Breaking the Cycle: Understanding the Roots of Suboptimal Feeding Practices in Rwanda
We unpack the suboptimal feeding practices in Rwandan households among pregnant/lactating women and young children that are leading to unacceptably high rates of malnutrition, and what to do about it
In Gakenke District, mothers assemble for a monthly participatory community dialogue on healthy child feeding, and caring practices. Community nutrition groups like this one are organized and led by Elisabethe Uwimana, a 50-year-old lead community health worker in Nemba Sector. Parents come at these events to have their children screened for malnutrition – a measurement exercise where Children's height, weight, and mid-upper arm circumference are also measured during these appointments, share each other’s experiences, and take part in counseling and cookery demonstrations provided by community health workers.
If the measurements are in the ‘yellow’ and ‘Red’ zone, Elisabethe refers them to the local health center immediately for further assessment and therapeutic interventions. Children’s diets are also augmented with micronutrients once they are six months old.
Progress towards healthier communities is slow, and for frontline workers like Elizabethe, such work is not easy. Nationally, the 2019-20 Demographic Health Survey revealed that 1 in 3 children under 5 are stunted, which is a drop from previous rates, but still a high number. Most of the children aged 6-23 months ate a diet that was below the minimum dietary diversity per age-specific recommendations. Good maternal nutrition during pregnancy and lactation, as important as it is, is also not closely observed by most.
To get a clearer understanding of this issue from the people’s perspective, UNICEF proposed an anthropological study on the household-level drivers of persistent suboptimal feeding practices among pregnant/lactating women and young children in Rwanda, which would help improve social and behavior change interventions in the fight against malnutrition. The study found that sensitization of the need for good Maternal, Infant and Young Child Nutrition (MIYCN) practices has been achieved, yet behavioral change has not. Despite high levels of nutrition knowledge, households still struggle to obtain nutritious foods.
While poverty is conclusively a factor that cannot be ignored, the challenge facing Rwanda is not just about economic constraints. Curating diets, whether for pregnant/lactating women, or for young children, was (is) not defined solely by economic limitations, but by decisions taken in light of both nutrition knowledge and perception of economic status. And even so, knowledge does not necessarily translate to behavior change. This 'educational model of social change', according to anthropologist Russell Bernard, is mostly ineffective because behavioral change does not usually depend on education.
Two of the main drivers in household-level decision-making that were identified were the choice between quantity and quality—where, quantity is typically preferred when weighed against nutritional value—as well as the separate acquisition and preparation of different meals for pregnant/lactating mothers, infants, young children and the rest of the household as recommended.
Now, the policy question facing Rwanda is how to leverage existing knowledge and economic incentives to drive the necessary last‐mile behavior change. To address this, a three-pronged approach (individual, community, & economic) is proposed; beyond providing knowledge, focus on shifting behavioral norms towards better food-choice decision‐making and stronger prioritization of obtaining— through cultivation or purchase—the foodstuffs which are necessary to construct nutritious diets for pregnant/lactating women as well as young children specifically on improved access to and utilization of animal source protein. In practice, this would be a shift in emphasis away from large quantities of starchy foods and toward greater diversity of micronutrient‐rich foods including more animal-source foods.
Social and behavior change communication (SBCC) should be directed at both community and household levels nationwide and should focus on the prioritization of nutritious and diverse foods. Additionally, an economic empowerment and incentivization layer is proposed to increase caregivers’ economic capability to pay for nutritious foods and incentivize this behavior change economically. This would target particularly more resource‐constrained households (identified either through the current ubudehe system, or via other targeting approaches). The incentives could also be applied to producers and industries in the food and nutrition sector, in various ways to transform the food systems in Rwanda ensuring safe and nutritious foods are available, accessible, and affordable for utilization by the households.
By implementing these interventions, caregivers will increasingly make the right decisions that give their children a healthier and brighter future, making the work of Community Health Workers like Elizabethe much easier.
In SBCC efforts to drive such last-mile behavior change, especially in the consumption of animal-source foods by young children in Rwanda, UNICEF, in partnership with the National Child Development Agency and with support from the Embassy of the Kingdom of the Netherlands (EKN), has launched a long-term campaign that is pushing for “One Egg per Child, Everyday”. The results and recommendations of this study are already guiding the campaign and other efforts made to drive lasting behavior change and nutrition-positive decision-making.
To read more about UNICEF’s campaign, click here.
Read the full MIYCN anthropological study here.