Narrator: Welcome to ENN's Field Exchange podcast. In this episode, our host, Stephanie Wrottesley, speaks with Natalie Roschnik, a Senior Nutrition Advisor at Save the Children UK and Technical Lead for nutrition programming in non-humanitarian settings. They discussed Maziko, one of Save the Children's flagship cash “plus” for nutrition projects, which focused on maternal and child nutrition.

Stephanie: Hello everyone, and welcome to today's podcast. My name is Stephanie Wrottesley and I'm one of the Senior Nutritionists at ENN. Today I'm delighted to welcome Natalie Roschnik to the podcast to talk about findings from Save the Children's Maziko inception studies in Malawi. A very warm welcome to you, Natalie. To start off, would you please introduce yourself to our audience?

Natalie: Hi Stephanie, and thank you so much for the invitation. Yes, I'm a Senior Nutrition advisor with Save the Children UK. I'm also actually a doctoral student at University of Geneva and I'm doing my PhD project on this project, so it's very nice to be able to speak about it. I'm based in France, and I've been working with Save the Children for over 20 years with Save the Children US on school health and nutrition for around fifteen years, and then the past eight years on nutrition.

Stephanie: Natalie, together with your colleagues, you wrote a fantastic article on one of Save the Children's flagship cash flow “plus” for Nutrition project, Maziko, which featured in Issue 71 of Field Exchange. Can you give the audience a bit of background on the Maziko project and why the team chose to implement it in this setting?

Natalie: So, it's a long story. It starts with early childhood development, over a decade ago, and we found that through all our early childhood development programming, that one of the biggest barriers to community-based preschools running was lack of food: when the preschools were not able to give food to the children when they came, and then the preschools would close. What Save The Children did at the time was to overlay a set of agriculture, food security and livelihood component with a nutrition component whereby communities would learn new climate smart agriculture, but also how to prepare more nutritious foods. And then we partnered with IFPRI and did a big cluster randomized trial and evaluated the impact of this ECD nutrition agriculture intervention on all the outcomes and found that it was very impressive. It had an impact across all the different early childhood development, nutrition and agriculture outcomes. This was then used by the government to get funding from the World Bank to scale it up across ten districts through this program, called investing in early years. So that’s the history. And then just in 2019, Power of Nutrition approached Save the Children with Give Directly, to suggest that we did a cash transfer project. And so we really built on that previous project and research, which we called NEEP. We built on that to design a similar multi sector integrated program, but this time with a cash transfer piece to it. And then the aim of the research was to evaluate added value of a cash transfer provided alongside these nutrition ECD agriculture interventions. That's how it sort of the idea and how it was designed. With that in mind, the Mazika project was launched in November 2021. Now in 2024, it's in its third year of implementation.

Stephanie: One of the key insights from the study was around maternal mental health and, in your article, you talked about being surprised by your findings. What surprised you most about the findings, and why do you think that the impact of maternal mental health on family nutrition was a surprise in this context?

Natalie: I think twofold. On the one hand, we had done the previous NEEP research so we knew that food security, poor hygiene, lack of access to services, we knew those would probably be issues and drivers of malnutrition, but we hadn't really collected any data on maternal mental health. So that was a bit of a blind spot. But, also, I think maybe naively, when I go to Malawi and we visit communities and everyone is dancing and singing and so happy, I thought maybe, oh, well, you know, these are not communities which have that kind of issue. So I was surprised, but I was also surprised by the extent of it. So, basically, the baseline survey quantitative found that 26% of women interviewed had symptoms of depression. There's an actual standard way of assessing it and then this qualitative immersion research, it also came out extremely strongly about how overburdened women are, too many chores, not feeling supported, and just anxious and stressed about so many different things. So, yes, it really was, a surprise and it just made me realize how important maternal mental health is for so many, for the growth and development of their children and themselves and their own wellbeing.

Stephanie: Yeah. On that note, there is an increasing acknowledgement globally on the importance of better integration of maternal mental health into maternal and child health and nutrition policies and programs. What do you think we need to do better to support mothers wellbeing?

