Mid-term ReviewWindow of Opportunity Program

Indonesia

Prepared for CARE USA Child Health and Nutrition Unit

Ruth Harvey, Consultant

May 14, 2011

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List of Acronyms

CFA Community focused approaches

CHAN Child Health and Nutrition

DHO District Health Office

FGD Focus Group Discussion

IYCF Infant and young child feeding

IYCF-E Infant and young child feeding in emergencies

KMS Kartu Menuju Sehat, Child Health Card

MCH Maternal child health

M&E Monitoring and evaluation

MOH Ministry of Health

MTMSG Mother to mother support group

MTR Mid-term Review

NGO Non-government organization

TBA Traditional Birth Attendant

TTU Timor Tengah Utara

UNICEF United Nations Children’s Fund

WHO World Health Organization

Definition of Terms

Bidan: A midwife serving in a village who is employed by the government health system.

Kader: Community Health Volunteer recruited for conducting monthly growth monitoring sessions.

Puskesmas: Public Health Center that provides basic health facilities. One Puskesmas usually covers several villages within one district. Staff includes doctors, nurses, midwives, nutritionists and others.

Polindes: A village health center, run by the village midwife. This provides basic medical care, ANC, delivery services, post natal care and also conducts the monthly growth monitoring session.

Posyandu: Monthly growth monitoring sessions with other activities such as mass education, immunizations and other services with activities carried out by the kaders and midwife.

Bubur saring: A special porridge (bubur) prepared for young children made from ground rice or corn mixed cooked with water.

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ContentsPROGRAM OVERVIEW.................................................................................................................................4

MID TERM REVIEW PROCESS.......................................................................................................................6

MTR Aims and Objectives........................................................................................................................6

Methodology and Sampling.....................................................................................................................6

Training and Data Collection for the LQAS...............................................................................................7

FGD Data Collection and Analysis............................................................................................................7

RESULTS AND DISCUSSION..........................................................................................................................8

Quantitative Component – LQAS Survey.....................................................................................................8

Changes in IFYC practices........................................................................................................................8

Health Communication and Coverage of MTSG and Counseling Activities............................................10

Decision making for mothers.................................................................................................................12

Qualitative Component.............................................................................................................................13

Focus Group Process.............................................................................................................................13

Findings from Focus Groups..................................................................................................................14

Conclusions from the Focus Groups......................................................................................................22

Interviews with volunteers and health workers....................................................................................24

Conclusions................................................................................................................................................27

Recommendations.....................................................................................................................................29

Appendices................................................................................................................................................32

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PROGRAM OVERVIEW

The goal of the Window of Opportunity program is to promote, protect, and support optimal infant and young child feeding (IYCF) and related maternal nutrition (rMN) practices. Specifically, the program’s interventions focus on improving the enabling environment, strengthening health systems to support optimal IYCF and rMN, and empowering communities and individuals to make optimal choices regarding breastfeeding, complementary feeding, and nutrition for women during pregnancy and lactation.

The Window of Opportunity (Window) program started in 2008 and is currently being implemented in five countries—Indonesia, Nicaragua, Sierra Leone, Bangladesh, and Peru.

Indonesia was one of the first countries under the Window’s program. From January 2007 to March 2008, CARE implemented the Infant and Young Child Feeding in Emergency (IYCF-E) project in two sub-districts of Timor Tengah Utara (TTU). The project’s aim was to prevent malnutrition in infants and young children under 24 months by increasing knowledge and skills of health workers and communities for optimal feeding practices. In 2008, additional funds were granted to expand the scope of the IYCF-E initiative into a more comprehensive program focused on development and emergency contexts, as well as maternal nutrition. Named Prima Bina, this IYCF project targets pregnant and lactating women in the same villages in TTU and an additional 8 villages in Belu district. The project now covers a total of 23 villages in these two districts of West Timor.

The goal of Prima Bina is to promote, protect and support infant and young child feeding and related maternal nutrition in the province of East Nusa Tenggara by 2010. Specific program objectives include building capacity of CARE staff, partners and volunteers; implementing a behavior change communication strategy; regular monitoring and evaluation of the program process and impact; and, institutionalization of best practices. Box 1 provides a brief timeline of key program activities to date. These include formative research, baseline assessments and planning during year one, and capacity building and training of local resources for group facilitators and counseling in year two.

Prima Bina uses two key strategies to provide support for mothers at the community level: Formation of Mother to Mother Support Groups (MTMSG), and IYCF Counseling – A community focused approach (CFA). By the time of the MTR, facilitators had been trained and activities started in 18 out of 23 villages. MTMSGs have been formed and operating in 14 villages (8 in TTU and 6 in Belu) and CFA counselors have been trained in four villages (in TTU).

For the context of this evaluation, it is important to understand that training of local resources for support and counseling has been initiated but is not yet completed. Facilitators have been trained in 18 out of the 23 villages leaving five villages where interventions

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Number of villages by Intervention Type TTU Belu TotalMTMSG 8 6 14CFA 4 4None 3 2 5

15 8 23

have yet to begin. Even in villages where facilitators have been trained, not all posyandu areas within the village are covered.

Timeline of Prima Bina Activities

2008 April - July IYCF project for Emergency and Development, transition from IYCF-E to Prima Bina

July - September Project staff recruited under IYCF-E Technical Specialist

June - August Pilot of formative research Project focus on learning from community October Project Manager hired November Formative research started, planning

Provincial workshop with DHO representatives and stakeholders from TTU and Betun

2009 January Consultant visit for formative research

February Formative research, community and social mapping completed

March 2-day workshop on Facilitation March-May Field staff "live and learn" in villages

April-May Update Census of all children under 24 months

June to September Prima Bina Baseline Survey

September - November Community Facilitators do home visits to learn about IYCF

2010 December - January Project workshops - 1/2 day Orientation for stakeholders in all project villages

January Facilitating MTMSGs - Training of Trainers for CFs and DHO

partners

MTMSG training starts - first batch March Baseline survey report completed

IYCF for CFA- Training of Trainers, plus one village level training

April-July MTMSG training continues - 5 batches August-September World Breastfeeding week activities for month September End of contracts, Replacement of 4 of 6 community Facilitators October Orientation and training of new project staff

Facilitating MTMSGs - Training of Trainers for new CFs

November Update Census of all children under 24 months November-December Project Mid Term Review

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MID TERM REVIEW PROCESS

MTR Aims and ObjectivesThe Window Program conducted a project Mid-term Reviews (MTR) in three countries which have completed baseline assessments and formative research and are in the process of rolling out IYCF and related maternal nutrition interventions. The aims of the review are to:

Measure progress towards program IYCF objectives Look at coverage of key intervention activities - counseling, Mother to Mother Support Groups

and group education, And also measure knowledge and awareness of interventions and attitudes towards Window

programming.

Methodology and SamplingThe MTR consists of a quantitative LQAS survey and a qualitative component using FGDs in project communities. Draft and final versions of data collection instruments and proposed sampling methodologies were shared and revised in consultation with Window HQ staff. These are included in Annex A and B.

For the LQAS survey, a quantitative instrument was provided by Window’s headquarters staff and adapted based on experience in Nicaragua and consultations with the field team in-country. The English questionnaire was translated to Bahasa Indonesia with a few refinements -mainly clarifying wording for interviewers and adjusting the food list for common local foods. The final English version of the questionnaire used for data collection and the survey frequency results are attached as Annex A.

The LQAS Survey sample was drawn for six Supervision Areas (SA), three in TTU district and three in Belu. Prima Bina has six community facilitators (CFs) - field staff who are each responsible for a project area (SA). A sample of 19 locations was selected for each SA using population proportional sampling. The sampling framework is included in Annex C. At each location, two households were selected, one with a child under six months, and another with a child aged 6 to 11 months. The sample size is 6 x 19 = 114 locations x 2 children, for a total of 228 children under age one.

For the qualitative component, communities were selected using purposeful sampling to represent the different types of activities, the different types of environments and populations served. MTMSG locations were selected to include a strong area (TTU), and another area where groups are active but not the strongest (Belu), and the most active CFA area was chosen.

