perceived constraints in the structured interviews among mothers.

• Cultural beliefs: We were unable to detect obvious cultural beliefs that certain foods were inappropriate for or detrimental to infants. Although it is noteworthy that women thought that they should not breastfeed her infant if she became pregnant again. To the contrary, a conceptual link between a diverse and nutrient-rich diet and a mother’s and infant’s health were apparent from the FGDs. Several positive behaviors and beliefs need to be reinforced—namely early breastfeeding initiation and the feeding of colustrum.

• Women’s work and workload: Time constraints and fatigue clearly limit the ability of many mothers in S Kivu to adequately feed their infants. This issue was raised frequently during the FDGs. Many women work in the field and leave their young infants at home, which is the reason for which non-breast milk liquids such as water are frequently fed to infants <6 m of age. Also, lack of time due to work demands are perceived as constraints to mothers spending adequate time to encourage their young children to eat. In addition, the absence of safe food storage facilities makes preparing frequent meals for young children very difficult. When mothers are unavailable or busy, the feeding of young children is often left to other caregivers (such as siblings) who may or may not have an adequate understanding of how and what to feed.

• Women’s own health status: We did not document the relationship between a

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woman’s own health status and whether this influenced the adequacy of child feeding. However, if women are frequently ill with malaria or gastrointestinal illness, they are likely to be less proactive in feeding their children. It is important that Leader Mothers and other community health workers be trained to recognize symptoms of ill health in the mother, provide referrals for treatment, and help the mother find assistance with child care and food preparation.

Photo: A focus group of women with children begins in Katala, a village in the mountains

• Decision-making within the household: The extent to which mothers have control over the amount and types of foods fed to young children can influence the adequacy of child feeding. The FGDs revealed a preference to adult males for nutrient-rich foods such as meat, and this may limit the foods available for young children. On the other hand, women recognized the need that young children required special, highly-nutritious foods. Based on the structured interviews, husbands play a key role in household expenditure and feeding decisions (Appendix 1: Table 11). Therefore, involvement of fathers in complementary feeding programs is an important element for increasing the

likelihood of positive behavioral change. It would be beneficial to have further small-scale research to determine the father’s perceptions and barriers of optimal maternal, infant and young child feeding. Grandmothers were also mentioned as an important influence on child feeding decisions. For these reasons, ADRA’s communications strategies should target the entire community rather than only the mothers.

• Ability to target those most in need: The

research sites for this study were located at or near health clinics, and although some sites, particularly those in the highlands were difficult to reach, there were more remote areas that were not included in this study. In the more remote areas, particularly where local food production is limited by physical and climatic conditions, families are likely to have few choices for enriching complementary foods with animal products, fruits and vegetables. Fish consumption, for example, was much lower among children 6-23 months of age in the non-lakeside vs. lakeside communities. In the more food insecure settings, a major constraint will be the availability and affordability of nutrient-dense foods. When developing its strategy, ADRA should consider co-locating appropriate components of its JENGA II project, including agricultural and income-generating interventions (esp. small animal raising and/or goat distribution) in the communities where local availability of nutrient-rich foods is limited.

• Need coordinated, systematic, and participatory approach: While there have been Leader Mothers identified and a Care Group curriculum developed, there is a need to ensure that (i) the target group is actively involved in the planning and implementation

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stages of the SBCC program, and (ii) that there is a coordinated effort to ensure that all of the JENGA-II components and their related agencies and activities are aware of and involved with addressing the multiple factors affecting maternal and young child undernutrition. The following “next steps” are recommended.

1. Examine and compare the findings of the large baseline study to the qualitative findings from this study to assess comparability of findings about feeding practices, nutrient deficiencies and factors that influence complementary feeding.

2. Evaluate samples of local complementary foods for their adequacy in meeting nutrient needs. Based on the formative research findings, which are qualitative and not representative, it appears that: (i) the energy density of complementary foods and meal frequency are inadequate, (ii) animal source foods are lacking in the diet, but without addressing cost and/or availability, these foods will be difficult to add to the diets of young children.

3. Conducting recipe trials and “trials of improved practices” (TIPs) to determine which recipes are acceptable to the local population, taking into consideration cost, convenience and constraints to adoption of new practices and/or foods. This should be done before mounting a full-scale program.

4. Find ways to increase nutrient bioavailability by promoting germination and fermentation of locally produced foods.

Photo: Children gather to meet the strangers

5. Explore ways to increase the quantity

and quality of foods that are provided to children during illness and recovery, by using TIPs methods. There is an apparent high morbidity load in this population, and there is little evidence that young children are fed an extra meal during convalescence, with the exception of breast milk where only some mothers provide additional breastfeeds. This seems to be a priority behavior to focus on in Care Groups.

6. Build periodic assessments into the Care Group implementation to determine reach, function, and effectiveness of the groups in terms of mothers’ receptivity, trial and adoption of recommended behaviors. Also, work with mothers to develop strategies to overcome constraints in adopting recommended behaviors and share these across other Care Groups.

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Communication Task

Target Groups: The findings suggest four distinctive target

groups, with their own distinctive behaviors and attitudes. However, between some groups, the distinctions are more pronounced, while among others they are minor.

1. Pregnant women 2. Nursing women 3. Mothers of infants 0-5 months of age 4. Mothers of infant 6-23 months of age Secondary target groups are leader mothers and health workers, who seem to be in a position to influence (positively or negatively) the behavior of mothers, and hence will themselves need clear communication to pass onto mothers. Another secondary target group are husbands who are in a position to influence a mothers feeding behavior, but whose awareness and support is needed to ensure (i) available nutrient-dense foods are prioritized for their pregnant or nursing wives and to their young children, (ii) their wives have adequate time to encourage their children to eat frequently, and (iii) that when their wives are ill, they are encouraged to seek treatment, and directly assist or find ways to assist with child care and food preparation. The rest of this section deals with each of these target groups and defines clear behavior messages, the possible resistance points to overcome and the motivational pegs that can be used.

Pregnant Women

The behavioral messages for pregnant women are to:

• eat one extra small meal or “snack” (extra food between meals) each day to provide energy and nutrition for her and her growing baby

• eat the best foods available, including milk, fresh fruits and vegetables, meat, fish, eggs, whole grains, peas, peanuts and beans

• take iron and folic acid tablets to prevent anemia as soon as she finds out she is pregnant and for at least 3 months after the baby’s birth

Other messages not explored in this

study but which are known to be relevant for pregnant women’s health and nutrition status include (i) sleeping under an insecticide-treated mosquito net and take anti-malarial tablets as prescribed in malaria-endemic areas, (ii) taking de-worming medications, and (iii) using iodized salt.

Photo: Women work hard to take care of their children

• No attitudinal resistances need to be overcome to lead to consuming an extra snack or meal and eating nutrient-dense foods, however, as mentioned already

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availability and affordability of these foods will likely limit consumption. There was no mention of fear of a baby being “too big” leading to obstetric complications. The only attitudinal resistance point that requires attention is the perception that meat “is reserved for men and beans are for mothers and children.”

• With respect to consuming iron tablets

during pregnancy, women seem positively disposed to this behavior. They reported that taking iron “protects the mothers against blood lost during delivery,” “protects the health of the child,” gives the mother energy to “push the baby out,” and prevents “dizziness” and “anemia.” Key components for successful maternal iron supplementation include an adequate supply of iron tablets, high access and participation in antenatal clinics, high-quality counseling by clinical and community health workers about the need for iron supplementation and its potential benefits and side-effects, and raising concern about maternal anemia among pregnant women and health workers.

• Suggested follow-up activities:

• Explore with women feasible ways to reduce their workload (gathering and storing food to reduce the need for daily trips to the field; collaborating with other women to reduce the burden of fieldwork during pregnancy).

• In collaboration with the village chief, sensitize men in the community, and within households, on the importance of reserving some of the nutrient-rich crops cultivated by the household, the

milk and meat from the animals they raise, and increasing women’s consumption of these during pregnancy. In addition, explore using the money from the sale to purchase animal-source foods (fish, meat, eggs), nutrient-rich plant foods (peanuts, beans), yellow and orange fruits and vegetables, other fruits (avocado), and red palm oil.

• Using the Trials of Improved Practices (TIPs) methodology, identify locally available and affordable nutrient-rich foods that could improve the diet during pregnancy.

o Conduct a Barrier Analysis to identify the barriers and facilitators to women taking IFA earlier in pregnancy; train Leader Mothers to identify women early in pregnancy and supply or improve access to IFA.

Nursing Women

• The behavioral message for nursing women are to:

o eat two extra small meals or “snacks” (extra food between meals) each day to provide energy and nutrition for the nursing mother and her baby.

o eat the best foods available, including milk, fresh fruit and vegetables, meat, fish, eggs, whole grains, peas, peanuts and beans.

• No attitudinal resistances need to be overcome to encourage additional consumption of food and the consumption of nutrient-dense foods; however, the availability and affordability of these foods is a major concern.

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• The nursing period seems to be characterized by a good appetite and strong realization of the need for a good diet to ensure adequate milk production and flow. Many women feel that having a diverse diet (using a variety of ingredients in preparing green leafy vegetables), adding certain foods (peanuts, hot tea) gives a woman good health and increases her appetite and food consumption which, in turn, helps milk production and results in “good quality” milk for the infant. Many also feel they can consume more food during lactation and that it is their “right,” because she needs to recuperate after pregnancy and produce milk.” At the same time, concern for the ability to breastfeed adequately to meet the requirements of the child is also high. There is little evidence of bottle feedings, however there is a temptation to give the infant water and/or non-breast milk when a mother feels her breast milk is insufficient, or when she must be away from her infant for a large part of the day due to her work load.

• Nursing women consume fufu au sombé daily, but the nutrient density of the diet needs to be increased by adding additional ingredients (eg. peanuts, oil, tomato, and fish).

• Suggested follow-up activities include: o Create village groups or

microfinance/IGA opportunities for women to get together (process peanuts or make soap from palm kernel oil) in which messages are shared by Leader Mothers.

o Encourage developing home gardens to grow nutrient-rich foods.

o In collaboration with the village chief, sensitize men in the

community, and within households, on the importance of reserving some of the nutrient-rich crops cultivated by the household, the milk and meat from the animals they raise, and increasing women’s consumption of these during lactation. In addition, explore using the money from the sale to purchase animal-source foods (fish, meat), nutrient-rich plant foods (peanuts), yellow and orange fruits and vegetables, other fruits (avocado), and red palm oil.

Photo: A woman in a focus group attentively listens while her baby sleeps

Mothers of infants 0-5 months of age • Behavior messages for this group:

o Early initiation of breastfeeding and giving of colostrum: Based on the structured interviews, about 80%-95% of mothers initiate breastfeeding early and give colostrum. This estimate should be verified with results from the larger baseline survey. If there is concurrence between the studies, early breastfeeding initiation and

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the giving of colostrum should be viewed as established positive behaviors that deserve recognition and praise.

o Exclusive breastfeeding through six months of age: Exclusive breastfeeding through six months of age appears to be problematic for many mothers, therefore, the priority behavioral messages for mothers of 0-5 infants are to: Feed ONLY breast milk to

the baby for the first six months

Breast milk provides all the food and water that a baby needs for the first six months of life and protects the baby from many illnesses such as diarrhea and respiratory infections.

Giving other liquids or foods before six months can damage the baby’s stomach, and reduce the protection he/she gets from breast milk.

• Resistance points that need to be addressed include the perception of breast milk insufficiency (i.e. women think they cannot produce enough milk because they do not eat well and women think a child cries because they aren’t satisfied from her milk). Also, many women have to work away from the home for several hours each day, usually harvesting cassava, fetching wood and water, which results in them being separated from their infants and leaving the infants in the care of others.

• Factors promoting exclusive breastfeeding include that (i) some women find it feasible to carry their child to the field

during farm work, (ii) others expressed a strong interest in learning how to express breast milk and there were a few ‘positive deviants’--one woman received support from the CHW and another from the district hospital in learning how to express her milk. Also, most women recognize the value of breast milk for the baby.

Photo: A local girl enthusiastically welcomes the study team in her village

• Suggested follow-up activities include: o Teach women strategies to

increase their milk production (frequent breast feeds and emptying the breast) and the importance of exclusive breastfeeding,

o Through positive deviant peer education, have a woman who carries her child to the field demonstrate her successful strategy,

o Ensure health workers and leader mothers are well trained in providing breastfeeding counseling and support,

o Through positive deviant peer education, teach women to

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express breast milk and to hygienically prepare the storage materials,

o Sensitize community members and families on the benefit to expressing breast milk and to supporting the mother by using it to feed the child during her absence,

o Sensitize women on healthy timing and spacing of pregnancies and their ability to breastfeed during pregnancy.

Mothers of infants 6-23 months of age

• Behavioral messages for mothers 6-23 months include:

At six months of age: • Continue breastfeeding on demand,

but giving other foods in addition to breast milk at 6 months of age

• Start by giving 2-3 tablespoons or “tastes” of food 2 times a day, after breastfeeding and gradually increase the amount.

• Start with porridge or mashed banana that should be thick enough to be fed by hand.

At 6-8 months of age • When giving complementary foods to

the baby, think frequency (3 times a day), amount (increase to ½ cup), thickness (mashed or pureed food) and variety (add animal source foods [egg/meat/fish/dairy products], staple food, legumes, and yellow/orange fruits and vegetables and/or green leafy vegetables. Mash the food or give small pieces of the food.

• Increase breastfeeding frequency during sickness and offer an extra feed or meal to the child following his/her sickness for two weeks.

At 9-11 months of age: • When giving complementary foods to

the baby, think frequency (4 times a day), amount (increase to ½ cup), thickness (give finely chopped family foods, finger foods, sliced foods) and variety (add animal source foods [egg/meat/fish/dairy products], staple food, legumes, and yellow/orange fruits and vegetables and/or green leafy vegetables. Mash the food or give small pieces of the food.


At12-23 months of age: • When giving complementary foods to

the baby, think frequency (5 times a day), amount (increase to ¾ to 1 cup), thickness (give finely chopped family foods, finger foods, sliced foods) and variety (add animal source foods [egg/meat/fish/dairy products], staple food, legumes, and yellow/orange fruits and vegetables and/or green leafy vegetables. Mash the food or give small pieces of the food.


• Resistance points are related to lack of money

to purchase food and lack of available nutrient-dense foods (children eat what the household grows yet many of the nutrient-rich foods are sold, poor access to markets). Also, as mentioned previously, cultural constraints will need to be overcome if the father controls the money and makes decisions about food (selling the harvest). There also appears to be a lack of awareness

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and “know how” in using nutrient-rich locally available and affordable foods to enrich porridge, snacks, and family foods. There also appears to be a lack of knowledge of increased dietary needs (quantity and quality) with age.

