Behavioural drivers of child feeding during and after illness in the Democratic Republic of the Congo: results from a qualitative study through the lens of behavioural science.

OBJECTIVE: For young children experiencing an illness, adequate nutrition is critical for recovery and to prevent malnutrition, yet many children do not receive the recommended quantities of food during illness and recuperation. Our research applied a behavioural science lens to identify drivers of feeding behaviours, including barriers inhibiting caregivers from following the feeding guidelines. DESIGN: In 2021, we conducted qualitative research informed by the behavioural design process. Data from in-depth interviews and observations were analysed for themes. SETTING: Research was conducted in South Kivu, Democratic Republic of the Congo. PARTICIPANTS: Research participants included caregivers of young children, other family members, health workers and other community members. RESULTS: Five key findings about behavioural drivers emerged: (1) poverty and scarcity impose practical constraints and a cognitive and emotional burden on caregivers; (2) health providers are distracted and discouraged from counselling on feeding during sick visits; (3) a focus on quality and hesitations about quantity obscure benefits of feeding greater amounts of available foods; (4) perceptions of inappropriate foods limit caregivers' choices; and (5) deference to a child's limited appetite leads to missed opportunities to encourage them to eat. CONCLUSIONS: Each of these behavioural drivers is triggered by one or more addressable features in caregivers' and health workers' environment, suggesting concrete opportunities for programmes to support caregivers and health workers to improve feeding of young children during illness and recovery. In other settings where these features of the environment are similar, the insights and programming implications are likely to translate.

Evaluation of the Confiance Totale Campaign in Togo: Associations Between Campaign Exposure and Family Planning Outcomes of Interest.

In Togo, family planning (FP) use remains low; only 24.1% of married woman ages 15 to 49 use modern FP. The West Africa Breakthrough ACTION (WABA) project developed the Confiance Totale radio campaign, which used a Saturation+ approach to encourage FP use. This study presents the results of an evaluation of Confiance Totale which investigates associations between campaign exposure and outcomes of interest. Following the broadcasts, the team conducted a cross-sectional household survey among 2,200 respondents ages 18 to 49. Combined and sex-stratified multivariable models predicting outcomes of interest controlled for sex, age, site, marital status, educational attainment, religion, and economic status. Upon hearing a campaign jingle, approximately 45% of participants had heard the campaign. Exposure to the campaign was associated with many ideational and behavioral outcomes including current use of a facility-dependent FP method (OR = 1.77, p < .001). In stratified models, several outcomes were significantly associated with exposure in the women-only models but not in the men-only models. Exposure to Confiance Totale was associated with nearly all ideational and behavioral outcomes of interest, particularly among women. This demonstrates that high dosage broadcasting may be effective in promoting confidence in the health system and improving perceptions of FP.

"You Take Medications, You Live Normally": The Role of Antiretroviral Therapy in Mitigating Men's Perceived Threats of HIV in Côte d'Ivoire.

Men diagnosed with HIV face gender-related barriers to initiating and adhering to antiretroviral therapy (ART). This qualitative study (73 in-depth interviews; 28 focus group discussions), conducted with men in three urban sites in Côte d'Ivoire in 2016, examined perceptions of ART, including benefits and challenges, to explore how ART mitigates HIV's threats to men's sexuality, economic success, family roles, social status, and health. Participants perceived that adhering to ART would reduce risk of transmitting HIV to others, minimize job loss and lost productivity, and help maintain men's roles as decision makers and providers. ART adherence was thought to help reduce the threat of HIV-related stigma, despite concerns about unintentional disclosure. While ART was perceived to improve health directly, it restricted men's schedules. Side effects were also a major challenge. Social and behavior change approaches building on these insights may improve male engagement across the HIV care continuum.

The Association of a Large-Scale Television Campaign With Exclusive Breastfeeding Prevalence in Vietnam.

