Core Principles and Practices for the Design, Implementation, and Evaluation of Social and Behavior Change for Nutrition in Low- and Middle-Income Contexts with Special Applications for Nutrition Sensitive Agriculture

Author: 

Mary Packard-Winkler

Lenette Golding

Tsedenia Tewodros

Emily Faerber

Amy Webb Girard

Publication Date

Affiliation: 

Independent consultant (Packard-Winkler); Save the Children U.S. (Golding); Rollins School of Public Health at Emory University (Tewodros, Girard); University of Alaska Anchorage (Faerber); Emory University (Girard)

“The design, implementation, and evaluation of effective SBC [social and behaviour change] strategies to achieve dietary behavior change is paramount to their success.”

Dietary behaviours sit at the intersection of dynamic and context-dependent ecosystems. Nutrition-sensitive agriculture (NSA) seeks to facilitate change in this complex ecosystem by addressing multiple immediate and underlying determinants of nutrition. Research in the field of NSA documents greater effectiveness when interventions include nutrition social and behaviour change (SBC) activities to shift dietary practices. This narrative review aims to capture, consolidate, articulate, and justify core principles and practices (CCPs) in the field of nutrition SBC and, where possible, for NSA more specifically. It offers programmatic examples that illustrate the CCPs’ application for NSA projects in low- and middle-income countries (LMICs).

The researchers conducted a narrative review following a 4-step iterative process to identify and describe SBC CPPs. They first reviewed general SBC frameworks and technical documents and developed a preliminary list of CPPs and their definitions. Following review and feedback from 8 content experts, they revised the CPPs and conducted a more specific search of the peer-reviewed and gray literature. They presented a revised draft of the CPPs to 26 NSA researchers, practitioners, and implementers at the 2022 Agriculture, Nutrition and Health Academy annual conference. They then conducted a focused review of each CPP, and 3 content experts re-reviewed the final draft. Overall, the search strategy for this narrative review followed a highly iterative and interpretivist approach.

The review of approximately 475 documents and resources resulted in a set of 4 core principles:

1. Follow a systematic, strategic method in designing, implementing, and evaluating SBC activities – Development of a theory of change (TOC) and strategy (based on evidence and social and behavioural theory) is a core part of making an SBC initiative strategic and systematic.
2. Ensure design and implementation are evidence based – A variety of research methods and data sources can be mobilised to build a project’s evidence base, ranging from desk reviews and situation analyses, pilot testing, field trials, and fidelity assessments, as well as routine monitoring of outputs and processes.
3. Ground design and implementation in theory – Addressing an issue may require integrating multiple theories and models, and SBC practitioners should embrace an ecological perspective that considers interpersonal, organisational, and environmental factors in activities aimed at influencing behaviour.
4. Authentically engage communities – This type of engagement involves working with communities and enlisting their active participation in identifying and analysing problems, setting priorities, planning and designing activities, implementing these activities, monitoring and evaluating them, and mobilising resources. Community members such as politicians, faith and other community leaders, service providers, researchers, and other decision-makers can provide key contextual considerations to the SBC strategy and its implementation and evaluation.

The review also identified 11 core practices and mapped theme to the different stages in the SBC design, implementation, and evaluation cycle. The paper provides detailed explaination of each practice, but, in brief, they include:

• Prioritise a limited number of behaviours.
• Conduct research to understand context and behavioural influencers.
• Apply formative research findings to design.
• Build upon existing structures.
• Engage multiple levels and groups.
• Use multiple complementary approaches.
• Apply participatory methods (e.g., seek and mobilise local knowledge and experience; demonstrate a respectful attitude that values and empowers underserved populations; engaging interested, affected, and relevant groups and individuals in analysis, planning, delivery, and evaluation of activities; and use visual tools, interactive methods, and skills practice in capacity strengthening).
• Test and adapt tools, methods, and communication materials.
• Strengthen and maintain SBC competencies for quality implementation.
• Track implementation quality and measure progress.
• Evaluate results, and replan to improve and scale.

