From promoting scientific evidence to addressing factual beliefs and normative expectations



Download 43.58 Kb.
Date25.04.2016
Size43.58 Kb.
A SOCIAL NORMS PERSPECTIVE IN IMPROVING INFANT FEEDING IN WEST AND CENTRAL AFRICA

FROM PROMOTING SCIENTIFIC EVIDENCE TO ADDRESSING FACTUAL BELIEFS AND NORMATIVE EXPECTATIONS



Felicite TCHIBINDAT, WCARO

Regional Nutrition Advisor

West and Central Africa Regional Office

Advances in Social Norms and Social Change

University of Pennsylvania, 07/13/2012

EXECUTIVE SUMMARY

The scientific evidence shows that by promoting exclusive breastfeeding to infants less than 6 months will reduce child mortality by 13% and providing timely and adequate complementary feeding to children 6 to 24 months will reduce chronic malnutrition by 19.8%. Despite the fact that this scientific evidence has been known from decade; infant and young feeding practices remain sup-optimal in West and Central Africa.

For instance, in the Plateau region in the central part of Republic of Congo which is studied here, the rate of exclusive breastfeeding is poor; less than 15% compared to 41% in Brazzaville (capital city). Moreover, there is a widespread tendency to introduce semi-solid food before six months; more than 50% of children less than 3 months receive complementary food in Plateau region compared to 36% in Brazzaville.

Thus, the harmful practice regarding infant feeding in Plateau region is the fact that most mothers do not exclusively breastfeed because they give water with breast-milk and they introduce semi-solid food much earlier than the recommended six months. Mothers behave this way because of their mothers in law and other young mothers in their village (Conditional Preference) and because they believe that other mothers are giving water before 6 months (Empirical Expectations). They believe also that their mothers in law; other elder women and their peer believe that they ought to give water to the infant (normative expectations); if they do differently, they will be consider as bad mothers (informal sanction) and if they conform to this behaviour, they will be seen as good mother (acceptance and sense of belonging to the village). In addition, mothers give the reason that breast-milk is hot and it heats the heart of the child and water is given to cool the heart otherwise the child will die (Factual belief).

The strategies developed at local level (legislative interventions; interpersonal and group communication) succeeded in addressing some of the knowledge of young mothers but did not foster new behaviours because the network groups (especially mothers in law) which are dense and influential were not part of the intervention.
Applying social norms perspective means changing factual beliefs about water and breast-milk and also the script on good/bad mother and the healthy child; building on existing social norms of obeying to the mothers in law and fostering adherence and commitment through creative means of public discussion and deliberations. Since people’s choices are based on what they expect others in their community are doing, there will be a tipping point at which enough of the community exclusively breastfeeds, so that all of the community will decide to do so.
The main recommendations for West and Central Africa region is to change the way the promotion of optimal infant and young child feeding is done by ensuring that: i)-baseline studies explore the factual beliefs, the social norms and the network groups; ii)-the intervention is bottom-up starting with the involvement of different core groups and creating space for deliberations and commitment; and iii)- the scaling up of the intervention should be done with a good understanding of the networks and the use of creative means of changing the factual beliefs and spreading the new behaviours and scripts.
INTRODUCTION

The first two years of a child's life are particularly important, as optimal nutrition during this period will lead to reduced morbidity and mortality, reduced risk of chronic diseases and better development. WHO and UNICEFi recommendations for optimal infant and young child feeding issued in 2002 were:



  • early initiation of breastfeeding with one hour of birth;

  • exclusive breastfeeding for the first six months of life; and

  • introduction of nutritionally adequate and safe complementary foods at six months together with continued breastfeeding up to two years and beyond.

In 2003, the Lancet series on child survival provided the scientific evidence that by promoting exclusive breastfeeding, child mortality will be reduced by 13%ii. Later on in 2008, the Lancet series on maternal and child undernutrition reinforced this message and added that timely and appropriate complementary feeding will reduce chronic malnutrition by 19.8% at 12 monthsiii.

Despite this solid scientific evidence, many infants and children in West and Central Africa Region do not receive optimal feeding; only 24% of infants less than 6 months are exclusively breastfed and less than 20% of children 6-24 months receive adequate complementary feedingiv. Although the rate of exclusive breastfeeding has improved in West and Central Africa Region (WCAR) over the last decade, it remains below the other regions (ESAR1 49%; SSA2 34%).

