Strengthening Maternal Nutrition in Rural Kenya through Community Health Promoters Engagement

Strengthening Maternal Nutrition in Rural Kenya through Community Health Promoters Engagement

Concilia Magaya Ogombo¹, Caren Jerop², and Hillary Busolo^3*

¹Department of Public Health, Nutrition and Behavioural Science, Alupe University, Kenya

²Department of Management Science, Development Studies and Communication, Alupe University, Kenya

³Department of Marketing, Hospitality and Human Resource Development, Alupe University, Kenya

*Corresponding Author

DOI: https://dx.doi.org/10.47772/IJRISS.2025.906000222

Received: 28 May 2025; Accepted: 05 June 2025; Published: 08 July 2025

ABSTRACT

Maternal undernutrition is a critical public health issue in low- and middle-income countries, including Kenya, where rural communities continue to suffer from prenatal and lactation nutrition challenges. The commitment of Community Health Promoters (CHPs) to improve maternal health and nutrition in Teso South Sub-County, a region with limited access to health care, food restrictions, and declining institutional support systems, was the subject of this research. The study was motivated by the need to understand how CHPs, as frontline workers, navigate these challenges and assist in enhancing maternal outcomes at the community level. In a qualitative research guide, the study employed in-depth interviews and focus group discussions among CHPs, pregnant women, mothers, and key health stakeholders. The findings revealed that CHPs play significant roles in early detection during pregnancy, referrals, personalized nutrition counseling, and hygiene promotion. However, their performances were constrained by systematic problems, including poor training and supervision, excessive workloads, lack of financial incentives, and stalled government-financed nutrition supplementation programs. Cultural religious faith also emerged as a significant constraint to the use of recommended nutrition interventions during pregnancy. On the basis of the above, the study concludes that even though CHPs play a vital role in the delivery of maternal nutrition interventions, their performances are constrained by structural as well as cultural barriers. It recommends the re-establishment and strengthening of institutional support for CHPs in the form of training, materials, and incentives. Further, appropriate health promotion and greater participation of the community can improve program responsiveness and sustainability. These findings support evidence-based policy and program planning to reduce maternal malnutrition in rural Kenya and other places.

Keywords: Community Health Promoters, Maternal Nutrition, Teso South, Cultural Practices, Health Systems, Qualitative Study, Kenya

INTRODUCTION

Maternal malnutrition has remained a prevalent public health problem in the majority of the world’s regions, including low- and middle-income nations like Kenya, where it contributes enormously to poor maternal and neonatal health status. According to the Kenya Demographic and Health Survey (KDHS, 2022), approximately 20% of pregnant women were malnourished, with rural areas worst affected by the problem due to poverty, low dietary diversity, and poor health services. Pregnancy and lactation-related malnutrition had long-term effects not only maternal mortality and morbidity, but fetal growth and development, birth weight and outcome, cognitive function, and life-time risk of disease in children (Black et al., 2013; Victora et al., 2021). Attempts by international and national stakeholders to enhance maternal nutrition such as micronutrient supplementation, food fortification, and education at the community level were frustrated by structural and socio-cultural obstacles.

In rural health care in Kenya, the Community Health Promoters (CHPs) have been the backbone of primary health delivery. The volunteers are selected from their communities and trained by the Ministry of Health. They serve as a critical bridge between homes and formal health systems. Their roles include maternal health promotion, follow-up vaccinations of children, hygiene and sanitation campaigns, and more recently, nutrition education (MOH, 2020). In 2006, Kenya adopted the Community Health Strategy, which formally integrated CHPs into the national health system of Kenya, with the mandate to link approximately 100 families per CHV to community health units and dispensaries (Ministry of Health, 2006; revised in 2020). Even though these positions are officially recognized, they usually work in difficult environments with limited resources, little financial compensation, and sporadic supervision (Nzinga et al., 2021; Kombe et al., 2019).