OBJECTIVES: To examine the association between exposure to breastfeeding television spots and exclusive breastfeeding (EBF). METHODS: We performed face-to-face interviews with 11 722 mothers of infants younger than 6 months using 5 cross-sectional surveys 6 or more months apart between 2011 and 2014 in Vietnam. Sample sizes were 2065 to 2593, and approximately 50% of participants lived in areas with (Alive & Thrive [A&T]-intensive [I]) and approximately 50% without (A&T-nonintensive [NI]) facilities offering counseling services. We analyzed data at individual and commune levels separately for A&T-I and A&T-NI areas. RESULTS: Exposure to television spots was associated with higher EBF in A&T-I (odds ratio [OR] = 3.33; 95% confidence interval [CI] = 2.70, 4.12) and A&T-NI (OR = 1.31; 95% CI = 1.03, 1.67) areas. In A&T-I areas, mothers who could recall at least 1 message were more likely to report EBF. In A&T-NI areas, only recall of at least 3 messages was associated with higher EBF. In communes, 1 message recalled (mean score range = 0.3-2.4) corresponded to 17 (P = .005) and 8 (P = .1) percentage points higher EBF prevalence in A&T-I and A&T-NI communes, respectively. CONCLUSIONS: Mass media should be part of comprehensive programs to promote EBF.

Systematic review of the effectiveness of mass media interventions for child survival in low- and middle-income countries.

Through a systematic review of the literature, this article summarizes and evaluates evidence for the effectiveness of mass media interventions for child survival. To be included, studies had to describe a mass media intervention; address a child survival health topic; present quantitative data from a low- or middle-income country; use an evaluation design that compared outcomes using pre- and postintervention data, treatment versus comparison groups, or postintervention data across levels of exposure; and report a behavioral or health outcome. The 111 campaign evaluations that met the inclusion criteria included 15 diarrheal disease, 8 immunization, 2 malaria, 14 nutrition, 1 preventing mother-to-child transmission of HIV, 4 respiratory disease, and 67 reproductive health interventions. These evaluations were then sorted into weak (n = 33), moderate (n = 32), and stronger evaluations (n = 46) on the basis of the sampling method, the evaluation design, and efforts to address threats to inference of mass media effects. The moderate and stronger evaluations provide evidence that mass media-centric campaigns can positively impact a wide range of child survival health behaviors.

"I'd do it for my baby": Lessons learned from qualitative research on COVID-19 vaccination among pregnant women in Côte d'Ivoire.

In January 2023, almost two years after the COVID-19 vaccines were authorized for the general Ivorian population, the Government of Côte d'Ivoire authorized the Pfizer vaccine for pregnant women. Qualitative research with 214 adults (including pregnant women) in three Ivorian cities in November 2022 revealed that most participants knew that the COVID-19 vaccine had not been recommended for pregnant women. Some participants felt that the policy change alone would be enough to motivate pregnant women to get vaccinated, but others felt that it would be difficult to convince pregnant women that the vaccine is safe for them and their babies. Pregnant women who participated in the study expressed a preference for waiting until after giving birth to get vaccinated against COVID-19, to be safe. They viewed the COVID-19 vaccine as risky during pregnancy but seemed unaware of the heightened risks that COVID-19 illness poses to pregnant women and babies. Pregnant participants stated that if they believed that the COVID-19 vaccine was good for the baby they would put aside their fears and get vaccinated. Reframing the conversation around the dangers of COVID-19 for pregnant women and their babies and positioning the COVID-19 vaccine as safe during pregnancy and protective, both during pregnancy and afterwards, could encourage uptake among this important segment of the population. Potential strategies to reinforce perceptions of COVID-19 vaccine safety for pregnant women include frequent and consistent messaging through both interpersonal and mass media channels; leveraging prenatal consultations and the relationship between health workers and pregnant women for both counseling and vaccination; and engaging influential others to support pregnant women in the decision to accept vaccination against COVID-19. Positive testimonials may help combat rumors that the vaccine negatively affects fertility and reproductive health, which could help to foster positive attitudes towards the vaccine before a woman even becomes pregnant and encourage broad vaccination among women of reproductive age.

"On the last day of the last month, I will go": A qualitative exploration of COVID-19 vaccine confidence among Ivoirian adults.

