Informing Video Topics and Content on Maternal, Infant, and Young Child Nutrition and Handwashing

Photo credit: Marjolein Moreaux, SPRING

In 2013, the USAID Global Health Bureau asked the SPRING project to collaborate with the Resilience and Economic Growth in the Sahel–Enhanced Resilience (REGIS-ER) project,¹ in providing support for maternal, infant and young child nutrition-related and hygiene-related social and behavior change communication.

In light of an earlier, successful collaboration between SPRING and Digital Green in India (Odisha), SPRING decided that the community video approach used by Digital Green could be tested for use in the resilience context of the Sahel. USAID emphasized the need to include not only REGIS-ER into the proof of concept, but also other interested Food for Peace partners, such as the Livelihoods, Agriculture and Health Interventions in Action project and the Sawki project to strengthen their SBCC work in the field of MIYCN.

Before developing the formative research protocol, SPRING conducted a situational analysis in September 2014, using available published and unpublished reports and other program documents, related to nutrition, water, sanitation, and hygiene, livelihoods, family planning, and gender practices in Niger, focusing on the Maradi region.

The partners selected four existing community groups in each one of the 20 villages to disseminate videos which were planned for production at a later stage. A situational analysis and formative research was to inform the content of the videos to be filmed in the commune of Guidan Roumdji and disseminated in the communes of Guidan Roumdji and Aguie.

Table 1. SPRING/Digital Green Partners and Implementation Villages

The formative research was designed to fill the gaps highlighted in the situation analysis for Maradi. A series of 10 focus group discussions and 12 in-depth interviews were carried out by two teams in two villages: Guidan Alkali and Hannou Ganzane, which were representative of the 15 villages in the Guidan Roumdji commune where the videos will be filmed. Each team was assigned a village and was responsible for conducting the discussions and the interviews. In Guidan Alkali, 51 village members participated in the discussions, while in Hannou Ganzané 70 members participated. Twelve interviews were conducted, including four women, four men, and four adolescent girls.

The majority of the Maradi population are subsistence farmers with extremely low levels of literacy. Adults and children alike tend to eat and prepare meals infrequently given the chronic and pervasive food insecurity and the local customs. Most of the maternal, infant and young child nutritional practices in Maradi are suboptimal due to external factors like a poor health care system and a harsh climate as well as internal factors such as low perception of self-efficacy in the difficult Sahel environment, long-existing local beliefs, migration, polygamy and its social complexity, and a low degree of male involvement.²

Summary of Findings

Eight priority topics for videos were highlighted as a result of the formative research:

• Women’s nutrition in the first 1000 days
• Exclusive breastfeeding for the first 6 months
• Complementary feeding
• Continued breastfeeding through at least 24 months
• Diarrhea and malaria prevention and management
• Handwashing
• Use of family planning services
• Use of maternal health services

For each topic, a set of recommended behaviors and their respective micro-behaviors were identified. A series of videos are planned on these priority topics and behaviors, articulating the barriers and motivators for each recommended practice.

Throughout this process, SPRING will work closely with local partners including the Regional Department of Public Health and Digital Green. Using the results of the formative research, the partners will develop a Package of Packages for each video before production. These Packages will contain the key technical and behavioral messages to be shown in the video. They will be the technical basis for the storyboard, which is the guidance for the video production team when they go to the field for filming.

1. Background and Objectives

In 2013, the USAID Global Health Bureau asked the Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) project to collaborate with and provide specific nutrition- and hygiene-related social and behavioral change communications (SBCC) to support the Resilience and Economic Growth in the Sahel–Enhanced Resilience (REGIS-ER) project. Awarded to a consortium led by the NCBA Cooperative League of the USA (CLUSA) International, the REGIS-ER project’s goal is to increase the “resilience of chronically vulnerable populations in agro-pastoral and marginal agriculture livelihood zones in Niger and Burkina Faso."³ The project includes three specific objectives: 1) increasing economic wellbeing, 2) strengthening institutions and governance, and 3) improving health and nutrition status.

In Niger, the collaboration between REGIS-ER and SPRING focuses on Objective 3 - improving health and nutrition status. It emphasizes the promotion of a rational use of food, dietary diversification, and access to new fortified foods, as well as access to health and nutrition services and improved water sources and sanitation.

After consultations with USAID/Niger and stakeholders, SPRING decided to introduce the community video approach, first developed in India with Digital Green for the promotion of agricultural practices, to the resilience context of the Sahel. The collaboration in Niger was intended to further test the feasibility of leveraging the approach for the promotion of key, evidence-based behaviors related to maternal, infant and young child nutrition (MIYCN) and those related to hygiene with a focus on the first 1000 days as a “window of opportunity.” Locally produced videos are to be filmed and watched by the local communities, with the idea that people learn better from their neighbors and others just like them than they do from external “specialists.”

SPRING was advised to work closely with REGIS-ER and other Food for Peace (FFP) partners: the Livelihoods, Agriculture and Health Interventions in Action (LAHIA) project, with Save the Children as the lead organization, and the Sawki project, with Mercy Corps as the lead organization. The LAHIA project was already using videos for its outreach activities. The approach is also aligned with Mercy Corps’ SBCC strategy. All three partners had received grants from USAID to work in the fields of livelihoods, governance, natural resource management and health, nutrition and WASH and this collaboration aimed at strengthening and consolidating their SBCC work in the field of MIYCN.

SPRING carried out a situational analysis and formative research to inform the content of MIYCN videos to be filmed in the commune of Guidan Roumdji and disseminated in the communes of Guidan Roumdji and Aguie, where the partners were implementing projects.

Depending on the villages, different types of community groups participated in focus group discussions (FGDs). The team led a series of these discussions with adolescents in safe spaces group, pregnant and lactating women in mother-to-mother support groups, women in savings groups, men in “écoles des maris”⁴ husbands schools, and men and women together in small community groups.

