CURRENT DEVELOPMENTS IN NUTRITIONO R IG I N AL RESEARCH Implementation Science Development and Testing of Responsive Feeding Counseling Cards to Strengthen the UNICEF Infant and Young Child Feeding Counseling Package Amber J Hromi-Fiedler,1 Grace J Carroll,1 Madelynn R Tice,1 Adam Sandow,2 Richmond Aryeetey,3 and Rafael Pérez-Escamilla1 1Yale School of Public Health, New Haven, CT, USA; 2Point Hope, Inc., Kasoa, Ghana; and 3University of Ghana School of Public Health, Legon, Accra, Ghana ABSTRACT Background: The UNICEF Community-based Infant and Young Child Feeding Counseling Package (C-IYCFCP) currently has limited responsive feeding (RF) content, thus limiting dissemination of RF messages within infant and young child feeding (IYCF) counseling. Objectives: This project 1) developed counseling cards based on existing evidence-based RF guidelines and 2) tested their feasibility in Ghana. Methods: Five RF counseling cards were developed focusing on eating with family; introducing new foods; hunger/satiety cues; food texture; and calming a child. Four focus group discussions (FGDs) were conducted with adult mothers and fathers of children younger than 3 y of age to assess the cultural appropriateness of the cards and accompanying key messages. The feasibility of including cards as part of IYCF counseling was tested via 1) systematic observation of 8 group education sessions utilizing the cards with the same target audience and 2) in-depth interviews with health care providers involved in IYCF training and/or counseling. Results: FGD findings guided changes to all cards to ensure comprehension and cultural appropriateness. The group education sessions suggested that the counseling cards provided important RF messages that are specific, clear, and feasible to implement. Health care providers strongly endorsed the need for and utility of the RF counseling cards and felt they were feasible and important to integrate into the C-IYCFCP currently being used to deliver IYCF training and counseling in Ghana. Conclusions: The counseling cards have a strong potential to add key RF dimensions to IYCF training and counseling in Ghana. Curr Dev Nutr 2020;4:nzaa117. Keywords: infant feeding, counseling, Ghana, child, responsive feeding, card, cues Copyright C© The Author(s) on behalf of the American Society for Nutrition 2020. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Manuscript received April 30, 2020. Initial review completed June 25, 2020. Revision accepted July 6, 2020. Published online July 15, 2020. This article was presented at Nutrition 2019, Baltimore, MD, 8–11 June 2019. Supported by the Hecht-Albert Leadership Award through the Global Health Leadership Institute, Yale University, New Haven, CT, USA (to AJH-F). Author disclosures: The authors report no conflicts of interest. RP-E is an Editor for Current Developments in Nutrition (CDN) and played no role in the Journal’s evaluation of the manuscript. No other authors are CDN Editorial Board members. Supplemental Materials 1–3 are available from the “Supplementary data” link in the online posting of the article and from the same link in the online table of contents at https://academic.oup.com/cdn/. The data underlying this article will be shared on reasonable request to the corresponding author. Address correspondence to AJH-F (e-mail: amber.hromi-fiedler@yale.edu). Abbreviations used: C-IYCFCP, community-based Infant and Young Child Feeding Counseling Package; FGD, focus group discussion; IYCF, infant and young child feeding; NutriDash, Nutrition Dashboard; PI, Principal Investigator; RF, responsive feeding; SPRING, Strengthening Partnerships, Results, and Innovations in Nutrition Globally. Introduction The first 1000 d of life is a highly sensitive period for early child- hood development. An infant’s early-life environment affects her im- mediate and long-term cognitive, physical, and emotional develop- ment, leading to lifelong deficits in the absence of nurturing care (1). Responsive feeding (RF), defined as “feeding practices that encour- age the child to eat autonomously and in response to physiological and developmental needs, which may encourage self-regulation in eating and support cognitive, emotional, and social development” (2), is an as- pect of responsive parenting that contributes to a nurturing and caring environment for children (3). RF guides caregivers on how to feed their young children, which complements existing global guidance on what to feed young children (2, 3). Caregivers who practice RF identify and respond to their infants’ and young children’s hunger and satiety cues in a nurturing manner, fostering healthy eating habits and reducing exces- sive weight gain risk (4). The nurturing environment created by RF has immense potential for optimal child growth and development outcomes (5, 6), especially where poverty and malnutrition in all its forms (includ- ing stunting, overweight/obesity, and micronutrient deficiencies) coex- ist (7). 1 D ow nloaded from https://academ ic.oup.com /cdn/article/4/9/nzaa117/5871815 by guest on 26 August 2020 https://orcid.org/0000-0003-4603-2836 https://orcid.org/0000-0002-1019-3892 https://orcid.org/0000-0003-4667-592X https://orcid.org/0000-0001-9416-8039 http://creativecommons.org/licenses/by-nc/4.0/ mailto:journals.permissions@oup.com https://academic.oup.com/cdn/ mailto:amber.hromi-fiedler@yale.edu 2 Hromi-Fiedler et al. Use of current global infant nutrition counseling materials, such as the UNICEF generic community-based Infant and Young Child Feed- ing Counseling Package (C-IYCFCP), has led to improvements in infant feeding practices (8) and subsequently better infant and young child growth and development outcomes, which are crucial for long-term well-being (1). Given that nurturing care can help prevent or mitigate the negative cognitive and physical effects of malnutrition and poverty in early life (9, 10), it can be argued that incorporating early childhood RF education into existing maternal–child nutrition services can em- power caregivers to use their limited resources better to positively in- fluence infant and young child feeding (IYCF) practices. Thus, integrat- ing early childhood RF counseling tools within existing IYCF provider training and parent education is a critical step toward providing com- prehensive IYCF training and counseling. Unfortunately, global infant nutrition counseling materials, includ- ing UNICEF’s C-IYCFCP, lack specific RF counseling guidelines and curriculum for provider training. With the development of the first evidence-informed RF guidelines in 2017 in the United States (4), there is tremendous potential to integrate RF into current global infant nutri- tion education materials using established key messages. The RF guide- lines take a comprehensive, multipronged approach to strengthen re- sponsive IYCF practices by empowering caregivers to respond to hunger and satiety cues with healthy food/beverage options in a nurturing man- ner and addressing behaviors that influence hunger and satiety, includ- ing physical activity, sleep, television use, and meal times (4). Given that UNICEF’s C-IYCFCP has been used by >80 countries since 2010 [UNICEF 2019 Nutrition Dashboard (NutriDash)], there is a tremen- dous benefit to testing the feasibility of including RF as a component to strengthen nurturing care practices associated with IYCF. The 4 primary study aims were to 1) develop RF counseling cards that complement UNICEF’s generic C-IYCFCP; 2) assess provider and caregiver perceptions of the utility of the cards; 3) test caregivers’ ability to practice RF messages; and 4) assess the feasibility of integrating the RF cards into the existing IYCF training and counseling delivery system in Ghana. Methods Study setting Ghana served as an ideal site given its national use of UNICEF’s generic C-IYCFCP, relatively high country rates of acute and chronic malnutri- tion among children <5 y of age (per 2014 data) (11), and existence of nonresponsive RF practices (12) which contribute to suboptimal child growth (13). Given that there is a need for RF education and skills among Ghanaian caregivers of young children (14), this study focused on 2 Central Region districts (Awutu Senya and Gomoa East), where in- fant growth and IYCF feeding indicators reflect national estimates (Sup- plemental Material 1) (11). Study design Five cards were developed and tested in 4 phases implemented from March to August 2018. Human subjects research ethics approvals were obtained from the Ghana Health Service and Yale University. Regional and district-level officials, plus community leaders, provided permis- sion to engage the targeted communities. Phase 1. Initial development of RF counseling cards. During this phase, 2 staff from the Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) project (SPRING was a USAID-funded implementing agency providing technical support to scale up nutrition practices and policies globally), who were evaluating the UNICEF C-IYCFCP in Nigeria, were consulted (15). Based on their feedback, 5 RF topics were identified as high priority: eating with fam- ily, hunger and satiety, introducing new foods, appropriate food texture, and soothing. Key messages for the 5 topics were extracted from the only set of comprehensive RF guidelines (4) and adapted to the local Ghanaian context (Supplemental Material 2). Messages were translated into the local dialect, Twi, then back-translated into English. Five cards were developed between March and May 2018 by a public health professional with graphic design experience (GJC). To ensure the style of images was consistent with UNICEF’s generic C-IYCFCP (16), the SPRING/UNICEF IYCF Digital Image Bank was used, which con- tains high-quality digital images that can be adapted for use in printable materials (17). The layout and design of the cards were done in Adobe InDesign and images from the UNICEF IYCF Digital Image Bank were modified using Adobe Photoshop. If specific images needed to convey key RF messages were unavailable in the UNICEF IYCF Digital Image Bank, a Photo-to-Illustration technique was used to develop new images (17). Phase 2. Revision of RF counseling cards. After the development of the counseling cards, a total of 4 focus group discussions (FGDs) (n = 27) were conducted to assess the cultural ap- propriateness of the cards and revise the cards as needed. First, 2 FGDs were held in a peri-urban town in the Gomoa East District with mothers (n = 7) and fathers (n = 6) separately so each group would feel comfort- able speaking freely among their peers. Mothers and fathers were eligi- ble if they were aged 18 y and older, with a child younger than 36 mo of age, and were involved with feeding the child. Eligible participants were identified by health care providers from the local Community Welfare Clinic as well as through door-to-door recruitment. Each FGD was held in Twi by a trained moderator (a nutrition of- ficer with years of delivering IYCF education). The cards developed in phase 1 were presented in each FGD 1 at a time. The moderator fol- lowed a FGD guide that had been developed by the Principal Investiga- tor (PI) to assist him with how to present the images within each card and what questions to ask related to each of the images. The process fol- lowed was that the first card, Enjoy Eating with Family, was presented with 1 image revealed. Participants described the image and what they thought it meant. The image was covered up and the next image ex- posed with the same discussion. Once all images on the card had been discussed individually, the full card was displayed and participants de- scribed what they thought it taught. The card messages were then ex- plained and participants recommended design changes. After the fifth card, participants were asked what information was new and if the cards would help caregivers. The FGDs lasted ∼1.5 h. Participants received soap (equivalent $2) for participating. The moderator, the notetaker, the project coordinator, and the study PI (AJH-F) debriefed together immediately after each FGD to identify recommended card revisions. Then, the cards were revised based on recommendations from both FGDs. CURRENT DEVELOPMENTS IN NUTRITION D ow nloaded from https://academ ic.oup.com /cdn/article/4/9/nzaa117/5871815 by guest on 26 August 2020 Development of responsive feeding counseling cards 3 After the card revisions, 2 more FGDs [i.e., mothers (n = 10) and fathers (n = 4), separately] were held in a rural village in Gomoa East District with the same target population using the same FGD methodology to ensure the cards were culturally appro- priate across both rural and peri-urban populations. These FGDs lasted ∼2 h. Participants also received soap (equivalent $2) for participating. After these 2 FGDs, the cards were revised again. The revised cards and key messages were submitted in early July to the Ghana Food and Drugs Authority for approval before conducting the group education sessions. Phase 3. Group education sessions. Eight sessions were conducted from July to August 2018 to assess par- ents’ perceptions of the utility of the RF cards and test their ability to practice RF messages. Mothers and fathers fitting the same inclusion criteria as in the FGDs were identified by health care providers from the local Community Welfare Clinic as well as through door-to-door re- cruitment. Separate group sessions were held with mothers and fathers living in 2 peri-urban towns and 2 rural villages within the Gomoa East and Awutu Senya districts to ensure the cards and messages were tested across both rural and peri-urban populations. A total of 4 group educa- tion sessions with mothers (n = 20) and 4 sessions with fathers (n = 18) were conducted. The same FGD moderator conducted the group sessions in Twi. Be- fore the sessions, a detailed training protocol was developed and ∼10 h of moderator training were conducted to standardize message delivery across the sessions. At each group session, the RF counseling cards and messages were taught. The moderator began each session by showing the first RF card and asking participants to explain that card’s mean- ing. The moderator then taught the RF messages for