The authorization of several high-efficacy vaccines for use against the novel SARS-CoV2 virus signals a transition in the global COVID-19 response. Vaccine acceptance is critical for pandemic control and has a variety of context- specific drivers that operate at the individual, group, and sociopolitical levels. Social and behavior change interventions can influence individual knowledge, attitudes, and intentions as well as community norms to facilitate widespread vaccine uptake. While considerable research has been done to explore vaccine confidence in high-income populations as well as with respect to childhood vaccinations, much work remains to be done in understanding attitudes and intentions in low and middle income countries for adult or novel vaccines. We conducted in-depth interviews with individuals who had recovered from COVID-19 (n = 8), people who had lost a family member to COVID-19 (n = 4), and health providers (n = 17). We also conducted focus group discussions with members of the general population (n = 24 groups) to explore social norms and community perceptions related to COVID-19, including prevention behaviors, stigma, and vaccines. Researchers collected data in Abidjan, Côte d'Ivoire, in November 2020. In considering whether to accept a future COVID-19 vaccine or not, individuals in the study weighed perceived risk of the vaccine against the severity of the disease. Perceived severity of rumored side effects or safety issues of vaccines were also a factor. Convenience was a secondary, albeit also important, consideration. While concerns about vaccine safety tended to produce an expressed intention to delay vaccination, conspiracy theories about those developing and promoting vaccines and their motives led people to say they would opt out entirely. Behavior change interventions must raise awareness and address misunderstandings about the purpose of vaccines, transparently communicate about vaccine safety and development processes, and engage trusted influencers to build an enabling environment for COVID-19 vaccine roll out.

"In our culture, if you quarantine someone, you stigmatize them": Qualitative insights on barriers to observing COVID-19 prevention behaviors in Côte d'Ivoire.

While vaccines are now authorized for use against the SARS-CoV2 virus, they remain inaccessible for much of the world and widespread hesitancy persists. Ending the COVID-19 pandemic depends on continued prevention behaviors such as mask wearing, distancing, hand hygiene, and limiting large gatherings. Research in low- and middle-income countries has focused on the prevalence of adherence and demographic determinants, but there is a need for a nuanced understanding of why people do or do not practice a given prevention behavior. The Breakthrough ACTION project led by Johns Hopkins Center for Communication Programs conducted a qualitative study in November 2020 in Côte d'Ivoire to explore people's experience with and perceptions of the COVID-19 pandemic. We conducted 24 focus group discussions and 29 in-depth interviews with members of the general population and health providers. This analysis explores barriers and facilitators to seven recommended prevention behaviors with a particular focus on response efficacy, self-efficacy, and social norms. We found these constructs to be salient for participants who generally felt that the behaviors were useful for preventing COVID-19 but were difficult to practice for a variety of reasons. The perception that COVID-19 prevention behaviors were anti-social emerged as a key theme. Behavior change interventions must reframe the recommended behaviors as pro-social, while making them very easy to practice by removing social and structural barriers such as the expense or inaccessibility of masks and hand sanitizer.

Real-Time Tracking of COVID-19 Rumors Using Community-Based Methods in Côte d'Ivoire.

Global misinformation and information overload have characterized the coronavirus disease (COVID-19) pandemic. Rumors are unverified pieces of information spreading online or person-to-person that reduce trust in health authorities and create barriers to protective practices. Risk communication and community engagement can increase transparency, build trust, and stop the spread of rumors. Building on previous work on Ebola and Zika viruses using Global Health Security Agenda systems strengthening support, the U.S. Agency for International Development-funded Breakthrough ACTION project developed a process and technology for systematically collecting, analyzing, and addressing COVID-19 rumors in real-time in Côte d'Ivoire. Rumors were submitted through community-based contributors and collected from callers to the national hotlines and then processed on a cloud-hosted database built on the open-source software District Health Information System 2 (DHIS2). Hotline teleoperators and data managers coded rumors in near-real-time according to behavioral theory frameworks within DHIS2 and visualized the findings on custom dashboards. The analysis and response were done in full collaboration with the Government of Côte d'Ivoire and implementing partners to ensure a timely and coordinated response. The system captured both widespread rumors consistent with misinformation in other settings, such as suspicions about case counts and the belief that masks were deliberately contaminated, as well as very localized beliefs related to specific influencers. The qualitative findings provided rapid insights on circulating beliefs, enabling risk communicators to nuance and tailor messaging around COVID-19.

