the implementation of in-home fortification and nutrition

In-Home Fortification Phase 1 Report

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The Implementation of In-Home Fortification and

Nutrition Education to Combat Anaemia and

Micronutrient Deficiencies Among Children 6-23

Months in Rwanda

Phase 1 Final Report

Funded by UNICEF

December 26, 2011

Republic of Rwanda

Ministry of Health

Prepared by: Kathy Ho and Judy McLean, PhD


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Acknowledgments

We are grateful to UNICEF for funding Phase 1 of the In-Home Fortification Project. We would

also like to thank Concern Worldwide, Care International, World Vision, and the institutional

advisors from INATEK, UBC, and NURSPH without whom this work could not have been

possible.

We would like to gratefully acknowledge the student survey teams for their time and superior

effort on Phase 1 of the In-Home Fortification Project in Rwanda.


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List of Abbreviations and Acronyms

BCC Behavior Change Communication

CHW Community Health Workers

DHS Demographic Health Survey

DPEM District Plans to Eliminate Malnutrition

IEC Information Education Communication

INATEK Institute of Agriculture and Technology in Kibungo

MDG Millennium Development Goals

MNP Multiple Micronutrient Powders

MoH Ministry of Health

NSEM National Strategy to Eliminate Malnutrition

NGO Non-Governmental Organization

NURSPH/NUR National University School of Public Health

UBC University of British Columbia, Canada

UNICEF United Nations Children’s Fund

USAID United States Agency for International Development

WFP World Food Program

WHO World Health Organization

WRA Women of Reproductive Age


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Table of Contents

Acknowledgments........................................................................................................................... 2

List of Abbreviations and Acronyms .............................................................................................. 3

List of Tables ................................................................................................................................... 6

Executive Summary ........................................................................................................................ 7

1. Background ............................................................................................................................... 10

1.1. Rationale for In-Home Fortification ........................................................................................................ 12

1.2. Goals ........................................................................................................................................................ 13

1.3. Objectives ................................................................................................................................................ 14

1.4. Activities .................................................................................................................................................. 15

2. Methods..................................................................................................................................... 15

2.1. Interview Instrument ................................................................................................................................ 15

2.2. Interviewed Population ............................................................................................................................ 16

2.2.1. For mothers and caregivers ............................................................................................................... 17

2.3. Sample Design ......................................................................................................................................... 17

2.4. Training .................................................................................................................................................... 18

2.6. Data Entry and Analysis ........................................................................................................................... 23

3. Results ....................................................................................................................................... 24

3.1. Introduction .............................................................................................................................................. 24

3.2. Breastfeeding and Complementary Feeding ............................................................................................ 26

3.2.1. Household Feeding Practices and Food Preferences ........................................................................ 31

3.3. Anaemia ................................................................................................................................................... 36

3.4. Sprinkles .................................................................................................................................................. 43

3.5. Summary of Results ................................................................................................................................. 51

4. Discussion ................................................................................................................................. 53


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4.1. Introduction .............................................................................................................................................. 53

4.2. Complementary Feeding .......................................................................................................................... 55

Recommendations ........................................................................................................................................... 55

4.2.1.Quantity ............................................................................................................................................. 55

4.2.2. Responsive Feeding .......................................................................................................................... 57

4.2.3. Frequency .......................................................................................................................................... 57

4.2.4. Variety and Nutrients ........................................................................................................................ 58

4.3. General Nutrition Knowledge .................................................................................................................. 60

4.4. Anaemia-Specific Knowledge and Treatment .......................................................................................... 61

4.5. Caregivers Response to MNP .................................................................................................................. 62

4.6. Limitations ............................................................................................................................................... 64

Appendix 1: Contributions .............................................................................................................................. 64

Appendix 2. FGD consent form ...................................................................................................................... 64

Appendix 3. Semi-structured interview consent form .................................................................................... 66

Appendix 4. Focus Group Discussion Guide .................................................................................................. 69

Appendix 5. Healthcare key informant interview guide ................................................................................. 94

Appendix 6. Sampling Methodology ............................................................................................................ 120

References ................................................................................................................................... 137


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List of Tables

Table 1: Interviews per sector ....................................................................................................... 16

Table 2: Field work support by in-home fortification team .......................................................... 19

Table 3: Field Activities Completed in Musanze ......................................................................... 20

Table 4: Field Activities Completed in Nyaruguru ....................................................................... 21


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Executive Summary

This formative work was conducted to inform the development of guidelines for the

implementation of an in-home fortification with multiple micronutrient powders (MNP) program

to be integrated with complementary feeding for young children 6-23 months of age in Rwanda.

Strong support was provided by UNICEF and key NGO partners, which led to very successful

outcomes for Phase 1 of the three Phase program.

As a backdrop to the proposed program, Rwanda is very committed to achieving the Millennium

Development Goals and has developed numerous national policies and strategies to that end that

integrate food security and nutrition with poverty alleviation. In particular, there is a National

Strategy to Eliminate Malnutrition (NSEM, 2010), Vision 2020, the Poverty Reduction Strategy

Paper, the National Policy on Health, and the National Policy on Agriculture, all of which have a

focus on the promotion of better nutrition for the population and introduce steps that are

perceived will have an impact, particularly for young children. As stated in the NSEM, “The

nutritional situation in Rwanda remains persistently poor. For the last two decades,

undernutrition remains a significant public health problem contributing to the high infant, child

and maternal mortality.” Our work is aimed at supporting government initiatives targeted at

reducing malnutrition with a focus on nutritional anaemia.

Phase 1 identified many key areas of weakness that need to be addressed in programs aimed at

reducing undernutrition, but also areas of strength. In-home fortification is not a stand-alone

intervention but is part of infant and young child feeding practices as recommended by the WHO

in areas where there is a high prevalence of anaemia among children and iron-fortified foods are

not affordable or available. WHO guidelines are being finalized in accordance with the results of

recent meta-analysis 1-3.

Our findings make clear that caregivers understanding of appropriate feeding practices for young

children is very limited with a highly apparent lack of knowledge regarding the importance of

energy dense foods or key foods important for reducing the risk of micronutrient deficiencies.

Energy dense foods are particularly important in Rwanda as stunting is highly prevalent and fat

intake is considered to be the lowest in the world. Stunting, low ‘height for age’, is a commonly


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considered to be a physiological response to inadequate nutrition during the first ‘1000 days’ of

life, or conception to about 2 years of age. Early child growth is dependant on children being

introduced to complementary foods that are timely, of adequate quantity, consistency, frequency,

and quality4-10. The focus in Rwanda among mothers and caregivers is on a ‘balanced diet’,

which may or may not meet the energy needs of a growing child11.

Of importance, the diet is very low in animal foods that are key sources of minerals, particularly

iron, as well as providers of high quality protein and essential fatty acids6, 11-15. It is clear that

these foods are not accessible on a regular basis to most families making preventing deficiencies

challenging. There is little knowledge among health care providers or caregivers of foods that

can help prevent anaemia, with common examples being tree tomatoes and green vegetables.

While the latter may contain iron it is poorly absorbed and there is not evidence that it will

prevent anaemia16-18. Tree tomatoes do not contain appreciable iron but are an example of the

widespread misinformation in the communities. Iron-fortified foods are not accessible due to

cost, making in-home fortification an important intervention in this region.

It is widely apparent that a strong complementary feeding education protocol is needed 19-22 and

the MNP program will greatly help as it is not a stand-alone intervention but will be introduced

as part of improved infant and young child feeding. Messages for caregivers will be targeted to

the needs of young children for growth to include frequent feedings of energy dense thick

porridge made from grains, with added foods such as meat, eggs, fish, ground nut paste,

avocadoes, where available. Oil or other fat should be added to porridge every time in

accordance with the current ‘Essential Nutrition Actions’. Fruits and vegetables add small

amounts of micronutrients, and variety promotes a wider acceptance of food but they are

generally lower in energy density and micronutrient bioavailability, other than vitamin C.

Poverty is an obvious issue but nutrition knowledge can still play a role as foods such as oil may

be present but family members may not know the high needs children have for fat in the diet.

Similarly small amounts of organ meats, rich in iron and vitamin A, can be added to children’s

food and may be present but their value not known.


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Few differences were found between districts although more did comment on limited access to

food in Nyraguuru. These limitations must be considered in the final implementation,

particularly with regard to suitable foods to which the MNP may be added.

It is quite likely that the in-home fortification program will be well received if messages are

properly delivered to caregivers as they were very receptive to the concept and expressed

willingness to add MNP to their children’s food. Of importance, caregivers want clear and

accurate information. Messages must be developed with that in mind and community health

workers and health staff must be trained such that they can provide answers to caregivers

questions.

Caregivers discussed important sources of information or where they would like to hear about

MNP and recommendations included radio, community health workers and other health care

providers. It is recognized that messages must be consistent, clear and frequently delivered if

they are to be effective at changing behaviours.19, 20


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1. Background

Micronutrient malnutrition, particularly among children under the age of five, continues to be a

challenge worldwide. Iron deficiency anaemia is the single most prevalent micronutrient

deficiency, affecting 56% of under the age of five children globally6, 17. The Government of

Rwanda recognizes the importance of improving the nutritional status of young children and it

has become a forefront public health priority as indicated by the recently published 2010

National Multisectoral Strategy to Eliminate Malnutrition in Rwanda following the official

prioritization of the fight against malnutrition.

According to the 2007/8 Rwanda Interim Demographic and Health Survey (RIDHS)1, 48% of

children under the age of five in Rwanda are anaemic. The prevalence of anaemia is even higher

among 6-9 month old children (77%). Anaemia among young children contributes to frequent

illnesses, decreased physical and cognitive development, and poor school performance, which

greatly affects the capacity and ultimately the productivity of those afflicted23-26. Indirectly, the

high prevalence of anaemia contributes to the current infant mortality rate in Rwanda which is

estimated at 62 per 1,000 live births2.

With respect to nutrition through the lifecycle, the first 2 years of life are crucial for the

development of the brain, motor skills and social-emotional skills. Children who suffer from

deficiencies of micronutrients early in life, particularly iron and iodine, are at higher risk of

suffering from irreversible impairment of physical and cognitive development, extending the

cycle of undernutrition and poverty27-30. The critical developmental period is often referred to as

the ‘1000 days’, which includes the time from conception into the first couple of years of life.

1 Ministry of Health(MOH) [Rwanda], National Institute of Statistics of Rwanda (NISR), and ICF Macro. 2009. Rwanda Interim Demographic Health Survey 2007-08. Calverton, Maryland, U.S.A.: MOH, NISR, and ICF Macro.

2 Ministry of Health(MOH) [Rwanda], National Institute of Statistics of Rwanda (NISR), and ICF Macro. 2009. Rwanda Interim Demographic Health Survey 2007-08. Calverton, Maryland, U.S.A.: MOH, NISR, and ICF Macro.


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The primary cause of anaemia among young children is insufficient bioavailable dietary iron

intake in relation to the high iron needs to support rapid growth and brain development18, 31-33.

For young children physiological iron requirements (as shown in Figure 1) are highest at a time

of life when they have limited stomach capacity which makes it difficult in the best of

circumstances to consume enough iron rich foods. The Rwandan diet is primarily plant based

with plantains, cassava, sweet potatoes and potatoes providing the majority of food energy. The

high level of anaemia among children in combination with what is known about the amount of

bioavailable iron in the Rwandan diet means that even if infant and young child feeding practices

were improved iron needs could not be met for young children.

Figure 1: Iron needs per kilogram body weight

It is generally recommended that when the amount of bioavailable iron cannot be immediately

improved through the diet, alternative measures, including supplementation, must be considered

to control iron deficiency anaemia6, 34, 35. This is the current situation in Rwanda. Apart from

improving overall health care and sanitation to reduce disease-related causes of anaemia, an

acceptable alternative to supplementation that has demonstrated success in other countries with

high compliance is in-home micronutrient fortification. The Community Based Nutrition


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Programme (CBNP) strategy, as described in Strategy 2 of the National Multi-Sectoral Strategy

to Eliminate Malnutrition in Rwanda, clearly indicates the importance of in-home fortification

using Micronutrient Powders (MNP). Accordingly, developing an appropriate program to

implement this recommendation is of utmost importance for young children especially those

aged between 6-23 months who are at the highest risk of anaemia and perhaps other

micronutrient deficiencies and their consequences.

1.1. Rationale for In-Home Fortification

Current strategies to improve micronutrient status include improved dietary diversification,

individual supplementation, biofortification of crops, and staple food fortification6, 19, 36-39. None

of these strategies specifically target iron-deficiency anaemia in the age group most susceptible,

infants aged 6-23 months, a crucial period of rapid growth and development translating into

higher iron needs (as shown in Figure 1).

An alternative strategy to combat childhood micronutrient deficiencies is through ‘in-home

fortification,’ which provides vulnerable populations with a multiple vitamin and mineral

preparation that can be directly added to foods prepared in the home1, 3. This concept enables

families to ‘fortify’ their young children’s foods at an appropriate and safe level with the needed

micronutrients at home. The preparations used are called micronutrient powders, or MNP, with

‘Sprinkles®’ being the most widely tested and used worldwide40-47.

MNP have been shown to be as effective in treating and preventing anaemia as iron syrup and

are better accepted and cause fewer side effects3. MNP have been found to reduce anaemia in

young children between 6 and 24 months by about 45%. In two studies (Bangladesh and Haiti),

the impact of MNP was found to be maintained even 6 to 7 months after a daily regime of MNP

for 2 months had ended.

While MNP are primarily designed to control micronutrient deficiencies, their introduction

provides an opportunity to accelerate implementation of the recommended IYCF strategy,

leading to improved growth among young children1. This has been repeatedly demonstrated in


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large-scale studies in multiple countries including Ghana, Bangladesh, South Africa, Cambodia

and Mongolia3. The reason for this is that MNP are not a ‘stand-alone’ intervention but are

implemented in concert with an improved IYCF education protocol for young children beginning

at 6 months of age. Caregivers are taught how to add MNP to appropriate complementary foods

which encourages their timely introduction. We believe similar results will be achieved in

Rwanda.

Multiple Micronutrient Powders such as ‘Sprinkles’, are single-serve sachets of mixed vitamins

and minerals in powder form, which can be instantly sprinkled onto prepared ready-to-eat

complementary foods for young children without changing the color or taste of the food. The

single dose sachets are packed to ensure that the correct amounts of micronutrients are given.

MNP are designed to prevent and control micronutrient deficiencies among young children aged

between 6 and 24 months of age and have also been used to reduce anaemia among older

children and pregnant women. Sprinkles is the original micronutrient powder, but it isn’t the only

one in the market. The reference to MNP as Sprinkles doesn’t show our endorsement of that

specific brand, but is because the original developers of this product, the Sprinkles Global Health

Initiative, have the most extensive database and studies on the efficaciousness, effectiveness, and

safety of the product.

MNP are a low cost scalable approach to improve nutritional status among young children and as

part of IYCF programs, have shown consistent results as well as offering a safe strategy that can

reach large numbers of young, vulnerable children in a relatively short period of time with long

lasting results1-3, 40. It is hypothesized that integrating Multiple Micronutrient Powders with

improved infant and young child feeding (IYCF) practices through a community based protocol

will reduce early childhood malnutrition, including iron deficiency anaemia, and its

consequences in Rwanda.

1.2. Goals

Overall Goal: To guide the development of an in-home fortification plus nutrition education

protocol that is culturally and regionally appropriate.


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Before introducing MNP for in-home fortification use in this project, we will explore nutrition

and IYCF knowledge, attitude and practices, particularly regarding anaemia and the proposed

use of MNP at the household level.

The assessment of social-economic factors, behavioural, familial, cultural, and structural factors

that may affect the population’s decision-making and actions towards consumption of MNP will

guide us in the process of identifying appropriate communication channels and in the

development of training tools and protocol for each community in the study areas based on their

needs.

Development of community based training materials are crucial to the success of any MNP

program because failure to provide culturally acceptable information, appropriate product

packaging and promotion guidelines can negatively affect the long-term effect of the program.

1.3. Objectives

1) To explore knowledge on anaemia and IYCF practices among child-caregivers,

healthcare personnel, midwives, CHWs and traditional birth attendants;

2) To evaluate the acceptability of in-home fortification with MNP or the treatment and

prevention of anaemia in the study areas;

3) To assess the feasibility and accessibility of different distribution channels for providing

MNP to caregivers of young children (i.e., healthcare centers, community healthcare

workers, village office, private vendors, pharmacies, etc.);

4) To inform and guide the training protocol and future phases for implementation of the

MNP program in 6 districts.


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1.4. Activities

• Conduct training of the field data collection team members (enumerators);

• Pre-test the translated questionnaires and modify according to the results;

• Conduct one-to-one interviews with key informants; child-caregivers, healthcare

personnel, midwives, CHWs, post-natal healthcare providers and nurses in charge of

maternity to examine their knowledge on anaemia, MNP and IYCF practices;

• Conduct focus group discussions (FGDs) with caregivers of young children to understand

their perceptions towards in-home fortification with MNP and identify possible barriers

to adherence to providing MNP to children as recommended;

• Develop information, education, and communication (IEC), and behaviour change

communication (BCC) materials, based on the findings using innovative approaches to

design and identify appropriate communication channels suitable for community needs;

• Develop national MNP packaging and other promotional materials that are unique to

Rwanda.

2. Methods

2.1. Interview Instrument

Semi-structured interview guides and focus group discussion guides were developed based on

the objectives of the phase 1 fieldwork. Information gathering was intended for the categories of:

breastfeeding and complementary feeding, anaemia, and Sprinkles feasibility. Open-ended

questions were asked about the knowledge, attitudes and practices of the topics mentioned

earlier. These tools, along with consent forms (Appendix 2, 3) were translated into Kinyarwanda

from English, back-translated to ensure integrity, pre-tested at the Kicukiro Health Centre in


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Kigali, and modified afterwards. Final healthcare provider question guides had 37 questions

(Appendix 4) caregiver question guides consisted of 43 questions (Appendix 5).

