Barriers to Adequate Complementary feeding

Differentiating between doers and non-doers

In 2014, I was selected to participate in a two-week training on Designing for Behavior Change seminar led by Bonnie Kittle. Two other health PCV's and I decided to conduct a formative research survey on nutritional behaviors together. The specific target behavior was worded as follows: mothers of children between the ages of 9 and 23 months feed their children foods from 3 of the 7 food groups daily. Over a period of 3 months, we surveyed 45 doers and 45 non-doers of the behavior in the Kaffrine/Kaolack region, for a total of 90 mothers. We conducted the interviews in Wolof (a major Senegalese local language) and French (the official language).

All three of us then met up in Kaolack several to code, analyze, and interpret the data. We shared our results at the 2015 All Volunteer Conference. The data allowed us to pinpoint specific barriers to behavior change, and led each of us to design activities to overcome those specific barriers. The data showed that lack of access to fresh foods was one of the reasons mothers could not feed their children 3 of 7 food groups on a daily basis.












To overcome this barrier, a local Community Economic Development (CED) volunteer and I designed a project to implement 12m by 12m Moringa plots in 8 local communities. Moringa, called Nebedaye ("Never-Die") locally, can be used in countless ways. Its nutritious leaves can supplement an otherwise poor diet, as they are rich in calcium, iron, vitamin A, vitamin C, and protein*. Research conducted in Burkina Faso demonstrated that children 6-59 months fed 10g (0.35274 oz) of moringa leaves per day gained more weight than a control group.


*It is still not clear whether the body can absorb significant percentages of these minerals and vitamins.

Direct-planting moringa seeds in zaï holes        

        

The grant the CED volunteer and I wrote financed wooden fences and their transportation to each site. With the help of local PCVs, we planted the Moringa, erected the wooden fences, and trained community members on related nutrition, agro-forestry, and CED topics. Ultimately, only 5 of the 7 communities selected were able to participate. Each hour-long training was followed (or preceded) by the installation. All told, we planted more than 1,000 trees and trained 138 people.

I taught sessions on the benefits of eating moringa regularly, especially for pregnant women and children under the age of 5. I also invited Juma Sow (77 054 3051), a representative of the NGO Nebedaye in Toubacouta to Dassilami Socé to assist me in teaching proper cooking techniques of moringa, and proper processing of the leaves into power.

Discussing the nutritional benefits of eating moringa

How to cook Nebedaye (moringa)

Better wash those leaves before you dry them... Look how dirty the water is!

These leaves are dry and ready to be pounded into powder

The project yielded mixed results. Before our intervention, community members only used Moringa as a traditional medicine to cure all kinds of health problems, including headache and diabetes. Even though my villagers are now aware of the potential health benefits of eating Moringa leaves, I am not convinced that they would really add it to their food on a regular basis, especially in its powdered form. One of the volunteer participants in this project does report that her villagers cook with Moringa leaves and power regularly, so it may be an acquired taste. Hardy Moringa will survive even if it is not watered on a regular basis; it is possible that in the months and years to come people will slowly start to include Moringa in their daily diets.

A Day in the Life

Abdoulaye, Oussman, Lawratou

 As part of youth month, I've interviewed a few members of my newly established english club. What follows is a simplified version of a spirited and trilingual conversation about a typical day in their lives. 

Naano: So I want to ask you guys about your lives. How old are you, and what do you do?

Abdoulaye Kane: I'm 20 years old. I'm a student at a French-Arabic school in Koalack.

Oussman Demba: I'm 27 years old. I'm a waiter at Fathala reserve.

Lawratou Diallo: I'm 17 years old. I'm a student at the lycee in Sokone.

Naano: Ok, so at what time do you wake up in the morning, and what's the first thing you do?

Abdoulaye Kane: On a school day, I usually wake at 8am. I drink some water, wash, and pray.

Oussman Demba: I wake up at 5:45am everyday. I wash, then I pray.

Lawratou Diallo: I get up at 7am. I also wash and pray as soon as I'm up.