Village Location District Group Activity Type of LocationOenenu Utara TTU MTMSG Rural Fatusene TTU CFA RuralKabuna Belu MTMSG Semi-urban/refugee

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Training and Data Collection for the LQASMid-term review preparation and data collection was a team effort of the Prima Bina Project team in West Timor working with an external consultant Ruth Harvey. The schedule for MTR activities and data collection is included as Annex D.

From November 12 to 17, Ruth provided training on the LQAS methodology and together with Project Manager Dr. Santi Wulandari and Assistant Project Manager Andarias Pagalla, trained the data collectors who were the CARE Community Facilitators. Survey training included a review of the concept of overage and key indicators, an overview of LQAS methodology, practice selecting households and respondents, interview techniques and an intensive review of the survey questionnaire. Training also included an afternoon practice session of interviewing respondents in a village setting.

Data collection was completed between November 18 and December 10th (November 18 to 24 and December 2 to 9 in TTU, and from December 2 to 9thin Belu.) The entire team travelled and worked together in each SA often splitting into two teams to cover two sample locations at once. The PM and APM worked as team leaders and field supervisors, and were responsible for selecting the starting households, supervising interviewers and checking questionnaires. Survey logistics were expertly handled by the PM and APM together with the project administrative and finance officers and provided good support for the survey activities. The final survey sample included all locations selected and two households per location. In one community, 20 instead of 19 locations were selected so the total number of respondents for the LQAS survey is 230.

Completed LQAS questionnaires were reviewed and checked in-country and then sent to CARE HQ for data entry, cleaning and initial analysis. Survey results in the form of an LQAS template spreadsheet and frequency distributions were sent to the consultant for program related analysis.

FGD Data Collection and Analysis A smaller team consisting of the PM, consultant and two community facilitators with capacity in local language conducted the focus group discussions. FGD guides were based on the guides used in Nicaragua and some previously used by the consultant for similar work. For group facilitation, the initial plan was for the PM to lead the FGDs with the two community facilitators translating in local language. However, this arrangement did not to work well because a higher level of local language skills was required to fully appreciate the nuances of the discussion. The project’s Administrative Officer (HRAP), who was initially included as a translator for the consultant, was found to have the best local language skills, so it worked best for her to function as the FGD facilitator under the guidance of the PM and consultant, and for community facilitators to serve as note takers. The qualitative team met directly after each FGD, compiled notes, discussed findings and the completed a summary matrix.

When possible during survey visits to the community, the consultant with a translator conducted key informant interviews with trained village kaders or midwives. Staff and translator availability and scheduling were all challenges and only four interviews were completed.

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Conducting both the LQAS survey and FGDs during the same period and involving some of the same staff in both activities posed a significant challenge. While this allowed the group to travel together, it added to logistical and supervisory burdens and limited the times available to schedule FGDs. Quality control of the LQAS survey did not suffer, however the quality of the FGD activities would have been better if scheduled for a different time. Language difficulties also hampered the ability to provide immediate input and guidance for FGDs which meant some opportunities to explore and probe further were lost.

RESULTS AND DISCUSSION

Quantitative Component – LQAS SurveyThe purpose of the LQAS survey was to measure IYCF practice indicators to see how the project has progressed since baseline and to measure coverage and exposure to information, messages and support. The survey instrument was adapted from the MTR survey format developed at CARE Atlanta to measure infant feeding indicators consistent with WHO and KPC standards in a manner consistent with measurements of the project baseline survey.1 Questions were added to measure coverage of program intervention activities and women’s decision making.

Changes in IFYC practices While statistical comparison of the baseline and MTR surveys is not really appropriate2, survey results do suggest a trend towards major improvements in key project indicators.

Proxy of Tendency for the Key IYCF Indicators (percentage)

Baseline3 Midterm Review (95% CI)

Timely Initiation of Breastfeeding 55 72 (66 – 78)

Exclusive Breastfeeding 63 83 (76 – 89)

Minimum Dietary Diversity 11 22 (14 – 29)

Minimum Meal Frequency 70 87 (81 – 93)

Minimum Adequate Diet 7 20 (13 – 27)

Early Breastfeeding – A large improvement is indicated for Timely Initiation of Breastfeeding. In addition, the large gap in coverage rates of the two districts found in the baseline is not seen in the MTR 1 WHO Indicators for Assessing Infant and Young Child Feeding Practices (2009), and the KPC2000+ and Rapid CATCH 2007 survey guidance as described in Infant and Young Child Feeding Practices: Collecting and Using Data: A Step-by-Step Guide. CARE 2010.2 This survey was not designed for direct comparison with Baseline. Sampling is different (LQAS and Cluster), the age group is different (0 to 11 months not 0 to 24 months, and the LQAS sample size is too small to allow for direct comparison on many indicators. For this reason, comparisons aren’t really valid but trends can be indicated.3 For comparison of trend purposes, figures used here are findings from the Baseline Survey for project intervention areas.

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results. Timely initiation of breastfeeding in TTU is 74% and in Belu is 70% suggesting that improvements in Belu have contributed to these results.

Exclusive Breastfeeding has also improved with 83% of children 0 to 5 months exclusively breastfed and similar improvements in each district. Of the twenty children who were not exclusively breastfed, more than a half (14) were being given water and six were being given formula milk. Six children were introduced to food too early, and all of these were in the 4-5 month age group. These results indicate that primarily water but also formula milk are barriers to EBF for all children under six months.4 Early introduction of solid foods is an additional barrier for children in the 4-5 months age group.

Of the children surveyed, 96% were currently breastfeeding. Of the few who were not breastfeeding, most were over the age of six months.5

Timely Introduction of Semi-solid and Solid foods was found for 98.5% of children age 6-8 months, and Timely Introduction of Complementary Food for 93% of those age 6-9 months. Only one child was not receiving semi-solid food but four children were no longer breastfeeding in this age group.

Grains+t

ub+plan

tain

Legumes

Dairy p

roducts

Fleshfoods

Eggs

Vit A fo

ods

Otherfru

itsveg

Oil, fats

Chocol, c

andies

Snack

s

Fortified

foods

0

10

20

30

40

50

60

70

80

90

100

Percent of children 6 to 11 months consuming key foods

TotalBeluTTU

According to responses to question 11, almost all children age 6 to 11 months were fed staple foods (90% are fed grains, tubers or bananas) and more than half were given vitamin A rich fruits or vegetables. Just over half of the children (55%) were given a source of animal protein. Animal flesh foods were given to 26% of children and eggs were given to 31% of children. Provision of snacks is widely practiced with 44% of children given candy, cake, chocolate or sweets in the previous 24 hours, 4 Three out of the 20 nonEBF children in the survey were no longer breastfeeding.5 There were 10 children not breast feeding at the time of the survey: 3 were under age 6 months, 1 was between 6-8 months, and 6 were aged 9 months or older.

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and 21% given snacks such as chips, krupuk or dry instant noodles. Only 15% of children were given fortified foods such as formula or a commercial complementary food such as SUN.

Dietary diversity continues to be a problem in the project area with not even a quarter of children (21.6% of 6-11 month olds) with diets which meet minimum diversity. This indicator was also lower in Belu (15%) than in TTU (25%). Compared to the baseline, however, the MTR findings suggest marked improvement.

Most children (87%) were fed the Minimum Meal Frequency which also suggests an improvement from the baseline. Yet as expected, when this indicator is combined with dietary diversity for the composite indicator Minimum Acceptable Diet, results are low (20%) because diversity is low (22%). The Minimum Acceptable Diet indicator for Belu (15%) is lower than for TTU (25%) however findings per district and overall suggest a trend towards major improvement in these feeding indicators.