2.2. Interviewed Population

Convenience sampling was used to select the study sample population. The providers (healthcare

workers) and users (caregivers of children under the age of 2) of the MNP program were

interviewed and/or engaged in focus groups. In each sector, activities targeting mothers and

those who may have an influence on child health and complimentary feeding practices were

conducted as described below in June and July 2011.

Table 1: Interviews per sector

Study Location Interviews

A village located at the healthcare facility, hospital (H) or health centre (HC)

• 1 interview with the hospital director (H) or titulaire (HC) • 1 interview with a midwife (H) or nurse in charge of maternity

(HC) • 1 interview with post-natal healthcare provide (HC) or ASM • 1 interview with nutritionist or staff in charge of nutrition • 1 interview with pharmacist or local drug vendor • 1 interview with a mother of a child under-two

A village located within 6 km from the healthcare facility

• 1 focus group with ~10 mothers of children 6-23 months • 1 interview with a father of a child 6-23 months • 1 interview with a grandmother of a child 6-23 months • 1 interview with a mother of a child 6-23 months – not

participating in the focus group A village located beyond 6 km from the healthcare facility

• 1 focus group with ~10 mothers of children 6-23 months • 1 interview with a father of a child under-two • 1 interview with a grandmother of a child 6-23 months • 1 interview with a mother of a child 6-23 months – not

participating in the focus group


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2.2.1. For mothers and caregivers

Focus group discussions (FGD) were conducted with 10 female child-caregivers to determine

their perceptions of anaemia and the addition of MNP to their children’s food. Additionally, the

most appropriate delivery channels for MNP (i.e., healthcare facility, community health worker,

village office, pharmacies or small shops in the community, etc.) and information dissemination

channels were determined. Since focus group discussions give a general overview of a particular

topic, semi-structured interviews were also conducted with individual women, other than those

from the FGD participants, to obtain more specific information and to validate information

obtained from focus group discussions.

2.2.2. For key informants in the community

Interviews were conducted with healthcare provider key informants (titulaires, nutritionists,

midwives, nurses in charge of maternity, post-natal care workers, and pharmacists) and

influential family members (fathers and grandmothers of children under 2) for compliance with

MNP to determine their knowledge and perceptions about anaemia and the addition of MNP to

complimentary foods.

Through interviews with stakeholders including district authorities, NGOs and other healthcare

providers, an evaluation of current complimentary feeding practices and messages being

promoted will be conducted to identify how best to incorporate the new MNP messages in the

existing IYCF program.

2.3. Sample Design

Conducting formative work in different geographical regions in communities that are located in

different provinces of the country; and both close to and far from health centers is of importance

due to differences in population and access to healthcare facilities.

A three-stage cluster sampling design was used for this phase of the project. At the first stage of

selecting districts, Musanze and Karongi were purposively selected as they represent different


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geographical areas of the country and have different socioeconomic and nutritional backgrounds.

District leaders have also shown great interest in this project and there is a strong NGO presence,

which translates into governmental and non-governmental partnerships that will be functional

and efficient because they are motivated, have the capacity to be fully involved, and available to

contribute both human and financial resources. This is so that we can work together to most

effectively collect high quality data to inform Phase 2, Phase 3 and future policies.

At the second stage, the following four to five sectors were selected using systematic sampling

with probability proportionate to size (PPS) (Appendix 6):

Musanze: Gacaca, Kinigi, Muko, and Shingiro.

Karongi: Gishyita, Murambi, Rubengera, Rugabano, and Twumba.

At the third stage of sampling, within each sector, a list of villages and their distances to the

nearest health center were obtained from the district. This list was separated into villages that are

within 6 kilometers of the health center and those that are further than 6 kilometers from the

nearest health centers. One village was randomly selected from these two lists where focus group

discussions involving mothers of children under two and key informant interviews were

conducted (described below). The sampling methodology for Musanze and Nyaruguru are shown

in Appendix 6. Interviews were also conducted with key personnel at the main health center in

each sector.

2.4. Training

The selection of the data collection enumerators was based those students who had experience on

collecting qualitative data, a basic knowledge on community nutrition and good communication

skills in English or French and Kinyarwanda. The enumerators were trained on basic nutrition,

nutrition in Rwanda, anaemia, micronutrient powders, the use of the qualitative data collection

materials and data entry processes by Judy McLean, Christine Macdonald, Jeanine Condo,

Angele Musibiyamana and Kathy Ho at INATEK and NUR-SPH. During this process

enumerators were trained thoroughly on the questionnaire to ensure uniformity in understanding.

A total of 97 key-informant interviews and 18 focus groups were completed in two districts for a


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comprehensive understanding of the knowledge, attitudes, and practices of caregivers, and

necessary information to inform a MNP training protocol for providers and users of the

micronutrient powder. Table 1 above shows the outline of field activities and Tables 3 and 4

below show the specific activities of what was actually performed in the two districts. Prior to all

field activities, consent forms were read to each participant and written consent was obtained (or

fingerprints if the participant was illiterate). These paper copies are currently held at the NUR-

SPH.

The field team consisted of student enumerators (3 from NUR-SPH, 5 from UBC, and 9 from

INATEK), and NGO workers. Deborah Collison from UNICEF oversaw all field activities and

phase 1 data collection with 2 representatives from the MOH. Other support is outlined below:

Table 2: Field work support by in-home fortification team

Who Musanze Field Days Nyaruguru Field Days

1 2 3 4 1 2 3 4 5 NURSPH student enumerators X X X X X X X X X UBC student enumerators X X X X X X X X X INATEK student enumerators X X X X X X X X X NURSPH support X X UNICEF support X X X X X X X X X CARE support X X X X X X CONCERN support X X X X X X World Vision support X X X X WFP support X X X X MOH support X X X X X X X X X

The following tables outline the specific field activities that were performed in each district.


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Table 3: Field Activities Completed in Musanze

Date Sector Village represented

Field Activities

July 4 Gacaca Karwasa 1 interview with a midwife/nurse 1 interview with a midwife 1 interview with the titulaire 1 interview with a nutritionist 1 interview with a pharmacist 1 interview with a mother of a U2 child

July 4 Gacaca Kanama (within 6km of health centre)

1 interview with a mother of a U2 child 1 interview with a father of a U2 child 1 interview with a grandmother of a U2 child 1 focus group with 10 mothers of U2 children

July 4 Gacaca Murora (further than 6 km from health centre)


July 5 Kinigi Kinigi 1 interview with a postnatal nurse 1 interview with the titulaire 1 interview with a nutritionist 1 interview with a pharmacist 1 interview with a mother of a U2 child

July 5 Kinigi Rutindo (within 6 km from health centre)


July 5 Kinigi Gahura (further than 6 km from health centre)


July 6 Muko Kabere 1 interview with a midwife 1 interview with the titulaire 1 interview with a nutritionist 1 interview with a pharmacist 1 interview with a nurse/pharmacy distribution 1 interview with a mother of a U2 child

July 6 Muko Rubanga (within 6 km from health centre)



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July 6 Muko Butare (further than 6 km from health centre)


July 7 Shingiro Shingiro 1 interview with a midwife 1 interview with the titulaire 1 interview with a nutritionist 1 interview with a postnatal nurse 1 interview with a mother of a U2 child

July 7 Shingiro Kadahenda (within 6 km from health centre)


July 7 Shingiro Rutagara (further than 6 km from health centre)


TOTAL FIELD ACTIVITIES

18 HCP interviews (4 midwives, 4 titulaires, 4 nutritionists, 3 pharmacists, 3 post-natal nurses) 8 fathers of U2 interviews, 8 grandmothers of U2 interviews, 12 mothers of U2 interviews, 8 focus groups of mothers of U2 (80 mothers)

Table 4: Field Activities Completed in Nyaruguru

Date Sector Village Field Activities July 24 Busanze Runyombyi 1 interview with the titulaire assistant

1 interview with a midwife 1 interview with a postnatal midwife 1 interview with a nutritionist 1 interview with a pharmacist 1 interview with a mother of a U2 child

July 24 Busanze Bugina 1 interview with a mother of a U2 child 1 interview with a father of a U2 child 1 interview with a grandmother of a U2 child 1 focus group with 10 mothers of U2 children

July 24 Busanze Gisenyi 1 interview with a mother of a U2 child 1 interview with a father of a U2 child 1 interview with a grandmother of a U2 child 1 focus group with 10 mothers of U2 children


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July 25 Muganza Muganza 1 interview with the titulaire assistant 1 interview with the midwife supervisor 1 interview with a postnatal care nurse 1 interview with a nutritionist 1 interview with a pharmacist assistant 1 interview with a mother of a U2 child

July 25 Muganza Bitaba 1 interview with a mother of a U2 child 1 interview with a father of a U2 child 1 interview with a grandmother of a U2 child 1 focus group with 10 mothers of U2 children

July 25 Muganza Gituntu 1 interview with a mother of a U2 child 1 interview with a father of a U2 child 1 interview with a grandmother of a U2 child 1 focus group with 10 mothers of U2 children

July 26 Ruheru Ruheru 1 interview with a titulaire 1 interview with a midwife 1 interview with a postnatal nurse 1 interview with a nutritionist 1 interview with a pharmacist 1 interview with a mother of a U2 child

July 26 Ruheru Ruganza 1 interview with a mother of a U2 child 1 interview with a father of a U2 child 1 interview with a grandmother of a U2 child 1 focus group with 10 mothers of U2 children

July 26 Ruheru Rukarakara 1 interview with a mother of a U2 child 1 interview with a father of a U2 child 1 interview with a grandmother of a U2 child 1 focus group with 10 mothers of U2 children

July 27 Kibeho Kibeho 1 interview with the titulaire assistant 1 interview with a prenatal midwife 1 interview with a midwife 1 interview with a nutritionist 1 interview with a pharmacist assistant 1 interview with a mother of a U2 child

July 27 Kibeho Agateko 1 interview with a mother of a U2 child 1 interview with a father of a U2 child 1 interview with a grandmother of a U2 child 1 focus group with 10 mothers of U2 children

July 27 Kibeho Rwimbogo 1 interview with a mother of a U2 child 1 interview with a father of a U2 child 1 interview with a grandmother of a U2 child 1 focus group with 10 mothers of U2 children

July 28 Ngoma Ngoma 1 interview with the titulaire


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1 interview a midwife 1 interview with a nurse in charge of maternity 1 interview with a nutritionist 1 interview with a pharmacist 1 interview with a mother of a U2 child

July 28 Ngoma Gihishabwenge 1 interview with a mother of a U2 child 1 interview with a father of a U2 child 1 interview with a grandmother of a U2 child 1 focus group with 10 mothers of U2 children

July 28 Ngoma Nteko 1 interview with a mother of a U2 child 1 interview with a father of a U2 child 1 interview with a grandmother of a U2 child 1 focus group with 10 mothers of U2 children

TOTAL 25 HCP interviews (5 titulaires/titulaire assistants, 7 midwives, 5 nutritionists, 5 pharmacists/pharmacist assistants, 3 post-natal/pre-natal/maternity nurses) 10 fathers of U2 interviews, 10 grandmothers of U2 interviews, 14 mothers of U2 interviews, 10 focus groups of mothers of U2 (100 mothers)

Total: 97 key informant interviews (43 HCP), 18 focus groups.

2.6. Data Entry and Analysis

Data was checked, labeled, translated, transcribed and entered into a word document in the field

by the field team. UNICEF’s Nutrition Officer, Deborah Collison, oversaw all data collection,

organized and compiled all documents from enumerators, managed and shared the data with the

study team every day by e-mail. These were compiled into 400 pages of textual data and a non-

linear iterative content analysis approach was used to analyze the data. Procedures followed

those outlined in Creswell’s spiral3: data managing; reading, memoing; describing, classifying,

interpreting; representing, visualizing.

In order for the data to guide the MNP program in Rwanda, the Integrative Theory of Behavior

Prediction (a integration of the Theory of Planned Behavior4 and the Social Cognitive Theory)

3 Creswell JW. Qualitative inquiry and research design: �choosing among five approaches. 2nd ed. Thousand Oaks: �Sage Publications, 2007.

4 Godin, G., Kok, G. The theory of planned behavior: A review of its applications to health-related behaviors.


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was used due to the interpersonal nature of MNP use: that individuals are not only influenced by

individual characteristics but the social environment as well. Themes and patterns were

identified and organized into pre-determined categories of the Integrative Theory of Behaviour

Prediction using deductive coding, as well as emergent categories through inductive coding to

ensure codes were not limited to the constructs of the theoretical model. This approach has been

useful and successful in other health research areas. Patterns and connections both within and

between the categories were identified and the relative importance was assessed based on the

objectives of the work. Computer software was not used due to the small size of the data set5,

timeline and the objectives of phase 1. A presentation of preliminary results was presented to the

MCH TWG on August 10th, 2011 on behalf of the NTWG, and again to the NTWG on

September 6th, 2011. The results are outlined below in the results section.

3. Results

The results have been organized by question, by district and by the kind of respondent:

healthcare providers (HCP) and caregivers (fathers, grandmothers, mothers of under-2 children),

in order to make a training protocol that meets needs of providers and users of the in-home

fortification program. Wherever “N/A” is indicated, it means the question was not asked to that

target group.

3.1. Introduction

Question Musanze Nyaruguru

American Journal of Health Promotion, Vol 11(2), Nov-Dec 1996, 87-98. 5 Kodish, S., Gittelsohn, J. Systematic Data Analysis in Qualitative Research: Building Credible and Clear

Findings. Sight and Life 2011;2:52-56.


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1. How many mothers/caregivers of young children do you usually care for/visit each month?

HCP: Answers ranged between 15 – 2000 people/month.

HCP: Answers ranged from 30 – 1,300 people/month, but most serve less than 100.

Caregivers: N/A Caregivers: N/A

2. What kinds of services do you provide? Any health programs relating to young children?

HCP: Education, counselling, consultations, treatment, provision of medications, vaccinations. On/for: Family planning, hygiene, post-partum issues, breastfeeding, infant feeding, infections, diseases (respiratory, GI), malnutrition, HIV.

HCP: Consultations, services, programs for immunizations, disease prevention, prenatal issues, birth delivery, HIV/AIDS, postnatal growth monitoring, and malnutrition (that education about food preparation, eating a balanced diet).


There is existing programming currently in place at the health centre regarding nutrition and

IYCF. This is a foundation for the in-home fortification project to be embedded into regular

programming at the health centre level, and an opportunity to have consistent IYCF messages

delivered according to the latest evidence-based international guidelines. This information also

gives insight into possible distribution and the training mechanisms, which would be the most

effective.


1. First I would like to ask if you have ever seen or heard any messages and/or advice about what you should feed young children?

HCP: N/A HCP: N/A

Caregivers: Almost all responded yes.

Caregivers: Almost all responded yes.

2. Where or from whom has given you messages and/or advice on how to feed young children?

HCP: N/A HCP: N/A

Caregivers: Many said they heard this at the health centre, through CHWs, or through the radio.

Caregivers: Many said they heard this through CHWs, health centres, and the radio.


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These responses indicate that current effective information dissemination sources to all

caregivers (mothers, fathers, and grandmothers) for IYCF messaging are predominantly through

the health centre, the CHWs in their community, and through the radio. For villages further than

6 km from the health centre, caregivers tend to receive IYCF information predominantly through

CHWs and the radio. This informs what currently works and is effective for possible

sensitization, targeted information dissemination, promotion for the MNP program.

3.2. Breastfeeding and Complementary Feeding


1. Do mothers ask your advice about how to feed their young children? (If yes, what types of questions do they ask?)

HCP: Not many concerns about breastfeeding, but more with complementary feeding. Many healthcare providers indicate mothers’ lack of knowledge in the area of what types of food to feed her baby and how to prepare food. Mothers expressed lack of weight gain, lack of appetite, and lack of growth as dominant health concerns.

HCP: Many mothers ask about breastfeeding practices and its issues (when to stop, complications, etc). They also ask about complementary feeding issues (i.e. timing, appetite loss, diarrhea/sickness, types of food, food preparation for a balanced diet). Concerns also include lack of growth and weight gain.


2. What are the common problems related to infant and young child feeding practices?

HCP: Same as above (types of food, how to prepare food, lack of growth, lack of weight gain, lack of appetite), and dietary diversity.

HCP: Many responses included poverty, soil infertility and polygamy as common problems. They also comment on the lack of understanding/knowledge on proper complementary feeding practices such as cooking practices, types of food, dietary diversity.


It appears that common problems relating to malnutrition issues in the community are social


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factors (such as poverty) but from the HCP’s perspective, there is general lack of knowledge on

complementary feeding among mothers in their community. IYCF and mothers’ concerns are the

types of food for an infant/young child, how to cook the food, and a lack of weight gain/growth,

as well as a lack of appetite.

In Musanze, a dominant concern is the lack of knowledge on cooking practices and food

preparation. In Nyaruguru, a common concern is how to provide a balanced diet for the young

child as every sector mentions it as a common question raised by mothers. These are all concerns

that can be addressed through a package intervention to improve IYCF practices particularly

complementary feeding beginning at age 6 months.


3. What are the main infant-feeding messages provided?

HCP: Exclusive breastfeeding for 6 months, prompt healthcare-seeking behaviour, proper hygiene, and complementary feeding with a “balanced diet”.

