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Background: We designed and tested an intervention that used dialogue-based groups to engage infants’ fathers and grandmothers to support optimal infant feeding practices. The study’s aim was to test the effectiveness of increased social support by key household influencers on improving mothers’ complementary feeding practices. Methods: Using a quasi-experimental design, we enrolled mothers, fathers, and grandmothers from households with infants 6-9 months old in 3 rural communities (1 intervention arm with fathers, 1 intervention arm with grandmothers, and 1 comparison arm) in western Kenya. We engaged 79 grandmothers and 85 fathers in separate dialogue groups for 6 months from January to July 2012. They received information on health and nutrition and were encouraged to provide social support to mothers (defined as specific physical actions in the past 2 weeks or material support actions in the past month).We conducted a baseline household survey in December 2011 in the 3 communities and returned to the same households in July 2012 for an endline survey. We used a difference-in-difference (DiD) approach and logistic regression to evaluate the intervention. Results: We surveyed 554 people at baseline (258 mothers, 165 grandmothers, and 131 fathers) and 509 participants at endline. The percentage of mothers who reported receiving 5 or more social support actions (of a possible 12) ranged from 58% to 66% at baseline in the 3 groups. By endline, the percentage had increased by 25.8 percentage points (P=.002) and 32.7 percentage points (P=.001) more in the father and the grandmother intervention group, respectively, than in the comparison group. As the number of social support actions increased in the 3 groups, the likelihood of a mother reporting that she had fed her infant the minimum number of meals in the past 24 hours also increased between baseline and endline (odds ratio [OR], 1.14; confidence interval [CI], 1.00 to 1.30; P=.047). When taking into account the interaction effects of intervention area and increasing social support over time, we found a significant association in the grandmother intervention area on dietary diversity (OR, 1.19; CI, 1.01 to 1.40; P=.04). No significant effects were found on minimum acceptable diet. Conclusion: Engaging fathers and grandmothers of infants to improve their knowledge of optimal infant feeding practices and to encourage provision of social support to mothers could help improve some feeding practices. Future studies should engage all key household influencers in a family-centered approach to practice and support infant feeding recommendations.
We conducted a multi-phased, multi-method study between June 2010 and July 2012 (Figure 2), which included the following components: Study Timeline Source: Thuita et al., 2015 31 A father in western Kenya feeds his child. Household members such as fathers and grandmothers often exert social influences on a mother’s adoption of optimal infant feeding practices. This paper reports on the 2 quantitative surveys (baseline and endline), which constituted the impact evaluation. We used a quasi-experimental panel study design with a comparison group that included the survey of the same households. We also used pre- and post-intervention observations of fathers’ and grandmothers’ knowledge of infant feeding practices and provision of social support as well as mothers’ knowledge, practices, and receipt of social support. Study sites were selected in 3 sub-locations in 3 districts of Vihiga County in western Kenya. Vihiga County is a densely populated rural area that produces tea and vegetables (commonly, maize and beans).32 Interventions were implemented in 2 sub-locations: Kitagwa, Hamisi District, for fathers, and Viguru, Vihiga District, for grandmothers. Findings in these sub-locations were compared with those in Mambai, Emuhaya District, which did not receive any intervention. The study sites were selected based on discussions with personnel from the Ministry of Health (MOH) and staff from the AIDS, Population and Health Integrated Assistance Plus (APHIAplus) Western Kenya Project funded by the United States Agency for International Development (USAID). Selection criteria included the presence of a functional community health unit and APHIAplus Western Kenya community-level activities. A functional community health unit is comprised of an employed community health extension worker (CHEW) who works out of a health center or dispensary and supervises a group of volunteer community health workers (CHWs). These CHWs form community health committees and elect their leaders. In functional units, CHWs and committees are actively providing and overseeing community health surveys. Subsequent baseline survey findings showed that the 3 areas were similar culturally and socially, as well as in regard to residents’ livelihood activities. The comparison area, Mambai, is approximately 35 km from the intervention areas and had a low likelihood of being affected by spillover from the study sites. A full description of the study design and behavior change interventions is provided elsewhere.31,33 We followed 3 different groups of study participants from the 3 sub-locations: We conducted pre- and post-intervention observations of the 3 groups. We selected only households that were willing to