Testing the Caregiver’s Feeding Style Questionnaire to Promote Dietary Diversity and Early Childhood Development through Responsive Feeding in Niger Authors: Leanne Dougherty, Kristina Granger, and Marjolein Moreaux

Presentation Objectives Detail the development of a responsive feeding indicator, how it was designed, and results from reliability testing.

SPRING/Digital Green Program in Niger (2015) Collaboration established between SPRING/Digital Green and 3 USAID/Niger programs: REGIS-ER (NCBA CLUSA), LAHIA (Save the Children), and Sawki (Mercy Corps) Involved 80 existing Hausa-speaking community groups, in 20 villages in the Maradi Region Niger In collaboration with Digital Green, REGIS-ER, Save the Children and Mercy Corps, the Niger proof of concept was implemented in a total of 80 community groups over the course of one year in 20 villages in Maradi region, Niger between January and December 2015. -Sahel context faces harsh climate conditions, food insecurity, and high levels of malnutrition -Activities and evaluation of a community video approach for maternal, infant, young child nutrition (MIYCN) and hygiene behaviors -Community video approach in Niger highlights active/responsive feeding – focus not just on getting diversity on the child’s own plate but practices for encouraging feeding a diverse diet. Focused on development and dissemination of 10 videos by community facilitators, working with 4 groups in each participating village

10 Prioritized video topics in Niger included: Importance of hand washing with soap Importance of the first 1,000 days Responsive feeding Importance of exclusive breastfeeding (EBF) EBF for on-demand feeding and working mothers Introduction of complementary food for the baby after 6 months Age appropriate complementary feeding for babies 6 to 24 months Maternal and adolescent girls diets Animal and human contamination, diarrhea, and management Dietary diversity and resilience Responsive feeding and feeding of young children from a separate plate was prioritized as an important video and evaluation topic based on results from formative research that showed young children were fed in a laissez faire style from a family pot which may be contributing to a lack of dietary diversity in their diets. A number of videos addressed dietary diversity and recommendations for complementary feeding.

Why Responsive Feeding? WHO 2001 Complementary Feeding Guidelines Only guideline that doesn’t have widely accepted associated indicators Not often monitored or evaluated - The nutrition community has made a call for indicators to assess holistic interventions for child growth and development that go beyond stunting to measure outcomes of integrated nutrition, health, and ECD interventions. - Science behind focusing on ECD and nutrition by having a standardized method for measuring responsive feeding, we can better advocate for the importance and promotion of responsive feeding as an important practice to improve nutrition and health outcomes and standardized monitoring and evaluate of our nutrition programs. - Outcome measures in nutrition focus primarily on anthropometry which is challenging to collect. - There is growing evidence that responsive feeding practices among children aged 6-23 months are linked to improved nutrition outcomes. The World Health Organization’s complementary feeding guidelines include recommendations on responsive feeding practices, yet there is no standard indicator to measure them. It is the only guideline without an associated and globally recognized indicator. Responsive Feeding was chosen as 1 of the 10 Guiding Principles. A. Guideline: Practice responsive feeding, applying the principles of psycho-social care (Engle et al., 2000; Pelto et al., 2002). Specifically: 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 contact. B. Scientific rationale: There is increasing recognition that optimal complementary feeding depends not only on what is fed, but also on how, when, where, and by whom the child is fed (Pelto et al., 2002). Behavioral studies have revealed that a “laissez-faire” style of feeding predominates in some populations (Engle and Zeitlin, 1996; Bentley et al., 1991; Bentley et al, 1992), with encouragement to eat rarely observed, or observed only when children refused food or were ill. It has been hypothesized that a more active style of feeding may improve dietary intake. The evidence to date on the impact of feeding behaviors on dietary intake and child health is sparse, however. In an urban population in Ghana, Ruel et al. (1999) found that a “care practices” scale (which included breastfeeding patterns, timing of complementary feeding, food quality, and two “active feeding” behaviors) was positively associated with child anthropometric status among mothers with little or no schooling. Several intervention studies that included feeding behaviors as part of the recommended practices have reported positive effects on child growth (Sternin et al., 1997; Creed de Kanashiro et al., 2002), but it is not possible to separate the influence of responsive feeding from that of the other changes that occurred in breastfeeding practices and the types of complementary foods offered. When more data are available from controlled research trials, it may be possible to pinpoint the types of feeding behaviors that make the most difference to child health and behavioral development. In the meantime, the recommendations above represent the current consensus on optimal practices among experts in the field.