However, some countries have made tremendous improvement: for instance, the rate of exclusive breastfeeding (EBF) has increased in Togo by 45 percentage points from 2001 to 2011 and in Ghana by 32 percentage points from 2002 to 2012 while other countries have made no or little progress (Chad: 2% and Cote d’ivoire: 4%). In the Republic of Congo, the rate of EBF is nationally 19% with wide sub-national disparities. In the Plateau region in the central part of Republic of Congo which is studied here, the rate of exclusive breastfeeding is poor; less than 15% compared to 41% in Brazzaville (capital city). With regard to complementary feeding, neither the introduction nor the nutritional composition of the foods provided meets international recommendations. For instance, there is a widespread tendency to introduce semi-solid food before six months; more than 50% of children less than 3 months receive complementary food in Plateau region compared to 36% in Brazzaville.

Thus, the main problem for infant feeding in Plateau region is the fact that most mothers do not exclusively breastfeed because they give water with breast-milk and they introduce semi-solid food much earlier than the recommended six months.




  1. WHAT HAVE BEEN THE APPROACHES TO PROMOTE OPTIMAL INFANT FEEDING PRACTICES

The importance of optimal infant and young child feeding for child survival and development has fostered different strategies and approaches to increase the rate of exclusive breastfeeding worldwide and especially in Sub-Saharan Africa.


    1. AT GLOBAL LEVEL

The Global Strategy for Infant and Young Child Feeding, endorsed by WHO Member States and the UNICEF Executive Board in 2002 is the framework through which the global community prioritizes research and development work in the area of infant and young child feeding, and provides technical support to countries to facilitate implementation. Actions that have been promoted to help protect, promote and support breastfeeding include:



  1. adoption of policies such as the ILO Maternity Protection Convention 183 and the International Code of Marketing of Breast-milk Substitutes (legal framework);

  2. implementation of the Ten Steps to successful breastfeeding specified in the Baby-friendly Hospital Initiative, including:

    1. Skin-to-skin contact between mother and baby immediately after birth and initiation of breastfeeding within the first hour of life

    2. Breastfeeding on demand (that is, as often as the child wants, day and night)

    3. Rooming-in (allowing mothers and infants to remain together 24 hours a day)

    4. Babies should not be given additional food or drink, not even water (EBF);

  3. supportive health services providing infant and young child feeding counselling during all contacts with caregivers and young children, such as during antenatal and postnatal care, well-child and sick child visits, and immunization (interpersonal communication); and;

  4. community support including mother support groups and community-based health promotion and education activities (group communication).

WHO and UNICEF developed the 40-hour Breastfeeding Counselling: A Training Course and more recently the five-day Infant and Young Child Feeding Counselling: An Integrated Course to train health workers to provide skilled support to breastfeeding mothers and help them overcome problems.




    1. AT NATIONAL AND LOCAL LEVELS

In Congo, the national code for drafted but never endorsed. In most reference hospitals, the baby friendly hospital initiative was implemented with the training of all health workers and the support from a team of national trainers.

In the Plateau region, the community resource persons’ approach was used. The community resource persons (CRPs) were all women selected by the village. They were trained on:


  • Benefits of breastfeeding;

  • Importance of exclusive breastfeeding;

  • Use of germinated maize and peanut butter to improve quality of local porridges.

In each village, one female CRP will serve twenty households. The CRP will visit each household and implement interpersonal communication around infant and young child feeding. In addition; she will organize once week a group animation to show how to germinate maize and how to prepare improved porridge.

After one year of implementation of the project, an evaluation showed that infant and young child feeding practices have improved but not in a significant way despite the work of the CRPs. Most women were knowledgeable about the benefits of breastfeeding including exclusive breastfeeding but the actual adoption of the adequate behaviour did not follow.

It was then decided to undertake an anthropological study in order to identify barriers to the adoption of EBF. This study helped to understand that in this region, milk and water were seen as dual: one was hot and the other cold. According to mothers, breast-milk heat the baby’s heart and in order to balance the temperature, it was important to give water. Hot/cold was ingrained in the way people in this region would decide their diet and the child’s diet and health.