To deeply understand the roles of CHPs in rural Kenya, this study was conducted in Teso South Sub-County, Busia County, a rural western Kenyan area with high rate of poverty, and limited access to quality healthcare. The sub-county was reported to have severe maternal and child nutritional problems, according to sub-county health reports (Busia County Health Office, 2022). Pregnant and lactating women in the area were likely to rely on traditional food systems, and cultural taboos such as not eating eggs, fish, or certain vegetables while pregnant are still prevalent (Kimiywe, 2015; Waswa et al., 2021). In this context, CHPs performed multiple functions: they reported early pregnancy, encouraged ANC visitation, conducted home visits, offered individual nutrition counseling, encouraged WASH behaviours, and followed up with underweight children and mothers. These were more than knowledge transmission these tasks required establishing trust, negotiation, and cultural awareness in order to work around contradictory beliefs and limited food sources.

The study was driven by the observation that despite the work of CHPs being widely documented in disease prevention and use of maternal-child health services (Olang’o et al., 2010; Kok et al., 2015), there was limited empirical literature on their role in shaping maternal nutrition practices in culturally diverse but nutritionally vulnerable regions such as Teso South. Previous literature tended to universalize CHV contributions without thematic area disaggregation, such as nutrition, or discussing the intersection of local practices and religious beliefs with their work (Perry et al., 2017). In addition, not many systematic evaluations of the challenges that CHPs faced in implementing nutrition-focused health education challenges such as inadequacy of refresher training and transportation, irregular supply of education materials, and weak facilitation of community mobilization (Chikaphupha et al., 2016; Mbau et al., 2022). This study therefore aimed to expose the realities of maternal nutrition promotion from the CHPs’ viewpoint in Teso South.

To attain its objective, this the study utilized a mixed-methods approach. The CHPs were interviewed using focus group discussions (FGDs) to obtain their experience and approach of engaging communities. In-depth interviews (IDIs) were conducted among leaders and health workers to provide institutional and sociocultural context, whereas structured questionnaires were administered among expectant mothers to collect individual food habits, health-seeking practices, and opinions regarding CHV support. The data were coded using thematic content analysis based on the socio-ecological model (Bronfenbrenner, 1979; Story et al., 2008), where nutrition outcomes are viewed as being determined by individual, interpersonal, community, and institutional factors.

LITERATURE REVIEW

The findings made from this study contributes both theoretically and practically to the body of literature on maternal health by illuminating the invisible work of CHPs and structural vulnerabilities undermining their work. Through the richly detailed lives, the study offered lessons for strengthening community-responsive nutrition interventions, furthering CHV support systems, and aligning maternal nutrition interventions with the realities and cultural references of the place.

The Irreplaceable Contribution of Community Health Promoters

CHPs have been responsible for strengthening a wide variety of health outcomes in LMICs, varying from child survival to infectious disease control to maternal health (Perry & Zulliger, 2012). For maternal health, CHPs contribute significantly to improving ANC coverage, skilled birth attendance, and postnatal care utilization (Kok et al., 2015). Their tasks mostly entail community mobilization, health education, home visits, detection of pregnant women, referral to health facilities, and follow-up of clients. For instance, research has proven that CHV-led interventions can significantly lower early ANC initiation and compliance with recommended visits, thereby enhancing maternal and neonatal outcomes (Okuga et al., 2015). The built-up trust through frequent relationship-based contact enables CHPs to provide more sustained and individualized care, which is generally scarce in overburdened health facilities (Kok et al., 2015).

Socio-cultural Determinants of Maternal Nutrition

Nutrition is a complex problem open to an immense number of determinants, such as socio-economic status, availability of food, and deeply rooted cultural and religious beliefs (Pelto et al., 2016). Pregnancy has been associated with food taboos and dietary restraint in most traditional societies, with origins rooted in beliefs intended to protect the mother or baby, ease childbirth, or influence the features of the child (Ochola & Masibo, 2014). The taboos lead to the prohibition of highly nutritious foods, which exacerbate micronutrient deficiencies. For example, eggs or certain varieties of meat are usually excluded in certain communities because women believe they may give birth to a large baby or complicate the childbirth process. In addition to taboo foods, intra-household food allocation patterns, where women and children eat less nutrient-dense or smaller quantities than men, also contribute to maternal malnutrition (Gittelsohn et al., 1997). This cultural sensitivity is critical in crafting effective nutrition interventions since biomedical advice has the tendency to contradict local established epistemologies (Kavle & Landry, 2018).

