Key Message Dissections on Complementary Feeding and Assessing the Favorable and Unfavorable Behaviors/Practices on Maternal Nutrition

Key Message Dissections on Complementary Feeding and Assessing the Favorable and Unfavorable Behaviors/Practices on Maternal Nutrition

1. Dissection of key message on the basis of K-A-B-A perspectives
1. Introduction/Identification of the message
The message on “Complementary Feeding Practice” was selected from “Maternal, Infant
and Young Child Nutrition (MIYCN) Flipchart-2072” published by former Child Health
Division (CHD)/Department of health Services in the fiscal year 2072. This flipchart can
also be found from the given link
http://www.chd.gov.np/downloads/3%20MIYCN_Flipchart.pdf [1]. This was developed
and printed in technical and financial support of USAID.

2. Target audience of message
This message is targeted for mothers of 6-24 months of children. When breast milk is no
longer enough to meet the nutritional needs of the infant, complementary foods should
be added to the diet of the child. The transition from exclusive breastfeeding to family
foods, referred to as complementary feeding, typically covers the period from 6 to 24
months of age, and is a very vulnerable period. It is the time when malnutrition starts in
many infants, contributing significantly to the high prevalence of malnutrition.

2. 3. Literature review
Inappropriate complementary feeding practice is one of the main reasons for
malnutrition among Nepal children aged less than two years. Exclusive breastfeeding
for the first six months followed by complementary feeding along with breastfeeding is
vital for proper growth and development of a child [4]. Appropriate diet is critical in
growth and development of children especially in the first two years of life. Infant and
young child feeding practices recommend exclusive breastfeeding up to age of six
months, timely initiation of feeding solid, semisolid foods from six months onwards
(WHO, 2003). It also recommends feeding small amounts, increasing the amount of
foods and frequency of feeding as the child gets older while maintaining breast feeding
as demanded by the child. (WHO, 2009).An inadequate complementary food is a major
cause of the very high prevalence of malnutrition in the developing world and this may
have long-term implications for growth, development, and health [5].
NDHS Report 2016 shows, 47%of children age 6-23 months receive meals with the
minimum recommended diversity (at least four food groups), 71% receive meals at the
minimum frequency, and 36% meet the criteria of a minimum acceptable diet. 45% of
children under age 2 are breastfed within 1 hour of birth, and 66% of children under age
6 months are exclusively breastfed. Thirty-six percent of children under age 5 are
stunted (short for their age), 10% are wasted (thin for their height), 27% are
underweight (thin for their age), and 1% are overweight (heavy for their height) [3].
Complementary feeding is required in appropriate quantity, quality, and frequency to
fulfill the daily energy needs for growth and development of child. Cultural practices;
beliefs and knowledge of parents regarding appropriate feeding practices influence
complementary foods.
It has been shown in India that only 17.5% of mothers started complementary feeding at
recommended time (at 6 months of age), 77% had delayed complementary feeding and
5.5% started complementary feeding early [6].
6 to 24 months of age is a very vulnerable period. It is the time when malnutrition starts
in many infants, contributing to the high prevalence of malnutrition in children under
five years of age world-wide. WHO estimates that 2 out of 5 children are stunted in low-
income countries. WHO recommends Complementary feeding shou ld be timely,
meaning that all infants should start receiving foods in addition to breast milk from 6
months onwards. It should be adequate, meaning that the complementary foods should
be given in amounts, frequency, consistency and using a variety of foods to cover the
nutritional needs of the growing child. WHO recommends that infants start receiving
complementary foods at 6 months of age in addition to breast milk, initially 2-3 times a
day between 6-8 months, increasing to 3-4 times daily between 9-11 months and 12-24
months with additional nutritious snacks offered 1-2 times per day, as desired [2].