• With respect to feeding sick children and those recovering from illness, children are not encouraged to eat more during and particularly following sickness. This should be an important focus of Care Groups due to the perceived high morbidity load children experience during the complementary feeding period.

Photo: Women consent participation before study begins

• It is possible to build upon limited, but existing positive practices, because some women already make porridge utilizing a variety of local ingredients (banana, sorghum, maize, soybean, rice, cassava flours, peanuts, avocado). However, the regular addition of animal-source foods appears to be largely absent from the diet. To the extent that these foods are available in the household, giving them to young children should be a priority.

• Suggested next steps include: o Sensitize women, families and

community members on the importance of beginning complementary foods at six months.

o Explore with women feasible ways to reduce their workload (gathering and storing food to reduce the need for daily trips to the field; collaborating with other women to reduce the burden of fieldwork so they can be around their infant more).

o In collaboration with the village chief, sensitize men in the community, and within households, on the importance of reserving some of the nutrient-rich crops cultivated by the household, and milk and meat from the animals they raise, and ensure children get these in porridge, through family foods and as snacks. In addition, explore using the money from the sale to purchase animal-source foods (fish, meat), nutrient-rich plant foods (peanuts), yellow and orange fruits and vegetables, other fruits (avocado), and red palm oil.

o Explore women’s perception of feeding children bananas.

o Sensitize women on changing a child’s diet as they grow (quantity, quality, frequency) and identify locally available and affordable nutrient-rich foods using the TIPs methodology. Identify with mothers practical ways of enriching the porridge and/or fufu fed to children.

o Explore the possibility of children who are not being breastfed until 2 years of age receiving cow and goat’s milk.

o Discover ways to increase nutrient bioavailability in local foods through methods such as germination and fermentation.

o Sensitize mothers about child’s increased nutritional needs during and following sickness.

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Communication Channels

• Based on the formative research, the health clinic staff appears to be a trusted and respected source of information about child health and child feeding. Most women interviewed both in FGDs and during structured interviews reported frequent contact with health clinic staff and the majority knew the health worker by name. These findings, however, should be interpreted with some caution because the study sites were often located at or near a health center and therefore may give an overly optimistic picture of the reach of health services and relationship between mothers and health workers. Nonetheless, in the study areas, nearly all women interviewed said they received prenatal care during their last pregnancy, which included nutritional counseling. Health workers have been successful in encouraging behaviors such as early initiation of breastfeeding and the feeding of colostrum, imparting knowledge about the three food groups, seeking antenatal care during pregnancy, and offering health services post-partum for mother and weighing and vaccines services for children.

• Leader mothers will need to be reached through specific training forums or through monthly meetings with the Community Promoter. It is not clear to what extent Leader Mothers have themselves embraced or used the recommended feeding behaviors. However, as intended agents of change in the community, these women will require special training to (i) clearly understand the recommended behaviors and their rationale and benefit, (ii) gain confidence in providing feasible but simple age-specific

child feeding recommendations to mothers, ideally demonstrating the food preparation, responsive feeding and other behaviors to mothers during home visits or group learning sessions.

• The link between Leader Mothers and clinic staff should be strengthened to facilitate timely two-way referral for sick children and for women experiencing challenges during pregnancy, lactation and child feeding. In addition, measures should be taken to ensure that Leader Mothers and clinic staff provide consistent feeding advice.

• Radio also seems to be a medium with high potential reach and should be used to reinforce behavioral messages, overcome attitudinal resistance points and link behaviors to credible and valued promises such as improved child and improved child learning potential. Almost 2/3rds of women interviewed said they listen to the radio daily, and of these about 70 percent listened to Radio Lemera or Radio Burundi (Appendix 1: Table 13).

• Television viewership appears to be quite low, though it may be higher in urban areas.

• Most of the women (~58%) interviewed participate in women’s groups. These groups should be identified by Leader Mothers and used for message reinforcement and as a way to reach out to target mothers (Appendix 1: Table 13).

• Husbands need to be a secondary target because of the influence they exert in the home regarding child feeding decisions. They could be encouraged to buy nutrient-rich foods for women and children and reserve the harvest for household consumption. One area to further explore is men’s perception of feeding children well and preventing

51

sickness, thereby potentially reducing overall expenses. Also there is a need to sensitize them on the need for women’s rest during pregnancy as more than half of women said if they have any free time their preference is to rest (Appendix 1: Table 13). Women recommended the involvement of the village chief in gathering the men in the community to attend group discussions about optimal caring and feeding practices. Sundays or afternoons are most practical given their field and market obligations.

• Mother-in-laws also emerged as a credible source of advice so they need to be included in any family counseling or community education.

Photo: A girl demonstrates her skills to her peers

• In terms of materials, there was strong

interest in being able to see what is being communicated- and flipcharts are what people are most familiar with. Brochures and pamphlets showing how to carry out practices and recipes for preparing dishes were also suggested. For ease in

maintenance and transporting, develop flipcharts using a three-ring binder with laminated removable pages so only the sheets with the current messages need to be carried.

General Recommendations 1. Use the TIPs methodology to identify

locally available, acceptable and affordable foods that can be used to enrich the diet of pregnant and lactating women and children under 2 years of age.

2. Ensure there is strong collaboration between Leader Mothers and Health Workers.

3. Identify Positive Deviants in the community to interact with Care Groups to share successful strategies regarding MIYCN.

4. Address women’s workloads and men’s attitudes toward women (day and night) in gender SBCC activities.

5. Research perceptions and barriers to maternal, infant and young child feeding practices with men and chief village leaders in the communities.

6. Include husbands and mother-in-laws/grandmas in any family counseling or community education.

7. Engage village chief when sensitizing men (Sundays, afternoons).

8. Encourage developing home gardens. 9. Create village groups or microfinance/IGA

for women to get together (process peanuts, making soap from palm kernel oil); pass messages via Leader Mothers.

10. Explore churches, radio, community-theater, and cooking demonstrations as affective channels of communication in villages.

11. Use flipcharts for individual counseling sessions (3-ring binder with laminated sheets).

References 1. GODRC Ministry of Planning and Macro International. 2008. Demographic and Health

Survey, Democratic Republic of Congo 2007. 2. Waterlow, J.C. (1988) Observations on the Natural History of Stunting. In: Waterlow,

J.C., (Ed.) Linear Growth Retardation in less developed countries., Raven Press] 3. Martorell, R. and Habicht, J.P. (1986) Growth in early childhood in developing

countries. In: Falkner, F. and Tanner, J.M., (Eds.) Human Growth: A Comprehensive Treatise, Volume 3, Methodology: Ecological, Genetic and Nutritional Effects on Growth edn. New York: Plenum Press]

4. Schroeder, D.G. and Brown, K.H. (1994) Nutritional status as a predictor of child survival: summarizing the association and quantifying its global impact. [Review] [46 refs]. Bull.World Health Organ. 72, 569-579.

5. Black, R.E., Brown, K.H. and Becker, S. (1984) Effects of diarrhea associated with specific enteropathogens on the growth of children in rural Bangladesh. Pediatrics 73, 799-805.

6. Keusch, G.T. (1990) Malnutrition, infection and immune function. In: Suskind RM and Lewinter-Suskin L, (Eds.) The Malnourished Child, Vevey/New York: Newtec Ltd/Raven Press]

7. Pollitt E, Gorman KS, Engle PL, Rivera JA, Martorell R. Nutrition in early life and the fulfillment of intellectual potential. J Nutr. 1995 Apr;125(4 Suppl):1111S-1118S.

8. Mendez MA, Adair LS. Severity and timing of stunting in the first two years of life affect performance on cognitive tests in late childhood. J Nutr. 1999 Aug;129(8):1555-62.

9. Grantham-McGregor SM, Powell CA, Walker SP, Himes JH. Nutritional supplementation, sychosocial stimulation, and mental development of stunted children: the Jamaican Study. Lancet. 1991 Jul ;338(8758):1-5.

10. Martorell R, Lechtig A, Yarbrough C, Delgado H, Klein RE. [Effects of diarrhea on growth retardation in Guatemalan children]. Arch Latinoam Nutr. 1977 Sep;27(3):311-24.

11. Lechtig A, Yarbrough C, Delgado H, Habicht JP, Martorell R, Klein RE. Influence of maternal nutrition on birth weight. Am J Clin Nutr. 1975 Nov;28(11):1223-33.

12. Ramakrishnan U, Martorell R, Schroeder DG, Flores R. Role of intergenerational effects on linear growth. J Nutr. 1999 Feb;129(2S Suppl):544S-549S

13. West KP Jr, Caballero B, Black RE. Nutrition. In: Merson MH, Black RE, Mills AJ (eds), International Public Health: Diseases, Programs, Systems, and Policies. 2nd edition. Sudbury, MA: Jones and Bartlett, 2006;5:187-272

14. Beaton, G.H., Kelly, A., Kevany, J., Martorell, R. and Mason, J.B. (1990) Appropriate Uses of Anthropometric Indices in children. Geneva: ACC/SCN.

15. Victora, C.G., Barros, F.C., Kirkwood, B.R. and Vaughan, J.P. (1990) Pneumonia, diarrhea, and growth in the first 4 y of life: a longitudinal study of 5914 urban Brazilian children. Am.J.Clin.Nutr. 52, 391-396.

16. Black RE, Brown KH, Becker S. Malnutrition is a determining factor in diarrheal duration, but not incidence, among young children in a longitudinal study in rural Bangladesh. Am J Clin Nutr. 1984 Jan;39(1):87-94

17. Dewey KG. Success of Intervention Programs to Promote Complementary Feeding, in Public Health Issues in Infant and Child Nutrition, edited by Robert E. Black and Kim Fleischer Machaelsen, Nestle Nutrition Workshop Series, Pediatric Program, Vol 48. Nestec Ltd., Vevey/Lippincott Williams & Wilkins, Philadelphia, 2002.

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Appendix 1: Tables from Structured Interviews

Table 1 Description of Respondents (Full Sample) N % Age, yr

<20 15 12.61 20-24 40 33.61 25-29 35 29.41 ≥30 29 24.37

Age of index child, mo <6 44 36.97 6-11 36 30.25 12-23 39 32.77

Currently pregnant 21 17.65 Currently lactating 114 95.8 Literacy Literate (Self) 52 44.7 Literate (Husband) 97 88.18 Education (Self)

No schooling 29 27.36 Some primary school 34 32.08 Completed primary school 14 13.21 Some secondary school 18 16.98 Completed secondary school 1 0.94 Completed more than secondary school 10 9.43

Education (Husband) No schooling 5 4.72 Some primary school 16 15.09 Completed primary school 10 9.43 Some secondary school 27 25.47 Completed secondary school 15 14.15 Completed more than secondary school 33 31.13

Religion Indigenous 0 0 Catholic 11 9.24 Protestant 82 68.91 Kimbanguism 0 0 Islam 10 8.4 Jehova’s Witness 1 0.84

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New Apostolic 7 5.88 Malikia wa Ubembe- sect 6 5.04 Bahai 1 0.84 Adventist 1 0.84

Tribe Kongo 0 0 Lingala 1 0.84 Luba 0 0 Mufulero 66 55.46 Mushi 4 3.36 Mzoba 1 0.84 Kibembe 36 30.25 Kivira 1 0.84 Other 1 0.84 Murundi 3 2.52 Muvira 1 0.84 Banintu 1 0.84

Dialect spoken at home French 0 0 Lingala 1 0.84 Kikongo 0 0 Swahili 20 16.81 Tshilubal 0 0 Kibembe 36 30.25 Kivira 2 1.68 Other 2 1.68 Kirundi 2 1.68

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Table 2. Economic status of Respondents (Full sample) N % Works outside of house 106 89.83 Worked in past 12 months 88 80 Duration of work in past 12 months

All year 72 68.57 Seasonally 2 1.9 Occassionally 25 23.81

Occupation (Self) Farmer (Crops) 9 8.18 Agricultural day labor 81 73.64 Non Agricultural day labor 3 2.73 Service/Salaried worker 3 2.73 Small/cottage industry 0 0 Business/Traders 10 9.09 Other Self-employment 1 0.91 Household

Worker/Housewife 0 0 Maid servant 0 0 Jobless 2 0 Student 1 0.91

Occupation (Husband) Farmer (Crops) 3 2.75 Agricultural day labor 49 44.95 Non Agricultural day labor 6 5.5 Service/Salaried worker 13 11.93 Small/cottage industry 0 0 Business/Traders 5 4.59 Other Self-employment 6 5.5 Household

Worker/Housewife 2 1.83 Maid servant 0 0 Student 3 2.75 Jobless 13 11.93 Handicrafts 1 0.92 Fishing 3 2.75 Seamstress 1 0.92 Pharmacy Worker 1 0.92 Veterinarian 1 0.92 Pastor 1 0.92

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I don't know 1 0.92 Percent of family income spent on food

Less than 10% 2 1.72 10% to 19% 3 2.59 20% to 29% 12 10.34 30% to 39% 13 11.21 40% to 49% 7 6.03 50% to 59% 17 14.66 60% to 69% 10 8.62 70% to 79% 9 7.76 80% to 89% 15 12.93 more than 90% 28 24.14

Income coming from the following activities Fishing 17 14.29 Small business 56 47.06 Temporary Wages 27 22.69 Spouse 41 34.45 Salaried Job 10 8.4 Relative 17 14.29 Rent 4 3.36 Handicrafts 4 3.36 Agriculture 55 46.22 Collects Firewood 1 0.84 Enterprise/working for others 2 1.68 Cook 1 0.84

Median 25% 75% Median income (IQR) $25,444 9200 27000

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Table 3. Breastfeeding practices (Full sample) N % Breastfeeding initiation time

within 1 hour 61 51.3 1 to 5 hours 37 31.1 6 to 11 hours 9 7.6 12 to 24 hours 5 4.2 1 day to 3 days 5 4.2 4 to 7 days 1 0.8 more than 1 week 1 0.8

Prelacteal feeding; immediately after birth 7 5.9

Prelacteal food used among those give prelacteals Honey 0 0.0 Mustard oil 0 0.0 Plain water 6 24.0 Sugar/glucose water 1 4.0 Tea/coffee 1 4.0 Breast milk 14 56.0 Other 3 12.0

Gave food other than breast milk in first 3 days of life

Type of food given in first 3 days in addition to breast milk (among those giving other food)

Honey 1 0.9 Mustard oil 0 0.0 Plain water 1 0.9 Sugar/glucose water 5 4.3 Tea/coffee 2 1.7 Cows milk 0 0.0 Water/tea 1 0.9 Vaccine 12 10.3 Manioc Porridge 2 1.7

Fed colostrum 107 89.9

Had difficulties initiating breastfeeding 44 37.0 Type of difficulty in initiating breastfeeding (multiple responses possible)