Inhibitors to Community Health Promoters

Despite their very important roles, CHPs are usually burdened with harsh conditions that inhibit them from being productive and sustainable. General systemic problems include overloading of work, lack of training, poor supervision, and minimal logistical backing in the areas of transport and study material (Olaniran et al., 2017). Most CHV interventions also suffer from poor incentives or remuneration that causes demotivation and turnover (Maes et al., 2014). Moreover, the connections of CHPs with the formal health system could be weak, limiting their access to supplies, reporting systems for data, and career progress. Structural barriers like these directly affect their ability to provide high-quality, uniform services and to reach hard-to-reach or distant populations.

The Role of Community Involvement in Health Programmes

Effective health promotion, particularly in sensitive areas like maternal nutrition, necessitates active community involvement and participatory approaches (Airhihenbuwa, 1995). Empowering communities to create and implement health programs ensures interventions become culturally attuned, adopted, and sustainable (Wallerstein et al., 2018). Participatory methods such as co-creation workshops, cooking demonstrations, and storytelling can facilitate mutual learning and cultural brokerage to allow health messages to reach more deeply within the community. Such methods extend beyond top-down communication to encourage people’s ownership of the communications and allow them to make knowledge-informed health choices (Pelto et al., 2016). Drawing upon existing social capital, including the legitimacy of traditional leaders, religious groups, and women’s organizations, can assist in optimizing the coverage and acceptability of health interventions (Wallerstein et al., 2018).

Gaps in the Literature

While there is extensive study of the general role of CHPs and the general impact of cultural determinants on diet, there remains a need for country-specific studies to examine the multifaceted interplay of these determinants in particular rural settings. Specifically, very little detailed qualitative research is done to explore CHPs’ everyday lives in managing cultural resistance to nutrition counseling, the direct impact of suspended government support programs on their activities, and the effectiveness of various community engagement strategies to promoting maternal dietary diversity in sub-counties like Teso South. This study attempts to fill these gaps by discussing these dynamics in some detail and offering valuable lessons for designing more effective and sustainable maternal nutrition interventions.

METHODOLOGY

The study was conducted in Teso South Sub-County, Busia County, Kenya, a predominantly rural area characterized by subsistence farming, primarily focused on maize production. The Iteso ethnic group predominantly inhabits the region. Although there are established health centres, access is often limited due to geographical and economic factors. Community-based care, and indeed services from Community Health Promoters (CHPs), therefore become critically significant for maternal and child health. The geographical proximity to the Ugandan border affects cross-border health dynamics and health-seeking behaviour.

To investigate maternal nutrition and the role of CHPs in this setting, the research employed a sequential explanatory mixed-methods approach. The research method involved the simultaneous use of both quantitative and qualitative data collection and analysis phases to integrate an inclusive image of the issue at hand.

The quantitative component involved administering structured questionnaires to 62 pregnant women, who were purposefully selected from various antenatal clinics and through CHP networks in different villages. The participants were chosen to represent variation in socioeconomic status and geographic locations, thus reducing potential sampling bias and enhancing representativeness. The questionnaire gathered data on socio-demographic variables, dietary practices, exposure to nutrition education conducted by CHPs, and barriers to eating. A culturally adapted food frequency questionnaire was incorporated into the instrument, which was pre-tested for clarity and contextual specificity.

The qualitative phase involved four Focus Group Discussions (FGDs) and In-Depth Interviews (IDIs). Participants for the FGDs were purposively chosen from survey respondents to advance emerging themes. An effort was made to form mixed, diverse groups based on age, parity, and residing village to prevent group dominance and facilitate free contribution. The discussions involved traditional beliefs about maternal nutrition, food security, and community experiences with community health programs (CHPs).

In-depth interviews were conducted with key informants, including experienced CHPs, nurses, nutritionists, and representatives from the Community Health Committee (CHC). These interviews addressed CHP daily practices, institutional and cultural barriers, and perceptions regarding community-level nutrition interventions. Semi-structured guides were utilized in all qualitative interviews and consultations, which were recorded with informed consent and transcribed verbatim.