HCP: Early initiation of breastfeeding, exclusive breastfeeding for 6 months, proper hygiene, food preparation (for a “balanced diet” and because infants’ foods are different than adults’)


Healthcare providers speak about dietary diversity (a balanced diet and consuming a variety of

foods, which have been reported as: immune building/illness prevention foods, body building

foods, and energy-providing foods; or carbohydrates, proteins, and minerals. According to the

respondents, the foods mentioned in these categories did not include animal foods or energy-

dense foods as part of a diet for the health of a young child. This is of concern for optimal health,

growth, and development of the infant due to the importance of energy density of an infant’s diet

due to high needs and a small, limited stomach capacity, and the high micronutrient needs of an

infant weaned off breastmilk (due to lower body stores of micronutrients and the low

micronutrient content of breastmilk). There appears to be more emphasis on variety than quantity

when both must be met.


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4. How long do you think a mother should provide her child with only breastmilk (no other foods or liquids)? 1. Can you tell me until what age a baby should receive only breastmilk, that is, no other food, water, or teas?

HCP: Almost all: 6 months 1 pharmacist: 4 months

HCP: Almost all: 6 months. 1 midwife: 4 months 1 nurse: 8 months.

Many caregivers said 6 months. But many responded with between 2-8 months.

Many caregivers said 6 months. But many responded with answers between 2 months – 1 year.

At the healthcare centre, it appears to be common knowledge for health care providers to advise

caregivers to exclusively breastfeed an infant for the duration of 6 months. However, there is a

difference between HCP advice/knowledge, to what is actually known and practiced in the

household.


5. At what age should she start feeding her child foods in addition to breastmilk?

HCP: Answers vary. Many said 6 months but many said older than 6 months, up to 1 or 2 years.

HCP: Answers vary. Answers ranged from 5 months to 2 years.


This question was used to check HCP response to the earlier question about exclusive

breastfeeding (question 4) to determine what advice and what messages are really being given to

caregivers. Caregiver response and practices were checked two questions below.


2. Can you tell me until what age, or for how long, a child should

HCP: N/A HCP: N/A

Caregivers gave answers that Caregivers: Answers ranged


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continue to receive breastmilk?

varied from 6 months to 5 years, but most caregivers’ answer was between 2-3 years. Some mothers mentioned the reason for breastfeeding this amount of time is for family planning. Reasons for stopping breastfeeding include the “preference” of the mother or the baby.

from 1.5 years to 5 years. Reasons for this duration ranged but common answers were that it was up to the child’s preference, and for family planning reasons.

There isn’t a distinct answer as the practices of mothers vary. Information about the maintenance

and duration of breastfeeding should be clarified for caregivers due to the nutritional importance

of continued frequent, on-demand breastfeeding until 2 years and beyond.


6. What foods should she start giving her child at this time? (How are these foods prepared?) 3. What are the first foods a young child should be given other than breastmilk? At what age should these foods be introduced to the young child’s diet?

HCP: Warm/hot foods. Porridge, fruits, green vegetables, mashed potatoes/bananas. Liquids such as milk, juice. (Nutritionists in all villages mostly mentioned porridge and fruits).

HCP: Sorghum porridge, vegetables, rice, fruits. Liquids such as milk, juice. Only 5 mentioned any animal foods excluding cow’s milk (3 meat, 2 fish).

Caregivers: Most mothers said porridge, fruit, tree tomatoes, and some said potatoes. Most mothers said 6 months, although many did say earlier (4 months), and later (6-8 months).

Caregivers: Most mothers said porridge and fruits (bananas and passion fruit especially). Other common responses were biscuits/bread, and cow’s milk. Responses ranged from 2-5 years.

Porridge (a combination of any of the following: sorghum, maize, cassava, water, milk, sugar),

and fruit appear to be common first foods. In Nyaruguru, there is an emphasis on hygienic

cooking practices, and straining foods and fruits such that a liquid food is prepared for the baby.

It was found that fathers’ responses varied greatly from the rest of the caregivers’ responses.


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7, 14. What foods are important for young children to be healthy?

HCP: Common answers were potatoes (for energy), beans, porridge, vegetables, and fruit. 3 people said meat, 7 people said fish, 4 said eggs.

HCP: A common answer was a balanced diet consisting of: - body-building foods (beans, small dried fish), energy foods (tubers), illness prevention foods (fruits and vegetables); or - proteins (soy, milk, meat), carbohydrates (tubers) minerals (fruits and vegetables).

Caregivers: The most common answers were vegetables and fruit. Many also responded with potato, porridge and fish. 17 said fish, 5 said meat, 2 said eggs.

Caregivers: Common answers were: green vegetables (44), beans, porridge, small dried fish (18). 6 said meat, 7 said eggs.

Since dietary inadequacy is the direct and main cause of micronutrient deficiencies, this question

was asked to determine the foods that are recommended by healthcare providers and what

caregivers perceive to be optimal foods for their young child. Education and information

dissemination from healthcare providers to caregivers is essential and the content of this

education should reflect accurate information. The responses from fieldwork activities indicate

that the optimal foods suggested are not appropriate for infants and young children due to the

low energy density and/or bioavailable micronutrient contents.


8, 15. Can you tell me some reasons these foods are important for young children? 16. Are these foods always available to you?

HCP: Common responses were to prevent illness/develop immunity, for energy, and for growth. Some mentioned micronutrients.

HCP: Common responses were that these foods are important for growth (weight gain and cognitive development), illness prevention.

Caregivers: Common responses were for growth, strength, and prevention/protection from

Caregivers: Common responses were that these foods contained nutrients for growth and illness


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illnesses. No, due to financial constraints.

prevention. No, due to financial reasons.

The responses from this question indicate the different perceptions of why the foods listed in the

previous question are important. These responses indicate that the optimal foods perceived and

recommended for an infant and young child and their functions are inaccurate. This is

exemplified in a quotation from a nutritionist in Nyaruguru who said “vegetables can prevent

malnutrition”.


19. Can you tell me how you know if a child is healthy? What are some signs of a healthy child?

HCP: N/A HCP: N/A

Caregivers: Many connected the health of a child to its playfulness (with others), appetite and growth/weight gain.

Caregivers: Many responded that a healthy baby is active/playful, has an appetite, and gains weight.

This question was asked to guide perceptions of health and to ensure that the development of a

promotional health message associated with micronutrient powders and nutrition education

reflects what is important to mothers. Many caregivers perceive a healthy baby as a playful baby

who has an appetite and is growing/gaining weight. While micronutrient powders itself has not

been shown to affect physical, linear growth so while it is an important characteristic of a healthy

baby for Rwandan mothers, it should not be advertised as so because it is false. MNP have been

shown to increase appetite and activity among those children who consumed it, so these are two

characteristics that can be used in a promotional message.

3.2.1. Household Feeding Practices and Food Preferences


4. What foods do young HCP: N/A HCP: N/A


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children like in this community?

Caregivers: Common responses were porridge, potatoes, bread.

Caregivers: Common responses were rice, porridge, Irish potatoes, beans, small dried fish.

5. What foods do young children dislike in this community?

HCP: N/A HCP: N/A

Caregivers: Many caregivers mentioned that children dislike hard foods, and many mentioned potatoes (Irish potatoes and sweet potatoes).

Caregivers: Many caregivers mentioned sweet potatoes because it is always available.

This question was asked to determine if food preferences would interfere with the

implementation of a MNP program because MNP cannot be added to just any kind of food. MNP

should be added to cooled, ready-to-eat soft cooked food, so anything such as bread or biscuits

are not a suitable mixing medium for the powder. It appears that porridge is liked by many

children and is an appropriate food vehicle for MNP consumption.


6. Do you encourage your young children to eat if he/she refuses? If yes, in what ways do you encourage your child?

HCP: N/A HCP: N/A

Caregivers: Almost all: Yes, by talking to the baby. Some mothers indicated that they don’t encourage feeding when the child is sick.

Caregivers: Almost all: Yes, by changing the food.

Many studies have indicated that how a baby is fed affects optimal complementary feeding.

While many mothers encourage feeding, it will be good practice for new training protocol to

review responsive feeding and apply principles of psycho-social care. While many mothers

appear to experiment with different food combinations and textures when a child refuses, it is a

good practice to reinforce, along with the practice of ensuring feeding time is a social interaction

with the mother and the child. It is also important to ensure new training protocol teaches

mothers to continue feeding during and after illness.


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7. Who makes decisions in your home about what foods to feed young children?

HCP: N/A HCP: N/A

Caregivers: Mixed answers of mother only, father only, and both mother & father.

Caregivers: Mixed answers of mother only, father only, and both mother & father.

8. Who prepares or cooks food for the young children you care for?

HCP: N/A HCP: N/A

Caregivers: Almost all responded with the mother. But it appears many older daughters/sisters of the baby cook as well.

Caregivers: Almost all responded with the mother. But it appears grandmothers and many older daughters/sisters of the baby cook as well.

Since using MNP in Rwanda means bringing a new commodity into the home and using it

appropriately and accurately in the household, these results show that it is essential for MNP

training to reach husbands/fathers as well. Decision-making about what foods to buy and feed

young children is not centered on just one person so it should be ensured that all caregivers

within the household equally understand the changed behavior and practice. There is a need to

ensure our training materials and training mechanism can reach a larger target audience than just

mothers.


9. Do you prepare separate food for your young child (6-23 months)?

HCP: N/A HCP: N/A

Some caregivers responded with no, and some responded that the young child is given different food (either in texture or type of food), but very few caregivers responded that they had a separate pot/cooking utensils for the baby.

Many caregivers responded with no, and some responded that the young child is given different food (either in texture or type of food). Many mentioned financial constraints as the reason why the whole family eats the same foods.

10. Does your young child eat from his or her own bowl? At what age do children

HCP: N/A HCP: N/A

Most caregivers responded with yes.

Most caregivers responded with yes.


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stop eating from their own bowl?

Answers vary, but it appears children have their own bowl for eating until at least 2 years of age.

Answers vary, but it appears children have their own bowl until 1.5 – 7 years old.

Many caregivers describe the act of cooking the whole family’s food in one pot, but then putting

it in a separate bowl for the young child, until the child can sit up by itself and share a common

bowl with other children. There is very much a realistic possibility of bringing the traditional

practice of agakono k’umwana (a separate cooking pot/bowl for the child) as it appears it is not

currently practiced due to restrictions of having to purchase and own another cooking pot. This

feeding practice can assist with the timeliness of age-appropriate foods for the complementary-

fed child.


11. Can you tell me how many times a day a child should eat any meals or snacks other than breastmilk: When they are 6-8 months? When they are 9-11 months? When they are 12-24 months?

HCP: N/A HCP: N/A

Caregivers: Answers vary a lot. Hard to summarize. (note- question were not recommended by the authors as quantitative questions are not suitable for focus groups)

Caregivers: Answers vary a lot. Hard to summarize.

Due to the limited stomach capacity of young infants (~200 mL), the frequency of feeding is

important to provide adequate dietary intake for the child. Training will outline both the quantity

of complementary food needed, as well as the meal and snack frequency in different age groups

due to differences in energy needs at different ages. Please refer to implementation guidelines.


12. What do young children 6-23 months usually eat in the morning?

HCP: N/A HCP: N/A

Caregivers: Caregivers:


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What do young children usually eat mid-day? What do young children usually eat in the evening? What snacks do young children consume during the day?

Morning: most caregivers say porridge. Mid-day: many caregivers say vegetables, cabbage, potatoes. (answers really vary) Evening: many say “same as mid-day”, potatoes, bananas. (answers really vary) Snacks: Many caregivers responded with fruit, porridge, or that snacks weren’t consumed at all.

Morning: most caregivers say porridge, tea and bread/biscuits Mid-day: many caregivers say sweet potatoes, beans, rice. (answers really vary) Evening: many say “same as mid-day”, potatoes, beans, greens. (answers really vary) Snacks: Answers really vary, or that snacks weren’t consumed at all.

It appears that meals consumed by the child vary in composition, textures and tastes throughout

the day. As mentioned earlier, the ideal food vehicle for MNP (a cooled, soft cooked food) is not

necessarily consumed consistently throughout the day. It appears most caregivers give porridge

in the morning and mid-day and evening foods are other foods such as potatoes, vegetables and

cabbage. It is good practice to be mindful of when MNP can be added to the young child’s food.


13. Where do you normally get your young children’s food from? Market? Shop? Own farm/land?

HCP: N/A HCP: N/A

Caregivers: Everyone responded with their own land only, or own land & market.

Caregivers: Responses varied. Most said land & market.

Many respondents were subsistence farmers so food supply may vary by region/seasonality.

More respondents in Nyaruguru said they supplement the food grown on their land with food

purchased at the market, most likely due to land use for tea-growing, as opposed to consumable

foods.



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17. What do you do if there is limited access to food? (Probe: Reduce the amount of food that other family members get? Reduce the number of meals per day? Give baby smaller portions?)

HCP: N/A HCP: N/A

Caregivers: Some responses: older family members eat less (either reduce meal size or reduce number of meals) Some responses: everyone eats less by reducing meal size or reducing number of meals.

Caregivers: Some responses: older family members eat less (either reduce meal size or reduce number of meals) Some responses: everyone eats less by reducing meal size or reducing number of meals.

It appears in many households, when food is limited, the older family members eat less while the

baby still consumes the same amount as before. It is uncertain when there will be limited access

to food for a family, but training should encompass appropriate coping mechanisms when those

times do occur.

3.3. Anaemia


1. Have you heard of a condition called anaemia?

HCP: All: Yes.

HCP: All: Yes.

Caregivers: Many: Yes. (Although they indicated yes, further answers indicate that they are confusing anaemia with general sickness or malnutrition/Kwashiorkor). Many: No.

Caregivers: Many: Yes. (Although they indicated yes, further answers indicate that they are confusing anaemia with general sickness or malnutrition/Kwashiorkor). Many: No.

2. What are some of the symptoms or signs that a person has anaemia?

HCP: Many: discoloured/white hands, eyelids. Some responded with edema.

HCP: Many: Pale palms, feet, eyes, dizziness/fainting. But some responded with incorrect answers like dry mouth, edema, dehydration, stunting.


37

Caregivers: A variety of answers, mostly swelling/edema, weak/dizzy, and pale hands/eyes.

Caregivers: A variety of answers from weight loss, hair colour change, pale skin colour.

Many HCP have a strong knowledge of the symptoms of anaemia, whereas caregivers do not.

Many HCP and caregivers associate or think anaemia is like Kwashiorkor. Some exemplary

quotations are: “I have heard from my neighbor that a person who has anaemia has HIV” [a

mother in Nyaruguru], and “the symptoms are edema and the person will get thin” [a FG

participant in Nyaruguru].

In general, there is a lack of knowledge on anaemia, as many participants did not respond to the

remainder of the questions in the anaemia module, and those who did, confused anaemia with

other health conditions such as general malnutrition.


3. How would you know if a young child has anaemia?

HCP: All: confirmed with a hemoglobin check.

HCP: Confirmation is done either by a hemoglobin test or a visual check.

Caregivers: Many responded with “I don’t know.” Some responded with a diagnosis from a health centre, not gaining weight, no strength/energy.

Caregivers: Many do not know. Some responded with weight loss, skin/eyes turn yellow, lack of growth, don’t have energy, not happy/playful.

4. How are children treated if they are found to have anaemia?

HCP: For severe anaemia, almost all: child is transferred to the district hospital, and some further elaborated that that is where they get a blood transfusion or IV. For moderate anaemia: Food (sosoma), iron folic acid, and counselling is given. Fruit (specifically tree tomatoes) are recommended.

HCP: For severe anaemia, they are transferred to the hospital where they are give For moderate: Common treatments are IV fluids, ORS, IFA tablets, nutrition counselling (which consists of how to prepare isombe “treatment includes advice for the mothers to feed the children


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foods which increase the blood, like fruits e.g. tree tomatoes, provision of iron supplements, and giving children plumpy nut for non-severe cases of anaemia” - nutritionist)


Although there isn’t a current anaemia prevention and control strategy in the country, what is

currently being performed at the health centres for treatment is not appropriate. HCP knowledge

on anaemia prevention and dietary counselling advice needs improvement (e.g. poor sources of

iron, such as red fruits with red juices like tree tomatoes should not be recommended as part of

dietary counseling to prevent or treat anaemia). Depending on the variety, tree tomatoes contain

less than 0.5 mg of iron6 of which 2% is actually bioavailable. The treatment of anaemia is

further discussed below.


5. What are the reasons a child might have anaemia? 4. Can you identify any causes of anaemia?

HCP: Many responded with malaria, and malnutrition (many did not elaborate, but some mentioned the lack of a balanced diet).

HCP: Malaria and malnutrition. GI diseases, diarrhea, vomiting. “The reasons are malnutrition (i.e. when children do not consume fruits like tree tomatoes, passion fruits and green legumes and the lack of a balanced diet” –nutritionist

Caregivers: Many responded with malnutrition/poor diet and sickness, but nothing specific.

Caregivers: When the child suffers from worms, malnutrition, I don’t know, blood loss during an accident or pregnancy

6 New Zealand Tamarillo Growers Assocation. http://www.tamarillo.com/vdb/document/153


39

HCP have some knowledge of the condition, whereas caregivers generally lack it. While there

are multiple causes of anaemia and some participants correctly identified them, it is estimated in

Rwanda’s population that nutritional anaemia is a predominant cause of iron-deficiency anaemia

in young children.


6, 5. Do you know of any foods that can prevent anaemia? If yes, list.

HCP: Many responded with green vegetables and fruit (especially tree tomatoes). Very few respondents said meat. Very few respondents said fish.

HCP: Many responded with isombe/green vegetables, fruits (notably tree tomatoes) “Yes, red legumes: carrots, tomatoes”

Caregivers: Many caregivers responded with fruits (specifically tree tomatoes), cabbage, greens. Only 8 respondents said meat. Only 12 respondents said fish.

Caregivers: Many said I don’t know. Many cited fruits and green vegetables. 10 said animal foods/meat, 4 said eggs. 8 said fish.

7, 6. Do you know of any other ways (non-dietary) to prevent anaemia?

