There is a total of six intervention arms including control: 1) BCC for mothers, 2) BCC for mothers and fathers, 3) food vouchers, 4) BCC for mothers and food vouchers, 5) BCC for mothers and fathers and food vouchers, and 6) control. The duration of intervention is six months, but individuals will be followed up to 12 months to see whether the child-feeding habits continue to stay with the households. All interventions have been pilot tested in the project site to refine the BCC materials and voucher procedures, and to assess the feasibility and acceptability of the interventions. All interventions will be conducted and funded by AFF.
1. Mother BCC
A behavior change communication (BCC) intervention on complementary feeding practice for mothers has been developed based on the Alive and Thrive’s BCC program materials that have been successfully implemented in Ethiopia. BCC will be delivered in groups of six through weekly sessions for a duration of 6 months. Key gaps in knowledge and barriers identified through formative studies are also addressed in the BCC modules.
We also conduct individually-tailored trainings based on participant’s food recall survey results, youngest child’s age, and child caring behavior. The training informs the participants what to eat (local sources of protein and vitamins A and C), what not to eat (e.g., excessive oil, sugar, and processed food), how much and when to eat (e.g., ideal eating frequency by age groups, when to introduce solid food for infants, when to introduce non-breastmilk liquid for infants, etc.), ideal intra-household allocation of food, and short and long-term benefits of good nutrition. Counseling will consist of comparing the household's nutrition level in terms of micro and macronutrients with the ideal standard, and helping the mothers to set monthly concrete goals. Mothers are also encouraged to keep a food log for self-monitoring. Training, counseling, and food recording is aided by highly image-oriented pictures and brochures. The training and counseling materials will follow, as appropriate, WHO and UNICEF guidelines on child growth and development.
2. Father BCC
A BCC intervention on complementary feeding practice for fathers has been developed based on the Alive and Thrive’s resources. Materials to raise awareness on gender related constraints between spouses will be adapted from Nurturing Connections developed by Helen Keller International and USAID’s infant and young child nutrition project targeting male group. Key gaps in knowledge and barriers identified through formative studies will be addressed in the BCC modules.
As the gender-related modules from Helen Keller International and USAID have not been tested for acceptability in Ethiopia, we tested the developed modules through multiple father focus group interviews and modified the contents reflecting the comments from the fathers.
Materials will be delivered in groups of six through weekly sessions for the duration of three months. As most fathers are orthodox farmers who do not work during orthodox holidays (about seven days a month), BCC training will be conducted during orthodox holidays or seven to eight am in the morning before work begins. This schedule was found to be the most convenient time from the formative study of fathers. Motivational interview technique will be used to individually counsel the fathers.
3. Food vouchers
Food vouchers are transferred monthly at the Project Office in Holeta. Eligible participants will receive approximately 15% of their monthly income, 200 ETB, estimated around US$10. Transferors will verbally state that the purpose of the vouchers is to enable households to consume healthier food and that they are nontransferable, while making clear that nothing is required of them to receive the voucher and that no rule or regulation is tied to the receipt of the transfers. Food vouchers will be distributed monthly to mothers at Holeta Project Office, and they will be given in denominations of 20 ETB to facilitate small transactions. At the first disbursement, careful instructions will be provided as to how to use the vouchers. Each voucher will have a blue-colored official stamp to prevent fake vouchers and a household identification number to be matched with household IDs to prevent transfers.
Vouchers will be redeemable for a broad list of food groups including cereals, tubers, fruits, vegetables, legumes, meats, fish, milk products, and eggs. Vouchers can be used at selected shops and regular markets in which voucher stands will be available for sellers to cash out the vouchers. Shops or sellers will be required to match the vouchers with the household IDs and to keep a record of the food items that they bought and their monetary amount. Vouchers can be used over a series of visits per month and must be redeemed within the month it was received.
Below are interventions that were considered, but not implemented
4. Access to healthy food
We originally planned to send petty traders with diverse food items to random half of the local market in the study area to assess the impact of accessibility to healthy food on feeding practices. This was taking into consideration that some mothers especially rural residents, have access to a limited set of food items in the market that they usually visit, lacking dairy, meat, vitamin A rich vegetables and fruits. However, we decided not to implement this intervention due to the political turmoil that was ongoing during the study period. Our original plan was to implement the study in 400 village. However, due to the political turmoil that was ongoing during the study period, we reduced the sample size to 105 villages of randomly selected 6 kebele (district). This resulted in limited number of local markets to implement the study.
5. Price variation of healthy foods
We planned to introduce variation in the prices of healthy foods that are sold through petty traders to estimate the impact of price on demand. This intervention was not implemented due to the political turmoil that was ongoing during the study period. We were worried that price manipulation may cause possible conflicts, risks, or misunderstanding about the NGO’s activities in the field, especially given the political and civil unrest.