the first card and discussed them with participants to ensure the card and mes- sages were understood. Participants were then asked to share what they had learned from that card, what was new, who had taught them the information they already knew, and if the messages would be easy for caregivers to practice. This process was repeated for all 5 cards. The moderator, notetaker, and project coordinator debriefed to- gether after each group education session to discuss participants’ re- sponses. Phase 4. In-depth interviews. In-depth interviews were conducted during the same time period in En- glish with 14 health care providers who delivered IYCF training to other providers and/or delivered IYCF counseling to caregivers of infants and young children. The aims and methodology have been described in de- tail elsewhere (14), but the feasibility of the cards and their integration into IYCF training and education are described here. Briefly, providers were shown each of the 5 cards and corresponding key messages. For each card, providers described the RF messages already taught, as well as the acceptability, importance, and ease of practice for caregivers. Lastly, providers shared thoughts on integrating the cards and mes- sages into the current Ghana IYCF training and education delivery system. All FGDs, group education sessions, and in-depth interviews were audio-recorded. Analyses FGDs. The moderator audio translated audio recordings into English which were then transcribed. Transcriptions were checked for accuracy (AJH- F). Each transcript was independently read (AJH-F, GJC, RP-E), then meetings were held to reach consensus on participants’ level of under- standing of each card plus additional card changes. Level of understand- ing was assessed as follows: 1) participants understood the card well and participants did not suggest modifications to understand it better; 2) participants understood the card well but participants suggested minor modifications to increase the understanding; 3) participants understood the card slightly and suggested major modifications to increase under- standing; and 4) participants did not understand what the images on the card were explaining and full revisions to the card were required to maximize understanding. Group education sessions. The moderator audio translated audio recordings into English transla- tions, which were thoroughly reviewed (AJH-F) and responses recorded to document if participants 1) could describe key card messages; 2) learned something new and, if so, what; 3) felt messages would be easy for caregivers to practice and, if so, what would be easy. In-depth interviews. Audio recordings were transcribed and transcriptions checked for ac- curacy (MRT). Half the transcripts were independently read and coded (AJH-F, MRT, RP-E) and saturation was reached. Meetings were held to reach consensus on domains, themes, and subthemes for a final code- book, which was applied to the data of the remaining 7 transcripts per- taining to the feasibility of the RF counseling cards and messages. Results Development and revision of the RF counseling cards FGD participant characteristics. The mean age of peri-urban and rural FGD mothers was similar (30.7 and 29.5 y, respectively), as was the mean age of peri-urban FGD fathers (32.8 y). Rural FGD fathers were older (mean: 38.2 y). Eighty percent of rural FGD mothers had only a primary education or less, whereas other FGD mothers and fathers had higher levels of education. Across all 4 FGDs, most participants were employed and married (Table 1). FGD findings. Analysis of the qualitative data by our team indicated that participants understood 4 of the 5 cards well. Only minor revisions were needed to improve their understanding of these 4 RF cards and ensure the cards were 1) compatible with the key messages from the 2017 RF guidelines and 2) culturally appropriate (Table 2). However, the images depicting the introduction of new food were not well understood as being illus- trative of that topic. Extensive revisions were recommended to this card within all FGDs and major revisions were made to ensure it described and relayed the key messages well. CURRENT DEVELOPMENTS IN NUTRITION D ow nloaded from https://academ ic.oup.com /cdn/article/4/9/nzaa117/5871815 by guest on 26 August 2020 4 Hromi-Fiedler et al. TABLE 1 Characteristics of Ghanaian mothers and fathers with young children in Central Region, Ghana participating in focus group discussions (phase 1)1 Peri-urban Rural FGD1 FGD2 FGD3 FGD4 Mothers (n = 7) Fathers (n = 6) Mothers (n = 10) Fathers (n = 4) Age, y 30.7 ± 5.5 32.8 ± 8.6 29.5 ± 5.8 38.2 ± 12.8 Children, n 3.0 ± 0.8 2.5 ± 1.0 3.2 ± 1.1 4.2 ± 1.5 Employed 71 100 70 100 Highest education None/primary 14.3 16.7 80.0 0 Junior high school 71.4 33.3 20.0 100 Senior high school 14.3 50.0 0 0 Married 85.7 83.3 80.0 100 1n = 27. Values are means ± SDs or percentages. FGD, focus group discussion. Table 3 describes the iterative development process taken to reach the final set of cards. FGD feedback and analysis led to multiple revisions across all counseling cards, with major revisions across 2 cards: Enjoy Eating with Family and Introducing New Foods. The card Enjoy Eating with Family was revised to include the father across all 3 images and 2 final cards were created to reflect diverse eating characteristics within Ghana, particularly eating on the ground (reflecting Northern Ghana) and eating at a table (reflecting the Central Region). Introducing New Foods card changes were dramatic after the first 2 focus groups, whereby the number of images was reduced to 3, musical notes were introduced to reflect singing, and a variety of foods were included. Revisions were also made to the card titles. “Satiety” was not deemed a commonly used word and was replaced with “satisfaction.” Similarly, “soothing” was not easily translatable to Twi and was replaced with “calming the baby.” Key messages were simplified to ensure they would be easily translatable to Twi. Testing Group education sessions. Adult participants were on average 33 y old with 3.5 children on aver- age. The median age of their youngest child was 18.0 mo (range: 0–36 mo). All participants were employed and most (94.6%) had a senior high TABLE 2 Level of understanding of the responsive feeding counseling card images across all 4 focus group discussions in Ghana’s Central Region1 Level of understanding of card images Card FGD2 Understood very well; no modifications Understood well; required minor modifications Understood slightly; required major modifications Limited understanding; required full consideration Enjoy Eating with Family 1 X 2 X 3 X 4 X Hunger and Satisfaction Cues3 1 X 2 X 3 X 4 X Introducing New Foods 1 X 2 X 3 X 4 X Texture 1 X 2 X 3 X 4 X Calming Your Baby4 1 X 2 X 3 X 4 X 1FGD, focus group discussion. 2FGDs 1 and 2 were conducted among mothers and fathers, respectively, in a peri-urban area, whereas FGDs 3 and 4 were conducted among mothers and fathers, respectively, in a rural area. 3Title was originally “Hunger and Satiety Cues” but was changed based on FGD feedback. 