Relevance
The integrated six-monthly contact point aligns with government developmental goals:
“It is being implemented at government facilities by government staff and the monitoring and supervision is also done by the government officials to ensure sustainability.” National
The six-monthly contact point enables integrated service delivery:
“We start with the health education, followed by growth monitoring, and the children that are for immunization. Then we check the health status of the mothers, because you cannot expect a sick mother to take care of a child.” PHU
Health workers undertake outreach services to remote areas;
“ we go monthly to access people that were not able to make it at the clinic on Fridays and the places are closer to them so they will just come and get the service that they missed.” PHU
Caregivers noted that the visit affords the health worker time to examine children unlike the campaigns.
“It is better when you come to the hospital because if anything is wrong with the child, they can give treatment.” PHU
Efficiency
Transition from an already established system required strong, inter-sectoral approaches.
“The collaboration of government with the international NGOs and partners made it easier to transition from the campaigns to the six-monthly contact point.” National
Activities were planned with the DHMTs who assigned duties to ensure efficient use of resources:
“ existing resources that are available can be tapped and they were also trained on how to use the monitoring and reporting tools that are part of the DHIS.” National
Mass training were conducted for all PHU ‘in-charges’ on the implementation and reporting:
“Helen Keller trained nurses from all government facilities on how to administer vitamin A and Albendazole and how to teach caregivers on hygiene practices, the preparation of the complementary feeding and family planning.” National
PHU ‘in-charges’ cascaded the training to junior colleagues:
“We were taught that as soon as lactating mothers completes the six months exclusive breastfeeding, their babies should start taking vitamin A and continue every six months till five years. They told us that after a child is six months, they will introduce complementary feeding. As soon as mothers give birth, we should start talking to them about family planning and show them all the particulars so that she will know about child spacing. She may decide to accept if she is not using LAM after 40 days to start taking family planning to space her children.” PHU
Social mobilizer officers held meetings with chiefs, market women, district councillors, chairpersons of the inter-religious council, drivers’ union and motorbike riders union representatives:
“We create demand for health services so that people would go on their own even if they have to walk long distance to the PHU.” District
PHUs in-charges attend monthly district meetings organised by the M&E Officer:
“Where the DHMT, nutrition units and EPI discuss observations made during monitoring at the health facilities.” National
Supportive supervision was performed by using an agreed checklist and the results sent electronically were widely shared with the National Nutrition Coordination Committee:
“Looking at VAS, deworming, complementary feeding, growth monitoring and promotion- that has to do with surveillance, and then all of the interventions like family planning, HIV and Aids, immunization all of this coming together was good for program integration” National
The RHFPP monitored family planning counselling and provision:
“Whenever we identify gaps, first and foremost we engage the DHMT members that are in-charge of these facilities and their service providers. We sit down with them and tell them about the gaps, and we plan a way forward. We do follow up to ensure that has been addressed.” National
Data collection from PHUs and is sent via the DHMT to the DFN and analysed with UNICEF support:
“At the end of the day’s work, the nurses will take a photo of the record they have and send it via WhatsApp and sometimes through email.” District
District nutritionist and M&E officers conduct quality checks on the monthly summaries:
“When I look at the in-charges reporting, I sometimes see inconsistencies on nutritional data, so I work together with the focal person to correct the discrepancies.” District
Effectiveness
Caregivers appreciated the six-monthly Albendazole given to children from 12 to 59 months to reduce the burden of intestinal worms plus the vitamin A and immunisations:
“ some years back, it was very common for babies that had just been weaned to be infested by worms. It used to affect newly weaned children because they would start eating all kinds of foods but because of the Albendazole they are giving us it is no longer common.” FGD.
“….we are blessed to have access to vitamin A and other vaccines which have prevented our children from many childhood diseases. Now we don’t have blindness, polio, and measles, thank God for the clinic” FGD
Immunization is done weekly in most of health facilities and daily in a few instances:
“Our own immunization is done daily; we have a lot of vaccines in our fridge. If the child is due for vaccination, we offer the service. We are here every day, even on Sundays.” PHU
Caregivers appreciated that routine visits to health facilities had resulted in healthier children:
“Coming to the clinic has improved the health of my child, because she used to be very sickly, but due to the health education on the feeding, everything is now fine.” FGD
Mothers are counselled on nutrition and how to prepare, provide and store local foods in a hygienic manner. Benni is recommended as a source of protein and essential fats and all mixtures containing benni are referred to as ‘local/homemade’ bennimix18. There are many varieties produced in different communities and seasons dependent upon the availability of other ingredients19.