Natalie: Speaking maybe with the Malawi context in mind on this specific project, all of those interventions we'd already designed to do in Maziko that we did in NEEP, those ones to support food security, cash transfers and behaviour change piece, which would all support maternal wellbeing. But what we decided to add to it, and this was a recommendation by the government of Malawi, was to integrate this ‘caring for the caregiver’ package, which is a package developed by UNICEF, and it was then adapted to the Malawian context and is only being done on a pilot basis in Malawi. So it was an opportunity, given as a big research component to integrate it. This ‘caring for caregivers’ is about training community volunteers. Just in Malawi, one of the interventions is to roll out the care group system, which is the government of Malawi's recommended behaviour change for nutrition, and there are mother volunteers who then are supposed to do home visits and group sessions with mothers to discuss health and nutrition and so, overled with that, they receive a training on how to talk about maternal mental health with women and their families, and help to support and tools to help them manage it, but referrals etc. We will hopefully learn through this project to what extent that makes a difference, and to what extent all the other interventions also make a difference. There's also a male engagement component, which we also added afterwards, and that involves engaging men to be more supportive in the household. And we're really hoping that that will also make a difference, because I think one of the main reasons why women are so stressed and overwhelmed is everything really falls on their shoulders. I mean, they're doing everything in the household and then having to care for the children, and the are stressed because they don't have any money, and so on. So I think having that should also hopefully make a difference.

Stephanie: You touched on it briefly there, but the role of fathers and husbands is also something that is commonly overlooked in maternal and child health policies and programs. And the findings from the Maziko project show that fathers were often absent or disengaged. Can you share any thoughts on the role that fathers and husbands could play in achieving improved nutrition and development outcomes for children? And how approaches like the male champions mentioned in the article, aim to promote better engagement of male partners and caregivers.

Natalie: That was definitely a big finding from both the quantitative and qualitative surveys. We found that many women were living alone, and then when they were living with husbands, or they had their husbands there, they would not be necessarily very engaged in their daily lives. We had our gender advisors who came and trained government and Save the Children people to roll out this male champions approach and it was a very practical with lots of games to really get men, including all our staff and colleagues and district government, to really think about gender norms and bias and when we get angry and all of these. But also, what is their vision for a happy, successful family focusing on sort of nutrition, child development and so on. This was rolled out in the similar manner as the care group following that structure where male champions are identified as role models, and they then train father leads, who then go out into the community and engage men and talk about them, and they try and reach out to them through their existing activities and so on. I just went to visit just in January, and they were very impressive. You can sometimes assume that men don't want to be engaged, but actually, you see that they do. They want a happy family. And many of them said, “my relationship with my wife is better”. We don't know yet how it's working, but anecdotally, women are saying that it's making a difference and I think it's especially important also when you're giving cash transfers, because there can be dynamics within the households that a cash transfer could exacerbate. For example, if the men don't want the women to control any money and then she's getting money directly, that can create issues. So I think it's actually very important to have a male engagement component within a cash transfer program as well.

Stephanie: To move on a little bit to your methods, your data was collected using quite a unique immersive approach in which researchers shared in women's experiences by living in their household for four days and four nights. That is quite an ask for women and their family members and for the researchers, and I'm sure had the potential to introduce bias. How was this approach received by those who were involved? And what, if anything, was done to ensure that the researchers got a realistic picture of women's lived experiences.

Natalie: It was definitely an unusual, and it's quite a new research method that Save the Children has used - we've only used it twice, once in Indonesia and then this time in Malawi. We were supported by this organization called Empatika, who are really the experts at this, and they normally they go and actually do the immersion - they're experts at doing immersion and they have a specific method of doing it. But this time we wanted our staff to do it themselves, also to just have more empathy and understanding of the issues that the communities we were going to support face. So they were then trained, I was actually also trained for a whole week by Empatika. We were trained on bias, on prejudice, on power, on how to gather information in an informal way rather than a formal way. Actually, it was very difficult, there was a lot of training and they coached them all the way through. There's also a specific way of entering the community, introducing what we're doing. And what's most important is that they live exactly the same way as the people are living: sleeping on the floor, eating exactly what they're eating, and then going to the field and gathering. It's gathering information through participating in all the everyday activities, going and queuing for the 2 hours at the health centre if needed, and then they can come back after these four days and four nights. And I think what is risky maybe in some ways is, one, I think it's risky in the sense that they're living in these households. It all went well, but you know, I think some of our colleagues felt a little bit nervous, but also when returning, they're not taking any notes, so they have domains of discussion that they want to collect and they have a job aid to just remember. They have just one page, just reminding them of the topics that they want to discuss. But they're not supposed to take notes because it distracts from that informal way. And then they immediately after these four days, they have a debrief with Empatika. It takes two days where they download all the information, and they just talk about it as a team so they triangulate the results and Empatika records it all and then writes it all down. So it is quite a different, less rigorous approach. But we found, at least in Indonesia and Malawi, that it actually degenerates much more in depth information and just to give you an example, one of the researchers was living in a household with a mother with a two-month-old baby, and all the mothers actually said that they exclusively breastfeed for six months. Of course we know that, but in fact it took him two days to find out that actually she was hiding giving her two-month-old porridge because she knew she shouldn't do it. But they want to because they don't believe they're breast milk is enough, they're exhausted and it helps the baby sleep and stop crying. So had we just done focus group discussions and interviews, we probably wouldn't have found that kind of thing out.