4Title was originally “Soothing” but was changed based on FGD feedback. CURRENT DEVELOPMENTS IN NUTRITION D ow nloaded from https://academ ic.oup.com /cdn/article/4/9/nzaa117/5871815 by guest on 26 August 2020 Development of responsive feeding counseling cards 5 TA B LE 3 D ev el o p m en t o f fin al ,c ul tu ra lly ap p ro p ri at e re sp o ns iv e fe ed in g ca rd s in G ha na 1 O ri g in al ca rd R ev is ed ca rd Fi na lc ar d 2 R ec o m m en d ed re vi si o ns fo r o ri g in al ca rd 3 Fi rs t re vi si o ns R ec o m m en d ed re vi si o ns to re vi se d ca rd 4 Fi na lr ev is io ns C ar d 1: En jo y Ea tin g w ith Fa m ily FG D 1: O ld er so n (Im ag e 2) w as th ou g ht to b e th e fa th er . Im ag e 2: Fa th er re p la ce d th e b oy fe ed in g th e ch ild . FG D 3: C hi ld w as to o yo un g an d sh ou ld b e on th e la p of th e m ot he r or fa th er . Fo od sh ou ld no t b e on th e flo or . Im ag e 2: C hi ld w as p la ce d on m ot he r’s la p of ft he flo or . C hi ld ’s b ow lm ov ed fr om flo or to m ot he r’s ha nd . FG D 2: Re m ov e b ow li n fr on t of fa th er (Im ag e 3) . Pr ov id e a “f ee d in g b ot tle w ith w at er .” Im ag e 3: Fa th er ’s b ow lr ep la ce d w ith a ch ild ’s cu p of w at er in fin al ca rd . A na ly se s: C hi ld ’s b ow li n Im ag e 2 w as b el ie ve d to ha ve w at er . C hi ld b el ie ve d to b e 3 m o ra th er th an 6 m o in Im ag e 2. D et er m in ed ch ild ’s g la ss w as m or e ap p ro p ria te th an ad ul t g la ss (Im ag e 3) . Im ag e 3: Re p la ce d ad ul t’s g la ss w ith ch ild ’s g la ss of w at er . C ha ng e no t m ad e: N o fr ui t ad d ed b ec au se d ee m ed ch al le ng in g to id en tif y va rie tie s in b ow l. Se co nd ca rd : A se co nd ca rd w as m ad e to in cl ud e ea tin g fr om a ta b le . C ar d 2: H un g er an d Sa tis fa ct io n C ue s FG D 1: N o ch an g es w er e re co m m en d ed . Ti tle : “S at ie ty ” w as ch an g ed to “S at is fa ct io n” b ec au se m od er at or an d st af fa t FG D s d ee m ed “s at ie ty ” w as no t un d er st oo d w el l. FG D 3: Fe lt m ot he r w as fo rc in g ch ild to ea t (Im ag e se t 2) . Im ag e se t 1: Re d uc ed th e si ze of th e in fa nt to re fle ct ag e of < 6 m o. Re d uc ed m ot he r’s b re as t si ze to sh ow th e ch ild ha s ea te n. M od ifi ed p os iti on of in fa nt to m ak e p os iti on in g an d la tc h ac cu ra te . FG D 2: A d d a b ib to ne ck of th e in fa nt /c hi ld to ke ep th em cl ea n. M ot he r in th e la st 2 im ag es w as fe ed in g th e ch ild w ith he r ha nd s, w hi ch th ey fe lt m ig ht no t b e cl ea n. Im ag e se t 2: Ro un d ed ch ild ’s ch ee ks so he d id no t lo ok si ck . FG D 4: Fe lt m ot he r w as fo rc in g ch ild to ea t (Im ag e se t 2) . C ha ng es no t m ad e: B ib no t ad d ed b ec au se no t co m m on in G ha na . A na ly si s: D is cu ss io n in b ot h g ro up s th at m ot he r’s b re as t in Im ag e se t 1 w as st ill fu ll ev en th ou g h w e ex p la in ed ch ild ha d al re ad y ea te n. Po si tio ni ng an d la tc h of th e fir st im ag e in Im ag e se t 1 w er e no te d to b e in ac cu ra te . (C on tin ue d ) CURRENT DEVELOPMENTS IN NUTRITION D ow nloaded from https://academ ic.oup.com /cdn/article/4/9/nzaa117/5871815 by guest on 26 August 2020 6 Hromi-Fiedler et al. TA B LE 3 (C on tin ue d ) O ri g in al ca rd R ev is ed ca rd Fi na lc ar d 2 R ec o m m en d ed re vi si o ns fo r o ri g in al ca rd 3 Fi rs t re vi si o ns R ec o m m en d ed re vi si o ns to re vi se d ca rd 4 Fi na lr ev is io ns C ar d 3: In tr od uc in g N ew Fo od s FG D 1: A d d sp ec ifi c tim es to m at ch th e su n im ag es . A d d sp ec ifi c fo od s to re fle ct d iff er en t tim es of d ay . N ot su re w ha t fo od w as g iv en . Re m ov ed su n im ag es . Te n im ag es w er e re d uc ed to 3. A lte re d fo od co lo r in b ow l to m ak e it cl ea r it is 1 fo od . A d d ed va rie ty of fo od s to sh ow fo od d iv er si ty . FG D 3: C hi ld ’s ha nd s an d le g s sh ou ld b e st ra ig ht en ed to av oi d ch ild lo ok in g d is ab le d . C hi ld sh ou ld b e he ld cl os er to th e m om w ith th e fa ce to w ar d it to sh ow nu rt ur in g . C hi ld ’s ha nd w as st ra ig ht en ed . Re d an d ye llo w ci rc le s ou ts id e im ag es w er e ch an g ed to sh ad es of g re en (to av oi d tr af fic lig ht as so ci at io n) . FG D 2: Re d uc e im ag es to 4 to sh ow p ro g re ss io n fr om b re as tf ee d in g to co m p le m en ta ry fe ed in g . In cl ud e im ag es of te xt ur e. FG D 4: N o ch an g es w er e re co m m en d ed . A na ly se s: Re d ,o ra ng e, an d g re en co lo rs w er e un d er st oo d as re fle ct in g st op ,s lo w , an d g o w ith ou t re la tin g it to th e ch ild ’s b eh av io r (re fu si ng ,s lo w ly ac ce p tin g ,a cc ep tin g fo od ). C ar d 4: Te xt ur e FG D 1: N o ch an g es w er e re co m m en d ed . A d d ed an as an ka to sh ow a cu ltu ra lly ap p ro p ria te to ol us ed to b le nd . FG D 3: Im ag e of th e b le nd in g to ol w e ad d ed w as id en tifi ed as a m or ta r an d p es tle ,n ot an as an ka . B le nd in g to ol im ag e ch an g ed to an as an ka . FG D 2: Pu t an as an ka an d a b le nd er on th e ca rd to sh ow to ol s us ed to b le nd fo od s to g et th e rig ht te xt ur e fo r th e ch ild re n. C ha ng es no t m ad e: A b le nd er w as no t ad d ed b ec au se it m ay no t b e ac ce ss ib le to m an y. FG D 4: N o ch an g es w er e re co m m en d ed . C ar d 5: C al m in g yo ur b ab y FG D 1: A d d ar ro w s lin ki ng to so ot hi ng st ra te g y. A d d im ag e of m ot he r ig no rin g ch ild w ith sa g g y d ia p er . Im ag e 1: D re w ar ro w lin ki ng ch ild cr yi ng to so ot hi ng st ra te g ie s. Li g ht en ed ch ild ’s fa ce an d ad d ed m or e te ar s. FG D 3: Im ag e 2: Th ou g ht b lo ck in fa th er ’s ha nd w as fo od , no t a to y. Pa rt ic ip an ts ha d d iffi cu lty se ei ng th at th e m ot he r w as p oi nt in g at th e ch ild . Ti tle :“ So ot hi ng ” w as ch an g ed to C al m in g Yo ur B ab y. (C on tin ue d ) CURRENT DEVELOPMENTS IN NUTRITION D ow nloaded from https://academ ic.oup.com /cdn/article/4/9/nzaa117/5871815 by guest on 26 August 2020 Development of responsive feeding counseling cards 7 TA B LE 3 (C on tin ue d ) O ri g in al ca rd R ev is ed ca rd Fi na lc ar d 2 R ec o m m en d ed re vi si o ns fo r o ri g in al ca rd 3 Fi rs t re vi si o ns R ec o m m en d ed re vi si o ns to re vi se d ca rd 4 Fi na lr ev is io ns Im ag e 3: C ha ng e ca nd ie s/ so d a b ot tle . Im ag e 4: C hi ld ad d ed in fr on t of m ot he r an d ha nd ra is ed hi g he r to in d ic at e ye lli ng . A na ly si s: “S oo th in g ” is n’ t us ed m uc h b y G ha na ia ns ; ho w ev er ,t he y re co g ni ze “c al m in g ” b et te r. Im ag e 2: C ha ng ed co lo r of b lo ck in fa th er ’s ha nd to lo ok le ss lik e fo od . FG D 2: A d d ch ild w ith m ot he r p oi nt in g fin g er at ch ild . C ha ng e ca nd ie s/ so d a b ot tle to re p re se nt th os e in G ha na . Im ag e 5: Li g ht en ed ch ild ’s fa ce an d ad d ed m or e te ar s. C ha ng es no t m ad e: Im ag e of m ot he r ig no rin g ch ild w ith w et d ia p er w as d ee m ed d iffi cu lt to p or tr ay an d fe lt im ag e of th e m ot he r ch an g in g th e ch ild ’s d ia p er su p p or te d th e p ra ct ic e of at te nd in g to th e ch ild w he n th e d ia p er w as w et . 