Over the last couple of years, a nutrition-sensitive approach has gained more traction than a nutrition-specific one in practice. That means the corresponding communication needs to be in sync, too, and not just about this shift. Merely increasing the knowledge base and awareness of good nutrition practices rarely lead to sustained behaviour change. Sustained change in nutrition behaviour is unlikely to be achieved through a single event or an activity such as a health talk or an exhibition.
This is where social and behaviour change (SBC) strategy—a collection of approaches and tools used to design public health interventions, including nutrition programmes—and its effective communication comes in.
When it comes to children, it has been observed that several behaviours or practices impact their nutritional status during the critical initial 1,000 days—pregnancy to age two—but some complex contextual determinants influence individual decisions to consider, test, adopt and sustain a given behaviour or practice.
One of the specific areas of focus needs to be on how a single, or a set of combined SBC interventions, can change certain types of behaviours among varied groups in the given context. What also needs to be looked at is how they can be designed and implemented to ensure cost-effectiveness, scalability and sustainability, and how investments in the SBC programme can be targeted to help proven interventions scale and foster continual innovations under the nutrition programme, including breastfeeding by lactating mothers.
In the case of breastfeeding, it is known that early and exclusive breastfeeding practices are the fulcrum of the nutrition programme. It is widely established that breastfeeding is one of the most cost-effective investments to improve the child survival rate, cognitive and motor development and also academic performance. Breastfeeding also imparts critical benefits like natural postnatal infertility to the mother. Despite the prevalence of breastfeeding practices, the rates, as per the World Health Organization standards, remain significantly low.
Leading researchers in nutrition have undertaken extensive literature review of SBC and breastfeeding practices to study what brings about a sustained positive behaviour change in lactating mothers as far as early and exclusive breastfeeding practices are concerned. They have observed that the effectiveness of the SBC approaches in improving breastfeeding practices supports the claim that a well-designed SBC can and does succeed in improving uptake of the nutrition behaviours. Hence, the momentum of well-designed SBC interventions needs to be maintained in order to sustain the process of positive health practices of caregivers.
There is a critical need to enhance the SBC skills of the managers addressing communication and nutrition, especially in deciphering the local community needs, designing interventions and developing locally contextual monitoring indicators.
Interpersonal Communication Drives Change
For intervention in most nutrition projects, interpersonal communication is the widely used SBC approach and in some cases, the only one. Media interventions and community and social mobilisation are also frequently employed and are invariably used in conjunction with at least one other communication approach.
Therefore, for a significant impact of SBC interventions, a holistic and comprehensive strategy is recommended—a full-fledged, multipronged campaign approach that includes a strong component of interpersonal communication. There exist umpteen cases wherein, in addition to regular exposure to nutrition messages beamed through multiple modes, sustained and effective interpersonal communication has brought about tangible results.
Take Sanju’s (name changed) case. Sanju, a child hailing from Pratappur village in the Majhgawan block of Uttar Pradesh’s Bareilly district, was extremely feeble. For varied reasons, the Anganwadi workers did not have substantial information about his overall nutritional status. It was only after the block coordinator, under the Maternal, Infant and Young Child Nutrition and C-SAM initiative of the United Nations Children's Fund and World Vision, learnt about Sanju that the Aanganwadi centre monitored his growth thoroughly. While the child was not demonstrating any medical complications, he was found to be a case of severe acute malnutrition. With the help of the Anganwadi centre and the block coordinator, Sanju’s caregivers were regularly counselled on the nutritious food already available in their house and the parameters of quantity, special care and hygiene in the context of the child’s health and growth. Additionally, the Anganwadi centre, through the hospital of the block, handed over appropriate medication for the child to the caregivers.
Subsequently, Sanju’s diet, the cleanliness of his surroundings and medication were monitored regularly. A change in the behaviour of his caregivers, who were previously not aware about childcare and growth parameters, brought around remarkable results in Sanju’s overall health and nutritional status. Within the next two months, Sanju’s nutritional level improved to that observed in a moderate acute malnutrition case. His mother testified that without relentless counselling on nutritional levels, daily food intake, cleanliness and care of the child, her son would have remained very sick with bleak future years of growth.
