Can Gossip Change Nutrition Behaviour?
Three members of the Environmental health Group, Sian White, Wolf-Peter Schmidt and Val Curtis, have recently worked with other collaborators to publish a paper on a unique nutrition behaviour change trial in Indonesia. The article was published recently in the Journal of Tropical Medicine and International Health and is available in full here. This research was supported and financed by the Global Alliance of Improved Nutrition (GAIN).
We asked one of the authors, Sian White, to explain the significance of the paper and its key findings.
Sian White and some of the Healthy Gossip Movement Facilitators doing a street visit to mothers and children in East Java. Tablets are used as a way of engaging mothers and screening the TV adverts.
Why is this study important?
Maternal, infant and child nutrition is a complex area to work in. Mothers often receive an array of information about what is best for their child, whether it be from the health worker when they go for their antenatal visits, or their peers, parents or parents-in-law, all desperate to share their experiences. Many nutrition programs to date have focused on either high end product development, such as food fortification, or education packages delivered through health systems. In spite of significant investment in such programs there are many countries, like Indonesia, where rates of stunting have been largely stagnant for the last 50 years. Stunting is a serious issue as it limits both the physical and cognitive development of the child and puts them at higher risk of non-communicable diseases later in life as well as infectious diseases. For a country like Indonesia, where one out of every three children is stunted has significant ramifications on the productivity and health of the nation. Intervening in the first 1000 days of life (from conception to a child’s second birthday) remains the critical window of opportunity to change the nutritional outcomes for children.
This study represents the first attempt to systematically apply a Behaviour Centred Design (a theoretical approach grounded in evolutionary psychology and marketing techniques) to the area of infant and young child feeding. We knew that nutrition knowledge was already high in the area we were working in, yet adoption of healthy nutrition practices was poor. Consequently we were interested to find out whether a theory-driven, scalable campaign which avoided educational messaging in favour of using strong behavioural levers could be effective in changing nutritional behaviour.
One of the facilitators doing an emotional-demonstration activity (emo-demo) about breastfeeding.
What are the key findings of the study?
A landscape analysis to assess current nutritional practices indicated that key behaviours were likely to be 1) exclusive breastfeeding for the first 6 months of life, 2) dietary diversity of complementary food and 3) reducing the feeding of unhealthy snacks. We used formative research to build on our understanding of these behaviours. We found that although mothers knew that “breastfeeding was best” most chose to supplement this with formula milk which was expensive and consequently perceived as a status symbol – showing you were able to provide for your infant. We observed that feeding normally took place outside the house in the street setting. Amidst this public setting mothers became easily embarrassed if their child started crying and often gave unhealthy snacks to their children as a way of keeping them quiet. Unfortuantely this practice of feeding children snacks at regular intervals meant that children were often not hungry when it came to their more nutritious meals. Having said this dietary diversity was observed to be poor, with most meals having only a couple of ingredients and being dominated by rice.
Social pressure from family members and peers was identiﬁed as a key driver of all three target behaviours; hence, the campaign that was designed centered on the afﬁliation motive. It was called Gerakan Rumpi Sehat – the Healthy Gossip Movement. Emblematic of the campaign was the character of Ibu Rumpi (Mrs Gossip) who was depicted as gossiping about and making judgements on the feeding practices of others before realising, to her great and comic embarrassment, that she was the one who had actually been doing the wrong thing. The theory of change was that the target audience would become more aware of the likelihood that their child feeding practices were being watched and judged by peers, so practicing the wrong behaviour would be embarrassing and damaging to one’s reputation.
We evaluated the campaign concept through a 3 month randomized control trial where one arm received television adverts and community activations, the second recieved only television adverts and the third received nothing. The pilot study found that there were some improvements in dietary diversity and the intake of fruit and vegetables. Interestingly we did not observe a reduction in unhealthy snacking yet healthy snack foods did increase! Although the study was too short to assess the impact on exclusive breastfeeding behaviour there were some positive early signs that the campaign may have had a postive impact on increasing exclusive breastfeeding for a longer duration.
An emo-demo about child feeding which is designed to make mothers feel embarrassed if they give snacks to close to meal time.
What are some of the things you learned personally while conducting the study?
There were a lot of big learning curves during this study, some of which are hopefully of use to others working on intervention trials.
- It is notoriously difficult to evaluate the impact of mass media interventions. In this case we chose a neighboring district to act as the control. It was the most similar area we could find that was not covered by the TV station yet it still proved quite different in its social-demographic characteristics, making the finding complicated to unravel.
- Exposure is the first critical ingredient to success. In our case we were working in a high urban area of East Java which there was a high level of media saturation and a lot of things competing for people’s attention. The exposure to our campaign was much lower than we had intended consequently making the effects much harder to measure.
- Keeping it simple was another big lesson. Our campaign was complex and involved various channels and touch-points. All interventions rely on human capacity and skill and so the more elements you add to a campaign the harder it is to maintain fidelity between villages and implement the intervention as intended.
If you are interested in learning more about Gerakan Rumpi Sehat you can follow the campaign on Facebook here, watch the three TV commercials below or read about the Emo-Demo Descriptions (emotional-demonstration activities) that were part of the campaign.