Naano: How do you get to work or school?

Abdoulaye Kane: I can walk to school. It's not far.

Oussman Demba: I walk 5km to work everyday, rain or shine.

Lawratou Diallo: I also walk.

Naano: Abdoulaye, you go to a Franco-Arabic school. How many languages do you speak then?

Abdoulaye (matter of fact): Wolof, French, Mandinka, Arabic. Some English, because Gambia is not far, and some Puular, because my mother is Puular.

Naano: Wow. Oussman, what kind of food do you serve at Fathala reserve?

Oussman Demba (proud): In the morning, we have a buffet with yogurt, fruit, village bread, beans, butter, jam... At lunch, we have Spaghetti Bolognese, chicken, and pizza.

Naano: Lawratou, who do you live with in Sokone?

Lawratou Diallo: I have family members in Sokone, so I live with them during the school year.

Naano: Don't you miss your mother?

Lawratou Diallo: Yes! But I usually go back to Dassilame every weekend, because it's not far.

Naano: Abdoulaye, at what time does school end for you, and what do you do after school?

Abdoulaye Kane: School ends at 7pm. I often watch TV for about an hour, then have dinner, than do homework until midnight.

Naano: Do you know what you want to do later in life?

Abdoulaye Kane: I want to live in the United States, in Washington. I'd like to be a teacher there.

Naano: What about you, Lawratou?

Lawratou Diallo: I want to be a nurse in a hospital.

Naano: Oussman, how many children do you want?

Oussman Demba: I want two, a boy and a girl. You can invest more in your children when you have fewer.

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Somewhere along the way, we talked about:
-Cheb Shacks
-favorite foods
-the difference between "tree" and "three", "choose" and "shoes"
-the n-word...
-Rihanna

It's peanut-planting season!

Interlude

I started my service with every intention of exclusively vacationing in other African countries. After all, when else would I have the opportunity to do so? A close Peace Corps friend suggested Ghana, so we spent some time looking for the cheapest plane tickets and cooing over stunning google images. But somehow, our plans never materialized. 

Why? Well, to quote my friend: "we had to get out of Africa". I don't miss San Francisco or the Bay Area, but I do get intensely homesick for France--a place I've never called home. For some strange reason, it usually hits me like a ton of bricks in the cookie aisle of the toubab food store. I have but to lay eyes on Petits Ecoliers or Prince biscuits to be transported Proust-style to another temporal dimension infused with nostalgia.

It's true: I dreamt of broccoli, pizza, and guacamole. I wanted to spend time with family in a familiar setting. But most of all, I needed to reconnect with the part of me that's always carefully hidden in village. So I booked a ticket to Paris, and I don't regret it. 

Building tippy-taps

Proper hand washing is a surprisingly complex behavior. Ideally, the "doer" washes his hands with soap or wood ash for 20 seconds and rinses with running water at the 5 critical times each day: after using the bathroom, before eating, before cooking a meal, after changing a baby, and after caring for a sick person. I'm sure that most Americans wouldn't qualify as "doers" according to this definition. How many of us actually scrub for 20 seconds?

Regardless, we do tend to wash our hands after using the bathroom. It's almost impossible to forget when you have a sink to serve as a constant visual reminder. You also have all the necessary materials on hand: the soap, the running water, and the towels. We've integrated hand washing into a sequence of actions: use the bathroom, flush, wash your hands, check your reflection in the mirror. We've come to crave the feel of cool water, the sweet smell of soap, and the tight skin we associate with cleanliness.

My first introduction to life in Senegal involved a latrine slab and a squatting demonstration. Turns out that using the bathroom here is a whole different game. Toilet paper isn't a thing; people use their left hand and water to clean themselves, which is why you always hand to use your right hand to greet and eat. Sinks are rare, even in towns with running water. In general, soap is reserved for laundry and bucket showers.

Enter: the tippy-tap.

