The roots of poor nutrition lie in human behavior. Improvements in nutrition are not possible without broad, widespread changes in the everyday behaviors of people and organizations around the world. Evidence shows that people can change their behaviors to improve nutrition outcomes, especially when the environment in which they live and work supports those changes.
Since 2012, Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) – a multi-sectoral nutrition project for the United States Agency for International Development (USAID) – has taken a behavior-centered approach to all of our work to reduce stunting and anemia. This means that from the beginning of any intervention, we have clear behavior-change goals in mind.
Over the life of SPRING, an emphasis on multi-sectoral nutrition has underscored the complexity of behavior change, expanded our understanding, and shifted the focus from communication to a more comprehensive behavior-centered perspective.
Adapting and Scaling Proven Strategies
To improve population-level nutrition outcomes, we must reach enough people with evidence-based social and behavior change (SBC) interventions while strengthening policies, markets, physical and social environments to influence behaviors. SPRING has focused on innovating and then adapting and scaling proven strategies to new contexts and sectors to contribute to population-level change.
In 2014, SPRING introduced a peer-based community-led video approach to vulnerable populations in Niger and Burkina Faso. The model, first developed and tested for nutrition by SPRING and the global development organization Digital Green in India, uses peer-led discussions of community-produced videos to promote key nutrition and hygiene behaviors.
We adapted and rolled out community video in the Sahel, followed by Guinea and Senegal, with different variations. In each context, the specific content of the videos as well as the groups that produced and disseminated them changed according to the needs and available resources. However, the core idea in the approach remained the same: When people see their peers engaged in particular behaviors, they are more likely to practice them.
A key to successful adaptation and scaling of the community video approach in the Sahel has been leveraging partnerships with established projects to engage key populations. SPRING created partnerships with groups that had been working in the Sahel for years, which accelerated the introduction of the approach to communities. Partnering with established groups and building local video production capacity has allowed us to scale the approach in a sustainable way.
Social connections and belonging are vital to human well-being. Decades of evidence on social and behavior change demonstrate that our actions are not determined in isolation; many other people shape our beliefs, attitudes, intentions and actual behaviors.
To create enabling physical, social, market and policy environments for people to practice improved behaviors, SBC interventions must reach the prospective “doers” of a promoted practice and those groups that are most likely to influence the “doers” when it comes to a particular practice. Using a mix of appropriate methods to reach “doers” and influencing groups is fundamental to effective SBC interventions.
This can be challenging because appropriate program-delivery platforms or approaches may vary by groups. Influencing groups can differ for different behaviors, or groups of “doers,” so it is important to make sure we focus on the right influencers, and to check our assumptions about influencers and “doers” periodically, through program observation and monitoring.
For example, in Sierra Leone we used formative research approaches drawn from both the agriculture and health sectors to inform interventions to improve nutrition-related practices in households and among agriculture value-chain actors – two distinct but overlapping audiences with unique sets of barriers and facilitators to nutrition-sensitive behaviors.
We conducted multiple barrier analysis studies as well as trials of improved practices – two methods commonly used in health programming for behavior change – to identify factors that motivate or discourage the consumption of pumpkin and fish by pregnant women and children aged 6–23 months old.
Additionally, we adapted a value-chain analysis, adding questions to identify opportunities to make fish and pumpkin more available, affordable and attractive to households with pregnant and lactating women, and children in the crucial early stages of development. The findings helped partners develop complementary SBC approaches to improve nutrition by effecting change among value-chain actors and household members.
Addressing Determinants of Behavior to Increase Improved Practice Uptake
In many of the places where SPRING works, multiple barriers make it difficult or risky for people to practice the nutrition behaviors we promote. For example, cultural norms may result in heavy workloads for women of reproductive age at home, limiting the time available to care for themselves, and to feed and care for their children. Cultural norms may also discourage men from trying out new childcare or other domestic tasks, especially in public. Through couples’ counseling and support groups for fathers, SPRING has effectively changed male partners’ attitudes, from “helping” with household chores when asked to taking responsibility for their family’s health and well-being. Male partners’ behaviors have also changed, with them actively engaging in day-to-day childcare and other household tasks.
A critical lesson from our SBC programming is the importance of catalyzing change using available resources. This means tailoring design, implementation and monitoring to partner and local priorities and capacities. Adapting existing design methods and implementation approaches for use across sectors, rather than re-creating them, helps achieve this relatively quickly.
Using SPRING’s Nutrition SBC Framework to guide our programming, and to reinforce with all stakeholders why we focus on nutrition SBC and how it works, has also helped SPRING design and implement quality, effective nutrition SBC at scale. As stated in the framework, this incorporates elements of the UNICEF Conceptual Framework on Nutrition (1990). By using proven delivery strategies to engage populations, programs can address the determinants of behavior to increase the uptake of nutrition-specific and nutrition-sensitive practices and improve nutritional status.
Our work in nutrition SBC is most effective when we work with partners toward longer-term social, physical, and market environment changes, while also facilitating faster change in a limited number of specific, feasible and high-impact practices. We have learned that amplifying our own and others’ successes, challenges and learning, and establishing connections to nutrition SBC stakeholders across countries and sectors, are key to moving the field of social and behavior change forward.
The views expressed in this article belong to the authors and do not necessarily reflect the editorial policy of Malnutrition Deeply.