To guide the MIYCN-focused video production and dissemination, the SPRING/Digital Green project’s team sought to understand the current nutrition and hygiene practices during the first 1000 days, as well as the socio-cultural and economic context. Results of the situational analysis and formative research aimed to clarify: 1) key target groups; 2) selected priority behaviors that can be promoted by community videos; and 3) how best to use videos to promote behavior change. The specific objectives of the research were to identify:

1. Existing family relationships in terms of decision-making: Who makes decisions regarding nutrition? (Mothers? Mothers -in-law? Husbands?). Who makes decisions regarding health? How does gender influence what is happening at household level regarding MIYCN?
2. The current MIYCN practices and barriers that need to be addressed such as food misconceptions (taboos); nutritional knowledge and practices of children under two years of age; who are those individuals influencing these practices.
3. The major nutritional issues adolescent girls and women face, such as societal structures/taboos/barriers, as well as promising practices on which to build.
4. Existing handwashing practices and determinants.
5. Households/individuals with positive behaviors who might be featured in the videos, and the motivators for their deviance from the norm.

2. Methodology

Prior to developing the formative research protocol, SPRING conducted a desk review—including both peer-reviewed and gray literature—related to MIYCN and WASH practices in Niger, with a focus on the Maradi region. Despite the large amount of information available, there were still a number of gaps related to priority MIYCN practices. Therefore, the formative research was conducted to delve deeper into barriers and enablers of these priority practices.

The methodology was adapted from the SPRING/Digital Green Community Video for Nutrition Guide⁵ developed in Keonjhar, India to suit the context of Maradi, Niger. The formative research protocol, as submitted to the Institutional Review Board (IRB), can be found in Annex 1.

Fifteen villages located in the Guidan Roumdji commune were considered for sampling. According to prior formative research conducted by Save the Children in 52 Maradi villages, only very minor differences were found between villages (LAHIA 2013). Field staff in Guidan Roumdji confirmed that there were almost no cultural or other differences across the 15 villages. In Guidan Alkali a total of 51 village members participated in focus group discussions while in Hannou Gazané 70 members participated. A total of 12 in depth interviews were conducted with four women, four men, and four adolescent girls. Three criteria were considered when choosing the key informants:

1. They participated in well-established community groups
2. The community health worker and lead mother in the village were enthusiastic community volunteers
3. The village chiefs were welcoming of the research team and partners.

Summary of Informants for Formative Research

Table 2. Summary of Informants and Tools for Conducting Formative Research

SPRING was responsible for drafting the formative research protocol and tools, and a SPRING team member served as the research manager. All tools were translated into Hausa although some of the discussion group mediators preferred to use the English versions as they had not learned to read Hausa in school and it is primarily an oral language in Niger. The tools were pretested and revised during the one-day training of the research team. While in the field, more revisions were made to the tools, in order to capture the participants’ feedback and contextual realities.

The formative research team consisted of men and women from the three USAID-funded projects in Maradi. Each team had four members: one local agent to plan logistics, one mediator, one note-taker and one observer. It was responsible for conducting the focus group discussions and the in-depth interviews in their respective villages.

Below is a description of the number of participants in each focus group discussion (per group and per village):

Table 3. Number of Formative Research Participants

After carrying out the FGDs, two members of groups 1, 4 and 5 mentioned above, were interviewed individually. The team leader conducted an additional interview with the Sawki’s agriculture project in order to learn Maradi’s seasonal calendar. (See Annex 5.)

3. Situation Analysis

3.1. The Maradi Context

When Save the Children carried out formative research in Maradi in 2013, it had anticipated that the beliefs, perceptions, and practices observed in five communes in three departments of Maradi would differ from one commune to the next. However, their research results showed strong similarities between the beliefs, perceptions and practices observed. This is in part due to the heterogeneity of the population in the region, predominantly Hausa, together with some groups such as Peulh and Touareg⁷ (LAHIA 2013).

3.1.1. Environment

With an area of 13, 600 sq. miles and a population of 3.1 million, the Maradi region lies in the Sahel, a zone of transition in Africa, between the Sahara Desert to the north and the Sudanian Savanna to the south. Having a semi-arid climate, the Sahel is covered mostly in grassland and savanna, with areas of woodland and shrubland.

3.1.2. Population Characteristics

The average household in Maradi includes approximately seven household members (USAID 2014). About half of all households include children under the age of 24 months. The majority of household heads are male (94 percent), and 88 percent of household heads have no formal education and are illiterate. Almost all households (91 percent) include an adult male and female. A challenge and one of the main factors contributing to high levels of stunting in Niger, is the very high rate of child marriage, among the highest in the world, with one out of three girls marrying by age 15 (Mebrahtu 2012). The DHS 2012 calculated that the mean age of marriage for women is 15.3 years in Maradi (vs 19.5 years in Niamey). Men get married at 24.6 years on average. Fifty two percent of the women interviewed in Maradi lived in a polygamous household (INS 2012).

3.1.3. Seasonal Labor Migration

Seasonal labor migration plays a significant role in the lives of people in Niger, primarily as a coping strategy for food insecurity and chronic poverty, and for increasing their income. Fifty to 70 percent of men migrate: internally to larger cities within Niger and externally to neighboring countries (Camber Collective 2014). Interviews found internal migration to be seasonal, with the vast majority taking place after the harvest and storage of crops (after January, and return May/June before the first rains). Only successful businessmen remain in their communities.

Even though this might bring extra income to certain families, some individuals indicated that men’s migration places added stress on the household, in particular on women, who then must bear the sole burden of caring for the household (Camber Collective 2014).

 They can [leave] without sending any money for us during six months, so it is the duty of the woman to feed the household in any way she can…. It is the role of the woman to feed all the family; she must look for money by any means because the husband is not around. 
--Camber Collective, women in Tounkourma

When the man is absent, the following persons are responsible for running the household (making decisions on food distribution, buying of soap, buying of extra food etc.): his mother (if she is in good health), the first wife, the father of the man, a friend of the man (businessmen do not migrate) or a brother of the man (Hamani 2013). Therefore depending on the relationship of this assigned person with the other family members, and especially the other wives and their children, this can create serious disparities in household distribution of foods and goods.

3.1.4. Gender

Partly due to the Muslim religion, partly because of culture, men are generally only accountable to other men - their peers and elders. Women are not expected to articulate their needs or the needs of their children and in Hausa culture, it is considered shameful for a wife to make demands.