1 FG D ,f oc us g ro up d is cu ss io n. N um b er s in ca rd s re fle ct im ag es to en ab le th e as so ci at io n of ch an g es w ith p ar tic ul ar im ag es . 2 Pe r th e U N IC EF /S PR IN G Im ag e b an k w eb si te (iy cf .s p rin g -n ut rit io n. or g ), “U SA ID /S PR IN G , th e U ni te d N at io ns C hi ld re n’ s Fu nd (U N IC EF ) an d U ni ve rs ity Re se ar ch C o. , LL C -C en te r fo r H um an Se rv ic es (U RC -C H S) co nt rib ut ed a si g ni fic an t nu m b er of ill us tr at io ns to th e Im ag e B an k, an d co nt in ue to ow n an d re ta in th e co p yr ig ht s to th es e im ag es .A ll im ag es fo un d in th e Im ag e B an k cr ed it th e sp ec ifi c or g an iz at io n re sp on si b le fo r d ev el op in g th e im ag e. ” Ya le U ni ve rs ity ,U ni ve rs ity of G ha na ,a nd Po in t H op e Ya le ac ce ss ed ,m od ifi ed ,a nd us ed im ag es fr om th e U SA ID /S PR IN G -U N IC EF IY C F Im ag e B an k (iy cf .s p rin g -n ut rit io n. or g )a s p ar t of th is re se ar ch .C om m er ci al us e, re d is tr ib ut io n, or se lli ng of th es e im ag es an d m at er ia ls is p ro hi b ite d . 3 C ar d s sh ow n to p er i-u rb an FG D s 1 an d 2. 4 C ar d s sh ow n to ru ra lF G D s 3 an d 4. school education or less. Over 80% of participants were married (data not shown). All participants could accurately describe ≥1 key messages relayed during the sessions (Table 4). For the first card, Enjoy Eating with Fam- ily, participants in 4 sessions reported learning new information. Moth- ers reported learning what they already knew about this topic primar- ily from their mothers, whereas fathers mostly expressed learning from both their parents. Within all sessions, participants felt practicing the messages would be easy for caregivers. However, they acknowledged that fathers may work late or may not be around the home a lot, mak- ing it difficult for the entire family to eat all together. One group of peri-urban fathers expressed that it may be difficult to eat as a fam- ily owing to financial hardships where the father needs to continually work. For the second card, Hunger and Satisfaction Cues, participants in 4 sessions reported learning new information. Mothers, parents, and ob- serving their own children had taught them what they knew about this topic. Within most sessions, participants felt messages would be easy for caregivers to practice. Peri-urban fathers felt messages would be difficult for those who haven’t been taught how to observe hunger and satiety cues, especially first-time mothers. For the Introducing New Foods card, participants in 5 sessions re- ported learning new information. Parents were the primary source of information already known about this topic. Participants across most sessions felt messages could be easily practiced by care- givers. Within 1 peri-urban maternal FGD session, participants felt some mothers may not have time to cook or calm a child to eat. One group of peri-urban fathers expressed the difficulty of in- troducing new foods if there was not money to purchase diverse foods. Almost all participants (7 of 8 sessions) learned new informa- tion from the Texture card: primarily that foods, especially meats, can be mashed into soft textures using tools like an asanka (i.e., a Ghanaian clay grinding pot with a pestle) or blender. Mothers, par- ents, and health care providers had taught them what they already knew. Most participants felt the messages would be easy for caregivers to practice, with both groups of peri-urban fathers expressing con- cern that it may be difficult if there was not money to purchase the tools. For the fifth card, Calming Your Baby, participants within 5 sessions reported learning new information, especially not to feed sweets to chil- dren to calm them as well as not to shout or hit crying children. What they already knew came primarily from their mothers or both parents. Almost all participants felt the messages would be easy for caregivers to practice. Some acknowledged that it is cultural to yell at and hit chil- dren so it may be a specific mindset that may be hard to change. Peri- urban fathers also shared that financial hardship may increase frustra- tion, leading to hitting young children. In-depth interviews. Participant characteristics have been described elsewhere (14). Health care providers reported teaching most key messages primarily during 1- on-1 counseling as needed rather than group education sessions. How- ever, messages were not relayed consistently to caregivers because 1) messages were only relayed to those who exhibited problems and re- quired individual counseling and 2) of a lack of RF training and not CURRENT DEVELOPMENTS IN NUTRITION D ow nloaded from https://academ ic.oup.com /cdn/article/4/9/nzaa117/5871815 by guest on 26 August 2020 https://iycf.spring-nutrition.org/ https://iycf.spring-nutrition.org/ 8 Hromi-Fiedler et al. TA B LE 4 P ar en t fe ed b ac k fr o m g ro up ed uc at io n se ss io ns (E S) o n p er ce p ti o ns o f th e ut ili ty o f th e R F ca rd s an d ab ili ty to p ra ct ic e R F m es sa g es 1 M o th er s Fa th er s R ur al P er i-u rb an R ur al P er i-u rb an Q ue st io ns E S 1 (n = 5) E S 2 (n = 5) E S 3 (n = 5) E S 4 (n = 5) E S 5 (n = 4) E S 6 (n = 5) E S 7 (n = 5) E S 8 (n = 4) C ar d 1: En jo y Ea tin g w ith Fa m ily D id al l p ar tic ip an ts d es cr ib e ke y m es sa g es ? Ye s Ye s Ye s Ye s Ye s Ye s Ye s Ye s D id p ar tic ip an ts le ar n so m et hi ng ne w ? N o Ea t to g et he r ar ou nd 1 b ow l an d in cl ud e yo un g ch ild re n. H av e a ha p p y fa ce b ef or e g iv in g th e ch ild fo od . H av e yo un g ch ild si t on la p an d of fe r th em fo od . H av in g th e ch ild si tt in g an d ea tin g w ith ad ul ts . N o B re as tf ee d in g ch ild sh ou ld b e at th e ta b le . Fa th er sh ou ld b e at ta b le w he n m ot he r b re as tf ee d in g ch ild . G iv e ch ild ow n b ow l, se rv e se p ar at el y. N o M ot he r ho ld in g th e ch ild an d th e fa th er fe ed in g th e ch ild . N o W he re d id p ar tic ip an ts le ar n w ha t th ey kn ew ? M ot he r G ra nd m ot he r M ot he r O b se rv in g ow n ch ild M ot he r Fa th er M ot he r H ea lth ca re p ro vi d er s Pa re nt s H ea lth ca re p ro vi d er s (C W C ) Pa re nt s Pa re nt s O b se rv in g ow n ch ild Pa re nt s Sc rip tu re s Te le vi - si on /m ov ie s Sc ho ol W ill m es sa g es b e ea sy fo r G ha na ia n ca re ta ke rs to p ra ct ic e? Ye s, if th ey ar e ta ug ht . Ye s, b ec au se it is ta ug ht b y th ei r m ot he rs . Ye s, b ec au se it ha p p en s al re ad y. M ay b e ha rd fo r so m e w om en if th e fa th er is no t ar ou nd . Ye s, b ec au se it is al re ad y b ei ng d on e in ho us eh ol d s. O th er s th ou g ht it m ig ht b e d iffi cu lt b ec au se so m e lik e to ea t on th ei r ow n, so m e ar e ve ry b us y, an d so m e fa th er s d on ’t co m e ho m e fr om w or k ea rly en ou g h to ea