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Problems with breast (pain) 44 37.0 Child did not suck well 5 11.6 Not enough time to feed child 5 11.6 Cracked nipples 8 18.6 Felt not enough breast milk 8 18.6 Plugged milk duct 13 30.2 Breast engorgement 3 7.0 Sick baby 6 14.0 Inverted nipple 0 0.0 Other

Had difficulties in breastfeeding when child was 3-4 months of age 24 20.2

Type of difficulty in breastfeeding when child was 3-4 months of age(multiple responses possible)

Problems with breast (pain) 5 20.8 Child did not suck well 2 8.3 Not enough time to feed child 5 20.8 Cracked nipples 3 12.5 Felt not enough breast milk 8 33.3 Plugged milk duct 6 25.0 Breast engorgement 4 16.7 Sick baby 4 16.7 Inverted nipple 0 0.0 Mother became ill 4 16.7

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Table 4 Complementary Feeding Practices (among children 6-11 months of age) N % Age of index child, months

6-8 22 18.5 9-11 14 11.8

Still breastfeeding 34 94.4 Reasons for terminated breastfeeding

Problems with breast (pain) 0 0.0 Child not suck well 0 0.0 Not enough time to feed child 0 0.0 Child already grown up/ No need for breastfeeding 0 0.0 Mother got pregnant 1 50.0 New baby born 0 0.0 Cracked nipples 0 0.0 Felt not enough breast milk 0 0.0 refuse herself 1 50.0

Percent who started giving the following foods Water 34 94.4 Other non breast milk liquids (sugar/glucose water, tea, fruit

juice etc.) 22 61.1

Cow/Goat milk 5 13.9 Porridge, rice gruel, maize gruel etc. 31 86.1 Semi-solid 15 41.7 Solid foods (rice, fufu/casava, wheat, other) 23 63.9 Fish 21 58.3 Meat (chicken, mutton, beef, etc.) 13 36.1 Eggs 8 22.2 Legumes (pulse, peas, etc) 16 44.4 Green vegetables 9 25.0 Yellow fruits or vegetables 13 36.1 Snack foods (chips) 5 13.9

Median age (months) when liquid or food was first given to child

Median 0.3 75%

Water 4.47 3.0 6 Other non breast milk liquids (sugar/glucose water, tea, fruit

juice etc.) 4.36 2.0 6

Cow/Goat milk 7.8 6.0 11 Porridge, rice gruel, maize gruel etc. 5.13 5.0 6 Semi-solid 7 5.0 8 Solid foods (rice, fufu/casava, wheat, other) 6.91 6.0 9

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Fish 6.52 5.0 7 Meat (chicken, mutton, beef, etc.) 6.46 5.0 7 Eggs 7.75 6.0 9.5 Legumes (pulse, peas, etc) 7.06 6.0 85 Green vegetables 7.67 6.0 9 Yellow fruits or vegetables 7.23 6.0 9 Snack foods (chips) 7.8 5.0 9 Median 0.3 75%

Median (IQR) breastfeeding frequency in last 24 hrs 3.43 1.0 5 Child given following liquids yesterday N %

Breast milk 33 91.7 Water 33 91.7 Baby formula (prepared food for child) 27 75.0 Any other kind of milk (powder, cow/goat milk etc.) 3 8.3 Fruit juice (made at home) 0 0.0 Fruit juice (purchased, packaged) 2 5.6 Water-based liquids, teas, sugar water, coffee 5 13.9

Use bottle to feed child in last 24 hrs 0 0.0 Median 0.3 75% Median (IQR) frequency complementary foods given in last 24 hrs

0.944 1.0 1

Amount number of "platefuls" (i.e. volume=250 ml) of complementary foods given in last 24 hrs

N %

None 2 5.6 half 15 41.7 one 7 19.4 one and a half 0 0.0 two 12 33.3 two and a half 0 0.0 three 0 0.0 three and a half 0 0.0 four or more 0 0.0

Child given following foods yesterday Rice 0 0.0 Cassava or maize porridge 15 41.7 Purchased baby cereals 3 8.3

Syrup or table that "increases the blood" (iron-containing) 6 16.7

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Green leafy vegetables 10 27.8 Pumpkin, orange yam, sweet potato, carrots, tomato (vitamin-A

rich) 4 11.4

Any other vegetables (starchy vegetables: potatoes, yam, plantain) 3 8.3

Ripe papaya or mango 2 5.6 Other fruits such as oranges, banana, grapefruits 11 30.6 Any other fruits 4 11.1 Meat such as beef, mutton 3 8.3 Chicken, duck, pigeon 3 8.3 Liver, heart, kidneys 1 2.8 Fish 13 36.1 Eggs 1 2.8 Peanuts, groundnuts, other nuts 10 27.8 Milk (non-human milk – cow, goat or powder) 3 8.3 Milk products (yogurt, rice pudding etc) 2 5.6 Fat (oil, butter, ghee) 13 36.1 Chips 0 0.0 Bread or buns or donuts 8 22.2 Candies or chocolates 3 8.3 fufu 12 44.4 beans 4 14.8

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Table 5 Complementary Feeding Practices (among children 12-23 months of age) N % Age of index child, months

12-23 39 32.8 Still breastfeeding 38 97.4 Reasons for terminated breastfeeding

Problems with breast (pain) 0 0.0 Child not suck well 0 0.0 Not enough time to feed child 0 0.0 Child already grown up/ No need for breastfeeding 0 0.0 Mother got pregnant 1 100.0 New baby born 0 0.0 Cracked nipples 0 0.0 Felt not enough breastmilk 0 0.0 refuse herself 0 0.0

Percent who already started giving the following foods Water 39 100.0 Other non breast milk liquids (sugar/glucose water, tea, fruit

juice etc.) 31 79.5

Cow/Goat milk 13 33.3 Porridge, rice gruel, maize grueletc. 35 89.7 Semi-solid 35 89.7 Solid foods (rice, fufu/casava, wheat, other) 37 94.9 Fish 33 84.6 Meat (chicken, mutton, beef, etc.) 28 71.8 Eggs 23 59.0 Legumes (pulse, peas, etc) 37 94.9 Green vegetables 11 28.2 Yellow fruits or vegetables 27 69.2 Snack foods (chips) 21 53.8

Median age when liquid or food was first given to child Median 0.3 75% Water 4.56 3.0 6 Other non breast milk liquids (sugar/glucose water, tea, fruit

juice etc.) 7.8 3.0 7

Cow/Goat milk 5.38 3.0 7 Porridge, rice gruel, maize grueletc. 5.71 5.0 6 Semi-solid 7.74 6.0 10 Solid foods (rice, fufu/casava, wheat, other) 8.37 7.0 11 Fish 8.27 6.0 12

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Meat (chicken, mutton, beef, etc., khichuri with meat) 9.39 6.5 12 Eggs 8.09 6.0 12 Legumes (pulse, peas, etc) 9.27 7.0 12 Green vegetables 7.36 6.0 9 Yellow fruits or vegetables 8.63 7.0 12 Snack foods (chips) 9.67 7.0 12 Median 0.3 75%

Median (IQR) breastfeeding frequency in last 24 hrs 3.46 2.0 5 Child given following liquids yesterday N %

Breastmilk 36 92.3 Water 34 87.2 Baby formula (prepared food for child) 26 66.7 Any other kind of milk (powder, cow/goat milk etc.) 2 5.1 Fruit juice (made at home) 2 5.1 Fruit juice (purchased, packaged) 2 5.1 Water-based liquids, teas, sugar water, coffee 7 18.0

Use bottle to feed child in last 24 hrs 0 9.0 Median 0.3 75% Median (IQR) frequency complementary foods given in last 24 hrs

1.08 1.0 1

Amount number of "platefuls" (i.e. volume= 250 ml) of complementary foods given in last 24 hrs

None 2 5.4 half 25 67.6 one 4 10.8 one and a half 0 0.0 two 5 13.5 two and a half 0 0.0 three 1 2.7 three and a half 0 0.0 four or more 0 0.0

Child given following foods yesterday Rice 4 10.3 Casava or maize porridge 3 7.7 Purchased baby cereals 1 2.6

Syrup or table that "increases the blood" (iron-containing) 6 15.8 Green leafy vegetables 23 59.0 Pumpkin, orange yam, sweet potatoe, carrots, tomato

(vitamin-A rich) 12 30.8

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Any other vegetables (starchy vegetables: potatoes, yam, plantain) 13 33.3

Ripe papaya or mango 4 10.3 Other fruits such as oranges, banana, grapefruits 8 28.5 Any other fruits 3 7.7 Meat such as beef, mutton 4 10.3 Chicken, duck, pigeon 1 2.6 Liver, heart, kidneys 2 5.1 Fish 8 20.5 Eggs 1 2.6 Peanuts, groundnuts, other nuts 8 20.5 Milk (non-human milk – cow, goat or powder) 1 2.6 Milk products (yogurt, rice pudding etc) 3 7.7 Fat (oil, butter, ghee) 6 15.4 Chips 0 0.0 Bread or buns or donuts 10 25.6 Candies or chocolates 4 10.3 Fufu 24 85.7 Beans 11 39.3

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Table 6 Feeding practices for a sick or recovering child (Full Sample) N % Amount of non-breastmilk liquids given when child is sick

Does not give 86 73.5 Same as usual 8 6.8 Less than usual 21 18.0 More than usual 1 0.9

Amount of breast milk given when child is sick Does not give 3 2.6 Same as usual 54 46.2 Less than usual 51 43.6 More than usual 9 7.7

Amount of semi-solid foods given when child is sick Does not give 49 41.9 Same as usual 12 10.3 Less than usual 54 46.2 More than usual 0 0.0

Amount of solid foods given when child is sick Does not give 79 67.5 Same as usual 4 3.4 Less than usual 32 27.4 More than usual 0 0.0

Amount of non-breast milk liquids given when child is recovering from sickness Does not give 87 75.7 Same as usual 14 12.2 Less than usual 8 7.0 More than usual 6 5.2

Amount of breast milk given when child is recovering from sickness Does not give 5 4.3 Same as usual 54 46.6 Less than usual 9 7.8 More than usual 47 40.5

Amount of semi-solid foods given when child is recovering from sickness Does not give 41 35.3 Same as usual 52 44.8 Less than usual 15 12.9 More than usual 7 6.0

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Amount of solid foods given when child is recovering from sickness Does not give 62 53.5 Same as usual 33 28.5 Less than usual 15 12.9 More than usual 5 4.3

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Table 7 Knowledge about selected IYCF practices (Full Sample) N % In your opinion, how long after birth should a baby start breastfeeding?

Within 1 hour of birth 87 73.1 1 hour later but less than 24 hr 21 17.7 1 day later 2 1.7 More than 1 day later 1 0.8 Do not think baby should be breastfed 0 0.0 Don't know 7 5.9

In your opinion, what should a mother do with the first milk or colostrum?

Discard first few drops 9 7.6 Discard all of it 5 4.2 Feed it to the baby 100 84.0 Don't know 5 4.2

In your opinion, should a baby under 6 months of age be breastfed whenever s/he wants or on a specific schedule or both?

Whenever baby wants 101 84.9 On a specific schedule 10 8.4 Both 2 1.7 When mother gets time 6 5.0 Don't know 0 0.0

In your opinion, how many times in one day (and night) should a baby be breastfed in the first 6 months of life?

1-2 times 2 1.7 3 times 11 9.2 4 times 10 8.4 5 times 3 2.5 6 times 3 2.5 7 times 4 3.4 8 times 3 2.5 9 times 3 2.5 10 times 4 3.4 12 times 7 5.9 14-97 times 4 3.4

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98 or more times 47 39.5 Don't know 15 12.6

According to you, if a mother thinks her baby is not getting enough breast milk, what should she do for herself and for her baby?

Breastfeed more often/more frequently 16 13.5 Give other liquids or foods 31 26.1 Mother needs to drink more water 11 9.2 Mother needs to eat more food 42 35.3 Go to the hospital/health center 12 10.1 Find medicine 1 0.8 Don't know 6 5.0

According to you, should infants under 6 months be given water if the weather is very hot?

No 49 44.1 Yes 60 54.1 Don't know 1 0.9

According to you, should a breastfeeding mother of a child under 6 months of age stop breastfeeding if she becomes pregnant again?

No 69 58.0 Yes 48 40.3 Don't know 1 0.8

In your opinion, should a mother stop breastfeeding when the mother has common illness such as fever, cough, cold or diarrhea?

No 100 84.0 Yes 18 15.1 Don't know 1 0.8

If yes, for what reasons should she stop breastfeeding? Mother is weak 1 4.2 Mother may get more sick 5 20.8 Child will get sick 10 41.7 Milk is insufficient 0 0.0 Milk is unhealthy 0 0.0

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Mother needs rest 0 0.0 Don't know 5 20.8

According to you, at the time of preparing or feeding porridge or rice, foods can you add to make it more nutritious for the child? (mother mentions)

Add colored fruits and vegetables 29 24.4 Add dark leafy vegetables 19 16.0 Add egg 23 19.3 Add beans 18 15.1 Add meat or fish or liver 24 20.2 Add milk to porridge 31 26.1 Add a spoonful of ghee or oil 17 14.5 Give thicker porridge 14 11.8 Add sugar 28 23.5 Add soy flour 36 30.3 Add sorghum flour 19 16.0 Add peanut flour 11 9.2 Add salt 5 4.2 Add biscuits 14 11.8 Add corn flour 11 9.2 Add banana flour 4 3.4 Add potato 3 2.5 Add rice flour 3 2.5 Add manioc flour 7 5.9 Add water 1 0.8 Add beans 1 0.8

Should not feed

What are the variety of foods that should be in a child’s daily diet at 6 months to 1 year of age? N %

Fish 24 20.3 Egg 50 42.4 Maize 46 40.0 Cassava 43 36.4 Yellow or orange fruits 31 26.3 Green leafy vegetables 47 39.8 Yellow vegetables 44 37.3 Other vegetables 47 39.8 Fat and oils 55 46.6

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Rice 40 33.9 Meat or poultry 49 41.5 Breast milk 50 42.4 Animal milk 59 50.0 Cake/biscuits 54 45.8

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Table 8 Attitude towards selected IYCF practices (Full Sample)

Agree Disagree

Neither Agree or Disagree

N % N % N %

I think that continuing breastfeeding at least until 24 months of age is important for the health of my baby 109 91.6 10 8.4 0 0

I am confident that I can breastfeed my baby exclusively through 6 months of age 104 87.39 13 10.92 2 1.68

I intend to keep this baby breastfed at least until he/she is 24 months old 105 88.24 13 10.92 1 0.84

I think adding foods such as meat, milk, eggs, fruits and vegetables to my baby's diet will be beneficial for my baby 113 94.96 6 5.04 0 0

The high cost of meat, fish, milk, and eggs makes it hard for me to prepare these foods for my baby 104 87.39 12 10.08 3 2.52

My mother-in-law would be opposed to me continuing to breastfeed my baby when he/she is sick 18 15.13 98 82.35 1 0.84

I don’t like to continue breastfeeding my baby when I am sick 16 13.45 101 84.87 1 0.84

I intend to keep breastfeeding my baby when s/he is sick 114 95.8 5 4.2 0 0

A lot of housework makes it hard for me to spend enough time encouraging my child to eat 48 40.34 69 57.98 2 1.68

I am confident that I can recognize and appropriately respond to my baby when s/he refuses to eat 84 70.59 35 29.41 0 0

I do not think that washing hands with soap after defecating is important to my child’s health 24 20.17 95 79.83 0 0

I think that washing two hands is more beneficial than Washing the right hand only

116 97.48 3 2.52 0 0

It takes too much time to reheat leftover food 59 49.58 59 49.58 0 0

Table 9 Prenatal Care (Full Sample)

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N %

Consulted Health professional during last pregnancy 118 99.2 If YES, who was this person?