In regards to marriage, 48.4 percent of the population in Maradi is monogamous compared to 63.7 percent nationwide. As soon as a man has climbed up the social or wealth ladder, he is expected to take a second, third, and even fourth wife. In rural areas, the first wife is chosen by the man’s parents during childhood and she is usually a person related to the family (like a cousin). This can cause problems as the mother-in-law and the first wife are often seen as “accomplices”, hence triggering jealously among other wives. However, there are rules of rotation which often prevent problems (Hamani 2013, Banque Mondiale 2014). The most common rotation method is giving another wife the responsibility of cooking for the entire extended household as well as sleeping with the man, every other day (SPRING).

 One woman who had four sets of twins (eight children) said: “I will not stop having more children, as I get more affection and attention from my husband when having young children.”

Early marriage is increasing in Maradi due to poverty (Camber Collective 2014). According to a gender study, parents feel that sending girls to schools leads to promiscuity, marriage is a surer path to a life without shame (Banque Mondiale 2014). After marriage, men establish a home within close range of his parents’ compound and the wife joins this household (USAID 2014).

Gender roles and responsibilities are clearly defined and are reflected in everyday life in Maradi. Men are the heads of households and primary decision makers on all matters related to the household. This includes decisions about food for consumption and other utilization, health care, economic activity, and children’s education. Women have to ask their husband to go out of the house (Banque Mondiale 2014). Men and women have separate resources, including livestock and sometimes land, although men can ask to “borrow money” from their wives when he does not have enough (Banque Mondiale 2014). Women have their own livestock, which the man can buy from his wife if, for example, he cannot provide sufficient food or health care for a child.

Prescribed gender roles by division of labor within the household and livelihood activity are sharply defined in the majority of Sahelian communities. Adult men typically engage in agriculture and young men in animal husbandry, while adult women engage in the harvest and the sale of food products, and young women are responsible for collecting wood for fuel as well as water used by the household. However, it is also common, particularly in Maradi, for women to have their own small allotments of land where they might grow food for household consumption, even though the man often decides what to do with the harvest. Women are responsible for rearing small animals such as goats, while men rear larger animals such as cows and bulls. Within the household, only the women are responsible for child care and preparing food, with female youths and children assisting in food preparation and with both female and male youths assisting in the collection of wood and water. Young children are also responsible for providing care to their younger siblings. When mothers-in-law are in good health, they also help with the typical female tasks but generally not with cooking as that is the wife’s⁸ role (USAID 2014).

In Hausa culture there are long-standing traditions governing the storage and partition of the cereal stock. Men are responsible for providing his wives with cereals to prepare the two staple foods – hura and tuwo.⁹ Women are responsible for finding a means to prepare the accompanying sauce or anything else (discussions with staff).

Who makes financial decisions in the family appears to differ between families depending, in part, on who has earned the money and who is on-site when the money needs to be spent. In general, it is the male head of household who is responsible for feeding the family, which means providing the cereal stock for the preparation of meals; and the income from women’s small businesses can be spent however the men see fit or can be used to feed the family if necessary. However, some men acknowledged that they make these decisions in conjunction with their wife or wives. Some women also said that her husband decides on the harvest she produces in her “own” plot of land (USAID 2014).

According to different sources, men are an important group to involve in health, as they are the decision makers in the households (LAHIA 2013, PASAM-TAI 2013), even for behaviors like exclusive breastfeeding (LAHIA 2013). For handwashing, the same LAHIA report mentions the importance of creating a dialogue between men and women, “to facilitate the implication of women in decision making, and to achieve a great responsibility for them” (LAHIA 2013).

3.1.5. Poverty

The majority of Nigeriens live near or below the poverty line, which significantly limits the population’s ability to access nutritious food. Incomes are insufficient for the poor to purchase food despite availability. Particularly in years with low rainfall, much of the annual harvest, especially high value crops like groundnuts and legumes, is consumed or sold to buy other foods before the end of the lean season, resulting in both insufficient availability for household feeding and a lack of capital for the purchasing of inputs for the following year. Because Niger is landlocked, food prices vary significantly with currency fluctuations (IFAD n.d.).

Poverty is a significant challenge in Maradi. The household survey found that almost two-thirds (64 percent) of the population in the survey areas is currently living in extreme poverty (less than USD $1.25 per day). Daily per capita expenditures average, USD $1.33 per day, per person. Participants in the study identified very few sources of income. The two income sources mentioned most frequently are agriculture (including the sale of crops, the sale of animals, and casual labor on farms),¹⁰ and remittances (USAID 2014).

3.1.6. Food Security

Niger is one of the world’s least developed nations. Less than one-third of Nigerien adults are literate, and more than three-fourths of the population lives on less than USD $2 per day (IFAD n.d.). Food crises are common in the region, and much of the population suffers from chronic malnutrition (USAID 2014).

Agriculture is central to the Nigerien economy, and more so in Maradi, which is known as the country’s bread basket and economic hub due to its close proximity to Nigeria. The Maradi area is generally a surplus producer of millet and cowpeas, and is an important commercial zone due to its geographic and cultural relationship with Nigeria. However, the rural poor are net consumers of food staples. Many rural families depend on low-yield, small-scale agriculture with insufficient productivity to meet the needs of their households (USAID 2014).

Labor is limited and most Nigerien farmers rely on their wives and children for cultivating and controlling weeds and pests. Normally, the leanest period for Nigerien farmers begins in June, when the family runs out of last year’s harvest, although food shortages for many families often start sooner (IRFC). The lean period coincides with the rainy season and runs through September or October.

Several coping strategies are utilized by individuals and households that experience food insecurity, and in this context, they are regularly used during the period following the harvest, leading up through the lean season. First is a food-specific strategy to reduce food consumption to once or twice a day. As a second strategy, respondents mentioned selling small animals such as goats or other small goods produced, such as beans. With money from these sales, individuals then purchase millet and other foods needed for their households. The third coping strategy involves the search for income sources, such as working as hired labor on someone else’s farm or casual labor. The biggest trend, however, is labor migration during the dry season, immediately following the end of harvest (USAID 2014).