Health Communication and Coverage of MTSG and Counseling Activities

Health Messages and Sources: More than three quarters of women (78%) recalled hearing health messages. When asked where they heard these messages, a majority of women cited health service providers: 65% said at posyandu, 28% puskesmas or polindes, and 6% at a hospital. The project’s World Breastfeeding Week activities (three months before the survey) were mentioned by 9%, and visits by care staff were mentioned by 6% of those interviewed. Radio, information boards and cooking demonstrations were not mentioned by any of the respondents. Mother to mother support groups were mentioned by only two mothers as a source of information.

other activities/places

Growth chart book

CARE staff

CARE World Breastfeeding week

Other NGO staff

Individual counseling

Mother to mother support group

Posyandu

Puskesmas/Polindes

Hospital, Maternity Center

0% 10% 20% 30% 40% 50% 60% 70%

Source of Information on Nutrition and IYCF

When asked to recall the specific health and nutrition messages, almost three quarters of these women mentioned messages about exclusive breastfeeding (74%) and a third mentioned messages about food

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diversity (35%) and maternal nutrition (33%). This is consistent with results from the FGDs where mothers and even some fathers exhibited knowledge and awareness about exclusive breastfeeding and foods to feed children.

Other

Nutrition in pregnancy or lactation

Variety of food I provide my child

Frequency of complementary feeding

Exclusive breastfeeding

Early initiation of breastfeeding

0% 10% 20% 30% 40% 50% 60% 70% 80%

Type of Message on Nutrition and IYCF

When women were asked about topics covered during counseling visits and MTMSG meetings, similar results were found. Exclusive breastfeeding was mentioned most frequently as a topic discussed in both MTMSG discussions and during counseling visits. MTMSG meetings tended to focus more on maternal nutrition and breastfeeding topics, while topics on complementary feeding as well as breastfeeding were covered during individual counseling visits.

Coverage of Individual Counseling and MTMSG: To capture any individual counseling on child feeding, the survey asked women if “someone knowledgeable” had talked with them alone about how to feed their child. Women were asked if they had had such an encounter during the last month, and during the last six months. Most women (80%) did not recall any individual counseling. Twenty percent of women mentioned counseling in the last six months, and only five percent said in the last month.

Counseling - last 6 months

Counseling - last month

MTMSG - last 6 months

MTMSG - last month

0102030405060708090

100

19.6

4.8 7.4 0.9

Percent of Women Reached by Activities

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When asked who gave them counseling most of the names given were either CARE field staff, or the local midwife. In only a very few cases did the mother mention the name of a kader who had been trained for counseling.

Women were also asked if they had participated in an MTMSG in the last month or last six months. Very few mothers said they had joined a group. Not even one percent in the last month, and only 7% in the last six months.

This low coverage is not a surprise because these project activities have not been fully implemented in the Prima Bina area. At the time of the MTR, the project has not yet completed training of MTMSG facilitators or of CFA counselors. Out of 23 villages in the project area, MTMSG training has only taken place for 14 villages, and CFA training in 4 villages. No facilitators or counselors have yet been trained in five villages. Not only have these activities not been implemented yet in all project villages, but within each village, not all areas are covered. Project villages are divided into sub-village areas (posyandu catchment areas) and training has been completed so far for selected posyandu areas only. To better understand this limitation, the Prima Bina team compared locations randomly sampled in the survey with mapping of the areas covered by project training activities (where we could expect mothers to participate in or receive services). This comparison shows that, at the time of the MTR survey, just over half of the survey locations (56%) were in posyandu areas covered by project-trained facilitators or counselors. This also differs substantially from one SA to another, so comparisons cannot be made between SAs.

Locations Type of Training TTU SA1 MTMSG training in 3 villages, CCFA training in 2 villages SA2 MTMSG training in 5 out of 5 villages SA3 CFA training in 2 villages, no training yet in 3 villagesBelu SA1 MTMSG training in 2 villages, no training yet in 1 village SA2 MTMSG training in 1 villages, no training yet in 1 village SA3 MTMSG training in 3 out of 3 villages Total 6 SAs MTMSG training in 14 villages CFA training in 4 villages No training yet in 5 villages

Decision making for mothersThe survey questionnaire included two questions to look at the ability of mothers to make decisions about their own health care or care for their children. These questions were not included in the baseline survey. Results show that a majority of women make these decisions alone or together with their husband. As the second bar in each chart below shows, however in a substantial proportion of families, roughly a quarter, the mothers say that the father makes the decision alone. The primary decision makers appear to be the wife and husband, either individually or jointly. These findings are

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consistent with findings in the FGDs where decisions about child feeding are made primarily by the parents together or by the mother alone.

Mainly Me

Mainly Husb

and

Wife and Husb

and jointly

Mother/Mother in

law

Other0

20

40

60

80

100

32 24 36 6 2

Decision making to seek care for a sick child

Perc

ent

Mainly Me

Mainly Husb

and

Wife and Husb

and jointly

Mother/Mother in

law

Other0

2040

60

80100

4123 26

8 2

Decision making to seek care during pregnancy

Perc

ent

Qualitative Component

The purpose of the qualitative component was to look at coverage and awareness of key program interventions and examine perceptions about key project activities (MTMSGs and CFA counseling activities) and whether they are providing empowerment and social support. The activity consisted of meetings and discussion with Prima Bina staff to understand progress of the project, and FGDs with mothers, fathers, and grandmothers in selected program communities. When possible, discussions were also held with village midwives and kaders to explore the value of project training and experience in their roles as group facilitators and counselors.

Focus Group Process Focus group discussions with mothers, fathers and grandmothers were arranged in three communities: Oenenu Utara and Fatusene in TTU and Kabuna in Belu. Oenenu Utara is a village about a 30 minute drive outside of Kefa, the main district town and just off the main road. Fatusene is tucked up in mountains north of Kefa . Driving takes about one hour on a more rugged mountain road, although villages still have ready access to town. Kabuna is a refugee resettlement area about half an hour outside of Atambua, the district capital.

Discussion guides were designed to stimulate a similar discussion in each group. These are included in Annex E. Key themes for the FGDs included:

Aspirations for their children – to identify what might motivate improved nutrition practices Grasp of key concepts related to success in Exclusive Breastfeeding and Complementary Feeding Household roles and decision-making about feeding children Advice seeking for IYCF problems (sources, credibility) Knowledge of MTMSGs and reasons for mother’s participation or not (disadvantages, barriers,

benefits)13

Participation in other community groups or nutrition activities in the locale Interest in learning and preferred forum for learning opportunities

A total of six FGDs were completed. In Oenenu Utara, FGDs were held with mothers and fathers. In Fatusene, all three FGDs were completed (mothers, fathers and grandmothers), and in Kabuna only the mothers’ FGD was possible. For the FGDs not held, attempts were made but invited participants did not turn up. In Oenenu Utara, three attempts were made to arrange FGDs with grandmothers but it was peak planting season and women were too busy and not available regardless of the time scheduled. In Kabuna, three attempts were made but the men, most of whom work long hours as motorcycle taxi drivers, were too busy earning a living.

VillageLocation District Project Activity Type of Discussion GroupMother Father Grandmother

Oenenu Utara TTU MTMSG v vFatusene TTU CFA v v vKabuna Belu MTMSG v

In all, a total of 18 mothers, 11 fathers and 2 grandmothers participated in group discussions. Almost all of the mothers had children under the age of one. The mothers’ groups included both women who had and had not participated in MTMSGs and counseling activities. To a large extent, participants in the father and grandmother groups were from same families as the women in the mothers’ groups.

Findings from Focus Groups

o Aspirations for children– to identify what might motivate improved nutrition practices (big benefits)

Participants were asked what they envision for their children in the future and about their hopes and dreams. Though this seemed a strange question to participants at first, the group was guided through a brief visioning process after which the discussion flowed. A strong theme on education emerged: parents and grandparents in all groups felt strongly that their child get the best education possible so they could get a good job and support themselves and their families in the future. Several parents wished for their children to have better opportunities than they had themselves, and parents in two locations stressed that children had a choice - with education children could be whatever they wanted to be.

We want our children to be educated and have a better life.

I want my child to go to school, this is most important so he can get a good job and take care of us.

I want my child to finish school so she can get a respectable job and earn good money

I want my child to go to school and become knowledgeable.

