Pesquisa Formativa Rápida - Grávidas e Lactantes - Eng

FORMATIVE RESEARCH ON DEMAND GENERATION FOR NUTRITIONAL REHABILITATION SERVICES
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A�� ........................................................................................................................................ 3
A�� A��................................................................................................................................ 4
E�� S��................................................................................................................................................ 5
K�� R�� ........................................................................................................................................................ 6
P�� 5 �� PLW ........................................................ 6
B�� 5 �� PLW 6
Barriers ................................................................................................................................................ 6
Motivational factors ................................................................................................................................ 6
N�� , ��
�� ................................................................................................................................................................ 7
Dynamics of the local community ........................................................................................................ 7
C�� M�� 7
C�� ................................................................................................................................................................ 8
R�� ........................................................................................................................................................ 9
Objectives of the formative research ........................................................................................................ 9
Specific Objectives ................................................................................................................................ 9
S�� ........................................................................................................................................10
M�� ........................................................................................................................................................11
Focus Group Discussions and areas covered................................................................................................11
Directing the work ................................................................................................................................12
P�� ................................................................................................................................13
P�� 5 �� ........................................................................13
P�� 5 �� ........................................................................13
P�� ........................................................................14
H�� 5 �� PLW ................................................................................15
Identified barriers ................................................................................................................................15
Motivational factors ................................................................................................................................16
N�� 5 ��
PLW ................................................................................................................................................................17
At family level ........................................................................................................................................17
At community level ................................................................................................................................17
At external level ........................................................................................................................................18
D�� ................................................................................................................19
Communication Channels ........................................................................................................................19
Radio programs: frequency of listening and listening hours ................................................................19
Types of preferred programs and messages they believe in ........................................................................20
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C�� M�� 20
Challenges faced by community mobilization in generating demand for the program ................................20
The role of community leaders and influencers as mobilizers of the audience ........................................21
Screening and referral of acute malnutrition cases ................................................................................21
A�� ................................................................................................................22
Creation of an environment favoring the demand for acute malnutrition services ................................22
Perception of the risks ................................................................................................................................22
Perception of the benefits ........................................................................................................................23
C�� R�� ................................................................................................................23
Perception of the health of children under 5 years of age ........................................................................23
Perception of the health of PLW ................................................................................................................23
B�� 5 �� PLW ........24
The Barriers................................................................................................................................................24
Motivational factors ................................................................................................................................24
N�� , ��
�� ................................................................................................................................................................25
At family level ........................................................................................................................................25
At community level ................................................................................................................................25
At external level ........................................................................................................................................25
D�� ................................................................................................................26
Communication Channels ........................................................................................................................26
Frequency and hours for listening to radio programs ................................................................................26
Types of preferred programs ................................................................................................................26
C�� 27
Challenges for community mobilization in generating demand for the program ........................................27
The role of community leaders and influencers as mobilizers of the audiences and beneficiaries ................27
Approach to sensitization activities ........................................................................................................27
A�� ................................................................................................................................................................29
Health of children under the age of 5 ........................................................................................................29
Health of PLW ........................................................................................................................................30
Health of children under the age of 5 and of PLW ................................................................................31
Network of trust and influence in the daily life of the audience, concerning matters related to health care 32
Communication channels and dynamics in the daily lives of the audience ................................................33
Awareness raising activities ................................................................................................................34
Communication channels and dynamics in the daily lives of the audiences ................................................36
B�� R�� ................................................................................................................................37
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The World Food Programme (WFP), in partnership with the Ministry of Health and the Health Directorates of
Zambézia and Cabo Delgado, wishes to thank all those who have made this rapid forma�ve research feasible by
par�cipa�ng directly or indirectly.
At central level, we thank the emergency response partners: UNICEF, UNFPA Care, World Vision, Save the
Children, Concern, CUAMM, WHO, USAID, the Mozambican Red Cross, CHAI, JAM, Medicos del Mundo, the Ariel
Glaser Founda�on, Pathfinder, Feed the Hungry, Fhi 360, Gain, Programas Progresso, ICAP, MSF, the Aga Khan Foun-
da�on, Irish Aid, Accão Agroalimentar Alemã Welthungerhilfe, OFDA.
At provincial level, we thank the DPSs of Gaza, Tete, Sofala and Nampula and the direct support of the DPSs of
the provinces of Cabo Delgado and Zambézia who were ac�vely involved in the study.
At district level, we thank the SDSMASs of the districts of Acuabe and Montepuez (Cabo Delgado) and of Nicoa-
dala and Mocuba (Zambézia) for immediately authorizing access to research areas; and the Health Units for the
organiza�on of focal discussion groups.
At community level, a huge thank you to all the par�cipants of the focus group discussions and to the communi-
ty leaders and key influencers who made it possible to achieve the results of this work, by sharing their life
experiences and percep�ons.
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A�� A��

CHW Community Health Worker
CLI Community Leaders and Influencers
DDHWSA District Directorate of Health, Women and Social Ac�on
FGDs Focus Group Discussions
HC Health Commi�ee
HC Health Centre
HU Health Unit
INGO Interna�onal Non-Governmental Organiza�on
MAM Moderate Acute Malnutri�on
MoH Ministry of Health
MUAC Mid-Upper Arm Circumference
NRP Nutri�onal Rehabilita�on Program
PHD Provincial Health Directorate
PLW Pregnant and Lacta�ng Women
SAM Severe Acute Malnutri�on
SBCC Social and Behavior Change Communica�on
UNICEF United Na�ons Children’s Fund
WFP World Food Programme
04
E�� S��
In order to generate demand for acute malnutri�on services within the nutri�onal rehabilita�on program context,
aimed at rehabilita�ng children aged 6-59 months and pregnant and lacta�ng women (PLW) showing signs of acute
malnutri�on, the WFP in partnership with the Ministry of Health, conducted a rapid forma�ve research to understand
how best to promote health seeking behavior. The objec�ve of this research was to understand the barriers and mo�va-
�onal factors related to access to and use of the program, the predominant internal and external rela�ons of trust and
influence in the audience’s environment, as well as the communica�on dynamics and channels exis�ng in the communi-
ty.
Thus, the ques�ons that have been formulated to address the concerns of the study are the following:
Percep�on of the health of children under the age of 5 and of PLW
a) Signs that draw a�en�on to the health of children under 5 and PLW, s
b) Percep�on of low weight
Barriers and mo�va�onal factors related to health care of children under the age of 5 and of PLW
a) Barriers faced in health care
b) Mo�va�onal factors in health care
Network of trust and influence in the daily life of the audience, concerning ma�ers related to health care
a) At family level
b) At community level
c) At external level
Communica�on channels and dynamics related to the daily life of the audience
a) Communica�on channels
b) Listening hours of radio programs
c) Types of preferred radio programs
Community Mobiliza�on as key element in genera�ng demand for the Program
a) Challenges faced by community mobiliza�on in genera�ng demand for the program
b) The role of community leaders and influencers as mobilizers of the audience
c) Approach to sensi�za�on ac�vi�es
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K�� R��
P�� 5 �� PLW
The research shows that when it comes to children’s health, concerns about low weight are secondary because it is not
regarded as a severity indicator, unless low weight is accompanied by other worrying signals. According to the Focus
Group Discussions (FGDs), the main signs of concern are fever, vomi�ng and diarrhea, given that they present these signs
as indica�ng the need for immediate interven�on by the caregivers of the children or the beneficiaries seeking care,
while low weight “can wait” in the search for treatment.
The percep�on of the health of PLW does not differ substan�ally from that of the health of children. Low weight in PLW
is even regarded with less concern, especially because the FGDs are of the opinion that this condi�on might be explained
by the effect on women of the huge physical burden of household ac�vi�es. They state that only the signs of constant
fever, headache and bleeding are considered as main indicators calling a�en�on to the health of PLW, and giving rise to
swi� interven�on in the search for treatment.
B�� 5
�� PLW
Barriers
The FGDs men�oned a great many difficul�es related to proper health care for children under 5 and PLW. Barriers can
be grouped into four blocks:
a) Limited access: this concerns the long distances between home and health unit (HU), and the lack of resources to
use local transport to the HU (in the villages where local transport is available that is). The distances referred to vary from
2 to 5 hours for one way only. According to the children’s parents it is very painful to take them for treatment on foot
when they are in very poor health, and the same goes for PLW;
b) Lack of Informa�on: this concerns the lack of informa�on about the nutri�onal picture that children and PLW
should present in order to be considered healthy. The FGDs also show not to be informed about the causes and conse-
quences of low weight both in children and in adults. It turns out they do not understand the severe condi�on that may
be caused by low weight, something which leads to delays in seeking treatment when low weight is no�ced;
c) Shortage of drugs/supplements in the HU: this concerns the unavailability of drugs/treatment in general. The
FGDs report that a�er consulta�ons people some�mes are unable to get hold of drugs, something which compromises
the mo�va�on because people allegedly do not have the material resources necessary to buy these products in private
pharmacies;
d) Unsa�sfactory a�endance at HU level: this refers to the care provided by HU professionals, which at �mes is not
sa�sfactory. According to the FGDs, par�cipants not always manage to be a�ended for arriving late at the health facility,
due to the long distances traveled. The HU staff informs the pa�ent that the unit is closed already and recommends him
or her to return the next day, thus seriously discouraging people.
Motivational factors
According to the FGDs, most important among the mo�va�onal factors for the health care of children and PLW is the
well-being of the family. Keeping a family healthy and free from the threat of illness and death is at the heart of people’s
concern. They point out that people are more mo�vated to immediately seek health services when they understand the
risks posed by the disease and the imminent danger to life. Death is men�oned as the saddest event in the life of a
family. The FGDs emphasize a number of aspects that are essen�al to bringing about treatment seeking behavior:
a) The informa�on on how to iden�fy those signs considered most threatening to health;
b) The percep�on of the risks of diseases, indica�ng the state of severity or the threat of death; and
c) The percep�on of the benefits of the treatment for the recovery of the health status of the beneficiary.
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N�� , ��
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At family level, the influen�al figures within the family nucleus as men�oned by the FGDs are, in descending order of
influence, the husband, the mother-in-law and the mother. In addi�on, the oldest people in the family also wield influen-
ce. The reason for the above order in the chain of influence, according to the GFDs, lies in the central role of the husband
- who is the person responsible for the decisions concerning care for the child and for the lacta�ng wife. However, the
husband is influenced by his mother, whom he consults about ma�ers related to the health care of his family. At commu-
nity level, members have full confidence in their community and religious leaders, influencers, model mothers, health
ac�vists, APEs etc., given that these are regarded as “people who act for the sake of the community”, who relate to
health personnel and who therefore are persons who are morally trustworthy and with a recognized track record of
providing services to the community. At external level, the FGDs state that they have total confidence in the public health
authority, which deserves to be carefully listened to when it comes to any statements in the media. This trust is also
reflected in the rela�onship with the HU staff, both with respect to counseling and care.
Dynamics of the local community