t to g et he r. Ye s, if th ey ar e ta ug ht . Ye s, if th ey ar e ta ug ht an d th ey ob se rv e ho w it is d on e. Ye s, b ut 1 ex p re ss ed it m ay b e d iffi cu lt if th er e is n’ t m uc h m on ey in th e ho us eh ol d . N o, b ec au se : fa th er s ar en ’t ho m e fo r d in ne r b ec au se of w or k; so m e fa th er s d o no t liv e w ith th ei r ch ild re n. (C on tin ue d ) CURRENT DEVELOPMENTS IN NUTRITION D ow nloaded from https://academ ic.oup.com /cdn/article/4/9/nzaa117/5871815 by guest on 26 August 2020 Development of responsive feeding counseling cards 9 TA B LE 4 (C on tin ue d ) M o th er s Fa th er s R ur al P er i-u rb an R ur al P er i-u rb an Q ue st io ns E S 1 (n = 5) E S 2 (n = 5) E S 3 (n = 5) E S 4 (n = 5) E S 5 (n = 4) E S 6 (n = 5) E S 7 (n = 5) E S 8 (n = 4) C ar d 2: H un g er an d Sa tis fa ct io n C ue s D id al l p ar tic ip an ts d es cr ib e ke y m es sa g es ? Ye s Ye s Ye s Ye s Ye s Ye s Ye s Ye s D id p ar tic ip an ts le ar n so m et hi ng ne w ? A yo un g ,h un g ry ch ild w ill cr y an d ca n th ro w ta nt ru m s, so ne ed p at ie nc e an d tim e to fe ed th em . C hi ld re n w ill g iv e a si g n to le t yo u kn ow th ey ar e hu ng ry . N o N o W he n a ch ild is sa tis fie d th ey b ec om e ha p p y/ sm ili ng . N o D id n’ t kn ow w he n th e ch ild is hu ng ry th ey ca n re q ue st fo od or b re as t m ilk . Ev er y st ag e ha s d iff er en t b eh av io rs to ex p re ss hu ng er . N o W he re d id p ar tic ip an ts le ar n w ha t th ey kn ew ? M ot he r Pa re nt s O b se rv in g ow n ch ild M ot he r Pa re nt s M ot he r O b se rv in g ow n ch ild re n O b se rv in g ow n ch ild re n M ot he r Pa re nt s H ea lth ca re p ro vi d er s O b se rv in g ow n ch ild re n M ot he r Pa re nt s W iv es O b se rv in g ow n ch ild re n M ot he r Pa re nt s O ld er si b lin g s O b se rv in g ow n ch ild re n M ot he r Pa re nt s Fe m al e si b lin g s O b se rv in g ow n ch ild re n H ea lth ca re p ro vi d er s W iv es W ill m es sa g es b e ea sy fo r G ha na ia n ca re ta ke rs to p ra ct ic e? Ye s, ca n b e ta ug ht an d ch ild w ill le t yo u kn ow . Ye s, b ec au se le ar ne d fr om m ot he r al re ad y. Ye s, ch ild ’s ac tio ns w ill te ll yo u s/ he ne ed s. B ut no t ev er yo ne w ill b e ab le to d o it. Ye s, ch ild ’s ac tio ns w ill te ll yo u s/ he ne ed s. Ye s, ca n b e ta ug ht an d ch ild w ill le t yo u kn ow . Ye s, b ec au se le ar ne d fr om m ot he r/ p ar en ts al re ad y. N o, if ha ve n’ t b ee n ta ug ht , su ch as fir st -t im e m ot he rs . N o, if ha ve n’ t b ee n ta ug ht , su ch as fir st -t im e m ot he rs . (C on tin ue d ) CURRENT DEVELOPMENTS IN NUTRITION D ow nloaded from https://academ ic.oup.com /cdn/article/4/9/nzaa117/5871815 by guest on 26 August 2020 10 Hromi-Fiedler et al. TA B LE 4 (C on tin ue d ) M o th er s Fa th er s R ur al P er i-u rb an R ur al P er i-u rb an Q ue st io ns E S 1 (n = 5) E S 2 (n = 5) E S 3 (n = 5) E S 4 (n = 5) E S 5 (n = 4) E S 6 (n = 5) E S 7 (n = 5) E S 8 (n = 4) C ar d 3: In tr od uc in g N ew Fo od s (in cl ud in g m es sa g es on fo od va rie ty ) D id al l p ar tic ip an ts d es cr ib e ke y m es sa g es ? Ye s Ye s Ye s Ye s Ye s Ye s Ye s Ye s D id p ar tic ip an ts le ar n so m et hi ng ne w ? N o C an ex p re ss b re as tm ilk an d m ix w ith ne w fo od . N ot su p p os ed to g iv e yo un g ch ild re n ev ap or at ed m ilk . N o Sh ou ld co nt in ue to tr y to of fe r a ne w fo od . D on ’t b e d is co ur ag ed w he n ch ild d oe sn ’t ea t ne w fo od , co nt in ue to of fe r it. D on ’t of fe r sw ee t d rin ks to a yo un g ch ild . C an ex p re ss b re as t m ilk an d m ix w ith ne w fo od . C er ta in m ilk s sh ou ld n’ t b e of fe re d at ea rly st ag es . Sh ou ld n’ t of fe r to ffe es an d su g ar d rin ks . C an si ng w he n in tr od uc in g ne w fo od to a ch ild . N o C an of fe r yo un g ch ild re n fr ui ts . C an ex p re ss b re as t m ilk an d m ix w ith ne w fo od . Sm ile ,s in g ,a nd ca lm ch ild re n w he n of fe rin g fo od . D on ’t us e su g ar w he n in tr od uc in g ne w fo od s. W he re d id p ar tic ip an ts le ar n w ha t th ey kn ew ? M ot he r Pa re nt s G ra nd p ar en ts M ot he r Pa re nt s H ea lth ca re p ro vi d er s (C W C ) M ot he r Pa re nt s H ea lth ca re p ro vi d er s M ot he r Pa re nt s H ea lth ca re p ro vi d er s (C W C ) Pa re nt s O b se rv e ow n ch ild Pa re nt s O b se rv e ow n ch ild H ea lth ca re p ro vi d er s M ot he r Pa re nt s A nt en at al b oo k Te le vi si on W ill m es sa g es b e ea sy fo r G ha na ia n ca re ta ke rs to p ra ct ic e? Ye s, b ec au se th e m es sa g es ca n b e ta ug ht to th em .S om e m es sa g es ar e ta ug ht at th e ho sp ita la nd in th e an te na ta l b oo k. Ye s, b ec au se th ey ha ve d on e it fo r a lo ng tim e an d so m e m es sa g es ab ou t d ie t va rie ty ar e ta ug ht d ur in g C W C . Ye s, b ec au se ca n le ar n to ca lm th e ch ild . A ls o ha ve to b e su re to ch ec k w he th er th e ch ild is no t ea tin g b ec au se s/ he is si ck . N o, so m e d on ’t ha ve tim e to co ok fo od fo r ch ild an d d on ’t ha ve tim e to ca lm ch ild d ow n to he lp th em ea t. A s w el l, so m e m ay al re ad y ha ve g iv en fo od s th at ar e no t g oo d fo r ch ild an d , b ec au se no th in g w en t w ro ng ,w ill no t ch an g e p ra ct ic e. Ye s, b ec au se th ey ob se rv e ot he r p ar en ts an d le ar n to b e p at ie nt w he n d oi ng it. M es sa g es ca n al so b e ta ug ht to th em . Ye s, b ec au se m es sa g es m ay ha ve al re ad y b ee n ta ug ht b y p ar en ts an d th ey kn ow it. M ay b e d iffi cu lt fo r fir st -t im e p ar en ts . Ye s, b ec au se m es sa g es ca n b e ta ug ht to th em . B ut m ay b e d iffi cu lt fo r w om en w ho w on ’t ha ve tim e, w ho ar en ’t w ill in g , or w ho m ay ha ve a fir st ch ild . Ye s, b ec au se th e m es sa g es ca n b e ta ug ht . B ut m ay b e ha rd fo r th os e w ho ha ve fin an ci al ha rd sh ip s b ec au se th ey ca n’ t se rv e th e ch ild a va rie ty of fo od s. (C on tin ue d ) CURRENT DEVELOPMENTS IN NUTRITION D ow nloaded from https://academ ic.oup.com /cdn/article/4/9/nzaa117/5871815 by guest on 26 August 2020 Development of responsive feeding counseling cards 11 TA B LE 4 (C on tin ue d ) M o th er s Fa th er s R ur al P er i-u rb an R ur al P er i-u rb an Q ue st io ns E S 1 (n = 5) E S 2 (n = 5) E S 3 (n = 5) E S 4 (n = 5) E S 5 (n = 4) E S 6 (n = 5) E S 7 (n = 5) E S 8 (n = 4) C ar d 4: Te xt ur e D id al l p ar tic ip an ts d es cr ib e ke y m es sa g es ? Ye s Ye s Ye s Ye s Ye s Ye s Ye s Ye s D id p ar tic ip an ts le ar n so m et hi ng ne w ? C an m as h ch ic ke n an d p ou nd it in to a p ow d er .A ll in fo rm at io n is ne w (1 p ar tic ip an t). H av e to m as h fo od co m p le te ly fo r yo un g ch ild . U nd er st an d no w ho w to m as h fo od b ef or e g iv in g to ch ild . C an m as h m ea t an d fe ed to a yo un g ch ild (6 –7 m o) . H ow to ch an g e te xt ur e of fo od s as ch ild g ro w s. C an m as h m ea ts an d fr ui ts an d fe ed to a yo un g ch ild (6 –7 m o) . N o H ow to b le nd m ea t fo r a ch ild . A ll in