Prioritizing

Social and Behavior Change

Outcomes
1. Steps to prioritizing
SBC outcomes

2. What do we know
about the
behaviours?

3. What do we all think

now?
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STEPS TO
PRIORITIZE
BEHAVIORS

3
Behaviours First
Effective design evolves from a behavioural analysis.

• Criteria for selection of behavioural outcome:

1. Scientific Evidence: behaviours that will make an impact on the
health outcome (stunting).
2. Participants’ Inputs: behaviors that people are able to do in the
context of their lives (may not be the ideal recommendations).
3. Practical Considerations: donor priorities, existing delivery
mechanisms, operational considerations, etc.

• Scientific evidence:
– Prevalence
– Association with malnutrition
– Which behaviors likely to shift more rapidly
BISA Logical Framework

Goal Reduce stunting among children under 2 in NTT and WJ

SO 1 Improved MIYCN and WASH practices of the first 1000 days
households and adolescent girls

SO 2 Improved access to high-quality nutrition services for children < 2,

adolescent girls, pregnant and lactating women, and caregivers

SO 3 Efficient and effective use of funding, policies and regulations, and

human resources at Provincial, District and National levels.
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SCIENTIFIC
EVIDENCE

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Scientific Evidence

Goal: Nutrition status: Associations with

Reduced • 27% (17.5-33.9%) stunting:
stunting in Stunting • LBW, short birth
C<2 length, low
• 13% WJ & 33% NTT maternal height
CED in WRA associated with
stunting
• 7% LBW (WJ 7.1% &
NTT 13.4%) • Not EBF

• 68-83% Anemia • Poor sanitation,

adolescents untreated drinking
water
• Stunting prevalence among 0 – 23 months children in Bandung Barat is 28,1%,
Sumedang 17,5%, Kupang District is 33,9% and TTU is 31,3%.
• The findings of the BISA baseline survey for stunting prevalence in these four
districts are lower than the findings from RISKESDAS 2018 (Bandung Barat is
36,7%, Sumedang 32,2%, Kupang District is 23,3% and TTU is 56,8%).
• Results from the BISA baseline survey shows Sumedang had the least
undernutrition prevalence compared to other districts, while Kupang had the
highest.
• The high prevalence of malnutrition in Kupang might be caused by socio-economic
conditions and mother’s nutrition knowledge. Kupang has the largest proportion of
household with low socio-economic status of mother/caregivers for children 0 - 23
month compared to other districts. Nadiyah et al. (2014) research results show that
low income level was a risk factor for stunting in Bali, West Java and East Nusa
Tenggara.
• These four districts are included in government stunting prevention programs,
which might help explain the progress in the reduction of stunting prevalence as
compared with the findings from RISKESDAS 2018.

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LIST OF KEY
BEHAVIOURS

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List of key behaviours – families

• Adolescent girls Care and Diet

1. Adolescent girls consume an adequate diet
2. Adolescent girls consume WIFA
3. Adolescent girls wash their hands at critical times

• Maternal Care and Diet

1. Pregnant women consume an adequate diet
2. Pregnant women consume the recommended number of IFA
3. Pregnant women reduce workload and take extra rest
List of key behaviours – families

• Infant and Young Child Care & Feeding

1. Early initiation of breastfeeding
2. Breastfeed exclusively for 6 months
3. Initiate complementary feeding at 6 months
4. Children 6-23 months consume a diverse diet
5. Children 6-23 months consume food frequently
6. During and after illness give children more fluids and food
7. Drink and use treated water and store it safely
8. Handwashing with soap at 5 key times
9. Safe disposal of child faeces and use of toilets
10. Separate animals especially goats, chickens and cows from houses and
community / clean play spaces
List of key behaviours - familes cont…

• Use of Nutrition Services

– Mothers utilizing all available health services (ANC, GMP, sick child)
 List of key behaviours – service providers & policy makers

• Provision of Nutrition Services

– Provide quality nutrition counseling to women and adolescent girls
– Stock Puskesmas and schools with key nutrition supplements

• Provision of Nutrition Policies, Budgets, Human

Resources
– Follow the 8 steps outlined in StraNas
– Set aside enough budget for key nutrition actions/programs
– Fill all positions to ensure nutrition services/programs can function

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POTENTIAL
BEHAVIORAL
OUTCOMES