HCP: Many did not know. Many responded with participating in malnutrition, vaccinations, and supplementation programs.

HCP: Many did not know. Many responded with malaria prevention (sleeping under a bed net)

Caregivers: Many responded with dietary ways to improve nutrition and many gave answers that do not pertain to anaemia. Some mentioned going to the HC, using mosquito nets/preventing malaria.

Caregivers: Many responded with “I don’t know”. Other responses included hygiene, spacing our pregnancies, and going to the health centre to seek medical advice.

Again, inaccurate dietary recommendations from the HCP have trickled down to the public (e.g.,

the recommendation of tree tomatoes, fruits, and other low-iron foods to prevent anaemia). There

is a general lack of knowledge on the prevention of anaemia and dietary sources of iron: “Isombe

(cassava leaves) because it is rich in iron. All green vegetables like beans, while many people

don’t like it, they are rich in iron” – A titulaire.


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8, 7. Are there any local programs to prevent anaemia in children? If so, what are they?

HCP: There are current malnutrition, vaccination, and kitchen garden programs, but no current program targeting anaemia specifically. They would like to see ones that educate.

HCP: No current programs targeting anaemia, and many expressed interest in ones being established to improve health and growth.

Caregivers: No. There are general nutrition programs, kitchen garden programs, and malaria/mosquito net programs.

Caregivers: No, just hygiene programs, general malnutrition programs run by CHWs, growth monitorings and kitchen garden programs (in the rainy season).

All respondents would like to see such a program to prevent anaemia. This indicates an interest

in a new program such as the MNP program from both the healthcare providers and those in the

community. An exemplary quotation is: “I would like to see such programs because of reduction

of infant mortality. There is a lack of knowledge about anaemia. For example, when fainting

occurs, the perception is that poison caused it.” [a postnatal healthcare provider].


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9, 8. How are children (medically) treated in your community if they are found to have anaemia?

HCP: If severe: transferred to hospital for blood transfusion. If moderate: Given advice, and iron folic acid supplements at the health centre.

HCP: If severe: transferred to hospital for blood transfusion. If moderate: Given advice, and iron folic acid supplements at the health centre. “When it is moderate we provide iron and we teach them how to prepare a balanced diet. We will tell them to eat tree tomatoes. When it is severe, the child gets referred to the district hospital where they do blood transfusion” – postnatal HCP

Caregivers: Many answered with bringing their children to the CHW, then to the HC/hospital, where the baby is given medicine.

Caregivers: Are weighed, given “medicine” at the HC, advice on how to feed young children.

10, 9. Where do children receive treatment for anaemia?

HCP: Health centre/hospital. HCP: Health centre/hospital.

Caregivers: Health centre/hospital

Caregivers: I don’t know / health centre / hospital.

The medical treatment of anaemia is also not in accordance with WHO guidelines, in which

severe anaemia in young children is treated with iron syrup, not IFA tablets (which are

appropriate for women of reproductive age and pregnant women). Other strategies currently

being used in the community, such as ORS, IV fluids and RUTF are not appropriate methods to

treat iron deficiency anaemia.


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Other general comments:

Many suggested prevention programs and to provide training.

“The children have anaemia because the mother is not educated on how to prevent it. It is important to have training because I need to learn about anaemia and how to protect the children from getting anaemia.” –a father “You can teach me about this disease because I really do not understand what you are talking about” – mother “I lack the knowledge about anaemia, but requires someone knowledgable to educate her, and believes that a service focusing on anaemia is needed” -nutritionist

There is a strong agreement within the community, in both districts that there is a lack of

knowledge on the condition and an interest to learn more and establish programs to educate,

prevent, and control anaemia.


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3.4. Sprinkles


1. Do you think mothers/caregivers would be willing to add Sprinkles, a micronutrient powder, to their children’s food? Continuously from the child’s age of 6 to 24 months?

HCP: All: Yes (but with sufficient training regarding its importance). Some answered that because it is from the MOH/government, caregivers will use Sprinkles.

HCP: Most: They will agree if there is sufficient information, education, and sensitization.

Caregivers: Almost all: Yes. Those who didn’t expressed that they need more information to make that decision.

Caregivers: All: Yes, I can accept. Those who didn’t:

2. Can you tell us any reasons you or other mothers might not be willing to add the powder to their children’s food?

HCP: N/A HCP: N/A

Caregivers: Many responded that no one would refuse. Many answered they can’t refuse because it is importance, can’t refuse health, and can’t refuse from the government. Some mentioned some may refuse if they don’t have adequate understanding and they don’t know the importance of Sprinkles.

Caregivers: Many responded that no one would refuse. “Some may refuse and say that their child did not receive Sprinkles grew up normally so it makes no difference” – FG Some mothers mentioned a financial constraint to usage.

2,3. Do you think some family members might object to the practice of adding this powder to their children’s food?

HCP: Most: No (because it comes from the HC, because the decision is the mother’s). Older/grandmothers, people with a lack of understanding, religious people.

HCP: Older, low level of understanding, those believing in traditional medicine (i.e. grandmothers).

Caregivers: No one would refuse. Those who would are ignorant, not educated on its importance.

Caregivers: Husband maybe (if they are not involved in decision-making), older people, people who didn’t use Sprinkles on their own children/previous children.


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There is high acceptability of using a MNP consistently in their household by all caregivers and

family members for the following reasons, if there is adequate understanding of Sprinkles

because it is important, because caregivers can’t refuse health, and can’t refuse from the

government. A focus group member said, “how could you refuse to give something that benefits

your child?”

Those individuals who may object are those who believe in traditional medicines or those who

did not use Sprinkles on other children.


3. Is there any possibility of facing social, cultural or religious objections to adding the powder to young children’s (6-23 months) food?

HCP: Many: No one would refuse. Some: Adventists, grandmothers, vegans.

HCP: Many: No one would refuse. Some: Adventists, herbalists, maybe religious leaders.


This was asked to ensure that the physical act of adding something to food is a culturally

acceptable practice. Proper sensitization and promotion within the community and among

households is important for the success of a MNP program and any barriers to so should be

identified. It appears that a small portion of the population may refuse due to their religious or

personal beliefs, and this should be accounted for and any rumour generation should be mitigated

early in the program.


4. What information do you think the mother will need to help her make a decision on whether she will give this to her child?

HCP: Majority of answers included: Sprinkles importance, directions of use, content/composition, side effects, benefits.

HCP: Information, origin, composition, benefits, utilization, taste, side effects, expected results, role in prevention of anaemia, cooking methods, consequences of non-use.

Caregivers: The responses were: Caregivers: Its importance, how


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-“how to use it”: specifically when to use it, food vehicle information (types of food, temperature of food), duration of use, amount to be used, cost, target group. -its use: benefits/importance, side effects -the product itself: Sprinkles contents/how it’s made, where to find the product, cost. -training/promotion: demonstration of use, testimonies/examples, samples

to use it, quantity needed, content, “how to use it”, where to find it, what it is made from, where it came from, who needs sprinkles, its name, side effects, types of food to be mixed with, side effects with stoppage of use, the price.

This information guides what mothers want to know, and the topics are extensive. It shows that

caregivers want to know accurate information that encompasses many topics. This guides our

implementation guidelines such that all information relating to micronutrient powders should be

made accessible to all caregivers.


5. Do you think a mother/caregiver would agree to feed one packet of Sprinkles to her young child mixed with semi-solid food every other day for 30 days? If no, why might they not agree?

HCP: Yes, if properly informed.

HCP: Yes, if educated.

Caregivers: Many responded with yes.

Caregivers: Many yes. “If we can find it, we will use it” – FG Some said if they can afford it, if they can find it.

The responses of this question indicate high acceptability for phase 2, in which we can closely

follow 60 households who receive MNP sachets over the course of 30 days to determine

acceptability of MNP and the appropriateness of the training protocol.


46


6. Would you be willing to pay a small amount of money for this powder to improve the health of your child?

HCP: N/A HCP: N/A

All: Yes, if the cost is low/if I can afford it.

All: Yes, but depends on the price/ if the cost is low/if I have the ability to pay it.

Caregivers are willing to pay, but if they have the ability to pay when the time comes is

unknown. The concept of a split or a market-based approach is a possibility in the future, but due

a consistent theme of poverty/lack of capacity in the textual data sets from both districts, starting

with a public distribution scheme is a good approach to ensuring MNP are accessable to those in

the intended target group.


7. Do you think a child will continue taking food if the food is mixed with Sprinkles?

HCP: Many responded that a child would not know the difference. Some noted that a flavour change (notably the bitter flavour), odour, and colour changes may affect the child’s preference.

HCP: It will depend on the child. If taste and smell do not change.

Caregivers: Those who responded with yes (many) said it is because they would be familiarized with the food over time and the mother is in control of the feeding. Some responded no due to odour and taste changes.

Caregivers: Most: Yes, (persistent encouragement will overcome that issue if it arises) if it doesn’t change taste, adversely affect the child’s health. “If the Sprinkles makes the food taste good, then they will eat more food than they normally do. But this may be a problem because we don’t have more food” - FG

8. If mixing Sprinkles changes the colour of food, do you think the children and/or caregivers will object to taking that food?

HCP: Same as above. HCP: Depends on child, and some preferences. i.e. colours, sauces

Caregivers: Many responded with no, some responded that it depends on the colour, and maybe, if there are

Caregivers: Most: Will still eat it/no problem, some: will depend on the child.


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taste changes, odour changes.

It appears childrens’ behavior and attitudes to changes in food vary, but it is good practice to

note that some of these flavor, odour and colour changes may occur, depending on the food

vehicle (content, temperature, consistency). These changes are noted in the implementation

guidelines such that problems relating to a baby eating the food can be solved.


9. What are the most effective, trusted sources of health information for mothers?

HCP: The most repeated answer were CHWs. Other dominant responses were the health centre/hospital, radio, and local meetings.

HCP: CHWs, health centres, radios.


Trusted, and effective information dissemination source: CHWs and health centers/hospitals.

The radio is also a trusted source. These can be used for adequate sensitization and promotion

within the community, and could be a source to mitigate any rumour generation that could

happen in the community.


10. What do you think are some barriers for Sprinkles promotion and counselling activities? Some opportunities?

HCP: Inadequate information/training and the cost of Sprinkles. Opportunities: good, quality training and education for promotion.

HCP: Rumours, “laws of the church”, cost, reluctance to accept new programs, mixing it with pepper sachets, selling the sachets for money, confused with sterilization, inadequate sensitization, sharing. Opportunities: Peer-learning sessions, increase sensitization,


48

ensuring proper age (by CHWs) to prevent selling/scamming.


11. In order for you (or CHWs) to train mothers on the use of Sprinkles, what will you need to adequately train them?

HCP: Many responses: Same as above. Some suggested cascade training to reach CHWs, and ultimately, households. Teaching materials suggested included pamphlets, demonstrations of use, and visual aids. A few recommended that transportation allowances are included to ensure training attendance.

HCP: Training, teaching materials (from notepads to foods for demonstrations), demonstrations, per diem/payment for trainers/transport fees, visual aids.


From the perspective of the healthcare providers, “Training-of-Trainers” (TOT) style is

suggested and is the most realistic approach to training all the mothers necessary to reach our

target group of 6-23 month olds in 6 districts. Realistic training needs of those involved in TOT

are outlined above. Visual aids such as pamphlets and cooking demonstrations were suggested

for optimal education and training sessions.


12, 9. Where do you think you and other family members should hear more information about this important powder? Who should help explain about this powder?

HCP: Responses similar to Q9. CHWs, radio, local leaders.

HCP: Local leaders, health centres, CHWs, radio.

Caregivers: Many responded with CHWs, local leaders, the health centre (doctor), and the radio.

Caregivers: CHWs, HCs, local leaders, radio.

For adequate education and support, all members in the community should be educated on MNP-

use and those trusted individuals in the community, such as CHWs and local leaders are trusted


49

sources of health information. Institutions such as health centres and hospitals are locations for

information, as well as the radio to reach caregivers in their home.


13, 10. What do you think mothers would need to know to help them decide whether to use Sprinkles powder or not?

HCP: The most dominant answers were Sprinkles’ importance/benefits and the Sprinkles’ origin/contents. Other repeated responses were, side effects of use and consequences of non-use/anaemia.

HCP: Composition, importance, side effects, utilization, possible negative effects, access, price, how to mix

Caregivers: Similar to Q4: The responses were: -“how to use it”: specifically when to use it, food vehicle information (types of food, temperature of food), duration of use, amount to be used, cost, target group. -its use: benefits/importance, side effects -the product itself: Sprinkles contents/how it’s made, where to find the product, cost. -training/promotion: demonstration of use, testimonies/examples, samples In addition: other answers mentioned included consequences of non-use/anaemia, and shelf life/storage, and these training/education activities to happen in their village.

Caregivers: How it will smell, taste, importance, how to measure quantity, benefits, colour, what foods, where to find it, how to use it, how to teach people to use it, examples, how to prepare, advantages, composition,

As previously discovered in Q4 of this module, mothers want comprehensive information. It is

imperative to have this accurate information accessible to everyone.


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14, 11. To build up people’s confidence in using and understanding Sprinkles what type of personalities/celebrities would you recommend in mass media appeals?

HCP: The most predominant answers were CHWs and the radio.

HCP: Local leaders, radio programs/journalists (uruana), plays, MOH.

Caregivers: Many responded with CHWs, local community leaders, political leaders in the village, doctors, radio journalists, MOH.

Caregivers: CHWs, local leaders (religious, political, or village chiefs), Same as above. Model mothers

15, 12. Which media may be the best for increasing the awareness and acceptance of Sprinkles in this community?

HCP: Same as above. HCP: Radio because of its reach and no need for literacy.

Caregivers: Responses included radio, brochures/leaflets, posters in the health centre, TV in the health centres, newspaper.

Caregivers: Radio, leaflet.

Trusted sources of promotion are people in their community (CHWs, local leaders), health

centre/hospital (personnel and brochures, leaflets, posters), and TVs in the health centre. These

are useful responses to when this program is implemented in 6 districts and social marketing

plans are necessary for MNP promotion.


16. Other comments: “I would like the implementation of Sprinkles as soon as possible because anaemia is a major issue in many developing countries and Sprinkles is an ideal way of preventing anaemia” –postnatal HCP “Thank you, Ministry of Health, for researching about this subject and hopefully, the Ministry of Health can implement these programs for prevention of

Many said thank you. Many had questions. “I think this is an innovation. So, you should start the implementation” – tutilaire Ensure training given out PRIOR to distribution. Assign one person as the expert. “I hope you will take action and follow through with you promises…”-nutritionist


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anaemia in such a way at the village level where the problems of anaemia occur.” – a pharmacist “If Sprinkles already provides nutrients for children in other countries, we have no time to waste because Rwanda needs it. That being said, we need to train people first.” – a titulaire

“Before introducing the new product Sprinkles, they send you to collect our opinion. It is good because we are the ones who will train and spread the message” – pharmacist “We want to thank you for talking to us and for bringing a new project to help our children” - FG

There is tremendous interest and gratitude regarding implementing a MNP program in the two

districts of Musanze and Nyaruguru.

3.5. Summary of Results

The results outlined will guide how the MNP program will be implemented in the Rwandan

context. The conceptual figure below shows the categories that emerged from the narrative data,

as well as the categories that fit into the constructs of the Integrative Model of Behavior

Prediction. The purpose of the diagram is to visually depict the encompassing aspects that would

influence a successful MNP program: one that reaches target caregivers with the correct

information, supports, motivates, and facilitates the practice and behaviour change for caregivers

to appropriately use MNP for their child(ren) aged 6-23 months in the household. As noted, the

ability for caregivers to do so is affected by individual factors, environmental factors, and the

self-efficacy of the caregiver. For an optimal MNP program, all of these factors must be

considered and properly supported to ensure a successful outcome. Possible mis-information or

rumours that could negatively impact the caregiver knowledge, attitude, and/or practice of

acquiring and properly using MNP for their child was explored. This conceptual figure visually

shows what influences rural Rwandans to adopt the practice of using MNP appropriately and

adhering to it. This visual figure is by no means exhaustive, but the discussion will interpret the

findings based on the priorities and objectives of the program: to guide phase 2 and 3.


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4. Discussion

4.1. Introduction

The results of the formative work including focus group discussions and key informant

interviews make clear the immediate need for improved community based nutrition education,

particularly as it relates to complementary feeding of young children, an essential component of

the MNP program. Current knowledge in the community is broadly lacking in areas of optimal

infant and young child feeding practices and anaemia, with serious gaps with regards to foods

that are important for child growth and development6, 11, 12. As the in-home fortification program

is part of complementary feeding the information being provided to caregivers must be accurate

or the integrated protocol will not have the overall desired impact on undernutrition. Rwanda has

numerous issues related to undernutrition among young children but the most notable is the high

prevalence of stunting (44%) according to the recent results of the DHS. Stunting is a

consequence of undernutrition during the key formative period from conception to about age

two, or what is commonly referred to as the ‘1000 days’6, 7, 48, 49. It is during this period that

energy and nutrient needs must be met both in the pregnant woman and her young child. It is

quite apparent from the results of our work that there is little understanding of the importance of

eating energy dense foods as part of complementary feeding or of animal foods as few

mentioned the latter and none mentioned fat, although young children should be getting at least

30% of energy from fat.

Wasting, or low weight for height, is less common than stunting although still a problem in

Rwanda. Wasting is the result of present undernutrition, often compounded by infection leading

to the insidious malnutrition infection cycle50-57. Underweight may be the result of either past or

present undernutrition and again, is very common in Rwanda with prevalence 11%. Dietary

solutions to the ongoing nutrition issues for children must be integrated into comprehensive

programs that also address sanitation and hygiene and other indirect causes of undernutrition,

which will be an aim of this program.