Mobile brigades, community gatherings (with health ac�vists, community and religious leaders), neighbors and friends,
the telephone and provincial and community radios are singled out as the main sources and channels of community
communica�on in the daily life of the audience. However, the use of the telephone is really limited because few people
in the community have a telephone, especially in the rural areas. The radio is widely used by most people, but not all
members of the community own one. The radio, apart from being a considerable communica�on channel in the commu-
nity, is also a source of interac�on because the neighbors who do not own a radio visit the house of the people who do
own one to listen together. As far as the frequency and the hours of listening to radio programs are concerned, members
of the community usually listen at random. However, there are three day�mes when most radio broadcasts are listened
to: in the morning: (before going to work in the field); in the a�ernoon: (a�er returning from work in the field), at night:
in the early evening (around dinner �me). The preferred types of programs are those that offer informa�on about daily
life, as well as those that offer some entertainment and informa�on about events in the life of the local popula�on.
C�� M��

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Forma�ve research shows that the main challenges for community mobiliza�on are the resistance to behavior change
(some�mes jus�fied by cultural beliefs and the lack of sufficient informa�on about nutri�onal health care of children
under 5 years of age and PLW; the lack of awareness about the severity of diseases and, of course, the great difficulty of
having access to health services, something experienced by most beneficiaries. Another relevant aspect is that individual
behavior becomes even more reluctant when the environment does not encourage change or the adop�on of new
prac�ces, thus limi�ng the individual to repea�ng old prac�ces. Research confirms that the involvement of community
leaders and influencers is crucial in addressing the challenges faced by the promo�on of health seeking behavior, not
only because they are part of the interven�on universe, but also because their service is recognized and trusted by the
audience.
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Within the emergency context, the WFP in partnership with the Ministry of Health is implemen�ng the Nutri�onal Reha-
bilita�on Program/PRN with a view to rehabilitate children aged 6-59 months and PLW showing signs of moderate acute
malnutri�on in the provinces of Gaza, Zambézia, Sofala, Tete, Cabo Delgado and Nampula. In Mozambique, sick children
and adults are treated in accordance with the Nutri�onal Rehabilita�on Programs I and II (for children and for adoles-
cents and adults respec�vely)1. Children under 5 years of age with moderate acute malnutri�on are rehabilitated using
the Food Supplement Ready for Use (ASPU); while PLW suffering from this condi�on are rehabilitated using Super Cereal
(SC)2.
In this regard, the WFP makes these products available in HUs, providing health workers with PRN training packages and
implemen�ng community mobiliza�on.3 The implementa�on of the community mobiliza�on component within the PRN
context is considered essen�al to dissemina�ng informa�on on the availability of the program and to promo�ng beha-
vioral change, leading to demand for services for the rehabilita�on of children under 5 years of age and PLW suffering
from moderate acute malnutri�on.
Community influencers, volunteers and ac�vists will thus be crucial in realizing this component at community level.
These agents will be responsible for the screening, the follow-up and the referral of cases of acute malnutri�on in
children under 5 years of age and in PLW. In an effort to increase the demand genera�on component, provincial radio
channels will also be used for the large-scale dissemina�on of messages about the existence of the program.
The strengthening and expanding of community mobiliza�on is expected to lead to an accelera�on of the demand for
treatment, an increase of the number of admissions to the program and, consequently, a reduc�on of the rate of acute
malnutri�on.
1
Ministry of Health, Nutri�on Department. Manual for Nutri�onal Treatment and Rehabilita�on – Volumes I and II. March 2011.
2
Within the scope of the joint response, UNICEF supports the nutri�onal rehabilita�on program for cases of serious acute malnutri�on through ATPU
and CSB+.
3
With main focus on the provinces of Zambézia, Cabo Delgado and Nampula, due to the partnership with Interna�onal Non-Governmental Organiza-
�ons/ONGI in these provinces.
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R��
Conduc�ng this forma�ve research is jus�fied by the need to produce informa�on that will guide the interven�on for
the demand genera�on component and to confirm the guidelines established for the sensi�za�on ac�vi�es to be
realized by the volunteers and key influencers, in view of promo�ng demand specific for the Nutri�onal Rehabilita�on
Program. The challenge of community mobiliza�on in responding to emergencies is to understand the subtle ques�on
of how best to cap�vate and en�ce the audience and program beneficiaries through interpersonal ac�vi�es of sensi�za-
�on and message dissemina�on. An effec�ve approach and clear interven�on guidelines define the success of the
program. Crea�ng the most appropriate approach requires the inves�ga�on of the daily lives of the audiences and bene-
ficiaries, leading to informa�on on how to s�mulate health seeking behavior resul�ng in immediate demand for the
program.
The results of this research will contribute to understanding how best to drive demand for the program and strategically
engage volunteers and key community influencers. In addi�on it will contribute to the use of local resources with a view
to strengthening sensi�za�on ac�vi�es, thus contribu�ng to the valida�on and reorienta�on of the guidelines for imple-
men�ng community mobiliza�on throughout the interven�on.
Objectives of the formative research

Understand barriers to and mo�va�onal factors for access to and use of PRN services, the rela�onships of trust and
influence, as well as the dynamics of communica�on and community mobiliza�on aimed at genera�ng demand for the
program.
Specific Objectives:
� Understand the percep�on of the health of children under 5 years of age and of PLW;
� Iden�fy barriers to and mo�va�onal factors for the demand for health services;
� Understand the network of trust and the influence of family and community on the daily life of the audience
when it comes to ma�ers related to health care;
� Understand the communica�on channels and dynamics surrounding the daily life of the audiences;
� Explore community mobiliza�on as a key part of genera�ng demand for nutri�onal rehabilita�on services.
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The following ques�ons have been formulated to obtain the answers the interven�on needs in order to rec�fy or
confirm the interven�on strategy to create demand for acute malnutri�on services.
Perception of the health of children under the age of 5 and of PLW

a) Signs that draw a�en�on to the health of children under 5 and PLW, and signs considered to be the most
alarming.
b) Percep�on of low weight
Barriers and motivational factors related to health care of children under the age of 5 and
of PLW
a) Barriers faced in health care
b) Mo�va�onal factors in health care
Network of trust and influence in the daily life of the audiences, concerning matters
related to health care
a) At family level
b) At community level
c) At the level health authori�es and staff
Local communication dynamics

a) Exis�ng community communica�on channels
b) Listening hours of radio programs
c) Types of preferred radio programs
Community Mobilization
a) Challenges faced by community mobiliza�on in genera�ng demand for the program
b) Mo�va�on of community leaders and influencers for community mobiliza�on
c) Approach to sensi�za�on ac�vi�es
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M��
The rapid forma�ve research was conducted in the provinces of Cabo Delgado (northern region) and Zambézia (central
region). Two districts of each province were selected, one located in an urban and the other one in a rural area. These
were Acuabe (rural area) and Montepuez (urban area) in Cabo Delgado; and Nicoadala (rural area) and Mocuba (urban
area) in Zambézia. This selec�on is jus�fied by the inten�on to take into account the diversity in these zones, because
rural and urban contexts are markedly different from the point of view of access to public services in general, access to
health services, educa�onal level, etc. This considera�on is relevant for the interven�on of the project because it will be
implemented on both loca�ons.
This research was conducted with FGDs involving audiences and beneficiaries of the interven�on, as well as community
leaders and key influencers. A total of 24 FGDs were involved, 6 in each district. Thus, 2 types of focus groups were
formed:
1. Parents of children under 5 years of age and PLW

The presence of parents is justified because they form the primary audience, being the direct caregivers of the
children; and the presence of the women is justified because they are, apart from being direct caregivers, benefi-
ciaries of the PRN.
2. Community Leaders and key Influencers

This group is justified by its influence on primary caregivers and direct beneficiaries, and by its role as community
mobilizer.
The involvement of the FGDs par�cipants is as follows:
F�� G�� D��

Number of
Province Districts Areas Focus group discussions
par�cipants
Cabo Delgado Ancuabe District Seat Parents of children under 5 years of age 06
(rural area)
PLW 08
Community leader and influencers 07
Community of Macaia Parents of children under 5 years of age 05
Community of PLW 10
Nanhomane
Montepuez District Seat Parents of children under 5 years of age 04
(urban area)
PLW 07
Community of Noémia Parents of children under 5 years of age 06
PLW 11
Zambézia Nicoadala District Seat Parents of children under 5 years of age 08
(rural area)
PLW 10
Community of Curungo Parents of children under 5 years of age 06
PLW 10
Mocuba District Seat Parents of children under 5 years of age 05

(urban
PLW 13
area)
Community of Parents of children under 5 years of age 06
Aeroporto 2
PLW 06
11
Directing the work
a) Pre-test of the research instruments

A pre-test of the instruments was conducted in the city of Pemba, Cabo Delgado and involved 4 FGDs as previously
men�oned. The research instruments were improved, in accordance with the gaps to be remedied found in the pre-test.
b) Facilita�on of Focus Group Discussions

The discussion of the focus groups was conducted by a researcher and a research assistant (for each province), a DPS
representa�ve who offered support by taking notes and by transla�ng. The research assistants were trained to familiari-
ze themselves with the research ques�ons and thus to be�er make notes and translate, in order to avoid interpreta�ons.
c) Gathering of informa�on
Some of the group discussions were conducted in the local language and were translated by the research assistants
(represen�ng DPS) into Portuguese. The research notes were submi�ed in Portuguese by the research assistants.
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P��
P�� 5 ��
Signs that draw a�en�on to the health of children under 5 and PLW, and signs considered to be the most alarming.
According to the research, the percep�on of children’s health is closely related to their physical well-being. The
interviewees men�oned signs such as lack of appe�te, frequent crying, fever, pimples, weakness, seizures, malaria,
diarrhea, red eyes, coughing and rapid breathing as main indicators of a child’s poor health. However, some signs among
the above are considered to be the most worrying – i.e. signs calling for an urgent response from the caregivers. Among
these are diarrhea, fever and vomi�ng. The reason given for the greater concern with these signs is the percep�on of the
severity of the diseases involved. According to the interviewees, these diseases abruptly affect a child’s health and can
even take its life:
Fever, vomiting and diarrhea worry us more because these are diseases that abruptly take away our
child. The child may be very well in the morning and at night it is gone ... This worries us a great deal and
we should act immediately. These signs make clear that one cannot sit back and wait.
(Zambézia, Nicoadala, health centre, parents of hospitalized children with acute malnutrition).
Therefore, the percep�on of severity leads the children’s caretakers to react immediately by seeking to protect the child
from the consequences, some�mes irreversible, of these diseases. It should be noted that the infec�ous diseases
men�oned as most threatening for the well-being and the lives of children are: diarrhea and signs of malaria, i.e. fever
and vomi�ng. Although other signs have been iden�fied as troubling, the interviewees say they do not require an imme-
diate reac�on such as taking the child to the health centre because” … there are signs indica�ng that one can wait ... For
example, a child that is underweight can wait [for being a�ended] because it is not serious”.4
P�� 5 ��
Curiously, the interviewees did not men�on low weight as a sign of concern.For the interviewees low weight only
becomes a relevant concern when it is associated with signs considered as severe, as men�oned above. The following
statement is quite revealing:
The child stayed at home for