“Every PHU has its nutritional corner with counselling cards, our people in the village learn by seeing. The nurse will demonstrate to them the various types of food, how to prepare them and show the food tray and counselling card.” District
One participatory approach to complementary food demonstrations used a pre-roasted blend of benni, sorghum and beans that only required caregivers to add hot water to make a porridge which they then feed their infant before returning home. This approach also introduced personal hygiene, using a cup and spoon (not hand) to feed the child and not to force feed a sick child.
“And every procedure in preparing food one has to wash her hands, so I learnt a lot. We learnt you cannot encourage flies to sit on baby’s food, some people knew this before whilst others didn’t know. I now know that when I am ready to feed my child, I should not use dirty water to wash my hands, but clean water and soap.” FGD
In addition, there are radio broadcasts and posters recommending the available, affordable local foods
“We have posters demonstrating the importance of food like potato leaves, palm oil and we also ensure to provide such information in our radio discussions” District
Other health facilities encouraged caregivers to bring local food for demonstration:
“We sometimes ask caregivers to come with other food stuffs like beans, benni, groundnut, oil as the case may be so that we will demonstrate how to go about the process by directing them so that when they go home, they will be able to do what they have been told to do. Complementary demonstration is done monthly which is the cooking but for the other demonstrations, we do it weekly. If we prepare benni this week, the following week we will prepare rice mixed with palm oil, beans, potato leaves, fish and also pumpkin.” PHU
Caregivers explained how to prepare complementary food using different ingredients:
“We use bonga fish , jumbo magi , rice, benni, beans and groundnut; put all in a pot, roast it and pound it into powder, and then you have your bennimix formula locally. When you need it, you only have to boil it as porridge or sometimes some people stir it.” FGD
Food demonstrations were also changing foods taboos:
“We still have people with the old traditional beliefs that you should not give an egg to a child to eat and if the mother cooks, the meat should not be given to the kids.” District
Health workers are keen to see that caregivers follow the guidelines:
.” …You might have taught them but they will forget later so if they come back and I see any complication on the child, from there I will begin to sensitize her again.” PHU
Caregivers explained how they were advised during the demonstrations:
“The food demonstrations have been very helpful for me because before now, we never saw anything wrong in feeding our babies with solid foods but we have learnt a lot.” FGD
Health workers and caregivers believed the food demonstrations had helped reduce malnutrition:
“The demonstrations help prevent malnutrition because they are receiving the right nutrient, at the right age, the right time and the right texture of the food and hygiene protocol.” PHU
“Before the introduction of this complementary feeding in the clinic, malnutrition was rampant especially in the rainy season, but now there is no case in this community, because we know the foods to give our children when they are six months and we know how to prepare it.” FGD
The food demonstrations have economic benefits:
“On the side of the family, it is very economical. Because before now they didn’t know that some of this local food that they have in their backyard garden are so important for the kids; instead, they were using expensive food that some could not afford.” PHU
Caregivers are aware that the local/home-made bennimix is cheaper than imported food:
“The bennimix is beneficial because it reduces the cost of buying baby food and it is obvious that we don’t earn much so for me it is a good idea and I am very grateful.” FGD
Health workers promote the introduction of complementary feeding when infants reach six months:
“ If the child is six months, I will ask the mother to change the diet and if not, I will tell them to be patient a bit.” PHU
Family planning counselling services to reduce maternal mortality and improve families’ quality of life:
“People are giving birth to too many children and some are so poor and uneducated to the extent that they don’t know the effect that will have on their livelihood. So, we were trained to ensure that people have children by choice. That is the only way we can get rid of poverty out of the communities and in the country as a whole. If you have a child today in less than one year or one year six months you have another child, the children will not grow well because you do not have the required food for them. But with family planning, you will be able to space your family so that the wife and the husband will be at peace.” PHU
Health workers had set up private rooms for family planning counselling or use the in-charge’s office:
“It’s a consultation room for just two people; the client and I, except if there is need for the patient’s relative or caregiver to be present there. We highly respect the privacy of our patients especially a community like this that frowns at family planning...” PHU
Caregivers attest to the privacy involved in family planning services provided at facilities:
“ because some do talk a lot that’s why the nurse doesn’t allow the two of you together in. If you say, ‘I come to accompany her’ they will tell you to wait for her outside.” FGD
There are health facilities with “the adolescent friendly corner” where they cater for teenage girls;
“Before this intervention, women and girls in this community were giving birth to children as if they were in a competition.” PHU
Clients are not coerced but are counselled to understand the importance of child spacing:
Our responsibility is to ensure that the person understands the various services and you will have to give her the free will to decide.’’ PHU
“They display the various commodities that they have after talking to us about prevention; that they have the depo, coil, captain band [hormonal implants] and pills. They tell us the wide range of choices of family planning commodities which are all free of cost.” FGD
“I thought family planning was only practiced by educated women or office workers.” FGD
Caregivers realize the dangers of having too many children especially without spacing pregnancies:
“We are farmers, if for instance I have one child around three years who cannot walk properly and the other around one year and I am also pregnant. In the morning my husband will go ahead to the farm, I have the two kids to carry to the farm and I am pregnant, I will force the 3-year-old to walk faster and carry the year old on my back. Remember I am weak and hungry carrying all these children with pregnancy, I will suffer more than the man. I see it necessary to talk to the husbands to allow us to join the family planning, so that we’ll space the kids, and the suffering will be less.” FGD
Birth spacing has improved family finances:
“Well, using contraceptives has helped me and my family to plan our family well in a way that we are able to take care of all our financial problems.” FGD
“ if there was no family planning some homes must have been devastated because women will just be giving birth.” FGD
Impact
During the transition community engagement structures were either developed, revitalized or modified:
“The role of the CHWs and the Mother Support Group has helped increase awareness on maternal, infant and young child feeding that has an impact on the reduction of morbidity and mortality. They have supported getting children vaccinated and mothers to plan their families in order to space childbirth and see how to care for those that they already have.” National
The complementary feeding demonstrations appear to have helped reduce malnutrition:
“There was a mother who was feeding her six-month-old baby with biscuit and ORS, the child’s health deteriorated until she came here, and we taught her how to prepare this bennimix; now the child has recovered. There are lots of that kind of story.” PHU
“The benefits that we are getting is that their children are getting healthier, and the caregivers are constantly getting information on health-related issues such as the importance of vitamin A for prevention of blindness and albendazole which has reduced worm infestation.” District
“Another important success is that infant mortality rate has also reduced because of the complementary feeding and the vaccine that has been given to the children.” CHW
Lessons learned and replicability
Enablers
Coordination with CHWs and the mothers support groups;
“ especially for older children because that is where we were having low coverage.” National
“ health workers were able to better coordinate because they were more aware the needs and problems of these communities and the communities themselves accepted it and they used this cordial relationship to pass on health-related messages.” District
Coordination with traditional leaders:
“The Paramount Chief called a meeting the last time and talked to us about family planning. He said that people should not be just giving birth rapidly….” FGD
Barriers
One-day’s training was insufficient:
“… you cannot do in-charges training in a day if you have 50 persons in a classroom.” National
“If you don’t know about basic nutrition, you will misinform the client.” PHU
Not everyone is pleased with the transition:
“ some of us are coming from very far communities and sometimes, we find it very difficult to get here because we have to make sure we do our domestic work in the morning.” FGD
Some caregivers are preoccupied with income generation:
“ it is better if the nurses go to the community. Even if they don’t meet the parent, they’ll ask for the age of the child around or in the compound and drop the vitamin A.” FGD
Difficulty and costs of transportation:
“When the water level goes up, they will never cross over here until we go and meet them. Those on the land, the cost of motor bikes sometimes affects them, because some can’t afford it.” PHU
No resources for CHWs:
“If CHWs in the past have been empowered to treat diarrhoea because they were able to actually carry ORS…, then Vitamin A should have been integrated….. So, I think we missed an opportunity.” National
Supply chain weaknesses remain:
“If you see our monthly chart for Vitamin A and Albendazole you will notice that we have zero for some months. The supplies come but they are not enough” PHU
Stockouts discourage attendance:
“When there are stock outs and caregivers are not getting the service, they want it is difficult to return; especially those whose husbands are suspicious of their movements.” PHU
“ we do not have the IUCDs and implants. Most patients come for these services, but they are not available, and we cannot ask them to buy them because family planning services are free and if you ask the patient to come at another time the next time, she will be already pregnant.” District
“For the implants, we have stock out of local anaesthesia, Povidol, and gauze and these problems are not just for this facility but for the whole district.” PHU
Some caregivers cannot afford or access even the local ingredients:
“They give them rice pap because that is what they can afford.’ CHW
“They do not have the chance to buy it all the time in this community as they have to go to the periodic market in other towns in search of those ingredients like beans and others.” CHW
The DFN developed and disseminated a complementary feeding recipe book and Food Based Dietary Guidelines, but these are not widely used20,21.
