Rigorous Design for IYCN Behavior Change:

Planning, Implementing & Assessing

Tina G. Sanghvi, PhD

Alive & Thrive Country Director, Bangladesh tsanghvi@fhi360.org

Acknowledgements • Government of Bangladesh, IPHN/DGHS-led multiple

departments & sectors

• 24 stakeholders of the National IYCF Alliance

• UNICEF, Nutrition & C4D Communication Teams

• BRAC, EHC & MNCS programs; Save the Children MNCH

• ICDDR,B & Dr. R. Haider for Formative Research

• Media: Nielsen, Asiatic, Unitrend, Dhansiri, Quantum, Mediacom, AVCom, Dharitri

• Professional Bodies: BBF, BPA, OGSB

• CIPRB, monitoring

• Alive & Thrive Team: FHI360, IFPRI & GMMB

Outline

• Background

• Formative research

• Strategy & materials

• Monitoring results

• TV ads

Shahjahanpur Upazila, Bogra District, Dec ‘09

Program Framework (2009-14)

In

Mothers

Care-

givers

Family Social Support

Educational institutions

Mass media

Advocacy policy

Less

illn

ess

, stu

nti

ng

&

an

em

ia

Increased

IYCF

know-

ledge,

skills

Increased

practice

of BF, CF,

HW, iron

intake

Partnerships

More

scale,

sustain-

ability

Institutional

environment

Skilled workers

Technical Basis

• Epidemiology of IYCN

• Theories of behavior change

• Feeding practices & determinants

• Media habits

Strategy & framework: National IPHN

-2.5

-2

-1.5

-1

-0.5

0

0.5

1 3 5 7 9 11 13 15 17 19 21 23 25

Age (mo)

Len

gth

-fo

r-ag

e Z

-sco

re

Boys WHO Girls WHO

Boys NCHS Girls NCHS

Age focus: Maximum damage 3-15 m

Kuntal K. Saha et al, FNB 2009

AREA FOCUS: STUNTING MAP

Most vulnerable age 3-15 months

Campaign focus: Reasons for the decline, why poor IYCF

020406080

100

% c

hild

ren

Urban & Rural Feeding Practices

Urban

Rural

Source: A&T 2009. HH survey, 24-h recall

Example: CF Practices

Problems

• Animal foods/diversity

• Quantity of semi-solids

• Child doesn’t want to eat ‘poor appetite’

TVC Stories

Why the problems

- Perceptions

- Social norms

- Mothers’ time

- Convenience

Sources: BDHS 2007, A&T 2009 (Dhaka slums,

Chittagong rural) HH survey, 24-h recall, TIPs

Father’s support TV spot : Level of Audience Interest LO

W

Key attracting factors that strengthen engagement

Key detracting factors that weaken engagement

HIG

H

Confuses viewers as to what is happening

Girl’s intelligence as a result of nutritious food intake from

childhood understood

Missing link: how the girl saved father is not clear. Fathers

coughing/ weakness miscued as illness (tuberculosis)

Proper care & nutrition during childhood and father’s

participation in child rearing enhances appeal to most primary

audiences

The story ends abruptly; weak

support for intelligence disengage

viewers

Father assisting in child rearing

fascinates viewers

Father washing dishes: negative

cultural sensitivity

9

Rural Media Habits - 2011

67 59

21 14

26

0 10 20 30 40 50 60 70 80 90

100

Watch TV Have mobile

Read newspaper

Listen to radio

Media dark

% of population

Source: Nielsen Media & Demographic Survey, 2011

Most Watched Channels & Programs

91%

33%

37%

32% 31%

• Bangla feature films

• Drama serials

• Sports e.g. WCC

• News

• News

Source: Nielsen Media & Demographic Survey, 2011

Role of mass media: reinforce & expand

Reach more mothers with what, why & how

Influence family & community decision-makers

Motivate & remind HW

Difficult to establish clean

control areas for evaluation

-Purchased air time for ads

-Engaged journalists

-Partnerships e.g.

Meena/UNICEF

Mothers Practice CF with HW: Not only talk

BRAC – Essential Health Care program

Large scale, sustainable platforms

• BRAC – 70,000 female health volunteers

• Ministry of H&FW workers – 42,000+

• Community Clinic workers – 13,500+

• High Schools – 76% girls 11-16 y (BDHS ‘07)

• Medical & nursing colleges

• UNICEF/GOB information channels

• DFID livelihoods programs & USAID initiatives

Monitoring

- Observation checklist

- Registers & lists

Cumulative No. of TV Ads Aired by Quarter

128

184

100 125

141 126

204

291

175 204

222 203

294

524

396

333 351

330 338

717

396

577 594

545

Early Initiation of BF Insufficient Milk Father's support Animal Food Quantity of Food Poor Appetite

Q1 (Dec 10 to Feb 11) Q2 (Mar 11 to May 11) Q3 (Jun 11 to Aug 11) Q4 (Sep 11 to Nov 11) Q1 (Dec 11 to Feb 12)

Data source: UNITREND, ASIATIC TVC Broadcasting Report

Save the Children MNCH Project Area

83

77

34

51

22

76 76

53

68

18

79 79

60

85

17

0

10

20

30

40

50

60

70

80

90

100

EIBF EBF App. Qty CF (7-12m) Animal Food (7-12m) HW-CF

Q3 (Jun 11 to Aug 11) Q4 (Sep 11 to Nov 11) Q1 (Dec 11 to Feb 12)

Data source: SCI-MaMoni, Quarterly Monitoring Reports n=1065

DHS 2011 Results - IYCF

46 45 46 42 43

64

21

0

20

40

60

80

100

93-94 96-97 99-00 2004 2007 2011 ACF

Exclusive breastfeeding (EBF)

Why, how EBF increased, why not CF?

Conclusions

Rapid results more likely with rigorous design, testing, monitoring when data used for:

• Motivating changes in mothers/families, social norms, institutional practices (address barriers)

• Appropriate mix of channels, high coverage & frequency maintained over time (3+ years)

• Partnerships & identifying opportunities for scale

International Consortium

Family Health International (FHI360) BRAC

Save the Children (US) International Food Policy Research Institute

GMMB University of California, Davis World Vision International