3 days in order to be brought to
the HU. She was underweight,
but we were not worried
because she was always there
doing her things, play a little.
But then she started having a
fever and vomiting and we took
her to the HU. But it took us 3
days to take her [to the health
centre], because we thought she
could still be treated at home ...
We brought our child to the HU
because she had a headache
and fever and didn’t relieve
herself, she did not want to eat. The HU from the village we live in gave her a drug against malaria. We did
the treatment and it was no use. So, we decided to bring her here to the seat a couple of days later. They
tested her and she was hospitalized. They say that she is very sick and needs to regain weight.
(Zambézia, Nicoadala, HU, parents of hospitalized children with SAM).
4 Zambézia, Nicoadala, HU, parents of hospitalized children with moderate acute malnutri�on.
13
An important aspect raised by the interviewees is that low weight in babies draws a�en�on to the state of health of the
child. However, the same does not happen with children over 2 years of age, because they share the idea that thinness
in such a child is normal because it is growing: “It is normal for an older child to be thin. A child older than 2 becomes
thin because it grows. That is why thinness in a child should not always be a cause for concern. But in a baby it is a cause
of alarm”.5
Another important aspect regarding weight, highlighted by FGDs, is that low weight may be caused by diseases or insuffi-
cient food but it can also be caused by “local diseases”,6 referring to diseases or “external manifesta�ons” beyond the
scope of medical science. According to the FGDs, people in the community are o�en affected by diseases that can only
be solved by a tradi�onal healer and not by health personnel, as the following tes�mony confirms:
Low weight is associated with roundworms and with a disease that is called nhala here, which drains
the body of the child and the child gets very thin. In this case one takes the child to the traditional healer.
The signs are that the skin gets strained and the bones start to appear (...)
(Cabo Delgado, Acuabe, community of Macaia, community leader)
The percep�on that low weight may be caused by “local diseases” leads the child’s caregivers to seek tradi�onal treat-
ment, thus preven�ng the child from having access to the nutri�onal rehabilita�on treatment available in the HU. Conse-
quently, there is an increase in cases of acute and chronic malnutri�on and of associated diseases. This percep�on is
based on a belief system historically rooted in the daily life of communi�es, especially in the rural areas. Add to this the
fact that for most rural communi�es the healer is geographically be�er accessible than the health centres, a situa�on
favoring a significant decrease in the demand for health services.
P��
The amount of care spent on the health of pregnant women is consi-

dered low, in view of the care pregnant women should receive.
However, a�en�on to lacta�ng women (breas�eeding a baby under
6 months of age) is even lower. According to the FGDs, lacta�ng
women having given birth already, do not need baby related a�en-
�on. Their nutri�onal status is also not associated with the impact
of lacta�ng.
The FGFs say that the signs that generally draw a�en�on to the
health of PLW are swelling, lack of appe�te, constant fevers, heada-
che, and bleeding. However, it is the last three signs that are most
alarming and lead to an immediate reac�on in the form of seeking
treatment. As previously men�oned about the health of children,
concern about the severity of the diseases that may be behind the
signs is first and foremost in the views of PLW, as illustrated by the
following statement:
Being pregnant, we are afraid of causing the death

of our baby. We also fear for our own health because
we know we can die. So, when we suffer from high
fever, a lot of headache and bleeding, we usually seek
help because we know that this is a sign that things
are not going well for the mother and the baby.
(Zambézia, Mocuba, District Seat HU, pregnant
woman).
5 Cabo Delgado, Acuabe, rural area, Pregnant woman.

6 “(…) In a personalis�c system of belief, illness is believed to be caused by the interven�on of a supernatural being or a human being with special
powers (…)”. h�p://www.dimensionsofculture.com/2011/02/culturally-based-beliefs-about-illness-causa�on/
14
It should be noted that, just as with children, low weight is not men�oned as a great variable of concern for PLW, unless
it occurs together with other signs: “Emacia�on and low weight are not a concern for us. We do not go to the hospital
just because of this. But if that low weight is accompanied by pain or fever so severe that we lose our strength, then we
go to the hospital (...)”7.
Low weight for PLW is also associated with hard work, and this some�mes leads to not directly associa�ng this with their
nutri�onal status, as the following tes�mony illustrates:
(...) Here it is normal not to have too much weight because we work. You see? We have to get water,
walk that whole distance [2 hours], then come home, prepare lunch for family, wash clothes. It's not easy.
So we get thin. It is suffering.
(Zambézia, Namacurra, District Seat HU, pregnant woman).
On the other hand, low weight is also associated with causes that health personnel would be unable to solve, even if
these causes are not necessarily linked to “external causes”: “If I realize that my arm is thin, I go to the healer. (...) Weight
loss may also be due to the problem of roundworms. So when that is the case it is the tradi�onal healer who has to use
the leaves so that people recover”.8
H�� 5 �� PLW
Identified barriers
c) Shortage of drugs/supplements in the HU: this concerns the unavailability of drugs/treatment in general. The
the mo�va�on for seeking treatment because people allegedly do not have the material resources necessary to buy
these products in private pharmacies;
or her to return the next day:
From our house we have to walk far to reach the HU, and often when we get there they tell us to come
back some other time. They do not have the patience to attend us. They do not want to understand our
situation. Some are patient and ask you to wait; others send you back home.
(Zambézia, Nicoadala, rural area, pregnant woman).
7
Cabo Delgado, Montepuez, community of Noemia, pregnant woman.
8
Cabo Delgado, rural area, Montepuez, lactating woman.
15
In addi�on to these factors, another aspect revealed by the FGDs is the fear for adop�ng a new prac�ce, even when it is
supposed to be beneficial and, above all, if it indicates the use or consump�on of a product. The fact is that o�en there
exists a fear of star�ng a prac�ce that has not yet been experienced in the community:
The community sometimes reacts suspiciously when new products arrive [for health care].9 They think
these things are bad, that they are going to harm one’s health. This happened with certeza for water
treatment and with condoms. They feel this as a threat. So far, many people do not use condoms because
they think the condom contains AIDS (...)
(Cabo Delgado, Acuabe, community of Macaia, traditional midwife).
Motivational factors10
According to the FGDs, most important among the mo�va�onal factors is the well-being of the family. Keeping
a family healthy and free from the threat of illness and death is at the heart of people’s concern. They pointed out that
the rapid search for health services is most encouraged by the presence of risks inherent in disease, because decision
making comes down to the immediate search for health services, jus�fied by the imminence of danger, as expressed by
the statement of one of the mothers of a sick child:
Today I went to work in the field but my child had a fever. So, I set everything aside to take my child
here to the hospital. My wish for my child to be healthy again gives me the strength to overcome the great
distance to the hospital. All I need to know is that his problem is serious and he or she needs help and I
have to fight to see my child smile again.
(Zambézia, Nicoadala, rural area, lactating woman).
Another factor repeatedly men�oned is the mo�va�on resul�ng from observing a certain prac�ce spread in the commu-
ni�es. The FGDs stated that when members of the community observe that many other people act in a certain way and
the benefits are visible, then this turns into a strong s�mulus and they start to repeat it, as expressed in the following
statements.
(...) I am a traditional midwife. I received training and they said that we had to convince the community
of not giving childbirth in the community and show the advantages of giving childbirth in the health unit.
We did that. The women picked up morale [they believed in it]. What we have said about the benefits is
something that they can see. When the benefits are there for all to see and they see that we are not lying,
then they will be interested in seeking treatment.
(Cabo Delgado, Acuabe, community of Macaia, traditional midwife)
When we see our neighbors doing things that are good for the health of the children, we want to do
the same thing. But sometimes we are afraid to start on our own. I wait to see things first.
(Cabo Delgado, Acuabe, rural area, mother of child 2 years of age).
9 A product used for purifying water.