Thematic analysis of the qualitative data was conducted following Braun and Clarke’s (2006) six-step method: (1) becoming familiar with the data, (2) generating initial codes, (3) searching for themes, (4) reviewing themes, (5) identifying and naming themes, and (6) producing the report. To achieve higher reliability and minimize interpretive bias, two researchers coded the transcripts separately, then compared and resolved discrepancies to agree on the final coding framework. The analysis was facilitated by an iterative coding structure developed throughout the process. Triangulation across data sources – survey, FGDs, and IDIs – was employed to enhance credibility and deepen contextual insights.

Ethical clearance was obtained from the Institutional Scientific, Ethics and Research Committee (ISERC) of Alupe University, following which further approvals were secured from the Busia County Department of Health and administrative offices. Participation was entirely voluntary and based on informed consent. Confidentiality was maintained through anonymization and secure handling of data.

FINDINGS

This study’s research highlights the varied roles played by Community Health Promoters (CHPs) in Teso South Sub-County and the complex socio-cultural and systemic context in which they operate. The data obtained through questionnaires, focus group discussions (FGDs), and in-depth interviews (IDIs) elicited valuable information regarding CHV activities, nutritional habits of the expectant women and barriers to optimal maternal nutrition.

The Multi-Faceted Role of Community Health Promoters in Maternal Nutrition and Health

Teso South Sub-County CHPs are the pillars of maternal nutrition and health interventions, providing critical facilitation, counseling, and education at the community level. Their role extends beyond standard clinical health education to encompass a range of in-depth, community-based activities that support the delivery of services and ensure the continuity of care during pregnancy, childbirth, and the postnatal period.

Identification of Pregnancy in Early Stages and Referral to Antenatal Care

Detection and registration of pregnant women in their respective community units by CHPs is one of the key functions and is referred to as “community surveillance” locally. Such an active role ensures early pregnancy initiation of antenatal care. CHPs achieve this through regular visitation of households and through using community intelligence to locate new pregnancy.

As one CHP detailed in a long interview “We go door to door to know who is pregnant and get them to attend ANC early enough. What we term as mapping”

CHPs play a crucial role in the detection of early pregnancy, increasing early antenatal care visits. The early detection aligns with evidence pointing to the importance of local monitoring systems in increasing maternal health-seeking behavior (Okuga et al., 2015).

Referral and Follow-Up for Continuum of Care

CHPs also have the responsibility of performing critical referral and follow-up activities, particularly for high-risk pregnancies, ANC visits lost-to-follow-up, and maternal warning signs. When women miss their ANC visits or experience health complications, CHPs step in through follow-up visits, performing health talks, and referrals to local health centres.

One respondent stated that, “If she doesn’t go for her checkup, I go again. If she is ill, I refer or take her to the health center and, sometimes, negotiate with the husband to assist her.”

This general model of engagement, with clients and with partners, promotes gender-responsive care and shared responsibility at the community level. CHPs are effective in enabling follow-up and referral, and they enable effective linkages to health facilities. These findings reinforce the work of Kok et al. (2015), who comment on the greater continuity of care delivered through CHPs in the form of relationship-based, trusted follow-ups.

Nutrition Education and Challenge to Local Beliefs

Teso South’s CHPs provide education in nutrition with sensitivity to local beliefs, economic status, and food habits. Despite the effort, their health education activity is usually met with resistance from deep-rooted cultural taboos, e.g., not eating eggs or some vegetables during pregnancy. In response to these beliefs, they encourage them to slowly try taking at least five groups of food out of ten.

“I teach them why they must eat vegetables, eggs, and legumes. I guide them slowly, even by example,” explained one CHP

CHV-guided nutrition counselling is observed to be associated with increased dietary variety among pregnant women, supporting the evidence of Muchiri et al. (2019), which emphasizes the significant role played by context-relevant interpersonal communication in improving maternal nutrition outcomes.

Environmental Hygiene Promotion

Furthermore, CHPs check for home environmental hygiene during home visits. They inspect the food storage, handwashing facilities, and water safety. All of these interventions are guided by World Health Organization (WHO, 2018) guidelines that integrate Water, Sanitation, and Hygiene (WASH) elements in maternal and newborn care promotion.

A CHP noted: “When I go, I notice where they prepare food is not clean, if they wash their hands, if water is covered. I show them how to make their environment clean for their sake and the unborn child.”

Regular visits by CHPs are associated with improved household sanitation practices, as supported by World Health Organization (WHO, 2018) guidelines integrating Water, Sanitation, and Hygiene (WASH) components into maternal and neonatal care promotion.