Doctor 87 73.7 Nurse/midwife 31 26.3 Person that helps at birth 0 0.0 Community/village health worker 0 0.0

When you were pregnant with your last child, how many months pregnant were you the first time you consulted a health professional

Did not consult a health professional 0 0.0 at 0 to 3 months 20 17.0 at 4 to 6 months 78 66.1 at 7 to 9 months 18 15.3 Don't Know 2 1.7

How many times did you consult a health professional during your last pregnancy?

Did not consult a health professional 0 1 time 9 7.6 2 times 15 12.7 3 times 25 21.2 4 times 30 25.4 5 times 16 13.6 6 or more times 23 19.5 Don't know 0 0.0

Took any iron supplements/syrup during last pregnancy 109 92.4

During your Last pregnancy how many times did you take an iron supplement/syrup?

Did not take any iron 0 0.0 less than 10 days 11 10.1 10 to 19 days 5 4.6 20 to 29 days 6 5.5 30 to 39 days 6 5.5

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40 to 49 days 0 0.0 50 to 59 days 5 4.6 60 to 69 days 16 14.7 70 to 79 days 0 0.0 80 to 89 days 2 1.8 90 to 99 days 15 13.8 100 days or more 42 38.5 Don't Know 1 0.9

During last pregnancy, received any counseling or information about nutrition for pregnant women? 106 89.1 Who did you receive this nutritional counseling from?

Doctor 81 81.8 Nurse/midwife 16 16.2 Traditional Birth Attendant 0 0.0 Reco-Community Health Worker 1 1.0 Uncle 1 1.0

During last pregancy, received any counseling on the need for pregnant women to get sufficient rest during their pregnancy 105 88.2

Who did you receive this counseling on rest during pregnancy from? Doctor 84 80.0 Nurse/midwife 18 17.1 Traditional Birth Attendant 0 0.0 Reco-Community Health Worker 2 1.9 Grandmother 1 1.0

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Table 10 Mothers Decision Making Authority (Full Sample) N %

In your house, who decides what to cook on a day to day basis? mother (self) 63 52.9 husband 44 37.0 grandmother of child 4 3.4 grandfather of child 3 2.5 sibling of child 0 0.0 father and mother together 4 3.4 other (not listed) 1 0.8

Who normally decides what to feed the children? mother (self) 73 61.3 husband 32 26.9 grandmother of child 5 4.2 grandfather of child 3 2.5 sibling of child 0 0.0 father and mother together 5 4.2 sister 1 0.8

If you have a savings of 1,000 Congolese Francs, who will decide what to do with it?

mother (self), don't consult others 47 39.5 husband 62 52.1 grandmother of child 5 4.2 grandfather of child 1 0.8 sibling of child 0 0.0 father and mother together 4 3.4

Who do you consult when you consult someone what to do with money? mother 27 22.7 husband 85 71.4 grandmother of child 3 2.5 grandfather of child 1 0.8 don't know 1 0.8 neighbor 1 0.8

Table 11 Sources of Advice and their Credibility (Full Sample)

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N %

Normally takes advice from someone within the house about matters relating to child feeding and health 109 91.6

Whose advice do you take the most often? mother 18 15.7 husband 74 64.4 other relative in the home 9 7.8 everyone 1 0.9 mother-in-law 5 4.4 grandmother 3 2.6 mother's father 4 3.5 father in law 1 0.9

Normally takes advice from someone outside the house about matters relating to child feeding and health 92 77.3

Whose advice do you take most often outside the home regarding child feeding?

community health worker 14 13.7 staff of medical clinic 49 48.0 traditional healer 1 1.0 other relative outside the home 8 7.8 friend 10 9.8 everyone 4 3.9 husband 4 3.9 mother-in-law 3 2.9 sister-in-law 1 1.0 neighbor 8 7.8

Whose advice would you really like to take regarding child feeding and health?

mother 13 11.3 husband 36 31.3 other relative in the home 3 2.6 community health worker 5 4.4 staff of medical clinic 43 37.4 traditional healer 1 0.9 friend 1 0.9

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everyone 4 3.5 grandmother 2 1.7 father-in-law 1 0.9 neighbor 2 1.7 father 1 0.9 chief of the village 1 0.9 mother-in-law 2 1.7

Whose advice do you trust the most? mother 16 13.7 husband 45 38.5 other relative in the home 3 2.6 community health worker 5 4.3 staff of medical clinic 41 35.0 everyone 2 1.7 grandmother 2 1.7 father 1 0.9 mother-in-law 2 1.7

Who do you feel in your village knows the best about child feeding and health?

mother 7 6.5 husband 16 15.0 other relative in the home 2 1.9 community health worker 14 13.1 staff of medical clinic 60 56.1 traditional healer 2 1.9 friend 3 2.8 Local chief 1 0.9 No one 1 0.9

Someone in your village has been specifically trained about child health and feeding 85 71.4

Who is that (that was trained about child health and feeding)? community health worker 27 31.0 staff of medical clinic 53 60.9 traditional healer 2 2.3 other 3 3.5

Table 12 Health Worker Contact and Credibility

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N %

Knows the name of the health worker assigned to her village 104 87.4

Knows who she is but doesn't know her name 64 53.8 How often do you meet her?

once or more a week 17 14.3 twice a month 29 24.4 once per month 28 23.5 3 to 4 times per year 14 11.8 2 to 3 tiems per year 3 2.5 once per year 6 5.0 never meet her 19 16.0 Don't know 3 2.5

How often does she come to your house? once or more a week 14 11.8 twice a month 12 10.1 once per month 13 10.9 3 to 4 times per year 7 5.9 2 to 3 tiems per year 6 5.0 once per year 2 1.7 never meet her 65 54.6

Takes health worker's advice on child health/feeding 92 77.3

Trusts health worker's advice about child health and feeding 111 94.1 If yes (if you take her advice), Why?

Health worker received training on child feeding 29 25.9 health worker is highly intelligent 26 23.2 health worker knows me well 9 8.0 health worker is caring 42 37.5 health worker tells the truth 2 1.8 health worker gives good advice 1 0.9

If no (you don't take her advice), Why not?

Health worker never visits my home 4 50.0

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Health worker is not knowledgeable about child feeding 0 0.0

Health worker has poor attitude 0 0.0

Health worker gives poor advice 1 12.5

Health worker is from a different tribe 0 0.0 Health worker costs money 1 12.5 Don't know 2 25.0

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Table 13 Leisure and Media Habits (Full Sample) N % Has free time after finishing work 75 63.6

How much free time do you have after finishing all the work? none 23 19.8 30 minutes to 1 hour 28 24.1 1 to 2 hours 39 33.6 2 to 3 hours 16 13.8 4 or more hours 10 8.6

What do you do during your free time? meet with friends or relatives 4 3.8 listen to the radio 4 3.8 watch TV 0 0.0 read 2 1.9 play with children 30 28.3 rest/sit/sleep/nothing 57 53.8 go to church 2 1.9 do hair 1 94.0

What would you ideally like to do? meet with friends or relatives 6 5.3 listen to the radio 10 8.9 watch TV 15 13.3 read 11 9.7 play with children 23 20.4 rest/sit/sleep/nothing 40 35.4 plan activities for others 1 0.9 make clothes 1 0.9 spend time with husban 1 0.9

How often do you meet together with other mothers in your village? everyday 9 7.6 multiple times per week 24 20.2 once per week 25 21.0 once every two weeks 11 9.2 once per month 15 12.6 once every 2-3 months 0 0.0 never 30 25.2

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What do you do during these meetings? discuss family life 48 56.5 discuss local news 20 23.5 make handicrafts 3 3.5 dance 0 0.0 sing 8 9.4 wash clothes 2 2.4 learn new skills 0 0.0 multitude of subjects 1 1.2 religious meetings 2 2.4

Member of a women's group 69 58.0 Member of any other group 63 52.9 Listens to a radio 77 64.7 Where do you listen to the radio?

home 62 79.5 friend's home 9 11.5 in community 2 2.6 neighbor 4 5.1

How often do you listen to the radio? everyday 55 71.4 multiple times per week 9 11.7 once per week 9 11.7 once every two weeks 2 2.6 once per month 1 1.3 once every 2-3 months 1 1.3

Which stations do you listen to? RTNC 2 2.6 Digital Congo 0 0.0 Bonesha FM 5 6.5 Radio Burundi 13 16.9 Radio Mandeleo 2 2.6 Mijas 0 0.0 Radio Mitumba 0 0.0 Radio Okapi 2 2.6 Impact Luvungi 4 5.2 BBC 1 1.3 Radio Fizi 6 7.8 Radio Mugano 3 3.9 Radio Uvira 3 3.9

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Radio Sange 4 5.2 Radio Faradja 2 2.6 Radio Voice of the Spirit 1 1.3 Radio Lemera 16 20.8 Don't Know 4 5.2

What types of programs do you listen to? News programs 28 36.8 Music programs 23 30.3 Dramas 3 4.0 Comedy 1 1.3 Talk Shows 15 19.7 Mother's Teaching/Training 3 4.0 Salutations/Greetings 2 2.6

Watches/Listens to a TV 15 12.6 Where do you listen ot the TV?

home 2 13.3 friend's home 7 46.7 in community 4 26.7 cinema 2 13.3

How often do you listen to the TV? everyday 4 26.7 multiple times per week 1 6.7 once per week 4 26.7 once every two weeks 2 13.3 once per month 2 13.3 once every 2-3 months 1 6.7 once per year 1 6.7

Which channels do you listen to? FTNC 0 0.0 Digital Congo 0 0.0 Burundi Television 1 6.7 Private channel 0 0.0 Other 14 93.3

What programs do you watch? News programs 0 0.0 Music programs 3 20.0 Dramas 1 6.7 Comedy 1 6.7 Talk Shows 1 6.7 Film 9 60.0

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Appendix 2: List of Interviewers

Name Sex Organization Position Role in Formative Research

Arsene Bonene Sanvura M ADRA M&E Assistant Structured Interviewer

Dr Junior Kazadi M World Vision Coordinator-Nutrition and Health

Structured Interviewer

Coco Molisho F ADRA Wash Trainer FDG Moderator

Mado Mabulay F ADRA Food Distributor FDG Moderator & Note taker

Solange Bantu Chiza F World Vision Community health

promoter IDI interviewer& Notetaker

Chantal Kongolo F ADRA Community health promoter

IDI Interviewer & Notetaker

Patrick Bahati M World Vision Community health promoter

IDI Interviewer and Structured Interviwer

Milinganyo Hassan Miki M ADRA WASH Agent FGD Moderator & Notetaker

Andre Lumona M ADRA WASH Trainer Structured Interviewer

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Appendix 3: Forms (FGD Guides, In-depth interview Guides and Structured Interview)

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FGD Guide on Infant and Young Child Feeding Behaviors (for mothers of infants <24 months of age) 1. Warm-up and Explanation

a. Introduction • Thank you for coming • Your presence is important • Describe what a focus group is—like an opinion survey, but very general,

broad questions b. Purpose

• We will be discussing the way you feed very young children, the foods you give them, and why you feel they should be fed this way. We will also include in our discussion how you monitor the growth of your children and why you do it.

• I’m interested in all of your ideas, comments and suggestions. • There are no right or wrong answers • All comments, both positive and negative are welcome. • Please feel free to disagree with one another. We would like to have

many points of view. c. Procedure

• I want this to be a group discussion, so you needn’t wait for me to call on you. Please speak one at a time, though.

• We have a lot to cover, so I may change the subject from time to time or move ahead. Please stop me if you want to add something.

2. General perception of good health among infants/young children

a. Definitions of good health • When can you say that an infant/young child has good health? What

makes you say so? Anything else? b. Ways to ensure good health

• What can you do to make sure an infant/young child has good health? Anything else?

• Are there any things you want to do, but cannot? What are they? Why can’t you do these things?

3. Breastfeeding a. Do you breastfeed your babies? Why/why not?

For those who are breastfeeding their babies, • How often do you breastfeed them in a day? • Did you breastfeed your babies since birth? • Did you breastfeed your baby with the first milk that went out from your

breast when the baby was born? Why/why not? • Until when will you breastfeed your babies?

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• Are you giving any other kind of milk (powdered or canned)? Why/why not?

For those who do not breastfeed their babies, • May I know why you do not breastfeed your babies?

4. Complementary Feeding

a. Introduction of semi-solid foods • Other than milk, what other foods do you give to infants? Why/why not? • Why do you give other foods? Probe. • When is the best time to start giving a young child food other than

breastmilk? Why? • What was the first food that you started to give regularly to young

children? • What were all the ingredients? How was it made? • How do you introduce foods to an infant? Why do you introduce food

in this way? • How often do you give semi-solid food to infants each day? Each week? • And how much do you give each time? • What kinds of foods do you think a young child should be given every

day? Why are those foods important to give each day? • What are ways to make porridge given to young children more

nutritious? Probe. Why do you say that? o Have you tried these ways? Why/why not?

b. Breastfeeding after introducing semi-solid food

• Do you continue giving breastmilk, even when you are introducing foods to your infant? Why/why not?

• Do you breastfeed before or after you give infants food? Why?

5. Changes in feeding behavior as infant grows older a. At what age do you change the diet of infants? Why?

How do you change it? Why? (Probe about the quality of food frequency of feedings, amount given at each feeding, variety of foods given)

Do you give only one food at a time or mix of foods to infants? • If mixes, what mixes do you give? Why? • If single foods, why only one food at a time?

Benefits of food given to child • What advantages or results have these foods given to your child? • Do you see any changes in your child as a result of giving these

foods? What changes have you noticed? Willingness to try new or different foods

• Would you be willing to try new foods for your baby?