The paper maps the CCPs – these 4 core principles and 11 core practices for the SBC process – to a generalised 5-step SBC process based on the original P Process SBC framework and later iterations. (See Figure 4 in the paper.) Detailed descriptions, illustrative examples, and resources for implementation are provided for each CPP.

In addition, Box 3 illustrates how the International Potato Center (CIP) has applied multiple CCPs to the development and implementation of SBC in their NSA projects to promote orange flesh sweetpotato (OFSP). CIP projects layer mutually reinforcing and strategically designed approaches, including interpersonal communication, group education, media, community engagement, and advocacy, across multiple levels. As of 2019, CIP’s OFSP promotion activities had reached 6.2 million households in 15 countries. Depending on the aim, design, and context, CIP OFSP projects have significantly improved consumption of vitamin A-rich foods, diet diversity indicators, vitamin A intakes, vitamin A status, infant and young child feeding practices, and reduced child diarrhoea.

To aid in the application of the CCPs, the paper provides references organised by each principle and practice (see Supplemental Table 2) and identifies online, free guidance tools for implementers.

Reflecting on the process of conducting the narrative review, the researchers note that the CCPs include reminders of the importance of structural and social factors and of engaging communities in a change process. However, they found that:

• “[T]he current status quo in SBC theory and practice remains weak on the ‘social’ component of SBC. Global health and nutrition work is still predominantly focused on changing individual behaviors instead of social norms, drawing primarily on behavioral science instead of social systems theory, and emphasizing information-based rather than dialogical approaches…”
• “These trends suggest that nutrition SBC… may insufficiently draw on theories and methods from disciplines such as community development, anthropology, sociology, and community psychology….As a result, the field of nutrition may struggle to operationalize SBC as an iterative, socioculturally grounded process of community-driven collective action for sustainable social change…”
• “Developing, documenting, and measuring the impact of more culturally grounded approaches to investigating and improving dietary practices, as advocated by some, may facilitate further refinement…” of the CCPs.

To further the CCPs’ refinement and application, the researchers recommend actions on the part of different key actors in the field of nutrition and NSA SBC. These recommendations highlight the need for continued investment in open-access research, community engagement, transparency, and accountability to create a culture of sharing and learning. They include, in part (see the full paper for more):

Implementers, governmental, and nongovernmental actors should, for example:

• Foster enhanced and transparent reporting that embodies a culture of learning. Go beyond sharing results to providing details on design, implementation, activities, processes, successes, and failures.
• Prioritise community and participant-engaged methods for deeper engagement, co-design, and shared learning.

Researchers should, for example:

• Co-design studies together with people with technical expertise, as well as those with lived expertise, organising expertise, and community history expertise who can contribute to implementation science on CCPs in nutrition SBC.
• Design, trial, and document innovative evaluation approaches that better capture the complexity of SBC interventions, particularly in multisectoral interventions.
• Conduct research that tests the value of individual core principles and practices to further understanding of what works and what does not work in the field of nutrition SBC.
• Investigate practitioner experiences with core practices such as behavioural prioritisation, participatory engagement, and SBC capacity strengthening.

Donors should, for example, ensure implementers are awarded sufficient funding, time, technical support, and other resources needed to enable the application of these CCPs and sharing of experiences on their utilisation.

In conclusion: “An explicit set of CPPs for SBC can serve as a guide for design, research, implementation, and evaluation of nutrition and NSA programs; help standardize knowledge sharing and production; and contribute to improved quality of implementation….The development of this framework of core principles and practices is a necessary first step in what we hope will be a robust and collaborative process to articulate, justify, and codify core practices for SBC in the field of nutrition more broadly and NSA more specifically. The next steps for this work require research to validate these core principles and practices in partnership with program designers, implementers, and SBC experts in LMICs. “

_{Images are for reference only.Images and contents gathered automatic from google or 3rd party sources.All rights on the images and contents are with their original owners.}