Informal Transnational Healthcare Access

Since Teso South borders Uganda, CHPs occasionally attend to clients who have crossed over to access services in facilities like Alupe Sub-County Hospital. Whereas CHPs themselves do not officially conduct outreach across the border, they also attend to Ugandan nationals who cross over for treatment. As one CHP put it;

“We don’t go to Uganda, but when the women come to Alupe, we still serve them. We don’t discriminate.”

This highlights the unstated transnational work that CHPs are doing, namely, in extending public health services across borders. MacPherson et al. (2014) also speak of concomitant trends in East Africa, highlighting the burden such demand puts on already stretched health systems.

Overloaded Workload Challenge

Despite their critical work, CHPs in Teso South face a significant challenge in the form of overloaded workloads, in most instances working with populations far in excess of the one-CHP-to-500 recommended norm by Kenya’s Community Health Policy. This overloading of work undermines the service quality and reduces the CHPs’ capacity to follow up regularly. One group reported managing up to 2,000 people, stating that they do it because there is no one else. Such reactions are consistent with the threats of Olaniran et al. (2017), who warn that such imbalances in personnel undermine the performance and motivation of CHPs, especially if compounded by poor incentives, poor training, and bottlenecks like transport.

Nutrition Practices and Challenges in the Community

Maternal food habits in Teso South Sub-County depict a forcefully entrenched dynamic influenced by economic struggle, cultural orientation, and undermined access to food. At the center of individuals’ eating ways is the hegemony of ugali as a staple food and cultural foundation. Not only is it regarded as food, but rather as the very epitome of eating. As one FGD participant put it: “Ugali is life here. You have not eaten if you did not eat ugali. Pregnant women even say that only ugali will satisfy them.”

Even though with caloric density, ugali is lacking in vital micronutrients such as iron, zinc, and vitamins, of concern being high among pregnant women. While CHPs have struggled to encourage diet variety within food groups such as fruit, vegetables, legumes, and animal foods, practice in the real world falls behind knowledge levels due to limited household budgets. A CHP commented: “We instruct them to consume at least five food groups like ugali, vegetables, eggs, beans or meat, and fruit but not everyone can manage.”

Pregnant women are expected to take at least five out of the ten food groups daily, as prescribed by Kenya’s Ministry of Health (2016). But from quantitative data from the questionnaires filled by pregnant women in this study, it was clear that the majority of women could only take two or three food groups regularly. The majority of their diets focused on ugali, vegetables such as osuga (black nightshade) or kunde (cowpea leaves), and beans sometimes. Seasonal fluctuation and the high cost of animal-source foods also worsen the situation. Even when mangoes and bananas, for instance, are within reach at certain points in the year, they are usually sold to make a living rather than consumed in the home. A pregnant woman noted: “Even if she likes fruits or meat, if she has no money, she will be consuming ugali with greens alone.”

Intra-household food allocation was also unequal. Cultural attitudes tend to put men and children first at the table, with women and pregnant women in general taking smaller or worse-quality servings. Such inequality is compounded by a gender system in which men are generally in charge of household budgets and make the ultimate decisions on food buying and food consumption sequence.

Cultural and Religious Barriers to Maternal Nutrition

Aside from economic factors, powerful religious and cultural values play a powerful role in pregnancy food avoidance. Generations of inherited residual food beliefs still strongly impact pregnant women’s diet and what they should not eat. Extremely healthy foods like eggs are sometimes avoided since pregnant women fear that they will complicate delivery. One FGD participant explained: “Others tell us eggs will cover up the baby and enlarge the baby, or mud fish will make women to have enlarged breasts”

These beliefs result in the elimination of meat and fish from the diet, with some women avoiding these foods on the grounds that they will negatively influence a baby’s appearance or temperament. These food taboos are so pervasive that even women who comprehend the nutritional value of these foods shun them for fear of social censure or disapproval. In other families, religious beliefs impose additional restrictions. For instance, some women fast during pregnancy, taking no food all day. Additionally, long-standing customary beliefs disapprove of pregnant women sharing meals together.

You cannot eat alongside another pregnant woman. That is what our grandmothers taught us.”

