Women's and family members' experience of participating in a practical demonstration based maternal nutrition education intervention: Qualitative evidence from rural Bangladesh

Background and objectives: Maternal under-nutrition is widely prevalent in South Asia, including Bangladesh. Undernutrition is associated with an inadequate food intake but choosing appropriate amounts of different foods is crucial. We developed a nutrition behaviour change communication to promote a balanced diet in pregnancy in rural Bangladesh and tested the impact with a cluster randomized controlled trial. The nutrition education was delivered through practical demonstrations of a balanced plate with appropriate portion sizes. As part of the evaluation, we conducted qualitative assessments to examine the barriers and coping strategies to adhere to the intervention from the perspectives of women, families and providers. Methods: We conducted in-depth interviews (n=24) with pregnant women, recently-delivered women, and husbands; focus groups with mothers-in-law (n=7), and key-informant interviews (n=6) with community health workers who provided the nutrition education intervention. Results: We revealed differences in experience reported by women, mothers-in-law and husbands regarding participating in the intervention. Pregnant women experienced visual presentation effective in recalling messages and easy to apply in practice. They often needed to borrow certain food items to make the balanced plate which supported a culture of food sharing. Some mothers-in-law found the messages contradictory to their traditional knowledge but accepted them considering the wellbeing of an unborn grandchild. Husbands felt the practical demonstration of portion seizes as an innovative and unconventional approach to nutrition education and were attracted to participate. Health workers regarded the intervention as an expansion of opportunity to engage with the community and use their professional training and everyday experience to educate their local community. Dominant barriers to complying with the intervention included financial constraints and scarcity of animal source foods. To cope with the additional costs for pregnant women's balanced diet, families often adjusted the budget or sourced freely available or cheaper local alternative produce. Conclusions: Maternal nutrition intervention through practical demonstration of portion sizes has potential for high uptake and adherence. Interventions should utilize local food culture, and engage families and community health workers to mobilise social support to create an enabling environment to bring changes in dietary habit