According to the people at http://www.tippytap.org, about 1.5 million children under the age of 5 die each year world-wide, and up to 40% of those deaths could be prevented if people washed their hands at the 5 critical times. That's 600,000 children!

My ASC does not record deaths or cause of death in village, but I do know that diarrhea is a huge problem here.

The tippy-tap is awesome for a couple of reasons: it's made out of cheap local materials; it marks a designated location for hand washing; it provides the necessary resources (soap, running water); it serves as a visual reminder. Of course, those reasons aren't enough to guarantee long lasting behavior change, but it's a start.

And so, we got to work:

At the French school... 

... and the Arabic school 

And then, we demonstrated proper hand washing techniques:

And finally, smiles all around:

The French school team

Guys at a garage trained by my coworker

Health hut inauguration

After more than two years of work, the Dassilame health hut was finally inaugurated on March 4th. It's the result of a Peace Corps service and a half, collaboration between three parties, representing five countries. This "jewel" of the senegalese health system has a sister health hut on the island Djinak Bara, which I visited in October 2014 to get inspired. Both were financed by Pharmaciens Sans Frontières, which is represented locally by my work partner, Ben N'Diaye.

The waiting room at Djinack Bara

Patients' room at Djinack Bara 

Two members of the NGO, Angele and Thierry, came to Senegal for over a month to wrap several local projects up. They met with local and authorities, brought furniture over from the island where it was being stored, and made last minute purchases. According to them, our health hut is one of the most functional of the region. Given the challenges we've faced, I'm gratified to hear that our hard work has paid off. In recognition of a job well done, Pharmaciens Sans Frontières has agreed to fund other peripheral projects at the health hut, like a fence and a maternity ward. They have also gifted us with a monthly stipend to buy additional medications, and a monthly bonus for our ASC. They will also support our ongoing efforts to turn the hut into a post. 

To celebrate this achievement, we decided to officially inaugurate the health hut. Two health relays and I were responsible for buying vegetables and drinks in Karang first thing in the morning. Volunteers from the village then proceeded to prepare enough food to feed all our guests, an incredible feat. 

Joni Senghor's first time using a camera! 

We invited local community members, village chiefs, mayors, prefects, ICPs, and community health agents. The ceremony started around noon on March 4th, and ended around 3pm for lunch. It was truly an honor to have these important guests attend. And for me, it was a great opportunity to thank my extraordinary work partners. 

Diene, one of my best work partners 

Nasunkaro, the village matrone, with more than 20 years' experience 

And without further ado, here's what the health hut looks like now:

Visitors admire the patients' room

Consultation room 

The waiting room

Onwards and upwards.... 

Government Health Campaigns

The job description of a Peace Corps volunteer isn't as straight forward as you might think. For example, I'm technically a preventative health educator intervening primarily in maternal and child nutrition, malaria, and water and sanitation. Many health volunteers also work on improving existing infrastructure, or facilitating infrastructure development at our respective sites. Most of our work is intentional--carefully planned, organized, and executed. But sometimes, we spontaneously participate in those events that just seem to come out of the blue, like government health campaigns.

I should start by noting that these health campaigns probably shouldn't so spontaneous. I think that part of the problem is inadequate or untimely communication between the different levels of the health system. By the time the information is trickled down to the lowest level of the health system (ie: health hut), it's pretty much time to get down to work. There's very little time to come up with an action plan. As a results, we often run out of medications, forms, or equipment. Last time, my supervisor forgot to give the chalk we needed to label the compounds we had visited. The work itself is often rushed: we're working on a dead-line, there are too few volunteers, and the target is too high. We have to visit each compound, which entails walking for hours in the heat and sand. It's also hard to be meticulous when kids are swarming around you, all clamoring or crying. So I'm sure the work isn't very high quality.

http://www.memoireonline.com/08/11/4636/m_Contribution--lamelioration-de-la-gestion-des-stocks-de-medicaments-cas-du-dept-de-la-pha13.html

The last campaign took place February 20th through February 21st. Our mission was to give deparasitizing medication and vitamin A droplets to children under the age of 5. Different age ranges got different doses of medication. Simultaneously, we also had to use a MUAC band to asses the child's nutritional status. 