fo rm at io n is ne w (1 p ar tic ip an t). C an us e an as an ka or b le nd er to m as h fo od s. W he re d id p ar tic ip an ts le ar n w ha t th ey kn ew ? M ot he r Pa re nt s H ea lth ca re p ro vi d er (C W C ) Pa re nt s H ea lth ca re p ro vi d er s (C W C ) M ot he r G ra nd m ot he r St ep m ot he r B ro th er Pa re nt s H ea lth ca re p ro vi d er s M ot he r Pa re nt s G ra nd p ar en ts H ea lth ca re p ro vi d er s (C W C , ho sp ita l) Pa re nt s O b se rv e ow n ch ild M ot he r Pa re nt s O b se rv e ow n ch ild M ot he r H ea lth ca re p ro vi d er s Te le vi si on Sc ho ol W ill m es sa g es b e ea sy fo r G ha na ia n ca re ta ke rs to p ra ct ic e? Ye s, b ec au se th e m es sa g es ca n b e ta ug ht to th em . Ye s, b ec au se th e m es sa g es ca n b e ta ug ht to th em an d m as hi ng is ea sy to d o. Ye s, b ec au se th e m es sa g es ca n b e ta ug ht to th em an d m as hi ng is ea sy to d o. Ye s, m as hi ng is ea sy to d o an d w an t to d o it fo r th e ch ild .M ay b e d iffi cu lt if so m eo ne is no t in te r- es te d /c om m itt ed to d oi ng it. Ye s, b ec au se th e m es sa g es ca n b e ta ug ht to th em . Ye s, b ec au se th e m es sa g es ca n b e ta ug ht to th em if th ey ha ve n’ t le ar ne d al re ad y fr om p ar en ts . Ye s, b ec au se b le nd in g is no t d iffi cu lt. B ut so m e m ay no t ha ve th e as an ka or b le nd er to m as h fo od .I f th ey d o, it m ay b e ha rd to w as h al lt he p ep p er ou t fr om th e as an ka to m ak e su re th er e is n’ t ho t p ep p er w he n m as hi ng fo od . N o, if th ey d on ’t ha ve th e m on ey to b uy an as an ka or b le nd er .I f th ey ha ve m on ey fo r an as an ka ,i t w ill b e ea sy to m as h fo od . (C on tin ue d ) CURRENT DEVELOPMENTS IN NUTRITION D ow nloaded from https://academ ic.oup.com /cdn/article/4/9/nzaa117/5871815 by guest on 26 August 2020 12 Hromi-Fiedler et al. TA B LE 4 (C on tin ue d ) M o th er s Fa th er s R ur al P er i-u rb an R ur al P er i-u rb an Q ue st io ns E S 1 (n = 5) E S 2 (n = 5) E S 3 (n = 5) E S 4 (n = 5) E S 5 (n = 4) E S 6 (n = 5) E S 7 (n = 5) E S 8 (n = 4) C ar d 5: C al m in g Yo ur B ab y D id al l p ar tic ip an ts d es cr ib e ke y m es sa g es ? Ye s Ye s Ye s Ye s Ye s Ye s Ye s Ye s D id p ar tic ip an ts le ar n so m et hi ng ne w ? D on ’t g iv e to ffe e or b is cu it w he n ch ild cr ie s to st op th em fr om cr yi ng . D on ’t g iv e to ffe e, sw ee ts , or sw ee t d rin ks w he n ch ild cr ie s to st op th em fr om cr yi ng . D on ’t hi t/ b ea t ch ild to g et th em to st op cr yi ng . D on ’t ne g le ct a cr yi ng ch ild . N o D on ’t sh ou t at th e ch ild w ho is cr yi ng . D on ’t hi t/ b ea t th e ch ild to g et th em to st op cr yi ng . D on ’t g iv e to ffe e, sw ee ts , or sw ee t d rin ks w he n ch ild cr ie s to st op th em fr om cr yi ng . D on ’t sh ou t at th e ch ild w ho is cr yi ng . N o D on ’t g iv e to ffe e, sw ee ts , or sw ee t d rin ks w he n ch ild cr ie s to st op th em fr om cr yi ng . D on ’t hi t/ b ea t ch ild to g et th em to st op cr yi ng . N o W he re d id p ar tic ip an ts le ar n w ha t th ey kn ew ? M ot he r M ot he r H ea lth ca re p ro vi d er s (C W C ) M ot he r Pa re nt s H ea lth ca re p ro vi d er s Pa re nt s W iv es Pa re nt s M ot he r Pa re nt s N ei g hb or s Si st er Te le vi si on O b se rv e ow n ch ild B oo ks W ill m es sa g es b e ea sy fo r G ha na ia n ca re ta ke rs to p ra ct ic e? Ye s, b ec au se th e m es sa g es ca n b e ta ug ht to th em . Ye s, b ec au se th e m es sa g es w er e ta ug ht to th em b y th ei r m ot he rs . Ye s, b ec au se th e m es sa g es ca n b e ta ug ht to th em an d so lu tio ns ar e ea sy (i. e. ,p ut ch ild on b ac k to ca lm ). It ca n b e d iffi cu lt in si tu at io ns w he re th er e is n’ t su p p or t to he lp p ar en ts . N o, b ec au se d iffi cu lt to ch an g e so m eo ne ’s m in d se t an d ha b its (i. e. ,i t w ill b e d iffi cu lt to st op b ea tin g or sh ou tin g at a ch ild w he n s/ he is d oi ng so m et hi ng w ro ng ). Ye s, b ec au se th e m es sa g es ca n b e ta ug ht to th em . Ye s, b ec au se th e m es sa g es ca n b e ta ug ht to th em . Ye s, b ec au se th e m es sa g es ca n b e ta ug ht to th em .I t ca n b e d iffi cu lt fo r so m e ca re g iv er s w ho m ay ha ve fin an ci al ha rd sh ip s or w ho b ec om e ea si ly fr us tr at ed . Ye s, b ec au se th e m es sa g es ca n b e ta ug ht to th em .I t m ay b e d iffi cu lt fo r so m e p eo p le w ho al re ad y ha ve th e ha b it of hi tt in g th ei r ch ild . 1 n = 38 .C W C ,C hi ld W el fa re C lin ic ;E S, ed uc at io n se ss io n; RF ,r es p on si ve fe ed in g . CURRENT DEVELOPMENTS IN NUTRITION D ow nloaded from https://academ ic.oup.com /cdn/article/4/9/nzaa117/5871815 by guest on 26 August 2020 Development of responsive feeding counseling cards 13 having access to a specific curriculum (14). Health care providers over- whelmingly felt that all the messages were applicable and important (Table 5). Almost all providers felt that the caregivers would understand all messages in each card and most felt they would be easy for caregivers to practice. Providers felt some hunger and satiety cues (i.e., fast breath- ing) would be difficult for participants to observe, resulting in the re- moval of this cue in the messages. Lastly, overall, providers liked the cards, felt they could help reinforce important RF messages, and pro- posed integrating the cards into existing counseling tools and utilizing them within IYCF counseling sessions. Hence the final set of ready-to- use RF counseling cards and corresponding messages are presented in Supplemental Material 3. Discussion Findings from this study demonstrated that the RF counseling cards and messages were wanted and needed within the Ghanaian health care system. The group education sessions demonstrated that caregivers were receiving RF messages primarily from family, with few provided through health care providers. Yet, health care providers reported relay- ing RF messages to caregivers. Given that providers deliver RF messages primarily through individual rather than group counseling, that they are not consistently trained on IYCF messages, and that current curric- ula and counseling tools used for provider training lack comprehensive messages on RF (14), RF messages are not delivered in a consistent, sys- tematic manner. To maximize delivery and uptake of RF messages, they must be delivered consistently and repetitively (18), neither of which is currently being done in Ghana. Providing health care providers with culturally appropriate RF counseling cards plus evidence-informed, clear, and simple RF messages specifically designed to complement cur- rent IYCF counseling can contribute to enhanced counseling of care- givers throughout the health care system, from the community to the clinic level. Furthermore, providers can use the full set of cards or select a subsample of cards to address specific nonresponsive feeding prac- tices. Indeed, integration of RF cards and messages strongly aligns with the very recent IYCF programming guidance issued by UNICEF, which