Stephanie: And I guess that's why you need to do the four days, to have a couple of days for them to get used to the researcher there as another household member and start acting like they're like part of the fold, which is interesting.
Natalie: Yeah, exactly. And I should say that most of them became sort of very close friends to them and we went back to sort of do a people driven design where you start thinking about solutions. It's a big reunion, they went back to the same households and so, you know, they developed quite strong relationships together. It's really nice in most cases.
Stephanie: Wow, that's really unique research approach. And in your article, you mentioned that Malawi's current national social support program only reaches 2% of mothers and children under two years. This number is surprisingly low given the emphasis in maternal and child health and nutrition policies and programs on the first 1000 days of life. Do you have any insight into why this gap exists?

Natalie: Yeah, so this is Save the Children's big advocacy piece, not just in Malawi but globally, to have more child sensitive or nutrition sensitive social protection systems. And I think the reason is that the social support system in Malawi is based on poverty mostly. They target households based on poverty, which might not be the households with small children. We did an assessment in 2020 and found that only 2% of children under two years their households were receiving any social support, so it's really nothing. What we advocate for, and we're hoping that this Maziko project generates evidence on, is for categorical targeting, which means targeting a group of the population, in this case it's mothers and children in their 1st 1000 days would be the priority - from pregnancy to two years - they would, regardless of income, receive a monthly cash transfer to support them and help them access nutritious food access, health and nutrition services and so on. So, the Maziko project is actually, it's a four-arm cluster randomized trial looking at the added value of cash over these other plus interventions. And we're actually looking at two cash transfer sizes.

Stephanie: You also emphasize the need for a multisectoral approach to address the drivers of malnutrition and poor child development that may have been missed in other cash interventions. Can you provide some more insight into what drivers are commonly overlooked and how the Maziko project came to tackle them?
Natalie: Yes, I think we identified the inception period, and the inception research really identified quite a few drivers, including food security, access to nutritious foods, lack of access to nutritious foods, issues with health, and nutrition services, hygiene, and gender inequality and this maternal mental health issue. Traditionally cash transfer programs or maternal and child cash transfer programs would limit themselves to just nutrition - adding the “plus” bit, which is recommended often, is just sort of nutrition messaging or nutrition education, which is definitely better than nothing, but, as we know, just telling people what to do doesn't usually make them change behaviours, and it doesn't address the main drivers. I think the Maziko project is a good example of a more multisectoral approach that addresses most of those drivers because it includes a food security, agriculture component, it includes a maternal mental health component, it includes the gender component, and all of the behaviour change through the care groups. I think that's really good. I think one of the challenges is that it becomes a lot. It becomes a very heavy plus piece to attach to a cash transfer. The challenge is all about finding the leanest yet, cost effective plus component to attach to a cash transfer, which addresses most of the main drivers. So, I'm really hoping that through this project, we will identify the best package is.

Stephanie: Building on this and that element of prioritization for a package, towards the end of the article, you describe one of the main challenges of multisectoral programming as the overwhelming number of issues that need to be addressed. At the same time, you also highlight maternal mental health and wellbeing as the priority driver that needs to be addressed to improve the potential impact of cash “plus” interventions. From your perspective, what key steps need to be taken to ensure that maternal mental health becomes embedded in multisectoral programming?

Natalie: So that's, I think, a very tricky question, and I'm not sure I have the answer, definitely on the maternal mental health perspective, but I think maternal mental health needs to be a cross-cutting component of any program. Any frontline worker who is in contact with women should really know how to identify and support a woman with mental health and refer if it's really difficult. So I think there's definitely that. I think, the challenge is, as you say with multisectoral, is there's so many issues and you still want to address everything, and it just becomes overwhelming. Just for example, we found in this Maziko project that a lot of the cluster leads and promoters end up also being the ones being trained on the caring for caregivers. So they've been trained on the care group, which is a big package, and then on the caring for caregivers, and then they also end up being the preschool facilitator, or they end up being often the same people and it becomes quite a lot at community level, but also at the different levels to manage these different components. I think it's just all about learning as you go along, but trying and then improving your patches. I'm hoping that this year, through a cost analysis, we're also doing, we've just done a quantitative midterm survey. We're doing another qualitative midterm survey, which will hopefully tell us where we can cut, where we can improve, and what's making the biggest difference in those women's lives.

