Building blocks of great nutrition SBCC: innovating while getting the basics right

Ashley Aakesson, The Manoff Group Lauren Bailey, JSI Sascha Lamstein, JSI Michael Manske, USAID This presentation was made possible by the American people through the U.S. Agency for International Development (USAID) under Cooperative Agreement No. AID-OAA-A-11-00031, the Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) project.

Why Social and Behavior Change?

“Behavior matters—particularly in nutrition. We know what works. We have to work together across uncommon allies . . . 45% of under-five mortalities are related to nutrition. If we do the right things for survival, then we do the right things for health. We can’t do these things without behavioral change.” —Katie Taylor, Deputy Child and Maternal Survival Coordinator, USAID

Why Social and Behavior Change?

The 2010 Global Burden of Disease report indicates that 5 of the top 20 health risk factors are predominantly behavioral, and the other 5 are highly influenced by behavior. (Lim et al., 2013) USAID in its Multi-Sectoral Nutrition Strategy considers SBCC strategies and approaches to be “essential for increasing optimal nutrition practices, demand for services and commodities, and ultimately, increasing utilization of services.” (USAID 2014) Behavior permeates global nutrition efforts (across sectors and whether preventive or curative).

Thinking Beyond the Individual 1. Freestanding, personal or lifestyle behaviors 2. Care-seeking behavior or demand 3. Client adherence and collaboration 4. Provider behavior 5. Pro-social and anti-social behavior 6. Policy and priority setting

Source: Shelton 2013. Global Health Science and Practice

Who we are

About SPRING

What We Do

Strengthen

global and country efforts to

scale up

high impact nutrition practices

Prevent

stunting and anemia in the first 1,000 days

Link

agriculture and nutrition under Feed the Future

Our Work

Build evidence and develop guidance for systems thinking approaches to nutrition Build capacity for systems thinking for nutrition programming at scale Strengthening Systems for Nutrition Build evidence (operations research, technical guidance documents, tools) Linking Agriculture & Nutrition Deliver technical assistance Share, learn, and build an active community of practitioners Engage with countries to strengthen anemia programming Build evidence on implementation and effective scale-up of existing interventions for anemia Preventing Anemia Partner with the global community to inform anemia prevention and control programs Catalyzing Social and Behavior Change Enhance evidence for promising SBCC delivery strategies Apply, document, share promising strategies Implement SBCC activities in the Sahel

Evidence for SBCC: Why SBCC?

“SBCC is fundamental to improving nutrition. . . . We need to de-mystify SBCC, and get lessons learned about success out there. We must push people to take risks, and learn from it. We need to inspire people and be creative.” —Ellen Piwoz, Senior Program Officer, Bill and Melinda Gates Foundation

SBCC is Crucial for Nutrition; Nutrition is Crucial for Development

Nutrition has gained importance for the development agenda, in large part due to the Lancet Nutrition Series 2008 and 2013 which documented the scope of malnutrition and the evidence base for effective interventions.

Scaling Up Nutrition has estimated that malnutrition costs some countries up to 3% of their GDP per year. Recent evidence has supported the crucial role of SBCC as a fundamental strategy for most nutrition-specific and nutrition sensitive interventions.

WHO, Maternal and Child Nutrition Study Group, 2013 Alive &Thrive special issue of the Food and Nutrition Bulletin, 2013 Journal of Health Communication, 2014

Core Elements of SBCC

Social Change to achieve shifts in the definition of an issue, people’s participation and engagement, policies, and gender norms and relations Behavior Change through efforts to make specific health actions easier, feasible, and closer to an ideal that will protect or improve health outcomes Communication using channels and themes that fit a target audience’s needs and preferences Adapted from: The Manoff Group. See: http://manoffgroup.com/documents/DefiningSBCC.pdf

Evidence for Nutrition SBCC

Evidence of the effectiveness of SBCC approaches in improving breastfeeding practices is strong and broad and supports the claim that SBCC approaches can and do succeed in improving uptake of the behaviors promoted. There is extensive evidence for positive impact of SBCC on improving infant feeding practices. There is little experience or evidence regarding the priority nutrition practices for adolescent girls and other WRA and how to effectively promote them.

Evidence for Nutrition SBCC (cont.)

There is evidence of effectiveness for a wide variety of delivery strategies including: interpersonal communication, community mobilization, social marketing; and to a lesser extent, mass-media campaigns, and environmental nudges.

One-on-one or small group communication is the approach most consistently and effectively used, with the most published evidence supporting it.

There is emerging evidence that mass media can be cost effective in creating individual behavior change.

Evidence for Nutrition SBCC (cont.)

Mutually reinforcing interventions through multiple delivery strategies, channels, and points of contact improves effectiveness of SBCC.