As discussed in the background to this report, anaemia is highly prevalent and the main target of

the MNP intervention program. Again this it is not a stand-alone intervention and will be


54

integrated with appropriate complementary feeding that will encourage an overall increase in the

diversity of foods consumed by young children as well as the quantity. Dietary diversification

offers the potential of broadly increasing a range of micronutrients, not only iron58-63. A diverse

diet can also promote iron absorption through the inclusion of absorption enhancing factors such

as vitamin C found in fruits, potatoes and some vegetables. Current nutrition counseling, as

reported in the results, offers suggestions that are not effective in increasing iron levels in the

diet e.g. consuming tree tomatoes. There is a clear lack of knowledge on all levels regarding

foods that can impact anaemia including widespread confusion about the difference between

foods that contain iron and foods that impact iron status. This will be discussed further under the

section on children’s needs for variety.

Dietary inadequacy is the direct and main cause of micronutrient deficiencies in infants and

young children. Infants and young children have very high energy and micronutrient needs due

to: rapid growth and development, nutritional depletion/low body stores, with the most quickly

depleted micronutrient being iron64, 65, low micronutrient content in breastmilk, and limited

stomach capacity. By 9-11 months of age, any breastfed infant needs to obtain 50-90% of

vitamins and minerals from complementary foods as breastmilk is not longer adequate. These

needs are very difficult to meet without the inclusion of animal source foods, iron-fortified

food66 or the addition of home fortificants such as MNP. Even in areas where children have

access to animal foods rich in iron, during the rapid growth period from 6-23 months, they are

unable to consume enough of these foods to meet their needs due to their limited stomach

volume.

The dietary counseling advice currently provided to caregivers is far from optimal but can easily

be improved due to strong programming that is currently in place, a functional, expansive

network of trusted CHWs, and keen interest from caregivers on learning accurate information

about a healthy diet for a baby. A MNP program is a food-based, preventative approach to

address micronutrient deficiencies, which are not currently being met through their current

malnutrition prevention, malaria prevention and kitchen garden programs. Integration into

current programming/upcoming CBNP training protocol in District Plans to Eliminate

Malnutrition (DPEM), using cascade training is an effective and efficient method to reach target

beneficiaries although nutrition messages much be accurate as defined by the evidence based


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Guidelines for Complementary Feeding of the Breast Fed Child, UNICEF IYCF Guidelines as

well as the recent recommendations from the conference on the importance of “Essential Fat in

the 1000 days” and the “Essential Nutrition Actions”.

As many issues came up in the focus group discussions and interviews that relate to the success

of the overall program which is not just to reduce anaemia but to improve overall children’s

overall nutrition, they will be discussed here in relation to complementary feeding

recommendations.

4.2. Complementary Feeding

Recommendations

The results of the formative work indicate little awareness regarding the quantity vs. the quality

of food consumed by young children as almost all comments were related to the need for a

‘balanced diet’. The international nutrition community is cognizant of this as a gap in many

programs and Rwanda has an opportunity to make needed changes to their nutrition education

programs to reflect needs for improvement. The following follows the basic recommendations

and relates it to the results.

4.2.1.Quantity

At six months of age a child should start to be fed with small amounts of food increasing the

quantity as the child gets older, while maintaining frequent breastfeeding11. The energy needs

from complementary food for infants with “average” breastmilk intake in developing countries

such as Rwanda are approximately 200 kcal per day at 6-8 months of age, 300 kcal per day at 9-

11 months of age, and 550 kcal per day at 12-23 months of age. In order to meet energy needs,

the recommendations for quantity per feeding and frequency of feeding need to be met, although

complementary foods in Rwanda may not be of adequate energy density as found in Phase 1.


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If an infant is consuming more or less breastmilk than the average, the amount needed from

complementary foods will differ accordingly. In practice, caregivers will not know the precise

amount of breastmilk consumed, nor will they be measuring the energy content of

complementary foods they offered. Thus, the amount of food to be offered should be based on

the principles of responsive feeding given below while assuring that energy density and meal

frequency are adequate to meet the child’s needs. Given a mixed diet, energy density should

range from 1.07 to 1.46 kcal/g and the approximate quantity of complementary foods that would

meet the energy needs of a young child is 137-187 g/d at 6-8 months, 206-281 g/d at 9-11

months, and 378-515 g/d at 12-23 months.

Foods identified by caregivers in Phase 1, such as vegetables, banana, and potato, are lower than

the recommended energy density. Porridge may be higher in energy density if it is thick although

frequently the porridge that is provided is more watery, like a thick beverage. There are foods

present in the Rwandan diet that are higher in energy but rarely mentioned. Children’s need for

fat was not mentioned by anyone as important for young children and clearly not understood.

Note from the Essential Nutrition Actions Key Messages: To help your baby grow and get

strong, enrich your baby/child’s food with 2 to 3 different types of foods (such as butter, oil,

peanuts, meat, eggs, lentils, vegetables and fruits) at each meal. One of their main points is: Add

butter and oil every time to the porridge.

This message does not seem to appear anywhere in the recommendations in spite of the

Rwandan diet being notably low in fat with the FAO reporting it to be close to the lowest in the

world at ~8% of total energy. This has strong implications for child growth. Foods such as

animal foods, oil, avocadoes and ground nut paste are more energy dense and small amounts of

these foods need to be added to young children’s diets to make up for the low energy density of

the staple foods10, 13, 49, 66, 67.

Ways to ensure quantity is appropriate for young children is not just to make sure the density is

sufficient but to feed the child the appropriate amount of food at each meal and to feed the child

the recommended number of meals and snacks11, 12. May caregivers in the focus groups from

both districts reported that they did not provide snacks. Snacks help provide extra energy

between meals as often kids will ‘fill up’ at a meal’ but be able to eat more a couple of hours


57

later. Responsive feeding by a caregiver will help a child consume more food and more varied

food.

4.2.2. Responsive Feeding

Caregivers must practice responsive feeding, applying the following principles: a) feed infants

directly and assist older children when they feed themselves, being sensitive to their hunger and

satiety cues; b) feed slowly and patiently, and encourage children to eat, but do not force them;

c) if children refuse many foods, experiment with different food combinations, tastes, textures

and methods of encouragement; d) minimize distractions during meals if the child loses interest

easily; e) remember that feeding times are periods of learning and love - talk to children during

feeding, with eye to eye contact11. When asked in focus groups almost all mothers said they

encouraged their young child to eat, primarily by talking to the baby. Some mothers indicated

that they don’t encourage feeding when the child is sick and while difficult, it is important to

continue trying to feed the child when ill in accordance with recommendation for the care and

feeding of sick children. The key recommendations for feeding a child over 6 months during

illness are:

• Take time to patiently encourage your sick child to eat as her/his appetite may be decreased

because of the illness.

• It is easier for a sick child over 6 months to eat small frequent meals so feed the child foods it

likes in small quantities throughout the day.

• It is important to keep feeding complementary foods to your child during illness to maintain

child’s strength and reduce the weight loss.

4.2.3. Frequency

Increase the number of times that the child is fed complementary foods as he/she gets older. The

appropriate number of feedings depends on the energy density of the local foods and the usual

amounts consumed at each feeding. For the average healthy breastfed infant, meals of

complementary foods should be provided 2-3 times per day at 6-8 months of age and 3-4 times

per day at 9-11 and 12-24 months of age, with additional nutritious (such as a piece of fruit, ½


58

avocado, bread or chapatti) offered 1-2 times per day. Snacks are defined as foods eaten between

meals-usually self-fed, convenient and easy to prepare. If energy density or amount of food per

meal is low, or the child is no longer breastfed, more frequent meals may be required10, 12, 49.

According to our findings, fruit or porridge were sometimes consumed as snacks but many

mothers reported no snacks were commonly fed to their children as noted above under quantity.

This should be an important message to caregivers as lack of snacks is associated with an

inadequate energy consumption and poorer growth.

In accordance with international guidelines, when energy density of the usual complementary

foods is less than 0.8 kcal/g, or infants typically consume amounts that are less than the assumed

gastric capacity at each meal, meal frequency would need to be increased with frequent snacks.

Hence, there may be even more snacks needed in Rwanda.

4.2.4. Variety and Nutrients

Recommendations are to feed a variety of foods to ensure that nutrient needs are met4, 11, 39. Most

caregivers seemed to have heard the message regarding the need for a ‘balanced diet’ although

there were keys foods that are part of a balanced diet that were not mentioned, or mentioned by

few. Meat, poultry, fish or eggs should be eaten daily, or as often as possible although we

acknowledge the constraints in Rwanda with regard to access and affordability. Vegetarian diets

cannot meet nutrient needs, particularly for key minerals such as iron and zinc, at this age unless

nutrient supplements or fortified products are used68-70. Vitamin A-rich fruits and vegetables

should be eaten daily although given the low stomach capacity of young children and the low

bioavailability of the form of vitamin A in plant foods, these will not meet their physiological

requirements for the vitamin. As stated earlier, diets in Rwanda are particularly low in fat, which

is also needed for fat soluble vitamin absorption. Caregivers need to be encouraged to add fat to

their children’s meals wherever possible and should be given key messages about the importance

of fat for growth and development. Cooking food in fat can help improve micronutrient

bioavailability and increase energy intake.

Because of the rapid rate of growth and development during the first two years of life, nutrient

needs per unit body weight of infants and young children are very high. Breast milk can make a

substantial contribution to the total nutrient intake of children between 6 and 24 months of age,


59

particularly for high quality protein, essential fatty acids and many of the vitamins. However,

breastmilk is relatively low in several minerals such as iron and zinc, even after accounting for

bioavailability. At 9-11 months of age, for example, the proportion of the Recommended

Nutrient Intake that needs to be supplied by complementary foods is 97% for iron, 86% for zinc,

81% for phosphorus, 76% for magnesium, 73% for sodium and 72% for calcium64. Given the

relatively small amounts of complementary foods that are consumed at 6-23 months the nutrient

density (amount of each nutrient per 100 kcal of food) of complementary foods needs to be very

high.

In Rwanda, complementary foods do not provide sufficient iron, zinc and vitamin B6 as these

minerals and vitamins are found primarily in animal foods, particularly in the form that can be

absorbed and utilized by the human body. Even in more affluent countries such as the U.S., iron

and zinc were identified as problem nutrients in the first year of life, despite the availability of

iron-fortified products, due to the small amounts consumed. Certain other micronutrients are in

short supply in many populations, due to the low nutrient density of local complementary foods.

These include riboflavin, niacin, thiamin, folate, calcium, vitamin A and vitamin C. Others, such

as vitamin E, iodine and selenium, may also be problem nutrients but there is insufficient

information to make this judgment in Rwanda.

While Rwanda-specific analysis has not been done, it is clear from analyses done in countries

with similar diets64, 71-73 that plant-based complementary foods by themselves are insufficient to

meet the needs for certain micronutrients. Therefore, it is advisable to include meat, poultry, fish

or eggs in complementary food diets as often as possible as available. Even small amounts where

available can go a long way to improving the quality of the diet. Dairy products are a good

source of some nutrients, such as calcium, but do not provide sufficient iron unless they are

fortified. In environments with poor sanitation such as rural Rwanda, promotion of liquid milk

products is risky because they are easily contaminated, especially when fed by bottle. Fresh,

unheated cow’s milk consumed prior to 12 months of age is also associated with fecal blood loss

and lower iron status (Ziegler et al., 1990; Griffin and Abrams, 2001). In the first year of life it is

best to consume extra milk only if it is mixed with other foods, e.g. in a cooked porridge.


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4.3. General Nutrition Knowledge

Caregivers want to know more about complementary feeding and how to prepare foods for

young children. This was very clear from the focus groups. Their knowledge and understanding

of the need to exclusively breastfeed up to six months was quite consistent across the two

districts although there was still a range from 2-12 months so the message needs regular

reinforcement. When it comes to complementary feeding the main message that caregivers and

CHWs seem to recognize was that the child needed a ‘balanced diet’. Balance, or providing

foods from different groups, is important as it can lead to an increase in nutrient consumption

and help a child become accustomed to different foods needed for a healthy diet. On the other

hand, balance alone is not enough if quantity is low. Messages need to be strong regarding the

amount and frequency of feeding with an emphasis on foods higher in energy. There seems to be

an overwhelming emphasis on vegetables in spite of their low energy density and the low

bioavailability of key nutrients such as iron and vitamin A. There are common beliefs in both

districts that feeding vegetables will prevent malnutrition which is also not true. Vegetables are

part of a healthy diet but most of the malnutrition in Rwanda is not related to an inadequate

vegetable intake.

No one in the focus groups mentioned a lack of food when it came to common problems related

to infant and young child feeding although they mentioned lack of growth and lack of weight

gain as well as lack of appetite. They are concerned with how to prepare food for children. The

only difference between Nyaruguru and Musanze was the health care providers in Nyaruguru

mentioned soil infertility and polygamy as issues in addition to poverty when asked about infant

and young child feeding.

In discussing foods that are important for young children to be healthy, health care providers

mainly mentioned plant foods in Musanze, primarily potatoes, beans, vegetables and porridge

with some in Nyaruguru talking about foods as body building, energy foods and illness

preventing. In both districts only a few mentioned meat, fish or eggs. When asked why certain

food were important for children many said growth or weight gain although no one mentioned

fat or oil. Many did say important foods were not always available due to financial constraints.


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Key complementary feeding messages are provided in appendix X. They will be modified in

accordance with the current community based nutrition program and feedback from the Nutrition

Technical Working Group prior to implementing Phase 3 of the intervention.

Caregivers did identify playfulness, growth and a good appetite as signs of a health child. A lack

of appetite is associated with anaemia and infection hence this program has a good opportunity

to provide women with one the main indicators of children’s health.

4.4. Anaemia-Specific Knowledge and Treatment

This is an area that was particularly weak in spite of the high prevalence of anaemia among

women and young children. There does not appear to be an anaemia prevention and control

program and WHO guidelines are not followed. While all health care providers had heard of

anaemia and most caregivers said yes they had, many of the latter were confused between

kwashiorkor, other forms of malnutrition and anaemia. The confusion was clear when they

identified symptoms such as edema and stunting. In addition when caregivers were asked about

how they would know if a child had anaemia, some accurately commented on low energy, not

playful (although these symptoms are not specific), others replied ‘not gaining weight’.

Common misconceptions include the following:

• Fruits and vegetables are good sources of minerals. They are sources of minerals but poorly

absorbed16, 68, 69, 74, 75. The focus for minerals should be on animal foods or fortified foods.

There is little support for the concept of fruits and vegetables as sources of minerals and this

needs to be corrected in all training materials.

• Anaemia can be prevented by red legumes, tree tomatoes and green vegetables. There seems

to be a strong believe that red colour benefits red blood. Depending on the variety, tree

tomatoes contain less than 0.5 mg of iron7 of which 2% is actually bioavailable. With regard

7 New Zealand Tamarillo Growers Assocation. http://www.tamarillo.com/vdb/document/153


62

to foods that can help prevent anaemia only a very few women noted meat or fish which

contain iron in a more bioavailable (absorbable) form.

• Anaemia can be treated with tree tomatoes or green vegetables e.g. isombe. Again, they

contain iron but the amount absorbed is very low for plant sources of iron due in part to the

high phytate content. Even when vitamin C is added the amount of absorbed iron will not

impact iron status. There is no research to support this assertion. Some said sosoma, an iron

fortified cereal for treatment and while it does contain iron it is not for treatment.

In general, there is a broad lack of knowledge on anaemia although there is considerable interest.

Health care providers needs to be able to give accurate information to women and this program

will provide them with the training and materials to do their work. Treatment for moderate

anaemia according with iron folic acids tablets is not the standard WHO recommendation and

consideration should be given to a more appropriate treatment protocol which could include

MNP instead of syrup. Presumably the tablets given fare iron folic acid for pregnant women

broken into smaller amounts as they would contain 60 mg of iron, which is far more than the

recommendation for young children with anaemia. Young children would also have difficulty

swallowing pills.

4.5. Caregivers Response to MNP

There was overwhelming support for the MNP concept and caregivers where very encouraging

and willing to accept a new intervention if it would improve their children’s health. Of note, they

want clear, accurate information. They also want thorough information about the composition,

possible side effects and benefits. They were also asked about their willingness to pay in the

future for MNP.

Needless to say the issues of poverty and financial constraints were recurring themes throughout

all modules when talking to healthcare providers and caregivers. While mothers indicated a

willingness to pay, their capacity to do so may be challenged due to inconsistent access to


63

income. Starting a program with a public/free distribution would be ideal to positively promote

MNP in the 6 intervention districts and to ensure accessability to the product. The team has

already planned for a public distribution scheme so this finding will have minimal effects on the

budget.

Possible constraints included the fact that young children may not have a consistent feeding

regime because sometimes there are other caregivers other than the mother who prepares food

(e.g. their older sisters/aunts/grandmothers), and possibly not all meals can be consumed in their

household (perhaps in a neighbour’s house). The realities of feeding practices in these

communities are not conducive to a strict, daily administration and dose (in which one sachet

administered each day for 180 days), which also has budgetary implications. Flexible

administration has been shown to be just as efficient to control anaemia prevalence76 so a dose of

even 60 sachets consumed over 180 days can impact anaemia prevalence.

The information learned from phase 1 fieldwork was very useful in guiding implementation

guidelines for MNP use in Rwanda. As discussed above, there is a strong need for nutrition

education in rural Rwanda that is targeted at improving infant and young child feeding practices,

with a focus on complementary feeding. Again, introducing MNP into a community provide an

opportunity to improve IYCF practices such as: the duration of exclusive breastfeeding and the

timeliness of introducing complementary foods, maintenance of breastfeeding, responsive

feeding, quantity, quality, consistency, and frequency of complementary foods, and the use of

micronutrient powders in complementary foods. These are outlined in the Manual and

Implementation Guidelines (in progress). Suggested optimal foods for health and for mixing

MNP with are also outlined in the report.