3. 4. Details of message
i. Format/design
 The Message have attractive caption which give concept about complementary
feeding and related behaviors
 The message is kept inside the rectangular text box with bold letters and different
suitable color has used to make visible and attractive.
 The Message have clear, simple and understanding figures with symbolic of
Frequency and quantity of food complementary food consumption
 The major key message and related other information are in the form of text
message and has addressed the areas of behavior change for Infant and young
child feeding practices recommend exclusive breastfeeding up to age of six
months, timely initiation of feeding solid, semisolid foods from six months
onwards.
ii. Focus of key message
 A child of 6-9 months should have 3 times complementary feeding in a day along
with breastfed. In initial should start with 2-3 small spoon and gradual increase
up to one tea glass (125 ml) feedings in a one time.
 A child of 9-12 months should have 3 times complementary feeding (Up to one
tea glass every time) and one times snacks along with breastfed.
 A child of 12-9 months should have 3 times complementary feeding (Up to two
tea glasses (250 ml) every time) and two times snacks along with breastfed.
 The meal should have soft, semi-solid and dense (No high amount of water).
 Ensure “HAREK BAR, KHANA CHAR”.
 Use iodized salt and filtered and boiled water
 Active feeding to children by playing, providing dolls, singing etc. to encourage
feed more.
 Special attention should maintain for hygiene and sanitation.
 Regular growth monitoring of children to ensure the nutrition.
 Encourage parents to have Vitamin-A to their children
iii. Supporting Messages
 Exclusive breastfeeding provides all the energy to baby needs from birth to 6
months of age.
 Continuous breastfeeding from 6 months to 12 months of age provides half of the
energy while another half of energy comes from the complementary feeding.
 Continuous breast feeding from 12 to 24 months of age provides 1/3
rd
of energy
while energy comes from the complementary feedings.

4. iv. Interpretation of the form of messages
 In the given message the lunar sun indicates morning, complete sun indicates day
(noon) time and moon indicates the evening time. Its means a baby should have
at least three times of feeding in a day.
 The flip have visible and clear pictorial messages on complementary feedings
with recommended behavior for healthy feeding practices.
 There is different column of messages for different age groups.
 In the bottom of flips there are additional recommended practices like use of
iodized salt, filtered and boiled water and regular growth monitoring of children.
v. Language in which messages are written
 The message are written in Nepali language
5. Dissection of message on K-A-B-A perspectives:
Knowledge and Attitude:
The message basically have focused to provide knowledge on
 Importance of breastfeeding up to 6-23 months of children
 Features of complementary feedings (AFATVAH: Age, Frequency, Amount,
Thickness, Variety, Active feeding, Hygiene)
 Recommended food and practices according to different age group (6-9, 9-12, 12-
24 months).
 Encourage to promote locally available foods items and production
 Additional behavior like consumption of iodized salts, boiled/filtered water,
Vitamin A and growth monitoring.
 Active feeding to child
 Encourage to maintain personal hygiene .
Recommended Behaviours:
 A child of 6-9 months should have 3 times complementary feeding in a day along
with breastfed. In initial should start with 2-3 small spoon and gradual increase
up to one tea glass (125 ml) feedings in a one time.
 A child of 9-12 months should have 3 times complementary feeding (Up to one
tea glass every time) and one times snacks along with breastfed.
 A child of 12-9 months should have 3 times complementary feeding (Up to two
tea glasses (250 ml) every time) and two times snacks along with breastfed.
 The meal should have soft, semi-solid and dense/thickness (No high amount of
water).

5. Action oriented message:
a. Active Feedings:
 Encourage children to feed as much as possible with active and patience to
feed their children.
 Feeding time is a time for children to learn and getting love so feed them
with playing and talking.
 Family member should also be active to feed the children well.
 Appreciating children complimenting children with happiness.
 Make happy to baby by telling story and playing with toys .
 Use clean bowls and spoons when feeding

b. Sanitation and Hygiene Maintenance
 Washing hands with soapy water before cooking, before meals, and before
feeding children, before touching.
 The child should wash his hands with soapy water before eating food
 Use only purified (Boiled, filtered, use chlorine) water.
 All members of the household pay attention to hygiene

c. Ensure “HAREK BAR, KHANA CHAR”.
 Ensure the at least one food items from the each four categories of food
items in every feedings like Cereals (maize, wheat, corn, rice, kodo, fapar,
potatoes, sweat potato etc), Gedagudi (Beans, lentils, grams, almond),
Fruits and Vegetables, meat and animal products.

