Behaviour Change Communication to Improve Complementary Feeding Practices in Ethiopia: Couples' Beliefs Concerning Paternal Involvement in Childcare

"More work is needed to develop and test effective methods for changing fathers' beliefs and practices."

Interventions to influence knowledge, attitudes, feeding practices, and child growth often seek to engage only mothers. However, existing studies show a positive association between fathers' involvement and children's diet. A maternal behaviour change communication (BCC), paternal BCC, and food voucher programme was designed and implemented in Ejere, Ethiopia, using a clustered randomised controlled trial (RCT) design. The research reported in this paper is a qualitative investigation of beliefs in a subset of participants who participated in the RCT. Its purpose is to examine the BCC programmes, characterising the behavioural, normative, and control beliefs of both mothers and fathers in their beliefs concerning men's roles in childcare, household chores, and intrahousehold decision making on household purchases.

The intervention groups in the RCT were as follows: maternal BCC only; maternal BCC and paternal BCC; voucher only; maternal BCC and food vouchers; maternal BCC, food vouchers, and paternal BCC; and control group. Fourteen participants from the same village formed one BCC group and met with a trained facilitator once a week for an hour. Maternal BCC lasted for 16 weeks and included messages about types, diversity, quantity, preparation and storage of complementary foods. Paternal BCC lasted for 12 weeks and included messages about diet diversity, consequences of malnutrition during the first 2 years, fathers' role in childcare, shared division of household labour, and gender-equal intrahousehold decision making.

In the qualitative study, 40 participants were included, with 13 mother-father pairs in the BCC + food voucher group, and seven pairs in the control group. Each participant was interviewed separately using a semistructured interview guide based on the theory of planned behaviour (TPB), which posits that behavioural, normative and control beliefs influence behavioural intention. Behavioural belief refers to whether a person has a favourable or unfavourable appraisal of a given behaviour. Normative belief refers to social pressure in a larger cultural context to perform or not to perform a given behaviour. Control belief refers to a person's perception of the ease or difficulty of performing a given behaviour. Behavioural belief, normative belief, and control belief influence each other and predict individuals' intention to perform a behaviour. The researchers incorporated a vignette for a topic related to decision making, a story about a father who gives mothers complete control over food purchasing decisions, and posed follow-up questions to evaluate participants' behavioural, normative, and control beliefs.

The data indicate that BCC mothers hold more gender-equal views than control group mothers, particularly regarding fathers' participation in household chores. Seventy-nine percent of BCC mothers view men's involvement in cooking, cleaning, and washing as culturally acceptable, in contrast to 29% of control mothers. Furthermore, 57% of BCC mothers believe it is easy for fathers to engage in these chores, in contrast to 14% of the control group. The majority of BCC mothers perceived themselves as knowledgeable and therefore able to take the lead in decision making. However, most control mothers were not confident in making decisions and therefore perceived decision making as a burdensome responsibility. 

By contrast, the beliefs of BCC and control fathers were similar overall, suggesting men are more resistant to gender-equal BCC despite having more years of formal education than women and greater exposure to gender-equal messages and norms. Overall, more than half of the fathers perceived fathers' engagement in childcare through feeding and bathing as socially acceptable, but at the same time, they perceived childcare as something difficult. Although some fathers believed that mothers can make decisions equally well, many fathers regarded lack of involvement in the decision-making process as being irresponsible as the head of the household. 

Both mothers and fathers perceived fathers' primary role in childcare as earning money, which influenced limited father involvement. While both parents recognised the benefits of fathers' involvement in childcare, the prevailing justification for fathers' limited engagement was their role as providers. 

In conclusion, the findings indicate that "maternal BCC may have influenced mothers' beliefs in a gender-equal direction and empowered them through peer influence, social support and the gaining of knowledge." However, the beliefs of BCC and control fathers were similar overall, which suggests that the paternal BCC programme should be designed with greater intensity and longer duration than the current 3-month weekly programme. In addition, the study's finding that mothers' traditional beliefs can be the driver of a traditional intrahousehold division of labour, which highlights the importance of addressing gender norm attitudes not only in men but also in women. Further work is needed to develop and test effective methods for changing fathers' beliefs and promoting gender equality to improve children's diet and growth."