participate and that had a child between 6 and 9 months of age. We hypothesized that the 2 intervention groups would report greater social support from the fathers and grandmothers who were engaged, resulting in greater improvements in mothers’ complementary feeding practices, than in the comparison group. The study was approved by the PATH Research Ethics Committee and the Kenyatta National Hospital/University of Nairobi Ethics and Research Committee. Research assistants reviewed informed consent protocols in the local language or in Kiswahili with the study participants and secured verbal consent before conducting interviews. The research assistants signed a standardized statement that they had followed the protocol for each interview. Prior to the intervention, the study team conducted a literature review and a qualitative formative assessment to understand the maternal and child nutrition knowledge and practices of mothers, fathers, and grandmothers.20,22 The formative assessment included separate focus group discussions with fathers and grandmothers of children under 2 years of age. Key informant interviews were conducted with community and religious leaders, MOH officers, CHEWs, and women’s group leaders, to explore culturally relevant ways to engage fathers and grandmothers in nutrition interventions.22 Using the findings from the formative research, we designed key messages for fathers and grandmothers in households in western Kenya. As per World Health Organization (WHO) and Kenya government infant feeding guidelines,34,35 messages focused on complementary feeding practices, appropriate consistency and variety of foods to be fed to infants (6 to 23 months), age-appropriate meal frequency, and the need for animal-source foods in a child’s diet. Diet diversity and frequent consumption of animal-source foods for pregnant and lactating women were also promoted. We emphasized social support actions that enabled mothers to get adequate rest and seek health services, as well as the provision of foodstuff by fathers and grandmothers. We used peer dialogue groups to facilitate behavior change among fathers and grandmothers by helping them gain new knowledge, share experiences and reflections, and apply communication and problem-solving skills that in turn would facilitate behavior change in mothers.36,37 We used existing volunteer multi-purpose CHWs operating in the targeted communities and community health units to support the intervention. Each CHW covers 10 to 15 households. To enhance services to the communities, the government encourages development partners to work with CHWs in their sub-location. The CHWs in the 3 study areas conducted a census of households with children 6 to 9 months of age with paternal grandmothers living nearby. Based on the census, we identified and invited mothers, grandmothers, and fathers from a random selection of households in the intervention areas to participate in separate dialogue groups of 8 to 12 participants each. To clearly demonstrate the impact of knowledge and actions of grandmothers and fathers on feeding practices, mothers of the targeted communities were not engaged in dialogue group activities. In sum, 18 dialogue groups were formed, with 79 grandmothers participating in 10 groups in the Viguru sub-location and 85 fathers participating in 8 groups in the Kitagwa sub-location. The study team designed separate curricula for training fathers and grandmothers, protocols for training CHWs and dialogue group mentors, and dialogue group discussion guides.38-41 Key messages were incorporated into the core intervention package. Each dialogue group selected one of its members to serve as the group mentor. Mentors were not required to have a certain level of education, but most had at least primary school education. Volunteer CHWs assisted those mentors that were illiterate, for example, to complete monthly reports. Over a 5-day period, mentors were trained in nutrition and health, social support, intrafamilial communication, and gender norms (Box 1). During dialogue group mentor training, trainers modeled adult learning methods, including activities and techniques to encourage participation, experience sharing, and critical reflection by making connections to participant experiences, which mentors then practiced.31 Dialogue group mentors were trained in the use of discussion guides and materials and group facilitation techniques.38,40 The mentors received dialogue group facilitation guides with maternal and child nutrition content as well as step-by-step instructions for facilitating activities and probing questions to encourage discussion with their group members.39,41 Before each meeting, mentors selected the discussion topic based on member interest and then facilitated discussions and activities with group members to promote their role supporting recommended nutrition practices, improving relationships and communication with mothers, and for fathers, reflecting on gender norms.33 Group members also participated in role plays, problem solving activities, storytelling, and cooking demonstrations; grandmothers also composed songs promoting recommended practices.32,33 A volunteer CHW was assigned to each dialogue group to provide support and monitor group activities. Each dialogue group met twice a month for 6 months between January and June 2012. According to members’ preferences, the father groups met in schools, churches, or sometimes homes, whereas the grandmother groups most often met in members’ homes. A small allowance was given to each participant to cater for tea during group meetings (approximately US$1 per meeting, or $2 per month). (The government recommends giving a maximum of $20 per month as an allowance to CHWs engaged in enhanced community health activities.) The participants preferred to receive cash instead of refreshments. Mentors facilitated dialogue groups using the discussion guides and associated materials.39,41 Members learned about optimal maternal and young child nutrition practices and the role that fathers or grandmothers could play in supporting recommended nutritional practices. They learned and practiced new communication and behavioral skills to support optimal maternal, infant, and young child feeding in their homes and to improve conflict resolution within families.39,41 Members were encouraged to share the information and provide support to mothers in appropriate ways. Dialogue groups fostered discussions in which members shared their experiences and strategies to promote improved nutrition practices in their households.32 CHWs supported the dialogue group mentors and closely monitored the groups to assure the quality and accuracy of the information discussed. Each intervention area had 2 paid government CHEWs who oversaw the work of the CHWs and dialogue groups. To provide continual quality control, CHEWs held monthly review meetings with the CHWs and dialogue group mentors. Grandmothers and fathers participating in dialogue groups learned about optimal maternal and young child nutrition practices and the roles they could play in supporting recommended practices. Other community mobilization activities were conducted in each study intervention area. These activities included 2 family bazaars (one in each intervention area) where fathers and grandmothers showcased what they were learning through songs, skits, dances, and testimonials. Representatives from the MOH in western Kenya, local leadership, religious leaders, and staff of development partners attended each bazaar along with community members. Dialogue group participants urged other community members to support the mothers to improve nutrition in their households. Mothers gave testimonials of improved familial relationships and increased provision of nutritious foods by their husbands and mothers-in-law. Food demonstration tents promoted dietary diversity coupled with a display of locally available highly nutritious foods for pregnant and lactating mothers and children under 2 years of age. Five “Fathers Days” were held at local clinics to increase men’s comfort and understanding of maternal and child health services. These Fathers Days were hosted by health facility staff and included health talks by male CHEWs. Fathers were encouraged to accompany their wives and children to the clinic and participate in growth monitoring sessions, and they were given opportunities to ask questions and receive advice from health staff. There were no dialogue groups in the comparison area. Following the baseline survey, mothers in all 3 locations received 1 home counseling visit from a CHW on maternal and child nutrition. At the end of the visit, the CHWs gave brochures with key messages to each mother in the sample. The mothers were surveyed at baseline and endline to assess any changes in their knowledge and practices that may have been positively influenced by grandmothers or fathers (see below). In December 2011, the study team conducted a household interview survey (baseline) in each of the 3 communities. Using the community census completed by CHWs to identify eligible households, we randomly selected 86 households from each of the 3 communities to achieve a final sample of 69 participants in each group. (Surveyed households were the same households that were included in the intervention and comparison groups.) At endline, we returned to the same households covered at baseline and interviewed those who were available. Findings from the formative research guided the development of survey tools.20-23 We developed separate tools for interviewing mothers, fathers, and grandmothers. We assessed knowledge and practices of mothers, fathers, and grandmothers in relation to breastfeeding and complementary feeding. In addition, we assessed the quantity of social support provided by grandmothers and fathers in all 3 communities as well as mothers’ perceptions of the social support they received from fathers and grandmothers. For the endline survey conducted in July 2012, research team members interviewed grandmothers, fathers, and mothers in their homes. These family members were from the same eligible households that were recruited at baseline. They assessed grandmothers’ and fathers’ knowledge and provision of social support as well as mothers’ knowledge, infant feeding practices, and receipt of social support. Social support is a multidimensional construct. In this study we included 2 domains of social support: receipt of social support (as reported by mothers only) and provision of social support (as reported by grandmothers and fathers). An overall social support index was generated based on responses to questions about specific social support actions over a specified period of time (Box 2). Grandmothers