I want my son to finish school so he can be whatever he wants to be

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I want my child to go as high as possible in school, even to university.

When asked whether the food the children eat now was related to this future, groups in all three villages talked about a link between good or nutritious food and brain development or “being smart.”

If the baby eats well, and eats good and healthy foods, the baby will be smart and can go very far in school. – a grandmother

If children eat nutritious food, it will be good for their brain. – mother

Yes there is a connection, we must give nutritious food now, it will be good for the brain. The best food is Asi. – mother

Asi will make my baby healthier, stronger and smarter – mother

If they eat nutritious food they will be smart. If not nutritious the baby will be stupid. – father

Give breastmilk and every month the baby will gain weight – mother

Mothers also talked about the importance of the right foods, and good foods for growth and weight gain. A few talked about avoiding malnutrition. When asked specifically about which foods these were, mothers emphasized Asi, and in all groups there was lengthy discussion about protein sources (eggs, fish, tofu, tempe) and adding fruits and vegetables to the children’s food.

o Grasp of key concepts related to success in Exclusive Breastfeeding

Mothers and fathers in all the discussion groups seemed genuinely convinced that breastmilk is the best food for a child until age six months, and specifically mentioned EBF as the best practice to follow. In groups, parents talked about how in the past, this was not the practice and food was introduced very early, even as early as the first month, but that now this has changed. In two locations, mothers and fathers gave examples of seeing a neighbor’s child be exclusively breastfed and become strong and healthy. In both mothers’ and fathers’ groups in two villages, participants also gave specific examples from their own family contrasting the experience with a more recent child who was exclusively breastfed with an older child who was not. Fathers were aware of EBF, and in one village another motivating factor was “the new rule,” a rule activated by the village authority.6 The grandmothers, however did not seem to be aware of exclusive breastfeeding, and one talked proudly of occasionally giving formula to her grandchild when the mother was away for long periods of work.

For those under six months, only Asi because that is the new rule.- a father

I heard from the kader at posyandu only to give Asi until six months.- a mother

The bidan told me to only give Asi and nothing else until six months , but she never explained why. I will follow her advice because I want my child to be smart, health and not get sick.- a mother

6 Mothers and fathers in one village both spoke about the EBF rule enacted by local leadership. While this provides a social endorsement for this practice and people spoke of a fine for violating the rule, no one could give specific consequences or examples of what happened when someone violated the rule.

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To explore women’s understanding of EBF concepts further, women were asked what a mother should do if she isn’t producing much breast milk. Women responded that the mother needed to drink more liquids, eat more and better quality foods including protein foods (nuts and lentils) and vegetables. Local customs mentioned during formative research were also mentioned here - using hot compresses on the breast or giving hot liquids or food to the mother make the milk flow. No one mentioned anything about frequent suckling and milk production.

We learned from the midwife to drink a lot and eat more hot meals to make the milk flow

During the discussion about common breast problems, one mother mentioned that cracked nipples came from the baby being fed in the wrong position. In another location, the mothers felt that this happened when the baby sucked too long and there was not enough breastmilk.

Parents in all three locations talked about the influence of the child’s grandparents towards early introduction of foods and other liquids, especially when the baby cries and they feel the breast milk is not enough. A mother and father talked about how with the previous child, the grandmother had insisted on starting food at four months and it was sick a lot, but that with this child they waited until six month and this baby has been really healthy. Another father talked about his own mother who had recently learned that it is best to start food at six months not early like before.

Our parents also say to give Asi and to give plain water. But the bidan says to give Asi instead of water.

When my baby was four months old, my husband wanted to start giving food. I said no, the child was not old enough and the kader said to wait until six months. I told him, if you start giving food then you can take him to the next posyandu and face the kader. So he didn’t and I gave the first food at six months.

With my first child, my husband’s mother decided when to start feeding food and gave food before four months. She’s no longer alive now and with this baby I will give food at six months.

o Grasp of key concepts related to Complementary Feeding

Mothers and fathers in all locations had heard the message to start giving food at age six months, and many seem to agree with this advice. However the grandmothers did not appear to be aware of this. Parents also seemed well familiar with the concept that young children need special soft foods and that small quantities should be introduced at first. They explained the recommendation to start with Bubur Saring/Topo or the commercial food SUN at six months, and then graduate to Bubur or Bubur saring at seven to nine months, and other mashed foods including local root crops and yams at age 9 months or one year. Mothers in two locations mentioned that if the food was too stiff or dry, that some liquid should be added to soften it. One of these mothers said she had heard from the bidan to use Asi to thin the food and that this had worked well. Another mother said she had learned about active feeding.

Both mother and father groups talked about other foods, in addition to starches, which should be added to the child’s soft food/bubur saring. Mothers in two of the groups talked of the importance of adding other foods to the bubur, yet there was disagreement among mothers at what age this should start.

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Some mothers felt that other foods should be added to the bubur saring starting at 7 or at 9 months, while others felt that it should be added from the beginning at six months. Mothers in one village stressed the foods to add were fish, tempe, tofu, and leafy green vegetables and another said eggs, carrots and green vegetables. In a different village, mothers agreed and said that bubur saring should be enriched with egg yolk, soft carrot and mashed green leaves with one mother saying she had added hati ayam.

When asked, fathers’ responses were consistent with the mothers’ - dark grean leafy vegetables and yams. In one group, a father said it was better not to give leafy vegetables because this can cause diarrhea while others disagreed and told him that their children were given greens with no problems. Another father piped up that carrots were tastey and soft and good to give. In Fatusene there was a lively discussion comparing feeding practices now (bubur saring) and in the past (bubur made from corn, and roasted root crops), with some fathers sharing strong opinions that in the past, when root crops were prepared for the child it made children grow strong. Those fathers with more than one child, had much stronger opinions and showed more confidence when discussing topics about child feeding than the fathers for whom this was the first child.

The grandmothers also mentioned that the young child needed more than just bubur saring or a rice-based food and said that when she had the money she would buy fish or carrots from the market so her grandchild could eat well. The grandmother also mentioned that with bubur saring mixed with infant formula is good because her grandchild had little appetite for bubur saring alone.

Another topic which engaged lively discussion was the topic of SUN – a commercial powdered weaning food which without prompting came out in all six FGD discussions. Cans of SUN was seen clearly displayed in village and nearby shops in most of the survey locations. In two villages, mothers and fathers mentioned that SUN had been recommended by neighbors as the best first food for children. In one location, some mothers said the bidan had recommended SUN for age six months,7 and then bubur saring starting at age seven months. Some parents felt that if you had the money, bubur SUN was good. One mother mentioned that SUN is quick and easy, besides that’s what the other people around me do. Several fathers and the grandmothers explained SUN was good because it was convenient and easy to prepare, and because it was a powder and easy to digest. However, in both the mother and father FGDs in the same village, some parents disagreed and felt strongly that SUN was not good for children. One mother said that because it’s mixed with water it would give her child diarrhea, while another said it was hard on the stomach and would cause constipation. Some participants in both the mother and father-groups said that they had heard from the bidan, kader or NGO workers that SUN will give side effects, and that it is full of preservatives and chemicals not good for a young child. In one village, the mother had learned from the posyandu that SUN was unnecessary and that home foods were better.

o Household decision-making and family roles about feeding children

7 There was conflicting information about the bidan’s advice in the same FGD. The Prima Bidan staff wonder if there had been some misunderstanding due to language problems since the recent bidan did not speak the local language.

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Most of the mothers participating in the FGDs said that they did not live with their mother or mother-in-law, although in some cases the child’s grandparents lived nearby. Mothers said that both they alone, or together with their husbands, made decisions about child feeding.8 Yet, fathers felt that this was the wife’s role and that she alone made all child feeding decisions. In both groups, some fathers expressed very confidently that their wife already knew what to do and to take good care of his child. These were fathers with more than one child.

Mothers and fathers both explained that in the past, elder parents in the household had more influence on how a young child is fed, but that is no longer the case today.9 They talked about how mothers had learned new information about feeding from the kaders, posyandu or bidan, and even if it meant going against advice from their mother or mother-in-law, the many women managed to follow this new advice. In some cases, fathers and grandmothers were also aware and had accepted the new advice.

