Who needs to do what? How we use data to plan for activating families and communities to support breastfeeding

Ashley Aakesson, SPRING
Kristina Granger, SPRING
Ann Jimerson, Alive & Thrive

Mothers are never alone in making choices about how to feed their children. Husbands, mothers-in-law, friends, village elders, doctors, employers, and even policymakers who surround mothers influence their nutrition practices.

It makes sense that we need to engage these influencers as well as mothers to facilitate sustainable change. The literature backs this up. Social norms, level of group cohesion, and individual and group self-efficacy are critically important for behavioral transformations. But simply reaching influencers isn’t enough. How does data help us do it better? Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING), USAID’s multi-sectoral nutrition project, teamed up with Alive & Thrive (A&T)—an initiative funded by the Bill & Melinda Gates Foundation and the governments of Canada and Ireland to improve maternal, infant, and young child nutrition practices and policies—to answer this question.

Beyond awareness
Preparing for a session at a recent seminar on breastfeeding sponsored by USAID’s TOPS project, several of us from A&T and SPRING explored how our programs are activating these influencers to improve breastfeeding practices. As behavior change specialists, we know that simply raising awareness is unlikely to translate to sustained behavior change; we have to work within the entire enabling environment to support families to adopt recommended behaviors.

SPRING and A&T prioritize a few small doable actions, the behaviors that will make the biggest difference and that mothers and families are most likely to adopt. Our processes and tools help program planners use data to choose the priority behaviors for both the mothers and the influencers who play important roles in behavior change.

WHO needs to do WHAT?
As we swapped stories, we at SPRING and A&T recognized that both teams place particular importance on learning what makes potential influencers tick. Everyone is moved to action when we have clear direction on what to do and when our emotions, sense of self-efficacy, and sense of social norms tell us we should act. The key is the research we as program planners do to learn about the fathers and grandmothers, doctors, and community leaders our programs activate. These are questions we put together that we try to answer before we even begin to design a community mobilization or family engagement activity:

1. WHO. There’s no need to guess who the most influential people are in a mother’s decision-making related to nutrition. We ask. We listen to the mothers themselves, and to family members and frontline health workers.

SPRING uses specific interview questions to reveal more: “Who makes decisions about when babies should have their first foods?” or “What happens when your community health worker says X and your mother-in-law says Y?” On task-shifting we may ask, “How is the baby fed when a lactating mother has to go work in the field?” Insights from questions like these are especially rich when designers seek out the different perspectives of mothers, grandmothers, and fathers around family roles and decision-making around nutrition in the household.

A&T father support

A father supports his wife to breastfeed. Credit: Alive & Thrive

The key is to listen carefully in every setting and situation. We’ve learned that in some communities, the mother-in-law may have the most say when it comes to putting the baby to breast in the first hour or not. But she may have little influence over when to feed the baby his first egg.

2. WHAT. Once we’ve figured out who are the key influencers for each nutrition practice, we come up with specific actions for those people. What can they do that will be most helpful for the mother and child? What actions are they willing and able to take? How and when do they fit this new practice into their daily lives?

SPRING’s daily activity chart exercise pulls together groups of mothers to explore how they spend their time at each point during the day. But we don’t stop with mothers. In the same communities, fathers and grandmothers fill in their own charts to indicate what they understand of the demands on each other’s time, too. Findings can be used to help family members discuss and make better decisions about mothers’ workloads, so that they have sufficient time to breastfeed. Findings can also help program designers spot the appropriate times for home visits or group meetings.

In another example, Alive & Thrive surveyed Bangladeshi doctors, asking them how likely they were to implement some of the specific actions the program might urge doctors to take. Doctors said “yes” to the idea that they could say the mother’s milk supply will increase with more frequent breastfeeding. But they were more hesitant to agree that they could say it’s harmful to feed anything else other than breastmilk. Once the data were analyzed, the program planners chose two specific calls to action for the doctors’ campaign: (1) Initiate a conversation about feeding with every mother, whether she brings it up or not; and (2) request the doctors’ pocket guide on infant and young child feeding from the Ministry of Health to learn more about the WHO-recommended practices.

Motivating influencers and building skills

Once we can identify who needs to do what as influencers to help support mothers to breastfeed, we still aren’t quite done. To really activate these influencers, we need to understand what will motivate them and what skills they need in order to adopt this new behavior(s).

