Change and Communication i. Formative Research Until the baseline KPC survey, the project relied on existing data that showed high immunization coverage in the project area. The baseline data shows that current coverage is quite low in three zones of the project area, that coverage is average to high in two zones, and that the drop-out rate is low indicating poor access. The project partners will need to do further formative research to identify the root causes for poor coverage. This research will include interviews with health facility staff, community members, and an assessment of supplies and equipment at the RHCs. Although the project will not purchase vaccines, vaccine supplies, or cold chain equipment, identifying shortages or weaknesses in any of these areas will allow partners to advocate with those who control resources to allocate more to immunization. Solutions to identified problems will come from partners and the community. Immunization is a stated priority of the Zambian government, and the health system prides itself in achieving high coverage. The partners feel strongly that highlighting gaps will provide opportunity for collaboration to act and improve weaknesses.
Change and Communication i. Formative Research The KPC confirmed that feeding practices for infants and children are not optimal in the project area. Many families only eat two meals each day, and many children are only fed once per day, particularly if the mother works outside the home. Only about 20% of children 12-23 months eat semi-solid food at least four times per day. Typical food includes nshima (maize meal), relish (cabbage, tomatoes, and onion), pumpkin leaves, chicken, and eggs. Wealthier families who have cattle and goats eat meat and drink milk. Certain food taboos, such as children and pregnant women not eating eggs, affect nutritional status even when food is available. HIV+ mothers are too sick to care for their children properly, or die while the child is very young, contributing to child poverty, malnutrition, and death. Breastfeeding practices are not optimal, particularly in such a high HIV prevalence area. Many mothers believe their breast milk can cause illness, so they stop breastfeeding if the child gets sick. Also, mothers who work on commercial farms usually wean early, and if a mother misses a feed, she will abruptly wean, believing that her milk has gone “sour.” The baseline KPC found that 44% of mothers began breastfeeding within one hour of delivery, and the same proportion of children under six months of age exclusively breastfeed. Complementary feeding is better; virtually all of the children six to nine months receive appropriate foods.xlviii The project will strengthen the coverage and quality of GM/P services at the start of the nutrition intervention to accurately identify which communities will implement Hearth. Because coverage of GM/P is already quite high, demand for these services is good, and health facilities prioritize the activity, it will be more cost-effective to use this system instead of a separate comprehensive anthropometric survey to complement the KPC. Additionally, strengthening the GM/P services also allows for continuous screening for malnutrition. (See IR 3.2a below.) The project will conduct a positive deviance inquiry (PDI) before the start of the nutrition intervention in year two. This exercise will uncover already-existing practices in the community that contribute to good nutrition. The PDI will identify the behaviors that the project will promote in addition to the ones already mentioned (increasing feeding frequency, breast feeding, etc.)
Change and Communication i. Formative Research The baseline information confirmed the need to increase attended deliveries, postpartum care, appropriate newborn care practices, and access to care. Although card-confirmed ANC attendance was low in the KPC, the high coverage of IPT and secondary data support that ANC coverage is quite high. To implement an effective intervention, the project will carry out future formative research to more fully examine the root causes of low coverage and access for postpartum care. Focus groups with communities (both younger and older women), key informant interviews with TTBAs and health workers, and the health facility assessment will help to identify the gaps in which the project will have the most impact.