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• What kind of other foods would you be willing to try? • Is there anything preventing you from giving these foods to your

child? What?

b. Mothers’ concerns about infants during the complementary feeding period • What worries you most about your 6-11 month old babies? Why?

(Probe) • Was there a particular time when you especially worried? What was

that time? What made you worry? • What do you do to make sure that does not happen again? Why?

c. Complementary food preparation

• How do you prepare food for your baby? • Do you get food for your baby from the food you prepare for the

other family members, or do you prepare food especially for your baby?

• Do you change the family food in any way before you give it to your infant (e.g. add special ingredients, leave out certain ingredients, mash it?)

• How do you change the preparation? Why do you prepare it in this way?

• Who usually prepares the food for young children? • How often do you cook these foods in a day?

d. Feeding young children

• Who usually feeds the young children? • How is the food given to young children (spoon, cup, prechewed by

mother and given by mother, by mothers’ hand) • Do you feed them semi-solid foods as often as you breastfeed him

during the day?

e. Encouraging young children to eat • When a child refuses to eat, what do you usually do to encourage

him/her to eat? Anything else? Why do you do that? • When a child does not have good appetite over a few days, what do you

usually do? Why do you do that? • What age do you think a child should be allowed to eat by him/herself?

Why at that age? • How do you know when a young child is hungry? • How do you know when a young child is full?

f. Feeding a sick child

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• When a child is sick do you think a mother should change the number of times she breastfeeds her infant? Should she increased, decrease or not change the number of breast feeds she gives her sick child? Why/why not?

• When a child is sick do you think a mother should change the kind of food she feeds to her infant or young child? Why/why not?

• When a child is sick do you think a mother should change the number of times she feeds her infant/young child each day? Should she increased, decrease or not change the number of times she feeds her sick child each day? Why/why not?

g. Feeding during recovery

• When the child has recovered from being sick, do you think a mother should change the number of times she breastfeeds her infant each day? Should she increased, decrease or not change the number of breast feeds she gives her infant/young/child who has recovered from being sick? Why/why not?

• When the child has recovered from being sick, do you think a mother should change the kind of food she feeds her infant? Why/why not?

• When the child has recovered from being sick, do you think a mother should change the number of times she feeds her infant each day? Should she increased, decrease or not change the number of times she feeds her infant/young/child who has recovered from being sick? Why/why not?

6. Food perceptions

a. Differences in the way infants of different ages are fed • Is there and difference between the foods you feed a 6-8 month old baby

and a baby is 9-11 months? If yes, in what way do you feed them differently? Why do you feed differently? (Repeat for 12-23 month old baby)

b. Foods good/bad for 6-8 month old baby

• In your area, are there any foods which are considered particularly good for an infant 6-8 months of age? What are these foods? In what way are they considered good?

• Are there any foods which are considered bad for young children 6-8 months of age? What are these foods? In what way are they considered bad?

c. Foods good/bad for 9-11 month old baby

• (Repeat questions above for 9-11 month old baby)

d. Foods good/bad for 12-23 month old baby

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7. Food functions a. Food functions (draw on the foods mentioned by the mothers earlier)

• Of the foods you mentioned earlier….. • Do you feel they have different functions? • What are these functions? • Which foods perform which functions?

• What are the foods that you feel are necessary for the functions of: • Giving the body energy • Protecting the body against diseases • Helping the body to grow • Helping intelligence to develop

8. Ways to improve complementary foods

a. Show different pictures of commonly consumed foods b. Have mothers select which they would give their child 6-11 months of age. c. Have them develop recipe ideas for combining the food categories

(meat/fish/egg; vegetables/fruits; porridge; oil) d. Probe on all the ingredients that should be included and the manner of

preparation After recipes are developed, ask them: • Have they tried feeding their child the recipe? Why/why not? • Would they be willing to try giving the recipe to their child? Why/why not?

9. Commodities/Rations

a. Do families receive rations to feed their young children? If so, what do the rations consist of?

b. How do you prepare these rations for your children? • If mixes, what do you mix with the rations? Why? • If given by itself, why do you give the ration without other food?

c. Is the ration given for your child enough? Why/why not? d. What are the advantages/disadvantages of the rations for your child? Why do

you say so?

10. Receptivity to proposed behaviors Exclusive breastfeeding from birth to 6 months of age Nowadays, health workers will advise you to exclusively breastfeed your babies

from birth to six months of age. Will you follow their advice? Why/why not? Feeding infants 6-8 months of age These days people say that by 6 months of age, breastmilk is not enough for the

baby. They say that in addition to breastfeeding a baby who is 6 months old, you should

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start to give 2-3 tablespoonfuls of thick porridge and well-mashed or soft foods 2-3 times per day plus frequent breast feeds.

• What do you think about this? • Do you feel you are able to do this with your child? Why/why not? • How interested would you be in trying this? • What, if any, advantage or disadvantage do you think this would have for your

infants? Why?

Feeding infants 9-11 months of age These days people say that infants between 9-11 months of age should be given

finely chopped or mashed foods such as fish, vegetables, fruit, banana/millet porridge/potato and food that a baby can pick up, and that these should be given to the baby 3-4 times each day in addition to breast feeds. What do you think about this?

• Do you feel you are able to do this with your child? Why/why not? • How interested would you be in trying this? • What, if any, advantage or disadvantage do you think this would have for your

infants? Why?


family foods that are chopped or mashed if necessary, 3-4 times each day plus 1-2 snacks in addition to breast feeds. The meals should consist of chopped or mashed foods such as fish, vegetables, fruit, banana/millet porridge/potato and food that a baby can pick up.

What do you think about this? • Do you feel you are able to do this with your child? Why/why not? • How interested would you be in trying this? • What, if any, advantage or disadvantage do you think this would have for your

infants? Why? 11. Closing

Before we end, I’d like to go around once more and ask each of you if there is anything else you’d like to say about how to feed infants. Anything that we haven’t mentioned that would be important to you in how you feed your baby, or how you would recommend other mothers feed their baby?

Thank you so much of coming. You have been a good group and I have learned

much from you. FGD Guide on Maternal Nutrition

(for women of reproductive age: 18-45 years) 12. Warm-up and Explanation

a. Introduction

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• Thank you for coming • Your presence is important • Describe what a focus group is—like an opinion survey, but very general,

broad questions

b. Purpose • We will be discussing the way women take care of themselves during and

after pregnancy, the foods they eat, the beliefs they have about food. • I’m interested in all of your ideas, comments and suggestions. • There are no right or wrong answers • All comments, both positive and negative are welcome. • Please feel free to disagree with one another. We would like to have

many points of view.

c. Procedure • I want this to be a group discussion, so you needn’t wait for me to call on

you. Please speak one at a time, though. • We have a lot to cover, so I may change the subject from time to time or

move ahead. Please stop me if you want to add something.

13. General perception of good health among women a. Definitions of good health

• When can you say that a woman has good health? What makes you say so? Anything else?

b. Ways to ensure good health • What can women do to make sure she has good health? Anything else? • Are there any things you want to do, but cannot? What are they? Why

can’t you do these things?

14. Kinds and Amounts of Foods Eaten During Pregnancy and Lactation a. What foods do women of childbearing age typically eat?

Pregnancy b. Is there and difference between the kinds of foods a pregnant and non-pregnant

woman eats? If yes, how do the kinds of foods differ? What is the reason for the different kinds of food eaten? (Probe about specific foods for pregnancy) c. Benefits of food eaten during pregnancy

• What advantages or results have these foods given during pregnancy? • Do you notice any changes in your newborn as a result of eating

these foods during pregnancy? What changes have you noticed? d. Willingness to try new or different foods

• Would you be willing to try new foods during your next pregnancy? • What kind of other foods would you be willing to try?

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• Is there anything preventing you from eating these foods during your next pregnancy? What?

e. Is there and difference in the amount of foods a pregnant and non-pregnant woman eats? If yes, how does the amount of food differ? What is the reason for this difference in amount of food eaten? (Probe about whether more, the same or less amounts of specific foods are eat during pregnancy)

Probe about benefits and willingness to try new amounts of each food during the next pregnancy in the same way as the example above.

f. Women’s concerns about pregnancy • What worries women the most about pregnancy? Why? (Probe) • Is there a particular time during pregnancy when a woman is

especially worried? What is that time? What makes women worry at that time?

• What can women do to make sure she does not have to worry about that happening again? Why?

Lactation g. Is there and difference between the kinds of foods a lactating and non-lactating

woman eats? If yes, how do the kinds of foods differ? What is the reason for the different kinds of food eaten? (Probe about specific foods for lactation) h. Benefits of food eaten during lactation

• What advantages or results have these foods given during lactation? • Do you notice any changes in your newborn as a result of eating

these foods during lactation? What changes have you noticed? i. Willingness to try new or different foods

• Would you be willing to try new foods during you’re the next time you breastfeed?

• What kind of other foods would you be willing to try? • Is there anything preventing you from eating these foods the next

time you breastfeed? What? j. Is there and difference in the amount of foods a lactating and non-lactating

woman eats? If yes, how does the amount of food differ? What is the reason for this difference in amount of food eaten? (Probe about whether more, the same or less amounts of specific foods are eat during lactation)

Probe about benefits and willingness to try new amounts of each food during the next lactation in the same way as the example above.

k. Women’s concerns about lactation • What worries women the most about lactation? Why? (Probe) • Is there a particular time during lactation when a woman is especially

worried? What is that time? What makes women worry at that time?

• What can women do to make sure she does not have to worry about that happening again? Why?

15. Perception of link between food intake and pregnancy outcome

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a. Do you think the kind of food eaten during pregnancy affects the health of the baby? If so, in what way? What kinds of foods are likely to be good for a healthy baby? Why do you say so?

• Are any of these foods ones would like to eat during pregnancy, but cannot? What are they? Why can’t you eat them?

b. Do you think the amount of food eaten during pregnancy affects the health of the baby? If so, in which foods should a pregnant women eat more of/less of? Why do you say so?

• Is there anything preventing you from eating more of the foods you think are good for the baby? What?

16. Perceptions of Food During Pregnancy and Lactation a. Foods good/bad for pregnant women

• In your area, are there any foods which are considered particularly good for pregnant women? What are these foods? In what way are they considered good?

• Are there any foods which are considered particularly bad for pregnant women? What are these foods? In what way are they considered bad?

b. Foods good/bad for lactating women • In your area, are there any foods which are considered

particularly good or lactating women? What are these foods? In what way are they considered good?

• Are there any foods which are considered bad for lactating women? What are these foods? In what way are they considered bad?

17. Food functions a. Food functions (draw on the foods mentioned by the women earlier)

• Of the foods you mentioned earlier….. • Do you feel they have different functions? • What are these functions? • Which foods perform which functions?


18. Receptivity to proposed behaviors Eating an extra serving of staple food during pregnancy Nowadays, health workers will advise you to eat more during pregnancy--like an

extra serving of maize porridge and ground nuts. Will you follow their advice? Why/why not?

Eating a more diversified diet

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Nowadays, health workers will advise you to eat more kinds of foods during pregnancy--like fruits and vegetables, animal products, and use iodized salt and fortified foods. an extra serving of maize porridge and ground nuts.

• What do you think about this? • Do you feel you are able to do this? Why/why not? • How interested would you be in trying this? • What, if any, advantage or disadvantage do you think this would have? Why?

Gain at least one kilogram per month in the 2nd and 3rd trimester Nowadays, health workers will advise that you gain one kilogram of weight every

month in the 2nd and 3rd trimester. Will you follow their advice? Why/why not? Rest more during pregnancy

These days people say that a woman should rest more than usually during pregnancy and lactation.

• What do you think about this? • Do you feel you are able to do this? Why/why not? • How interested would you be in trying this? • What, if any, advantage or disadvantage do you think this would have? Why?

Consuming daily supplements of iron and folic acid Nowadays, health workers will advise that you to take an tablet containing iron and

folic acid every day during pregnancy and for the first three months postpartum. • What do you think about this? • Do you feel you are able to do this? Why/why not? • How interested would you be in trying this?

Eating an extra meal during lactation Nowadays, health workers will advise that you eat an extra meal during pregnancy

to have enough energy for lactation. • What do you think about this? • Do you feel you are able to do this? Why/why not? • How interested would you be in trying this?

19. Closing Before we end, I’d like to go around once more and ask each of you if there is

anything else you’d like to say about how to eat and care for yourself during pregnancy and lactation. Anything that we haven’t mentioned that would be important to you in how you care for yourself or how you would recommend other women care for themselves during pregnancy and lactation?


much from you.

94

In-depth Interview Guide for Leader Mothers 1. Introduction

a. Greetings. Introduce self. We are conducting a study in this area to understand the people’s current practices and food habits. We are interviewing some people like you who are involved in ensuring the health of the people. I will be grateful if you could spare some time to answer a number of questions. This questioning will run for less than an hour.

2. Socioeconomic and demographic data a. How long have you been a Leader Mother worker? b. Did you have any other position in the community before that? What position? c. What made you decide to be a mother leader/volunteer? How were you elected

to be a Leader Mother? d. Totally, how much time would you spending in a month as a mother

leader/volunteer?

3. Job Description I would like to try to understand what does the job of a mother leader/volunteer

involve.

• Can you tell me all your activities that you undertake as a mother leader/volunteer? Anything else? How much time do you spend on each of these activities, say in a month?

• Which of these do you like the most? Why? • Which of these do you not like at all? Why? • If you were asked to change the work or activities you do as a mother

leader/volunteer, what change would you make?

4. Nutrition and Health Information Let me now ask you about the nutrition education component of your work as a

Leader Mother. Do you……?

• Identify sick children • Counsel caregiver/mother on health and nutrition related issues covered in

this training • Use flip charts to counsel the caregiver/mother on key household behaviors • Apply counseling techniques in communication, listening and relaying health

behavior change messages according to the challenged faced in the home-see comment on training modules.

95

• Arrange for follow-up visits • Make follow-up visits1 • Do you tell mothers anything about nutrition or how to feed themselves and

their babies? • What do you tell them? Anything else? • What do you think is good for a pregnant mother? • What are all the things she should do to ensure a healthy pregnancy?

Repeat the last two questions for lactating mothers, infants 6-11 months, and infants

12-23 months. • When do you talk to the mothers about nutrition? • How often in a month? Where? • Do you go to their houses or do they go to you? Leader Mothers make

household visits to PLW and mothers of young children. • Do you address them in a group? No, only in their home. • Do you enjoy this part of your work? Why/why not? • Do mothers listen to you? • Do they follow your advice? • Do you face any difficulties in doing this work? What difficulties do you

face? Need to do a barrier analysis to really know the difficulties in behavior change.

