Engaging Fathers to Support Child Nutrition Increases Frequency of Children's Animal Source Food Consumption in Rwanda

"This study adds to the limited literature on SBCC [social and behaviour change communication] interventions to engage fathers in child nutrition by providing evidence on the impacts of a multi-component intervention on child ASF [animal source food] consumption and fathers' knowledge and support through quantitative data collected from fathers."

In many low- and middle-income countries (LMICs), cultural norms indicate that women are responsible for childcare and feeding, while men are responsible for providing resources for and leading the family. These gender roles constrain women's ability to carry out optimal child feeding practices, including adequate feeding of milk and other animal source foods (ASFs), because men are expected to provide ASFs, and women often have limited decision-making power and resources to procure them if men do not fulfil their role. In Rwanda, the researchers designed and implemented a social and behaviour change communication (SBCC) strategy to engage fathers in understanding and supporting child nutrition practices, especially consumption of milk and other ASFs. The aims of this study were to evaluate the effects of that SBCC intervention and to collect data on the feasibility and acceptability of the intervention from participants and implementers.

This was a follow-on study to a trial that tested the effects of an SBCC intervention promoting ASF consumption by children in households that received an exotic or crossbred cow through the Government of Rwanda's Girinka "One Cow Per Poor Family" programme. The trial was conducted in Nyabihu and Ruhango Districts from 2018 to 2020 and provided SBCC to mothers but included fathers when available. The trial showed that the SBCC intervention increased mothers' knowledge and awareness of ASF consumption by children, and children's odds of consuming milk two or more times in the last week increased with maternal exposure to the intervention. A delayed SBCC intervention was provided to mothers in the non-intervention arms prior to the present pre/post study, which addressed fathers in households across the trial study arms.

The 5-month intervention was implemented from June through October 2021, but no in-person activities were permitted in July and August 2021 because of the government's COVID-19 restrictions on travel and gatherings. Intervention design was based on findings from the initial study plus additional formative research with men, women, and key informants conducted to learn about the barriers to and enablers of men's participation in nutrition and the best channels to reach them, which included group meetings for men, weekly text messages to men's mobile phones, a leaflet and a poster, and megaphone blasts. These activities were conducted by 29 community extension and health officers (CEHOs) and 23 model fathers, who were trained by the project. Model fathers were selected from intervention households in each administrative sector. They were identified by CEHOs and agriculture extension workers as leaders in their communities with some knowledge on nutrition and animal husbandry.

Baseline quantitative survey data was collected from 149 fathers with a child 5 years old and younger (December 2020 to January 2021); endline survey data was collected from October to November 2021. At endline, the researchers conducted separate focus group discussions (FGDs) with fathers (four FGDs, total of 24 fathers) and mothers (four FGDs, total of 24 mothers) and in-depth interviews (IDIs) with CEHOs (N = 6) and model fathers (N = 6).

Select quantitative findings:

• Nearly all fathers (98%) had heard about ASFs through community-based meetings where milk or other ASFs were discussed in the last 4 months. Nearly all model fathers used the SBCC materials developed by the project.
• The odds of children consuming any type of ASF 2 or more times in the last week increased from baseline to endline (odds ratio (OR) 4.9, 95% CI 1.9, 12.3), as did the odds consuming milk, eggs, and beef, but not fish.
• Fathers' mean ASF knowledge and awareness scores increased from baseline to endline (knowledge: 2.3 to 3.5 out of 4 items, P<0.001; awareness: 2.5 to 3.0 out of 3 items, P<0.001), with the largest changes observed in knowledge of timing of introduction of milk and other ASFs. (Health-related knowledge and awareness are considered prerequisites for behaviour change.)
• The percentage of fathers who offered 2 or more supportive actions for their children's milk and other ASF consumption increased from baseline to endline (milk: 19.5% to 31.5%, P = 0.017; other ASFs: 18.8% to 37.6%, P<0.001).
• The percentage of fathers reporting that decision-making about use of home-produced milk is made jointly by husband and wife increased from baseline to endline (64.4% to 77.9%, P = 0.002). (Social support from fathers for child feeding practices is often instrumental in ensuring that mothers are able to carry out optimal practices or that mothers and fathers work together to implement them [19, 42], and interventions targeted at fathers can be effective at increasing their social support for child feeding practices

Select qualitative findings:

• Fathers liked the monthly meetings that were facilitated by the model fathers because they encouraged the family to eat and buy ASFs that were accessible to them. They were inspired by the model fathers' actions as examples in their own communities. Most mothers stated that they noticed positive changes in their husbands' actions after attending the sessions with model fathers. They said they heard about the fathers' intervention messages from their husbands after the men had participated in the meetings held by model fathers. Some also said that their husbands shared the text messages they received about the importance of ASF and milk consumption for family nutrition.
• All fathers in FGDs mentioned that lack of financial means to purchase ASFs, especially flesh foods, is the main barrier to consumption of ASFs in their household. However, with encouragement from model fathers and reminders through text messages, fathers explained that they tried their best to find more affordable ASFs for their young children, such as small fish and eggs.
• Fathers appreciated gaining knowledge on child nutrition in a setting specifically for men, and they liked having role models (e.g., model fathers) whose practices they could emulate and who were trusted sources of information.
• Fathers liked the print materials, which featured inspirational that showed men and women collaborating and positive messages about specific actions fathers can take to support child nutrition in their households.

CEHOs and model fathers suggested that future interventions should train community leaders at the outset to increase their support and collaboration by making them aware of the importance of the community-based meetings. Model fathers and CEHOs agreed that more model fathers, community volunteers, community health workers, and CEHOs should be trained and more leaflets produced. CEHOs also suggested that the megaphone blasts should include testimonies from mothers.

The researchers advance several ideas for future research, in light of the fact that programme implementers need evidence to help them determine whether child nutrition interventions should have a separate strategy for fathers, be combined with women's empowerment interventions, use a gender-transformative approach, or try to incrementally shift gender norms. For example, effective child nutrition programmes that involve fathers should document their intervention strategies and facilitators and barriers to implementation. Such information can be used to develop best practices for engaging fathers in child nutrition.

In conclusion, this study showed that a low-cost SBCC intervention that reached out to fathers improved child feeding practices, increased fathers' knowledge of and support for child feeding, and increased joint decision-making by fathers and mothers about the use of home-produced foods.