3. What motivates any particular group of influencers?

Aware that simply knowing the recommended practices is unlikely to activate the doctors, A&T used concept testing to explore what kinds of appeals would best motivate this group. Several possible messages were shared with the doctors, appealing to their pride, their commitment, or a “doctor’s purpose.” The winning idea was a message in which people shower the doctor with recognition for her contributions to the community. One of the ads that ran in local and national newspapers read “Thank you, doctor!”Doctor poster

SPRING wanted to better understand what might motivate fathers and mothers-in-law or grandmothers to support improved maternal and infant care practices. We asked mothers, fathers, and mothers-in-law to describe good family relationships and to answer the question, “Whose job is it to care for pregnant and breastfeeding women?” SPRING was delighted to find a common vision of an ideal family was one where members are friendly with each other, share household and farm tasks, and make decisions together. In addition, there was strong consensus that fathers and mothers-in-law had separate, but equally important, roles in caring for women. SPRING has tapped into these ideals through community videos that show improved practices in the context of such ideal families.

4. What skills do these influencers need to adopt new actions to support mothers?

SPRING has found in multiple contexts—India, Kyrgyzstan, Uganda, Niger, and Burkina Faso—that influencers need basic communication and decision-making skills to support improved practices. Ample evidence shows that these softer skills can be improved with guidance, practice, and growing self-efficacy. SPRING uses community videos to demonstrate positive family communication techniques and joint household decision-making by role-modeling these skills for families to imitate. In addition, SPRING’s training for community-level workers includes role-plays to practice communication and family decision-making so that community workers can in turn help family members and community leaders to improve their skills.

A small study in Vietnam, funded by Alive & Thrive, offers evidence that men exposed to a campaign to engage fathers to support best breastfeeding practices is associated with more fathers doing specific supportive actions and with more exclusive breastfeeding than in the comparison area. These results were likely due in part to the intervention’s activities that built fathers’ skills for saying the right things to stand up for breastfeeding. In a contest called “Who loves his wife and children most?” teams of fathers faced off to show the skills they had learned. In one challenge, each team had a couple of minutes to respond to a short video “scenario” showing real-life obstacles to exclusive breastfeeding. Judges scored their responses and fathers walked away with the skills and social support they needed to “be there” for their wives in specific, loving ways that might prolong and improve breastfeeding. See those short video scenarios here and here.

Using data to identify who needs to do what and which motivators will activate people is key to effective program design that moves influencers to action. Finally, building their skills—and not just counting on raising awareness—goes a long way toward turning families and communities into allies within a supportive environment to improve breastfeeding and nutrition.

This blog is also featured on JSI’s PUMP blog.


An unexpected bit of data: Choosing which complementary foods to promote

By Ann Jimerson, Behavior Change Specialist, Alive & Thrive

As our blog’s name, “Less Guess,” implies, we’re big on using data to make program choices. And we’re particularly glad when we can find the data we need without conducting a big new research effort. We found an excellent source in the form of a free and readily-available resource: local Demographic and Health Surveys. This “data tip,” based on Alive & Thrive’s work in Bangladesh, may help your choices too.

Here’s how it worked. Global evidence points to animal source foods, like meat, fish, poultry, and eggs, as crucial for children’s optimal growth and cognitive development. And since very few Bangladeshi children were fed these foods as recommended—starting at 6 months of age—there was plenty of room for improvement. It seemed like an obvious “small behavior” to promote.

But was it “doable”? That is, was the behavior feasible for poor Bangladeshi families?

When we suggested a focus on animal source foods, some of our partners argued that it was not ethical to suggest to families that they should offer their babies meat, fish, poultry, or eggs every day. Poor families could not afford those foods for their children. If our program promoted these foods, our partners said, we could leave families feeling poorer and more dejected.

But buried deep in the 2007 Bangladesh Demographic and Health Survey (BDHS) report, on page 157, Tina Sanghvi, our country director, found a table that made a different case.

BDHS table v2-01

This table in the 2007 Bangladesh Demographic and Health Survey (BDHS), “Foods and liquids consumed by children in the day or night preceding the interview,” offered an unanticipated bit of data for A&T’s choice of behaviors to promote. This helpful bit was on page 157.

The BDHS survey had asked mothers what foods and liquids they had given their children in the day or night preceding the interview. Not surprisingly, only 10% of children 6 to 7 months old had eaten meat, fish, poultry, or eggs. Perhaps families really were too poor to offer these foods to their children.

Instead of leaving the discussion at that, though, Tina ran her finger further down the column of figures. In the same sample of mothers, 75% said they had fed these foods the day before the survey to their children who were 2 to 3 years old. The majority of families did have the resources to feed their older children these highly valued foods on a daily basis. They apparently just weren’t convinced that it was appropriate to give these foods as early as 6 months of age.