d. Additional actions and recommended practices/behaviors
 Regular growth monitoring to ensure the nutritional status
 Vitamin A to every child.
6. Critical analysis of the Message
Pros:
 Readability: The different messages and features of complementary feeding for
different age groups have a separate column that make easy to understand. The
text messages are readable and understandable. The texts are colored and kept
inside the rectangular box.
 Pictorial interpretation: The design of picture is generally good as it consist
of picture and text messages too. Each supportive message consists of distinct
picture.
 Availability: This booklet is available on all types of government health
institutions. And we can also get it from the website of FWD.
 The features of MIYCN (AFATVAH) in horizontal line and age group of children
in vertical line have clarified the messages according to age groups.

6.  The pictorial message below the flips have also emphasized on additional
practices should ensure along with MIYCN practices like use iodized salts,
Vitamin A supplementation, growth monitoring and water purification which are
the supporting actions to enhance the nutrition status of children.
 Multiple features of MIYCN practices have mentioned in single sheets so it make
easy to gain information from one flip and in short time.
 There is logo of MoHP, USAID and SUAAHARA in the bottom of flip which
represents the publication from a authorized body so it is valid flip we can also
assume from the logo that this flip has been published in the financial and
technical support of MohP, USAIND and SUAAHARA.

Cons:
 Almost all messages are in pictorial form which needs more explanation to make
understand to illiterate/lay people.
 The complexity (8 columns of MIYCN features, 3 rows of age group and 1 rows of
supporting action) of messages may take time to understand and interpret it.
 Sometimes lay man people can misinterpret the actual message of pictorial form
because in the flips almost all the messages are in pictorial form
 Illiterates couldn’t understand the message by viewing the pictures only.
8. Conclusion
The Knowledge on feeding practices of infants and young children is essential for
improving health and nutrition status. Promotion of optimal breast feeding and
complementary feeding has been expected as a key strategy of promoting nutritional
status of children and management of malnutrition. Hence, these messages provide the
knowledge and information about proper feeding practices among under 2 years
children. From the K-A-B-A perspectives it has more emphasize on proper feeding
practices, and action to be taken to promote the nutrition status of children.
9. Recommendations
 Make a simple flips and no more messages in single sheets
 Define the meanings of Symbolic messages like meaning of half sun, full sun and
moon in the given pictures.


7. Assessment of Favorable and Unfavorable Behaviours/Practices on
Maternal Nutrition
Introduction
Pregnancy and postpartum period is the most crucial nutritionally demanding period of
every woman’s life. The high demand of nutrients to deposit energy in the form of new
tissue, growth of existing maternal tissues such as breast and uterus and increased
energy requirements for tissue synthesis makes pregnant women more vulnerable to
malnutrition. Dietary practice is defined as an observable actions or behavior of dietary
habit and can be classified as good dietary practices and poor dietary practices. The
incidence of dietary inadequacies as a result of dietary habits and patterns in pregnancy
is higher during pregnancy when compared to any other stage of the life cycle.
Objectives of Assessments
 To assess the dietary practices (Favorable and Unfavorable behavior) and
associated factors during pregnancy and postpartum period
Methodology
Literature review was done to identify the variables of maternal nutrition. And from the
review of different literature I got the following variables to assess the favorable and
unfavorable behaviors of maternal nutrition:
a. Dietary intake
b. Food avoidances
c. Dietary taboos
d. Decision making power in family
e. Physical workload
f. Health seeking behaviors (Iron intake, ANC/PNC Visits, Nutrition practices)
Based on the variables, questionnaire was developed to assess the favorable and
unfavorable nutritional behavior among pregnant and postpartum mothers. The
collected information have analyzed to assess the practices/behaviors.
Findings
a. Dietary Intakes
Favorable Behaviors Unfavorable
Behaviors
Associated Factors
Same amount and
frequency of food
consumption in
pregnancy as in normal
No adequate knowledge
that extra energy is
required during the
pregnancy period

