People-driven SBC in Practice Combating Stunting in Indonesia

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By Julia Weatherson, Ritu Ghosh, Eriana Asri, Octavia Mariance and Firda Dewi Yani and Tutut Sri Purwanti

Hnin (Julia) Weatherson is the Asia Regional Nutrition Advisor at Save the Children UK and is a public health nutrition specialist and certified breastfeeding specialist, currently based in Cambodia. Julia has nine years of experience in the humanitarian and development sectors with a passion for social behaviour change (SBC) and community system strengthening for improved nutrition.

Ritu Ghosh is the Asia Regional Manager-BCC at Nutrition International. She has a PhD in health and nutrition with more than 15 years’ experience of conducting formative research, KAP studies, impact assessments, evaluations and SBC strategies development using the human-centered design approach.

Eriana Asri is an Adolescent Nutrition Advisor for the BISA Project, Nutrition International Indonesia and has five years of experience in leading the implementation of adolescent nutrition technical assistance programmes to the Government of Indonesia.

Octavia Mariance is a BISA Social Behaviour Change Specialist at Save the Children Indonesia and has seven years of experience in maternal, infant and young child nutrition and behaviour change projects, both in humanitarian and development settings.  

Firda Dewi Yani is a Humanitarian Health and Nutrition Advisor at Save the Children Indonesia. Firda has more than nine years’ experience in maternal, newborn, child health and nutrition in both development and humanitarian settings.   

Tutut Sri Purwanti is the Maternal and Child Nutrition Advisor for the BISA Project and has more than 10 years of experience in leading the implementation of the Maternal, Child and Adolescent Health and Nutrition technical assistance programme for the Government of Indonesia.

Introduction and background

Despite Indonesia’s significant economic gains and sustained improvements in human capital, the prevalence of malnutrition remains high and child development outcomes are poor. The prevalence of stunting in children under five years of age is 31% in West Java and 43% in Nusa Tenggara Timur (NTT) and the prevalence of anaemia is very high in adolescent girls aged 14 to 20 years, with the lowest prevalence being in West Bandung (68.8%) and the highest in Sumedang (82.6%) (Dewi et al, 2020). “Better Investment for Stunting Alleviation” (BISA, which means “We can” in Bahasa Indonesian language) is a five year integrated nutrition programme planned for 2019-2024, implemented jointly by Nutrition International and Save the Children in partnership with The Power of Nutrition and The Department of Foreign Affairs and Trade. It aims to reduce stunting by improving the nutritional status of adolescent girls, pregnant and lactating women, women of reproductive age and children under the age of two across two provinces, NTT and West Java. This report summarises the adolescent-focused findings from BISA’s formative research which piloted the people-driven design of social behaviour change (SBC).

People-driven social behaviour change

In BISA, we emphasise the need for local solutions. Our vision is that when local people in communities are engaged, and when their own ideas of what they want to change and what can work for them are applied, this will result in sustainable behaviour change.

Formative research and people-driven design of SBC approaches were thus carried out following four steps to inform the programme design:

1. Immersion research by living in people’s homes to understand their day-to-day realities
2. Structured qualitative field research
3. SBC design generation to develop ideas to change behaviours around their priorities
4. Trialling SBC designs by testing out the ideas generated by the community themselves

Among adolescent girls, we aimed to deepen our understanding of the context and determinants around two prioritised behaviours: iron intake (consumption of daily iron-rich food and weekly iron and folic acid supplements – WIFAS) and handwashing with soap.

Key findings on adolescents’ perceptions and behaviours

While adolescent girls received WIFAS, the provision of tablets was insufficient, especially for school-based distribution, and thus adherence to consumption at the recommended dose was very low. Barriers included adolescent views that supplementation was not necessary as they did not have symptoms of anaemia and a lack of understanding about how iron consumption may affect future pregnancies. Adolescents also wanted to delay pregnancy and preferred to have a job first before starting a family.

Adolescent diets were generally based on rice and were low in protein. Adolescent girls did consume iron-rich/iron-fortified foods, more so in West Java (92%) than in NTT (84%), but in minimal amounts. In West Java, adolescents used pocket money to purchase fried, sweetened and packaged food for their school meals whereas less packaged snacks were eaten in NTT.

Although 81.7% to 96.9% of adolescents reported washing their hands with soap after defecation at baseline, direct observations did not confirm this finding. During immersion homestays with families, including adolescents, we found that families associated handwashing with removing visible dirt, smells and sweat rather than non-visible germs. This was a barrier to appropriate hygiene.

Girls preferred information that was provided in “fun” ways, such as through games. They valued the opportunity to ask questions and preferred that facilitators be peers, rather than their teachers. They indicated that “preaching/telling” them what to do was not useful, as it did not relate to their own experience and did not use their informal and local language.

Learning to action

The immersion research tested whether reported behaviour was the same as practiced which was found to not always be the case. Research also gathered new insights that highlighted several gaps which helped to refine programme design. Those findings were used in BISA to ensure effective behaviour change among adolescent girls, for example:

• WIFAS was disconnected from the motherhood message: “Healthy Adolescent Girl, Bright Future!"¹was created as an overarching theme in SBC materials which included digital stickers, GIFs², posters and audio-visuals to promote the regular consumption of WIFAS.
• Facilitation was interactive, activity-based and dialogue-learning driven: Each group session featured discussions to limit lecture/preaching tendencies and peer-led group sessions were the prioritised delivery platforms for adolescents, coupled with activities/games.
• Balanced and iron-rich diet was promoted: For example, adolescents visually demonstrated diversity and portions of foods consumed in the previous day in “balanced plate” activities.
• Healthy snacking was promoted instead of salty, fried, sweet snacks and junk foods: The “Emo Demo”³activity triggered a negative emotion of disgust when mixing chips with colourful flavoured drinks. Digital stickers also promoted the key message to avoid junk food.
• Visual cues helped to increase handwashing with soap: Rice Ball Germs⁴ is an SBC material that reveals invisible germs on a rice ball rolled by clean hands versus clean-looking dirty hands.

Going forward

This pilot project demonstrated that people-driven SBC design processes had traction with people in communities and garnered support from local service providers. As the BISA programme’s implementation continues until 2024, it will build on these innovative approaches and integrate them within its suite of SBC interventions, as the programme intends to expand across West Java and NTT.

For more information please contact: j.weatherson@savethechildren.org.uk

¹ https://www.youtube.com/watch?v=FIEwa9y3uDo

² A GIF (Graphical Interchange Format) is an animated image format or soundless video that will loop continuously and does not require anyone to press play.

³ https://youtu.be/VsEH7SpwKc8

⁴ https://www.youtube.com/watch?v=GsHMmaMkh7Q

References

Dewi et al (2020) BISA Baseline survey.

Gerakan Rumpi Sehat (2017) Introduction to Emo-Demo. Youtube.com https://www.youtube.com/watch?v=VsEH7SpwKc8 

Nutrition International (2019) Weekly iron and folic acid supplementation to prevent anemia in Indonesia. Youtube.com https://www.youtube.com/watch?v=FIEwa9y3uDo 

Save the Children Indonesia (2021) Reaksi nasi pada tangan yang sudah dan belum dicuci. Youtube.com https://www.youtube.com/watch?v=GsHMmaMkh7Q