On the complementary food, one big issue was the early introduction of food, as earlier as one week; an infant can be given cassava tuber. It is mostly done by the mother-in-law. The anthropologist tried to understand why the women will resist delaying the introduction of food. He found out that people were convinced that a baby is born with hunger. If an adult is eating and the baby cries; it means that the baby wants the food the adult is eating and so it was the norm to give to the child, the same food as the adult even if the child was a newborn.

A mother will not go against the will of her mother in law or the whole village.

Unfortunately, the results of the formative research were not used to change the way the intervention was implemented. The project ended without further changes and till today, capacity building of health workers and community resource persons; interpersonal communication are the main strategies to promote infant and young child feeding.

This approach was reinforced lately (2011) by the recently developed UNICEF new set of generic tools for programming and capacity development on community based IYCF counselling. Aimed for use in diverse country contexts, the package of tools guides local adaptation, design, planning and implementation of community based IYCF counselling and support services at scale. It also contains training tools to equip community workers (CWs), using an interactive and experiential adult learning approach, with relevant knowledge and skills on the recommended breastfeeding and complementary feeding practices for children from 0 up to 24 months, enhance their counselling, problem solving, negotiation and communication skills, and prepare them to effectively use the related counselling tools and job aids. This IYCF counseling package is supposed to be rolled out in each country.




  1. ANALYSIS OF THE PROBLEM

The problem of giving water during the first six months of life found in the Plateau region – Republic of Congo is widespread (Pattern of behaviour). Mothers conform to this behaviour because of their mothers in law and other young mothers in their village (Conditional Preference) and because they believe that other mothers are giving water before 6 months (Empirical Expectations). They believe also that their mothers in law; other elder women and their peer believe that they ought to give water to the infant (normative expectations); if they do differently, they will be consider as bad mothers (informal sanction) and if they conform to this behaviour, they will be seen as good mother (acceptance and sense of belonging to the village). In addition, mothers give the reason that breast-milk is hot and it heats the heart of the child and water is given to cool the heart otherwise the child will die (Factual belief).


During the intervention, some mothers understood importance of exclusive breast feeding but they did not adopt the new behaviour because of the fear of harming the baby (factual belief was not addressed), the fear of being seen as bad mothers (the script was not changed) and the risk of disobeying their mothers in law (social expectations were not used).
We see a pattern of behaviour such that mothers prefer to conform to it on condition that they believed that (a) most people in their relevant network conform to it (empirical expectation), and (b) that most people in their relevant network believe they ought to conform to it (normative expectation) – this is a definition of social norm according to Cristina Bicchieriv.



  1. ANALYSIS OF THE STRATEGIES

The strategies implemented at national and local levels were in line with the global guidelines with some particularities in the Plateau region:



  • The national code of marketing of breast-milk substitutes drafted as legal framework to protect breastfeeding was not endorsed till now.

  • The training of health workers and community resource persons was limited to scientific facts and did not address the factual beliefs.

  • The communication activities used materials that were not developed based on the results of the formative research and they only targeted young mothers and not the network group of mothers in law.

  • The group communication focused on how to improve complementary food but not on addressing factual beliefs and facilitating coordination among mothers and mothers in law.

The strategies developed at local level (legislative interventions; interpersonal and group communication) succeeded in addressing some of the knowledge of young mothers but did not foster new behaviours because the network groups (especially mothers in law) which are dense and influential were not part of the intervention.




  1. WHAT CAN BE DONE TO ADDRESS BETTER THIS ISSUE IN PLATEAU REGION AND MORE GLOBALLY IN WEST AND CENTRAL AFRICA REGION?

The new approaches should aim at changing factual beliefs on water and breast-milk but also changing the script on good/bad mother and the healthy child. This will be done by building on existing social norms of obeying to the mothers in law and listening to the elder women. Since people’s choices are based on what they expect others in their community to do so, it will be important to reach a tipping point at which enough of the community exclusively breastfeeds, so that all of the community will decide to do so. The scaling up of the intervention should be based on the network group analysis to identify the peripheral nodes in order to deal with the factual beliefs:




  • Changing factual beliefs: it is important to use creative ways to render visible the fact that a baby does not extra water when s/he is exclusive breastfed. It is important for mothers and mothers in law to see that breast-milk contains water (for instance, putting breast-milk in a glass of water and letting it settle down and then mothers and mothers in law can see milk in the bottom of the glass and water on top). Another issue is the notion of cold and hot; a solution can be offered which does not change this vision of the health but provide a new way of maintaining this equilibrium (To cool the child, there is no need to give water but by wash the child or humidify its body; it will achieve the same results).

