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Influencing the Influencers_Mukuria_5.12.11
1. Influencing the influencers, CORE Group Spring Meeting May 12, 2011 Engaging grandmothers and men: a family-focused approach Altrena Mukuria, DrPH Infant & Young Child Nutrition (IYCN) Project
13. Thank you Please visit www.iycn.org Photo: PATH/Evelyn Hockstein
Editor's Notes
The IYCN Project is primed by PATH with subcontracts with the Manoff Group, CARE, and URC. There are staff from each organization that sit in the PATH offices.
Malnutrition is one of the most important health and welfare problems among infants and young children. Malnutrition is an underlying cause of more than one out of every three child deaths in poor countries each year and a major contributor (11%) to the total global burden of disease according to The Lancet series report. In developing countries, more than 3.5 million mothers and children younger than five die each year worldwide as a result of undernutrition. Malnutrition is a result of both inadequate food intake and illness. Inadequate food intake is a consequence of insufficient food available at the household level, improper feeding practices, or both. Improper feeding practices include both the quality and the quantity of foods offered to young children, as well as the timing of their introduction. Poor sanitation puts young children at increased risk of illness, in particular diarrheal disease, which adversely affects their nutritional status. Both inadequate food intake and poor environmental sanitation reflect underlying social and economic conditions.
Most policies, research and programs on infant and young child nutrition and health in Africa, Asia and Latin America focus on mothers of young children. The results of community interventions with this focus have been disappointing. There is growing recognition that in order to bring about sustained enhancements in household-level nutrition practices there is a need to adopt a wider approach that involves other influential household actors, including senior women, or grandmothers , and men . Grandmothers play a leading role in decision-making related to their various domains of expertise, namely: maternal nutrition; pregnancy and delivery; newborn care and breastfeeding; complementary feeding; home care of sick children; and referral of sick children to traditional and formal health sector specialists. They also serve as the primary care-givers of women and children. Men/fathers are rarely involved in either care giving or advising on these issues. In most cases, the role of husbands/fathers is an indirect and supportive one consisting primarily of providing food for the family and resources to finance logistical and other costs associated with both routine and emergency health care for children and women. Most IYCF programs focus on women of reproductive age and their young children, a few explicitly involve men, and even fewer involve grandmothers.
In Kenya, suboptimal infant and young child feeding practices contribute to high rates of malnutrition, morbidity, and mortality. They also increase the risk of HIV transmission among HIV-exposed infants. About 12.7 percent of infants under six months are exclusively breastfed and 30 percent of Kenyan children aged 6–23 months of age consume a minimum acceptable diet with 45.2 percent being fed with minimum dietary diversity. Diets of children are limited to the foods that are available to the household and according to culturally acceptable foods for children like porridge. Mostly starchy and watered down to soften for ease of feeding. 58.4 percent being fed the minimum meal frequency. Infants under 2 years are fed 3 times a day when they should be fed 4-5 times per day depending on their age. (WHO 2010, Indicators for assessing IYCF practices, part 3: country profiles) Child care and feeding are seen as the domain of mothers as primary caregivers. However feeding practices are strongly influenced by cultural beliefs. Grandmothers are the custodians of these beliefs and are central to propagating social norms. However because of the focus of programs and services on mothers as the primary care-givers, Grandmothers and men often have inadequate knowledge of recommended ways of feeding young children. Roles of males and females are culturally distinct and gender-specific. Male family members are primarily responsible for providing the financial resources for basic household activities, including certain foodstuffs. Grandmothers or elder women serve as advisors to younger women and act as caregivers to women and children. Their role allows them to transmit the rules and procedures or norms that are prescribed within family systems from one generation to the next. For HIV positive mothers and their children this is even further complicated by interventions to reduce MTCT through safer infant feeding practices are weak in Kenya. Mothers are often given poor advice to stop breastfeeding and lack support within their households and communities to carry our optimal feeding practices. Studies have shown that the key influencers to infant feeding practices other than facility-based health workers are mothers-in-law and male partners. Israel-Ballard et al recommended that improved male involvement in infant feeding decision-making would provide the physical and psychosocial support for mothers during the weaning period. So we wanted to demonstrate how to engage men and improve maternal and infant and young child feeding processes and thereby improve maternal dietary practices and complementary feeding practices.