8. period
No follow up of “HAREK
BAR, KHANA CHAR”
and no balanced diet
No knowledge about
every meal should have
at least one items from
the four types of
categorize food items like
Cereals, Meat and animal
products, fruits and
vegetables and Gedagudi.
Use locally available
vegetables in their farm

No timely eating Busy in indoor works and
no support from family
members
Use of filtered water
Use of Iodized salts
(having logo of two child)
No proper tighten of
cover and open
insincerity

b. Food Avoidance
Favorable Behaviors Unfavorable
Behaviors
Associated Factors
No green leafy vegetables
consumption
Mother thinks it cause
diarrhoea and cold to
baby
Use of chilly and Spicy
foods
It gives tastes for foods.
Avoidance of fish/meats Bad scent/smell
associated with vomiting
tendency in some mother
Use of Pickles and acetic
foods more
It is believe that acetic
food decrease the
tendency of vomiting in
pregnancy

c. Dietary Taboos
Favorable Behaviors Unfavorable
Behaviors
Associated Factors
Fasting during pregnancy
No colostrum feeding to
baby
It is believed that
colostrum milk is
unhygienic so it should
not feed to baby
Practice of feeding honey
to newborn baby
It is believed that feeding
sweet foods to baby will
speak polite and gentle

9. talk in their future life
Avoidance of hot and cold
foods



d. Decision making power in family
Favorable Behaviors Unfavorable
Behaviors
Associated Factors
Practice of taking meal
after eating the male and
senior member of family
Traditional Beliefs
Male member gives
priority in selection for
nutrition decision (Choice
of what to eat)
Male dominant society



e. Health Seeking Behaviors
Favorable Behavior Unfavorable
Behaviors
Associated Factors
ANC and PNC check up
Use of Iron and folic acid
Immunization
No exclusive breast
feeding up to 6 months.
Inadequate knowledge
no aware about the
importance of exclusive
breastfeeding
Bottle feeding to their
child

No colostrum feeding
Heavy loading in
pregnancy
No family support,
Nuclear family
No personal and
environment hygiene
maintenance

Dry food consumptions

Conclusion
Maternal dietary practices during pregnancy and postpartum play an important role in
determining the long-term health and nutritional status of both the mother and her
growing fetus. Poor dietary practices during pregnancy may result in increased rates of
stillbirths, premature birth, low birth weight, maternal and prenatal death.

10. Dietary practices of pregnant and postpartum women were suboptimal some have good
practices and some have conservative believes towards the food consumption. Maternal
nutrition regarding specific dietary practices such as skipping usual diets, avoiding
certain food items and consumption of fresh fruits and vegetables were sub optimal.
Pregnant women having good dietary knowledge were more likely to have good dietary
practices compared to women who do not have dietary knowledge. Dietary practices can
be influenced by culture, socioeconomic and environmental determinants.
Recommendations
 Improving knowledge on nutrition through nutrition education and integrating
key nutrition messages.
 Social and Behavior change communication (SBCC) for changing unhealthy
behavior and practices among mothers
 Availability of food stocks in the home
 Family support to pregnant women and postpartum mothers

11. Health Education, Promotion and Communication Approaches
of NHEICC
Introduction
In Nepal, health communication program began with the starting of promotive and
preventive health services and National Health Education, Information and
Communication Centre (NHEICC) was established under the Department of Health
Services (DoHS) in 1993 for planning, implementation, monitoring and evaluation of
health promotion and communication programs of all health programs and services in
an integrated manner.
All of the health offices have health education, information and communication
programs since 1993. There is health education and communication (HEC) Section in
the provincial Health Directorates, Training and Health Information Section in the
Health Offices in the district. These sections implement health promotion and education
and health communication activities utilizing various media and methods according to
the needs of the local people in the region, district and community.
Local media and languages are used in the district and community for the dissemination
of health messages so that people can understand health messages clearly in their local
context and language. So, NHEICC not only develop, produce and disseminate IEC/BCC
materials but also plan, implement, monitor and evaluate all health promotion and
education and health communication programs.
Developing, producing and disseminating health messages and materials to promote
and support health programs and services in an integrated manner is part of the
responsibility to achieve national health goals and the SDGs. The center is the lead for
all health promotion, education and communication programmes including multi-
sectoral health initiatives. The center uses advocacy, social mobilization and marketing,
behavior change and community led social change strategies to implement its
programmes.
Goal of NHEICC
The goal of the National Health Education, information and Communication
program is to contribute to attaining the national health programme goals and
objectives by providing support for all health services and programmes.