• How do you think these can be overcome? • Do you feel you have adequate knowledge about nutrition for mothers,

infants and young children? • Would you like to know anything more? • What more would you like to know? • Normally, on what topics do you talk to mothers? Any others? • On which topics do you spend most of your time? Why? • And on which ones do you spend relatively less time? Why? • Do you feel that you need any help to talk to the mother and advise

them? What kind of help would you like? • Is there anything else you feel will help mothers to follow your advice?

What? • Which activity do you feel has benefited mothers the most? What

makes you say so?

1 Community Case Management Essential: Treating Common Childhood Illnesses in the Community. A Guide for Program Managers.

USAID, Core Group. 2010

96

5. Teaching Aides/Materials

a. Do you use any teaching aides when conducting health or nutrition counseling? b. Which did you enjoy using the most? Why? c. Which did you enjoy using the least? Why? d. Which material do you feel benefited the mothers you interact with the most?

What makes you say so? e. Are you still using these materials? If not, why not?

6. Pregnancy

Pre-natal Check-up a. Do pregnant mothers in your area have themselves checked up? Why/why not?

By whom? Where? b. What is being done during these check-ups? c. What is being given to these mothers who go for check-ups?

• Supplements? • Immunizations? • Malaria medicines?

d. Do you give advice to these mothers? What advice do you give them? e. What suggestions can you give to improve the pregnancy check-up in your

village? Other questions a Leader Mother can ask of pregnant women

• How will you feed your baby? • If the mother does not plan to breastfeed her baby, ask why. • Have you heard of exclusive breastfeeding and why it is essential? • Did you encounter any difficulties breastfeeding other children? What? • Have you already been to a health clinic for ANC and for Iron/Folic Acid

supplementation? Do you take the supplements every day? • Did you get your deworming medicine? • Did you get your tetanus vaccination? • Do you sleep under an insecticide treated net? • If HIV testing and counseling is available, have you thought of taking an HIV test?

7. Breastfeeding practices

a. How can you support optimal breastfeeding practices? b. Do most mothers in your area exclusively breastfeed their babies from 0 to 6

months? Why do you say so? c. Do they give their first milk (first yellowish milk) d. What other kinds of milk (powdered, canned) do mothers give their babies?

Why? e. What problems do mothers have in breastfeeding their babies?

97

f. What advise do you give them? 8. Home Visits by Leader Mothers

a. How often do you meet with the Community Health Promoter? b. Where do you meet her? c. When you meet him/her, what does he/she normally do? d. Do you feel her visits to your village are helpful to you in anyway? In what way

are they helpful? e. Do you feel you get to meet her often enough? f. Does anybody else from the outside come periodically to help you in your work?

Who comes? g. Do you find these visits helpful? Why/why not?

9. Food habits in the area

a. What do you feel about the way mothers feed their infants and young children in your area?

b. Do you feel young children, say 6-11 months of age, get adequate quantities of all needed foods?

c. Do you feel that there are some foods which are lacking in their diet? Which ones? Any others?

d. Why do you feel they are lacking? Why do they not eat them enough?

10. Advice about infant and young child feeding Now I’d like to talk to you about advice you may give to mothers about ways

to feed their infant and young children. • Do you ever talk to mothers about ways to feed their infants who are

between 6-23 months of age? What do you tell them? (Probe) • When do you recommend a mother start giving food other than breast

milk? Why at that age? • What is the first semi-solid food that you recommend a mother start

giving her child regularly? • What are the kinds of foods you recommend a mother give her 6-23

month old baby every day? Why do you recommend these foods? • What is the number of times you recommend a mother to feed these

foods in a usual day? Why that many times? • How much do you recommend that a mother feed her baby 6-11 months

of age during each feeding? (show cup) • How much do you recommend that a mother feed her baby 12-23

months of age during each feeding? (show cup) • What are the ways you think mothers in your area can improve the way

they feed their infants? • Are there any foods that are not well tolerated by young infants? Which

are these? In what way are they not well tolerated?

98

• Are there any foods that are considered bad for young children who are 6-11 months of age? What are these foods? Why are they considered bad? Why do you give other foods? Probe.

• When do you tell mothers is the best time to start giving a young child food other than breastmilk? Why?

• What was the first food that you recommend a mother start to give regularly to young children?

• What are the ingredients? How is it made? • How do you recommend that mothers introduce foods to an infant • What recommendations to you give about… • how often to give semi-solid food to infants each day? Each week? • And how much to give each time? • What kinds of foods to give a young child every day? • What are ways to you recommend to mothers to make porridge given to

young children more nutritious? Probe. Why do you say that?

a. Breastfeeding after introducing semi-solid food • Do you continue giving breastmilk, even when you are introducing foods

to your infant? Why/why not? • Do you breastfeed before or after you give infants food? Why?

11. Changes in feeding behavior as infant grows older

b. At what age do you change the diet of infants? Why? How do you change it? Why? (Probe about the quality of food frequency

of feedings, amount given at each feeding, variety of foods given) Do you give only one food at a time or mix of foods to infants?

• If mixes, what mixes do you give? Why? • If single foods, why only one food at a time?



• Would you be willing to try new foods for your baby? • What kind of other foods would you be willing to try? • Is there anything preventing you from giving these foods to your

child? What?

b. Mothers’ concerns about infants during the complementary feeding period • What worries you most about your 6-11 month old babies? Why?

(Probe) • Was there a particular time when you especially worried? What was

that time? What made you worry?

99

• What do you do to make sure that does not happen again? Why?

c. Complementary food preparation • How do you prepare food for your baby? • Do you get food for your baby from the food you prepare for the







mother and given by mother, by mothers’ hand) • Do you feed them semi-solid foods as often as you breastfeed him

during the day?

e. Encouraging young children to eat • When a child refuses to eat, what do you usually do to encourage

him/her to eat? Anything else? Why do you do that? • When a child does not have good appetite over a few days, what do you

usually do? Why do you do that? • What age do you think a child should be allowed to eat by him/herself?

Why at that age? • How do you know when a young child is hungry? • How do you know when a young child is full?


• When a child is sick do you think a mother should change the number of times she breastfeeds her infant? Should she increased, decrease or not change the number of breast feeds she gives her sick child? Why/why not?

• When a child is sick do you think a mother should change the kind of food she feeds to her infant or young child? Why/why not?

• When a child is sick do you think a mother should change the number of times she feeds her infant/young child each day? Should she increased, decrease or not change the number of times she feeds her sick child each day? Why/why not?

100

• How do you know when a child is well again? Once the fever has gone, once the child’s illness has gone or once the child returns to his/her normal weight?


• When the child has recovered from being sick, do you think a mother should change the number of times she breastfeeds her infant each day? Should she increased, decrease or not change the number of breast feeds she gives her infant/young/child who has recovered from being sick? Why/why not?

• When the child has recovered from being sick, do you think a mother should change the kind of food she feeds her infant? Why/why not?

• When the child has recovered from being sick, do you think a mother should change the number of times she feeds her infant each day? Should she increased, decrease or not change the number of times she feeds her infant/young/child who has recovered from being sick? Why/why not?

12. Food perceptions








d. Foods good/bad for 12-23 month old baby • (Repeat questions above for 12-23 month old baby)

13. Food functions

a. Food functions (draw on the foods mentioned by the mothers earlier) • Of the foods you mentioned earlier…..

• Do you feel they have different functions? • What are these functions?

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• Which foods perform which functions? • What are the foods that you feel are necessary for the functions of:

• Giving the body energy • Protecting the body against diseases • Helping the body to grow • Helping intelligence to develop


a. Show different pictures of commonly consumed foods b. Have mothers select which they would give their child 6-11 months of age. c. Have them develop recipe ideas for combining the food categories




a. Do families receive rations to feed their young children? If so, what do the rations consist of? CSB and Oil



you say so?



baby. They say that in addition to breastfeeding a baby who is 6 months old, you should start to give 2-3 tablespoonfuls of thick porridge and well-mashed or soft foods 2-3 times per day plus frequent breast feeds.


infants? Why?

102




infants? Why?





Before we end, I’d like to go around once more and ask each of you if there is anything else you’d like to say about how to feed infants. Anything that we haven’t mentioned that would be important to you in how you feed your baby, or how you would recommend other mothers feed their baby?


much from you.

103

In-depth Interview Guide for Health Workers 1. Introduction

a. Greetings. Introduce self. We are conducting a study in this area to understand the people’s current practices and food habits. We are interviewing some people like you who are involved in ensuring the health of the people. I will be grateful if you could spare some time to answer a number of questions. This questioning will run for less than an hour.

2. Socioeconomic and demographic data a. How long have you been a health worker? b. Did you have any other position in the community before that? What position? c. What made you decide to be a health worker? How were you selected to be a

health worker? d. Totally, how much time would you be spending in a month as a health worker?

3. Job Description

I would like to try to understand what does the job of a Health Worker involve.

• Can you tell me all your activities that you undertake as a Health Worker ? Anything else? How much time do you spend on each of these activities, say in a month?

• Which of these do you like the most? Why? • Which of these do you not like at all? Why? • If you were asked to change the work or activities you do as a Health Worker ,

what change would you make?

4. Nutrition and Health Information Let me now ask you about the nutrition education component of your work as a

Health Worker. Do you……?

• Identify sick children • Counsel caregiver/Health Worker on health and nutrition related issues

covered in this training • Use flip charts to counsel the caregiver/Health Worker on key household

behaviors • Apply counseling techniques in communication, listening and relaying health

behavior change messages according to the challenged faced in the home-see comment on training modules.

• Arrange for follow-up visits

104

• Make follow-up visits2 • Do you tell Health Workers anything about nutrition or how to feed

themselves and their babies? • What do you tell them? Anything else? • What do you think is good for a pregnant Health Worker? • What are all the things she should do to ensure a healthy pregnancy?

Repeat the last two questions for lactating Health Workers, infants 6-11 months,

and infants 12-23 months. • When do you talk to the Health Workers about nutrition? • How often in a month? Where? • Do you go to their houses or do they go to you? • Do you address them in a group? No, only in their home. • Do you enjoy this part of your work? Why/why not? • Do Health Workers listen to you? • Do they follow your advice? • Do you face any difficulties in doing this work? What difficulties do you

face? Need to do a barrier analysis to really know the difficulties in behavior change.

• How do you think these can be overcome? • Do you feel you have adequate knowledge about nutrition for Health

Workers, infants and young children? • Would you like to know anything more? • What more would you like to know? • Normally, on what topics do you talk to Health Workers? Any others? • On which topics do you spend most of your time? Why? • And on which ones do you spend relatively less time? Why? • Do you feel that you need any help to talk to the Health Worker and

advise them? What kind of help would you like? • Is there anything else you feel will help Health Workers to follow your

advice? What? • Which activity do you feel has benefited Health Workers the most?

What makes you say so?

105

5. Teaching Aides/Materials a. Do you use any teaching aides when conducting health or nutrition counseling? b. Which did you enjoy using the most? Why? c. Which did you enjoy using the least? Why? d. Which material do you feel benefited the Health Workers you interact with the

most? What makes you say so? e. Are you still using these materials? If not, why not?

6. Pregnancy

Pre-natal Check-up a. Do pregnant Health Workers in your area have themselves checked up?

Why/why not? By whom? Where? b. What is being done during these check-ups? c. What is being given to these Health Workers who go for check-ups?

• Supplements? • Immunizations? • Malaria medicines?

d. Do you give advice to these Health Workers? What advice do you give them? e. What suggestions can you give to improve the pregnancy check-up in your

village? Other questions a Health Worker can ask of pregnant women

• How will you feed your baby? • If the Health Worker does not plan to breastfeed her baby, ask why. • Have you heard of exclusive breastfeeding and why it is essential? • Did you encounter any difficulties breastfeeding other children? What? • Have you already been to a health clinic for ANC and for Iron/Folic Acid

supplementation? Do you take the supplements every day? • Did you get your deworming medicine? • Did you get your tetanus vaccination? • Do you sleep under an insecticide treated net? • If HIV testing and counseling is available, have you thought of taking an HIV test?

7. Breastfeeding practices a. How can you support optimal breastfeeding practices? b. Do most Health Workers in your area exclusively breastfeed their babies from 0

to 6 months? Why do you say so? c. Do they give their first milk (first yellowish milk) d. What other kinds of milk (powdered, canned) do Health Workers give their

babies? Why? e. What problems do Health Workers have in breastfeeding their babies? f. What advise do you give them?

8.

106

9. Home Visits by Health Workers a. How often do you meet with mothers of young children? b. Where do you meet them? c. When you meet them, what do you normally do? d. Do you feel your visits are helpful to you in anyway? In what way are they

helpful? e. Do you feel you get to meet her often enough? f. Does anybody else from the outside come periodically to help you in your work?

Who comes? g. Do you find these visits helpful? Why/why not?

10. Food habits in the area

a. What do you feel about the way Health Workers feed their infants and young children in your area?

b. Do you feel young children, say 6-11 months of age, get adequate quantities of all needed foods?

c. Do you feel that there are some foods which are lacking in their diet? Which ones? Any others?

d. Why do you feel they are lacking? Why do they not eat them enough?

11. Advice about infant and young child feeding Now I’d like to talk to you about advice you may give to Health Workers

about ways to feed their infant and young children. • Do you ever talk to Health Workers about ways to feed their infants

who are between 6-23 months of age? What do you tell them? (Probe) • When do you recommend a Health Worker start giving food other than

breast milk? Why at that age? • What is the first semi-solid food that you recommend a Health Worker

start giving her child regularly? • What are the kinds of foods you recommend a Health Worker give her

6-23 month old baby every day? Why do you recommend these foods? • What is the number of times you recommend a Health Worker to feed

these foods in a usual day? Why that many times? • How much do you recommend that a Health Worker feed her baby 6-11

months of age during each feeding? (show cup) • How much do you recommend that a Health Worker feed her baby 12-

23 months of age during each feeding? (show cup) • What are the ways you think Health Workers in your area can improve

the way they feed their infants? • Are there any foods that are not well tolerated by young infants? Which

are these? In what way are they not well tolerated?

107

• Are there any foods that are considered bad for young children who are 6-11 months of age? What are these foods? Why are they considered bad? Why do you give other foods? Probe.

• When do you tell Health Workers is the best time to start giving a young child food other than breastmilk? Why?

• What was the first food that you recommend a Health Worker start to give regularly to young children?

• What are the ingredients? How is it made? • How do you recommend that Health Workers introduce foods to an

infant • What recommendations to you give about… • how often to give semi-solid food to infants each day? Each week? • And how much to give each time? • What kinds of foods to give a young child every day? • What are ways to you recommend to Health Workers to make porridge

given to young children more nutritious? Probe. Why do you say that?

a. Breastfeeding after introducing semi-solid food • Do you continue giving breastmilk, even when you are introducing foods

to your infant? Why/why not? • Do you breastfeed before or after you give infants food? Why?