In a baseline survey by USAID, results show that hunger is a challenge for many households in the region, even though food supplies were predicted to be adequate during the survey months. Nearly one-third (29 percent) of households surveyed suffered from moderate or severe hunger. The hunger models indicated that the drivers of household hunger are related to food access and availability, which are further influenced by seasonal conditions and income sources. Qualitative data indicated that, despite the availability of food in markets, lack of income prevents individuals from accessing these foods and that crops produced for household consumption are generally insufficient to meet the needs of the household for the entire year. Additionally households are motivated to sell their most nutritious food crops so that they can increase their cereal stocks to feed a greater number of individuals (USAID 2014).

3.1.7. Household Dietary Diversity

USAID’s baseline survey found an overall Household Dietary Diversity Score (HDDS) score of 3.4, which indicates poor dietary diversity during 24 hours before the survey was conducted with only three to four of the 12 food groups consumed, on average. Almost all households consume foods made from cereal grains such as millet, sorghum, maize, rice, and/or wheat. Less than 20 percent of households consume meat or poultry, and less than 10 percent consume eggs or fish. The HDDS as a measure of food access and socioeconomic status indicates that the population in the program areas has limited means to access diverse foods.

The qualitative baseline data suggested a direct relationship between seasons and the types of food produced for consumption and food purchased. In some areas where the water table is high and gardening is sustainable, home vegetables, such as potatoes, peppers, and tomatoes, are also grown for household consumption. However, the majority of vegetables consumed are foraged from trees and fields in the vicinity. When asked what type of vegetables are foraged, one respondent stated, “There are the leaves of trees which serve us as vegetables [such as]…ridi [sesame leaves], rama [sorrel], tafassa.” Most households do not have the means to purchase meats, fruits, and vegetables, and only purchase them occasionally (USAID 2014).

The vast majority of participants in both regions indicated millet as the primary type of food consumed in all seasons in various forms of preparation.¹¹ Other foods less frequently consumed include sorghum, cassava flour, and occasionally vegetables, niébé (black-eyed peas), milk, meat, fish, eggs, peanuts, rice, macaroni, and couscous (USAID 2014).

3.1.8. Water, Sanitation, and Hygiene

Access to improved water sources and proper sanitation were among the biggest challenges in the survey population in the USAID baseline (USAID 2014). More than three quarters of households (77 percent) reported that they do nothing to make water safer to drink. Only nine percent of households reported using an improved sanitation facility, in most cases consisting of a pit latrine with a slab. Interviews revealed that open defecation in the bush is common in most communities, even where some latrines exist in villages. Although respondents reported using the bush or common village basic pit latrines, they also reported a lack of cleanliness in the communal latrines (USAID 2014).

Interviewers from the household survey observed the presence of water and soap, detergent, or another cleansing agent at the place for handwashing in only 15 percent of households. However, almost all respondents (90 percent) correctly identified that washing hands is critical before eating. Few were able to identify any of the other four other critical moments for handwashing: after defecation (16 percent), after cleaning a child’s bottom (13 percent), before preparing food (7 percent), and before feeding a child (7 percent) (USAID 2014).

3.1.9. Selling vs. Consumption Practices

Qualitative analysis of the USAID baseline data indicated farmers sell surplus millet and other crops after calculating annual needs. Respondents indicated that livestock and poultry serve as a source of income and savings and that crops produced for household consumption are generally insufficient to meet the needs of the household for the entire year. Typically, households eat food produced only a few months of the year—in some cases, only for one to three months after harvest.

Given that there is a standard to eat millet paste with sauce, there isn’t much of a decision to be made. The men control the cereal stocks and women forage for whatever else they can add to the meal to make it more robust. Men are the decision makers when it comes to the utilization of foods within the household.

As a general rule: the men are responsible for providing the amount of staple food given from his store, the salt and some extra ingredients for the sauce which accompanies the staple (e.g. tomato paste, onion, dried okra) – which he can buy himself at the market or send a woman from the household. After this, whatever food is still lacking for the sauce, the women will provide, buying it, getting it from the garden or gathering wild foods. Most often, there is no money to buy extra ingredients and women are solely responsible to look for the ingredients for the sauce (conversations with staff).

3.1.10. Intra-household Food Distribution

The majority of participants in the USAID-led baseline reported that everyone in the household ate the same foods, including children and women. Men and women reportedly ate the same types of food and in the same quantity. In some cases, when there was sufficient means, respondents indicated that vegetables, fruits, beans, milk, eggs, and meat were purchased in markets for children and women (USAID 2014). Milk is sometimes purchased but meat, fruit and vegetables are seldom purchased. Men often have their outside of the household while they are with their friends in the markets (conversations with staff).

The woman who is cooking that day (i.e. where the man will spend the night), will divide the food, based on the man’s morning instructions. The man would have estimated portion for each wife, based on the number of children she has. The man gets his personal bowl, the older children get one bowl of food to share and all wives, and often neighboring adult women eat together from a shared bowl. The younger children (below one or one and a half years old) eat with their mothers (SPRING).

3.1.11. Women’s Health and Nutrition

USAID’s anthropometry results indicated nutritional challenges for women ages 15-49 in the program areas. Dietary diversity scores indicate that their diets lack nutritionally diverse foods, and while 74 percent of women ages 15-49 in the survey population have a body mass index (BMI) within the normal range, 20 percent are underweight, and 5 percent are moderately to severely underweight—indicating inadequate health status and/or caloric intake. On daily average, women consume about 3.3 of the nine basic food groups researched in this study. Grains, roots, and tubers (97 percent) and green leafy vitamin A-rich vegetables (76 percent) are the most frequently consumed food groups. Dietary intake of protein is lacking: 55 percent consumed pulses, 38 percent milk or milk products, 17 percent of women consumed flesh foods, and 6percent consumed other protein-rich foods such as organ meat or eggs in the 24 hours preceding the survey (USAID 2014). Women are extremely active and engage in labor that puts extraordinary demands on their bodies; they burn significant calories as they carry heavy gourds of water, pound millet, and breastfeed. (observations).

Over half (52 percent) of mothers of children under 24 months said they attended four or more antenatal visits; a higher rate than that reported in the 2006 DHS of 11.1 percent. Qualitative study findings suggest that there is an increase in the number of women delivering in health centers; however, many respondents reported giving birth at home with traditional midwives, despite strict government fines of 5,000 francs and a legal prohibition against home births. Women predominantly reported using health centers for prenatal, delivery, and postnatal care when health centers are available in their communities; however, women living far from clinics find it difficult to use these services.