Multipronged Approach, Mobilisation The Way Forward
Evidence suggests that using multiple SBC approaches, channels and platforms to change behaviour is more effective than restricting oneself to a single platform. Talking about breastfeeding, it was also noticed that targeting multiple contacts had a greater effect than targeting only the lactating mother and that more visits or human-to-human contacts result in a significant change. Several studies strongly suggest that increasing the number of contacts—frequency of access to nutrition messages—heightens the positive effect of SBC on breastfeeding practices.
Differences in local context, including social norms, culture and environmental factors, as well as differences in the implementation and scale of implementation, also directly impact the success of interventions. This underscores the importance of proper context assessments which include risk factor analysis and formative research or ethnographic study prior to SBC implementation.
Within the context of nutrition or breastfeeding and SBC, some areas are significant for future understanding through research. These include—(i) the effect of targeting multiple audiences, or the influencers of the behaviours being promoted, rather than focusing on one target population; (ii) the effect of the same SBC intervention implemented in different contexts (social and environmental); (iii) the effectiveness of different approaches, including intensity and targeting, for different behaviours; (iv) the cost and cost-effectiveness of various SBC approaches, particularly as it relates to scalability and (v) the effectiveness and sustainability of these approaches when implemented at scale.
In the documented field research for SBC in child-centered development and health, it is found that the social mobilisation and community-based communication has witnessed broader shifts in its conceptual approach over a period of time—from information, education and communication, health promotion, health education, programme communication to SBC communication, especially in the nutrition sector in several developing countries.
Regardless of how the communication for nutrition is titled, strategic amalgamation of meeting the information and communication needs of marginalised, hard-to-reach and vulnerable people is integral to programme design. This becomes important when integrating them with the empowerment process as the intended communities evolve to a more positive behaviour change in making informed choices for an improved quality of life and safer health practices.
Community First, Change Next
It is within communities that the reality of development is experienced. Thus, community participation in the designing and implementation of health and development programmes remains an essential element to the positive change process. Communication strategies, especially targeting development and health programmes for sustained behaviour change interventions, need to work on the premise of individual or people-centered development.
Alternative communication systems, local and community-owned, and media practices are, therefore, regarded as significant means for local people to engage in health and development activities. It can be seen as a two-way process in which communities can participate as key change agents in evolving to a more positive behaviour. Inherent to the paradigm is an increased priority given to horizontal and multidirectional communication methods that utilise a mix of channels and emphasise the importance of two-way communication through sustained dialogue in facilitating trust and mutual understanding. This will provide adequate space to the voice of the socially excluded and disempowered people and empower them to identify ways of overcoming the targeted problems in order to improve their own health and well-being.
In the process of behaviour change, the ultimate end result is also gauged through the number of change catalysts, also termed as advocacy agents, who, in turn, serve as positive deviants in a given community. These are converted advocates of a given health behaviour, such as adhering to a breastfeeding practice, as they not only practise it but also serve as positive examples. It demonstrates how positive behaviour by a few individuals in a community, who do things differently or practice healthy behaviours as compared to others in the community, can eventually lead to far-reaching positive changes in that community.
Mothers practicing breastfeeding, the ones who have emerged as child health champions, can serve as the forceful advocates of the nutrition programme. Such catalysts invariably encourage the rest of the community in promoting appropriate nutritional practices, including breastfeeding. Positive deviance offers a systematic framework to identify assets, indigenous knowledge and home-grown solutions, and to amplify them for wider adoption. Local nutrition managers need to widely utilise such positive deviants in a community through various available communication platforms as catalytic change agents.
In the case of nutritional practices and sustaining breastfeeding behaviours, mothers, their families and communities require relentless communication support, including counselling services. Among many public health goals, one significant objective is to communicate effectively to inform and educate people about health, factors that influence it, and how to improve it.
To achieve effective communication on public health and developmental practices, health communication experts recommend several approaches such as communicating with accuracy and necessary speed and using appropriate channels to reach intended audiences and, in some cases, even using social media and peer-to-peer networks.
It is reckoned that the overall mission of the public health interventions is to protect and promote the health of all people in all communities, including the hard-to-reach, vulnerable and socially excluded. This public health goal became more apparent during the Covid-19 pandemic. Centered on the concept of equity, key messages for public health need to reach every citizen and thus, the necessary behaviour change should ideally be practised and sustained by individuals in every community.
(Dr. Deepak Gupta is a senior consulting advisor in strategic communication and programmes with the United Nations System in Asia. He has served in various countries and regions with the UNFPA, UNODC, UNICEF and WHO.)