Organizations involved
Bangladesh Rural Advancement Committee (BRAC), FHI360
Summary
Over the past decade, Bangladesh has made rapid progress in improving life expectancy at birth and per capita income. However, much remains to be done in tackling the persistent issue of malnutrition, which affects more than 80 percent of young infants resulting in stunting and wasting. An intervention leveraging information diffusion and social norms by Alive and Thrive (A&T) increased interactions within mothers, families, mothers’ networks and groups leading to a positive change in maternal, infant and young child nutrition practices. The issue of maternal and child nutrition also has a gender component where the programme directly works by increasing women’s agency and beliefs. The intervention programme (2010 - present) was deployed in 20 rural sub districts in Bangladesh initially and later scaled up nationally through various development partners and the government.
Social norms of interest
Proportion of mothers who believe most mothers in their community 1) Breastfeed immediately after delivery, 2) Do not give prelacteals to babies right after delivery, 3) Breastfeed the child exclusively for 6 months, 4) Feed mashed family food after 6 months, 5) Feed eggs, meat, fish, and other animal-source foods to children aged less than 6 months.
Proportion of mothers who strongly agree with the following statements: Most people who are important to me 1) Think that a mother, after normal delivery, can breastfeed her infant within 1 hour, 2) Think that a mother after cesarean delivery can breastfeed her infant within 1 hour, 3) Think that I should feed my infant only breast milk, and no other food, water, or infant formula for the first 6 months, 4) Do not approve of me giving my baby water before she/he reaches age 6 months, 5) Do not approve of me giving my baby infant formula before she/he reaches 6 months, 6) Do not approve of me giving my baby semisolid or solid foods before age 6 months, 7) Think that I should add egg, fish, liver, meat, or chicken in addition to other foods every day, starting at 7 months, 8) Think that I should feed my baby mashed family cooked foods (rice, vegetable, daal) along with breast milk after age 6 months, 8) Approve of me feeding my child after 6 months at least 3 meals/day.
Behaviors of interest
Maternal, infant and young child nutrition practices; exclusive breastfeeding; children’s diet diversity; maternal consumption of 5 food groups; information-sharing/diffusion
Project components
The project utilized behaviourally-informed interventions, focusing on interpersonal counselling, community mobilization and mass media campaigns including TV shows. Routine home visits were conducted in households with pregnant and lactating women by health workers and volunteers, who were given performance-based incentives. There were several sub-parts to every intervention. Community mobilization for example involved meetings and forums of women with husbands, religious, and other local leaders.
Social norms measurement
This study used data from a follow-up study to assess the sustained impact of A&T interventions, using a sampling design similar to that of a cluster-randomized impact evaluation. The household surveys were conducted at the intervention endline in 2014 and two-year follow-up in 2016, consisting of interviews with mothers of children under 24.
Information on mothers’ perceptions of social norms was obtained through the use of two types of questions: whether they believed most mothers in their community practiced optimal IYCF practices (descriptive norm, measured both at endline and follow-up), and whether they perceived that most people important to them approved or disapproved of practicing the recommended feeding behaviors (injunctive norm, measured at follow-up only).
Key findings to date
- The intervention demonstrated a pathway for scaling interventions working with social norms in their integration with government systems and development partners. The programme suggests how insights from social norms can be institutionalized and integrated within large-scale programmes and improve results. The significant gains showcase that apart from traditional behaviour change communication through mass media campaigns, community level interventions through mobilizations and interactions can lead to better nutrition outcomes in a sustainable manner.
- Information on maternal, infant and young child nutrition practices was passed through mothers and their social networks with significant positive outcomes on their knowledge and eventually their practices.
- The interventions saw an increase in information-sharing around infant and young child feeding practices, as well as perceived injunctive norms and descriptive norms linked to breastfeeding and maternal health and nutrition behaviours. The mothers noticed that their own expectations, and those within their communities, about breastfeeding practices had changed.
- Between the baseline at 2010 and endline in 2013 (2014 and 2017 for maternal nutrition), exclusive breastfeeding increased from 48.5 to 83.4% or 36.8% against control; diet diversity in 6-23 months children improved from 32.1 to 61.8% or 16.2% against control; maternal consumption of 5 food groups from 60.7 to 88.8% or 30% against control.
- A sustainability study conducted by Alive and Thrive also showed how the interventions sustained and led to as much as a 12-17 percentage point increase for breastfeeding and other aspects of maternal nutrition like consumption of iron-rich foods. Information-sharing also improved significantly by family members and health workers.
Attribution statement
This case study was written by Pavan Mamidi, Centre for Social and Behaviour Change, with colleagues and Project Concern International India. Special thanks to Thomas Forissier, Kristen Kappos, Deborah Ash and the team at Alive and Thrive along with their development partners for their invaluable support and comments towards this case study.