When asked to list illnesses that affect their communities, an overwhelming majority of people across all regions reported malaria and diarrhea to be the most common illnesses affecting both adults and children. Other illnesses described were colds and fevers, particularly during the rainy season, eye and ear infections, hemorrhoids, tooth pain, stomach ulcers, heart disease, paralysis, fistula, skin disease, and chicken pox. A discussion of malnutrition as the main cause for many illnesses came up frequently, but not as an illness itself (USAID 2014).

Although there are some cases where women make decisions about when to seek medical attention for themselves or their children, the majority of respondents indicated that male heads of households are the primary decision makers, and their decision-making authority includes the issue of where women give birth (USAID 2014).

3.1.12. Children’s Health and Nutrition

Food utilization is poor in Niger due to unsuitable food choices and feeding patterns and poor health and sanitation practices. Less than a quarter of children under six months of age are exclusively breastfed (Coen 2010), and introduction of complementary foods is generally not in line with recommended practices (FEWS NET 2006). Young children have particularly low levels of diversity in their diets.

USAID baseline data indicated that more than half (58 percent) of the children under five years of age in the survey population showed signs of moderate and severe stunting. This rate is comparable to that reported in the most recent 2012 DHS in Maradi where 54 percent of children under five years of age were stunted. The USAID baseline found malnutrition rates to be negatively related with access to agriculture land or raising livestock.

USAID’s household survey results indicate that 43 percent of children 0-5 months were exclusively breastfed in areas where the Food for Peace programs will be implemented, with no differences between program areas and none between male and female children. The prevalence of exclusive breastfeeding is highest in the two- to three-month range (54 percent) and gradually decreases with each month thereafter. About 23 percent of children in the 18- to 23-month age range are no longer breastfeeding. At six to eight months, 55 percent of children are breastfeeding with the addition of complementary foods, with the proportion increasing with age. However, only eight percent of children 6-23 months are receiving a minimum acceptable diet (MAD). The majority of qualitative respondents discussed predominant breastfeeding for children under six months and also discussed breastfeeding as part of their traditional culture (USAID 2014). The DHS indicates that 16.7 percent of children 9-11 months and 8.2 percent of children between 12 and 17 months had not started taking semi-solids or solids yet (INS 2012).

USAID’s household survey also found that 14 percent of all children under age five had diarrhea in the two weeks preceding the survey, and 19 percent of this subset had blood in their stools. The 2012 DHS reported a national rate of diarrhea in Niger of 14.1 percent. Caretakers sought advice or treatment for almost two-thirds of the children with diarrhea (64 percent), and more than three-quarters of children with diarrhea were treated with oral rehydration therapy (ORT), compared to the 45 percent found in the DHS 2012. Respondents reported an improvement in the general health of their communities in recent years. However, respondents frequently reported the need for health facilities, community health care workers, and medicine (USAID 2014).

3.1.13. Aspirations

According to the gender study, people consider others as having succeeded socio-economically when they do not need to do rough household work anymore (like weeding or harvesting.). Men have the following aspirations for their children: more opportunities, money and a better life. Often parents invest in one son, for schooling or for migration. Girls themselves would like to become teachers, lawyers or doctors, showing that they are choosing another way of life than their mothers. Boys aspire to become lawyers, doctors, bookkeepers or to go into politics (Banque Mondiale 2014).

4. Formative Research Findings

The formative research aimed at clarifying:1) key target groups; 2) selected priority behaviors that can be promoted by community videos; and 3) how best to use videos to promote behavior change. Specifically, the research objectives were to identify:

1. Existing family relationships in terms of decision-making: Who makes decisions regarding nutrition? (Mothers? Mothers -in-law? Husbands?). Who makes decisions regarding health? How does gender influence what is happening at household level regarding MIYCN?
2. The current MIYCN practices and barriers that need to be addressed such as food misconceptions (taboos); nutritional knowledge and practices of children under two years of age; who are those individuals influencing these practices.
3. The major nutritional issues adolescent girls and women face (societal structures / taboos / barriers / promising practices to build upon).
4. Existing handwashing practices and determinants.
5. Positive deviant households / individuals who might be featured in the videos, and identify their motivators for their current behavior.

The research carried out by the SPRING project was able to highlight the following priority themes to be further developed into community videos. The results also identified specific practices, barriers, and recommendations to include for each video.

1. Women’s Nutrition during the First 1000 Days

Recommended behaviors during pregnancy:

1. Eating one small extra meal each day
2. Administrating and taking of iron/folic tablets
3. Reducing workload

Recommended behavior during breastfeeding:

1. Eating two small extra meals each day

Current Practices

Men’s support for their wives is practically non-existent regarding nutrition and household level chores, especially for breastfeeding women. Women often do not support other co-wives because of jealousy, especially of the younger wives who may be the husband’s favorites.

However, there seems to be an awareness of the need to spare pregnant women from a heavy workload and to increase their intake of quality food. Some men do help their pregnant wives fetching wood and water. Men are the ones determining intra-household food distribution, followed by the mother-in-law of his first wife in case of his absence. Men appear to be influential individuals in the uptake of a new behavior. This behavior is a very sensitive one, as men in polygamous households need to maintain peace within the household, and giving one pregnant woman more food than a non-pregnant woman might cause intra-household problems. Therefore we would want to stress the need of discussions involving the whole extended family.

Women strive to be good religious women: meals are prepared less frequently during fasting season and most women fast during Ramadan, even when they are pregnant or breastfeeding.

For breastfeeding women, there is not such a strong awareness of the need for extra food, although people believe that the milk of women who do not eat enough is of a bad quality.

Barriers Identified

Awareness about women’s nutritional needs during breastfeeding is low; women have little knowledge of how to overcome the nausea that might occur when taking iron-folic acid tablets during pregnancy; polygamy makes it difficult to provide different foods for one pregnant or breastfeeding wife compared to the other. Even though pregnant women are not obliged to fast during religious holidays, they often do because of social pressure.

Recommendations for Video Production

To help lower the socially created expectation of having to fast, we would recommend an Imam supporting his wives to not fast during pregnancy and breastfeeding. We would also encourage and portray couples dialogue in the videos.

Men asked for practical tips on how to better determine and control intra-household distribution, an excellent topic for videos.

