An intriguing message: Where did it come from and why does it work?

ANN JIMERSONBEHAVIOR CHANGE SPECIALISTALIVE & THRIVEFHI 360

I wasn’t joking when I told Mary Penny and Hilary Creed-Kanashiro that the Skype call we had recently fulfilled a fantasy for me. For some time, I’ve been fascinated with a study they and their Peruvian colleagues were part of about 10 years ago. And now I’d been granted my wish to ask my questions.

In the early 2000s, the Peru group tested a streamlined interpersonal communication intervention to improve complementary feeding. Using formative research, the program designers arrived at three key messages. In intervention health centers, staff were encouraged to repeat the three messages to all mothers of babies over 6 months old. The mothers’ feeding practices improved. And to their surprise, the researchers discovered that by 18 months, the babies they had followed who were born at the beginning of the program and lived near the intervention health centers had grown taller than babies in the same town who went to other health centers.[1]

Children who grow to their full height become healthier, smarter, and even more economically productive adults. Nutritionists have been clear about which behaviors will improve children’s growth and development. But the kind of success seen in the Peru study is rare.

What’s so special about delivering three simple messages?

The first two messages are standard admonitions to feed nutritious thick foods rather than thin broths; and to add animal source foods like chicken liver, egg, or fish to the baby’s daily diet.

But the third message has intrigued me: Teach your child to eat with love, patience, and good humor.

Photo courtesy of Rebecca Robert, Catholic University of America

Photo courtesy of Rebecca Robert, Catholic University of America

In a streamlined message set, why “waste” one of only three messages on this seemingly vague plea that doesn’t really lay out a measurable “small doable action”? I’d met several others who were involved with the study, and asked them about that third message. Each smiled before gushing over this one. Is it possible that this message is what set the study apart from others that were less successful? But no one could tell me where this message came from.

Imagine my excitement to take my questions to two women who might have the answer. They too smiled when I asked about that third message. Yes, they said, it did play an important role. They didn’t have the data to tease out the role of each message. But they had observed clinic visits where this message changed everything.

“Even with trained staff, there often was a mismatch between the concerns a mother expressed and the nurse’s response,” Hilary Creed told me the other day. “The mother would say, ‘I’m worried that my child isn’t eating,’ and the nurse would say, ‘Feed more liver.’ It just didn’t connect. Finally the nurse would deliver that third message, and it softened the counseling atmosphere. The mother smiled, and the nurse smiled. The message helps you past an impasse, it’s the bridge. It makes it feel possible to solve the problem.”

The message has persisted. A decade later, parents can repeat it, even in regions far from the study area. Mary Penny explained, “It’s gone viral, really. And surprisingly, it really appeals to men. I was speaking recently with a community group about feeding in the first two years of life. A man stood up and said, ‘But you haven’t even mentioned that you must teach your child to eat with…’ [yes, you guessed it] ‘…love, patience, and good humor.’”

So the others were right. There really was something magical about this particular message. I had to know: “How did you come up with it?”

Hilary filled me in. “We hit it lucky, really. It was a creative anthropologist who came up with it, thinking about the findings from formative studies. Then we tested it in a few TIPs-type[2] studies, where you explore with mothers and then look at the impact and the feasibility of the behavior. This message was a winner, right from the beginning.”

An intriguing message, yes, almost magical. But still it had emerged from solid formative research and passed the test with mothers. Only then did this message become part of a winning trio. Maybe further study will someday explain why this message. Meantime, Peruvian mothers and fathers take it to heart, and their feeding practices improve.

Yes, we’re all for “less guess” – using research to shape messages and then testing them like crazy. But it’s good to be reminded that often it’s the informed creative leap that makes the difference.

[1] The stunting rate in the intervention group was three times better (lower) than in the control group (5% vs 15%).

[2] TIPs, or Trials of Improved Practices, is a method developed by The Manoff Group and AED, to learn which household behaviors are most feasible for mothers. See more about TIPs here and here.

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3 thoughts on “An intriguing message: Where did it come from and why does it work?

  1. So it sounds like the message was more of a way to build a relationship between the health worker and parents rather than necessarily being something that changed what the parent did with the child directly. It opened them up to listening to a lot of the advice offered since it became clear that the person liked them. This is the sort of finding that I think can help us to move forward quickly in behavior change — creating the sort of relationship that doesn’t just help with one behavior, but opens the person up to change in many ways … in this case, because they now have someone who both knows what needs to be done AND that they trust. We heard loud and clear at final evaluation of the FH Care Group model in Mozambique that the volunteers had gained a tremendous amount of respect from other mothers, from their husbands, from clinical workers, and from community members. When we asked, “Who respects you more now than they did before you began working as a CG Volunteer?”, a long list of people was mentioned, and other women was at the top of that list. We see that as not only a way to ensure low volunteer turnover (it was < 5% a year), but also to improve the *effectiveness* of the volunteers in helping people to change their behavior. That respect was a marker for improved relationships, and that respect, love and concern between the volunteer and the mothers served greased the wheels for behavior change. There were still other barriers to overcome, but being able to trust the person that is talking to you and to know that they like you and wish you the best makes a big difference in a person's willingness to really listen, and to try things out, simply because you want to please the other person who cares about you.

    "Liking" has long been recognized as an important factor in persuasion, but we probably don't devote the time to it that it deserves. We could do better in helping to assure that parents actually LIKE the health worker that they have contact with, and that they do things and say things that leads to a closer relationship. I think some of the emotion-based counseling has focused more on this principle, and trying to form a closer bond between mothers and the person counseling them. (More on that approach here: http://touchingheartstouchingminds.com/overview_emotioncounseling.php).

    Tom Davis

  2. I guess being a disciple of Paulo Freire and having taught his methodologies applied to health for many years, I am surprised by the surprise! Freire is considered the father (now grandfather) of learned-centered participatory education. It has always been my thought that Freire’s real contribution was the linking of the emotional and the cognitive. He speaks of “generative themes:” issues so important to the community or individual that they generate enough energy to break through apathy and move them to action. The basic idea being that unless you reach people through those things about which they care deeply, they are not moved to act. I have experienced this over and over around the developing world as well in USA classrooms full of cynical graduate students. When you talk about love, patience and good humor towards children to a parent you are touching their generative theme and they are, hence, moved to action. Eating more liver or consuming more blood in Peru may be the on-target message for an indigenous woman in Peru and if she did it she would see improvements in her child’s growth. But liver doesn’t touch her emotions, her love or her dreams for that child. When we get there, to that sweet spot, the cognitive is joined to the emotional touchstone and people are moved to act. In Bangladesh we took a similar approach, more akin to appreciative inquiry, getting father’s to talk about their dreams for their children. Once they were hooked into their dreams the actions they could take to help that child fulfill their dreams became much more significant to them and moved them to action. Let us not forget, we are not only bodies with a mind but that we also are deeply heart and soul and that our deepest concerns, passions and loves are what motivate us to grow in knowledge and action.

  3. Thanks, Bethann and Tom, for these insightful comments. The emotional breakthrough was what seemed most prominent for the local observers and I’m sure that’s a major part of this message’s impact. I wonder, too, about the value of promoting “responsive feeding” actions — like facing the child when you feed him so that you know how he’s responding to new tastes or whether he still wants more to eat. A mother who pays close attention to TEACHING her child to eat will naturally learn to give a variety of tasty foods and to feed until the child is satisfied. With more focus on “responsive feeding” actions, could we cut back on all that complicated instruction about “1/2 a bowlful 3 times a day at 9-11 months of age”?

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