12. NHEICC Objectives:
General Objective
To raise the health awareness of the people as a means to promote improved
health status and to prevent disease through the efforts of the people themselves
and through full utilization of available resources.
Specific Objectives
• Increase awareness and knowledge of the people on health issues.
• Promote desired behavior change on EHCS and beyond.
• Create demand for quality EHCS among all castes and ethnic groups, and
disadvantaged and hard to reach populations.
• Advocate for required resources (human and financial) and capacity
development.
• Increase access to new information and technology on health programmes.
• Control Non Communicable Diseases (NCDs) and its risk factors.

Major Strategies of NHEICC

Advocacy - Get political and social commitment and gain support for specific
health issues for the successful implementation of the program

Social mobilization – mobilize society, network and resources at the district
and community level for the successful implementation of the program

Behavior Change Communication - inform people about health issues,
services available and promote positive behaviors

Process of Media/Material Production and Distribution



NHEICC Approaches :
• Health communication programs will be implemented through health structures
at federal, province and local level in decentralized manner.
• Coordination and collaboration with local bodies and other stakeholders for
implementing health communication programs in decentralized manner.

13. • Policy of planning and implementing health related communication programs of
all health service and programs in one door system and integrated approach will
be implemented through Ministry of Health and Population, NHEICC.
• Advocacy, community mobilization and behavior change communication
programs will be implemented at different levels by formulating subject wise
health communication strategies of health services and programs in an integrated
manner.
• Health communication programs of different health service and programs will be
integrated while formulating annual programs and budget of Ministry of Health
and Population and will be implemented through NHEICC
• Budget will be allocated annually according to the policy for the implementation
of health communication related programs while formulating annual program
and budget.
• The bodies under UN and external development partners will be encouraged and
facilitated to invest in health communication programs.
• Certain tax will be levied on any services or commodities used by general public
and on behavior or commodities that adversely affect health. Some percent of the
tax will be deposited in health messages or information dissemination
management fund for utilizing to implement health promotion and
communication programs.
• The practice of free distribution and use will be discouraged and managed by
developing standards of health related communication messages or information,
materials, equipment and services.
• Health Communication Coordination Committee will be formed comprising
stakeholders to assist in the implementation of policy and decisions taken by high
level health communication direction committee.
• Adolescents, youths, journalists, professionals, institution and various
organizations will be mobilized for the promotion of healthy behavior, basic
health services and programs in coordination and collaboration with different
relevant ministries and institutions.
• Modern electronic communication media such as radio, television, FM radio,
website, telephone, mobile etc will also be used timely to disseminate health
messages. Arrangements will be made to include health message and its link in
all governmental websites.
• Booklet, pamphlet, poster, calendar, dairy, signage, sticker, flip-chart, wall chart,
flyer, flash card, flex, bulletin hoarding board will be produced, published and
displayed for effective dissemination of health message or information.
• Also health messages or information will be published and displayed through
various means and materials like outer cover page of text and practical books,
package and bags of various materials and food items, tickets, postal letters, T-
shirts.

14. • Traditional and local folk art, culture and rituals like Maruni, Rodi, Dhan Nach,
Shakewa Nach, Nautanki, Dohori Geet, Deuda, Ghatu, Dhami Jhankri, Gaine,
Fine Art, Street Drama, Puppet Dance, Miking etc of powerful folk
communication media and its related arts will be used timely to disseminate
health related messages or information.
• Various carnivals, festivals, days, events, exhibitions will be organized to spread
health message and information effectively up to the public community.
• Innovative ideas of art especially articles, Radio and Television program,
Interaction, Drama, Film, songs with message, dance, fine art, sculpture etc will
be encouraged for raising health awareness. Other sectors will also be encouraged
for conducting similar types of activities.
• Interpersonal communication program will be promoted upto the doorsteps of
the people through community groups, local organizations, schools, FCHVs,
students, teachers, religious leaders, media, health workers and influential
persons.