10
People require mo�va�on, which is o�en determined by their a�tudes, beliefs, or percep�ons of the benefits, risks, or seriousness of the issues that
programs are trying to change(…)Mo�va�on to change behaviors happens along a con�nuum from being controlled by others (external mo�va�on) to
being able to self-determine (internal mo�va�on). Internal mo�va�on leads not only to more enjoyment of a behavior change, but also more
persistence to maintain a new behavior. USAID. 2012. C-Change Modules. A learning package for Social and Behavior Change Communica�on. Module
0, p. 42
16
N�� 5
�� PLW
At family level
The influen�al figures within the family as men�oned by the FGDs are, in descending order of influence, the husband,
the mother-in-law and the mother. In addi�on, the oldest people in the family also wield influence. The reason for the
above order in the chain of influence, according to the FGDs, lies in the central role of the husband - who is the person
responsible for the decisions concerning care for the child and for the wife. However, the husband is influenced by his
mother, whom he consults about ma�ers related to the health care of his family, as illustrated by the following state-
ments:
So, my wife when she comes to me to complain, I sometimes don’t know what to do. So I go to my
mother to find a solution; or tell my wife to talk to my mother to get advice, even concerning her own
health.
(Cabo Delgado, Montepuez, rural area, husband of pregnant woman).
I usually tell my wife what she should do about that child that is sick, or even about her own health.
She has to follow my advice because it is good for her. Now, when there is something I know nothing
about, I send her to talk to my mother and she has to heed her advice.
(Cabo Delgado, Montepuez, HU in district seat, father of child under 1year of age).
The elderly influencers of the family are recognized by their age and life experience. They are people who can be indica-
ted by a woman’s mother-in-law or by her husband, if he thinks that his mother does not have the experience necessary
to deal with a given situa�on: “We follow the persons of our family who have more experience because they have lived
through the situa�on we are experiencing. They may belong to my family or to my husband’s family. He is the one to
decide, depending on the subject.”11
At community level
The FGD refer to community leaders, religious leaders, APEs, health ac�vists, HU staff and tradi�onal midwives as
influen�al figures at community level. The reason is that all these people have worked for community improvement and
are always informed about health issues because they are always interac�ng with the HU staff. They are men�oned as
the persons who bring first-hand news about vaccina�on campaigns, the availability of services in the HU, community
mee�ngs, etc. At the same �me, religious leaders (even if they have no interac�on with the HU) and neighbors are also
considered influen�al, because they are “good people” with whom emo�onal and affec�ve rela�onships are
established: “I really believe in the pastor of my church. He always leaves good messages about what should be done.
That’s why I always listen to him. He is the voice of my church (...) I also listen carefully to my neighbor, because he knows
my life, he wishes me well and will offer good advice”12.
As far as other influencers are concerned, there exists a rela�onship not only established by bonds of trust, but also by
the clear recogni�on of accumulated experience based on community ac�vism: “I listen a lot to community leaders and
ac�vists because they have experience, control the community and receive trainings from government and health
organiza�ons”13. As far as this is concerned, these persons are the main references for the community members when it
comes to trust and advice on health care. Based on this rela�onship of trust, community members state that they seek
these persons for counseling, but that they themselves also respond posi�vely when being sought out by these persons.
11
Zambézia, Nicuadala, zona rural, lacta�ng woman.
12
Cabo Delgado, Montepuez, community of Noemia, pregnant woman.
13
Cabo Delgado, Montepuez, community of Noemia, lacta�ng woman.
17
At external level
Public health authori�es are persons referred to as absolutely credible, and to whom they devote par�cular a�en�on.
HU staff are referred to as people entrusted with health care and counseling by the members of the community. There
is a realiza�on that health authori�es are people of profound knowledge; and the HU staff are the direct caretakers of
community health: “The health staff helps us with our health; they are our caregivers. We really trust them. They offer
us treatment, advice, weigh the children, vaccinate. So, we really believe in them”.14
14 Cabo de Delgado, Acuabe, rural area, father of child under 1 year of age.
18
D��
Communication Channels
Mobile brigades, community gatherings (with health ac�vists, community/religious leaders), neighbors and friends, the
telephone, the provincial radio and community radios are singled out as the main sources and channels of community
communica�on in the daily life of the audiences. However, the use of the telephone is really limited because few people
in the community have a telephone, especially in the rural areas. The radio is widely used by most people, but not all
members of the community own one, as shown by the following cita�on:
The radio has a large following. The radio never fails. Now
the telephone here in our area does not work very well, because
many have no phone. There is an area that has no network,
others do have it. People do not have the money to buy a phone.
Also, among the few who have a phone there are those who have
no money to buy credit. When things are like that, communica-
tion can only fail.
(Cabo Delgado, Acuabe, community of Macaia, community
leader).
It is important to emphasize that radio, besides being a broad communica�on medium, is also a source that gets people
together, since the neighbors who do not have a radio join those who do have one so that they can listen together, thus
crea�ng a space of interac�on around the news that inspires conversa�on and debate, as seen in the following state-
ment:
(...) I have my radio. But my neighbor doesn’t. So, he comes here [at home] to listen. I like it. Then he
leaves or stays longer to talk about the news we heard. When there is news that interests others here in
the community, then we also involve them in the conversation. It's good.
(Zambézia, Nicoadala, rural area, community leader).
Radio programs: frequency of listening and listening hours
The radio, both provincial and commu-

nity radio, is listened to every day.
Community members prefer the
community radio for local news and the
provincial radio for na�onal news.
According to the FGDs, community
members usually listen to the radio in
the morning: the start of the day (befo-
re going to the field); in the a�ernoon:
when returning from the field; at night:
in the early evening (around dinner
�me).
We always have some

time to listen to the radio.
We make our appointments, we go to our field, but we always have that time to listen to the radio. It's the
way of knowing what's going on in the city (...)We often know about vaccination campaigns through the
radio. That way we warn our neighbor who has no radio and so we pass on the information.
(Cabo Delgado, AcuabeCommunity of Nanhomane, community leader).
19
T��
The kinds of preferred programs are those that are informa�ve and those offering entertainment, especially programs
about real situa�ons, things that happen in the daily life of the popula�on, expressing the dilemmas and problems faced
by communi�es In this sense, there is a lot of confidence in radio programs presen�ng the living experience of a person
of the community, where community members recognize themselves in the narra�ve and iden�fy with the narrator:
We really trust the advice of the mother in our area who has the same problems that we all have here
in the village and who tells her story on the radio. From her story we learn to avoid problems, because she
tells what happened and what she did to overcome it. Through her story, we know how to avoid having the
same problem and we learn how to overcome it if we have to face it.
(Cape Delgado, Acuabe, HU, pregnant woman).
The FGDs also reveal that they believe in the messages broadcast on the radio, because all informa�on that has been
conveyed, especially things related to health issues, can be verified. That is why communi�esare always willing to
respond posi�vely to calls made on the radio:
We follow the messages on the radio, because the radio usually gives the news about vaccination and
what they say really happens. When they say they have a vaccination campaign and they urge us to go to
the HU and we go, the campaign is real. So, we have no reason to doubt the radio messages.
(Cape Delgado, Acuabe, rural area, father of a child under 3years of age).
C�� M��

��
Challenges faced by community mobilization in generating demand for the program
a) The community leaders and influencers (CLIs) report their experiences with mobilizing audiences and reveal that
the challenges for being successful are enormous. They men�on some aspects they consider fundamental for an
interven�on that aims at adop�on of a certain behavior by the target audience: More resistance to change on the part
of men. They state that men are more resistant to behavior change than women. In addi�on, it is the men who decide
on the health of the child. For this reason, their involvement in community mobiliza�on is impera�ve, because “the
mothers may be convinced, but if the husband at home is not, things will go nowhere”.15
b) Lack of a clear percep�on of the benefits of

the interven�on. According to the CLIs, it takes �me
for the audience to convince themselves that they
should adopt a new behavior or improve an exis�ng
one. They point out that the job of the leader is to
promote this change, but that the leader himself has
to master the subject to know how to promote this
change, given that “without enough informa�on on
the subject one cannot convince the community.
Leaders need to fully understand the benefit of this
treatment [PRN] to be able to convince people. But
first we ourselves have to be convinced”.16
15 Cabo Delgado, Acuabe, community of Macaia, religious leader.