The information gathered and KAP explored in Phase 1 helped guide key messaging that will be

used to promote MNP in the household and in the community. Perceptions of a healthy baby: a

playful baby who has an appetite, is growing and gaining weight, was a key finding in the work.

While MNP have not shown an effect on physical growth8, the other two positive characteristics

8 WHO guidelines on the use of multiple micronutrient powders for home fortification of foods consumed by infants nd children 6-23 months of age. 2011.


64

have been shown as an effect of increased iron stores: an increased appetite and reported

increased activity/playfulness9.

Trusted sources of health information were identified as CHWs, local leaders, health centres and

the radio and will be utilized as education and promotion vehicles. It will be important to convey

the purpose and rationale to key people in the community as political leaders were also identified

as being useful for mass appeals. A broad communications strategy needs to be developed to

ensure uptake is optimal. Communication must include religious leaders, local leaders and older

people such as the grandmothers.

4.6. Limitations

As with all qualitative work there are limitations. Focus groups may be influenced by dominant

individuals who may or may not represent the thinking of all members. The researcher's

presence, including the Canadian and Rwanda students as well as UNICEF and NGO

representatives, during data gathering, may have affected the participants’ responses. t is more

difficult to determine the validity and reliability of linguistic data. It is harder to determine the

extent of influence that the researcher had over the results (e.g., through researcher bias). That is,

there is more subjectivity involved in analysing the data.

“If MNP already provide nutrients for children in other countries, we have no time to waste

because Rwanda needs it. That being said, we need to train people first.” A titulaire.

Appendices

Appendix 1: Contributions

Appendix 2. FGD consent form

Icyemezo cyo kugira uruhare mu bushakashatsi icyiciro cya 1: Inyigo – ubumenyi, imyifatire

hamwe n’imikorere

9 Sprinkles Global Health Initiative. 2008. Micronutrient Sprinkles use in Infants and Young Children: Guidelines on Recommendations for use and program monitoring and evaluation.


65

Ubwoko bw’icyemezo : imenyekanisha rikozwe mu magambo.

Nitwa ___________________________ nkaba ndi umunyeshuri muri INATEK. Nkorera

umushinga wa Minisiteri y’Ubuzima ifatanyijemo n’ubuyobozi bw’akarere ka___________.

Turagutumirira kugira uruhare mu biganiro bikorerwa mu matsinda bijyanye n’ibibazo bijyanye

n’imirire hamwe n’ubuzima bw’umwana. Impamvu ry’ibi biganiro byo mu matsinda ijyanye ni

uko tugiye gutangiza umushinga ugamije guteza imbere ubuzima n’imirire y’umwana mu

Rwanda. Amakuru ava muri ibi biganiro ni yo azaha uwo mushinga umurongo-ngederwaho. Turi

hano kugira ngo tubigireho, tumenye ibikorwa bijyanye n’imirire y’umwana hamwe n’ibikenewe

kugira ngo tugire amakuru ahagije azakoreshwa n’uwo mushinga mu ishyirwa mu bikorwa

byawo ku nyungu z’abana.

Ibi biganiro birakorerwa ________________ kandi nta wundi wemerewe kuba muri ibyo

biganiro utari mu itsinda ryanyu hamwe hamwe n’iryacu. Turaza gufata amajwi b’ibi biganiro

kugira ngo hataza kugira ikiza kutwisoba mu gihe cyo gusesengura no kuvana amasomo ku

byabivuyemo. Ikindi nta muntu n’umwe uza kuvuga amazina ye mu rwego rwo kubika ibanga

rya buri wese. Kaseti iriho aya majwi izabikwa ahantu hafunzwe neza muri Ministeri

y’Ubuzima. Ibanga rizakomeza kubikwa, kuko nta wundi wemerewe kumva amajwi yanyu utari

umwe mu bagize itisinda ryacu. Iyi kaseti kandi izatwikwa nyuma y’amezi 12

Niba uhisemo kugira uruhare, amakuru uduha azagirwa ibanga, kandi nta wundi uzayamenya

utari uwo mu itsinda ryacu. Tuzubaha ibanga hamwe n’amakuru akwerekeyeho. Kugira uruhare

muri iri bazwa ni ubushake, kandi niba hari ikibazo utifuza gusubiza, ufite uburengenzira bwo

kubimenyesha nkagisimbuka; ikindi kandi ushobora guhagarika iri bazwa igihe icyo ari cyo

cyose. Nta ngaruka mbi zizakugeraho niba uhisemo kutagira uruhare muri iri bazwa cyangwa

gusimbuka ibibazo bimwe na bimwe. Umwanzura wafata nta wundi uzawumenya, hakubiyemo

ndetse n’abayobozi. Ariko, turizera uri bwemere kugira uruhare kuko amakuru mwaduha

akenewe.

Iri bazwa riteganyirijwe iminota 120 kandi ufite uburenganzira bwo kwemera ko yose ikoreshwa

cyangwa se ntikoreshwe. Banza utekereze neza mbere yo guhitamo kugira uruhare muri iyi nyigo.

Tuzanezezwa no gusubiza ibibazo byose waba ufite byerekeye iyi nyingo. Uramutse ufite ibindi

bibazo byerekeye iyi nyigo, cyangwa ukaba wifuza kutubwira ibintu bitagushimishije muri iyi


66

ubushakashatsi, cyangwa ikibazo cyerekeranye n’ubushakashatsi wabaza umuhuzabikorwa w’iyi

nyigo witwa Dr Jeanine CONDO kuri telefoni 0788300308. Niba wifuza kuganira

kuburenganzira bwawe nk' umuntu uzagira uruhare mu bushakashatsi/inyigo, kuganira ku

bibazo, kubona ibisobanuro cyangwa se gutanga ibitekerezo ukabibwira umuntu usobanukiwe

ariko udafite uruhare mur' ubu bushakashatsi, wakwitabaza Umuyobozi wa Komite inshinzwe

kurengera uburenganzira bw’abakorerwaho ubushakashatsi mu gihugu uhamagara Dr. Justin

Wane, kuri telefoni 0788500499 cyangwa umunyamabanga wiyo Komite Dr Emmanuel

Nkeramihigo, kuri telefoni 0788557273.

Ndabaha kandi n’inyandiko ngero y’amasezerano cyangwa se ubwumvikana kugira ngo

uzamenye aho uzajya

Mbese urashaka kugira uruhare muri iyi nyigo? Yego Oya

Iyi nyandiko yo kwemera kubazwa yasomwe ndayisobanukirwa kandi niyemeje kugira uruhare

muri iyi gahunda y’ubushakashatsi bwasobanuwe haruguru. Nanyuzwe n’ibisobanuro bijyanye

n’intego rusange, uruhare rwanjye, imbogamizi n’ibindi bishobora gutungurana mu

bushakashatsi. Ndumva neza ko bishoboka ko nahagarika uruhare rwanjye igihe cyose byaba

ngombwa.Umukono wanjye cyangwa igikumwe ni icyemezo ko nahawe iyi nyandiko.

_____________________________________ ____________

Umuntu ubazwa Itariki

_____________________________________ _____________

Umuntu wemerewe guhabwa amakuru Itariki

Appendix 3. Semi-structured interview consent form

Icyemezo cyo kugira uruhare mu bushakashatsi icyiciro cya 1: Inyigo – ubumenyi, imyifatire

hamwe n’imikorere

Ubwoko bw’icyemezo: Imenyekanisha rikozwe mu nyandiko.


67

Nitwa ___________________________ nkaba ndi umunyeshuri muri INATEK. Nkorera

umushinga wa Minisiteri y’Ubuzima ifatanyijemo n’ubuyobozi bw’akarere ka___________.

Turabatumirira kugira uruhare mw’ibazwa rijyanye n’imirire hamwe n’ubuzima bw’abana bo

murii aka karere. Impamvu y’iri bazwa ijyanye n’itangizwa ry’umushinga ugamije guteza imbere

imirire n’ubuzima bw’abana mu Rwanda. Amakuru ava muri iri bazwa niyo azaha uwo

mushinga umurongo-ngederwaho.

Niba uhisemo kugira uruhare, amakuru uduha azagirwa ibanga, kandi nta wundi uzayamenya

utari uwo mu itsinda ryacu. Tuzubaha ibanga hamwe n’amakuru akwerekeyeho. Kugira uruhare

muri iri bazwa ni ubushake, kandi niba hari ikibazo utifuza gusubiza, ufite uburengenzira bwo

kubimenyesha nkagisimbuka; ikindi kandi ushobora guhagarika iri bazwa igihe icyo ari cyo

cyose. Nta ngaruka mbi zizakugeraho niba uhisemo kutagira uruhare muri iri bazwa cyangwa

gusimbuka ibibazo bimwe na bimwe. Umwanzura wafata nta wundi uzawumenya, hakubiyemo

ndetse n’abayobozi. Ariko, turizera uri bwemere kugira uruhare kuko amakuru mwaduha

akenewe.

Iri bazwa riteganyirijwe iminota 45 kandi ufite uburenganzira bwo kwemera ko yose ikoreshwa

cyangwa se ntikoreshwe. Banza utekereze neza mbere yo guhitamo kugira uruhare muri iyi nyigo.

Tuzanezezwa no gusubiza ibibazo byose waba ufite byerekeye iyi nyingo. Uramutse ufite ibindi

bibazo byerekeye iyi nyigo, cyangwa ukaba wifuza kutubwira ibintu bitagushimishije muri iyi

ubushakashatsi, cyangwa ikibazo cyerekeranye n’ubushakashatsi wabaza umuhuzabikorwa w’iyi

nyigo witwa Dr Jeanine CONDO kuri telefoni 0788300308. Niba wifuza kuganira

kuburenganzira bwawe nk' umuntu uzagira uruhare mu bushakashatsi/inyigo, kuganira ku

bibazo, kubona ibisobanuro cyangwa se gutanga ibitekerezo ukabibwira umuntu usobanukiwe

ariko udafite uruhare muri ubu bushakashatsi, wakwitabaza Umuyobozi wa Komite inshinzwe

kurengera uburenganzira bw’abakorerwaho ubushakashatsi mu gihugu uhamagara Dr. Justin

Wane, kuri telefoni 0788500499 cyangwa umunyamabanga wiyo Komite Dr Emmanuel

Nkeramihigo, kuri telefoni 0788557273.

Ndabaha kandi n’inyandiko ngero y’amasezerano cyangwa se ubwumvikana kugira ngo

uzamenye aho ubariza mu gihe ugize ikindi kibazo


68

Mbese urashaka kugira uruhare muri iyi nyigo? Yego Oya

Iyi nyandiko yo kwemera kubazwa yasomwe ndayisobanukirwa kandi niyemeje kugira uruhare

muri iyi gahunda y’ubushakashatsi bwasobanuwe haruguru. Nanyuzwe n’ibisobanuro bijyanye

n’intego rusange, uruhare rwanjye, imbogamizi n’ibindi bishobora gutungurana mu

bushakashatsi. Ndumva neza ko bishoboka ko nahagarika uruhare rwanjye igihe cyose byaba

ngombwa.Umukono wanjye cyangwa igikumwe ni icyemezo ko nahawe iyi nyandiko.

_____________________________________ ____________

Umuntu ubazwa Itariki

______________________________________ ____________

Umuntu wemerewe guhabwa amakuru Itariki


69

Appendix 4. Focus Group Discussion Guide

FOCUS GROUP DISCUSSION TOOL FOR MOTHERS’ GROUP FOR:

THE IMPLEMENTATION OF IN-HOME FORTIFICATION AND NUTRITION

EDUCATION TO COMBAT ANAEMIA AND MICRONUTRIENT DEFICIENCIES AMONG

YOUNG CHILDREN IN RWANDA

MOTHERS OF

CHILDREN UNDER 2

ABABYEYI BAFITE ABANA

BATAGEJEJE KU MYAKA 2

Y’AMAVUKO Project Title: The Implementation of In-Home Fortification and Nutrition Education To Combat

Anaemia and Micronutrient Deficiencies Among Young Children in Rwanda (Phase 1: Formative

Work – Knowledge, Attitudes & Practices)

Field Work Dates: July 2011

Method: Focus group

Topic: IYCF, Anaemia, Sprinkles

Target Audience: Mothers of children under 2

Principal Investigator(s): Dr Judy McLean and Dr Condo Jeanine

Instrument Title: Focus Group Discussion Guide

Total Participant time required: 2 hours (120 minutes)


70

IBIGANIRO NGENDERWAHO:

Turifuza ko ibiganiro byaba muburyo busanzwe ku buryo mutakwirirwa mudutegereza mu

kubashishikariza mu gutanga ibisubizo. Mu byùkuri turabashishikariza gusubiza ku bitekerezo

byatanzwe nàbandi. Niba mutumvise ikibazo, turabasaba kubitumenyesha. Turi hano kugira ngo

tubabaze, tubumve, muniyumvisheko buri wese afite uruhare rwo gutanga ibitekerezo bye. Kandi

mwiyumvisheko ibisubizo byose bidufitiye akamaro.

Niba mugusubiza hari uwihariye ijambo dushobora kumuhagarika, cyangwa niba mwicecekeye

dushobora kubahamagara. Niba tubikoze musabwe kutabyumva nabi; nibwo buryo dufite bwo

kugira ngo buri wese atange igitekerezo nìcyifuzo cye.

Dusaba ko buri wese agira umwirondoro wa mugenzi we, uruhare nìbitekerezo bya buri wese

aba ari ibanga. Turizera ko buri wese avugana ubwisanzure nùkuri. Inkuru tuganiraho

tuzayisesengura nùburemere bwayo uko yakabaye kandi nta zina tuzakoresha muri ubwo

busesenguzi.

Turafata amajwi mu kiganiro, kuko tutifuza gutakaza igitekerezo icyo aricyo cyose mwatanze.

Nta muntu n’umwe utari muri iki cyumba uzamenya ibyìzi nyandiko, nyuma yo kurangiza

gukora raporo zizatwikwa.

Muri iki kiganiro turi kumwe n’ umwanditsi -------------------------------------------------

nàbagenzuzi banjye bashobora kuza kuhagera kugira ngo bamfashe niba mbikeneye.

KWIBWIRANA KWÀBITABIRIYE IKIGANIRO

Gusaba buri wese kwibwira abandi akoresheje uyu murongo ngenderwaho :

Bwira abandi izina ryawe, amakuru yawe bwite, nko kumenya uko umuryango wawe ungana,

icyo ushinzwe.

Ikindi, uvuge nìbi bikurikira:

Imyaka yawe

Umwuga


71

Irangamimerere (Yarashatse, nìngaragu, yatanye nùwo bashakanye, ni umupfakazi, afite abana

bangahe/ abuzukuru).

Amashuli yize

IKIGANIRO MU ITSINDA

Uyoboye ikiganiro ashishikariza abitabiriye ikiganiro gutanga ibisubizo ku bibazo byabajijwe,

no kugira icyo bongera ku bitekerezo byatanzwe n’abandi. Aho kugira ngo buri muntu asubize

ukwe, ibibazo rusange bizabazwa abagize itsinda basubize mu buryo bwìkiganiro. Ibibazo

bikurikira bigomba kubazwa mu kwihutisha ibiganiro.

DISTRICT/AKARERE:

DATE/ITALIKI:

SECTOR/UMURENGE:

MODERATOR/UMUFASHA-

BIGANIRO:

VILLAGE/UMUDUGUDU:

NOTE-TAKER/UMWANDITSI:

INTERVIEW #/IBAZWA #:

FIELD EDITOR/UHAGARARIYE

IBAZWA:

TRANSLATOR/UMUSEMUZI:

Transcription saved as/Iyi nyandiko ibitswe nka:

District_Sector_Village__FGD.doc


72

Seating arrangement/Uburyo bwatenyijwa bwo kwicara:

I. Introduction:

1. First I would like to ask if you have ever seen or heard any messages and/or advice about

what you should feed young children?

Nashakaga kubabaza niba mutarigeze mubona cyangwa mwumva amakuru/ubutumwa ku

bijyanye no kugaburira abana bato.

2. Where or from whom has given you messages and/or advice on how to feed young children?

Ni he /ni kuri nde mwaba mwarakuye amakuru/ubutumwa ku bijyanye no kugaburira

abana bato?

Now I would like to ask some specific questions about when and what young children are fed in

this community.

Noneho rero ndashaka kubabaza ibibazo bijyanye n’igihe n’uburyo abana bato

bagaburirwa muri aka gace.


73

II. Breastfeeding and complementary feeding:

1. Can you tell me until what age a baby should receive only breastmilk, that is, no other food,

water or teas?

Mushobora kumbwira imyaka/igihe umwana yagombye kumara yonka gusa nta fashabere(

nta biryo nta mazi nta n’icyayi)?

2. Can you tell me until what age, or for how long, a child should continue to receive breast

milk?

Mwambwira se imyaka/igihe umwana ashobora kumara acyonka?

3. What are the first foods a young child should be given other than breastmilk?

Ni irihe funguro mfashabere umwana ashobora guheraho?


74

At what age should these foods be introduced to the young child’s diet?

Yagombye gufata iyo mfashabere amaze igihe kingana iki avutse?

4. What foods do young children like in this community?

Ni irihe funguro abana bato bakunda ino aha?

5. What foods do young children dislike in this community?

Ni irihe funguro abana b’ino badakunda?

6. Do you encourage your young children to eat if he/she refuses?

Mujya mushishikariza abana banyu kurya igihe babyanze?


75

If yes, in what ways do you encourage your child?

Niba ari yego ni ubuhe buryo mukoresha kugirango mushishikarize abana banyu kurya?