BD diet diversity v2-01This fresh look at the BDHS won over the stakeholders. That one bit of data allowed our program partners to feel confident they could encourage mothers to feed these to their babies every day, starting as young as 6 months.

Instead of dropping that important behavior, the program planners shifted their attention to figuring out the best ways to convince mothers, families, and decision makers of every type that it was important—and safe—to feed these nutrient-rich foods to babies starting at 6 months.

That decision to promote animal source foods actively, as one part of a comprehensive program, paid off. Our aim had been to improve dietary diversity among children 6 to 24 months of age. In just four years, in the areas where the program operated most intensively, dietary diversity doubled, from 32% to 64%. Some of the greatest increases were in the animal source foods we promoted: following the program intervention, almost three times as many children in that age group ate eggs compared with before the program; six times as many ate liver or other organ meats; and twice as many ate fish.


The BDHS data helped planners feel comfortable with broadcasting this TV spot to promote animal foods for all babies over 6 months of age.

No need to guess—or base decisions on incorrect assumptions. Instead, search for data to shape your strategy. And remember that sometimes the data are there all along, waiting. You just need to track them down.

Tackling gender equity, one nutrition TV spot at a time

By Ann Jimerson, Behavior Change Specialist, Alive & Thrive

As the clock ticks to mark the first hour of the baby’s life, a young mother raises her hand to contradict her mother-in-law, who wants to give the baby honey instead of breastmilk. It’s one of my favorite TV spots from Alive & Thrive’s (A&T) program in Bangladesh. Every time I view this TV spot, I feel a surge of emotion when the young mother firmly says, “No, give her to me. I have to breastfeed.”

bangladesh 1

This young mother surprised viewers by taking control of her baby’s first hour of life.

So it caught me off guard when a participant in the recent SUN Movement Global Gathering questioned the program planners’ decision to portray this young mother standing up to the authority of elders. “Why did you show the mother that way? It’s completely unrealistic. That would never happen,” the participant said.

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Breastfeeding: Working to make it work

Ellen Piwoz, Senior Program Officer, the Bill & Melinda Gates Foundation
Originally posted on Devex

The theme of World Breastfeeding Week 2015 is “Let’s make it work!”—focusing on supporting working women that breastfeed. The reality is that all women work, whether in the home or in an office, factory, or field. The question then is: What do we need to do to make breastfeeding work for women and their children, no matter where they live or what they do?

An important first step is ensuring that women have the accurate information needed to make feeding choices for their children. Just last week, a National Institutes of Health study found that 20 percent of new moms in the United States did not receive any breastfeeding guidance from their doctors. The World Health Organization recommends initiating breastfeeding within one hour of birth and breastfeeding exclusively — no water, nor anything else — for the first six months.

To read the full text, please visit: Breast-feeding: Working to make it work

Remembering Luann Martin: Promoting breastfeeding for 25 years


In memory of our friend, colleague, and long-time advocate for infant and young child feeding, Luann Martin, we are sharing a personal story that she wrote last year at this time. Luann recently passed away on July 14, 2015.

luann for webLuann and I met in 1994 in Washington, DC. We had both recently returned from living overseas and soon discovered we had much in common. From that time on, we worked together for the next 20 years. Most recently, I had the pleasure of working with her on Alive & Thrive, from the beginning in 2009 until December 2014 when she retired.

Luann cared deeply about improving the lives of women and children and her work touched the lives of millions of children and their families around the world.

In celebration of Luann’s legacy and in honor of World Breastfeeding Week, here is her story. We welcome you to share memories of Luann in the comments of this blog post.

Originally published during World Breastfeeding Week 2014.

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In Ethiopia, rapid improvements in child feeding behaviors are possible

Dr. Manisha tharaney, senior technical advisor, nutrition, ALIVE & THRIVE



Alive & Thrive recently released results from its first five years in Ethiopia, where infant and young child feeding programs reached an estimated two million mothers of children under two. As in Bangladesh and Viet Nam, we found that a comprehensive approach led to rapid improvements in feeding practices.

The prevalence of exclusive breastfeeding—already at high levels—increased to more than 80 percent in program areas. We also saw promising gains in complementary feeding practices. More children started receiving appropriate complementary foods at around six months of age and the percentage of children eating a diverse diet, while still extremely low, doubled in just four years.

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Scaling up nutrition works: Three strategies for success

JEAN BAKER, project director, ALIVE & THRIVEFHI 360

Can interventions be delivered at scale to improve nutrition during a child’s critical first two years? That is the question we set out to answer more than six years ago. And now the evidence is in—rapid, large scale increases in infant and young child feeding practices are feasible.

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