|Food, Nutrition and Agriculture - 10 - Nutrition Education (FAO - FPND - FAO, 1994)|
|Improving nutrition behaviour through social marketing1|
1 This article is based on a case-study prepared for the International Conference on Nutrition entitled Communicating to improve nutrition behavior: the challenge of motivating the audience to act. The work was supported by the United States Agency for International Development.
M.B. Parlato, C. Fishman and C. Green
Margaret Burns Parlato is Vice-President for Nutrition, Academy for Educational Development (AED). Claudia Fishman is an Account Executive with Porter/Novelli. They are Director and Deputy Director, respectively, of AEDs Nutrition Communication Project. Cynthia Green is an independent consultant.
For 20 years, social marketing - the promotion of socially responsible products, behaviour and ideas through the application of commercial marketing principles - has been used successfully to promote better nutrition. The premise of social marketing is that consumers weigh the perceived benefits of alternative behaviours against the costs in terms of economic assets, time, energy or psycho-social value. The challenge to programme planners is to develop the best product, behaviour or idea at the least cost and to promote it in such a way that it clearly stands out from the competition. A successful product offers a benefit that is perceptible and valued by the consumer.
Nutritional products (such as certain foods or dietary supplements), practices or concepts may be valued not for their inherent nutritional qualities but for other attributes, and they must be promoted accordingly. For instance, implementers of programmes to prevent vitamin A deficiency found that mothers value green leafy vegetables because they are believed to give children bright eyes, shiny skin and good health, not because mothers fear that their children will develop night blindness and xerophthalmia (Favin and Griffiths, 1991; Shafritz, 1989).
Consideration has to be given to what consumers must exchange if they adopt a new behaviour to improve nutrition. Only those products or recommended behaviour changes that are economically feasible for consumers should be promoted. Costs to consumers may include monetary expenditures (for ingredients, fuel, etc.), time (for fixing a special weaning food or tending a kitchen garden), opportunity costs (carrying a nursing baby to market instead of more food to sell) and psychological costs (the strain of adopting a new feeding practice not sanctioned by tradition).
Seasonality may apply in cost-benefit considerations. For example, the Academy for Educational Development (AED) vitamin A programme in Mali recognized that the purchase and/or gathering of nutritious fruits, vegetables and herbal seasonings is affordable for most of the year. At times of the year when these items are not available, however, the purchase of small quantities of high-nutrient foods, such as liver, can be highly cost beneficial.
For behavioural change to occur, the product or service must be available and easily accessible and messages must reach the intended audience. Nutrient-rich foods must be present in the marketplace; nutritional supplements must be available in health clinics or on the open market; and distribution outlets (markets or service delivery points) must be accessible. Instead of relying exclusively on health centres, communication programmes can benefit by promoting nutrition through local markets and communities where decisions about food are made.
DEVELOPING A COMMUNICATIONS PROGRAMME
A promotion strategy should be developed only after the issues of product, price and place are resolved, The first step to developing a plan involves market research to obtain qualitative and quantitative information about the knowledge, attitudes and practices of consumers. This step is essential to shaping message development and evaluating a programmes impact.
Interpreting the results of the formative research to develop a comprehensive strategy is the second step, This strategy will be revised after the programme has been pre-tested and experience has been gained in implementing it. An important component of the strategy is audience segmentation. Most nutrition programmes define a primary target audience, i.e. those who may actually change their nutrition practices, Few programmes try to reach those who influence the primary audience (e.g. health and nutrition care providers, family and friends and popular public figures). It is also important to reach decision-makers, financial supporters and other influential people who can make the programme a success.
Selecting the channels of communication is the third step. Interpersonal communication is generally considered the most persuasive and influential means of communication, largely because of the intimacy, responsiveness and client participation that it affords. The use of this method can be problematic, however, unless investment in the training and supervision of field workers (agents) is sufficient to ensure that they have the skills to be open, patient and non-prescriptive when conveying new ideas.
The frequency of contact between agent and client determines the success of interpersonal education, Many nutrition programmes rely on health centre personnel for interpersonal education, which limits total client contact. In many parts of Africa and Latin America, less than half the population is within the catchment area of modern health facilities.
Programme planners should identify community workers, teachers and religious leaders to carry an interpersonal message. Reaching these non-traditional agents requires new institutional structures or interagency agreements, expanded management systems and cooperative training and supervision. Interpersonal education is necessary so that clients can explore the many facets of a proposed habit change with a known and knowledgeable agent.