“ [caregivers] don’t understand that some of the local food that they produce can also serve as complementary food, instead they may decide to buy tin food.” National
“In most cases caregivers are not aware of the usefulness of their own local foods in providing the nutrients to support their child growth but resort to manufactured foods which are sometimes above their means.” National
“ demonstrations should be context specific. The food that is available in one district may not be readily available in another.” National
“ they told us to be giving the child other nutritious foods like eggs, corn, potatoes, yams, fish and a lot more.” FGD
Some men do not agree with their wives using family planning. If women insist it can lead to fights or even divorce. Most women who join family planning do so without informing their husbands.
“ I joined secretly. When he asked me why I wasn’t getting pregnant, I told him God’s time has not reached yet. When it is time, I will get pregnant” FGD
Men constitute a barrier to family planning:
“The sooner they detect it [Jadelle] they will straight away come to the health facility to get it removed; the only alternative now is the injection. With the injectable you take it quietly and leave the card with me, when your time is due you come, or I remind you to come.” PHU
Some men believe their wives use family planning to engage in extramarital affairs:
“ no sooner your husband learnt that you have started taking family planning, those things that you were doing that were not considered serious, they would start taking them very seriously. Whatever you do now, he would begin to ask plenty questions.” FGD
Only one spouse admitted that his wife was on family planning and his change of mind happened only when she started visiting the PHU even though he had been aware:
“ now I thank God as we do not expect unwanted pregnancy.” Spouse
One spouse admitted that his wife had pleaded to be allowed to join family planning, but he had refused:
“Yes, we have discussed family planning. She told me that she wanted to rest a little on childbearing because she is too young to have the number of children she is presently having. I agreed, but I told her it shouldn’t be for five years or more because childbearing is in the hands of God. There are people who are looking for children, but they don’t have them so if God has given them to us, then we shouldn’t deny them. The only thing is that we should pray so that God will make provision for us so that we will be able to take care of them.” Spouse
Religion also limits family planning uptake:
“Sensitization in family planning should continue because we are still having challenges, especially with the religious people because there are some verses in the Quran that says you should not kill your child and so for some people when they read that verse, they will think that the purpose of family planning is to kill their babies. The same thing also with Christians, so we need people to explain that killing a child and preventing pregnancy are different.” National
Some religious leaders assert that the Bible and Quran, have passages that are against family planning:
“It’s very fearful and haram/forbidden” FGD
“Modern contraceptives are the root cause of all manner of diseases today, and that it is not good for anything. He [Imam] further said that in their days their mothers used to give chance to nature to play part, that is women may deliver children up to the time of God’s will. But today if you want a woman to give birth you have to beg her, because it’s no more God, but they control the birth, which is very sinful and must be accounted for on the day of judgement for killing human being.” FGD
Few health workers have the expertise to insert hormonal implants:
“I am the only person trained to insert implant, which means if I am away for a workshop or any other activity that area will remain vacant. With that one-day absence so many things could go wrong, but if the two are trained my colleague will render the service.” PHU
In most communities family planning services are free but not always:
“Money is the major barrier in getting family planning in this community. You have to pay for all family planning services, that is one of the main barriers.” PHU
Women reported that they paid Le25,000 for a hormonal implant insertion and again for removal. Injectables and pills cost between Le10,000 and Le15,000.
Sustainability
The program has been integrated into PHU weekly schedules and annual DHMT workplans and budgets. Caregivers spoke of the camaraderie between them and service providers that encourages health-seeking behaviour. In 2021 the CHWs curriculum and entry criteria were revised and now they report directly to the local PHU-in-charge who delegates, monitors and supervises their performance rather than reporting directly to the DHMT22,23.
Helen Keller worked with the religious leaders in FOCUS 1000 at national level to fully understand family planning and modern contraception and identify passages in the Bible and Quran that would support birth-spacing24. They then worked together with the DHMTs to advocate with religious leaders in the districts and cascaded those advocacy meetings to every chiefdom so that religious leaders would inform the men in their congregations. This chiefdom-level advocacy with district and village level religious leaders was repeated in the second year of transition and contributed to the high level of awareness of family planning despite ongoing hesitancy.
Men are the heads of households and the decision makers. Their opposition to family planning is a challenge for their wives who understand and desire spacing of childbirth.
“It is important to educate men on family planning because as women some of us find it very difficult to do some of these things without the support of our husbands.” PHU
Caregivers believed that if health workers spoke directly to their husbands, it would be Dmore effective:
“The worst of it some of the men will not agree for us to take the family planning but if they also know about the importance of taking family planning it will be very good for all of us.” FGD
Religious leaders command the most respect in their communities:
“The message is as important as the messenger” National
“ if they involve the Imams and the Pastors, I can say we have gone halfway in our sensitization. Because they have larger following that listens to them more than anyone else.” PHU