2016 Lancet Early Childhood Development Series This Series considers new scientific evidence for interventions, building on the findings and recommendations of previous Lancet Series on child development (2007, 2011), and proposes pathways for implementation of early childhood development at scale. The Series emphasizes 'nurturing care', especially of children below three years of age, and multi-sectoral interventions starting with health, which can have wide reach to families and young children through health and nutrition. Children’s early development requires nurturing care—defined as health, nutrition, security and safety, responsive caregiving, and early learning—provided by parent and family interactions, and supported by an environment that enables these interactions.

Testing the responsive feeding indicator during a mixed method evaluation We conducted a mixed methods evaluation which included a quantitative, qualitative, and costing data. In this, we developed a tool to measure responsive feeding and using a separate plate.

How Was the Indicator Developed? What indicators exist related to responsive feeding? –Some indicators used in the Propan tool and developed under IYCN touch on some aspects of responsive feeding like sitting close to a child, using a separate plate, and encouraging positive interactions while feeding. But we were looking for more on the latter. The Caregiver’s Feeding Style Questionnaire (CFSQ), currently used in developed countries, consists of 20 questions aimed at assessing child feeding styles. Where and how it’s been used? – modified version used in Ethiopia. Our objective was to test this indicator in the developing country context of Niger to measure responsive feeding. And we combined the use of this tool with indicators on proximity to the child while feeding and using a separate plate to get a holistic sense of the responsive feeding behaviors.

Example of CFSQ items How often during the meal do you promise [CHILD NAME] something other than food if he or she eats? How often during the meal do you encourage [CHILD NAME] to eat by arranging the food to make it more interesting? How often during the meal do you ask [CHILD NAME] questions about the food (e.g. Do you like these? Shall I give you more leaves?)? How often during the meal do you tell [CHILD NAME] to eat at least a little bit of food on his or her plate? How often during the meal do you reason with [CHILD NAME] to get him or her to eat (e.g. Milk is good for your health because it will make you strong.)? How often during the meal do you say something to show your disapproval of [CHILD NAME] for not eating their meal? 20 Questions. 1. NEVER 2.RARELY 3. SOMETIMES 4. MOST OF THE TIME 5. ALWAYS

Methods Study Design: Three rounds of survey data collection Baseline (April 2015) Second survey (June 2015) Endline (August 2015) Sample: Approximately 300 women with a child between 6-23 months at each data collection point Analysis: Factor analysis of CFSQ items to generate a factor score ranking responsive feeding construct into high, medium, and low terciles Reliability testing of scores using cronbach alpha Bivariate analysis to assess changes over time The CFSQ was administered to female participants with children under the age of two participating in a community video intervention to improve nutrition and hygiene behaviors. A local video on responsive feeding was screened by participants during a facilitated discussion. Data were collected at three points - baseline, approximately one month following the screening, and two to four months following video exposure with a cohort of approximately 300 at each data collection point. The data were analyzed using factor analysis and scores were ranked into high, medium and low terciles to indicate levels of responsive feeding. Women with scores in the top tercile were considered to exhibit high levels of responsive feeding.

Reliability Testing of Indicator Results from the reliability testing on the performance of the questions found a high level of internal consistency, as determined by a Cronbach alpha of 0.9326. Chronbach alpha: 0.9326

Responsive Feeding Behaviors

Conclusions The CFSQ provided a reliable measure of responsive feeding in the resilience context of Niger. The CFSQ should be considered for use in other developing country contexts to measure responsive feeding and elevate the importance of this practice for both nutrition and ECD outcomes. The presence of an indicator elevates the importance of responsive feeding as a critical nutrition practice to encourage dietary diversity and improve complementary feeding. The indicator provided a means to measure the link between nutrition and ECD as related to feeding and parenting styles and elevated the importance of responsive feeding as a critical nutrition practice to encourage dietary diversity and improved complementary feeding.

Marjolein Moreaux marjolein_moreaux@jsi.com Thank you! Kristina Granger Leanne Dougherty Kristina_granger@jsi.com leanne_dougherty@jsi.com Marjolein Moreaux marjolein_moreaux@jsi.com www.spring-nutrition.org/CommunityVideo