The mass media have an equally important role in providing clients with initial information about a habit change and in encouraging favourable attitudes towards it. Both channels of communication should be programmed together. In a diarrhoeal disease control programme in Swaziland, for example, interpersonal activity alone had a profound effect on behaviour, but only a limited audience was reached. Radio was used to reach large numbers of people but had less impact on habit change. Twenty percent of the mothers who had interpersonal contact with a health or outreach worker were likely to use a home rehydration solution appropriately, while only 13 percent of the mothers who had been heavily exposed to radio used the remedy properly. However, 60 percent of the population heard the radio messages, while health workers were able to reach only 22 percent of the people and outreach workers spoke with only 16 percent (Hornik, Rice and Atkins, 1989).
Using mass media can be a cost-effective means of reaching key audiences, including families living in rural and peri-urban areas and those not reached through the health system. Messages can be repeated to ensure adequate frequency of message exposure. Mass media format and presentation can be varied to appeal to different audiences. Dramas, soap operas, quiz shows, advertisements and catchy tunes have been used successfully. Popular actors may perform gratis to promote an important social cause, adding to the appeal and memorability of a spot or show. In Brazil in 1981-82, famous actors, singers and athletes appeared in television spots to support breast-feeding. Four years after the campaign ended, 85 percent of mothers and health professionals interviewed recalled at least one spot, indicating their effectiveness (da Cunha, 1991).
In Swaziland, radio spots on the control of diarrhoeal disease reached 60 percent of the target population - Au Swaziland, des messages radio sur la lutte contre la diarrhatteignent 60 pour cent de la population vis- En Swazilandia, los mensajes radiales sobre la lucha contra la diarrea llegaron al 60 por ciento de la poblaci la que se dirig
Development and pre-testing of materials is the fourth important step in social marketing. The importance of pre-testing all materials, products and messages cannot be overstated. Pre-testing is often seen as an unwanted expense in terms of money, time and effort which would slow down the programme. However, omitting this step could lead to an even greater loss and to the failure of the entire communication activity.
Monitoring and evaluation may be considered a fifth step although they are not a separate stage but continuous processes that feed regular analyses of the results back into the programme. Careful monitoring identifies constraints that have been overlooked or underestimated, provides insight into audience characteristics that were misunderstood and suggests important factors that have changed during the programme. Evaluation includes measurement of the overall impact of the communication programme (i.e. degree of habit change, improvement in attitudes or increase in knowledge and understanding) and analysis of the degree to which individual programme elements (research, planning, training, media production, etc.) have contributed to programme success or failure. Solid data on a programmes impact are often key to obtaining continued funding.
SUCCESSFUL NUTRITION PROGRAMMES
A number of programmes have succeeded in improving nutritional status using a social marketing approach involving market research, mixed media and advertising or consumer-based communication.
In the Dominican Republic, the prevalence of malnutrition among 4000 rural children under age five fell from 12.2 percent to 6.9 percent and breast-feeding practices improved. Feeding of newborns on demand rose from 35 percent in 1983-84 to 63 percent in 1986 (USAID, 1988).
Community nutrition education through individual counselling, print and audiovisual materials and use of mass media was among the key elements in Thailands Nutrition and Primary Health Care Programme. This programme reduced the prevalence of severe malnutrition among children under five in rural areas from 36 percent in 1982 to 20 percent by 1989 (INPF, 1989).
After a national breast-feeding campaign was carried out in Jordan from 1988 to 1990, 94 percent of the women interviewed recalled the song used in radio and television spots. The proportion who knew about the appropriate time to initiate breast-feeding rose from 41 to 74 percent, while the proportion having knowledge regarding delayed supplementation grew from 36 to 61 percent. The proportion of mothers initiating breast-feeding within six hours of birth increased from 38 to 56 percent (McDivitt and Ayman, 1991; Seidel, 1992).
In Indonesia, radio, banners and outreach by health workers and village health volunteers increased the proportion of young children who received a vitamin A capsule from a health post from 24 to 51 percent in test areas (Seidel, 1992). A second project used radio spots, promotional marketing activities and counselling materials for health workers to promote vitamin A-rich foods. Among those who heard the radio spots, the daily consumption of dark-green leafy vegetables increased from 19 to 32 percent among pregnant women, from 14 to 33 percent among nursing mothers, from 10 to 21 percent among infants aged 5 to 12 months and from 17 to 27 percent among children aged 13 to 60 months (Favin and Griffiths, 1991).