12. Changes in feeding behavior as infant grows older

c. At what age do you change the diet of infants? Why? How do you change it? Why? (Probe about the quality of food frequency

of feedings, amount given at each feeding, variety of foods given) Do you give only one food at a time or mix of foods to infants?

• If mixes, what mixes do you give? Why? • If single foods, why only one food at a time?



• Would you be willing to try new foods for your baby? • What kind of other foods would you be willing to try? • Is there anything preventing you from giving these foods to your

child? What?

b. Health Workers’ concerns about infants during the complementary feeding period

• What worries you most about your 6-11 month old babies? Why? (Probe)

108

• Was there a particular time when you especially worried? What was that time? What made you worry?

• What do you do to make sure that does not happen again? Why?

c. Complementary food preparation • How do you prepare food for your baby? • Do you get food for your baby from the food you prepare for the







Health Worker and given by Health Worker, by Health Workers’ hand)

• Do you feed them semi-solid foods as often as you breastfeed him during the day?

e. Encouraging young children to eat

• When a child refuses to eat, what do you usually do to encourage him/her to eat? Anything else? Why do you do that?

• When a child does not have good appetite over a few days, what do you usually do? Why do you do that?

• What age do you think a child should be allowed to eat by him/herself? Why at that age?

• How do you know when a young child is hungry? • How do you know when a young child is full?


• When a child is sick do you think a Health Worker should change the number of times she breastfeeds her infant? Should she increased, decrease or not change the number of breast feeds she gives her sick child? Why/why not?

• When a child is sick do you think a Health Worker should change the kind of food she feeds to her infant or young child? Why/why not?

109

• When a child is sick do you think a Health Worker should change the number of times she feeds her infant/young child each day? Should she increased, decrease or not change the number of times she feeds her sick child each day? Why/why not?

• How do you know when a child is well again? Once the fever has gone, once the child’s illness has gone or once the child returns to his/her normal weight?


• When the child has recovered from being sick, do you think a Health Worker should change the number of times she breastfeeds her infant each day? Should she increased, decrease or not change the number of breast feeds she gives her infant/young/child who has recovered from being sick? Why/why not?

• When the child has recovered from being sick, do you think a Health Worker should change the kind of food she feeds her infant? Why/why not?

• When the child has recovered from being sick, do you think a Health Worker should change the number of times she feeds her infant each day? Should she increased, decrease or not change the number of times she feeds her infant/young/child who has recovered from being sick? Why/why not?

13. Food perceptions








d. Foods good/bad for 12-23 month old baby • (Repeat questions above for 12-23 month old baby)

110

14. Food functions

a. Food functions (draw on the foods mentioned by the Health Workers earlier) • Of the foods you mentioned earlier…..

• Do you feel they have different functions? • What are these functions? • Which foods perform which functions?



a. Show different pictures of commonly consumed foods b. Have Health Workers select which they would give their child 6-11 months of

age. c. Have them develop recipe ideas for combining the food categories




a. Do families receive rations to feed their young children? If so, what do the rations consist of? CSB and Oil



you say so?



baby. They say that in addition to breastfeeding a baby who is 6 months old, you should

111

start to give 2-3 tablespoonfuls of thick porridge and well-mashed or soft foods 2-3 times per day plus frequent breast feeds.


infants? Why?




infants? Why?





Before we end, I’d like to go around once more and ask each of you if there is anything else you’d like to say about how to feed infants. Anything that we haven’t mentioned that would be important to you in how you feed your baby, or how you would recommend other Health Workers feed their baby?


much from you.

112

Structured Interview for Mothers of Children 0-23 months

Structured Interview for Mothers of Children 0-23 monthsADRA/JHU Formative Research, Jenga-ll

Module 1: Identification

Village? village

1-Katala 6-Sebele2-Lemera 7-Swima3-Ndolera 8-Ndunda4-Ake 9-Katoga5-Kenya Plage 10-Kigurwe

11- Other ____________

Date of Interview:1 2

date

day month year d d m m

Name of Interviewer int

1- Andre 4-Patrick2- Arsen4 5-Other 1______________3- Junior

Result Code: formstatus

1-Completed2-Incomplete3-Refused

Module 2: Status, Education, Employment

1 How old are you? mage

(years)

2 What is your marital status? mmari

1-married 3-separated/divorced2-widowed 4-other _____________ 1

3 What is your relationship to the head of mhhd

household?1-self 6-sibling of2- only wife of 7-other relative of3- one of the wives of 8-non-kin of4-child of 9-other5-parent of

4 Can you read or write a letter in French, Kikongo, mread

Swahili or Tshiluba?0-No 1-Yes

5 Can your husband read or write a letter in French, hread

Kikongo, Swahili or Tshiluba?0-No 1-Yes

6 What is the highest class you completed? medu

00-None 14-Degree or higher01 to 13- From class 1 to 13 Don't know--99

7 What is the highest class your husband hedu

completed?00-None 14-Degree or higher01-->13- From class 1 to 13 99-Don't know

8 What is your religion? mrel

1-Indigenous 5-Islam2-Catholic 8-Other______________3-Protestant 9-Don't know4-Kimbanguism

9 What is your ethnicity? mtribe

1-Kongo 4-Zande2-Lingala 5-Alur

2

3-Luba 9-Other______________

1 0 Dialect spoken at home? dialect

1-French 4-Swahili2-Lingala 5-Tshilubal3-Kikongo 9-Other______________

1 1 Apart from your household chores, are you doing work mjob

that generates income or not for your family?0-No (Go to 15) 1-Yes

1 2 In the past 12 months, have you done that work employ

(referred to in question 11)?0-No 1-Yes

1 3 Is this work seasonal, or do you work wseasonal

occasionally, or do you work all year round?1-All year round 3-Occasionally2-Seasonally

1 4 What is the MAIN work you do, apart from your usual mocc

household chores?

01-Farmer (Crops)08-Household Worker/Housewife

02-Agricultural day labor 09-Maid servant03-Non Agricultural day labor 14-Other ___________04-Service/Salaried worker05-Small/cottage industry06-Business/Traders07-Other Self-employment

1 5 What is your husband's MAIN occupation? hocc

01-Farmer (Crops)08-Household Worker/Housewife

02-Agricultural day labor 09-Maid servant03-Non Agricultural day labor 10-Student

3

04-Service/Salaried worker 11-Retired/Old age05-Small/cottage industry 12-Jobless06-Business/Traders 13-Caring for Child (age <5)07-Other Self-employment 14-Other ___________

1 6 What are other sources of your household income?

(READ RESPONSES)

0-No 9-Don't Know1-Yes

a Fishing? income_a

b Small business? income_b

c Temporary wages? income_c

d Spouse? income_d

e Salaried job? income_e

f Relative? income_f

g Rent? income_g

h Other?______________ income_h

1 7 What is the approximate income of your family income

per month?(Congolese Francs)

1 8 What percent of the family income is spent for pincome

food?0- Less than 10% 5- 50% to 59%1- 10% to 19% 6- 60% to 69%2- 20% to 29% 7- 70% to 79%3- 30% to 39% 8- 80% to 89%4- 40% to 49% 9- more than 90%

4

Module 3: IYCF Practices of Index ChildNote: Please ask the name of the child to use in questions about the child, but do not record.

1 9 How old is (name of child) in months? cage

00- less than 1 month 01-->23- age in months

2 0 Are you pregnant? pregnant


2 1 Are you lactating? lactating

0-No 1-Yes

2 2 How soon after birth did you put the child to the timebf

child to the breast for the first time?0- within 1 hour 4- 1 day to 3 days1- 1 to 5 hours 5- 4 to 7 days2- 6 to 11 hours 6- more than 1 week3- 12 to 24 hours

2 3 Did anyone put anything inside the baby‘s mouth prelac0

IMMEDIATELY after the birth?0-No (Go to 25) 9-Don't Know (Go to 25)1-Yes

2 4 What was put in the child‘s mouth IMMEDIATELY prelac1

after birth? 1-Honey 6-Cows milk2-Mustard oil 8-Other _____________3-Plain water 9- Don't know4-Sugar/glucose water5-Tea/coffee

5

2 5 During the first 3 days after the baby was born, prelac2

what was given to the child by you or anyoneelse other than breastmilk?1-Honey 6-Cows milk2-Mustard oil 7-Nothing3-Plain water 8-Other _____________4-Sugar/glucose water 9- Do not remember5-Tea/coffee

2 6 Did you give the child your first thick yellowish colostrum

milk (colostrum)?0-No 9-Don't Know1-Yes

2 7 Did you face any concerns or difficulties when bfprob_0

you first started breastfeeding the baby?(Mark all responses mentioned)0-No (Go to 28) 9-Don't Know (Go to 28)1-Yes

a Problems with breast (pain) bfprob_a

b Child did not suck well bfprob_b

c Not enough time to feed child bfprob_c

d Cracked nipples bfprob_d

e Felt not enough breast milk bfprob_e

f Plugged milk duct Note: Responses f and g are bfprob_f

g Breast engorgement similar. Mark both if mentioned. bfprob_g

h Sick baby bfprob_h

i Inverted nipple bfprob_i

j Other______________ bfprob_j

6

2 8 Did you face any problems with breastfeeding laterbf

LATER ON, when the child was 3-4 months old?0-No (Go to 30) 9-Don't Know (Go to 30)1-Yes

2 9 What problems did you face?

(Mark all responses mentioned by mother)0-problem not mentioned 1-problem not mentioned

a Problems with breast (pain) bfprob3_a

b Child did not suck well bfprob3_b

c Not enough time to feed child bfprob3_c

d Cracked nipples bfprob3_d

e Felt not enough breast milk bfprob3_e

f Plugged milk duct bfprob3_f

g Breast engorgement bfprob3_g

h Sick baby bfprob_h

i Inverted nipple bfprob_i

j Other______________ bfprob_j

3 0 Did you face any concerns or difficulties when you sssdff

started feeding semi-solid/solid foods to the baby?0-No (Go to 35) 9-Don't Know (Go to 35)1-Yes

3 1 What problems did you face?

(Mark all responses mentioned by mother)0-No 1-Yes

1-Child refusal or child spits it out sssdff1

7

2-Child sick sssdff2

3-Child's poor appetite sssdff3

sssdff4

5-Family does not have resources sssdff5

6-Family members discourage sssdff6

7-Other_________ sssdff7

3 2 Were you able to overcome these problems by yourself? sssfprob


3 3 Did you seek help from anyone to help help

address this problem?0-No 9-Don't Know1-Yes

3 4 Who did you seek help from? helper

1-community health worker 4-other relative2-mother 5-friend3-husband 6-staff of medical clinic

7-other________________

3 5 Is the child still breastfeeding? stillbf

0-No 9-Don't Know1-Yes (Go to 38)

3 6 If no, at what age did you stop breastfeeding the child? agestopbf

00-1 to 29 days 07-7 to 9 months01-1 months 08-10 to 12 months02- 2 months 09-13 to15 months03-3 months 10-16 to 18 months04-4 months 11-19 to 21 months

4-Mother does not have time to prepare/feed

8

05-5 months 12-23 to 24 months06 -6 months 13-more than 24 months

99-Don't know

3 7 Why did you stop breastfeeding? whystopbf

1-Problems with breast (pain) 5-Mother got pregnant2-Child not suck well 6-New baby born3-Not enough time to feed chil 7-Cracked nipples4-Child already grown up/ No 8-Felt not enough breastmilk

9-Other _____________

3 8 At what age did you start giving the following

liquids/foods to the child? (Read responses)00-Less than 1 month 88-Don't know01-->24 month of age 99-Not yet given

a Water start_a

b start_b

c Cow/Goat milk start_c

d Porridge, rice gruel, maize grueletc. start_d

e start_e

f Solid foods (rice, fufu/casava, wheat, other) start_f

g Fish start_g

h Meat (chicken, mutton, beef, etc., khichuri with meat) start_h

i Eggs start_i

j Legumes (pulse, peas, etc) start_j

k Green vegetables start_k

l yellow fruits or vegetables start_l

m snack foods (chips) start_m

Semi-solid foods (soft or mashed maize/casava/potato, ripe banana, other mashed family foods etc.)

Other non breast milk liquids (sugar/glucose water, tea, fruit juice etc.)

9

3 9 How many times did you breastfeed (name of child) bfnight

yesterday, during the day or night?0-Did not breast feed child 3-7 to 9 times1-1 to 3 times 4-10 to 12 times2-4 to 6 times 5-13 or more times

9-don't know

4 0 Yesterday (during the day or the night) did you give

any of the following liquids to the child?0-No 9-Don't Know1-Yes

a Breastmilk liquid_a

b Water liquid_b

c Baby formula (prepared food for child) liquid_c

d Any other kind of milk (powder, cow/goat milk etc.) liquid_d

e Fruit juice (made at home) liquid_e

f Fruit juice (purchased, packaged) liquid_f

g Water-based liquids, teas, sugar water, coffee liquid_g

4 1 Yesterday (during the day and the night), did you bottle

use a baby bottle to feed the child?0-No 9-Don't Know1-Yes

4 2 How many times did (name of child) eat solid, othermilk

semi-solid or soft foods other than liquids yesterdayduring the day or night?Semi-solid foods such as soft rice, mashed potato, ripe banana, other mashed family foods etc. Solid foods such as rice, wheat, puffed/pressed rice etc.

