Engaging Communities through Enhanced Community Conversations

“ENGINE’s SBCC activities focused on behavior-centered programming, which provides opportunities for families, health workers, and other community members to participate in formulating and testing proposed practices, strategies, activities, messages, and materials that support improved behaviors and relationships between couples.”

This technical brief describes the use of community conversations, which formed part of the social and behaviour change (SBCC) approach used by the Empowering the New Generation to Improve Nutrition and Economic Opportunities (ENGINE) project, a multisector nutrition project implemented in Ethiopia from September 2011 to September 2016. Led by Save the Children, ENGINE partnered with Ethiopian ministries to strengthen existing multisector coordination and to support the development and revision of nutrition policies, guidelines, and standards. It integrated instruction on nutrition into the pre-service curriculum for health and agriculture workers and built the capacity of frontline workers to provide high quality nutrition services. The project’s SBCC activities, including the community conversations, promoted optimal maternal, infant, and young child feeding practices and dietary diversity at the community level.

A baseline study showed that pregnant and lactating women in ENGINE-supported areas of Ethiopia consume mainly grains and pulses, and to a lesser extent, vegetables. Women generally do not increase their consumption of food when pregnant. They are motivated to eat nutritious food but socio-economic constraints and gender role disparities restrict their access to and control of household income and agricultural produce. Heavy workloads limit time available to rest and cultural values make women reluctant to prepare food for themselves, eat differently from other family members, or eat outside of family meal times.  The diets of children in the region are also not optimal. Quantitative and qualitative data showed that children between the ages of 6 and 23 months had very low diversity in their diets, which lacked animal source and micronutrient-rich foods that are critical for growth. In addidtion, the water, sanitation, and hygiene (WASH) environments in their homes put them at high risk for stunting.

To address the identified barriers to healthy maternal, infant, and young child nutrition (MIYCN) practices, ENGINE developed an evidence-based SBCC strategy, which included mass media, engagement with religious leaders, frontline health and agriculture workers, as well as community meetings (see Related Summary below). The strategy positioned nutrition as “A Family Affair” and promoted evidence-based behaviours to reduce chronic under-nutrition in children under two years of age.

Based on lessons learned from a community conversations pilot initiative, ENGINE developed the enhanced community conversations (ECCs) which went beyond raising awareness and knowledge to promote the adoption of nutrition-related skills, behaviours, and gender transformative roles. As explained in the brief, ECC groups consisted of a maximum of 20 people and were composed of either pregnant and lactating women, husbands of pregnant or lactating women and fathers of children under two years of age, or grandmothers of children under two years of age. All ECCs included information on nutrition, health care-seeking practices, and agriculture-nutrition topics and were held every week or every other week for ten consecutive meetings.

ECCs used interactive methods and activities to help adults learn. In addition to nutrition talks, discussions, and stories, ECCs included role plays, games, contests, and singing, and at the end of each meeting participants received take-home materials or activities to spark discussion with their families and neighbours. To enhance skills-based learning, groups were occasionally sub-divided into smaller groups of two to five, which gave participants more time to practice skills and to have in-depth conversations about a specific issue. Highly-engaging audio recordings of virtual facilitators (VFs) supported the CCAs and provided a level of consistency across all ECC meetings. These VFs involved professional actors playing the roles of husband and wife, who are both knowledgable on maternal and child nutrition, and nutrition sensitive agriculture. The two characters help
the CCA facilitate the group activities, tell stories and jokes, and give advice.

To support the ECCs, ENGEN designed a set of SBCC materials to communicate about MIYCN and the importance of nutrient-rich foods necessary for pregnant or lactating women and children 6 to 24 months old. The nature and development of each of these materials is explained in the brief which include: the take home materials which consisted of five posters, a series of “how to”leaflets, and a series of good role model personal testimony cards; the VF audio recordings, as well as games and role-plays. The development of all the materials was based on an understanding of the objects, places, events, rituals, roles, relationships, traditions, values, and people with special significance in the local context that had the potential to promote desired behaviours.  For example, to explain a balanced diet, the materials used the image of a traditional cooking pot that is balanced on three clay pillars. Also, the tradition to decorate the home with colourful posters, photographs, and decor inspired the idea to give ECC participants printed materials such as posters and stickers to take home.

To assess the impact of the ECCs, ENGINE conducted quantitative baseline and endline surveys of 120 ECC participants, conducted focus group discussions with mothers, fathers, and grandmothers, observed mothers preparing genfo (thick porridge for infants) in their homes, and interviewed the mothers after the observations. According to the brief, the ECCs have contributed to significant improvement in MIYCN and WASH behaviours and family relationships within ENGINE-supported communities. Respondents reported changing their spending practices to purchase more nutrient-dense foods and also reported producing and saving more of these foods at home for family consumption. Men who participated in the ECCs have become more supportive of their wives, especially when the women are pregnant or breastfeeding, so that they have more time to rest and eat. Other findings related to MIYCN showed that the proportion of children between 6 and 24 months of age who consumed food from four or more food groups each day increased from 27 to 52 percent. Similarly, the proportion of pregnant or lactating women who consumed five or more types of food per day increased from 8 to 17 percent. Related to changes in WASH practices, data showed significant improvement in hand washing practices at most critical times. However, the proportion of men who reported washing their hands after tending fields decreased from 71 to 60 percent.

The brief outlines some of the lessons learned, which include the following:

• Participants admired the respectful, kind, and loving relationship modelled by the VFs and strove to emulate their behaviours.
• Both quantitative and qualitative data showed that women with older children (7 to 24 months old) perceived the VFs to be the least useful SBCC materials.
• The diversity of SBCC materials created challenges for their procurement, warehousing, packing, and distribution.
• Care must be taken to ensure SBCC materials are distributed appropriately.
• The use of multiple creative concepts in the materials may have been unnecessary.
• It may be useful to shorten the length of ECC sessions.