NHEICC Program Components and Scopes
S.N. Program Components Scope and Function
1 Health Promotion • Standardize, regulate and update
health promotion, education and
communication related initiatives
and contents.
• Develop, produce and
disseminate messages, materials
and tools.
• Ensure target audience centric
approach.
• Conduct periodic formative
studies for evidence based
planning.
• Coordinate initiatives to promote
healthy life style.
• Provide strategic guidelines to
partner organization to plan
evidence based promotion of
intervention.

2 Environmental Health,
communicable Diseases control
program
• Develop, implement and update
framework and strategies for
multi – sectoral collaboration to
improve environmental and
occupational health

15. • Develop community/school
based health and hygiene
programs
3 Reproductive Health and Child Health • Develop, Implement and update
evidence based strategies and
action plan to promote maternal,
newborn, and child health, sexual
and reproductive health and
multi sector nutrition plan.
• Provide health promotion,
education and communication
technical support to maternal,
newborn, and child health, sexual
and reproductive health
programs.

4. NCDs and Tobacco Control • Standardize, regulate and update
NCD and its risk factors related
health promotion, education and
communication initiatives.
• Develop, produce and
disseminate messages, materials
and tools
• Collaborate with State and non-
state partners for maximize
program outreach

5. Public Health Emergency,
Preparedness and Responses
• Develop and update public health
emergency communication
preparedness and response plan
• Ensure allocation of contingency
fund from stakeholders.
• Ensure availability of preposition
materials.


Decentralized Activities of NHEICC
a. At federal level
• Support development of policy and strategy health promotion, education
and health communication program
• Implement National Health Communication Policy 2012
• Development of program and budget for central, region, district and
community.
• Development of Program guideline and directives

16. • Development and publication of health messages through Newspapers
• Development, production, dissemination and distribution of IEC/BCC
materials
• Program orientation to regional & district level program manager & focal
person
• Advocacy -Global Hand Washing Day, World Health Day and World No
Tobacco Day Celebration
• Coordination – conduct Technical Committees meetings
• Capacity building on health promotion, education and health
communication
• Conduct health promotion, education and health communication
researches
• Supervision, Monitoring and evaluation of health promotion, education &
health communication program
• Conduct Non-communicable disease (NCD) & its risk factors control
program
• Conduction of environmental health, hygiene and sanitation program
• Press meet and health news collection, distribution and dissemination
• Knowledge management particularly Health Library and its management

b. At Province Level
• Regional mass media activities
• Supervision and Monitoring of IEC/BCC activities
• Sensitization program for prevention and control of epidemics
• Distribution of IEC materials through Regional medical stores

c. At Local Level
• Strengthen district IEC corner by supporting electronic equipment
• Sensitization program for prevention and control of epidemics
• Production of need based IEC materials
• Production & airing of health radio programs & messages including family
planning through local FM radio
• Exhibition to promote health services & programs
• Publication of health messages in print media
• Community interaction program for health service promotion
• Establishment and management of IEC corner in each health facilities
• IEC program on anti-tobacco and non-communicable diseases control
• Supervision and Monitoring of IEC activities
• Celebration of Health days
Issues:

17. • Limited BCC and demand generation activities focusing on hard to reach
populations
• IEC/BCC related message and material not adequately distributed through
online, electronic and social media.
• Inadequate personnel for designing and developing message and media.
• Performance gap among health education personnel
• Limited focus on NCDs
• Less priority program in local levels
• Inadequate allocation of budget on the basis of planned programs
• Delayed in disbursement of IEC in hard to reach area
• Inadequate compliance with one-door policy and duplication of IEC activities
• Abstinence of health promotion and IEC program in HMIS.

Recommendations
• All government organizations, INGOs, NGOs and other stakeholders should
follow the policy
• Proper policy making and implementation of program on the basis of changing
situations
• Adequate dissemination of budget and proper program planning according to the
needs and priorities
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