To address the nausea related to iron-folate tablets, the video could show a woman taking the pills at night, just before going to bed, and with some food.

Our recommendations are to include breastfeeding in the video on maternal nutrition, raising awareness, providing practical tips on how to support breastfeeding women, and showing an Imam talking about his wife who does not fast during the first six months of breastfeeding. However, we need to stress the importance of extra food to maintain the woman’s body and prevent her from feeling hungry.

2. Exclusive Breastfeeding for the First Six Months

Recommended behaviors:

1. Early initiation of breastfeeding
2. Placing the newborn on the breast within one hour of delivery
3. Giving no pre-lacteal feeds; No bottle-feeding
4. Practicing EBF from birth until six months of age
5. Emptying both breasts at each feeding;
6. Frequent breastfeeding – about 10 times/24 hours
7. Good positioning and attachment

Current Practices

Although almost all women feed colostrum to their babies, not all do this within the hour after giving birth. Women give pre-lacteal liquids to the newborn instead of the colostrum to eliminate the first black stools and they often give water and herbal teas before babies are six months old, which replaces breastmilk consumption and can give the child diarrhea. Pressured to return to work, women may rush feedings and not empty both breasts.

People in Maradi believe that a baby needs water (during hot weather) as well as decoctions (a local herbal tea to protect against illnesses). To address widespread and deeply rooted beliefs, we should find mothers who did not administer anything other than breast milk during the first six months of their babies’ lives, in order to illustrate that exclusive breastfeeding does not cause death. It is also recommended to emphasize that goat’s milk is valuable for both pregnant and lactating women and children 6-23 months. As explained under “early initiation”, women also need to be convinced that breast milk is always good, even after the mother has been outside in the sun, is hungry, and even during pregnancy.

The issue about women’s high workload should again be addressed by trying to get other community members, especially men, mothers-in-law or other wives, to support breastfeeding women in the household. In the interim, women need practical information on how to take time and sit or lie down to breastfeed, and to feed the infant from both breasts.

Barriers Identified

Even though it is diminishing among respondents, there is a widespread belief that herbal teas are needed to expel the first stools after birth. There is a belief that the first milk might be of a bad quality. Many women do not know that they can increase their milk production by breastfeeding more frequently and many have so much work they may not take time to breastfeed correctly on both breasts. Some may also believe that breast milk can get bad if the mother is pregnant or has been absent and may lead to early cessation of breastfeeding.

Recommendations for Video Production

We recommend that early initiation be mentioned in one of the videos on exclusive breastfeeding, emphasizing that it helps bring in the colostrum which helps to activate the baby’s digestive system so the black stools can be eliminated. The video needs to include information that breast milk is always good, and the faster the baby is put on the breast, the faster and the more milk the mother will produce.

As the colostrum of goats and cows is highly valued, we should test the concept that the video might want to include this and also explain its importance for human babies too.

There are lots of issues regarding breastfeeding, related to local beliefs but also to women’s high workload, all of which could be addressed through the medium of video by finding positive deviant mothers.

To address the fact that people administer goat milk to newborns because Mohammed also drank it at birth, we recommend finding an Imam who wants to explain that babies drinking goat’s milk was acceptable during the time of Mohammed, but that science has now proved that goat’s milk is only valuable for young children above 6 months as well as for older children and women.

3. Complementary Feeding

Recommended behaviors:

1. Complementary feeding from 6 until 24 months (Starting at six months, Amount of food offered, Frequency of feeding, Thickness of complementary foods, Diversity of foods, Responsive feeding, Separate plate, Hygiene)

Current Practices

According to the research findings, complementary foods are often not diverse, the consistency is too liquid, and not offered sufficient times a day. Additionally, young children from 6-24 months eat from the family bowl so that the mother or other caregiver does not know how much an individual child ate; and there is little to no active feeding. No other snacks expect “boule”¹² are left behind for the child and the boule is prepared by adding (non-treated) water.

While it is recognized that people in the Sahel live in very difficult circumstances with very little access to a variety of foods, it is still possible to improve dietary diversity by underlining the importance of drying and storing certain nutrient-rich foods for pregnant and lactating women and children 6-24 months. The drying of certain products already takes place, but it is sold and not used for household consumption (e.g. dried tomato (cowda), dried pepper (tattassey), dried tamarind (tsamia), dried fish/meat, dried okra, dried hibiscus leaves (yakua), dried moringa leaves, dried fruits like dried goruba and other locally available and affordable foods). Also dried groundnut resin¹³ (kuli-kuli), dried dates,¹⁴ goat’s milk, oil and cow’s butter are accessible and can enrich one’s diet considerably. These should be shown to be added to the diets of children and women during lean seasons. Men will also need to be sensitized as they are the ones making the decisions regarding what is eaten in the household.

In light of a mother’s high workload, we think that all recommendations to prepare baby food should start from the family diet. Staple foods in the Sahel are “boule” (millet porridge) or cereal “pate”, which can both easily be mixed with more nutrient-rich ingredients. Boule is already mixed with sugar and milk, and in some instances peanut butter paste. This practice should be encouraged, although it should be stressed to try to give the boule as fresh as possible before the millet ball or the milk is fermented. Fermentation causes the boule to have a sour taste which might not be liked by a baby who then decreases his/her consumption. Another problem with boule is that often untreated water is added. Porridge is more hygienic, if the caretaker’s workload can allow her to cook special food for the baby. The pate is always eaten with some kind of sauce; it will need to be stressed that also the very little ones can eat this, but ensuring that the caregiver picks the best pieces from the sauce to mash in into the baby’s food. Caretakers need tips on how they can decrease the size of meat, beans, leaves, so that the lack of teeth cannot be an excuse to not give certain types of food to young babies over six months.

There is little data to show how much food children actually consume. All children of a same household receive their food from the same single dish. It is assumed that the little ones receive less food than the older children because they are slower, less dexterous, and more easily distracted. Responsive feeding practices could be done by the mother, but also by alternative caregivers who feed the children when the mother is absent. Practical tips and suggestions are needed, like the special dish exclusively for the baby or explaining to the older sibling where the baby’s food is placed for later, which snacks can be taken to the field, how to ensure alternative caretakers have fed the child.