(urugero:kubaganiriza,kubaha ibiyiko byinshi byo kurisha n`ibindi)

7. Who makes decisions in your home about what foods to feed young children?

Ninde utanga umwanzuro w’ibiryo bagaburira abana?


76

8. Who prepares or cooks food for the young children you care for?

Ninde utekera abana banyu bato cyangwa abo murera ?

9. Do you prepare separate food for your young child (6-23 months)?

Ese mutegurira abana banyu bato ifunguro ryihariye (amezi 6 kugeza kuri 24)?

10. Does your young child eat from his or her own bowl?

Umwana muto afite icyo ariraho yihariye?


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At what age do children stop eating from their own bowl?

Ni ryari abana bato barekeraho kurira ku masahane bihariye?

11. Can you tell me how many times a day a child should eat any meals or snacks other than

breastmilk:

- When they are 6-8 months old?

- 9-11 months old?

- 12-24 months old?

Mushobora kutubwira inshuro umwana muto yahabwa andi mafunguro mfashabere ku

munsi?

Mu gihe afite:

-amezi 6-8


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-amezi 9-11

-amezi 12-24

12. What do young children 6-23 months usually eat in the morning?

Abana bafite hagati y’amezi 6-23 bafata irihe funguro mu gitondo?

What do young children usually eat mid-day?

Ni ayahe mafunguro bafata saa sita?

What do young children usually eat in the evening?

Ni ayahe bafata nijoro?


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What snacks do young children consume during the day?

Hagati y’amafunguro manini/y’ingenzi atatu azwi, ni ayahe mafunguro yandi bahabwa?

13. Where do you normally get your young children’s food from?

Market? Shop? Own farm/land?

Ni he mukura ibyo mugaburira abana?Mu isoko? Mu maduka? Mu murima wawe/ku

matungo yawe?

14. What foods are important for young children to be healthy?

Ni ayahe mafunguro y’ingenzi yatuma abana bagira ubuzima bwiza?


80

15. Can you tell me some reasons these foods are important for young children?

Mwambwira zimwe mu mpamvu ayo mafunguro ari ingenzi?

16. Are these foods always available to you? (Probes: cost, seasonality, etc.)

Mbese aya mafunguro mushobora kuyabona igihe cyose muyakeneye (Tekereza ku:

ibiciro, ibihe by’isarura, n’bindi)?


81

17. What do you do if there is limited access to food? (Probes: Reduce the amount of food that

other family members get? Reduce the number of meals per day? Give baby smaller portions?)

Mubyifatamo mute iyo hatabonetse ibyo kurya nk’uko mubyifuza? (Tekereza ku:

kugabanya ibyo kurya abandi abagize umuryango bagomba kubona? Kugabanya incuro

zo kurya mu munsi? Kuha umwana ibyo kurya bike?)

18. Do your young children eat some of their meals away from your home?

Hari amafunguro abana banyu bafatira ahandi hatari mu muryango iwanyu?

If yes, where else do they eat meals?


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Niba ari yego, ni hehe

19. Now for the last question in this section, can you tell me how you know if a child is healthy?

What are some of the signs of a healthy child?

Mushobora kumenya ko umwana afite ubuzima bwiza? Ni ibihe bimenyetso bibibereka

Now I want to ask you some questions about a condition that could affect the health of family

members.

Ubu noneho ngiye kubabaza ibibazo bijyanye n’imimerere ishobora kugira ingaruka mbi

ku buzima bwa bamwe mu bagize umuryango wanyu.


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III. Anaemia


Wigeze wunva ku ndwara yo kubura amaraso/kugira amaraso make?


Ushobora kumbwira bimwe mu binyetso byayo?

3. How would you know if a young child has anaemia?

Ese ni gute umenya ko umwana ayirwaye?

4. Can you identify any causes of anaemia?

Wambwira impamvu ziyitera?

5. Do you know of any foods that can prevent anaemia?

Hari amafunguro mwaba muzi ashobora kurinda indwara yo kubura amaraso/kugira

amaraso make?

If yes, list:


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Niba uyazi yavuge

6. Do you know of any other ways (non-dietary) to prevent anaemia?

Hari ubundi buryo uzi bwo gukumira indwara yo kubura amaraso/kugira amaraso make?

7. Are there any local programs to prevent anaemia in children?

Probe: If so, what are they? What do they offer? How frequent do they run? Are mothers

obligated to attend? How many attend? Who runs the programs?

Hari gahunda iba muri aka gace yo gukumira iyi ndwara mu bana?

Niba ihari ni iyihe?

Ibaha ubuhe bufasha?

Ingengabihe yazo yo ziteye zite?

Ni itegeko ko ababyeyi /abita ku bana bakwitabira izo gahunda? Abayitabira ni bangahe?

Ninde ukurikirana cyangwa ugenzura izo gahunda?


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8. How are children (medically) treated in your community if they are found to have anaemia?

Ese umwana afashwa/avurwa ate iyo iyi ndwara yamugaragayeho?

9. Where do children receive treatment for anemia?

Ni he umwana yabonera ubufasha igihe afite iyi ndwara?

10. Other general comments:

Ibindi byongerwaho muri rusange.


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IV. Sprinkles

Now I will tell something about a product that is being used to prevent anaemia in children in

other countries. This product is called Sprinkles. "Sprinkles", is a powder form of vitamins and

minerals, contained in small packets (show packet). In particular it contains iron which helps

prevent anaemia in young children and make them healthier. This powder can be mixed with any

soft cooked food prepared for a child who has reached 6 months. Anaemia in children has been

reduced in different countries by caregivers using Sprinkles mixed with semi-solid or soft

cooked food on a regular basis. I would like to ask you some questions about how you think

mothers would feel about adding Sprinkles to your children’s food.

Ubu noneho ngiye kubabwira ibyerekeye ifu y’inyongera-ntungamubiri ikoreshwa mu

bindi bihugu mu rwego rwo gukumira indwara yo kubura amaraso/kugira amaraso make

mu bana bato. Ni agafu karimo za vitamini n’imyunyungugu, gafunze mu gapaki(mwereke

agapaki). By’umwihariko harimo umunyungugu (fer) ufasha mu kwirinda indwara yo

kubura amaraso/kugira amaraso make mu bana bato. Aka gafu gashobora kuvangwa

n’ifunguro ryamaze gutegurwa rigiye guhabwa umwana ugejeje ku mezi atandatu.

Mu bihugu binyuranye, iyi ndwara yo kubura amaraso/kugira amaraso make mu bana

bato yaragabanutse hakoreshejwe ubu buryo bwo kuvanga iyi fu mu mafunguro yoroshye

yamaze gutegurwa, bigakorwa bifite ingengabihe. Ndashaka kubabaza ibibazo birebana

n’uburyo mutekereza ko ababyeyi bakwakira ibirebana no kongera/kuvanga iyi fu

nyongerantungamubiri mu mafunguro y’abana .

1. Would you be willing to add this powder to your children’s food? Continuously from age of 6 to 24 months of age?

Wumva wakwemera kongera iyi fu y’inyongera ntungamubiri mu ifunguro ry`abana uhereye ku mezi 6 kugeza 24 y’amavuko?


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2. Can you tell us any reasons you or other mothers might not be willing to add the powder to their children’s food?

Ushobora kutubwira impamvu iyo ariyo yose yatuma wowe /abandi babyeyi mutemera kongera iyi fu y’inyongera ntungamubiri mu mafunguro y’abana?

3. Do you think some family members might object of the practice of adding this powder to their children’s food?

Mutekereza ko hari abandi bantu bo mu muryango batabyemera?

Who might object? Why might they object?

Ni bande ukeka ko batabyemera? Ese kuki batabyemera?


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4. What information would you need to help make a decision on whether you would give this powder to your child?

Ni ayahe makuru /ubumenyi mwakenera kugirango mube mwafata icyemezo cyo guha iyi fu umwana?

5. Would you agree to feed one packet of Sprinkles to your young children mixed with soft cooked food every other day for 30 days to help us see how well your child accepts the powder?

Wakwemera kugaburira abana bawe agapaki kamwe k`ifu y’inyongera ntungamubiri (sprinkles) mu ifunguro ryoroshye rya buri munsi mu minsi mirongo itatu (30)?

6. Would you be willing to pay a small amount of money for this powder to improve the health of your child?

Wakwemera kwishyura amafaranga make cyane kuri iyi fu kugira ngo wongerere umwana wawe ubuzima bwiza?



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Ese utekerezako umwana ashobora gukomeza gufata ifunguro nk’uko bisanzwe riramutse ririmo ifu y’inyongera ntungamubiri?

8. If mixing Sprinkles changes the color of food, do you think the children and/or caregivers will object to taking that food?

Ese igihe ifu y’inyongera ntungamubiri ihinduye ibara ry`ibiryo umwana ashobora kubyanga?

9. Where do you think you and other family members should hear more information about this important powder? Who should help explain about this powder? Circle all.

a. Doctor

b. Community Health worker/midwife

c. Respected persons in the community (elders, religious leaders etc)

d. Advertisement on Radio

e. Advertisement in TV

f. Others (please mention)...

Ni hehe Mwaba mutekereza ko ababyeyi /abandi bita ku bana n’ abandi bo mu muryango bakumvira/bakura amakuru aruseho yerekeye iyi ifu y’inyongera ntungamubiri?


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a. Ku muganga (Dogiteri)

b. Ku mujyanama w’ubuzima /ababyaza

c. Inyangamugayo(Abantu bakuze, abihaye Imana)

d. Kwamamaza kuri Radiyo

e. Kwamamaza kuri Televiziyo

f. Hari Ahandi? Havuge


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10. What do you think mothers would need to know to help them decide whether to use Sprinkles powder or not?

Ni ibiki mutekereza ko ababyeyi/ abita ku bana bakeneye kumenya byabafasha gufata umwanzuro wo gukoresha ifu y’inyongera ntungamubiri cyangwa wo kutayikoresha?

11. To build up people’s confidence in using and understanding Sprinkles what type of personalities/celebrities would you recommend in mass media appeals? a. Local well-known actors/actresses

b. Sports personalities

c. Political leaders

d. Religious leaders

e. Doctors or other medical people

f. Other – please mention

Ni abahe bantu bazwi cyane (ibyamamare) wasaba ko bakoreshwa cyangwa bagaragara mu itangazamakuru mu gushishikariza abaturage kugirira icyizere ifu y’inyongera ntungamubiri?

a) Abakinnyi b’ikinamico cyangwa filimi bazwi neza ino aha

b) Abakora siporo/imyitozo ngororamubiri

c) Abayobozi/abanyapolitike

d) Abihaye Imana


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e) Abaganga cyangwa abandi bakozi bo kwa muganga

d) Abandi (bavuge)


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12. Which media may be the best for increasing the awareness and acceptance of Sprinkles in this community?

a. Radio

b. Television

c. Newspaper/ Magazine

d. Billboard/Signboard

e. Leaflet

f. Other

Ni irihe tangazamakuru ryaba ryiza kurusha ayandi ryakoreshwa mu gusobanurira abantu iby’ifu y’inyongera ntungamubiri no kubashishikariza kuyikoresha?

a. Radiyo

b. Televisiyo

c. Ibinyamakuru

d. Ibyapa

e. Udutabo

f. Ibindi

13. Other general comments (at the end of the discussion, ask mothers if there is anything else they would like to tell us).

Ibindi bisobanuro (Murangije ikiganiro, baza ababyeyi/abarera abana niba hari ikindi bashaka kongeraho)


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Thank you.

Murakoze.

Appendix 5. Healthcare key informant interview guide

SEMI-STRUCTURED INTERVIEW GUIDES FOR KEY INFORMANTS FOR:

THE IMPLEMENTATION OF IN-HOME FORTIFICATION AND NUTRITION

EDUCATION TO COMBAT ANAEMIA AND MICRONUTRIENT DEFICIENCIES AMONG

YOUNG CHILDREN IN RWANDA


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HEALTHCARE PROVIDERS

ABASHINZWE UBUZIMA

Project Title: The Implementation of In-Home Fortification and Nutrition Education To Combat

Anaemia and Micronutrient Deficiencies Among Young Children in Rwanda (Phase 1: Formative

Work – Knowledge, Attitudes & Practices)

Field Work Dates: July 2011

Method: Semi-structured interview

Topic: IYCF, Anaemia, Sprinkles

Target Audience: Healthcare providers

Principal Investigator(s): Dr Judy McLean and Dr Condo Jeanine

Instrument Title: Semi-Structured Interview Guide

Total Participant time required: 45-60 minutes


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IBIGANIRO NGENDERWAHO:

Turifuza ko ibiganiro byaba muburyo busanzwe ku buryo mutakwirirwa mudutegereza mu

kubashishikariza mu gutanga ibisubizo. Mu byùkuri turabashishikariza gusubiza ku bitekerezo

byatanzwe nàbandi. Niba mutumvise ikibazo turabasaba kubitumenyesha. Turi hano kugira ngo

tubabaze, tubumve, muniyumvisheko buri wese afite uruhare rwo gutanga ibitekerezo bye. Kandi

mwiyumvisheko ibisubizo byose bidufitiye akamaro.

Niba mugusubiza hari uwihariye ijambo dushobora kumuhagarika,cyangwa niba mwicecekeye

dushobora kubahamagara. Niba tubikoze musabwe kutabyumva nabi; nibwo buryo dufite bwo

kugira ngo buri wese atange igitekerezo nìkifuzo cye.

Dusaba ko buri wese agira umwirondoro wa mugenzi we, uruhare nìbitekerezo byaburi wese

aba ari ibanga. Turizera ko buri wese avugana ubwisanzure nùkuri. Inkuru tuganiraho

tuzayisesengura nùburemere bwayo uko yakabaye kandi nta zina tuzakoresha muri ubwo

busesenguzi.

Turafata amajwi mukiganiro, kuko tutifuza gutakaza igitekerezo icyo aricyo cyose mwatanze.

Nta muntu n’umwe utari muri iki cyumba uzamenya ibyìzi nyandiko, nyuma yo kurangiza

gukora raporo zizatwikwa.

Muri iki kiganiro turi kumwe n’ umwanditsi -------------------------------------------------

nàbagenzuzi banjye bashobora kuza kuhagera kugira ngo bamfashe niba mbikeneye.

KWIBWIRANA KWÀBITABIRIYE IKIGANIRO


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Gusaba buri wese kwibwira abandi akoresheje uyu murongo ngenderwaho :

Bwira abandi izina ryawe, amakuru yawe bwite, nko kumenya uko umuryango wawe ungana,

icyo ushinzwe.

Ikindi, uvuge nìbi bikurikira:

Imyaka yawe

Umwuga

Irangamimerere (Yarashatse, nìngaragu, yatanye nùwo bashakanye, ni umupfakazi, afite abana

bangahe/ abuzukuru).

Amashuli yize

IKIGANIRO MU ITSINDA

Uyoboye ikiganiro ashishikariza abitabiriye ikiganiro gutanga ibisubizo ku bibazo byabajijwe,

no kugira icyo bongera ku bitekerezo byatanzwe n’abandi. Aho kugira ngo buri muntu asubize

ukwe, ibibazo rusange bizabazwa abagize itsinda basubize mu buryo bwìkiganiro. Ibibazo

bikurikira bigomba kubazwa mu kwihutisha ibiganiro.


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IBIBAZO RUSANGE

DISTRICT/AKARERE:

DATE/ITALIKI:

SECTOR/UMURENGE:

INTERVIEWER/UBAZA:

VILLAGE/UMUDUGUDU:

INTERVIEWEE/UBAZWA:

INTERVIEW #/IBAZWA #:

FIELD EDITOR/UHAGARARIYE

IBAZWA :

TRANSLATOR/UMUSEMUZI:

Transcription saved as/Iyi nyandiko ibitswe nka:

District_Sector_Village__Interviewee.doc


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Job/position

(CHW, doctor, midwife)

Akazi/icyo mushinzwe mu

kigonderabuzima

(umuganga, umuforomokazi….)

Number of years experience

Imyaka y’uburambe ku kazi

Level of education and years of schooling

Ikigero cy’amashuri yize? Imyaka

ingahe?

Size of community served per month

(population)

Umubare w’abaturage mwakira buri

kwezi

Main location of work (e.g. health center,

hospital, community)

Aho ukerera (ikigonderabuzima,

kubitaro, mu baturage)


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I. Introduction:

1. How many mothers/caregivers of young children do you usually care for/visit each month?

Mu kwezi mwakira ababyeyi/abandi bita ku bana bangahe?

2. What kinds of services do you provide? Any health programs relating to young children?

Mubafasha iki mu rwego rw’akazi kanyu? Haba hari gahunda y’ubuzima yihariye igenewe

abana?

II. Breastfeeding and complementary feeding

1. Do mothers ask your advice about how to feed their young children?

(If yes, what types of questions do they ask?)

Ababyeyi bajya babasaba inama ku bijyanye no kugaburira abana bato?


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(Niba ari yego ni ibihe bibazo bababaza?)

2. What are the common problems related to infant and young child feeding practices?

Ni ibiye bibazo rusange bijanye n’imirire y’abana?

3. What are the main infant-feeding messages provided?

Ni ubuhe butumwa bujyanye no kugaburira abana butangwa?


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4. How long do you think a mother should provide her child with only breastmilk (no other foods

or liquids)? (record in months)

Utekereza ko umubyeyi agomba kumara igihe kingana iki yonsa umwana nta rindi

funguro? (bivuge mu mezi)

5. At what age should she start feeding her child foods in addition to breastmilk?

Ni ku myaka ingahe yagombye kugaburira umwana irindi funguro ryiyongera ku

mashereka?

6. What foods should she start giving her children at this time? (How are these foods be

prepared?)

Ni irihe funguro yatangirira ho guha umwana muri iki gihe? (Ni gute ayo mafunguro

ategurwa?)


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7. What foods are important for young children to be healthy?