Assuming under this belief is that two pregnant women never should, and must not, take food from the same pot, lest one of the baby dies at birth. This establishes the expectation of cooking several meals in one household something not practical and often cost-deterrent. These practices, though they have historical and group identity roots, greatly limit the intake of protein and micronutrient-containing foods at a very critical growth period. Existing studies, for example, Ochola and Masibo (2014), concur that while there is evidence that health education has covered most mothers, cultural beliefs remain paramount to these, there being an inherent gap between what women know and what they are able to do or willing to do.

Institutional Lack and the Need for Ongoing Support

Government-funded nutrition supplementation schemes used to play a huge proportion in supplementing the diet of pregnant women in Teso South. Supplement and flour fortification schemes supplemented dietary deficiencies, particularly by economically poor households. Cancellation of the program has left a tangible gap.

One FGD respondent remembered: “We would sleep well when the government gave us maize or flour. They now just say eat well, but most of them don’t.”

The absence of such interventions has put CHPs in a difficult position. Although they still provide life-saving nutrition counseling, they no longer have something to give to the women they counsel. This has caused frustration and hopelessness among mothers and CHPs, who feel marginalized. Mothers are being progressively forced to choose between food and other essentials such as rent, school fees, and medical care. Although women with apparent symptoms of nutrient deficiency such as edema, headaches, or severe tiredness they do not complain. CHPs do understand the reason. One CHP explained: “Sometimes their feet are swollen and they complain of headaches, but we know it is because they eat only ugali. They never complain, but you can tell they nutrintion deficiency.”

CHPs remain quite at the forefront of the maternal health program within the community, endeavoring day and night to ensure there is information and to drive behavior change. However, unless interventions such as food subsidy or the reimplementation of nutritional support programs are incorporated, their efforts cannot be optimized. Without those, efforts to improve the mother’s nutrition may not be sustained in the long term.

Intersectoral Collaboration and Support Networks

CHPs in the FGDs indicated they had good working relationships with different organizations like Kenya Red Cross, AMREF Health Africa, Population Services Kenya, and Living Goods, which provide logistical support, job aids, and recurring training. CHPs also indicated that they worked with faith leaders, Community Health Committees (CHCs), and church groups to enhance message uptake and program acceptability. One of the CHP participants described: “We sometimes work with the church or community leaders. When they work together, people come in hundreds.”

Such partnerships become crucial in avoiding resistance to biomedical advice and gaining program legitimacy. CHPs understood that residents are likely to show up for nutrition sessions or clinics if the message is accompanied by the support of very respected individuals. Such a coordination system is appropriate under public health frameworks, classifying social capital as a health action determinant of communities (Wallerstein et al., 2018).

CHPs also discussed participation in group outreach work conducted on market days or after church services, capitalizing on community events to disseminate nutrition information. All the CHPs reported the same distinctions regarding whether or not women will accept nutrition advice based on education and gender. They reported that better-educated younger women are more likely to accept advice, while older women tend to follow cultural tradition or experience.

A CHP respondent clarified: “Young girls who have gone to school listen. Older women or those who had children years back think they know.”

CHPs emphasized the need for differentiated communication approaches that respect traditional knowledge but incorporate new, evidence-based interventions. A few CHPs testified to the use of storytelling or referencing local success stories in order to challenge old assumptions in a respectful manner without appearing to be disrespectful. As one CHP participant testified: “When you speak in a manner respectful of their experience, they are more likely to listen.”

The strongest finding of the FGDs was the requirement for participatory learning in bringing about behavior change. The CHPs stated that cooking demonstrations, drama, and role-plays were more helpful compared to leaflets or posters alone. These interventions allowed women to see, taste, and ask questions about healthy food made from easily accessible local ingredients.

One participant from a CHP said “We used to do a demonstration of cooking with vegetables within the area and people liked it. They would say, ‘Now we know better than from a poster.'”

Another CHP described a session where women prepared porridge using millet, groundnuts, cassava, and dried fish food not commonly utilized.

Participatory learning methods, such as cooking demonstrations, were reported by CHPs as highly effective at inducing behavior change. These methods allowed women to see, taste, and ask questions about healthy food made from local food materials that are easily accessible. Experiential learning methods are strongly recommended by Pelto et al., (2016), who propose culturally sensitive and participatory methods in community nutrition interventions.