About half of the children are not fed the minimum recommended number of times a day, even though one source claimed that boule is always available in the household throughout the day and throughout seasons. In this case, the problem might be that young children are not able to ask for it, and that signs of hunger are not recognized, or that women are too busy to feed more than 2-3 times per day.

Barriers Identified

Very few seem to be aware that they need to provide special foods and care for their children, especially between the ages of six and 24 months; dried foods are sold rather than kept for the family; and mothers work in the field so other caretakers are responsible for feeding.

Recommendations for Video Production

It will be important to show the preparation of complementary food of the right consistency in the videos. We recommend comparing the thickness needed with the thickness of “pate” eaten at the evening meal with the consistency of the boule given as a snack. Dried foods should also be portrayed as alternative and complementary during more difficult times. Men in the households should be featured as they are the decision makers.

The videos should also encourage caregivers to give young children a special dish so there can be some control on what and how much they eat at each meal as well as in between meals. Additionally, it should be shown that children should be actively fed and encouraged to eat.

In regards to hygiene and its relationship to complementary feeding, handwashing with soap - for both the child and caregiver - before food preparation and feeding should be shown in every video. Addressing hygiene for food preparation should mainly focus on adding boiled/treated water to the boule of the child.

4. Continued Breastfeeding until 24 Months

Recommended behavior

1. Continuing frequent, on demand breastfeeding until 24 months of age and beyond.

Current Practices

Women stop breastfeeding when they become pregnant again. If not pregnant, weaning happens around 18 months depending on the village norm. Despite these norms, it seems that it is mostly the individual choice of the parents. The most common reason for cessation of breastfeeding is a subsequent pregnancy.

Barriers Identified

The belief that the milk of a pregnant woman will make the nursing child ill, perhaps fatally, is strongly held among the Maradi population.

Recommendations for Video Production

Any video mentioning breastfeeding should include a message on breast milk still being OK when the mother is pregnant.

5. Diarrhea and malaria prevention and management

Recommended behaviors:

1. Using preventative health services for children (including vaccinations and regular weighing)
2. Recognizing danger signs and using curative services for malaria and diarrhea
3. Continuing to feed during illness
4. Feeding more after illness.

Current Practices

Malaria and diarrhea are considered “normal” and people do not act when they first see signs; mothers often turn to self-medication to fight the fever and no special diet is administered during and after the illness.

Many misconceptions about diarrhea and malaria continue to exist and parents think that they are a normal part of life, including their children’s lives. Parents do not realize the negative impact these illnesses have on children’s health, and they often do not seek medical attention, nor do they change feeding habits when the child is sick.

Parents need to pay extra attention to what their children eat during and after illness/diarrhea as they rarely prepare extra or the child’s preferred food. No food taboos were found for sick children. However, in the Maradi context, due to the large number of children, it is difficult for some children to be singled out and be given extra or special foods.

Animals are kept inside the compound where people live and children play. In most cases the small ruminants are not tied, and chickens are never kept pinned.

Barriers Identified

There seems little understanding that diarrhea can be prevented, that it is not a part of normal life, and that it can be life threatening for young children. There is often no catch-up feeding after diarrhea. Overall, it seems that the most important barrier to the use of the health care system is the poor quality of care, the inefficiency and the discrimination women face at the health center when not accompanied by a male member of the family.

In the case of malaria, the population understands that fever comes during certain seasons. People know that malaria is caused by mosquitos, but they do not seem to realize that each time someone gets malaria, it has been transmitted by a mosquito. Furthermore, caregivers have no knowledge that a recovering child needs to be fed more than others.

Recommendations For Video Production

Male involvement and explaining why it is important should be promoted in every video.

We therefore recommend a video explaining the link between mosquitos/flies/lack of hygiene with diseases and weight loss, which could lead to a less developed child.

The danger of self-medication for all illnesses should also be highlighted in the video.

A woman accompanied by a male family member will probably receive better and more efficient care and treatment. It would also help the women to adhere better to treatment since medical instructions are often not very clear.

In the video about diarrhea, it should be clarified that children explore their world by putting things in their mouths. This video should show a household where animals and feces (animal and human) are kept away from playing children.

6. Handwashing

Recommended behavior

1. Handwashing with soap and running water at key moments

Current Practices

Handwashing is part of the religious ritual before praying. It is done with running water from the traditional and available “kettle”; using soap is not a habit, even if people know that soap is needed. There are no fixed handwashing stations in crucial living areas (latrines, kitchen).

Despite some knowledge about handwashing, few people wash their hands before/after the key moments.

Using ashes to wash hands was very acceptable to all focus group participants, as ashes are already used for removing difficult stains and dirt. It should be promoted in case of absence of soap, as it is always available.

Barriers Identified

Cost is sometimes mentioned as a barrier, but it is less important than children often playing with soap and animals eating the bars of soap, hence making it expensive. The soap is hidden and not easily accessible for these reasons, and is mostly used to wash the body and clothes.

There are no fixed places where people wash their hands as kettles for handwashing are lying around the compound.

Men are responsible to buy soap, and since they are not very present in the household, they tend to forget.

Handwashing before eating a main meal is more frequent than before a snack.

Recommendations for Video Production

Based on the research results, a video featuring practical tips on how to make water and soap available at places where handwashing is recommended (e.g. after using the latrine, after cleaning the baby’s bottom and before preparing food or feeding). The simplest solution to make handwashing with soap accessible would be to establish a handwashing station and encourage tying soap near the kettle, making it accessible for everyone. To protect soap from animals and to make soap cheaper, they can make liquid detergent from washing powder and install pierced plastic water bottle or the soap can be placed in a deep soap holder made from a plastic bottle.

Because men are the decision makers and influence most behaviors in their households, we recommend making them responsible for hand hygiene in the home.

7. Use of Family Planning Services

Recommended behavior

1. Using family planning methods to space children

Current Practices

In the Maradi region, there is low knowledge of family planning although there is much interest. It is not discussed in the households.

The fertility rate in Niger is one of the highest in the world, and polygamy is one of the contributing factors. Women compete amongst each other to have more children. Having another child results in more attention from the husband, which the older wives crave when their husband has younger spouses. Culturally, having many children equates wealth and status, as children are expected to care for their aging parents later in life.

