Tubaramure, a Food‐Assisted Integrated Health and Nutrition Program, Improves Maternal Health and Nutrition Knowledge in Burundi
Authors: Iruhiriye Elyse , Heckert Jessica , Olney Deanna K , Leroy Jef L , Ruel Marie 
Published: June 2021

BackgroundSub‐optimal hygiene and nutrition knowledge and practices contribute to child undernutrition. Behavior change communication (BCC) strategies designed to improve maternal knowledge and practices are often incorporated into integrated health and nutrition programs. However, the impact of these programs on knowledge is not well documented.ObjectiveWe estimated the impact of Tubaramure’s BCC approach. Tubaramure (funded by USAID's Office of Food for Peace and implemented by a CRS‐led consortium) used a cascade system whereby paid program staff (health promoters) trained elected leader beneficiary mothers (LM), who in turn trained other beneficiary mothers (BM) at bi‐monthly care group meetings on hygiene and nutrition topics. In addition, we evaluated how the BCC approach facilitated changes in knowledge and identified areas of improvement.Methods60 clusters were randomly assigned to 3 intervention (I) groups (food rations from pregnancy until 24 m of age, rations until 18 m, rations until 24 m but not during pregnancy) or a control (C) group. I groups were pooled for analyses since the BCC component was the same across groups. We used data from 2 cross‐sectional surveys of potential beneficiary mothers conducted at baseline (2010, I=1733 and C=889) and at 2 y follow‐up (2012, I=1743 and C=871). We used sum‐scores to evaluate knowledge on hygiene (range=0–5), child feeding during illness (0–6), micronutrients and undernutrition (0–7), complementary feeding (0–3) and breastfeeding (0–5). Difference‐in‐difference (DID) estimates were used to assess impact. Knowledge in 2012 was also compared between LM (n=132) and BM (n=995). To understand the pathways of impact, we used qualitative process evaluation data collected in 2011 on beneficiaries’ opinions and perceptions of the BCC strategy and on implementation quality.ResultsMaternal hygiene and nutrition knowledge were low at baseline (BL). Tubaramure significantly (p<0.05) improved maternal knowledge of optimal hygiene (0.3), child feeding during illness (0.4), micronutrients and undernutrition (0.3), and complementary feeding (0.1) practices. There was no impact on breastfeeding knowledge, which was moderately high at BL with a sum‐score of 3.6 out of 5. At follow‐up, hygiene, complementary feeding and breastfeeding knowledge was significantly higher among LM compared to BM. Our qualitative data show that the program's health promoters were generally very knowledgeable about recommended practices, and they conducted higher quality care group meetings for the LM, with higher participation, than those conducted by the LM for the BM.ConclusionsTubaramure was effective in improving knowledge of a number of key hygiene and nutrition practices. Though the cascade training system was effective, knowledge was higher among the LM (trained by skilled health promoters) compared to the BM (trained by LM). The quality of the training provided by the health promoters and the greater participation of LM in the trainings likely contributed to their higher levels of knowledge. It is possible that further improvements in LM's knowledge and in the quality of the training they led could have further improved knowledge among all BM.Support or Funding Information“Funded by USAID's Food and Nutrition Technical Assistance Project & CGIAR Research Program on Agriculture for Nutrition and Health (A4NH), led by IFPRI.”