Framing Nutrition as Part of Birth Preparedness

CHPs highlighted more focus on the way birth preparation is being discussed with pregnant women. Originally focused on transportation, savings, and where to get delivered, birth preparedness now includes nutrition planning counseling. As one CHP participant explained: “We instruct them to prepare for delivery by preparing their bodies through food, not cash.”

CHPs encourage families to investigate low-cost, locally sourced food and to budget not only for transportation but also for nutritious food. They reported, however, that few of the families at present consider nutrition when they plan. Even with CHPs’ efforts to connect nutrition with birth preparedness planning, it would appear that meal planning is not yet routine birth preparedness in CHP-monitored households. This implies that there is still more messaging to be done on nutrition as a critical aspect of safe motherhood.

DISCUSSION

This study presents a closer examination of the complex picture of maternal nutrition in Teso South Sub-County, Kenya, and the illumination of the critical role of Community Health Promoters (CHPs) and the multi-dimensional nature of challenges confronted by them. The findings bring to focus the critical function of CHPs in bringing primary healthcare facilities to the community level, that is, early pregnancy detection, referral, nutrition counselling, and promotion of hygiene. However, they also report severe barriers, including deep-rooted cultural beliefs, socio-economic constraints, and institutional loopholes at the policy level, which individually impact maternal food habits and effectiveness of CHP interventions.

The Role of CHPs in Maternal Health Outcomes

The findings of this research support other studies on the significant contribution of CHPs toward improved maternal health outcomes (Lewin et al., 2010; Kok et al., 2015). The significant role of CHPs in identification during early pregnancy and utilization of more early ANC visits further support their effectiveness as community-level surveillance agents. Early detection is central to early utilization of antenatal care, a mainstay in safe motherhood promotion (WHO, 2016). The CHPs’ dedication to referral and follow-up, negotiation with partners, indicates a holistic and gender-sensitive strategy that enhances continuity of care and strengthens community trust, aligning with relationship-based models of care advocated by Kok et al., (2015). Their environmental hygiene promotion also indirectly advocates for a healthier home environment, nurturing maternal and child health by reducing exposure to infection (WHO, 2018). The informal transnational aspect of their work, while unplanned, highlights their humanitarian commitment and the porous nature of healthcare access in border regions, a phenomenon observed elsewhere in East Africa (MacPherson et al., 2014).

Influence of Cultural Beliefs on Dietary Behaviors

The study unequivocally demonstrates that cultural and religious beliefs profoundly influence maternal dietary practices in Teso South, often overriding biomedical nutrition advice. The prevalence of ugali as a staple and large-scale food taboos on traditional foods that are nutrient-rich like eggs, meat, and fish contribute significantly to low dietary diversity among pregnant women. This is supported by existing research findings from other African settings where pregnancy foods are culturally determined (Ochola & Masibo, 2014). The perception that food complicates delivery or impacts the baby’s appearance, and food prohibitions among pregnant women, is indicative of the profound epistemic dissonance between past epistemologies and modern health science (Kavle & Landry, 2018). This form of cultural resistance presents a stern challenge of will for CHPs, who must labor within these deep-seated beliefs without alienating the public. The quantitative data from questionnaires, showing most women consuming only two or three food groups, provides empirical evidence of the pervasive impact these economic and cultural determinants have had on actual dietary diversity.

Approaches to Enhancing Community Involvement in Nutrition Programs

The study highlights the potential for intersectoral coordination and culturally tailored communication approaches to enhance community involvement and overcome resistance. CHPs’ partnerships with NGOs, religious officials, and birth attendants are critical in framing legitimacy and message acceptability in accordance with the social capital concept of health promotion (Wallerstein et al., 2018). The reported differences in age and educational uptake of messages further support calls for differentiated communication strategies. More educated, younger women may be more receptive to evidence-based advice, but older women may require approaches that respect traditional knowledge respectfully.

Above all, the findings strongly endorse participatory learning approaches, such as role-play and cooking demonstrations, over pedagogical ones. The effectiveness of these hands-on methods, as evidenced by increased knowledge and application of new recipes, is consistent with recommendations by Pelto et al., (2016) for culturally responsive and participatory nutrition education. These methods allow for in-practice application of knowledge, immediate feedback, and seeing how healthy meals can be made with locally available and affordable ingredients. Furthermore, aligning nutrition with birth preparedness as a central rather than sole focus of consideration, is a strong potential route for re-framing healthy eating in an existing frame of thought and value that is already appreciated and known to the population.

