The “Great SBCC Example” below was featured during the Designing the Future of Nutrition Social and Behavior Change Communication Conference and can be used as a learning aid or as an illustration of key concepts from country-level experts attending the conference.
Background
In Nepal, four in 10 children are stunted; one in three women and five in 10 children are anemic, and one in 10 children is wasted. Suaahara (“Good Nutrition”) is implementing a multisectoral, multiplatform approach to reducing these problems by promoting better practices at the community and household level.
Description of Intervention
The Bhanchhin Aama (“Mother knows best”) intervention is a combined community-level and mass media campaign designed by the Johns Hopkins Center for Communication Programs, a partner in the Suaahara program, which is led by Save the Children. The intervention utilizes a trusted, knowledgeable, friendly mother-in-law character to model and promote positive behavior change. A logo with her image appears on all of Suaahara’s materials, including field activity guides, posters, pamphlets, billboards, games, and toolkits, ensuring that the program has a branded “look and feel.” The intervention’s field activities include leveraging contact during key life events to promote the campaign’s messages for women and families, supporting them in overcoming barriers, and motivating them by promoting local role models identified as “ideal families.”
The Bhanchhin Aama entertainment education program includes a twice-weekly Bhanchhin Aama radio drama and Hello! Bhanchhin Aama call-in radio programs broadcast in three languages. The aim is to generate discussion at the household and community levels to facilitate and sustain behavior change. The programs cover a broad range of topics related to maternal and child health and nutrition, including infant and young child feeding (IYCF), hygiene and sanitation, agriculture, and family planning. To promote high levels of community conversation around these topics, the program supports more than 240 radio discussion groups among marginalized populations. The discussions, which are integrated into existing discussion groups, are facilitated by trained social mobilizers using companion comic books featuring the mother-in-law character. The intervention components were designed and carried out by engaging in multi-sectoral partnerships.
Design Process
Formative research was conducted to gain an in-depth understanding about the primary determinants of key behaviors, including breastfeeding, complementary feeding, feeding practices, sanitation and hand washing, family planning, and other behaviors related to infant and childcare.
Research methods included:
- Focus group discussions among mothers, fathers, and mothers-in-law
- In-depth interviews with traditional healers, community health workers, model farmers, and government officials
- Participant observations of public places and markets
- Perceptual mapping techniques
Venues and participants were chosen to capture a maximum diversity of practices, perspectives, and social norms. Special care was taken to include members of marginalized groups. In addition to determining current behaviors and barriers and motivators to behavior change, formative research identified families’ aspirations for their children.
Design Strategies
The intervention was designed to respond to the findings of the formative research, including these insights:
- Concerns about children’s education and future prospects are important motivators: Mothers, fathers, and grandmothers at all study sites identified education as the key to their children’s future, whether with respect to job opportunities, social status, or general happiness. Education was also perceived to be related to agency, or the ability to make positive changes in one’s life, including the adoption of nutritious food habits.
- Having a higher level of education is linked to progressive behaviors and openness to change: Higher educational levels were associated with the respondents’ practice of more “progressive” behaviors, such as delivering a baby at a health center, eating tastier foods, and aspiring for a better life for themselves and, especially, their children. These respondents tended to view the present as better than the past, were optimistic about the possibility of change, and indicated a willingness to carry through with necessary changes.
- Mothers-in-law are key sources of influence and information: Mothers-in-law continue to play an important role in family life and seemed to welcome social changes that they noted were unfolding in their communities. They are a potential resource that can be tapped by providing positive role models of mothers-in-law in media programming and by including them in community mobilization activities.
The program utilized these insights in activities targeting families’ aspirations to improve health and nutrition behaviors at the household and community levels. The design was informed by behavior change theories (stages of change, theory of reasoned action, and diffusion of innovation).
Implementation Strategies
- Develop an evidence-based entertainment-education campaign.
- Mobilize communities around women and children’s nutrition as a major opportunity for a better future.
- Use multiple communication channels, promoting small, feasible actions that improve nutrition, focusing on personal aspirations and perceived benefits of the new behaviors while promoting role models who are practicing the behaviors and creating behavioral norms.
- Use a multi-level approach that includes harmonizing interpersonal communication, community mobilization, and mass media.
- Use a multi-sectoral approach that integrates nutrition, hygiene, agriculture, family planning, reproductive health, and child health.
Evidence of Effectiveness
The campaign is being implemented in 25 of Nepal’s 75 districts, aiming to improving nutrition among 350,000 children under two years and their mothers or caretakers. Secondary audiences include husbands, mothers-in-law, female community health volunteers, peers, and traditional healers. According to a 2014 district-level study, four of every five people (81.7%) who listened to the program (28% of the population or half of those who own a radio), self-reported taking an appropriate action related to IYCF and more than half (53.3%) discussed the issues with their friends and families. In addition, an independent survey of 2,500 mothers found that their child’s dietary diversity, consumption of food from four or more food groups, consumption of fruits and vegetables, and consumption of animal source foods were positively and significantly associated with the frequency of listening to the Bhanchhin Aama program.
I like this show very much and I never miss it. Earlier I didn’t know many things about how to bring up children, but after listening to this program, I have started being conscious about it. This show has really become fruitful to me in bringing up my little daughter.
- Uma B.K., Ghanapokhara, Lamjung
In 2015, Suaahara will collect midline data to assess communication impact and understand how specific knowledge, attitudes, and behaviors have changed since the radio program’s inception.
Key Takeaways for Nutrition Social and Behavior Change Communication
- A unified-theme, “branded” campaign links community and household-level approaches and mass media to reinforce key attitudes and behaviors and enhance the enabling environment for change.
- To help families makes changes to established cultural practices, it is critical to use a trusted information source, such the mother-in-law figure. For example, many nutrition behaviors in Nepal, such as very low rates of feeding eggs, meat/fish, or vegetables to children under two years, are guided by cultural practice—but the radio programming helped promote the idea of the mother-in-law persuading families to practice new behaviors that would strengthen children’s health and benefit their futures.
- Using personal communication technology can be critical to effectively engage target audiences. Mobile phone ownership was high—over 80%—and many people listened to the radio via their phones. The intervention capitalized on this by incorporating a call-in radio show that made participation simple and convenient. This interactive element helped the program make adjustments and strengthen its relevance to audience needs.
- Getting all stakeholders onboard from the outset helps to ensure successful development and implementation of a multi-sectoral, multi-platform program.
- Ensuring the participation of male family members needs greater attention. The participation of men was relatively low, as a result of several factors, including travel for migrant work. However, the direct participation of males in activities can be essential to facilitating and continuing behavior change, as males are typically key decision-makers at the household level.
Project: Suaahara
Suaahara is a five-year integrated nutrition program designed to improve the nutrition of women and children in 41 districts in Nepal (increased in 2014 from 25). It is funded by USAID/Nepal and involves these partners: Save the Children, Helen Keller International, JHPIEGO, Johns Hopkins Center for Communication Programs, Nepali Technical Assistance Group, Nutrition Promotion and Consultancy Service, and Nepal Water for Health. The program also works closely with the government’s Child Health Division and National Health Education, Information and Communication Center as well as the Family Health Division and the National Health Training Center, Agriculture Department, Livestock Department, Department of Water Supply and Sewerage, and Ministry of Federal Affair and Local Development from the central to the community level. Suaahara integrates health, nutrition, agriculture, and food security activities. All project approaches support the Government of Nepal’s Multi-sectoral Nutrition Plan 2013–2017 and the Hygiene and Sanitation Master Plan 2011–2015.