Complementary Feeding Social and Behavior Change Communication for Fathers and Mothers Improves Children's Consumption of Fish and Eggs and Minimum Meal Frequency in Kaduna State, Nigeria

"A multipronged SBCC intervention improved complementary feeding practices, fathers' and mothers' knowledge of complementary feeding, and fathers' support for complementary feeding, despite low levels of reported exposure..."

At the age of 6 months, breast milk alone is no longer sufficient to meet an infant's nutrient needs. Multiple factors affect complementary feeding practices, such as: parental knowledge, attitudes, and beliefs; household decision making about food purchases; and influence of family members. Mothers are often the priority group for complementary feeding social and behaviour change communication (SBCC) interventions, but fathers can play important roles, including by providing informational, emotional, and instrumental social support for feeding to the mother. This study reports on an intervention designed by the Alive & Thrive (A&T) initiative in Nigeria to engage fathers in Kaduna State to support complementary feeding practices.

The study was conducted in 6 of 12 wards in the Igabi local government area (LGA) of Kaduna State. The 12-month intervention was designed based on formative research. Implemented by the I Care Women and Youth Initiative (ICARE), it used a multipronged approach that included interpersonal communication, community mobilisation, and print and mass media. (TV and radio spots that were part of A&T's overall intervention were also available to participants in this study.)

More specifically:

• Fathers who owned mobile phones received weekly mobile phone messages on complementary feeding through short message service (SMS) text messages and voice prompts (prerecorded voice messages) promoting dietary diversity. They were also reached with messages on complementary feeding through religious leaders and community-based organisations (CBOs). Religious leaders (14 imams and 4 pastors) were trained on complementary feeding and given sermon guides they could use where fathers were present. Also, the leaders of the CBOs were trained on complementary feeding SBCC, including the use of the pamphlets and counseling cards. During their regular CBO meetings, they included short discussions about complementary feeding before starting other activities and provided the pamphlets to members. Complementary feeding posters were placed in strategic locations in communities, including at CBO meeting points, in places of worship, and in health facilities. Although the complementary feeding information shared during religious services and CBO meetings was targeted at fathers, mothers could also participate and hear the messages through these channels.
• Sixty community health extension workers (CHEWs) were trained to conduct at least 2 home visits with each mother of a child aged 6-23 months and were given complementary feeding counseling cards to serve as a guide during their visits. They delivered age-specific complementary feeding messages, provided each household with the A&T feeding bowl (which shows diverse nutritious foods and has markings indicating the quantity of food to feed the child at different ages), and gave copies of the pamphlets to mothers, fathers, and other family members present. If fathers were at home, CHEWs included them in the discussions of complementary feeding.

Cross-sectional population-based surveys of cohabiting fathers and mothers with a child aged 6-23 months were conducted, and regression models were used to compare results at baseline (n = 497) and endline (n = 495). The baseline survey was conducted in June 2019, and the endline survey was conducted from August to September 2020.

Children's minimum dietary diversity did not change from baseline to endline (62% to 65%, P = 0.441). However, children's consumption of fish (36% to 44%, P = 0.012) and eggs (8% to 20%, P = 0.004) and minimum meal frequency (58% to 73%, P < 0.001) increased. Several elements of complementary feeding knowledge differed significantly between the baseline and endline for both fathers and mothers; for example, fathers' and mothers' knowledge of the timing of introduction of different foods and meal frequency improved. Fathers' support for child feeding by providing money for food increased (79% to 90%, P < 0.001).

Fathers' and mothers' reported intervention exposure was low (11-26% across types of SBCC). For example, ICARE's monthly data showed that the percentage of fathers who participated in CBO meetings ranged from 4% to 14%, excluding April and May 2020, when no CBO meetings were held due to the COVID-19 pandemic. Child feeding outcomes were not associated with fathers' intervention exposure. However, children's odds of both fish and egg consumption increased significantly with mothers' exposure to community meetings, religious services, home visits, and television spots, and children's odds of minimum meal frequency increased significantly with mothers' exposure to home visits. "It is possible that fathers' intervention exposure influenced child feeding practices indirectly by providing support to mothers to carry out the practices."

In fact, at endline, more mothers also indicated that fathers offered advice about child feeding, they considered fathers a source of child feeding information or advice, and they said their husband is the person who influences their child feeding practices the most. These findings indicate that more fathers were giving instrumental and informational support to mothers.

As reported here, fathers' self-reported exposure to complementary feeding mobile phone messages was "surprisingly low, given that a majority of fathers had mobile phones or access to them and ICARE kept an up-to-date list of eligible fathers to whom they sent the messages." Endline qualitative data indicated that some fathers were reluctant to read or listen to the messages because they came from an unknown sender. The researchers suggest that this and other barriers to mHealth participation should be addressed to increase fathers' exposure to complementary feeding text and voice messages in future interventions.

Despite low reported exposure to some intervention components, the researchers found substantial improvements between baseline and endline in complementary feeding knowledge among both fathers and mothers. Previous research has shown that fathers' and mothers' nutrition knowledge contributes to adequate complementary feeding practices.

In conclusion, "The findings reinforce the importance of involving fathers in programs to improve complementary feeding. They also leave several questions that require further investigation prior to scaling up the intervention in Nigeria, including how to increase intervention exposure..."