Nudging for nutrition: Utilizing feeding chart to promote complementary feeding

Summary:

Optimal Complementary Feeding (CF) is a proven intervention for reducing malnutrition, but CF practices lag in many countries, including Rwanda. Most interventions rely on health promotion and counseling and there are few alternative tools and strategies available for CF. The Feeding chart (FC), a household-based behavior nudge, is an innovative tool composed of images of caring parents; columns of diverse food groups; age segmentation; and finger-sliding, green/red colored cards to tally daily CF practice. The tool was piloted in two Districts of Rwanda and can be displayed in homes to remind parents to feed children age-appropriate frequent diverse diet daily. Parents use its green-red sliders to indicate food types prepared, and what to prepare for next meal. The pilot testing assessed acceptability, appropriateness and feasibility of the tool. The FC was developed through a collaborative process engaging MoH, national health promotion technical working group, USAID technical advisors, and the national early childhood development program. The FC was piloted in 50 households through focus group discussion (FGD), observation checklist and Likert scale questionnaire to collect participants' perceptions about the tool. Parents used the FC as intended and appreciated its ability to remind them how to feed their children daily; many shared their experiences with neighbors. The FC stimulated family discussions about CF and allocation of financial resources to child feeding. Parents are interested to continue using the FC. FC is more useful for rural than urban communities mainly because the former spend more time in their homes.

Background/Objectives:

The mid-term evaluation of USAID's flagship nutrition project in Rwanda, Gikuriro, showed gaps between knowledge and adoption of optimum CF behaviors. Gikuriro's assessments and program reports have pointed out a need to design an innovative SBC tool to address these gaps and to sustainably improve CF practices. Gikuriro developed a FC, an innovative household-based behavior nudge, a tool composed of images of caring parents; diverse food groups; age segmentation; and finger-sliding, green/red colored cards to tally daily CF practice. This tool was piloted among parents with children 623 months to test acceptability, appropriateness, feasibility and scalability.

Description of Intervention and/or Methods/Design:

The FC was developed through a collaborative process engaging MoH, national health promotion technical working group, technical advisors from USAID and the national early childhood development program. FC consists of images that remind users to feed their children diverse diet with appropriate meal frequency, along with continued breastfeeding. Pictorials remind food groups and promote male engagement. Caregivers use green-red sliders on FC to indicate types of food in each meal and remember what to buy or prepare for the next meal. FCs cost approx. $4 and are provided to target families to display in their homes. CWHs and health staff assessed users' experience during their visits. 50 HHs from Gikuriro beneficiaries from a rural and an urban district were randomly selected to pilot-test the FC. FGD guide, observation checklist and Likert scale questionnaire were used to assess participants' perceptions on acceptability, appropriateness, feasibility and scalability of the FC.

Results/Lessons Learned:

Most participants reported that they liked the FC because it reminded them to provide diverse diet to their children at age-appropriate frequency every day. Many parents reported that it improved communication with their spouse regarding child feeding and resource allocation to acquire diverse foods. Mothers were observed using the FC correctly to prepare a balanced meal and clearly reported applying the tool the previous day. All participants confirmed that the FC is culturally appropriate, and that they will continue to use FC as a reminder for optimum feeding practice. Most also stated that they had shared their new knowledge and practice with neighbors and that the latter were eager to add the FC in their own homes. Some participants reported that limited access to diverse foods and work outside home are hindering factors to the consistent use of the FC to encourage good complementary feeding.

Discussion/Implications for the Field:

The feeding chart is an innovative SBC tool that has been tested and found to be an acceptable, appropriate and valuable household-based behavior nudge to improve complementary feeding practices. It can serve as a useful daily reminder to provide diverse foods at age-appropriate frequency to children 6-23 months. The FC stimulated healthy conversations between couples to promote shared responsibility regarding child feeding, care and decision making over household resources. Preliminary results from the FC pilot indicate that this SBC tool is a cost-effective and scalable tool to improve CF for children 623 months in rural Rwanda.

Abstract submitted by:

Aimable Mbituyimana - Catholic Relief Services (CRS)
Yvonne Serubibi Umurungi - CRS
Alemayehu Gebremariam - CRS