Nutrition Education & Behavior Change Communication: How Much is “Enough” to Achieve Measurable Results for Nutrition in Social Protection Programs?

Nutrition Education & Behavior Change Communication: How Much is “Enough” to Achieve Measurable Results for Nutrition in Social Protection Programs?


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Nutrition education and behavior change communication (BCC)  improve infant and young child nutrition.[1] In combination with cash, nutrition education may influence caregivers’ preferences towards more nutrient-rich foods, intra-household allocation of food to benefit pregnant and lactating women and children, and other practices related to child feeding, caregiving, sanitation and hygiene, and use of health services.[2] Although the overall results to date regarding the effectiveness of transfers (cash and in kind) to improve nutrition is mixed, the global evidence base is growing and effective incorporation of complementary nutrition messaging within social protection programs has been associated with improved nutrition outcomes.[3],[4],[5] 

Preliminary findings recently reported by IFPRI in Bangladesh indicate that stunting decreased only when transfers were combined with intensive BCC, which underscores the importance of designing effective interventions within transfer programs to change the household practices that drive nutrition status.[6] However, research conducted thus far has not adequately evaluated the impact pathways from social protection to improved nutrition outcomes.[7]                   

As a result, when nutrition-sensitive social protection programs fail to achieve improvements in nutrition, it is all too easy to say “the program did not work”, rather than “the nutrition education and BCC component was insufficient”. The relative importance of key factors of nutrition education and BCC (e.g. the intensity of the engagement, qualifications of the promoter, format of the delivery platform) are not well enough understood. Yet, in a recently published compendium of case studies of global nutrition-sensitive social protection programs, the vast majority included a nutrition education and BCC component.[8]

For these programs, somewhere along the path from design to implementation, decisions are made about what nutrition messages to promote, how they will be conveyed, by whom, how often, and what tools will be provided to support this work. Hopefully, but not always, these decisions are rooted in formative research and a clear understanding of their respective merits. These decisions have major implications for program delivery, cost, and impact, yet their relative effectiveness within the scope of at-scale nutrition-sensitive social protection programming remains unknown.    

When all efforts “count” equally in formal and informal impact evaluations, it is impossible to differentiate well-designed nutrition education and BCC components from those that are not, and difficult, even, to elucidate programmatically substantive lessons learned. It is of little surprise then that, as evidenced by the compendium, what constitutes nutrition education and BCC varies greatly from program to program.

If indeed simply doing some form of nutrition education and BCC is not enough to ensure improved nutrition outcomes, we need to be able to be more prescriptive about what effective nutrition education and BCC in nutrition-sensitive social protection programming entails. Perennial debates over the terminology and scope of various health communication strategies (e.g. BCC versus social behavior change communication (SBCC) versus Information, Education and Communication (IEC) versus Behavioral Science, etc.) are indicative of the general confusion around health promotion, even among experts.[9] Also, under the umbrella of what constitutes BCC falls an array of communication channels, including mass media (e.g. radio, television), community mobilization and “sensitization” campaigns (radio listening clubs, community theater), and interpersonal communication (IPC) (house visits, visual / job aids). Health and nutrition education workshops and Growth Monitoring and Promotion are additional BCC channels commonly used in nutrition-sensitive social protection programs.[10]     

These all represent very different interventions—each with a unique rationale for use and target audience—and vastly differing levels of intensity. Furthermore, experience from Alive & Thrive—whose systematic approach encompasses advocacy and policy, IPC and social mobilization, and mass communication—underscores the importance of layering multiple strategies to affect widespread change in social norms and beliefs.[11]

What actually comprises an effective behavior change strategy is the subject of a different blog (and countless publications). The point here is merely to highlight that what is often casually referred to as “behavior change” is, rather, a complex process on which social protection programs aiming to improve health and nutrition outcomes depend. Lacking clear guidance, design decisions are made in a vacuum, driven primarily by feasibility rather than evidence for impact. Consequently, a lot is riding on the capacity of the frontline health workers (FHWs) charged with implementing the program.                   

FHWs are crucial partners in the effort to improve child outcomes globally through prevention and promotion activities, including education and BCC.[12] Yet, historically, FHWs in large-scale programs are under-resourced in terms of training, supervision, supplies, and logistical support.[13],[14] Poorly designed efforts at nutrition education and BCC within nutrition-sensitive social protection programmes thereby have the potential of setting up already overburdened FHWs to fail.

Given all that we don’t know, how can we ensure that nutrition-sensitive social protection programs incorporate “robust enough” education and BCC? For Frontline Health Workers (FHWs) delivering BCC in low capacity and weak infrastructure country contexts, what means exist to maximize self-confidence, accuracy of messaging, and effectiveness? What’s needed are minimum standards; what we have currently are rough guidelines supporting  the notion of ‘more is better’.

Written by Andrea L Spray with key contributions from Aaron Buchsbaum and Ale Marini.
See also the first and the second blog in this series.

[1]Bhutta, Z. A., Ahmed, T., Black, R. E., Cousens, S., Dewey, K., Giugliani, E., … Shekar, M. (2008). What works? Interventions for maternal and child undernutrition and survival. The Lancet371(9610), 417–440.
[2] Leroy, JL. 2009. The impact of conditional cash transfer programs on child nutrition: a review of evidence using a program theory framework.
[3] ODI. 2016. Cash transfers: what does the evidence say?
[4] UNICEF. 2015. Cash Transfers and Child Nutrition: What We Know and What We Need to Know.
[5] Alderman, H. 2014. Can Transfer Programs Be Made More Nutrition Sensitive?
[6] IFPRI. 2016. Channeling Social Protection Programs for Improved Nutrition in Bangladesh: Outcomes of the Transfer Modality Research Initiative. (Final report forthcoming)
[7] UNICEF. 2015. Social Cash Transfers and Children’s Outcomes: A Review of Evidence from Africa.
[8] WBG. 2016. Compendium of Case Studies Prepared for the Global Forum on Nutrition-Sensitive Social Protection Programs, 2015.
[9] The Manoff Group. 2013. Defining Social and Behavior Change Communication (SBCC) and Other Essential Health Communication Terms.
[10] Basset. L. 2008. Can Conditional Cash Transfer Programs Play a Greater Role in Reducing Child Undernutrition?
[11] Alive & Thrive. 2014. Interpersonal Communication & Community Mobilization: Infant and young child feeding at scale.
[12] Perry, HB. 2014. Community Health Workers in Low-, Middle-, and High-Income Countries: An Overview of Their History, Recent Evolution, and Current Effectiveness.
[13] Berman, PA. 1987. Community-Based Health Workers: Head Start or False Start Towards Health for All?
[14] Perry, HB. 2014. Developing and Strengthening Community Health Worker Programs at Scale.

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Congratulations, Andrea (and Aaron and Ale), you have really hit dozens of nails on their heads.
We need to insist that e.g. (a) social protection schemes and other "nutrition-sensitive" programs (agriculture, investment) assess education components independently to see what difference it makes, (b) all reports, research studies, journal articles, program and project proposals spell out the approaches they adopt, the rationale for them, the formative enquiries they are based on and the nature of the interaction, and (c) (maybe this is asking too much) that sustainability/ or longevity of effect is measured in long-term impact assessments.
It's great to know that you are out there!

Jane Sherman, nutrition education consultant, ex-FAO

NB Re research into social protection schemes and FNE, isn't there some on SNAP-ED? I had the impression that it had proved itself quite thoroughly.

Your Name: 
Jane Sherman