emphasized the inclusion of RF practices into IYCF education (8). Al- though this would add to the duration of health care provider training, counseling, and education delivery, providers strongly supported inte- grating RF into the IYCF system (14). The systematic process taken to develop and test the feasibility of the 5 cards is consistent with the development and testing of other nu- trition education materials (15, 19, 20). Indeed, this study ensured that the RF cards and key messages would be feasible for providers to teach and for caregivers to practice. This innovative approach provides evi- dence that the cards and messages are simple and clear for health care providers to teach and Ghanaian caregivers to practice. However, it can- not be overlooked that findings suggested a few RF messages may be challenging for all caregivers to practice in the context of food and financial insecurity. In the face of financial and food hardship, emo- tional distress has been shown to lead to physical and neglectful be- havior by caregivers (21–24). Peri-urban fathers specifically highlighted how financial hardship may make it difficult to eat together as a fam- ily as well as to introduce new foods owing to the inability to serve a diverse diet or afford a blender or asanka to provide appropriate food texture. As documented within the fathers’ sessions, these hard- ships can lead to caregiver frustration and ultimately lack of adher- ence to RF messages, such as shouting or hitting a crying child. There- fore, more work is needed to explore approaches for those caregivers experiencing extreme hardships to help improve compliance with RF messages. This study has a few limitations. First, this study is limited in its generalizability because testing was conducted within the Central Re- gion in Ghana and the only language used was Twi. Although the cards were designed to be applicable across varying demographic, socioe- conomic, and religious characteristics, further work within other re- gions may be needed to ensure the RF cards and messages are applica- ble and understood throughout Ghana. For example, there are several other local dialects spoken within the Central Region, and RF concepts such as satisfaction or satiety might be represented differently within those languages. Indeed, an RF curriculum for the cards is currently being developed and informed through a counseling pilot study our team is currently conducting, which will contribute additional knowl- edge in this direction. Second, the cards’ utility and acceptability were tested across mothers and fathers, yet other caregivers (i.e., grandmoth- ers, nannies, daycare providers) would also benefit greatly from RF counseling. The cards and messages were not tested among these care- giver subgroups. Because mothers and fathers are the primary recip- ients of IYCF counseling within hospitals, clinics, and child welfare clinics in Ghana, this study focused on a highly relevant population. More research should be conducted to understand the use and feasi- bility of RF counseling cards and messages among other caregivers to ensure RF practices are supported. Third, there are additional relevant RF topics (4); however, 5 cards were considered appropriate for this study to add to the existing Ghanaian IYCF training and delivery sys- tem. Fourth, the cards were intentionally designed to complement the generic UNICEF C-IYCFCP, therefore card images were restricted to those available within the UNICEF IYCF Image Bank (17). Fifth, the messages accompanying the RF cards were adapted from the 2017 RF guidelines from the United States (4), which drew from evidence from high-income countries. However, as seen in this study, the clear accept- ability of and ability to follow RF messages among Ghanaian parents suggest that, when adapted to be culturally appropriate, these messages can be applied to low-income countries. Finally, we acknowledge that it may be difficult to implement a new practice even if caregivers feel they can in the moment they are asked. In the counseling session, mothers and fathers were asked if they felt the messages were possible to prac- tice. In several, participants expressed that there were situations when changing practices might be challenging. This suggests that participants were cognizant of barriers that would need to be addressed to promote RF behavior change, which needs to be considered when counseling on RF. Despite these limitations, the development of a methodology to design and test culturally appropriate and applicable RF cards and messages that align with the UNICEF C-IYCFCP represents a major contribution to strengthening IYCF counseling to caregivers of infants and young children in Ghana and beyond. Worldwide, >80 countries use the generic UNICEF C-IYCFCP or an adapted version (with some adding RF components) to provide IYCF counseling (UNICEF 2019 NutriDash). Indeed, the RF cards and corresponding messages from this study can be used or adapted by other countries to strengthen their CURRENT DEVELOPMENTS IN NUTRITION D ow nloaded from https://academ ic.oup.com /cdn/article/4/9/nzaa117/5871815 by guest on 26 August 2020 14 Hromi-Fiedler et al. TABLE 5 Feasibility of responsive feeding guidelines among health care providers that conduct IYCF training and/or deliver IYCF education in Ghana1 Card All messages applicable All messages important Understand all messages All easy to practice Enjoy Eating with Family 100% 100% 86% 86% Hunger and Satisfaction Cues 100% 100% 64%2 92% Introducing New Foods 100% 100% 100% 100% Texture 100% 100% 86% 92% Calming Your Baby 100% 100% 100% 86% 1IYCF, infant and young child feeding. 2Some providers thought specific hunger cues, such as fast breathing, might not be recognized as such. own IYCF counseling systems. Furthermore, additional RF cards and messages can be developed so countries can choose a set of cards for RF messages they feel are most important for their IYCF educational package. Acknowledgments This work was previously presented at Nutrition 2019 in Baltimore, MD in June 2019 (25). We thank Point Hope Ghana for their com- mitment and support during the implementation of this study. We are also very thankful to Bismark, Emmanuel, and Hassan for their dedi- cation to working on this project, including conducting and translat- ing focus groups and counseling sessions. The authors’ responsibili- ties were as follows—AJH-F, RP-E, RA, and AS: designed the research study; GJC: designed the counseling cards; AJH-F, MRT, RP-E, and AS: designed the assessment tools; MRT, AS, and AJH-F: implemented the research study; RP-E, GJC, AJH-F, and MRT: analyzed the data; AJH-F and RP-E: wrote the manuscript and had primary responsibil- ity for the final content; and all authors: read and approved the final manuscript. References 1. Richter LM, Daelmans B, Lombardi J, Heymann J, Boo FL, Behrman JR, Lu C, Lucas JE, Perez-Escamilla R, Dua T, et al. Investing in the foundation of sustainable development: pathways to scale up for early childhood development. 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