Table 7 Actions identified to address the prioritized household level determinants of LBW

1

Nutrition diary/calendar

Recorded the food consumed in each diet. Guided mothers to fulfill the daily nutrition requirements. Was adopted from the “Happy child diary” concept used in a child health promotion project [13].

2

Participation calendar

A tool to record and monitor the support received from family members by pregnant women. Commonly hung in the living room so that the others can monitor their participation in caring for the pregnant woman.

3

Happiness calendar

A tool to record and monitor the “happiness” of members of the household [13, 17].

4

Stimulation calendar

To record and monitor the activities to stimulate the fetus. Was adopted from “Happy Child diary”, a tool used to monitor the stimulation for children under 5 years [13].

5

Expenditure diary

Recorded and monitored the expenditures of the family. This was divided into three categories.

1. “Sensible Expenditures”: those with positive consequences—nutritious food, education, improving housing and sanitations conditions etc.

2. “Not-so-sensible”: those with negative consequences—tobacco, alcohol, processed food, excessive sugar, fats etc.

3. Expenditures without negative consequences but not much in positive consequences and expenditures perceived as a “waste”—expensive clothing, unnecessary utensils, etc.

6

Vibhaga Pohora (= “Brain Fertilizer”, to do well academically)

The homemade multiple micronutrient supplement was named such, based on the mothers’ hope of making the child clever. Includes heads of dried sprats (normally thrown away) roasted and mixed with an equal portion of dried Moringa leaves. The mixture ground to a powder, used as an additive when preparing flour based food or curries.

7

Model menus

The menus comprised of locally available, low-cost food items with high nutrient value [20]. They were either prepared as “Set menus” (a meal with fixed food items), or based on “Food group charts”, from which participants can select food items for each meal.

8

Food sharing

Is based on a common cultural practice among Sri Lankan communities. When a female becomes pregnant, relatives, friends and neighbors visit her with meals, comprised of food she prefers. This custom was enriched, so that the meal was of good quality and well balanced—based on “Model menus”.

9

Home gardening

A home garden, containing food identified in Model menus, especially dark green leafy vegetables was promoted. Partners, family members and neighbors helped in finding crops and maintaining the garden.

10

Reduction of processed food use

Aimed to shift the dietary habits of the households towards healthier options. Was also coupled with Model menus.

11

“Smoke-free home”

Household level initiatives to stop smoking inside the house [18]. Stopping the idle gatherings of tobacco smoking visitors in the house; discouraging alcohol-centered ‘parties’; displaying posters on effects of tobacco smoke on the fetus, consequences of tobacco smoke to the smokers and non-smokers; verbal requests and discussions with the smokers to motivate them to quit were the actions implemented

12

Reduction of tobacco use

Was coupled with “Smoke-free-homes”. Apart from the actions mentioned, reducing availability of cigarettes by motivating the local vendors to stop selling them; improving awareness on the industrial influence by poster campaigns and informal discussions; reducing smoking in public places using poster campaigns and informal discussions were the other actions implemented.

13

Reduction of alcohol use

Was coupled with reduction of tobacco use and used the same strategies. Additionally, myths on alcohol related behaviors and undue privileges for users were also addressed [19].

14

Remodeling kitchens

Cleaning chimneys, establishing vents and windows to improve air flow, replacing open fires with bio-mass efficient cookers were implemented. Partners played a major role and the expenses were covered by the money saved from cutting down unnecessary and unhealthy expenditures as explained under the “Expenditure diary” (#5, above).

15

Siriyavantha Nivasa

= A pleasant house

Aim was to generate a clean and safe environment. Improving illumination and ventilation, re-organizing furniture to improve space and avoid accidents, keeping the floor clean of clutter and free of dust, keeping the garden clean and free of mosquito breeding sites, making the house a pleasant place by hanging family portraits and pictures on nature and discouraging loud music being played on record players were the common actions implemented.

16

Pregnant mother’s room

Was adopted from “Baby room” concept [13]. Participant, partner and the family and friends engaged in preparing the room for the newborn. The purpose was to create a room or space with adequate illumination and ventilation, free of tobacco smoke, clean, and decorated to provide stimulations for the new born.

17

Listening to lullabies

In addition to providing stimulation for fetal development, listening to lullabies and other soft, soothing music, was aimed at improving maternal mental wellbeing and bonding with the newborn. Mothers were encouraged to sing it by themselves or together with partners, older children and other family members. Lullabies were collectively sung in collective play houses as well.

18

Collective play houses

Mothers living nearby gathered every evening in a play house to engage in interactive play with the children [13]. The play house was rotated among the group members, thus, the mother owning the house got the leadership to organize the sessions. As mothers’ capacities differ, all the children in the community got equal opportunities for stimulation. Presence of neighbors in the households in the evenings prevented smoking and drinking “parties” and post-drunkard violence [15]. Partners and other family members got involved in building the play houses and engaged in its activities. As older children were engaged every evening in the play house, pregnant women were relieved of taking care of them and had an opportunity to rest.

19

Collective feeding

Aim was to provide an adequate, good quality meal for all children at least once a day. Commonly coupled with collective play houses. Mothers prepared the meal as a group, sharing the resources, ensuring its quality, diversity and adequacy. Children fed as a group were found to eat better than alone, playing and stimulating each other [13].

20

Interactions with nature

Spending time in the home garden, looking at birds and butterflies, enjoying the night sky, nature expeditions to local settings such as lakes were the actions promoted. Participation of other children, partners and family members in those interactions was also encouraged. Aim was to facilitate bonding between the family members and improve family wellbeing and provide stimulation for older children.