My wife knows how to raise my child, she knows what foods to prepare

When my child was four months old, I thought it was time to start giving food. I asked my mother-in-law and she said to wait until six months.

Before when the baby cried, we’d give topo. Now my wife decides, she learned from CARE and PLAN and DHO so we don’t do that anymore.

Still, the mothers and fathers do consult their parents for advice and in one village, fathers said that this was still a strong influence on family practices.

When asked about their role in child feeding, grandmothers said that their role was to help the mother, such as heating water for a bath and holding the baby while she’s working, and to buy extra food for the family when they could. They talked about going to the field or to the market to by rice, vegetables, fish and carrots because these were good for the baby.

If the family runs out of milk, then I will buy more milk

Fathers felt that child feeding was the mother’s role and saw their role is one of support. Their primary role was to bring the food from the field and some fathers mentioned that they might help the mother with washing or collecting water. Usually the mother fed the child although in both groups there were a few fathers who said that sometimes they feed the child. In one group, some of the fathers replied nervously that the mother always feeds the child, that they were afraid they would do something wrong and the baby would choke. These were young men and new fathers. Only one father, who had worked a while in Jakarta, mentioned that he helped the mother to prepare food.

o Advice seeking for IYCF problems (sources and credibility)

To explore further the role of others to influence mothers, and to elicit mothers’ perception of credible sources of information about breastfeeding issues, mothers were asked where they would seek advice about sore or cracked nipples. Since few mothers had had this problem, we asked about this situation 8 In two villages both responses were given, but in Kabuna women said they were the prime decision makers.9 In the rural areas, both mothers (of children over age 3 or 4 months) and the grandmothers go to work in the field.

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hypothetically and also asked where she would seek advice for a problem like engorged breasts. The answers for both problems were the same. In one village, women would ask the bidan, or ask the kader who they said would refer them to the bidan, while in the other two villages, women talked only of seeking advice from their mothers. One woman said she sought help from her sister who was a kader. Women talked about having learned information about breastfeeding from the bidan, and one woman talked of what she had learned from a CARE facilitator, but for help with a problem most women first consult their own mothers or family members.

When asked about who they would go to for advice on feeding of food to their young child, women in all three villages first mentioned a neighbor or family member. A few women also talked about seeking advice from the kader and one mother told how she had identified a successful mother at the posyandu and had sought her suggestions and advice. The bidan and kader at posyandu were mentioned as sources of information but not necessarily resources for problem solving or advice. In two of the locations, women and men recalled that the posyandu had held cooking demonstration about preparing enriched porridge for young children.

o Knowledge of MTMSG and why or why not mothers participate

Women were vaguely aware of the Mother Groups. When probed, they didn’t know when it started, why it exists or what its function is. They only knew that mothers gather together and “chit chat”. In one FGD, the facilitator had to probe quite a bit before one mother started talking about the arisan group which meets after the posyandu and where mothers discuss how to feed the child. She said that the group had 15 members, and had met three times.

Mothers sit together and talk talk talk.

They chit chat, I don’t know what they do.

Fathers didn’t know anything about the groups. They knew about the posyandu and that CARE and WVI had done group activities in the village but they said their wives never tell them about what does on in these groups. One father did recognize the group and mentioned that his wife had gone once when she was pregnant, but that was all he knew.

Only a few mothers had participated in the groups, three in one location and one in the other. In one village, the women had only attended once several months ago. They said they went because they got an invitation for the first time, but they didn’t receive another invitation and didn’t know there were any more meetings. One said she went to a second meeting, but the facilitator didn’t show up and another said she didn’t see the purpose of women sitting around for a chit chat. One woman recalled some discussion about initiation of feeding and to give food at six months, and another talked about sharing with women which she felt was useful. In the other location, only one woman had joined the group at the invitation of the kader and had attended twice where women shared their experiences with feeding their children. She said she had learned from the group about how to position the baby for breastfeeding, and the importance to relax and reduce stress to aid breastfeeding.

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Women said they liked the support provided by other women in the group, and one said that the group provided an opportunity for women to share with each other how they had overcome challenges, not only on child feeding but on other subjects of concern. However, mothers in one group were concerned at how the group was perceived by non-members – and that villagers might think that women were gossiping about others and would cause some discord.10

It’s hard to have group meetings here because others think we are gossiping and talking about them.

Women who had not attended the MTMSG had not heard about the group and said they had not attended because they not been invited. FGD participants in Kabuna who had never heard of the group before and said they would like to join. No one in either FGD knew who was invited to join the MTMSGs, why these mothers were selected or who were eligible to join the groups.

In the father and grandmother FGDs, with such a lack of awareness, it was very difficult to elicit any opinions about the MTMSG, the advantages, disadvantages and barriers.

o Knowledge and experience with individual counseling in the CFA areaFGDs were conducted in Fatusene where a kader had been trained to do house to house visits for counseling. Discussions with mothers confirmed that home visits started shortly after the CFA training and initially the kader and CARE Community Facilitator visited homes together. Five of the six mothers in the discussion group had been visited and most said they received monthly visits and counseling for the first few months, but that visits had stopped about three months ago.

Women talked about being visited during pregnancy and getting information about breastfeeding and how food that the mother ate helped the baby to grow in the womb. One talked about being visited the day after delivery to ensure that the baby had started breastfeeding. Some mothers talked about learning about EBF and to start giving bubur saring at 6 months. Women said they liked having the counselor visit as long as they were not busy at the time, and they enjoyed getting new information.

Fathers did not appear to be aware of any counseling visits, but that is not a surprise since they are not home during the day. One of the grandmothers was aware that someone came to talk to her daughter about feeding the baby but she did not know what happened during the visit or what was discussed. She mentioned only the CARE facilitator but not the kader who had come for the visit.

o Participation in other community groups, knowledge of other nutrition activities Though the FGD did not look specifically at posyandu attendance, participants in all the discussion groups, without any prompting, talked about the posyandu and the kaders as a key source of information about child feeding. Both mothers and fathers mentioned that their children attended the monthly posyandu and talked about specific information or messages they had heard during education sessions at the posyandu. Parents talked about specific messages to reinforce exclusive breastfeeding and emphasis to wait until age six months to introduce foods. From discussions with both mother and father groups, it appears that information learned from the posyandu had empowered some women to 10 This women was from a refugee area where there was already some suspicion and distrust among neighbors.

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go against the usual family practice to introduce food early. In one area, the motivation was linked to worry over the kader’s negative reaction if she introduced food to early and this caused her child not to gain weight appropriately. Parents also made a clear link between the food that the child consumed, whether they followed the kader’s or bidan’s advice and whether their child gained weight each month. In two areas, mothers enthusiastically recalled cooking demonstrations or practice sessions at the posyandu and what they had learned about adding additional foods to enrich the bubur. One woman explained that the emphasis was on using foods already in the home.

Beyond this, FGD facilitators had a difficult time eliciting more information about other nutrition activities or group activities in the community. In one village, women talked about a women’s group which was a farmers group, and some of the activities focused on making different products from the crops they grow (jamu, coconut oil, snack foods). The village also had men farmers’ group. Both mothers and fathers in this same village also talked enthusiastically about cooking demonstrations on preparing healthy food for children. This was an activity done by a local NGO YMTM supported by PLAN, and with more probing was found to have occurred more than a year ago.

o Interest in learning and preferred form for learning opportunities

Mothers in all groups were eager to learn more, especially about first foods for children and how to prepare healthy foods. Some had been exposed to cooking demonstrations before, had found them useful and fun, and were eager to gain more experience and practice with such sessions. While mothers showed confidence when discussing breastfeeding, they seemed less confident when talking about giving foods for their children. Grandmothers also wanted to learn more about preparing good food for their grandchild so that they could help and support their daughter more.

I want to learn more about healthy foods, and about how to cook good food for my baby

It’s good to learn something new. I want to learn a good way to feed my baby especially what food to prepare.

