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.
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.
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!”
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.