Nutrition Behaviour Change Communication Causes Sustained Effects on IYCN Knowledge in Two Cluster-Randomised Trials in Bangladesh

"Impacts of BCC programmes may be underestimated if persistence of effects is unaccounted for."

This paper assesses the effect of nutrition-sensitive social protection interventions on infant and young child nutrition (IYCN) knowledge in rural Bangladesh, both during and after intervention activities. In that country, chronic under-nutrition is widespread: 36% of children under 5 years old are stunted, leading to poorer preschool nutrition outcomes, and subsequently, to poorer health, education, and labour outcomes in adulthood. Behaviour change communication (BCC) has been found to improve IYCN knowledge, practices, and health outcomes. An under-researched question, particularly for intervention design, is the appropriate duration of BCC and whether knowledge gained from BCC persists.

The researchers use data from two, 2-year, cluster randomised control trials (RCTs) that included nutrition BCC in some treatment arms. Conducted between March 2012 and May 2014, the Transfer Modality Research Initiative (TMRI) was designed and evaluated by the International Food Policy Research Institute (IFPRI) and implemented by the United Nations' World Food Programme (WFP). Two RCTs were conducted in rural areas: In the north, study villages were randomly assigned to a control group or one of four treatment arms in which beneficiaries received a cash transfer ("Cash"), a food ration ("Food"), a half cash transfer and half food ration ("Cash&Food"), or a cash transfer along with nutrition BCC ("Cash + BCC"). In the south, study villages were also randomly assigned to a control group or one of four treatment arms; the first three treatment groups were the same as in the north. The final treatment group in the south was different: Instead of a cash transfer along with nutrition BCC, beneficiaries received a food ration along with nutrition BCC ("Food + BCC"). All beneficiaries were economically poor households with a child aged 0-24 months in March 2012. Transfer payments were made for 24 months.

The main BCC intervention was a 1-hr group session held weekly in the village in which participants resided, led by a trained community nutrition worker (CNW). The group sessions covered the following topics: nutrition, diet diversity, and health; handwashing, hygiene, and health; diet diversity and micronutrients; breastfeeding; complementary foods for children 6-24 months; feeding and treatment of children with diarrhoea; maternal nutrition; encouraging homestead food production; and women's status and relationships with influential family members such as husbands and mothers-in-law (e.g., negotiating intrahousehold relationships related to feeding preschool children). The sessions used a variety of methods, including question and answer, presentations, practical demonstrations, role playing, and interactive call and answer. Some sessions were held exclusively for beneficiaries; in other sessions, husbands, mothers-in-law, and other influential individuals from beneficiaries' homes were also encouraged to attend.

The BCC session materials were derived from material developed for Alive & Thrive (A&T) in Bangladesh (see Related Summaries, below). A&T drew on a variety of methods to design the programme, including: several behaviour change theories (these theories - the theory of "reasoned action"; models focused on interpersonal interactions, self-efficacy, and learning from role models; and community models emphasising the diffusion of information through social networks - were combined to produce the socioecological model that guided their programme design), quantitative and qualitative formative research, trials of improved practice, previous studies in other countries, assessments of media habits, and stakeholder consultations. As in A&T, the BCC in TMRI focused on the first 2 years of life. TMRI also followed A&T in terms of the content of the BCC sessions and an approach that included community engagement, group BCC sessions, and home visits. TMRI used the same approach to the BCC across the two regions.

CNWs also conducted home visits to beneficiaries to follow up on topics that were discussed in the group sessions, as well as to answer any questions or concerns that beneficiaries may have had. Attendance at the nutrition BCC sessions was a soft condition of receipt of the transfers. When a mother missed a session, a CNW would follow up with a home visit to uncover what the reason was for missing the session, and no beneficiaries were dropped from the study for failing to attend sessions. The nutrition BCC group sessions were carried out for 2 years, from May 2012 to April 2014.

IYCN knowledge was measured at baseline, after 1 year and after 2 years of intensive BCC, and 6-10 months after the BCC ended.  They analyse data on IYCN knowledge from the same 2,341 women over these 4 survey rounds. They construct a number correct score on 18 IYCN knowledge questions and assess whether the impact of the BCC changes over time for the different treatment groups. Effects are estimated using ordinary least squares accounting for the clustered design of the study.

There are 3 main findings:

1. The BCC improves IYCN knowledge substantially in the first year of the intervention; participants correctly answer 3.0-3.2 more questions (36% more) compared to the non-BCC groups. This is after attending about 48 or 49 BCC sessions on average. Relative to the baseline scores for the control groups, this is equivalent to a 36% increase in the number of correct answers.
2. The increase in knowledge between the first and second year was smaller, an additional 0.7-0.9 correct answers; that is, much of the gain in knowledge is achieved in the first 12 months of training.
3. Knowledge persists; there are no significant decreases in IYCN knowledge 6-10 months after nutrition BCC activities ended.

The researchers surmise that this improvement and then persistence in knowledge may be due to a number of factors. It is possible that the frequency of the BCC sessions enabled high uptake and retention of information. Involvement of other household members may have encouraged further discussion of these topics at home and made it easier not only to learn but also to retain the information. It is also possible that the home follow-up visits by CNWs when sessions were missed provided an opportunity for participants to ask questions about and seek clarifications of material that was covered in the group BCC sessions. It may be that it was the combination of these factors that was important for this sustained knowledge gain.

They offer a few caveats for interpreting the results. For example, depending on food availability, cultural norms, and potentially other factors, knowledge gain and retention do not necessarily translate into behaviour change. Knowledge is necessary, but is not sufficient. Also, there is no treatment arm that is BCC only; the researchers are attributing the effects on knowledge to the BCC because there were no impacts in the non-BCC intervention arms.

The core finding of the study that knowledge gained through nutrition BCC is retained after the BCC ends implies that the costs of well-implemented, intensive BCC can be justified by the long-term effects, and that children born post-intervention may benefit from their mothers' improved IYCN knowledge. The researchers would be interested to see whether the persistence continues over a longer period of time than 6-10 months. It would also be useful to know whether these knowledge gains could be achieved through a shorter duration of BCC activities or through activities that were less intense and less costly. Such an assessment should also consider whether a shorter duration, or a less intensive approach, affected the extent to which caregivers act on this knowledge and whether the shorter duration/reduced intensity affected impact on measures of nutritional status. Future work could examine these issues.