Implications for Policy and Practice

The findings have several significant implications for policy and practice in strengthening maternal nutrition in Teso South and similar contexts. First, the voluminous workload burden on CHPs needs urgent policy adjustment and resource allocation to ensure a more equitable CHP-to-population ratio. Otherwise, the stability and quality of their essential services will still remain compromised (Olaniran et al., 2017). Second, the suspension of government nutrition supplementation programs has created a significant gap, exposing pregnant women further. Policy makers should keep in mind the option of reviving such programs or establishing alternative food subsidy schemes to provide tangible support as well as nutrition counseling.

Third, training programs for CHPs must be improved to equip them with additional skills in culturally sensitive communication and participatory learning methods. This includes developing locally translated pictorial education materials and providing supportive logistics such as bicycles and gumboots to improve their coverage and impact. Finally, applying and integrating the cultural resources within the realm of health promotion is an interesting point of entry for nutrition message communication that is done in a way that ensures maximum sustainability (FAO, 2019).

Limitations in the Study

This research, as much as it has some vital findings, is limited to some extent. The purposive sampling, while appropriate for qualitative research to gain in-depth understanding, limits the generalizability of findings to the larger population of Teso South Sub-County or elsewhere. The reliance on self-reports of eating habits in questionnaires is vulnerable to recall bias or social desirability bias. Besides, the cross-sectional study design does not support causal inferences between CHP intervention and long-term maternal nutrition outcomes. Quantitative data based on previous reports, as much as they are useful, were not collected as part of this study’s initial quantitative phase targeting questionnaires from expectant women. Future longitudinal studies with larger, representative samples would be indicated to track trends of changes in food consumption patterns and health outcomes over time.

Future Research Recommendations

Based on the findings and limitations of the current study, some future research priorities are suggested:

1. Longitudinal studies-To assess the long-term impact of CHP interventions on maternal nutrition outcomes and track changes in dietary diversity during pregnancy and postpartum.
2. Intervention studies-To evaluate the effectiveness of specific culturally tailored nutrition education interventions, namely participatory ones like cooking demonstrations, in improving maternal dietary diversity.
3. Driver studies of CHP motivation, retention, and impacts of different incentive models can be utilized to establish more sustainable CHP schemes.

CONCLUSION

Teso South Sub-County Community Health Promoters are the unsung pillars of maternal nutrition and health programs, proving exemplary commitment and effectiveness in extending critical services to the grass root. Their high community embeddedness and culturally sensitive approaches are critical in bridging the chasm between formal healthcare systems and people’s surroundings. However, their highly effective contribution is extremely constrained by systems problems like excessive volumes of workload, endemic cultural opposition to best eating habits, rudimentary levels of logistical support, and the core absence of government-funded nutrition supplementation programs.

For the purpose of maximizing maternal nutrition benefits in Teso South, there is a requirement for adopting an integrated and multi-faceted strategy. The strategy needs to accord highest priority to long-term and culturally sensitized care for CHPs, including rationalization of their work distortions, provision of required facilities such as local language-translated education materials and improved modes of transport, and exploring the feasibility of reviving or beginning alternative nutrition support schemes. Moreover, strategically applying existing cultural resources as well as establishing strong intersectoral alliances are necessary for enhancing the acceptability, relevance, and overall effectiveness of nutrition interventions. By acknowledging and actively engaging with the intricate interplay of sociocultural forces and systemic issues, and by empowering these important community health workers, it is feasible to produce a more supportive and facilitative context for maternal nutrition, ultimately enhancing the health and well-being of women and children in Teso South.

ACKNOWLEDGEMENTS

The authors express their gratitude to Alupe University for its financial support, the Teso South Sub-County Community Health Promoters, the expectant mothers and other community members whose involvement greatly enhanced the research results. Finally, the local healthcare professionals for their cooperation and facilitation, which were crucial to the successful completion of this study.

Conflict Of Interest

The authors do not have any conflict of interest.

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