Exploring Social and Behavior Change Communication to Support Delivery of Micronutrient Powders in Rural Uganda

"Effective micronutrient powder distribution programming requires a behavior change strategy that is both effective and appropriate in a specific context."

Drawing on the experience of the United States Agency for International Development (USAID)'s Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) project, this presentation explores the use of social behaviour change communication (SBCC) to support delivery of micronutrient powders (MNP) in rural Uganda. In examines anaemia landscape in Uganda, the SPRING pilot distributing MNP in Namutumba district and associated SBCC, and data collection methods and findings.

In Uganda, anaemia is the third leading cause of mortality among children. It is considered a severe public health problem among children under 5 (>40%), and a moderate public health problem among pregnant women and women of reproductive age, or WRA (20-29.9%). Considering that micronutrient deficiencies are a significant contributing factor to anaemia in Uganda, the Ministry of Health (MOH) expressed interest in implementing programming to deliver MNP. Efficacy of MNP to reduce micronutrient deficiencies is high when protocol adherence is assured, but there is little evidence about how to implement an effective MNP programme.

Thus, in 2012, the MOH partnered with SPRING, the World Food Programme, and the United Nations Children's Fund (UNICEF) to conduct a series of pilots to inform national programming. The SPRING pilot distributed MNP in Namutumba district, Uganda, to children ages 6 to 23 months. All sub-counties in the district were randomly assigned to either receive MNP through facility- or community-based distribution.

To support and encourage positive caregiver and distributor behaviours, SPRING focused efforts on developing a SBCC strategy. To explore factors that encourage or discourage adoption of promoted MNP-related behaviours, SPRING conducted formative research to design the behaviour change strategy to accompany MNP distribution. The team conducted key informant interviews with local council chairpersons and health care representatives and conducted 6 focus groups with mothers, fathers, and grandmothers. Findings included that people trust health workers (HWs) and village health teams (VHTs) to provide formal advice. They felt involving radio show hosts would be a good way to spread the message about MNP and that messaging should utilise churches and women's groups to reach women and markets to reach fathers. They reported that it would be necessary to get fathers on board with providing MNP to their child because their approval would be needed. Finally, politicians should not be involved in promotion of MNP and they were seen as being biased and not trustworthy.

The resulting strategy focused on hot button drivers like family values, power, security, and messaging that resonated with fathers, mothers, and grandmothers. It included: mass media through top-of-the-hour radio announcements; community engagement through presented dramas and sensitisation meetings; distribution of printed materials including posters and stickers depicting how to give MNP and adherence calendars to track which days a caregiver should give their child MNP; cinema videos reaching out to men; and counselling by MNP distributors that included messaging infant and young child feeding practices. This counseling focused on key behaviours including: proper consistency of complementary foods, providing diverse foods to complement the MNP, mixing MNP into food to avoid taste or colour changes, supporting children to eat the full serving of food, and continuing to breastfeed. [Click here to view and listen to SBCC materials that were developed as part of the pilot.]

After 9 months of MNP distribution, the team conducted 144 qualitative interviews with caregivers, fathers, and distributors and 1,060 endline household surveys on caregiver attitudes, exposure to SBCC, and MNP use and adherence.

Qualitative interviews found that:

• Caregivers were concerned about negative side effects, but further counselling was helpful. Calendars and stickers were seen as helpful reminders.
• Distributors felt that ongoing training was necessary so they would be equipped to appropriately answer caregiver questions. In addition, nearly all distributors reported that MNP distribution created additional work for them, with many reporting that counseling required extra time.

Quantitative findings from the endline survey showed that:

• Almost all participants had heard of MNP (99%), and radio announcements were the most common method reported. This highlights the point that radio is a particularly important method for reaching participants.
• The endline found that receiving counselling the first time a caregiver received MNP and receiving the calendar or the sticker significantly predicted whether the caregiver adhered to the promoted MNP protocol (defined as a combination of 3 practices).
• Despite some caregivers reporting in the endline survey that their child had diarrhoea, negative side effects did not significantly impact adherence to protocol. This can be explained by the qualitative finding that caregivers who received counselling knew what to expect as potential side effects of MNP and in turn typically continued MNP use despite diarrhoea.

In conclusion, this study has sought to add to the evidence base of SBCC to provide support for adhering to an intervention addressing malnutrition that requires continued and sustained practice.

Editor's note: The above is a summary of an oral presentation delivered by Hillary Murphy at Shifting Norms, Changing Behaviour, Amplifying Voice: What Works? The 2018 International Social and Behavior Change Communication (SBCC) Summit reaturing Entertainment Education, held April 16-20 2018 in Nusa Dua, Indonesia.

Click here for the 13-slide PowerPoint presentation.