I want to learn about good foods for children and about how to cook it. I want to get more experience by cooking demonstration.

Many fathers were also very keen to learn more about child feeding, especially about preparing foods. Fathers were particularly interested in what mixtures of foods were good for young children and said that they would like to learn to cook. In both groups, fathers with only one child were eager to learn about child feeding, while those with three or four children felt that their wives were experienced and already knew what they needed about child feeding.

I want to learn because I don’t know. This is my first child, my wife is breastfeeding now but we need to know what foods to give at 6 months.

I want to learn so that I know that me and my wife are doing the right thing.

I want to learn how to cook food with vegetables and proper mixtures.

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When asked about the types of activities to offer such learning opportunities, mothers and fathers in two locations suggested cooking demonstrations. They explained that this approach had been effective in the past for mothers and found them to be fun. Mothers and fathers in two villages thought that sessions could be arranged with women’s and men’s farmers groups, but thought that any sessions organized using a hands on approach would be of interest and well attended. In the other location, mothers said that any learning opportunity would work well if organized with groups of women.

Conclusions from the Focus Groups

o Key motivations and motivating factors for IYCF

Parents already recognize a “big benefit” of EBF and good child feeding practices. A child’s education is highly regarded and seen as a link to good opportunities in the future, and some parents understand the link between child feeding and brain development and the capacity to learn. This desire can be a strong motivating factor for promoting optimum feeding practices.

The communities also have experience with practices like EBF and waiting until six months to introduce food. Not only have parents found these practices feasible, but some have also noted benefits (effectiveness) of following these practices. Parents gave examples of positive outcomes with their own child compared to previous children, or talked about the benefits they had seen with a neighbor’s child such as not being sick, and growing healthy and strong. Such examples “make it real” and can motivate more tentative parents to try the new practice. This also suggests that using role models and peer support can be an effective approach.

Community members have already been exposed to the key IYCF messages and parents have basic knowledge of the practices being promoted. They know about EBF, to introduce food at six months and that nutritious foods should be added to the child’s bubur. Only grandmothers were less aware of feeding recommendations and since they are who mothers often first turn to for advice, they are an important secondary target for key messages.

Findings also suggest that perceived social norms are changing – especially introduction of foods at six months instead of earlier. Early introduction which used to be the norm is now discouraged by bidans, kaders and knowledgeable mothers. At the same time, women say they learn from their neighbors and follow what their own family and neighbor’s advice. For example, giving water and infant formula are barriers to EBF and used to be common practice. Though less common now, they are still being recommended by grandmothers or practiced by neighbors which influences what mothers will do. For this reason, it is important to expand promotion of IYCF to those from whom mothers seek advice and example.

Building parents confidence and skills with IYCF will help them to adopt recommended behaviors. Mothers seemed confident when talking about breastfeeding but felt they needed to learn more about which foods to prepare and how to prepare good foods for their infant. Fathers expressed the desire to help with child feeding but admitted they did not know what to do, and some were afraid they might do something wrong and hurt their child. Fathers with their first child were especially keen to learn to help

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their wives and make sure their child is well taken care of. Grandmothers wanted to learn more so that they could provide help and support.

o Participation in Counseling and MTMSGs

MTMSGs is used as a major project strategy to reach mothers. Yet, a major barrier to participation is the limited access to the groups, facilitators and meetings. Even in the FGD areas where MTMSGs have been established, only two facilitators have been trained per posyandu and MTMSG membership is limited to 12 women. When MTMSGs are formed from existing groups, mothers who are not already members of that group may not be invited to join. No one really understood about MTMSG groups or how membership is determined. There also doesn’t appear to be any mechanism to ensure that those women who should be the priority for support are invited to join in. The project needs to determine in which communities MTMSGs are most appropriate, and then develop a plan to ensure that most pregnant women and women with infants can participate. In larger communities, this may mean forming more than one support group. Clarifications will also be needed about membership - who is eligible, and whether women phase out at some point and new members join the support group.

A related barrier is the irregularity of meetings with women unclear about when meetings will be held. The project also needs to plan for the role of the CARE Community Facilitator and how they can support MTMSGs without the group facilitators being totally dependent on them to hold the meetings. The project also needs to consider long term plans such as how many groups will be established before the end of the project? Whether groups are expected to continue after the project, and what support is needed in the longer term?

Women who had attended the group meetings highlighted some perceived benefits. They said they had learned things during the MTMSG meeting and liked the peer support. Several women spoke of the reassurance of learning from another mother who had faced a similar problem and found a solution.

The CFA approach appeared to reach more women with women receiving monthly visits in their homes. However these meetings in one location were not continued, and stopped three months ago when the CARE Community Facilitator was transferred to another community. While mothers value the visits as a source of information relevant to childcare, there may be problem with credibility of the kader as the counselor. Mothers spoke more about the CARE facilitator and some didn’t even mention presence of the kader. More exploration is needed about how to increase the credibility of the kader in this role, and how CARE Community Facilitators can best be supportive without creating total dependency.

o Topics for MTMSGs and counseling sessions

While the project has done a good job using MTMSG and counseling visits as an opportunity to share important information about IYCF practices, group discussions and counseling visits need to move beyond the recommendations and focus more on practical details and problem solving. For example: why water is not needed for young infants and how providing food or liquids too early interrupts milk production; what a mother who is working away from the home can do for exclusive breastfeeding; how young children eat and why soft foods need to be of a particular consistency, and problems associated with foods which are too liquid, and how existing family foods can be adapted as suitable

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semi-solid foods. Group facilitators and counselors also need to consider the timing – that the topic of discussion is relevant to the women at the time or in the very near future. For example, it is of little use to discuss initiation of breastfeeding if there are no pregnant women in the group, or about introducing solid foods if the group is a mother with newborns.

o Use of existing community structures and linkages to reinforce messages

The reliance on MTMSGs and CFAs as the major strategies of the project has limitations, especially regarding reach and coverage. Training and supporting counselors and facilitators takes time, and these activities reach only the mothers. Using additional channels (posyandu gatherings, church activities, other groups) to reach more women will help to widen the coverage and reinforce the learning of the group participants.

Grandmothers also play a role and could be reached through farmer’s groups, women’s church groups or special gatherings organized for the project. The project has done some activities to promote the father’s role in IYCF and could do more to more to build the fathers role for support.

Kaders and bidans are seen as a credible source of information on young child feeding. By training kaders as counselors and by working with bidans, the project is strengthening linkages between DOH services and project communities. However, there are more kaders active in the project area. The project could look at how they too could be mobilized to support and reinforce key IYCF messages. Reaching the community through multiple channels will reinforce messages and support behavior change.

Interviews with volunteers and health workers

When the opportunity presented itself, informal discussions were conducted with one bidan and with five kaders in four locations, two locations in each district. The kaders interviewed had all been trained by the project as MTMSG facilitators. Questions were asked to assess knowledge and experience of breastfeeding and complementary feeding, IYCF related issues in their communities, their perspective on training provided by the project and their impressions and experience as facilitators of the MTMSGs.

o Knowledge and Understanding of Issues related to IYCF

The bidan and all of the kaders had been active in the project area for many years, the bidan for more than 10 years, and the kaders for four to eight years. They had all received training from the District Health Office on breastfeeding with several specifically mentioning that they were trained by a certified lactation counselor. All were thoroughly convinced about exclusive breastfeeding, the benefits of exclusive breastfeeding and the importance of waiting until 6 months to introduce food. Only the bidan spoke about correct positioning and what a mother could do to ensure sufficient breastmilk production. In three of the locations, kaders mentioned that the DHO suggested for them to discourage mothers from using SUN and encourage the use of family foods for making complementary foods, and one kader told mothers to be wary about what was added to the SUN. However, in another location the kaders thought SUN was a good food if families could afford it, because it was convenient, delicious and it was more hygienic than regular food because it was made with hot water.