The CORE Group and TOPS Project analyzed project data and found that projects using any SBCC approach had better outcomes than those not using SBCC.

Continued recognition of the importance of social and structural/environmental change to support individual behavior change. Mass media and advocacy for enabling policies and structural investments play a role in bringing about those changes.

What We Need…

Evidence of the optimal combinations of approaches, channels, and target audiences More complete and comparable documentation of “the black box of design” Indicators which are standardized, endorsed by WHO, and widely used, to measure nutrition-related behaviors and SBCC processes Best approaches and tools for bringing about and measuring social change

Eat a diverse diet Take protein/energy supplements Eat adequate quantity of food Dietary practices during pregnancy and lactation Improved nutritional status during the first 1000 days Continue BF for 2 years BF on demand Exclusive BF for 6 months Initiate BF early diverse diet Feed Feed a Eat iron-rich/ fortified foods Eat Vitamin A Use multiple micronutrient powder Properly store/treat water actively / appropriate frequency supplement / Sleep under responsivel fortified foods prophylaxis treated Wash feces Breastfeeding (BF) practices Complementary feeding (CF) Control and prevention of anemia WASH

Maternal, infant, and young child nutrition care practices

www.spring-nutrition.org/publications/briefs/sbcc-pathways-improved-maternal-infant-and-young-child-nutrition-practices www.spring-nutrition.org/publications/series/evidence-effective-approaches-social-and-behavior-change-communication

Dietary intake Improved nutritional status Health status (disease)

Care Practices Food

security Access to quality

health

services and

environment Diet during pregnancy and lactation Breastfeeding Complementary feeding Control and prevention of anemia WASH

Awareness, knowledge, and understanding Ability to act (skills and efficacy, agency, and control of resources) Motivation, attitudes, convictions, perception, and beliefs Demand Individuals / caregivers Families, partners, and peers Social norms and role models Enabling systems and policies Environment Community leaders and service providers Availability of health services and food Quality of health services and food Supply Government, business, NGO, and faith leaders

Community / social mobilization

(campaigns, community events)

Behavior change communication

(IPC, small media, and mass media)

Advocacy

(raising resources and political/social leadership commitment)

Non-Communication Strategies

(policy change, systems strengthening)

Building Blocks for Great Nutrition SBCC

Taxonomy of Behaviors

Stages of Change Model

Drivers of Behavior

Drivers of behavior can be conscious or unconscious, internal or external, physical or social, and at multiple systemic levels The World Bank’s recent Mind, Society, and Behavior report highlights cognitive drivers Humans think automatically Humans think socially Humans use mental models Good design makes the optimal behavior easy and desirable, and sometime the default Choice architecture and cues for action approaches

Choice Architecture

Source: Slideshare presentation by Lola Sanchez Great design makes it easy and fun to do the optimal behavior. "Flies" in urinals improve, well, aim. When Amsterdam's Schiphol Airport was faced with the not uncommon issue of dirty urinals, they chose a unique solution: by painting "flies" in the (center of) commodes, men obligingly aimed at the insects, reducing spillage by 80 percent.

Brainstorming Key Design Elements

Strategic Agenda for Great Nutrition SBCC

Promote SCALE-FOCUSED nutrition SBCC Drive EXCELLENCE in design and implementation Engage WORLD-CLASS people and partners Build on the EXISTING EVIDENCE BASE for SBCC’s impact on nutrition Persuade decision-makers that SBCC IS CRITICAL for tackling malnutrition

Innovation at SPRING (round tables) Community generated, human mediated digital media Applying SBC basics to nutrition-sensitive agriculture design Avoiding “faith-based scaling” through evaluation

• • • • • • • • •

Resources

Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2224–2260.

USAID.2014. Multi-Sectoral Nutrition Strategy 2014-2025. Washington D.C. http://www.usaid.gov/sites/default/files/documents/1867/USAID_Nutrition_Strategy_5 09_508.pdf

Shelton JD. The 6 domains of behavior change: the missing health system building block. Glob Health Science and Practice 2013;1(2):137-140. http://dx.doi.org/10.9745/GHSP D-13-00083.

http://www.thelancet.com/series/maternal-and-child-undernutrition http://www.thelancet.com/series/maternal-and-child-nutrition http://scalingupnutrition.org/about/why-nutrition Alive &Thrive special issue of the Food and Nutrition Bulletin,

Food & Nutrition Bulletin

,

34:3

(Supplement), 2013

Population-Level Behavior Change to Enhance Child Survival and Development in Low and Middle-Income Countries: a Review of the Evidence.

Journal of Health Communication 19:1, 2014.

World Bank. 2015.

World Development Report 2015: Mind, Society, and Behavior.

Washington, DC. http://www.worldbank.org/en/publication/wdr2015

Thank you!

For more information on SPRING, visit: www.spring-nutrition.org