16 Cabo Delgado, Community of Nanhomane, Acuabe, member of the Health Committee.
20
c) Lack of clear informa�on about the interven�on to be disseminated. The CLIs pointed to the need to rely on the
interven�on that will guide mobiliza�on work with the community. Knowing clearly what it is about as well as what the
real health benefits for the beneficiaries are is key for the trust in the interven�on that leaders and influencers need to
have. According to them: “We should have informa�on about this product [supplementary feeding], what its purpose is.
This flour for pregnant women ... we do not know this, what is it? This product never arrived here, we never saw it”.17
d) Lack of priority treatment by the HU of people who have been referred. The CLIs report that they have been
involved in other interven�ons in which they are supposed to refer (e.g. in cases of malaria) and where the referral card
referring the pa�ent to the HU does not priori�ze him or her for receiving care, something which demoralizes the pa�ent
as well as the referral agent because they do not see their referral valued by the HU.
I think the HU staff should pay more attention to the cases we are referring because these people are
really suffering. Around here, the APE usually treats malaria. But he most serious cases are sent to the HU.
However, when they arrive there they are treated like everybody else. Despite carrying a referral card
issued by the APE, they are told to queue just like the others.
(Zambézia, Nicoadala, rural area, community activist).
The role of community leaders and influencers as mobilizers of the audience
Despite the difficul�es community mobilizers encounter in convincing people to adopt a change in their behavior, the
CLIs turn out to be very mo�vated to carry out this work. According to them their main mo�va�on is the commitment
to contribute to improving the health condi�ons of the community. However, they indicate that some encouragement
would be seen as a great s�mulus to leverage their work with the audiences, given that the work they do is voluntary:
Here we all work with immense pleasure and receive nothing for it. It’s our life anyway. But those
trainings we get to learn something new, that motivates us (...) But it would also be good to have an
incentive. It doesn’t need to be money. But at least a T-shirt for what we're doing could be good; even a
bar of soap would be an incentive for us.
(Cabo Delgado, Acuabe, community of Macaia, traditional midwife).
Screening and referral of acute malnutrition cases
The FGDs stated that they do not know how to iden�fy cases of acute malnutri�on, nor when it is necessary to refer
people to the HU, but their statements also show that some leaders have a certain experience in demonstra�ng
enriched porridge as well as in conduc�ng counseling sessions for the preven�on of malnutri�on. Nonetheless, no
ac�ons linked to the nutri�onal rehabilita�on program have been realized. This ini�a�ve, however, is greeted with
immense sa�sfac�on and enthusiasm:
Here we do not yet screen our children and women. But we would be glad to do it. To go with the
MUAC tape from house to house and have a quick look at the children and women who are sick and make
the referral. We take a keen interest in learning this because it will help our community and also our own
family.
(Zambézia, Mocuba, District Seat Health Center, traditional healer)
17 Cabo Delgado, Acuabe, community of Macaia, religious leader.
21
I already have that tape [MUAC] but I never used it. I thought it was only the HU staff who could use it.
But this way, if I am able to use it I will be very happy. I just need to receive the training (...) To understand
well how we should act, and then do so. We are proud to use this health material to help our community
and learn something new.
(Zambézia, Mocuba, rural area, community leader).
The involvement of community leaders and influencers is very important for the genera�on of demand for nutri�onal
rehabilita�on services, because of the experience they have built up in community mobiliza�on and because of the trust
they enjoy among the audiences, which accept and value their capacity for persuasion.
A�� 18
Creation of an environment favoring the demand for acute malnutrition services
Based on the experience they gathered, community leaders and influencers indicate that the strategy to be used is the
large-scale dissemina�on of informa�on on the use of supplementary feeding for the recovery of the nutri�onal status
of children and PLW, using the home visit for “dissemina�ng informa�on word-of-mouth (…)”.19 In addi�on to home
visits, they pointed to the churches as poten�al places for the dissemina�on of messages, since, apart from being home
to many people they also are places of trust for the audience, especially when messages are disseminated by religious
leaders. They strongly advocate the use of places that inspire trust, and indicate that people go to church for comfort
and believe in the counsel of their leaders.
Thus, it is essen�al to intervene in the environment to create references or “posi�ve deviants”,20 by drawing a�en�on to
the surrounding environment and promp�ng people to ask themselves: What is going on here? What are these people
doing? What should I do? Should I do the same? The presence of “posi�ve devia�ons” will contribute to the crea�on of
an environment geared towards new ac�ons by community members.
Perception of the risks21
Another relevant aspect indicated by the FGDs is the severity of the problem to be addressed. They state that communi-
ty members need to raise awareness about acute malnutri�on and its consequences, because “To convince someone to
take their child to the HU we need examples that are frightening, that show that the child’s health is in danger. People
here are very afraid of serious illnesses.”22
18
The Health Belief Model approach addresses the barriers leading to non-compliance with recommended health behaviors, as well as what should
be taken into account in promo�ng healthy behavior. Health Belief Model Constract Chart. Jones and Bartlelt, LLC. NOT FOR SALE OR DISTRIBUTION.
19
Zambézia, Nicoadala, ruralarea, matron.
20
At interpersonal level, the theory of social learning postulates that people learn to behave by: 1) observing the ac�ons of others, 2) observing the
apparent consequences of those ac�ons, 3) verifying those consequences for their own lives, and 4) rehearsing, experimen�ng with those ac�ons
(C-Change, p. 12).
21
It is important here to highlight the percep�on of risks and benefits, because this discernment can contribute significantly to ini�a�ng change. It is
necessary that the individual/group understands how suscep�ble it is in rela�on to a certain disease (expansion of the epidemic), and how serious it
is (severity, short-medium-long-term consequences, death risks, etc.). Idem.
22
Cabo Delgado, Acuabe, community of Macaia, community leader.
22
Perception of the benefits23
The research also points out that dissemina�ng informa�on about the benefits of treatment contributes to influencing
the audience. That is why every success story is crucial (...) “spread the word that treatment is good for our children and
pregnant women.”24 Clearly, the percep�on of the benefits of treatment is fundamental to cap�vate the a�en�on and
confidence of the audience, because the beneficiary is mo�vated by knowing that making an effort (ac�on) results in a
gain (benefit)25.
C�� R��
Perception of the health of children under 5 years of age
The research shows that when it comes to children’s health, concerns about low weight are secondary because it is not
regarded as a severity indicator, unless low weight is accompanied by other worrying signs. According to the FGDs, the
main signs of concern are fever, vomi�ng and diarrhea, because they present these signs as indica�ng the need for
immediate interven�on by the caregivers of the children or the beneficiaries searching for care, while low weight “can
wait” in the search for treatment.
Recommenda�on:
The messages should introduce low weight in children under 5 years of age as an indicator of severity, in order to influen-
ce the audience to react immediately and seek nutri�onal rehabilita�on services.
Perception of the health of PLW
With regard to low weight, the percep�on of the health of PLW does not differ substan�ally from that of the health of
children. Low weight in PLW is even regarded with less concern, especially because the FGDs are of the opinion that this
condi�on might be explained by the effect that the huge physical burden of domes�c ac�vi�es has on women. They
state that only the signs of constant fever, headache and bleeding are considered as main indicators drawing a�en�on
to the health of PLW, giving rise to swi� interven�on in the search for treatment.
Recommenda�on:
The messages should emphasize the health care of PLW, especially low weight as a manifesta�on of severity and its
associa�on with the health of the fetus or the child that is being breas�ed.
23
Experience to date with CMAM suggests that there is normally a moment when the community comes to recognize the effect of RUTF on sick
children. Once recognized, program admissions increase rapidly, leading to good coverage levels. Valid Interna�onal. Community-based Therapeu�c
Care/CTC, 2016.
24
Zambézia, Mocuba, rural area, community leader.
25
At Social/Community level: the diffusion theory of innova�ons describes how new ideas and prac�ces (innova�ons or technologies, such as the use
of indoor insec�cides for malaria preven�on) are disseminated through social networks over �me. This diffusion depends on the perceived characte-
ris�cs of the innova�on and the characteris�cs of the social network. (C-Change, p. 12).
23
B�� 5 ��
�� PLW
The Barriers
c) Shortage of drugs/ supplements in the HU: this concerns the unavailability of drugs/treatment in general. The
the mo�va�on for seeking treatment because people allegedly do not have the material resources necessary to buy
these products in private pharmacies;
or her to return the next day, thus seriously discouraging people.
Recommenda�on:
Strengthen the services of mobile brigades, primarily in the most remote communi�es showing numbers of admissions
below the expected target. Community mobiliza�on should be closely connected with the mobile brigade program in
order to ensure that it is done in a �mely manner. At the same �me, it is essen�al to ensure that the mobile brigades
ensure the availability of supplements for the nutri�onal rehabilita�on of their beneficiaries in order to avoid a sense of
frustra�on or lack of trust with respect to the work of community volunteers. As far as the care for beneficiaries at HU
level is concerned, it is crucial that the HU give priority a�en�on to cases of acute malnutri�on, thus avoiding that bene-
ficiaries return home without receiving care.
Motivational factors
According to the FGDs, most important among the mo�va�onal factors for the health care of children and PLW is the
well-being of the family. Keeping a family healthy and free from the threat of illness and death is at the heart of people’s
concern. They point out that people are more mo�vated to immediately seek health services when they understand the
risks posed by the disease and the imminent danger to life. Death is men�oned as the saddest event in the life of a
family. The FGDs emphasize a number of aspects that are essen�al to bringing about treatment seeking behavior: a) The
informa�on on how to iden�fy those signs considered most threatening to health; b) The percep�on of the risks of
diseases, indica�ng the state of severity or the threat of death; and c) The percep�on of the benefits of the treatment
for the recovery of the health status of the beneficiary.
Recommenda�on:
The emphasis on the percep�on of disease risks, as well as on the percep�on of the benefits of treatment should be
strongly reinforced in all communica�on channels - community mobiliza�on, consulta�ons in HU and radio programs –
because these are the essen�al elements in mo�va�ng audiences and beneficiaries.
24
N�� , ��
��
At family level
The influen�al figures within the family as men�oned by the FGDs are, in descending order of influence, the husband,
the mother-in-law and the mother. In addi�on, the oldest people in the family also wield influence. The reason for the
above order in the chain of influence, according to the FGDs, lies in the central role of the husband - who is the person
responsible for the decisions concerning care for the child and for the lacta�ng wife. However, the husband is influenced
by his mother, whom he consults about ma�ers related to the health care of his family.
Recommenda�on:
Involve the husbands and the children’s fathers both in community mobiliza�on as well as in messages is crucial for
influencing the way they counsel their wives. It is also important to emphasize the need for their ac�ve involvement in
sensi�za�on ac�vi�es, including the use of air�me to influence other fathers by referring to posi�ve experiences.
At community level
At community level, members have full confidence in their community and religious leaders, influencers, model
mothers, health ac�vists etc., given that these are regarded as “people who act for the sake of the community”, who
relate to health personnel and who therefore are persons who are morally trustworthy and with a recognized track
record of providing services to the community.
Recommenda�on:
Large-scale involvement of community structures in leading sensi�za�on ac�vi�es, screening and referral of children
under five and PLW with acute malnutri�on, as well as in mobilizing audiences and beneficiaries for the dissemina�on
of success stories on community radio and among caretakers and PLW in HU wai�ng rooms.
At external level
The FGDs state that they have total confidence in the public health authority, which deserves to be carefully listened to
when it comes to any statements in the media. This trust is also reflected in the rela�onship with the HU staff, both with
respect to counseling and care.
Recommenda�on:
Assign space to public health authori�es in provincial radio programs and to HU staff in community radio programs,
broadcast at the hours when the audiences usually listen to the radio.
25
D��
Communication Channels
Mobile brigades, community gatherings (with health ac�vists, community religious and leaders), neighbors and friends,
the telephone, the provincial radio and community radios are singled out as the main sources and channels of communi-
ty communica�on in the daily life of the audiences. However, the use of the telephone is really limited because few
people in the community have a telephone, especially in the rural areas. The radio is widely used by the most people,
but not all members of the community own one. The radio, apart from being a considerable communica�on channel in
the community, is also a source of interac�on because the neighbors who do not own a radio visit the house of the
people who do own it to listen together.
Recommenda�on:
Large-scale use of mass media for dissemina�ng messages about the existence of the programme as a complement to
community outreach ac�vi�es, while trying to keep these two components connected so that the audience receives the
same message from different sources, thereby crea�ng an environment of “pressure”.
Frequency and hours for listening to radio programs
Members of the community usually listen at irregular hours. However, there are three day�mes when most radio broad-
casts are listened to: in the morning: beginning of the day (before going to work in the fields); in the a�ernoon (a�er
returning from the field), at night: in the early evening (at dinner �me).
Recommenda�on:
Ensure that radio programs are broadcast at the preferred hours for listening: between 5 and 6 am; between 2 and 4 pm;
between 6 and 8 pm.
Types of preferred programs
The audiences prefer programs that offer informa�on about daily life, as well as those that offer some entertainment,
above all those that deal with problems faced in the daily life of the popula�on.
Recommenda�on:
Create radio programs with drama�zed messages, expressing real day-to-day situa�ons in the community, involving local
people as characters in the messages. This will enable the audience to create empathy with the narra�ve and the narra-
tor.
26
C��

��
Challenges for community mobilization in generating demand for the program
The CLIs presented at least 4 challenges that need to be overcome for the interven�on to succeed:
1) greater resistance to change by men;
2) lack of a clear percep�on of the benefits of the interven�on;
3) lack of clear informa�on on the interven�on to be disseminated; and
4) lack of priority treatment of referred cases by the HU. Of these, at least the first three aspects can be incorpora-
ted into training. The fourth aspect involves the health structure and needs to be dealt with within this structure
Recommenda�on
Prepare a training package that directly responds to the difficul�es and needs presented by the members of community
structures. As far as the priori�za�on of acute malnutri�on cases referred to the HU is concerned, refer the ma�er to
the SDSMAS and to the DPS for the appropriate measures, at least during the emergency response.
The role of community leaders and influencers as mobilizers of the audiences and beneficiaries
The research confirms that the involvement of community leaders and influencers is crucial for addressing the challen-
ges related to the promo�on of search behavior, not only because they are part of the interven�on universe but because
their interven�on is recognized and trusted by the audience. The research also drew a�en�on to the need to draw up
guidelines capable of guiding the whole interven�on, both with respect to the involvement of community structures and
to their interac�on and approach of audiences. The leaders were very enthusias�c about their involvement in tracking
and referring cases of acute malnutri�on. However, they clearly stated the need to be properly trained in order to be
able to adequately start their work in the community. Also men�oned was the need to receive some encouragement
(such as t-shirts and soap).
Recommenda�on
Within the interven�on context the crea�on of good condi�ons in the field is crucial because it is the CLIs who will
directly lead the process of raising awareness in the community. In this sense, it is necessary to create a training package
that includes prac�cal exercises that ensure that their daily work (tracking, referrals and sensi�za�on ac�vi�es) is done
efficiently. On the other hand, given the daily efforts to be made by the CLIs, it will be necessary to develop a monthly
package of incen�ves, which is distributed based on the delivery of the report describing the ac�vi�es carried out in the
corresponding period.
Approach to sensitization activities
The forma�ve research shows that the main challenge for community mobiliza�on is resistance to change (some�mes
jus�fied by cultural beliefs), the lack of sufficient informa�on about health care (of children under 5 years of age and of
PLW), the lack of awareness about the severity of the diseases and, obviously, the great difficulty of having access to
health services experienced by most of the beneficiaries. Another relevant aspect concerns the fact that individual beha-
vior becomes even more reluctant when the environment is not promising when it comes to change or the adop�on of
new prac�ces, thus limi�ng the individual to repea�ng old prac�ces.
27
Recommenda�on
Design guidelines for community mobiliza�on that consider the aspects that have an impact on the behavior of the
popula�on, by sending out messages that not only are able to increase the level of informa�on but also to touch the
audience emo�onally. Therefore, it is cri�cal to address the mo�va�onal factors for health care, the risks and conse-
quences of acute malnutri�on, as well as the benefits gained by treatment. The guidelines should promote an environ-
ment of trust and op�mism among the beneficiaries about the treatment they receive, by encouraging health seeking
behavior that is visible and, consequently, can be reproduced by others. Communica�on materials should be developed
in order to support these guidelines.
28
A��
Focal Discussion Groups:
Groups of parents of children under the age of 5 and PLW

Groups of parents of children under the
Questions Statement
age of 5 and plw
Health of children under the age of 5
Which are the signs that 'Lack of appe�te, frequent crying, fever, 'Lack of appe�te, frequent crying, fever, pimples, weakness, convul-
draw a�en�on when pimples, weakness, convulsions, malaria, sions, malaria, diarrhea, red eyes, coughing and rapid breathing are all
your child is not well? diarrhea, red eyes, coughing, rapid breathing. signs telling us that our children need treatment. There are the more
Why? These are signs indica�ng that the child's serious signs which may cause a lot of concern; and those that are less
health is not good. serious and indicate problems that can even be treated at home (Cabo
Delgado, Mecufi, rural area, father of child under 5 years of age).
The child does not play or laugh and
some�mes it cries.
Which are the signs 'Fever, vomi�ng and diarrhea are the most 'Fever, vomi�ng and diarrhea are more worrying because theseare
considered to be the worrying signs because of the seriousness of diseases that soon take our child. The child may be well in the morning
most alarming, which these diseases. and at night it is gone. This worries us a great deal and we have to act
make you visit the US? immediately - when these signs occur one cannot wait. A child that only
Other signs, such as low weight, indicate
is underweight can wait because that is not serious (Cabo Delgado,
problems that can wait.
Mecufi, rural area, mother of child under 5 years of age).
The most worrying signs are those linked to
The child stayed home for 3 days before we brought her to the US. She
diarrhea and malaria, because these illnesses
was underweight, but we were not worried because she was always
kill children quickly.
there doing her things, playing a bit. But then she started having fever
and vomi�ng and we brought her to the US. But we waited 3 days to
bring her here [US] because we thought she could s�ll be treated at
home, and also the distance from us to the US does not help. It is 3
hours on foot (Zambézia, Nicuadala, health centre, parents of hospitali-
zed children).
We brought our child to US because she had a headache and a fever and
she hardly relieved herself, did not want to eat. The US from the village
we live in gave her an�malaria pills. We did the treatment and she did
not get be�er. So we decided to bring her here at ghe centre a couple of
days later. They did tests and hospitalized her. They say that she is very
sick and needs to gain weight (Zambézia, Nicuadala, health centre,
parents of hospitalized children).
What do you think is 'Weight is a concern because it may be that 'Low weight is associated with roundworms and also to a disease called
happening to the child the child does not have enough blood. "nhala", which sucks the body of the child and the child becomes very
when it is underweight? thin. So people go and visit the healer. The signs are that the skin gets
When the child is underweight one does not
What do you do when very �ght and the bones start to potrude. When that happens we advise
know what the reason is.
you realize that your people to take the child to the healer or to the hospital. Why to the
child is underweight? hospital? Because there they can discover other diseases, such as HIV /
AIDS (Cabo Delgado, Acuabe, community of Macaia, community
leader).
As leaders we recommend to take the child to the healer in these more
serious cases. In simpler cases we recommend the health unit. "Because
when it is a spell the hospital cannot cure it. It is the healer who
removes the spell (Cabo Delgado, Acuabe, community of Macaia,
community leader).
Here we weigh the children, but we do not know what this means. We
are not told because the child has to have the right weight. If the child is
underweight but s�ll playing then we normally don't worry because
there are many thin children here. But if the child stops playing, then we
are concerned. (Zambézia, Namacura health center, parents of hospita-
lized children).
It is normal for an older child to be thin. A child over 2 years of age
becomes thin because it is growing. Therefore not every child is a cause
for concern. But in the case of a baby it is worrying (Cabo Delgado,
Mecufi, rural area, pregnant woman).
29

Questions Statement
age of 5 and plw
Health of PLW
Which are the signs that 'Swelling, bleeding, lack of appe�te, constant 'Swelling, bleeding and lack of appe�te are signs of concern for a
draw a�en�on when fevers, headache pregnant woman because she is carrying a baby. Not for the breas�ee-
your health is not well? dig women, she is not carrying a baby, only nursing it (Cabo Delgado,
Why? Montepuez, Noemia community, pregnant woman).
Which are the signs 'Constant fevers, headache and bleeding. 'In my case, I am pregnant and afraid to cause my baby to die. I also fear
considered to be the for my own health because I know that I can die, so when wesuffer from
These signs are alarming because they may
most alarming, which high fever,vstrong headaches and bleeding, we usually seek help
indicate things that affect the baby's health.
make you visit the US? because we know these are signs that things are not going well for the
mother and the baby (Zambézia, Mocuba, health centre, pregnant
woman)
Do you think PLW may 'A pregnant woman may have a low weight if 'Weight loss, low weight is no concern for us. Only because of this we do
be underweight? Why? she does not eat well. not go to the hospital. But if that low weight comes with pain or fever,
Is it a cause for then we go to the hospital. Only in the case of serious weight loss, one
A pregnant woman may also have problems in
concern? which leaves us without any strength, we go to the health unit (Cabo
her lower abdomen when she works hard.
Delgado, Montepuez, Noemia community, pregnant woman).
For a pregnant woman weight is not a concern
When I see that I have a thin arm I go to the healer. I'm going to the
and she is not going to the US because of this
healer closer to my house. There is weight loss caused by roundworm.
alone.
So in this case it is the healer who has to put leaves to recover (Cabo
When a pregnant woman thinks that her Delgado, health centre Montepuez, breas�eeding woman).
weight is too low she does her best to eat
When I realize that I am underweight, I will eat more to gain weight and
more in order to gain weight.
I will not go straight to the health unit. Here it is normal to have low
weight, because we work. You see? We have to fetch water, walk that
whole distance [2 hours], then come home, prepare lunch for the
family, dp the laundry. It is not easy. Some�mes we do not even have
the �me to eat well. So we get thin. It is because of the work, the
suffering (Zambézia, Namacura, health centre, pregnant woman).
30

Questions Groups of parents of children under the Statement
age of 5 and plw
Health of children under the age of 5 and of PLW
Which are the barriers 'The great barrier is access to the unit - 10 km 'There are a lot of barriers because of the drought. Hunger is widespre-
to properly taking care away. ad. People do not get the things to take care of their health, not even a
of your own health and coconut. It is difficult. It did not used to be like this. But we have been
The lack of understanding of what is
that of your child. suffering for some �me (Zambézia, Nicuadala, health post, parents of
happening with the mother or the child.
hospitalized children).
The lack of informa�on on the health of
Lack of informa�on about all the care one should offer a child. Some
children and pregnant and nursing women.
communi�es around here have informa�on on malaria. But on
The lack of knowledge about malnutri�on in
children's weight, there is no informa�on. Even about the weight of the
children and pregnant and breas�eeding
mother, we are not informed. We weigh both the mother and the child,
women.
but we are not informed about the details of the weight in ques�on
The lack of informa�on on concerns about her (Cabo Delgado, health centre Montepuez, breas�eeding woman).
own health of a mother who is breas�eeding a
The great barrier is the distance. From my house to the US are 12km. It
baby up to 6 months of age.
is difficult. The minibus costs 40 me�cais. There are even people here
The lack of knowledge about other diseases who pay 100 me�cais. O�en I do not have this money. When a woman
that endanger the lives of young children and already is heavily pregnant, to walk all the way for 2 hours to the US is
pregnant and nursing women. very difficult. And it is also not certain that we will be a�ended. If we
arrive late, those health people no longer a�end us. They say come back
Lack of informa�on about the symptoms in
tomorrow. And that does not mo�vate you to come back (Cabo
children and pregnant women that should
Delgado, rural area, Mecufi, breas�eeding woman).
warrant a quick reac�on.
Here we tend to take care of our children. In the case of health issues we
Not associa�ng low weight with dangerous
immediately them to the US, but when we deal with other diseases
diseases
[beliefs] we take them to the healer to cure them because these health
The belief that low weight can be caused by a people can't do that. So in this case it is only the healer (Cabo Delgado,
'local disease' called nhala ('which that sucks Acuabe, community of Macaia, pregnant woman).
the body of the child and the child becomes
Transport is expensive. You have to have 40 me�cais to go and come
very thin').
back, depending on the village where you are. There are villages where
The prac�ce of taking the child to the healer you have to spend 100 me�cais or more. It depends on the distance
when it shows the thinness associated with (Zambézia, Nicuadala, health centre, parents of hospitalized children).
the disease called nhala.
From our house we have to walk really far to reach the US, and o�en
when we get there they tell us to go back. They do not have the pa�ence
to a�end you. They do not want to understand our situa�on. Some are
pa�ent and ask themto wait, but others send them home (Zambézia,
Nicuadala, rural area, pregnant woman).
What could mo�vate 'Maintain good health. 'Today I went to the field but my child had a fever, so I put everything
you to take proper care aside to bring my child here to the hospital. The strength I muster to
Take care of the family. Without good health a
of your health and that overcome the barrier of the distance to the hospital is the desire to
family is sad.
of your child? (What have my child's health back (Zambézia, Nicuadala, rural area, breas�ee-
would you say to Good care / recovery of health / love of life / ding women). All I need to know is that his problem is serious and he
convince a neighbour finding a solu�on to suffering, needs help and I will fight to see my child's smile coming back
who is pregnant or (Zambézia, Nicuadala, rural area, breas�eeding woman).
Having a happy family
lacta�ng woman and
When we see our neighbors doing things that are good for the health of
who is very thin to go to Avoid death. Death is the cause of much
their children, we want to do the same. But some�mes we're afraid to
the US?) sadness.
start on our own. we wait to see things first (Cabo Delgado, Mecufi,
Enjoying health being happy rural area, mother of child under 5 years of age).
Seeing good health care prac�ces
31