Alassane wields le MUAC band 

Mama gives a child drops of Vitamin A

And then it gets a little crazy.... 

Not sure how legible this is--but here is the form for Boutilimite 

This campaign was particularly difficult: 

-There three things to do: give anti-parasite medication, administer the Vitamin A drops, and measure arm circumference. 

-Many kids cry when they see Alassane, because he sometimes gives them shots. It's not easy to swallow and cry at the same time. 

-Sometimes, the kids weren't home or were crying too hard, so we have to give the medication to the parents. Did they actually give the meds to their kids? No way to know for sure. 

-We would sometimes come across swarms of children so overwhelming that we couldn't possibly take MUAC measurements. 

Hopefully, we'll do better next time.... 

Mixed Messages

A group of volunteers, including myself, has just completed a Behavior Change seminar facilitated by Bonnie Kittle in Thiès.

Peace Corps volunteers work to promote certain behaviors among their host country nationals. A health volunteer wants mothers with children under the age of 5 to wash their hands with soap and running water at the 5 critical moments every day. An agg volunteer wants rice cultivators to weed their fields a certain number of times per month. A CED volunteer wants entrepreneurs to reinvest a certain percentage of their monthly profits back into their business. We want them to preform behaviors--hand washing, for example--that are scientifically proven to reduce a specific problem, such as high child mortality.

The current Peace Corps approach to promoting various behaviors is flawed. It recognizes that some people aren't doing the beneficial behaviors, but assumes that lack of knowledge is the biggest barrier to behavior change. As a result, Peace Corps promotes activities primarily designed to increase knowledge. For example, health volunteers are encouraged to hold mosquito net care and repair demonstrations. The problem is, there are many other different barriers to behavior change that aren't taken into consideration.

The Designing for Behavior Change framework helps us answer the question why: why are some people preforming the behavior, while others are not? Thanks to the Barrier Analysis, we can accurately determine which barriers are most significant by interviewing members of our priority group. We can then implement activities designed to directly address those barriers. The DBC framework proves that there's no need to guess or assume anything. Activities shouldn't be generic and universally applicable. They must be tailored to the specific target group, their environment, their culture...

The activities we partake in and the messages we promote are only the tip of the iceberg. A successful outcome is contingent on what's under the surface. 

I thought it might be fun to take a look at some ads and public health messages. To keep it interesting, I've selected two conflicting messages. What are some of the determinants and bridges at play? 

Getting young people to stop smoking

Positive consequences: increase the perception that doing the behavior will result in positive things
Action efficacy: increasing the perception that the action effectively deals with the problem (high mortality rates correlated with smoking)  

Culture: decrease the perception that smoking is associated with young culture 

Getting young people to smoke
Social norms: increase the perception that the influencing group approves of the behavior
Perceived positive consequences: increase the perception that smoking makes you attractive and intrinsically yourself

 Make sure that young people never start smoking
Social norms: increase the perception that the influencing group disapproves of the behavior
Perceived negative consequences: increase the perception that smoking gives you bad breath
Perceived positive consequences: decrease the perception that smoking makes you attractive

Getting young people to stop smoking
Perceived Severity: increase the perception that smoking kills
Perceived susceptibility: increase the perception that young people are susceptible

Getting smokers to continue smoking
Social norms: increase the perception that the influential group approves of the behavior
Perceived negative consequences: reduce the perception that smoking is bad for your teeth
Perceived severity: decrease the perception that smoking is detrimental to your health 

These advertisements and public health messages are all effective in their own ways. Their creators know their target audience well. All its concerns are minimized in the cigarette ads, or maximized in the public health messages. Each plays on different universal motivators to its advantage: attractiveness, health, long life, success. It's interesting to see that two conflicting behaviors can be promoted with such different motivations. This information is powerful, and isn't always used in a beneficial way.