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One kader shared her own convincing experience with exclusive breastfeeding commenting on how strong her baby had grown and how he was never sick. She also was encouraged by the report she had received herself from the MTMSG. Two other kaders shared how convinced they became about exclusive breastfeeding as they watched other mothers have success, how well the babies had grown, how rarely they were sick and how other mothers noticed. One told a story about a four month old child who was given food and then got sick and lost weight and that this experience was a lesson to other mothers. Kaders mentioned that it wasn’t hard to convince mothers to exclusively breastfeed to four months but that between four and six months it became more of a challenge. When the baby cries, families are convinced that the baby is hungry and they want to give food. Also at this age, the mother goes out to the field for work and has little control and the family often ends up giving food. Kaders in two locations talked about the important influence of grandmothers and that they are often the ones pressuring for early introduction of foods. One kader said that she had included fathers and any interested family members in the support group and that she had had a positive experience with grandmothers. Once they understood the importance of exclusive breastfeeding and basic child feeding recommendations they became a strong supporter in the household.

All kaders talked introducing soft mashed food six months, and adding mashed carrots, spinach and vegetables, and how this practice was changing from the old habit of very early introduction even at one month. One emphasized adding egg saying that she informed the family that these foods were more important for the baby than the father. The kaders had all heard the message to feed the child three times a day but several voiced concern that children were not fed enough and that families did not have sufficient food and that sometimes meals were skipped. None of those interviewed knew anything about consistency and quantity of complementary foods although they expressed a strong desire to learn more. They also wanted to learn more about which specific foods are best for young children and how the family could prepare food from what’s available in the home.

o Feedback about Training of MTMSG Facilitators

When asked about the Prima Bina training and training of MTMSG facilitators, all gave positive responses. Some mentioned the technical information on breastfeeding and how this reinforced what they had already learned, and another mentioned that it was a great opportunity to share experiences with other kaders. The aspect most mentioned as beneficial by the kaders were those related personal development. One kader mentioned that it was very useful to learn how to handle emotions and control anger, and three kaders mentioned how useful it was learning to set personal goals and how to prepare themselves and their children for a good future. The process also received positive feedback. One kader talked about the confidence that she had developed, that she learned to speak in front of other people. Others mentioned the valuable communication skills they had learned.

I enjoyed that chance to give my opinion. This is the first time, usually we just sit there and listen to a lecture only.

I learned about behavior and attitude when we go to people’s homes, how to approach the mother. Now we know the right way to do that

Before I was just a teacher and talk too much. From CARE training I learned to listen to mothers and I learn many things.

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I change my behavior as a kader, now I say hello to other people and act more kindly.

o Thoughts about MTMS Groups

Kaders had all facilitated four or five group sessions and discussed how CARE staff had supported them in their role and provided valuable feedback. The venues for the meetings were all different11 and each covered a range of topics. Most groups had included discussions in one or two sessions on infant feeding. Facilitators felt that the group meetings were a worthwhile activity, especially the way they were conducted and how it encouraged women to speak and share experiences. They gave specific examples of how mothers convinced one another to try something new, or follow a recommended practice and how one mother’s positive experience was good motivator for other mothers to try. Several kaders also mentioned that support was not limited just to MTMSG meetings, but that women kept each other informed and supported one another outside of meetings as well. The group process and methods were appreciated by the kaders.

It’s good to have meetings. Mothers share experiences and do group problem solving together

They learn new information. Sharing experience and information is good about how to feed the children. Grandmothers can use it. They talk about what is a good thing and wrong thing to do. This is important because in the past parents started feeding way too early.

The group is very happy with methods we use.

Two of the kaders talked about the initial challenge of getting mothers to talk, that mothers were used to receiving information. With the help of CARE staff, they were able to design some discussion questions to get women talking. All but one of the kaders expressed confidence that group discussions were going well. One kader, from a refugee community, shared some frustration that it was difficult to get women to talk and that women were reluctant to share. Overall the trained facilitators seemed to feel positively about the project training. They felt that both the MTMSG activity and especially the approach used were very useful for both themselves and the mothers in the community.

11 Two groups were with arisan and posyandu meetings, one as an independent group, and another linked to a prayer group meeting.

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Conclusions

1. Survey results show trends which suggest big improvements in key child feeding indicators in the project area. Rates of exclusive breastfeeding and timely initiation of complementary feeding are high, and all the key IYCF indicators appear to be increasing. Even the food diversity indicator, which is known to be a challenge in West Timor appears to be improving. This provides an overall picture that the investments in IYCF made by CARE, partners and other agencies over the years are paying off. Findings from the FGDs are consistent with and support the survey results.

The project Baseline Survey found that IYCF indicators for Belu to be lower than those from TTU. While this is also true for the MTR results, gains are being made in Belu to close this gap.

2. In FGDs, community members, especially mothers, showed a high awareness and knowledge of recommended IYCF practices. They have been well exposed to messages about initiation of breastfeeding, exclusive breastfeeding, introducing foods at six months, and adding nutritious foods to the child’s soft foods. There is also a good level of awareness of the benefits of the recommended practices.

3. When mothers talk about what they’ve learned and advice they’ve received from the facilitators and counselors, this learning appears to be more information based – what should be done and what the benefits are. This is great, but there seems to have been little discussion about practical solutions and problem solving – how mothers can overcome known barriers and what might make the practice easier or more acceptable to do. The MTR results provide information about many of these determining factors which influence mothers’ practices. A focus on these will help to motivate more effectively for behavior change in IYCF.

4. Most of the attention in the project so far has focused primarily on breastfeeding. In the FGDs mothers, fathers and grandmothers expressed an interest to learn more about child feeding, especially about good foods to feed children age 6 to 12 months. Parents also seem to hold a high regard for local foods and foods grown in the community. This interest can provide a platform to address practical ways to improve the quality of foods fed to young children

5. The project’s World Breastfeeding week activities appear to have been effective in getting out key messages of exclusive breastfeeding and the importance of support for the mothers. These activities were referred to during both the quantitative survey and during FGDs as a source of information on child feeding.

6. Coverage of MTMSGs was very low in the survey, but since training of facilitators has only covered about half of posyndu and project area, this is no surprise. Access to group activities appears to be a major barrier as well as a lack of awareness and understanding about the groups. Also, meetings are not held regularly in some areas and some women don’t see the value of the meetings as a good use of their time. Benefits identified are that women feel they receive support and like getting new information,

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and some women enjoyed learning based on the experience of their peers. Another positive finding from the FDGs is that the MTMSGs appear to have gone beyond just providing information, and operate as the methodology intended – a forum for women to discuss and share their experiences, and an opportunity to socialize with others. One kader also mentioned that mothers support one another outside of group meetings, a benefit which may not have been picked up adequately in the survey.

MTMSGs which were integrated with existing groups seemed to be functioning better than newly established groups. However, this also introduces some issues such as whether membership should be open or closed, and whether women without children in the target age group should participate. These issues will need to be addressed.

7. Coverage of individual counseling activities is higher than that of MTMSGs and may be an effective way to reach women, but coverage is still low and few women report monthly visits. Women report counseling visits by bidans and kaders who are perceived as credible sources of information on IYCF. However, these visits still appear to be for purpose of giving information and less for counseling, discussion and problem solving.

8. Both MTMSG and CFA activities were interrupted by the turnover of CARE field staff in August and September which affected the coverage rates. Still, despite these difficulties, the project has continued and appears to be making progress in supporting IYCF behaviors. The project may need to clarify roles and find a way to ensure that community activities are not completely dependent on CARE staff.

9. The training of kaders as group facilitators and counselors makes good use of existing resources known and active in the community. It also provides an opportunity for new information and skills from the project to be used in posyandu interactions and other ongoing DOH activities. Kaders seem to be accepted by mothers in their role as MTMSG facilitators, and are perceived as credible sources of information on IYCF. One question that still needs to be answered for the CFA approach is whether mothers consider kaders acceptable the role of individual counseling in the community.