Addressing Uptake of HIV Testing and Linkage to Care Among Men in Côte d'Ivoire: An Evaluation of the Brothers for Life Program Implementation.

BACKGROUND: Historically, men in sub-Saharan Africa have worse outcomes along the HIV care continuum than women. Brothers for Life (BFL) is a community-based behavior change intervention for men, adapted for Côte d'Ivoire, involving group discussions that address salient gender norms and promote HIV prevention, testing, and linkage to care with support from peer navigators. The goal of this study was to describe the BFL program as implemented in Côte d'Ivoire, evaluate program implementation, and report uptake of HIV testing and treatment among BFL participants. SETTING: Three urban and periurban sites in Côte d'Ivoire. METHODS: The implementation evaluation assessed the fidelity and acceptability of the BFL program and the reach of program completion, testing and peer navigation using qualitative and quantitative approaches. RESULTS: BFL facilitation fidelity and content fidelity were high. Semistructured interviews with BFL participants indicated that men appreciated the format and content and that the BFL program helped some participants overcome their fears and adopt more positive attitudes and behaviors around testing and treatment. Assessments of reach showed that, of the 7187 BFL participants, 81% tested for HIV as part of BFL and 2.3% (135) tested HIV-positive. Of those, 76% (102) accepted peer navigator support, and 97% (131) initiated treatment. After 6 months, 100% of the 131 men who initiated treatment remained in care. CONCLUSION: The implementation of BFL in Côte d'Ivoire successfully achieved the goals of engaging participants in discussions around HIV prevention, encouraging HIV testing, and achieving linkage to care, treatment initiation, and retention.

Men's perceptions of HIV care engagement at the facility- and provider-levels: Experiences in Cote d'Ivoire.

Men in sub-Saharan Africa have lower rates of HIV testing and are less likely to initiate treatment compared to women. Service delivery dimensions are a key factor in facilitating engagement along the HIV treatment continuum for men and women, yet male specific overall perceptions of the service delivery environment have received little attention in West Africa. This study draws on qualitative data collected in Côte d'Ivoire to explore provider-level and structural factors affecting men's engagement in HIV testing and treatment through interviews and focus group discussions conducted with health workers and men living with HIV (some on ART) or whose HIV status was unknown. Factors influencing decisions to test or initiate treatment were considered in terms of perceived benefits and costs. Men described costs at the interpersonal (client-provider) level, such as unwanted disclosure or stigma, which were weighed against the potential for social support and clinical guidance. Likewise, fear of unwanted disclosure operated at the facility level, as the layout of facilities sometimes grouped clients living with HIV together. Notably, the benefits men described from engaging in HIV testing and care all operated at the interpersonal level and none at the facility level. In light of the fact that provider- and facility-level factors influenced the perceptions and experiences of men along the treatment continuum, we offer recommendations to reduce barriers to testing and engagement in care related to service delivery.

Bringing fear into focus: The intersections of HIV and masculine gender norms in Côte d'Ivoire.

This qualitative research study explored the role of masculinity in men's engagement in the HIV care continuum in Côte d'Ivoire. The researchers conducted 73 in-depth interviews and 28 focus group discussions with 227 Ivoirian men between November and December 2016 across three urban sites. Participants in the study expressed that fear was the primary barrier to HIV testing and treatment. These men described five value domains-health, sexuality, work and financial success, family, and social status. Men saw HIV as a direct threat to their agency and strength with respect to each of these value domains, thus shedding light on their reluctance to discover their HIV status through HIV testing. With this data, the researchers created the Masculine Values Framework, a descriptive framework of masculine values that can be applied to better understand the behavior men exhibit in Côte d'Ivoire in the face of HIV. The Masculine Values Framework offers practical guidance for developing gender-sensitive HIV-focused social and behavior change programming in Côte d'Ivoire and similar contexts to reach the UNAIDS 90-90-90 targets.