Men and women realize that a high number of little children complicates life, and from both sides there is much interest in family planning, especially with the objective of spacing births. According to the DHS the fertility rate is higher than the ideal numbers of children, so there is some space to promote family planning. Men have asked practical tips on how to talk to their wives as there is no discussion among couples.

Barriers Identified

There is a lack of understanding about benefits, effects, and side effects of family planning methods. Often, lactation amenorrhea method (LAM) cannot work because of suboptimal breastfeeding practices. Strongly anchored religious beliefs attribute the number of children and the frequency of births to the work of Allah.

Recommendations for Video Production

The first recommendation is to feature couples having discussions around family planning in all videos. The use of champion couples can be explored to show families with children whose births were well-spaced.

Exclusive breastfeeding in the first six months should be mentioned as a family planning method (LAM), and it should also be mentioned in the video on the “1000 days”, as birth intervals of less than three years is correlated to higher child mortality and poor health of women and children.

8. Use of Maternal Health Services

Recommended behaviors

1. Pregnant women going for at least four prenatal visits
2. Women delivering at the health facility

Prenatal care is apparently on the rise in Maradi, especially for the first prenatal visit. However, there is a drop after the first visit if the mother perceives the pregnancy to be going well. Many of the other barriers to the use of prenatal services are external and seem not to be related to the willingness to practice the behavior. Even if more women would want to practice the behavior, it would be difficult to have an effect if the barriers related to the weak health care system are not addressed. Therefore we do not recommend tackling this behavior through video alone.

Similarly when it comes to encouraging women to deliver at health facilities, many of the barriers are external: the weak health care system seems to be the main cause of low delivery rates in their premises. Therefore we do not recommend this as a key behavior to address through video.

5. Conclusions

The formative research confirmed that nutrition, health (including intra-household allocation of food and health resources), and WASH behaviors must be understood within the range of constraints under which fathers, mothers, and other caregivers operate. These include chronic livelihood insecurity, with the concomitant need to maintain productive assets and social and symbolic capital. The development of community videos should take into account power relations at the local household level, polygamy, and widespread migration. In order for behavior change to happen in this environment, it needs to go hand in hand with social change (i.e. increased dialogue between husbands and wives, greater male involvement, and women’s decision making). The workload of women in Maradi is undeniable with household chores, childcare, and farming falling on their shoulders. Even though Maradi is the breadbasket of Niger, malnutrition rates will remain high if women’s workload is not addressed, with more support from their immediate environment and the community as a whole. Additionally, attempts must be made to allow women to communicate their needs within the household without being penalized. The situation of women in Niger, and especially Maradi, is one of worst of the world, according to Save the Children’s 2012 Mother’s Index which compares the well-being of mothers and children in 165 countries, Niger ranks last (LAHIA 2013).

Problems related to polygamy, religion, or the very high fertility rates add to the difficult environment not necessarily conducive or ready to embrace change. However, if tackled through the community video medium, crucial initial social and behavioral changes might be possible to begin to take hold.

Eight priority topics for videos were highlighted as a result of the formative research:

• Women’s nutrition in the first 1000 days
• Exclusive breastfeeding for the first 6 months
• Complementary feeding
• Continued breastfeeding until 24 months
• Diarrhea and malaria prevention and management
• Handwashing
• Use of family planning services
• Use of maternal health services

SPRING will need to plan on meeting with local partners, including the Regional Department of Public Health, and DG in order to discuss the proposed video topics. Collaboratively, SPRING/DG should develop a Package of Practices (POPs) for each of the proposed priority video topics which will serve as a guide providing specific technical details regarding the recommended MIYCN and hygiene behaviors and micro-behaviors to promote. These POPs contain the key messages to be shown in the video, some ideas for a storyline as well as the questions and answers, called annotations, to appear in the video. The POPs form the technical basis for the storyboard, which is the guidance for the video production team when going to the field and shoot the video.

To ensure cultural sensitivity while stimulating behavior and social change, we recommend that all videos showcase the following:

• Each video should show a man with several wives, but supporting and respecting each one of them
• Each wife should have several children but all well-spaced
• The mother-in-law should live in the household and play an active role in the raising of all wives’ children and provide support to her daughters-in-law.
• Older wives should be shown supporting younger wives.
• Videos should portray the age-related hierarchy, showing older women (mothers-in-law or older wives) as role models, having something to teach and providing specific support to the younger ones.

Notable findings from the formative research include:

• Handwashing is widely practiced for religious reasons but that there are no fixed stations and people do not typically use soap.
• Women receive no special care or food while pregnant or lactating and issues of multiple wives and favoritism are important barriers to adequate women’s nutrition.
• Complementary foods are not diverse and too watery; young children from 6-24 months eat from the family bowl so that the mother or other caregiver does not know how much an individual child ate.
• Breastmilk is often supplemented in the first 6 months and breastfeeding ceases when the woman becomes pregnant again.
• There is high interest and unmet need for family planning but lack of couple communication is a major barrier.
• Malaria and diarrhea are both considered normal and many don’t know that these diseases are preventable.

More specifically, the videos should:

• Provide solutions to the goats eating the handwashing soap, provide memory aids to remind people to wash hands.
• Show how one can give a child a separate plate without harming cultural practices and how to be responsive to the feeding needs of a young child.
• Show giving newborn colostrum, and that it is not harmful.
• Address beliefs surrounding breast milk: not having enough and spoiling with heat or pregnancy.
• Show examples of healthy babies at six months who have not drunk a drop of water.
• Show examples on how to diversify a young child’s diet, taking into account the difficult local context.
• Show how to increase dietary frequency using practical examples.
• Focus on the diet of women and how to adapt it according to the age and reproductive stage.
• Address the barrier stating that some diarrhea is part of normal life and does not need treatment, combine with poor sanitation linked to animal husbandry in and around the home.
• Show how intra-household discussions on harvest planning might improve the nutritional status of the family.

These results of the formative research are fundamental to the adaptation of the approach, informing the selection of priority nutrition behaviors for the videos, the adaptation of a series of nutrition sensitization trainings for key community agents, the overall strategy for the production and dissemination of the nutrition videos, and the verification points for the behavioral adoptions tracking plan.

To view the annex, please download the full report above.