Improving health in grassroots communities often means getting people to change the way they have been doing things for generations. It isn’t an easy task because attempts to improve old habits must be conducted with care and sensitivity. But one social and behavioral change communication (SBCC) effort in the Lao PDR is yielding good maternal and child health outcomes by changing dietary practices for young children in four northern provinces with low nutritional indicators.
The change communication campaign uses good gender practices to guide its activities, for example by encouraging mothers to make family decisions, urging family and friends to give mothers support, and asking how existing cultural norms and gender roles can be adjusted to allow better nutrition practices and hygiene behavior. SBCC is a $5.2 million component of the Health Governance and Nutrition Development Project (HGNDP), which is co-financed by the Advance Universal Health Coverage Multi-Donor Trust Fund. The trust fund was initiated by Australia’s Department of Foreign Affairs and Trade and is also financed by partners including Gavi, the Global Fund, and the Gates Foundation.
Nutrition is the challenge
Despite the progress Laos has made, malnutrition remains a key development challenge. The 2017 Lao Social Indicators Survey showed that 33% of children under five years old are stunted (low height for age), 21% are underweight, and 9% are wasted (low weight for height). Such undernutrition is caused by low quality diet during pregnancy, inadequate feeding of infants and young children, insufficient micronutrient intake, poor hygiene, and limited access to and use of quality health services. Undernutrition is also associated with beliefs, customs, and cultural norms, which can include throwing away a mother’s vital first milk yield (the colostrum), and imposing food taboos on pregnant women and new mothers. Such practices are compounded by a lack of education and knowledge among mothers, plus low levels of gender equality and women’s empowerment.
Thus, social and behavioral change communication is crucial to improving mother and child health. SBCC aims to improve individual behavior and household practices, promote collective action in communities, and increase demand for essential mother-child health and nutrition services. It supports behavior change communication activities in 881 villages across 12 selected districts of Phongsaly, Oudomxay, Houaphan, and Xieng Khouang, provinces with large ethnic populations and the lowest nutritional indicators in the country. The Lao Ministry of Health and Ministry of Agriculture and Forestry rolled out the scheme in four phases from 2016 to 2021 as part of the nationwide HGNDP.
Wide range of target groups
The focus of behavior change communication is not only on the primary target group — pregnant women and the mothers of young children — but also other “influencers” such as husbands and grandmothers, plus local officials, teachers and health service providers. Communication is through diverse channels including individual and group counseling, informal community gatherings, formal sessions through health services, school curricula and mass media. The range of nutritional topics discussed includes breastfeeding, complementary feeding, dietary improvement, hygiene and sanitation, and use of health services. Mother and child nutrition is of utmost importance because deficiencies in certain nutrients are associated with maternal complications and death, fetal and newborn death, birth defects, childhood stunting, and poor cognitive function later in life.
To tackle this, female village facilitators give mothers practical lessons on how to rapidly raise nutrition levels. During monthly meetings and home visits, they show the women how to make a home-made pre-mix that can be used to quickly prepare nutritious meals for their children. These meals, and the overall diet, can be further complemented by adding fish powder and goat milk, by planting home gardens, and by raising livestock and fish. Mothers are also taught not to give sweetened beverages or commercial cookies and candies to children under two. Multi-media peer learning, through village Facebook and WhatsApp groups, is used in these activities.
Gender equality issues are also raised with women and their husbands through discussions on their respective roles in domestic and farm work. The sessions stress the importance of improving maternal diets, husbands taking wives to health facilities for antenatal and postnatal care services, and making family work plans based on agreements made during community group meetings. Although husbands already do much of the heavy physical work, they are asked to take on more during the first 1,000 days of their babies’ lives (from conception to two years old), since their wives are still doing heavy work around the house and in the field. Most husbands happily oblige when their roles are clearly defined.
Early impacts
SBCC has made great progress, completing all planned activities and achieving a high number of targets. Over 3,000 village facilitators have been trained and are now delivering monthly change communication sessions and growth monitoring home visits in 881 villages. More than 47,500 children under 5 years old have received at least four growth monitoring and promotion sessions, with their growth plotted on charts, while 514 villages were declared free of open defecation, surpassing the target of 100 villages.
The SBCC village platform has proven an effective approach to nutrition promotion. The Knowledge, Attitude and Practices Study Mid-Term Report 2020 found the messages about nutritional requirements for pregnant and lactating women, infants, and children under 2 were well received. About 90% of mothers expressed their appreciation for this information.
More importantly, the adoption of good nutrition practices has resulted in the following health outcomes:
- 83% of infants age 0-6 months are exclusively breastfed, up from 63% at the baseline;
- Immunization shot up to 78% of children, from a baseline of just 34%;
- Nearly 80% of children under 2 have their growth monitored under national guidelines, a significant increase from 43% at baseline;
- Antenatal care (at least four sessions during pregnancy) increased to 80% of mothers from 71% at baseline;
- Household dietary diversity expanded, with 78% of households eating from four or more food groups in the past 24 hours, up from 64% at baseline.
Work continues
Much remains to be done to improve nutrition in Laos and the World Bank will continue to use this effective SBCC community-based platform in the new Health and Nutrition Services Access Project (HANSA). This successor to HGNDP aims to improve access to quality health and nutrition services in targeted areas of the country. HANSA runs from 2020 to 2025 and SBCC will play an important part since results so far prove that while old habits may die hard, they are not impossible to break.