Ni ayahe mafunguro y’ingenzi yatuma abana bagira ubuzima bwiza?

8. Can you tell me some reasons these foods are important for young children?

Mwambwira zimwe mu mpamvu ayo mafunguro ari ingenzi?

With regard to their young children’s health, what are mothers’ most common concerns?

Twitaye ku buzima bw`abana ni izihe nshingano zikomeye z’ababyeyi ku bana?


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III. Anaemia


Wigeze wunva ku ndwara yo kubura amaraso/kugira amaraso make?


Ushobora kumbwira bimwe mu binyetso byayo?

3. How would you know/confirm if a young child has anaemia? (diagnosis)

Ese ni gute umenya/wemeza ko umwana ayirwaye?(isuzuma rikorwa)

Probe: (visual check, hemoglobin check, from mother’s description of symptoms, other)

(gupimisha ijisho, gupimisho igipimo gipima amaraso (haemoglobin), guhera ku

bimenyetso wabonye kuri nyina w’umwana, ibindi: sobanura)


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4. How are children treated if they are found to have anaemia?

(given medicine-identify, mother is counseled, no treatment is given) other?

Probe: (Counseled? Is the medicine well received? What if the mother does not have mutuelle?

What do you tell the mother to do? Do they come in for further assessment? Referral?)

Muvura cyangwa mufasha gute abana baje bafite icyo kibazo cyo kugira amaraso make?

(kubaha imiti (ubwoko bwayo) ______________, kugira nyina inama, ntacyo dukora,

ibindi)

Reba: (bagirwa inama? Ese imiti bahabwa bayakira neza? Bigenda bite iyo Umubyeyi nta

bwishingizi (Mutuelle) afite? Usaba Umubyeyi gukora iki? Baba bagaruka gukorerwa

irindi suzumwa? Cyangwa koherezwa ku bindi bitaro?

5. What are the reasons a child might have anaemia?

Ni izihe mpanvu zitera umwana indwara yo kugira amaraso make?


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6. Do you know of any foods that can prevent anaemia?

Hari amafunguro mwaba muzi ashobora kurinda indwara yo kubura amaraso/kugira

amaraso make?

If yes, list:

Niba uyazi yavuge

7. Do you know of any other ways (non-dietary) to prevent anaemia?

Hari ubundi buryo uzi bwo gukumira indwara yo kubura amaraso/kugira amaraso make?

8. Are there any local programs to prevent anaemia in children?

Probe: If so, what are they? What do they offer? How frequent do they run? Are mothers

obligated to attend? How many attend? Who runs the programs?

Hari gahunda iba muri aka gace yo gukumira iyi ndwara mu bana?


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Niba ihari ni iyihe?

Ibaha ubuhe bufasha?

Ingengabihe yazo yo ziteye zite?

Ni itegeko ko ababyeyi /abita ku bana bakwitabira izo gahunda? Abayitabira ni bangahe?

Ninde ukurikirana cyangwa ugenzura izo gahunda?

If no, would you like to see such programs in this district? Would it be beneficial to mothers?

Niba ari ntazo, mwifuza kubona izi gahunda mura aka gace? Zagirira ababyeyi akamaro?


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9. How are children (medically) treated in your community if they are found to have anaemia?

Ese umwana afashwa/avurwa ate iyo iyi ndwara yamugaragayeho?

10. Where do children receive treatment for anemia?

Ni he umwana yabonera ubufasha igihe afite iyi ndwara?

11. Other general comments:

Ibindi byongerwaho muri rusange:


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IV. Sprinkles

Now I will tell something about a product that is being used to prevent anaemia in children in

other countries. This product is called Sprinkles. "Sprinkles", is a powder form of vitamins and

minerals, contained in small packets (show packet). In particular it contains iron which helps

prevent anaemia in young children and make them healthier. This powder can be mixed with any

soft cooked food prepared for a child who has reached 6 months. Anaemia in children has been

reduced in different countries by caregivers using Sprinkles mixed with semi-solid or soft

cooked food on a regular basis. I would like to ask you some questions about how you think

mothers would feel about adding Sprinkles to your children’s food.

Ubu noneho ngiye kubabwira ibyerekeye ifu y’inyongerantungamubiri ikoreshwa mu bindi

bihugu mu rwego rwo gukumira indwara yo kubura amaraso/kugira amaraso make mu

bana bato. Ni agafu karimo za vitamini n’imyunyungugu, gafunze mu gapaki(mwereke

agapaki). By’umwihariko harimo umunyungugu (fer) ufasha mu kwirinda indwara yo

kubura amaraso/kugira amaraso make mu bana bato. Aka gafu gashobora kuvangwa

n’ifunguro ryamaze gutegurwa rigiye guhabwa umwana ugejeje ku mezi atandatu.

Mu bihugu binyuranye, iyi ndwara yo kubura amaraso/kugira amaraso make mu bana

bato yaragabanutse hakoreshejwe ubu buryo bwo kuvanga iyi fu mu mafunguro yoroshye

yamaze gutegurwa, bigakorwa bifite ingengabihe. Ndashaka kubabaza ibibazo birebana

n’uburyo mutekereza ko ababyeyi bakwakira ibirebana no kongera/kuvanga iyi fu

nyongerantungamubiri mu mafunguro y’abana .

1. Do you think mothers/caregivers would be willing to add Sprinkles, a micronutrient powder, to their children’s food? Continuously from the child’s age of 6 to 24 months?

(If no, why do you think they would not be willing?)


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Mutekereza ko ababyeyi cyangwa abandi bita ku bana bazakira ubu buryo bwo kuvangira abana babo mu biryo iyi fu y’inyongera ntungamubiri uhereye ku mezi y’amavuko 6 kugeza kuri 24?

(Niba ari oya kubera iki wumva ko batazabyakira?)

2. Do you think some family members might object to the practice of adding this powder to their children’s food?

Mutekereza ko hari abandi bantu bo mu muryango batabyemera?

Who might object? Why might they object?

Ni bande ukeka ko batabyemera? Ese kuki batabyemera?

3. Is there any possibility of facing social, cultural or religious objections to adding the powder to young children’s (6-23 months) food?

Haba hari uburyo mbonezamubano,umuco cyangwa bwìdini muhura nabwo bugira intego yo gushyira amafu yìnyongera ntungamubiri mu mafunguro yàbana? (amezi 6-23)


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4. What information do you think the mother will need to help her make a decision on whether she will give this to her child?

(prompt if needed e.g. cost, side effects, health benefits, availability, accessibility)

Ni ayahe makuru cyangwa ubumenyi umubyeyi akeneye kugirango afate umwanzuro wo guha ibyo twavuze haruguru umwana we?

(urugero:ikiguzi,ingaruka zabyo,cyangwa akamaro byagira ku buzima)

5. Do you think a mother/caregiver would agree to feed one packet of Sprinkles to her young child mixed with semi-solid food every other day for 30 days?

(If no, why might they not agree?) Umubyeyi cyangwa undi wita ku bana azemera kugaburira umwana muto agapaki kamwe k’ifu y`inyongera ntungamubiri ivanze n`amafunguro byoroshye buri munsi mu minsi mirongo itatu (30)?

(Niba ari oya,kuki bashobora kutazemera?)



114

Ese utekerezako umwana ashobora gukomeza gufata ifunguro nk’uko bisanzwe riramutse ririmo ifu y’inyongera ntungamubiri?

8. If mixing Sprinkles changes the color of food, do you think the children and/or caregivers will object to taking that food?

Ese igihe ifu y’inyongera ntungamubiri ihinduye ibara ry`ibiryo umwana ashobora kubyanga?

9. What are the most effective, trusted sources of health information for mothers?

Ni iyihe nkomoko iboneye kandi yizewe yafasha ababyeyi kubona amakuru kubijyanye n`ubuzima?

10. What do you think are some barriers for Sprinkles promotion and counselling activities? Some opportunities?

Utekereza ko ari izihe mbogamizi zabangamira ikoreshwa ry’aya mafu nyongera-ntungamubiri n’akazi k’ubujyanama?


115

11. In order for you (or CHWs) to train mothers on the use of Sprinkles, what will you need to adequately train them? (e.g. visual aids, refresher trainings)

Kugira ngo mwebwe (cyangwa abajyanama b’ubuzima) bahugure ababyeyi ku ikoreshwa ry’ifu nyongera-ntungamubiri, ni iki mwakenera kugira ngo mubahugure mu buryo bugera ku ntego? (urugero: amashusho, amahugurwa yo kwiyibutsa)

12. Where do you think you and other family members should hear more information about this important powder? Who should help explain about this powder? Circle all.

a. Doctor

b. Community Health worker/midwife

c. Respected persons in the community (elders, religious leaders etc)


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d. Advertisement on Radio

e. Advertisement in TV

f. Others (please mention)...

Ni hehe Mwaba mutekereza ko ababyeyi /abandi bita ku bana n’ abandi bo mu muryango bakumvira/bakura amakuru aruseho yerekeye iyi ifu y’inyongera ntungamubiri?

a. Ku muganga (Dogiteri)

b. Ku mujyanama w’ubuzima /ababyaza

c. Inyangamugayo(Abantu bakuze, abihaye Imana)

d. Kwamamaza kuri Radiyo

e. Kwamamaza kuri Televiziyo

f. Hari Ahandi? Havuge

13. What do you think mothers would need to know to help them decide whether to use Sprinkles powder or not?

Ni ibiki mutekereza ko ababyeyi/ abita ku bana bakeneye kumenya byabafasha gufata umwanzuro wo gukoresha ifu y’inyongera ntungamubiri cyangwa wo kutayikoresha?


117

14. To build up people’s confidence in using and understanding Sprinkles what type of personalities/celebrities would you recommend in mass media appeals? a. Local well-known actors/actresses

b. Sports personalities

c. Political leaders

d. Religious leaders

e. Doctors or other medical people

f. Other – please mention

Ni abahe bantu bazwi cyane (ibyamamare) wasaba ko bakoreshwa cyangwa bagaragara mu itangazamakuru mu gushishikariza abaturage kugirira icyizere ifu y’inyongera ntungamubiri?

a) Abakinnyi b’ikinamico cyangwa filimi bazwi neza ino aha

b) Abakora siporo/imyitozo ngororamubiri

c) Abayobozi/abanyapolitike

d) Abihaye Imana

e) Abaganga cyangwa abandi bakozi bo kwa muganga


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d) Abandi (bavuge)

15. Which media may be the best for increasing the awareness and acceptance of Sprinkles in this community?

a. Radio

b. Television

c. Newspaper/ Magazine

d. Billboard/Signboard

e. Leaflet

f. Other

Ni irihe tangazamakuru ryaba ryiza kurusha ayandi ryakoreshwa mu gusobanurira abantu iby’ifu y’inyongera ntungamubiri no kubashishikariza kuyikoresha?

a. Radiyo

b. Televisiyo

c. Ibinyamakuru

d. Ibyapa

e. Udutabo

f. Ibindi


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16. Other general comments (at the end of the discussion, ask mothers if there is anything else they would like to tell us).

Ibindi bisobanuro (Murangije ikiganiro, baza ababyeyi/abarera abana niba hari ikindi bashaka kongeraho)

Thank you.

Murakoze.


120

Appendix 6. Sampling Methodology

A three-stage cluster sampling design was used to select the locations of the Phase 1 Field Work.

1. FIRST STAGE: SELECTING DISTRICTS.

Method: Purposive sampling.

The districts of Musanze and Nyaruguru were purposively selected at the first stage as they

represent different geographical areas of the country and have different socioeconomic and

nutritional backgrounds. District leaders have also shown great interest in this project and there

is a strong NGO presence, which translates into governmental and non-governmental

partnerships that will be functional and efficient because they are motivated, have the capacity to

be fully involved, and available to contribute both human and financial resources. This is so that

we can work together to most effectively collect high quality data to inform Phase 2, Phase 3 and

future policies.


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2. SECOND STAGE: SELECTING SECTORS.

Method: Systematic sampling with probability-proportionate-to-size.

A sampling frame of clusters (sectors) and their measures of size (population) is used. The

measure of size (population) is likely correlated with the number of participants of interest in a

given cluster (caregivers of children under the age of 2). PPS means that larger clusters have a

greater change of selection than smaller clusters.

2.1. Musanze Sampling

Steps in the selection of systematic-random sampling of clusters using PPS:

1. Prepare a list of sectors and with a corresponding measure of size for each (2009 NISR population data was used).

2. Calculate the cumulative measure of size (cumulative population).

Sectors Population (2009) Cumulative PopulationBusogo 32,991 32,991Cyuve 24,250 57,241Gacaca 13,815 71,056Gashaki 21,723 92,779Gataraga 19,416 112,195Kimonyi 14,151 126,346Kinigi 23,543 149,889Muhoza 42,829 192,718Muko 16,637 209,355Muzanze 28,648 238,003Nkotsi 12,797 250,800Nyange 24,811 275,611Remera 18,879 294,490Rwaza 16,416 310,906Shingiro 20,790 331,696Total 331,696


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3. Calculate the sampling interval by dividing the total cumulative measure of size by the planned number of units to be selected (in this case, 5 sectors are to be chosen).

Cumulative measure of size (cumulative populations) 331,696Number of units to be selected 5Sampling interval 66,339

4. Select a random start between 1 and the sampling interval. The following function was used and the random start generated is outline in Table 1.

Random start =RANDBETWEEN(1,66339)

5. The unit within whose cumulative population this random start falls in is the first sample unit (highlighted in Table 1).

6. Subsequent units are chosen by adding the sampling interval to the random start.


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Random start 63100

Unit #1 (sector #1) 63,100 =D5Unit #2 (sector #2) 129,439 =D7+D3Unit #3 (sector #3) 195,778 =D7+(D3*2)Unit #4 (sector #4) 262,118 =D7+(D3*3)Unit #5 (sector #5) 328,457 =D7+(D3*4)

Sectors Population (2009) Cumulative Population Sampling numberBusogo 32,991 32,991Cyuve 24,250 57,241Gacaca 13,815 71,056 63,100Gashaki 21,723 92,779Gataraga 19,416 112,195Kimonyi 14,151 126,346Kinigi 23,543 149,889 129,439Muhoza 42,829 192,718Muko 16,637 209,355 195,778Muzanze 28,648 238,003Nkotsi 12,797 250,800Nyange 24,811 275,611 262,118Remera 18,879 294,490Rwaza 16,416 310,906Shingiro 20,790 331,696 328,457Total 331,696

*Musanze field work was planned for the week of July 4th, but due to July 4th being a public

holiday and only allow 4 days of field work, one sector was randomly selected to be excluded

(Nyange).

2.2. Nyaruguru Sampling

Steps in the selection of systematic-random sampling of clusters using PPS:

7. Prepare a list of sectors and with a corresponding measure of size for each (2009 NISR population data was used).


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8. Calculate the cumulative measure of size (cumulative population).

Sectors Population (2007) Cumulative PopulationBusanze 25,209 25,209Cyahinda 19,660 44,869Kibeho 17,095 61,964Kivu 16,691 78,655Mata 11,928 90,583Muganza 18,290 108,873Munini 14,117 122,990Ngera 19,740 142,730Ngoma 19,638 162,368Nyabimata 16,149 178,517Nyagisozi 16,360 194,877Ruheru 21,468 216,345Ruramba 16,136 232,481Rusenge 20,214 252,695Total 252,695

9. Calculate the sampling interval by dividing the total cumulative measure of size by the planned number of units to be selected (in this case, 5 sectors are to be chosen).


10. Select a random start between 1 and the sampling interval. The following function was used and the random start generated is outline in Table 1.

Random start =RANDBETWEEN(1,50539)

11. The unit within whose cumulative population this random start falls in is the first sample unit (highlighted in Table 1).

12. Subsequent units are chosen by adding the sampling interval to the random start.


125


Random start 2453

Unit #1 (sector #1) 2,453 =D5Unit #2 (sector #2) 52,992 =D7+D3Unit #3 (sector #3) 103,531 =D7+(D3*2)Unit #4 (sector #4) 154,070 =D7+(D3*3)Unit #5 (sector #5) 204,609 =D7+(D3*4)

Sectors Population (2007) Cumulative Population Sampling numberBusanze 25,209 25,209 2,453Cyahinda 19,660 44,869Kibeho 17,095 61,964 52,992Kivu 16,691 78,655Mata 11,928 90,583Muganza 18,290 108,873 103,531Munini 14,117 122,990Ngera 19,740 142,730Ngoma 19,638 162,368 154,070Nyabimata 16,149 178,517Nyagisozi 16,360 194,877Ruheru 21,468 216,345 204,609Ruramba 16,136 232,481Rusenge 20,214 252,695Total 252,695


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3. THIRD STAGE: SELECTING VILLAGES.

Method: Stratified random sampling.

Three villages are selected from each sector. One village at the health care facility (either the

hospital or the health centre, whichever is present in the sector), one village close to the health

care facility (<6km), one village far from the health care facility (>6km). The villages away

from the health care facility are randomly selected from lists put together by the district.

3.1. Musanze Sampling

i. Gacaca

Village at the health care facility: Karwasa Centre de santé


127

128

ii. Kinigi

Village at the healthcare facility: Kinigi Centre de santé

129

iii. Muko

Village at the healthcare facility: Kabere Centre de santé

130

iv. Shingiro

Village at the healthcare facility: Shingiro Centre de santé

131

3.2. Nyaruguru Sampling

i. Busanze

Village at the health care facility: Runyombyi Centre de santé

132

ii. Kibeho

Village at the healthcare facility: Kibeho Centre de santé

133

iii. Muganza

Village at the healthcare facility: Muganza Centre de santé

134

iv. Ngoma

Village at the healthcare facility: Ngoma Centre de santé

135

v. Ruheru

Village at the healthcare facility: Ruheru Centre de santé

137

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