10. Kaders and bidans are perceived as important source of information and have been effective in promoting breastfeeding practices in the community. Yet few know practical information related to complementary feeding and issues such as food quantity, quality, frequency and consistency. They also have no materials and tools to work with except for the information on the child growth card. Refresher training and counseling tools focused on practical aspects, decision making and how to negotiate for behavior change would be well received and would help to build confidence and skills. More generalized tools on the recommended feeding practices will be of less use since knowledge levels are already high.

11. Most family and child care decisions are made by the mother, the father or by the parents together, and fathers expressed a keen interest to learn and be involved more in child feeding. There may already be existing community groups (farmer’s groups or church groups) as a means to reach out to and involve fathers more.

12. Grandmothers , siblings and neighbors were identified as the first people the mothers turn to for problem solving and advice on child feeding. Training of grandmothers and engaging them to promote

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optimum IYCF practices in the community could change their influence from a barrier to a positive influence.

13. Parents place a lot of emphasis on bubur saring as the first food for young children and this has been promoted heavily in the project area. This consultant has concerns about the consistency and nutritional density of what is being given. If the project decides to focus more in depth on complementary feeding this is an area which would need further research and attention to ensure that recommended foods are nutritionally adequate.

Recommendations

1. Both qualitative and quantitative results suggest that the Window of Opportunity Prima Bina project is making significant improvement in child feeding practices, and that awareness of and exposure to key messages especially those related to breastfeeding is high. At the same time, the MTR found that coverage of key program activities MTMSGs and the community counseling is low because these activities have yet to be fully implemented. With this anomaly, it appears that project improvements are not dependent on the two key strategies and likely are a cumulative result of all of the project activities - orientations, trainings, widespread communication efforts such as the World Breastfeeding Week activities and liaison with posyandu and government health services. The project would do well to document this array of project inputs to learn which approaches have been most effective, what’s made the difference, and how lessons learned can be included in planning for the second half of the project.

2. Prima Bina would also benefit from a clear plan of action for the second half of project. The consultant observed that while project staff understood the end purpose of the project and its activities, there was not a clear sense of specific project goals and targets. The MTR results provide a lot of information and a prime opportunity to assess what has been achieved so far and to clearly define some specific behavioral goals which will be for the remaining months, and then use this as a basis to define the optimum package of activities for achieving these goals.

To this end, Prima Bina would benefit from defining a BCC strategy following a similar process to that in the BEHAVE framework – identifying the specific behavioral objectives, the key primary and secondary target groups for each, key determinants and motivating factors to be addressed, and the corresponding activities to effect these changes. Realistic goals also need to be set given the remaining time of the project and several key questions need to be answered: 1) What level of effort will go towards supporting and sustained current levels of breastfeeding practices? 2) For optimum breastfeeding, which areas are still problematic and need more attention and what is most likely to motivate families towards these practices? And, 3) given the large number of behaviors and sub-behaviors related to complementary feeding, how much of the project emphasis will move towards complementary feeding, and what level of change is realistic in the remaining time of the project? It is not possible to address all areas fully in a limited time, so priorities will need to be determined and activities focused for maximum impact.

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3. Project messages need to be tailored more specifically towards behavior change. MTR results show that awareness and exposure to key breastfeeding messages and some complementary feeding messages is already high. This suggests that it’s time to move beyond giving information and messages and focus on how to change specific practices. Both quantitative and qualitative findings can be used to prioritize current practices and identify the important target groups and motivating factors for the desired behavior change. Staff can also explore further who has adopted and not adopted certain practices and why, and who is most influential. Messages need to focus not just on key messages and benefits but on how to overcome barriers and build skills and confidence for a select group of priority behaviors.

In addition, for the secondary audiences (the key people who will support mothers and families for optimum IYCF practices) the focus needs to move from that of knowledge, “teaching” and giving information, to a more practical and problem solving approach. For example, what works, why it works, what approach will likely be most convince for mothers to try or adhere to the practice, and what mothers/families can do to make the practice easier, more fun and most acceptable to follow. Similarly, what other groups in the community need to be reached? how will they be reached?, and how can existing groups in the community (churches, other NGOs), and existing services such as posyandu and health services and be used more effectively as channels to support families?

4. A focus on coverage for MTMSG and CFA. For the key approaches to influence and support behavior change, the project needs to ensure maximum coverage of these activities. Prima Bina would benefit from a mapping exercise for each district and supervision area, to map the number of groups which have been and will be started, and the CFA contacts which can be achieved, based on the training schedules and resources being developed by the project. In this way, the project can realistically assess what coverage can be achieved by these main two strategies, and look at alternative to reach all target audiences.

On a related note, this consultant observes that while implementation of MTMSGs under the project has been a well implemented and positive experience, the project has also found that balancing quality control and the speed of implementation can be challenging. Because of this, Window’s might give some consideration to use of this approach in shorter duration projects (two and three years), or whether this strategy is better suited for four or five year projects and more long term efforts.

5. To summarize the three recommendations above, it might be helpful for the project to briefly articulate a results-based plan for the remaining months of the project. This could be a process of sharing MTR results with partners, reviewing key findings of this MTR report, and using the information to clearly define program objectives and specific targets as well as key emphasis areas and major activities to be undertaken. A corresponding and simple M&E system would also be beneficial, one specific to Prima Bina which focuses on expected results of project activities and not just on activities and inputs. This exercise could be used as a basis to simplify the current M&E system, decrease some of

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the reporting burden and provide managers with an effective tool to monitor both progress towards key objectives as well as status of implementation.

6. It would be worthwhile for Prima Bina to collect and assess available tools and materials already existing in country for breastfeeding and complementary feeding and consider adapting and expanding on these as tools for the project. Mercy Corps and other groups have some good tools and training materials for breastfeeding. Through work of The Weaning Project (USAID/Manoff International) and HKI and other groups, Indonesia has a wealth of experience of work in complementary feeding however since this was done in the late 1980s and early 1990s much has been forgotten. Materials and tools from these projects still exist and some have a very practical approach, emphasize local foods and adapting family foods for complementary feeding. In addition, there are also some very practical tools which have been effectively used in projects internationally which might be useful as examples for this project. These include the Freedom from Hunger health education curriculum on IYCF for working with mother’s groups, and the recently published ENA messages guide which distills more than 10 years of experience of the Linkages and Basics Projects.

7. In Indonesia, with the Ministry of Health and Presidential mandate to address the high rates of stunting in the country, infant feeding and especially complementary feeding is fast becoming a high priority area for intervention in Child Health. With effective strategies and useful tools in this area, CARE will be well placed to provide much needed local experience and valuable resources to be picked up by MOH and other organizations. Prima Bina is well positioned to make a major contribution in the country and some planning and emphasis is needed, not only ensuring ongoing support to the program from Jakarta and HQ, but also budgeting and planning for dissemination and sharing of experience and effective tools and approaches.

8. The process followed for the MTR was efficient and effective with due attention to quality control provided by project managers and staff. However, there were a few lessons learned from the experience which can apply to future evaluation work:

Conducting the quantitative survey and qualitative work at the same time is not recommended. The logistical support required for proper supervision of the quantitative survey severely limited the flexibility of the schedule for qualitative work, and there was insufficient staff to be split between the two activities. Another benefit of doing these activities at different times is that the qualitative work can probe to find additional information to explain some of the quantitative findings, or the other way round. If both activities are done at the same time, this opportunity for eliciting additional and more detailed information is missed.

The quantitative questionnaire needs to be translated and back translated carefully to ensure that questions are phrased correctly. All effort should be made to ensure that women are interviewed in the language in which they are most comfortable. During training, it would be helpful to review phrasing in tribal languages to ensure consistency among interviewers. Also, more attention is needed during both training and supervision to ensure that interviewers follow the questions and ask questions consistently. The supervision approach and quality control worked very well and is recommended for future surveys.

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For the qualitative work, experienced FGD facilitators with capacity in the local language is critical for sufficient probing and to pick up the nuances in the discussions. The approach used during the MTR with listeners and note takers and the discussion groups afterwards worked very well.

Appendices

A. Quantitative survey instrument with frequency results

B. Quantitative methodology

C. LQAS Sampling Framework

D. Schedule for mid-term review

E. Qualitative discussion guides

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