Recognizing these roles and responsibilities in the household and community, IYCN embarked on promoting the inclusion or engagement of grandmothers and men in maternal nutrition and infant and young child feeding by focusing on behavior change in Kenya Our approach is heavily evidenced-based, and we hope to result in an evaluation that will demonstrate how to influence these influencers that will result in improvements in maternal nutrition and infant feeding practices. In 2008, IYCN received Public Health Evaluation funding for a study on infant feeding practices of HIV positive mothers and the infant feeding counseling they received particularly focusing on the transition period from breastfeeding to replacement feeding. Conducted by Kiersten Israel-Ballard. Findings indicated that mother’s infant feeding practices are influenced by key household and community members. Recommendations suggested counseling messages on complementary feeding were needed and engaging grandmothers and men would be important. A review of the literature on IYCF found that there are gaps While there is adequate national level information on the status of IYCF practices in Kenya, there was scanty information on community-level determinants and influencers of maternal dietary and infant and young child feeding practices. Knowledge is high on breastfeeding but practices are not necessarily reflective of this knowledge Knowledge is lacking on complementary feeding. In 2009, more PHE funds were received to follow up on findings Utilizing existing structures of the USAID AIDS, Population and Health Integrated Assistance Project (APHIA II) in Eastern and Western Kenya, IYCN conducted some pilot activities to see if there was interest in engaging men and grandmothers. PATH was involved with Male group leaders in Western Kenya Previously trained in a gendered approach on family responsibility We developed a MIYCN training based on the Engendered Health’s Men as Partners curriculum entitled Men’s as Partners: A Program for Supplementing the Training of Life Skills Educators In Eastern Kenya, PATH was involved with Community Health Workers Conducted a five-day training to sensitize CHW on the roles of grandmothers in MIYCN and how to talk with grandmothers. Conducted group discussions with grandmothers and Pile sorts of foods fed to children Designed and implemented formative research in Eastern and Western Kenya Conducted
Although knowledgeable about breastfeeding practices, less awareness about complementary feeding Grandmothers: are highly esteemed. They are actively involved in the financial and in-kind support or their sons’ families. Grandmothers are frontline caregivers and powerful influencers of related decisions Key to decision related to food preparation and feeding of infants Men: Culturally defined roles of men as father of the family is to provide food, clothing, shelter, school fees, transportation and pay hospital bills Care and feeding of children under two is primarily women’s work, however men listen to the counsel of their mothers who they see as more experienced than their wives. Men are interested in obtaining more information on maternal and child nutrition and health They want the information from trained knowledgeable professionals: health workers, community health workers, teachers
Grandmother-Mother pairs Grandmother dialog groups Father-Mother pairs Male dialog groups Two intervention areas Grandmothers Grandmother/Mother pair Interviewed and counseled together GM dialog groups to meet twice each month for three months facilitated by an existing CHW Plus other community activities Fathers Father/Mother pair Interviewed and counseled together Male dialog groups to meet twice each month for three months facilitated by an existing CHW Plus other community activities Objectives are to improve: Maternal diets—animal source foods Infants diets 6-12 months: diversity, frequency and overall minimum acceptable diet Also looking at thickness of food and responsive feeding See how social support from grandmothers and fathers will influence infant feeding practices and maternal nutrition
Family-centered approach maybe the best way to affect change. Men are not male women. They are concerned about their families and have been a bit marginalized by the public health system and approach Get men more actively involved in maternal and child nutrition through their family roles as leaders and providers Be more supportive of their relationships with their families as fathers, husbands, and sons Advocate for more male-friendly health services and approaches to public health Grandmothers are key family influencers Custodian of norms and caregivers of women and children
Pay attention to the socio-cultural context To influence the influencer you need to know their roles and responsibilities and engage them from their perspective Take the time to review the literature and conduct formative research Adopt a family-focused approach not just the mother-child dyad. View grandmothers and men as resources not just obstacles
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