Stephanie: Great. Thanks so much, Natalie. Finally, can you share with us any further progress that has been made within the Maziko project since the article was written and any future plan?

Natalie: 2025, for us, is really the year of learning about how we are implementing and how to improve on it. As I was just saying, we did a midterm survey in November, which was led by IFPRI and Palm consultants, with initial results suggesting that the cash transfers were making a big difference, the “plus” component as well. But there was also a reflection meeting through that on what that means. I think one of the big issue from Save the Children's side on the “plus” element is really getting the monitoring and supervision system working better across those interventions, but especially for the care groups and the male champions, because what's happening is that you have all these different layers, maybe too many layers, but it's a way of reaching as many people as possible. And that last level where the cluster leads women have to do home visits or where the father leads have to reach out to men, we have very little visibility because the monitoring system is based on a paper-based monitoring system, it's actually the government's care group monitoring system, and it's just not effective so we're not getting the information going all the way up to district. It's missing, it comes late and so on. Similarly for the supervision is, although there's Save the Children and district colleagues who do supervisory visits, they're not the daily supervisors of these women and father leads because there's so many of them and they're supposed to be the one level up or either the village committees, or the promoters who are supposed to supervise. We found that that wasn't really happening. It means that there's questions about the quality of counselling. We actually don't know that much about it, how good the counselling is, but we also don't know to what extent it's being done. 

So we are partnering with Viamo, who's a sort of digital company, who are going to help us digitalize our monitoring system through existing mobile phones. It's amazing what they can do with these mobile phones, which are basically the basic mobile phones that people use. But we can, on the one hand, get information each time they do a home visit or whatever activity, at the same time also provide information so you can do refresher trainings and support with motivation and all sorts of different things. We're hoping that can support that. We're also planning to do a qualitative evaluation using the quip method - it's called qualitative impact protocol. It was developed by Bath Social and Development Research Centre. And it's great, actually. We love it at Save the Children because it really gives insight into the drivers of change. It's double blinded, it's quite rigorous. Interviewers go into the community, go and talk to program participants, but the interviewers nor the participants know anything about the project or Save the Children and they ask about what has changed in the past two years since the program started, and then really try and dig down to understand what has driven that change. Then all of this information gets mapped out into a causal map and you can see sort of what interventions are making a difference, but also what non-interventions, you know, things have got nothing to do with it, is making a difference. It's super interesting. So hopefully that's happening now. We hope we'll have results in the next two months, and then we'll bring that together with our quantitative and monitoring system to generate some learning. What's worked well, less well, what should we improve? 

And just to add a final thing, Save the Children has two sort of tools: one is the cost of the diet tool and software, and the other is the household economy analysis. And we've used those both recently to look at the affordability gap of nutritious foods. It's really shocking to see actually the increasing gap since 2021. Just to give you a sense, we identified a $24 affordability gap back in 2021, and it's now gone up to $89 approximately. I just sort of did a quick rough estimate with the exchange rates, and it's due to devaluations, due to a huge increase in the cost of fertilizers and exports. But also, there's the impact of El Niño this year so our household economy analysis projected the impact of El Niño on harvests and food and income. I think this 24/25 year is going to be extremely difficult. It's just a reminder of the importance of cash transfers with all these plus components. Malawi has just declared also a state of disaster over the drought predicted with El Niño, and at the same time, Save the Children had a warning of flooding in other areas. The effect of climate change on these households is really terrible and so it's really important to have these support cash “plus” types of programs there to support them through these various crises.

Stephanie: Yeah, that's really an astounding increase on the affordability of diets and it sounds like it's a perfect time for the Maziko project to be uncovering how best to support these households. And thank you again, Natalie, for taking the time to join me today for this fascinating conversation. For everyone listening who would like to hear more, please check out the article if you haven't already. It's ‘Maternal and child nutrition findings from inception studies in Malawi’, which can be found in FEX 71 on ENN's website.

Narrator: Thanks for listening to ENN's Field Exchange podcast. For more background on the story and for more nutrition stories from around the world, please go to ennonline.net/fex.