  • Re-categorisation: the script of the good/bad mother will be re-categorise by promoting the good mother as the one who exclusively breastfeed her infant; by showing that exclusively breastfed infants have less diarrhoea and pneumonia.

  • Leveraging the coherence: This will be done through group communication within the network group of young mothers and mothers in law by helping them to dialogue and find their own solution. By convincing mothers in law; we build on the trust others have for them. The young mothers, the mothers in law, the traditional birth attendants and the fathers can be part of a core group through which the new behaviour is diffused. The composition of the core group needs to be confirmed by a network analysis. The network analysis will help to identify the entry point (which village to start with; who in the villages are the central nodes and the bridges) and to identify the pathways which will be used to for scaling up the intervention. Since, we’re dealing with factual beliefs; the organized diffusion will use the peripheral nodes.

  • Fostering adherence and commitment: The Congolese society is fond of local theatre; this type of entertainment can be good mean to show new behaviours and create space for argumentation and deliberations. Because older women in the Plateau village have a strong role of keeping the norms and provide advises on child rearing; it’ll be better to have group discussions around infant and young child feeding with on one side older women and in the other side young women. Mixed group will come later in order to get commitment from older women. Men will be involved in order to get their support although they have little say on the feeding of young children. In each village, there is a central place where people meet to debate critical issues that request everybody opinion and decision (it is called “Mbongui”). Using this space will help to get commitment. Other spaces can be used to diffuse the commitment: i) organizing interactive popular theatre; using stilts walkers or puppets during market places; ii) using sisterhood groups (the sisterhood groups are small groups of 5 to 10 women that support each other for the agriculture work) for deliberations.




  1. RECOMMANDATIONS FOR WEST AND CENTRAL AFRICA REGION

This case study has shown that the strategies used for improving infant and young child feeding, especially the issue of exclusive breastfeeding were incomplete and made it difficult to achieve sustained results. The whole process was also top-down which did not help to empower the communities to find their own solutions. It is recommended for West and Central Africa Region to ensure that:


  • UNICEF supports the implementation of a full-fledged qualitative study on infant and young child feeding practices that will help to understand the factual beliefs and the social norms supporting the factual beliefs and the scripts in the specific communities and the type of interventions that will bring a rapid change by using hypothetical questions (for instance, if the other mothers stop giving water or if their mothers in law tell them to stop giving water or if people in the village believe that good mothers don’t give water; what will they do?); the network groups (for instance, who listens to whom; who trusts whom; who are the central nodes; who are the bridges).

  • UNICEF supports the implementation of creative ways of changing factual beliefs and scripts by working with artists and children. First of all; a mapping of how the information is spread in the communities; the social media and other means of communication or even totally new ways of doing things will help to re-categorise the issues.

  • UNICEF supports the documenting the processes of changing factual beliefs and social norms as a mean to ensure that lessons learnt are used to improve the interventions.

  • UNICEF supports the development of tools for monitoring and evaluating social norms’ perspective in nutrition.

  • UNICEF supports local civil society organizations to create spaces for deliberation and public commitment; and artists to find creative ways of diffusion new factual beliefs and new scripts.

LLikouala



Lekoumou
Brazzaville

Pool


Cuvette

Sangha


Cuvette

Ouest

Plateaux

Niari


Kouilou

Bouenza



1 ESAR-East and Southern Africa Region

2 SSA- Sub-Saharan Africa

i http://whqlibdoc.who.int/publications/2003/9241562218.pdf

ii http://www.who.int/maternal_child_adolescent/documents/lancet_child_survival/en/

iii http://www.thelancet.com/series/maternal-and-child-undernutrition

iv http://www.unicef.org/sowc/files/SOWC_2012-Main_Report_EN_21Dec2011.pdf

v Cristina Bicchieri. Social norms, social changes. Lecture at Pennesylvania University, Summer courses (July 2012)



Share with your friends:




The database is protected by copyright ©essaydocs.org 2020
send message

    Main page