10

MEALS include both MEALS and SNACKS (other than trivial amounts)0-None 3-7 to 9 times1-1 to 3 times 4-10 to 12 times2-4 to 6 time 5-13 or more times

9-don't know

4 3 Of the cooked foods that you fed the child yesterday, plate

could you tell us about how many plates (show the plate) you offered the child to eat yesterday?0-none 5-two and a half1-half 6--three2-one 7-three and a half3-one and a half 8-four or more4-two 9-don't know

4 4 Did your child eat (or drink) any of the following

foods yesterday (during the day or night)? (READ responses)0-No 9-Don't Know1-Yes

a Rice yfood_a

b Casava or maize porridge yfood_b

c Purchased baby cereals yfood_c

d Syrup or table that "increases the blood" (iron-containing) yfood_d

e Green leafy vegetables yfood_e

f yfood_f

g yfood_g

h Ripe papaya or mango yfood_h

Pumpkin, orange yam, sweet potatoe, carrots, tomato (vitamin-A rich)

Any other vegetables (starchy vegetables: potatoes, yam, plantain)

11

i Other fruits such as oranges, banana, grapefruits yfood_i

j Any other fruits yfood_j

k Meat such as beef, mutton yfood_k

l Chicken, duck, pigeon yfood_l

m Liver, heart, kidneys yfood_m

n Fish yfood_n

o Eggs yfood_o

p Peanuts, groundnuts, other nuts yfood_p

q Milk (non-human milk – cow, goat or powder) yfood_q

r Milk products (yogurt, rice pudding etc) yfood_r

s Fat (oil, butter, ghee) yfood_s

t Chips or chanachur yfood_t

u Bread or buns or donuts yfood_u

v Candies or chocolates yfood_v

w yfood_w

x Fufu yfood_x

y Legume yfood_y

4 5 When your child is sick with diarrhea or fever or cough and cold, compared to your usual amount , how much did you feed the child……1-does not give 3- less than usual2 -same as usual 4 - more than usual

a non-breast milk liquid sick_a

b breast milk sick_b

12

c semi-solid food sick_c

d solid food sick_d

4 6 In the week after your child recovered from

sickness, how much did you feed your child…..1-does not give 3- less than usual2 -same as usual 4 - more than usual

a non-breast milk liquid recover_a

b breast milk recover_b

c semi-solid food recover_c

d solid food recover_d

Module 4:Child Feeding Knowledge

4 7 In your opinion, how long after birth should a baby kbfstart

start breast feeding?1-Within 1 hour of birth 4-More than 1 day later2- 1 hour later but less than 24 hr

5-Do not think baby should be breastfed

3-1 day later 9-Don't know

4 8 In your opinion, what should a mother do with the kcolustrum

first milk or colostrum?1- Discard first few drops 3-Feed it to the baby 2-Discard all of it 9-Don't know

4 9 In your opinion, should a baby under 6 months kbfwant

of age be breastfed whenever s/he wants or on aspecific schedule or both? 1-Whenever baby wants 4- When mother gets time2-On a specific schedule 9-Don't know3-Both

13

5 0 In your opinion, how many times in one day (and night) kbftimes

should a baby be breastfed in the first 6 months of life? 01-97=times 99=Don't know98= 98 or more

5 1 According to you, if a mother thinks her baby is not kbfnotenuf

getting enough breast milk, what should she dofor herself and for her baby?1-Breast feed more often/more frequently

4-Mother needs to eat more food

2-Give other liquids or foods 8-Other______________

3-Mother needs to drink more water

9-Don't know

5 2 According to you, should infants under 6 months be kwater

given water if the weather is very hot?0- No 9-Don't know1-Yes

5 3 According to you, should a breast feeding mother of kbfpreg

a child under 6 months of age stop breast feeding if if she becomes pregnant again?0- No 9-Don't know1-Yes

5 4 In your opinion, should a mother stop breast feeding kbfsick

when the mother has common illness such as fever, cough, cold or diarrhea?0- No (Go to 56) 9-Don't know (Go to 56)1-Yes

5 5 If yes, for what reasons should she stop breastfeeding? kbfreason

(Mark responses given by mother)14

1-Mother is weak 5-Milk is unhealthy 2- Mother may get more sick 6-Mother needs rest3-Child will get sick 9-Don't know4-Milk is insufficient

5 6 According to you, at the time of preparing or feeding

porridge or rice, foods can you add to make it more nutritious for the child? (Mark responses given by mother)

0-Mother did not mention food item

1-Mother mentioned food item

a Add colored fruits and vegetables

food_a

b Add dark leafy vegetables food_b

c Add egg food_c

d Add dal or beans food_d

e Add meat or fish or liver food_e

f Add milk to porridge food_f

g Add a spoonful of ghee or oil food_g

h Give thicker porridge food_h

i Other__________________ food_i

5 7 What are the variety of foods that should be in a child’s

daily diet at 6 months to 1 year of age? (Record responses given by mother)0-Should not feed 1-Should feed

a Fish variety_a

b Egg variety_b

c Maize variety_c

d Cassava variety_d

e Yellow or orange fruits variety_e15

f Green leafy vegetables variety_f

g Yellow vegetables variety_g

h Other vegetables variety_h

i Fat and oils variety_i

j Rice variety_j

k Meat or poultry variety_k

l Breast milk variety_l

m Animal milk variety_m

n Cake/biscuits variety_n

I will now say a few statements. Please tell me if you agree, disagree or neither agree nor disagree with these statements.

5 8 I think continuing to brestfeed until abf24

24 months of age is important for the health of my baby1-Agree 3-Disagree2-Neither agree nor disagree

5 9 I am confident that I can breast feed my baby exclusiely abfexbf

through 6 months of age1-Agree 3-Disagree2-Neither agree nor disagree

6 0 I intend to keep this baby breastfed at least until abfi24

he/she is 24 months old 1-Agree 3-Disagree2-Neither agree nor disagree

6 1 I think adding foods such as meat, milk, eggs, fruits afood

and vegetables to my baby's diet will be 16

beneficial for my baby1-Agree 3-Disagree2-Neither agree nor disagree

6 2 The high cost of meat, fish, milk, and eggs makes it acost

hard for me to prepare these foods for my baby1-Agree 3-Disagree2-Neither agree nor disagree

6 3 My mother-in-law would be opposed to me continuing ainlaw

to breastfeed my baby when he/she is sick1-Agree 3-Disagree2-Neither agree nor disagree

6 4 I don’t like to continue breastfeeding my baby abfmsick

when I am sick1-Agree 3-Disagree2-Neither agree nor disagree

6 5 I intend to keep breastfeeding my baby when abfcsick

s/he is sick1-Agree 3-Disagree2-Neither agree nor disagree

6 6 A lot of housework makes it hard for me to spend awork

enough time encouraging my child to eat1-Agree 3-Disagree2-Neither agree nor disagree

6 7 I am confident that I can recognize and appropriately arefuse

respond to my baby when s/he refuses to eat1-Agree 3-Disagree2-Neither agree nor disagree

6 8 I do not think that washing hands with soap after ahwash

defecating is important to my child’s health 17

1-Agree 3-Disagree2-Neither agree nor disagree

6 9 I think that washing two hands is more beneficial a2hwash

than washing the right hand only1-Agree 3-Disagree2-Neither agree nor disagree

7 0 It takes too much time to reheat leftover food aleftover

1-Agree 3-Disagree2-Neither agree nor disagree

Module 5: Pregnancy and Postnatal Care

7 1 When you were pregnant with your last child, anchw

did you consult any health personnel?0-No (Go to 75) 9-Don't know (Go to 75)1-Yes

7 2 If YES, who was this person? ancwho

1 - Doctor 4- Community/village health k2 - Nurse/midwife 5-Other______________

3 - Person that helps at birth

7 3 When you were pregnant with your last child, ancmonths

how many months pregnant were you the first time you consulted a health professional0-Did not consult a health professional

3-at 7 to 9 months

1-at 0 to 3 months 9-Don't know2-at 4 to 6 months

7 4 How many times did you consult a health anctimes

professional during your last pregnancy?18

0-Did not consult a health professional

4-4 times

1-1 time 5-5 times2-2 times 6-6 or more times3-3 times 9-Don't know

7 5 During your last pregnancy did you take any anciron

iron supplements/syrup?0-No (Go to 77) 9-Don't know (Go to 77)1-Yes

7 6 During your last pregnancy how many times anciron1

(total number of days or months) did you take an iron supplement/syrup?00-did not take any iron 06-50 to 59 days01-less than 10 days 07-60 to 69 days02-10 to 19 days 08-70-79 days03-20 to 29 days 08-80-89 days04-30 to 39 days 09-90 to 99 days05-40 to 49 days 10-100 days or more

99-Don't know

7 7 During your last pregnancy, did you receive any ancc

counseling or information about nutrition for pregnant women?0-No (Go to 79) 9-Don't know (Go to 79)1-Yes

7 8 Who did you receive this counseling from? anccwho

1 - Doctor 4 - Traditional birth attendant

2 - Nurse/midwife5 - Community/village health worker

3 - Auxiliary midwife 6-Other______________

7 9 During your last pregnancy, did you receive any ancbf

counseling about breastfeeding infants and young children?

19

0-No (Go to 81) 9-Don't know (Go to 81)1-Yes

8 0 Who did you receive this counseling from? anccbfwho




8 1 During your last pregnancy, did you receive any anccrest

counseling on the need for pregnant women to get sufficient rest during their pregnancy?0-No (Go to 83) 9-Don't know (Go to 83)1-Yes

8 2 Who did you receive this counseling from? anccrwho




Module 6: Mothers Decision-making Authority

8 3 In your house, who decides what to cook on a dmcook

day to day basis?1-mother (self) 5-sibling of child2-husband 8- other ________3-grandmother of child 9-Don't know4-grandfather of child

8 4 Who normally decides what to feed the children? cmfood

1-mother (self) 5-sibling of child2-husband 8- other ________3-grandmother of child 9-Don't know4-grandfather of child

20

8 5 If you have savings of 1,000 Congolese Franc, dmspend

who will decide what to do with it?1-mother (self) 5-sibling of child2-husband 8- other ________3-grandmother of child 9-Don't know4-grandfather of child

8 6 Will you decide yourself or will you decide dmwho

in consultation with someone else?1-mother (self) (Skip to 88) 5-sibling of child2-husband 8- other ________3-grandmother of child 9-Don't know4-grandfather of child

8 7 Who will you consult? dmwho1

1-mother (self) 5-sibling of child2-husband 8- other ________3-grandmother of child 9-Don't know4-grandfather of child

Module 7: Sources of Advice and their Credibility

8 8 Do you normally take any advice from anyone adhome

within the house about matters relateing to child feeding and health?0-No (Skip to 90) 9-Don't know (Skip to 90)1-Yes

8 9 Whose advice do you take the most often? adhwho

1-mother 8-other__________2-husband3-other relative in the home

9 0 Do you normally take any advice from anyone adoutside

outside the house about matters relateing to 21

child feeding and health?0-No (Skip to 91) 9-Don't know (Skip to 92)1-Yes

9 1 Whose advice do you take most often? adowho

1-community health woker4-other relative outside the home

2-staff of medical clinic 5-friend3-traditional healer 6-other______________

9 2 Whose advice would you really like to take? adlike

1-mother 5-staff of medical clinic2-husband 6-traditional healer3-other relative in the home 7-friend4-community health woker 8-other______________

9 3 Whose advice do you trust the most? adtrust

1-mother 5-staff of medical clinic2-husband 6-traditional healer3-other relative in the home 7-friend4-community health woker 8-other______________

9 4 Who do you feel, in your village, adfeeding

knows the best about child feeding and health?1-mother 5-staff of medical clinic2-husband 6-traditional healer3-other relative in the home 7-friend4-community health woker 8-other______________

9 5 Is there anybody in your village who has been adtrained

specially trained about child health and feeding?0-No (Skip to 97) 9-Don't know (Skip to 97)1-Yes

9 6 Who is that? adtwho

1-community health woker 3-traditional healer2-staff of medical clinic 8-other______________ 22

Module 8: Health worker contact and credibility

9 7 Do you know the name of the health worker hwname

assigned to your village? Wk 1-HW=midwife; Wk 2-3=general health personnel0-No 1-Yes (Go to 99)

9 8 Do you know her, but not know her name? hwknow

0-No (Go to 99) 1-Yes

9 9 How often do you meet her? hwmeet

1-once or more a week 5-2 to 3 times per year2-twice a month 6-once per year3-once per month 7-never meet her4-3 to 4 times per year 9-Don't know

1 0 0 How often does she come to your house? hwhouse

1-once or more a week 5-2 to 3 times per year2-twice a month 6-once per year3-once per month 7-never meet her4-3 to 4 times per year 9-Don't know

1 0 1 Do you ever take advice from her hwfeed

on child health/feeding?0-No 1-Yes

1 0 2 Would you trust her advice about hwtrust

child health and feeding?0-No (Go to 104) 1-Yes (Go to 103 and skip 104)

1 0 3 If yes, Why? hwwhy

1-Health worker received training on child training

8-Other______________

2-Health worker is highly intelligent

9-Don't know23

3-Health worker knows me well4-Health worker is caring

1 0 4 If no, Why not? hwwhynot

1-Health worker never visits my home

5-Health worker is from a different tribe

2-Health worker is not knowledgable about child feeding

8-Other____________

3-Health worker has poor attitude

9-Don't know

4-Health worker gives poor advice

Module 9: Leisure and Media Habits

1 0 5 Do you get much free time after doing all the work? lmtime

0-No 1-Yes

1 0 6 How much free time to you have after lmamount

finishing all the work?0-none 3-2 to 3 hours1-30 minutes to 1 hour 4-4 or more hours2-1 to 2 hours

1 0 7 What do you do during your free time? lmdo

1-meet with friends or relatives4-read2-listen to the radio 5-play with children3-watch TV 8-other_______________

1 0 8 What would you ideally like to do? lmlikedo

1-meet with friends or relatives4-read2-listen to the radio 5-play with children3-watch TV 8-other_______________

24

1 0 9 How often do you meet together with other lmmeet

mothers in your village?1-everyday 5-once per month2-multiple times per week 6-once every 2-3 months3-once per week 8-other_______________4-once every two weeks 9-Never (Skip to 111)

1 1 0 What do you do during these meetings? lmmwhat

1-discuss family life 5-sing2-discuss local news 6-wash clothes3-make handicrafts 7-learn new skills4-dance 8-Other__________

1 1 1 Are you a member of any women's group? lmwgroup

0-No 1-Yes

1 1 2 Are you a member of any other groups? lmgroup

0-No 1-Yes

1 1 3 Do you listen to a radio? lmradio

0-No (Skip to 118) 1-Yes

1 1 4 Where do you listen to the radio? lmradiow

1-home 3-in community2-friend's home 8-other_______________

1 1 5 How often do you listen to the radio? lmradioho

87 1-everyday 5-once per month2-multiple times per week 6-once every 2-3 months3-once per week 8-other_______________4-once every two weeks

1 1 6 Which stations do you listen to? lmrstat

0-RTNC 5-Mijas1-Digital Congo 6-Radio Mitumba

25

2-Bonesha FM 7-Radio Okapi3-Radio Burundi 8-Other ____________4-Radio Mandeleo 9-Don't know

1 1 7 What programs do you listen to? lmrprog

1-News programs 4-Comedy2-Music programs 5-Talk shows3-Dramas 8-Other ____________

1 1 8 Do you listen to a TV? lmtv

0-No (Finish interview)+D699 1-Yes

1 1 9 Where do you listen to the TV? lmtvplace

1-home 3-in community2-friend's home 8-other_______________

1 2 0 How often do you listen to the TV? lmtvoften

1-everyday 5-once per month2-multiple times per week 6-once every 2-3 months3-once per week 8-other_______________4-once every two weeks

1 2 1 Which channels do you listen to? lmtvchanel

1-RTNC 4-Private Channel2-Digital Congo 5-other__________3-Burundi Television

1 2 2 What programs do you watch? lmtvprog

1-News programs 4-Comedy2-Music programs 5-Talk shows3-Dramas 8-Other ____________

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formative research to examine perceptions and behaviors ... · perceptions on maternal nutrition...

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