Questions Statement
age of 5 and plw
Network of trust and influence in the daily life of the audience, concerning matters related to health care
Within the family, who 'First of all the husband, then the mother-in- 'The mother-in-law has priority over the mother because she comes
influences and advises -law and then the mother. from the husband's'side. The husband wants his mother to be listened
you on health care? to so that her advice is heeded. So I usually listen to my mother, but the
The elderly people in the family also have
most important advice is the one offered by my mother-in-law. If
influence.
anything goes wrong, my husband will blame me and saying that I did
not listen to his mother. That is why I prefer to listen to the advice of my
mother-in-law rather than that of my mother (Cabo Delgado, Mecufi,
rural area, pregnant woman) I would like to listen to the advice of my
mother-in-law and not my mother. .
I usually tell my wife what she should do about a child that is sick or
even when it is healthy. She has to follow my advice because it is good
for her. Now when there is something I know nothing about I send her
to talk to my mother and she has to follow what my mother advises her
to do (Cabo Delgado, Montepuez, health post, father of child under 5
years of age).
We follow the people of our family who have more experience because
they have lived in situa�ons like the ones we are going through. They
may be from my family or from my husband's. He will tell, depending on
the subject (Zambézia, Nicuadala, rural area, breas�eeding woman).
Within the community, 'Community leaders and APEs because they 'The members of the community trust the health staff because they are
who influences and have authority in the community, because educated and help us with health care. A mother who has a sick child
advises you on health they communicate with the staff of the health believes in examples, when someone tells her what happened, that a
care? unit and are well informed. child was sick and then reovered, the treatment chosen to save that
child, all of this, then this mother follows that advice (Zambézia,
Who do you trust? Health workers are also reliable because they
Mocuba, health centre, pregnant woman).
(community leaders, always advise on how to take care of one's
health ac�vists, health and they also run campaigns to protect We listen to the neighbour because he always wants the best and will
religious leaders, HU children against diseases. not give bad advice (Zambézia, Mocuba, health centre, breas�eeding
staff) Why? woman).
Religious leaders, because they always leave
messages for the good of all. I believe in the pastor of my church. He always offers good messages
about what should be done. That's why I always listen. He is the voice of
Midwives and ac�vists, because they receive
my church and everything he says I follow because he is the one guiding
guidance from the health staff.
all of us from that church. I also listen well to my neighbour, because he
knows my life, he wants the best for me and will tell me good things
(Cabo Delgado, Montepuez, Noemia community, pregnant woman).
I listen to the community leaders a lot because they have experience,
they control the community and receive training from the government
and health organiza�ons (Cabo Delgado, Montepuez, Noemia commu-
nity, pregnant woman).
Do you believe that the 'The advice is good and we can trust it 'Good advice always depends a lot on who gives it. Here in the family
advice you receive is because the people who advise us are people and in our community we have people we choose for giving advice.
trustworthy and good who are going to tell us good things because They are people that we have a habit of looking for and who always give
for your health or that they want our good. us advice that we follow. We do not look for other people. We look for
of your child? the ones who always help us and that is why we rely on their advice
The people we consult are th older members
(Zambézia, Mocuba, health centre, pregnant woman).
of the family. These are people who are used
to giving advice.
32

Questions Groups of parents of children under Statement
the age of 5 and plw
Communication channels and dynamics in the daily lives of the audience
Which are the exis�ng Provincial radio 'Here we communicate very well with our neighbour and we talk to each
communica�on other about what we learned. Some�mes my neighbour goes to the US
Community radios
channels in the and tells me what they told her. And Ido the same when I listen to some
community? Mobile brigades advice or heard on the radio that the US is doing a vaccina�on campaign
(Cabo Delgado, Mecufi, breas�eeding woman).
With whom do you Health ac�vists and community / religious
communicate about leaders The radio is very well listened to. Now the telephone here in our area
your health or that of does not work very well, because many people do not have one. There
Neighbours and friends
your child? area areas that have no network, other areas do have it but people do
Phone (limited) not have the money to buy a phone. There are also those few who have
a phone but do not have the money for credit. In that case communica-
Radio (limited) �on can only fail (Cabo Delgado, Acuabe, community of Macaia,
community leader).
Here we communicate very well with our neighbor and we talk to each
other what we learn." Some�mes my neighbor goes to us and tells me
what they told her, so I do when I listen to an advice or listen on the
radio (Cabo Delgado, Mecufi, breas�eeding woman).
I have my radio. But my neighbour does not. So he comes over at my
place to listen. I even like that. Then he leaves or stays a bit longer to talk
about the news we heard. When there is news that interests others here
in the community, then we also involve them in the conversa�on. It's
good (Zambézia, Nicuadala, rural area, community leader).
Are people used to Morning - very early, before going to he field. 'Here the people who go to the field usually wake up very early in the
listening to the radio morning, at 4 or 5 am. We eat our breakfeast, listen to the radio and go
A�ernoon - in the middle of the a�ernoon,
here? At what �me of to the field. We like to listen to the radio before going to the field
upon freturning from the field.
day? because then we know what is happening in the city (Cabo de Delgado,
Night - at the beginning of the night, when Acuabe, rural area, father of child under 5 years of age).
things have calmed down.
Do you in general 'People believe radio messages because the They follow the messages of the radios because the radio usually offers
believe the messages radio usually gives news of things that are news about vaccina�on and in fact what the radio says happens. When
you hear on the radio? happening. they say that they have a vaccina�on campaign and they urge us to go
Why? to the US and we go, then there is the campaign. So we have no reason
The radios announce vaccina�on campaigns
to doubt the radio (Cabo de Delgado, Acuabe, rural area, parent of child
and things the government does.
under 5 years of age).
Here, do people usually 'People believe in the public health staff, both 'The health staff help us with our health and we always try to follow
fully trust what the the US and the Ministry of Health. their health advice.We really trust them. They offer us treatment,
public health authority advice, weigh the children, vaccinate. So we really believe in them (Cabo
People believe the woman that is on the radio
says when it is on the Delgado, Acuabe, rural area, father of child under 5 years of age).
to tell a story that happened, because she is
radio talking about
talking about a real situa�on, something that We really trust the advice of the mother in our area who has the same
health? Why?
happens in the community. And the advice problems that we all have here in the village and who tells her story on
Do you also trust when that is being given should be heeded because the radio. From her story we learn to avoid problems, because she tells
someone from the it is based on a real situa�on. what happened and what she did to overcome it. Through her story, we
village is on the radio know how to avoid having the same problem and we learn how to
and tells a story about overcome it if we have to face it (Cabo Delgado, Acuabe, health centre,
something that pregnant woman).
happened to her/him
We believe in the tes�mony of a father who is telling the story about
and do you heed
what happened to his son. Let us believe what the mother is saying
her/his advice? Why?
because she has lived through that experience (Zambézia, Mocuba,
health centre, pregnant woman).
33
Community leaders and key influencers - provinces of Cabo Delgado and Zambézia
Questions For the groups of community Statement

leaders and key influencers
Awareness raising activities

What do you think has 'Leaders need to realize the problem in order 'In order to convince the person to take the child to the US, we need
to be done to create to know how to approach it with the examples that frighten us, explaining that the health of the child is at
demanda for acute beneficiaries. risk, people here are very afraid of serious illnesses (Cabo Delgado,
malnutri�on Acuabe, community of Macaia, community leader)
Use spaces that people trust, like the
rehabilita�on services?
churches. People go to church for comfort and The leaders need to really understand the benefits of this treatment
believe in the counsel of their leaders. If the [PRN] and then we can convince people. If new things are introduced
leaders are well informed on the subject, then here without our involvement, the community becomes suspicious. So
they will be able to persuade the audience. we need to be well informed in order to be able to properly inform the
community. Without enough informa�on on the subject one cannot
To convince someone to take a child to the US,
convince others. Community leaders need to be well-informed about
we need to give examples that frighten
what they are going to do to convince the community. But first we need
people, explain them that the child's health is
to be convinced ourselves (Cabo Delgado, Acuabe, community of
in danger.
Macaia, community leader).
What do you think the 'Men are more resistant to behavioural change 'The community some�mes reacts suspiciously when new products
challenges of this than women. However, it is they who decide arrive [for health care]. They think these things are bad, that they are
mission would be? about the health of the child. going to harm one’s health. This happened with the product Certeza for
In general, the popula�on does not easily accept water treatment and with condoms. They feel this as a threat. So far,
And how do you think
a change of behaviour. It does not accept new many people do not use condoms because they think the condom
you could deal with
messages and puts up a lot of resistance. contains AIDS. I am a midwife. I received training and they said that we
them?
The leaders some�mes do not know the had to convince the community of not giving childbirth in the communi-
problem they are facing and therefore they ty and show the advantages of giving childbirth in the health unit. We
cannot convince the members of the communi- did that. The women picked up morale [they believed in it]. What we
ty. have said about the benefits is something that the women can see.
The way to overcome the problem is to talk When the benefits are there for all to see and they see that we are not
about it. We have to spread the word that the lying, then they will be interested in going and seeking treatment (Cabo
treatment is good for our children and pregnant Delgado, Acuabe, community of Macaia, midwife).
women.
To overcome these problems one has to show the dangers of the
The leaders need to be very well informed about
disease. Make the comparison with healthy childrens. Then return to
the products they are going to tell the communi-
the home that was visited to show the example of a sick child that has
ty about. When we ourselves are convinced, we
recovered. But avoid raising false expecta�ons. For example, the
speak with one voice and communicate. But we
wai�ng room. Urge the mothers to go to the wai�ng room but when
have to know what the product is and what it is
they arrive there they suffer, there is no food, there is nothing. Because
for. This flour for pregnant women, we do not
of this, many rooms are already closing because people lose confidence
know what it is. Here this product never arrived.
in the service. The trust between the health unit and the community is
shaken. I'm telling you what I'm seeing. (Cabo Delgado, Acuabe,
community of Macaia, midwife).
Here many people do not value the hospital. I have a neighbor who has
a 4-year old child who is very skinny. I told her to take it to the US. I told
her many �mes. But she doesn't. The child is s�ll there in the same
condi�on. Lack of interest. They do not value the hospital. (Cabo
Delgado, Mecufi, model mother).
I think the US staff should pay more a�en�on to the cases we are
referring because these people are really suffering. Around here, the
APE usually treats malaria. Now the most serious cases are sent to the
US. However, when they arrive there they are treated like everybody
else. Despite carrying a referral card issued by the APE, they are told to
queue just like the others. (Zambezia, Nicuadala, rural area, community
ac�vist).
Inluen�al community 'There is a lot of mo�va�on and willingness to 'Here we all work with immense pleasure and receive nothing for it. It’s
leaders would be improve the health condi�ons of the our life anyway. But those trainings we get to learn something new, that
mo�vated to carry out community. mo�vates us (...) But it would also be good to have an incen�ve. It
mobiliza�on work with doesn’t need to be money. But at least a sweater for what we're doing
The mo�va�on comes from the support in
the community? could be good; even a bar of soap would be an incen�ve for us.
terms of training, supervision and incen�ves.
(Cabo Delgado, Acuabe, community of Macaia, midwife).
It is a joy to start a new mission for the good
of the community because this is the life of
the leader - dedica�ng himself to his
community.
34
For the groups of community