and fathers were asked in the baseline and endline surveys whether they had provided any support actions to mothers. Mothers were asked about the support actions they had received from the grandmothers and fathers during the past 2 weeks. Based on the formative research and on previous research by the lead author in Nairobi, Kenya,5,22 the index was initially categorized based on the total reported number of social support actions provided to mothers and the number of each of the following types of support: Based on previous infant feeding research conducted in Kenya,5,22 we included a number of questions in the baseline and endline questionnaires to assess social support provided to mothers of infants by the fathers or grandmothers of the infants. The questions comprised 9 key social support actions conducted for the mother in the 2 weeks preceding the study and 3 material support actions conducted in the past month, as follows. Past 2 weeks: Past month: Social support provided to mothers could range from accompanying the mother to a clinic and helping with shopping to providing money to buy food. For this study, we focused on the material, financial, and physical support actions that were more likely to be provided by both fathers and grandmothers. These actions are more dynamic than the other measures, which showed no variability between groups. In this study, complementary feeding practices were dependent variables. We assessed knowledge and practices of complementary feeding for infants 6 to 9 months of age (baseline) and repeated the assessment for the same households when infants were 9 to 18 months old (endline). The discrepancies in ages (not exactly 6 months after the baseline) were due to the reported age by the mothers and not actual birth dates. We assessed the following practices: We constructed a socioeconomic status (SES) index using information collected on durable asset ownership, household possessions (such as clock, radio, television, farm animals, and mobile phones), access to a sanitation facility, and source of water. Initial descriptive analyses were carried out for all of these variables, assessing means and frequencies to help inform decisions on which variables to include in the analysis. Factor analysis was then used to generate a wealth score, which was divided into 3 categories (lowest, middle, and highest). The dietary diversity indicator was used for sample size computation. At the time of the study design (in 2009), preliminary data on infant feeding practices were gathered from the Kenya Demographic and Health Survey. Among children aged 6 to 23 months in Western Province, an estimated 25% received adequately diverse diets—defined as being fed foods from 4 or more food groups per day.9 We hypothesized that the intervention areas would demonstrate an improvement of 30 percentage points in infant feeding practices, whereas the comparison area would demonstrate an improvement of 5 percentage points. Therefore, the expected proportions of young children with adequate dietary diversity within the intervention and comparison groups would be 54.7% and 29.7%, respectively. Using this information and assuming a 5% significance level and 80% power, we calculated that a sample size of 69 individuals per group would be required to detect a 25% difference between the intervention and comparison groups for a total sample of 483 participants. The sample size computation was done using EpiInfo version 3.5.1. We recruited a total of 7 groups, including 3 groups of mothers (1 for each site; total of 207 mothers); 2 groups of fathers (2 sites only; total of 138); and 2 groups of grandmothers (2 sites only; total of 138). The sample size was subsequently adjusted to 86 for each group (total 602) to accommodate an anticipated 20% loss to follow-up. The baseline analysis included a descriptive analysis of household characteristics and mother/infant characteristics by study site. Indicators for grandmothers, fathers, and mothers/infants were generated and compared across the sites using proportions, mean, or median. Comparisons were made using chi-square tests for categorical variables, and nonparametric tests (Mann-Whitney and Kruskal-Wallis tests) were used where the median was reported as a summary measure. The impact of the intervention was evaluated using a difference-in-difference (DiD) approach (net difference) based on a community-level analysis. This approach considers the difference between baseline and endline in the comparison group versus the difference between baseline and endline in the intervention groups. The DiD odds ratio (OR) is obtained by assessing the difference between the 2 differences. This approach eliminates the difference that may occur over time in the absence of interventions or differences that may be due to sample selection bias.42,43 The significance of the observed DiD was assessed using logistic regression through interaction of study location (representing intervention group) and time period (i.e., baseline or endline). A logistic regression was used to determine if the quantity of social support actions (as reported by mothers) was associated with the minimum number of meals, minimum dietary diversity, and minimum acceptable diet, after adjusting for the study site. Significance levels were set at P<.05.
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