In Peru, a new weaning food for children with diarrhoea was developed using recipe trials with mothers. It was promoted through radio spots, cooking demonstrations in mothers clubs and local markets, a flip chart, a calendar and training materials for health professionals. In the test area, 80 percent of women interviewed had heard of the food, 16 percent had tried it and 12 percent said that they would continue using it (Johns Hopkins University, 1990).
KEY FEATURES OF SUCCESSFUL PROGRAMMES
A number of lessons can be derived from nutrition communication experiences worldwide. First, successful programmes have used in-depth research to build an effective communication strategy. To influence nutrition knowledge and behaviour, programme planners must have an understanding of the factors affecting dietary practices in at-risk populations. This foundation is obtained through careful, in-depth analysis of current nutrition status, dietary practices, food availability and cost, cultural beliefs and use of social services.
To select the most appropriate interventions, it is necessary to identify barriers to sound nutrition (e.g. families inability to afford nutritious foods or improper food preparation) and address them directly, Among the specific problems identified, those most harmful or widespread and most amenable to change must be determined. Possible interventions need to be assessed for their feasibility, cost and potential nutritional impact.
Effective nutrition communication campaigns and products are based on consumer preferences. Usually, programme managers seek to identify a nutrition behaviour that is susceptible to modification, to develop a new recipe or mode of delivery for a food supplement or to introduce improved feeding or care practices. If consumers are involved in identifying and perfecting the end product - whether it be a tangible product, a practice or avoidance of something harmful - the chances of the end products sustained adoption are increased.
Successful programmes promote simple, practical habit change. In the past, many nutrition communication programmes promoted complicated and unrealistic actions and had little effect in changing nutrition behaviour. In contrast, recent campaigns such as those in the Dominican Republic (USAID, 1988) and Cameroon (Hollis et al., 1989) have focused on highly specific behaviours, for example by promoting specific numbers of meals, specific quantities and other defined, related feeding tasks.
Often people are more willing to accept a new food or product than a change in their customary eating patterns. Products that do not alter the basic adult meal are more acceptable. Cultural rules concerning childrens food or between-meal foods are generally more flexible. Snack foods could overcome cultural barriers, for example by helping women to increase their own dietary intake without increasing the total amount of food provided at family meals.
Experience shows that successful programmes identify and reach audiences that have the power to influence the primary target audience. Many nutrition communication programmes focus on mothers, who are often the main providers of food and child care. Fathers and other family members, however, often influence decisions regarding food purchasing and food allocations within the family.
Family members influence dietary practices by their opinions, their financial contribution to food purchases and the labour they contribute to the household. Changes in nutrition behaviour often entail shifts in time allocation among household members. For example, if women are devoting more time to breast-feeding or food preparation, other household members may have to take on additional responsibilities such as carrying water or fuelwood. Therefore, it is important to direct some messages to other family members and to involve them in efforts to improve family diets. For example, in Mali a communication effort reinforced fathers traditional practice of buying small pieces of liver (high in vitamin A) as a snack for their children (Fishman, Tournd Gottert, 1991).
Community leaders can help identify problem areas and possible solutions, ensure acceptance of new products or practices and establish new cultural norms related to nutrition. While the level of community involvement varies greatly among projects, it is critical that leaders help identify the most severe nutrition problems, provide advice on proposed behaviour changes, messages and communication channels and give overall support for community-level activities.
A father purchasing a nutritious snack of liver - Un p ach un casse-croutritif de foie - Un padre de familia comprando un bocadillo nutritivo de hdo
TRAINING AND MANAGEMENT OF OUTREACH WORKERS IS KEY
Effective agent training uses a social marketing approach that teaches outreach workers to view the women they see in health centres or visit in communities as clients or consumers of the services and information they offer.
This perspective requires that outreach workers:
· understand the clients circumstances and why current opinions and feeding practices are prevalent;
· seek solutions to nutritional problems in collaboration with the consumer, based on the resources available to the family;
· be systematic about follow-up and community sensitization, knowing e.g. when to check back with the client; whether a problem could be brought to the attention of a village health committee; whether a topic is suitable for a group demonstration, health talk or role-play activity.
As outreach workers both sell information to their own clients and consume it from their superiors, communications materials (such as lively bulletins, videos and self-evaluation checklists) have been developed to motivate and reinforce their confidence while helping to improve their nutrition counselling skills.
Involving community leaders in project planning helps to ensure their cooperation and active participation in project implementation.
A balance between centrally managed functions and community input is necessary. Central management ensures accurate, consistent messages, allows economies of scale and provides specialized expertise, while community advice ensures that messages are culturally appropriate and that they reach their intended audience.