Questions Statement
Awareness raising activities

How do you think you 'Insist that parents who have children with 'Most people here do not care when a child has low weight. They do not
would mo�vate parents problems take them to the US. worry it is not accompanied by illnesses or fevers. What is a relief is that
with a malnourished many mothers have to go and weigh their children. Then, they are
Talk to the husband of that mother who has a
child to seek acute informed that their weight is very low. They have to take care of that.
sick child. That woman has to listen to that
malnutri�on Pregnant women as well, when they go for a consulta�on they are
husband. But the husband has to be told
treatment? weighed and they learn about their state of health, and if necessary
many �mes, because men usually do not
they are told to take care of themselves. And they do (Zambézia,
listen the first �me they are being told
Mocuba, healtyh centre, pregnant woman).
something.
35
Questions For the groups of community Statement

Communication channels and dynamics in the daily lives of the audiences

Which are the Provincial radio 'Here in our community, what helps to mobilize the community are the
community's exis�ng means of communica�on that we have. But what we use most arethe
Community radios
communica�on community mee�ngs. Whenever there is something happening in the
channels? Mobile brigades community we call all leaders, heads of the neighbourhoods, all the
people who work in the community in order to communicate what is
Health ac�vists and community/religious
happening. So those who a�end the mee�ng, when they arrive in their
leaders
village they spread the informa�on to the ones who stay there. And that
Neighbours and friends is how we communicate. (Cabo Delgado, Nanhomane Community,
Acuabe, community leader).
Radio (limited)
Telephone (limited)
Community mee�ngs
Are people used to 'We listen to the radio every day, both the ' It is the way of knowing what is going on in the city. In this way we hear
listening to the radio provincial and the community radio. a lot of general news, but also things about health issues. O�en, we
here? know about vaccina�on campaigns through the radio. So, we warn our
MORNING: daybreak (before going to the
neighbour who does not have a radio and that is how we pass the
At what �me of day? field),
informa�on. (Cabo Delgado, Nanhomane Community, Acuabe, commu-
AFTERNOON: in the middle of the a�ernoon, nity leader)..
(when we returns from the field),
Here the whole community listens tothe radio. Local and community
NIGHT: from nigh�all to midnight. radio and na�onal radio. We listen at the beginning of the day, before
going to the field, in the middle of the a�ernoon when we return from
the field and at the end of the day. (Cabo Delgado, Nanhomane commu-
nity, Acuabe, religious leader).
Do you in general 'The people here believe in messages because 'O�en, we wait un�l we hear the radio announcing that tomorrow we
believe the messages they find proof of what they hear. have to go to the US to get vaccines for our children. So, today we
you hear on the radio? organize things in order to get there. So we value the messages we hear
People listen to the radio because they want
Why? on the radio. Some�mes they also no�fy the audience about the health
to know what is going on in their province.
fair, so we also try to organize ourselves to par�cipate. It is always good
The radio always gives informa�on that rturns
to listen to the radio. We feel that we are well informed. (Cabo Delgado,
out to be true.
Nanhomane community, Acuabe, member of the Health Commi�ee).
36
B�� R��
Alberto Albuquerque Gomes. Usos e possibilidades do grupo focal e outras alterna�vas metodológicas. V. 2. n. 1 - Julho
de 2003. Rio de Janeiro, Brasil.
Alive & Thrive. IYCF Prac�ces, Beliefs, and Influences in SNNP Region, Ethiopia. 2103.
Concern. Barrier Analysis Report. Linking Agribusiness and Nutri�on in Mozambique (LAN). 2014.
Care. Forma�ve Research: A guide to support the collec�on and analysis of qualita�ve data for integrated maternal and
child nutri�on program planning
Interna�onal Medical Corps. Care Groups in Emergencies: Evidence on the Use of Care Groups and Peer Support Groups
in Emergency Se�ngs. 2015.
Health Belief Model Contract Chart. Jones and Bartlelt, LLC. NOT FOR SALE OR DISTRIBUITION.
h�p://www.dimensionsofculture.com/2011/02/culturally-based-beliefs-about-illness-causa�on/
Kodish, S. & Gi�elsohn, J. Forma�ve research to inform a government of Mozambique nutri�on interven�on in Cabo de
Delgado Province. 2013.
Ministério da Saúde. 2015. Estratégia Orientadora de Comunicação para a Mudança de Comportamento para a Preven-
ção das Desnutrição Crónica em Mocambique 2015-2019, Maputo,MZ.
Ministério da Saúde, Departamento de Nutrição. Manual de Tratamento e Reabilitação Nutricional – Volume I e II.
Março de 2011.
Mhirter, P. T; Florenzano, U.; Ramon, U.; Souble�er, P. 2002. El modelo transteorico y su aplicación al tratamiento de
adolescentes com problemas de abuso de drogas. Adolesc. La�noam, vol.3, no.2.
Roll back Malaria partnership The Strategic Framework for Malaria Communica�on at the Country Level 2012–2017.
Saul Guerrero & Tanya Khara (Valid Interna�onal). Community Par�cipa�on and Mobilisa�on in CTC (Special Supplement
2). 2017.
Saul Guerrero and Steve Collins. Le�er on community mobilisa�on in outpa�ent
Management of severe malnutri�on. 2017.
Sarah Morgan, Robert Bulten and Dr Hector Jalipa. Community case management approach to SAM, Angola. 2017.
USAID. 2012. C-Change Modules. A learning package for Social and Behavior Change Communica�on (SBCC)
Valid Interna�onal. Community-based Therapeu�c Care/CTC, 2006.
37
1302 Avenida do Zimbabwé,
Maputo, Moçambique
Fax: + 258-21-491719
Telefone:: + 258-21-482200
Email: WFP.Maputo@wfp.org

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FORMATIVE RESEARCH ON DEMAND GENERATION FOR NUTRITIONAL REHABILITATION SERVICES

A������������ ��� A�������

Percep�on of the health of children under the age of 5 and of PLW

b) Percep�on of low weight

a) Barriers faced in health care

b) Mo�va�onal factors in health care

b) Listening hours of radio programs

c) Types of preferred radio programs

Community Mobiliza�on as key element in genera�ng demand for the Program

a) Challenges faced by community mobiliza�on in genera�ng demand for the program

b) The role of community leaders and inﬂuencers as mobilizers of the audience

c) Approach to sensi�za�on ac�vi�es

P��������� �� ��� ������ �� �������� ����� ��� ��� �� 5 ��� �� PLW

Dynamics of the local community

C�������� M����������� �� ��� ������� �� ���������� ������ ��� �����������

Objectives of the formative research

S���� �� ��� ��������

Perception of the health of children under the age of 5 and of PLW

b) Percep�on of low weight

b) Mo�va�onal factors in health care

c) At the level health authori�es and staﬀ

Local communication dynamics

b) Listening hours of radio programs

c) Types of preferred radio programs

b) Mo�va�on of community leaders and inﬂuencers for community mobiliza�on

c) Approach to sensi�za�on ac�vi�es

1. Parents of children under 5 years of age and PLW

2. Community Leaders and key Inﬂuencers

F���� G���� D���������� ��� ����� �������

Mocuba District Seat Parents of children under 5 years of age 05

Directing the work

a) Pre-test of the research instruments

b) Facilita�on of Focus Group Discussions

P����������� �� ��� �������

P��������� �� ��� ������ �� �������� ����� 5 ����� �� ���

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The child stayed at home for

P��������� �� ��� ������ �� �������� ��� ��������� �����

The amount of care spent on the health of pregnant women is consi-

Being pregnant, we are afraid of causing the death

5 Cabo Delgado, Acuabe, rural area, Pregnant woman.

H����� �� �������� ����� 5 ����� �� ��� ��� �� PLW

9 A product used for purifying water.

D������� �� ��� ����� ���������

Radio programs: frequency of listening and listening hours

The radio, both provincial and commu-

We always have some

T���� �� ��������� �������� ��� �������� ���� ������� ��

C�������� M����������� �� ��� �� ���������� ������ ��� ����� ������������

Challenges faced by community mobilization in generating demand for the program

b) Lack of a clear percep�on of the beneﬁts of

15 Cabo Delgado, Acuabe, community of Macaia, religious leader.

The role of community leaders and inﬂuencers as mobilizers of the audience

Screening and referral of acute malnutrition cases

17 Cabo Delgado, Acuabe, community of Macaia, religious leader.

A������� �� ������������� ����������18

Creation of an environment favoring the demand for acute malnutrition services

Perception of the risks21

Perception of the beneﬁts23

C��������� ��� R��������������

Perception of the health of children under 5 years of age

Perception of the health of PLW

D������� �� ����� �������������

Frequency and hours for listening to radio programs

A�� A��

P�� 5 �� PLW

C�� M��

S��

F�� G�� D��

P��

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P�� 5 ��

P��

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