Frequent, direct message exposure is widely recognized as a key factor in behaviour change. Putting the message out does not necessarily guarantee that it is received and understood by the target audience. For example, health and field workers may be inadequately trained in nutrition, or people may not listen to radio broadcasts. The message may be misinterpreted, or it may be understood but ignored. People usually need to hear messages over and over again before they take action. It is a mistake to assume that once people have heard the message they will immediately and flawlessly adopt the desired behaviour. In reality, people have many demands on their time and many preoccupations. Even the most clever message must cut through the clutter of everyday communications.
Combined use of interpersonal communication and mass media is important to attain different objectives, The mass media can bring new ideas and information to large audiences, encourage favourable attitudes towards them and generate support among opinion leaders. Interpersonal education can provide the intimate, interactive contact with clients necessary for final habit change.
A recent assessment of 16 health communication projects concluded that programmes that achieved a high mass-media exposure (reaching at least 60 percent of the target audience) were associated with substantial change in behaviour, while most of those with low rates of exposure (below 30 percent) resulted in little or no change (Hornik, Rice and Atkins, 1989). Since it is assumed that in both cases intensive, high-quality interpersonal education was a constant, it can be concluded that the mass media have a complementary role in preparing the way for behavioural change.
While mass media costs can be high, particularly in privatizing economies bent on cost recovery, they can be reduced. Free air time for short public service announcements can be secured from networks, stations or government ministries of information. It may be possible to negotiate for free production services from advertising agencies or commercial companies with a large and visible presence. Messages can be integrated into already-popular programmes.
Special efforts to train outreach workers in counselling and communication skills and to provide regular supervision are important. Working far from a centralized authority in remote communities, these workers must always be - and feel - part of an integrated management system. In which their needs are met, their contribution is acknowledged and their performance can continuously improve. The investment required to achieve such a system is significant, including transport for supervision, resources for training and improvements in financial and benefits packages to make remunerations commensurate with job effort and responsibility.
Finally, successful programmes are long-term commitments for which the return is sustained behaviour change. While brief interventions have produced measurable results, new behaviours are fragile and can rapidly disappear. Evaluations of communication projects over time strongly support the need for long-term, intensive efforts. The implication for programme planners is that sufficient funds, human resources and political commitment are required to obtain results. Even after most people have adopted the desired behaviour, reinforcing messages are needed to prevent reversion to original behaviour (decay). In addition, audiences keep changing: young people start families and need to know about infant and child feeding, rural people move to the city and income levels change. By sequencing messages over time, building in audience feedback and using evaluation results to plan new campaigns, programme managers can build on past efforts and reinforce behaviour change.
da Cunha, G. 1991. The national programme to promote breast feeding. Brazil. Paper presented at the Sixth International Conference of the International Nutrition Planners Forum, Paris, 4-6 September.
Favin, M. & Griffiths, M. 1991. Social marketing of micronutrients in developing countries. Washington, DC, Manoff Group.
Fishman, C., TourD. & Gottert, P. 1991. Nutrition promotion in Mali: highlights from a rural integrated nutrition communication program. Sixth International Conference of International Nutrition Planners Forum, Paris, 4-6 September.
Hollis, C., Seumo, E., Mal Bappa, A. & Griffiths, M. 1989. Improving young child feeding practices in Cameroon: project overview. Washington, DC, CARE/Cameroon; Education Development Center; Manoff Group.
Hornik, R., Rice, R. & Atkins, C. 1989. Channeling effectiveness in development communication programs. In Public communication campaigns. Newbury Park, California, USA, Sage Publishing. 2nd ed.
International Nutrition Planners Forum (INPF). 1989. Crucial elements of successful community nutrition programs. Report of the Fifth International Conference of the INPF, Seoul, 15-18 August 1989.
Johns Hopkins University. 1990. Dietary Management of Diarrhoea (DMD) Project: final report. Baltimore, Maryland, USA.
McDivitt, J. & Ayman, A. 1991. The HEALTHCOM Project in Jordan: final case study evaluation report. Philadelphia, Pennsylvania, USA, Centre for International Health and Development Communication, University of Pennsylvania.
Seidel, R. 1992. Results and realities: a decade of experience in communication for child survival. Washington, DC, Academy for Educational Development.
Shafritz, L. 1989. Social marketing approach to vitamin A communication. Washington, DC, Academy for Educational Development.
United States Agency for International Development (USAID). 1988. Growth monitoring and nutrition education: impact evaluation of an effective applied nutrition program in the Dominican Republic, CRS/CARITAS, 1983-86. Washington, DC.