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Adolescent Care & Diet

• Adolescent girls consume an adequate diet

• CED is high during and outside of pregnancy (34% and 36% in 15-19 yo.)
(Riskesdas 2018)
• More than 90% eat less than 5 servings FV per day, more than 50% junk
food more than once per day (Riskesdas 2013)
• Adolescent girls who consume an iron-rich or iron-fortified food is high in
WJ (92%) and in TTU (83%) but lower in Kupang (53%) (BISA Baseline)
• Dieting and meal skipping did not come out in our Formative Research,
but has been found in other studies (GSHS, 2015).
• Adolescents eat same diet as rest of the family, rice fills you up (FR)
• Those with pocket money for meals at school consume more fried,
sweetened and package foods (Formative Research)
 Adolescent Care & Diet cont…
• Adolescent girls consume WIFA WIFA contributes to less CED, and LBW?
• Anemia is very high among 14-20 y.o. girls in BISA areas (68-83%) (BISA
Baseline). Much higher than national data, (18% 15-24 y.o, Riskesdas 2013).
• Most adolescents receive at least some WIFA (75%, 10-19 y.o.) but
consumption of WIFA as recommended is very low (1% in West Java and 0.1%
in NTT) (Riskesdas 2018)
• Similar to Riskesdas data, most adolescents receive some WIFA but receive
insufficient amounts of WIFA and adherence is very low in WJ (<2%) and NTT
(<8%) (BISA Baseline).
• Most common reason for non-adherence was side-effects, other reasons
included missing school (in NTT), not seeing a reason to take it (WJ), and not
feeling well that day (BISA Baseline).
• Adolescents, like pregnant mothers, confused low blood pressure with anemia
(FR)
• WIFA mostly considered unnecessary since girls feel they do not have
symptoms. Those who had taken said didn’t notice any difference as a result
and so did not see the point in taking them (FR).
Adolescent Care & Diet cont…
• Adolescents washing hands with soap at critical times
• Most adolescents reported handwashing with soap after defecation (81-
96%) and before eating (87-99%), fewer before preparing food especially
in NTT (49-83%) (BISA Baseline)
• The insights from immersion with families will apply to adolescents .
'washing is associated with removing visible dirt, smells and sweat'
'washing hands is more prevalent after eating ( to remove grease, smell).
No washing of hands before preparing food. (BISA FR)
HWWS is already practiced ? (not sure as this is reported behaviour), so
perhaps this can be easily inserted in issue slide 15, work more with
adolescents as ‘agent of change-voice up issues’ for changes of HWWS at
larger community members rather than themselves?
Maternal Care & Diet
• Ante Natal Care is divided into 3 categories, namely ANC 1 (received ANC at
least once throughout their previous pregnancy), ANC K1 (received ANC in
their first trimester during their previous pregnancy), and ANC K4 (received
ANC at least four times throughout their previous pregnancy) (Ministry of
Health 2018).
• The findings of BISA baseline survey found almost all mothers (more than
98%) in East Nusa Tenggara had received ANC at least once in their last
pregnancy (ANC1), while in West Java the number was lower, i.e. 65.3% and
78.0% for West Bandung and Sumedang, respectively.
• Almost all mothers who received ANC, received it at least four times, while
less mothers received ANC K1. The trend is similar in all districts.

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Maternal Care & Diet
• Regarding ANC practices using the services of traditional birth attendants
(TBA), in two districts in NTT this practice is almost nil, while in two
districts in West Java the practice is high, 63,6% in Bandung Barat and 57,6%
in Sumedang (BISA baseline survey).
• Besides going to skilled health providers, most respondents in West Java also
received ANC from TBAs.
• Thus, most of the respondents in West Java received ANC from both skilled
health providers and TBAs.
BISA’s SBC strategy will need to focus on improving mother’s knowledge on
ANC and promoting behaviour for accessing ANC services at heath care
services providers, particularly in Bandung Barat and Sumedang.

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 Maternal Care & Diet
• PLW women eat an adequate diet
• CED among WRA in WJ is 13% and 33% in NTT, worse in pregnancy (14%
and 37%) (Riskesdas 2018)
• LBW, short birth length, short maternal height associated with stunting (Beal et
al 2017, Aruastami et al. 2017)
• Belief that a smaller baby means an easier birth in one West Java location, but
recent studies found rejected elsewhere (Formative Research)
• Mothers meet MDD varied across districts, ranging from the highest in
Sumedang (78.4%), to the lowest in TTU (13.7%) The proportion was higher
in West Java compared to East Nusa Tenggara (BISA baseline)
• Similarly, the consumption of animal sourced /iron fortified food were higher
among mothers in West Java than East Nusa Tenggara (90% vs 60%). (BISA
baseline)
• No special diet is considered necessary for PLW, the continue to eat the same
rice-heavy, low-protein diet as rest of the family. Increase consumption of rice
but not generally other foods (Formative Research).
• Although women can describe a good diet during pregnancy (Formative
Maternal Care & Diet cont…
• Pregnant women take IFA as recommended
• Nationally, many pregnant women are anemic (43%) (Riskesdas, 2018)
• Proportion of mothers of infants 0-5 months who knew the benefit of IFA tablets was still
relatively low. Almost half of the mothers in TTU didn’t know the benefit. Only around half of
mothers can answer at least one benefit of taking IFA (39%-61%) (BISA Baseline)
• Mothers mostly associate the need to take IFA with low blood pressure (Formative Research)
BISA’s SBC strategy will need to focus on improving pregnant mother’s understanding on the benefits of
IFA to overcome anemia, especially in TTU.
• Almost all mothers of infants 0-11 months received IFA in their last pregnancy across all four
districts, this finding is similar with the findings from RISKESDAS 2018 (more than 90%
received any tablets of IFA both in West Java and NTT provinces). However, the figure of BISA
baseline survey was lower for those who received 90 and 180 IFA tablets.
• Consumption of the recommended 90+ tablets varies across districts (45-87%). The adherence
was overall good, i.e. there was not much difference between the number of tablets received and
consumed. (BISA Baseline)
• There is an assumption that the IFA supplies were not adequate, so that less pregnant mothers
received 90 and 180 IFA tablets, particularly in Bandung Barat (58,5% received and 44,6%
consumed 90 IFA tablets) and Kupang districts (76% received and 47,3% consumed 90 IFA
tablets).
Deeper analysis on the challenges and gaps on IFA tablets supply chain will be further explored and
addressed in the BISA’s supply chain assessment and capacity building
Maternal Care & Diet cont…
• Families support pregnant and lactating women to reduce
workload, take extra rest and be allocated extra foods
• Views vary as to what is good care during pregnancy – but in most locations
chores/heavy lifting are reduced and work in the field (FR).
• Importance of the culture of ‘40 days’ post giving birth. Some traditional practices
have a basis in good care and some are concerning (FR).
• Fathers concerned about mothers and encourage them to rest, help by holding
babies while the mother eats, trying to pacify child (FR)
• No understanding of any need to increase calorie and protein intake during
breastfeeding (Formative Research).
• Women control household expenses and primarily make decisions about food
purchases. Most household chores done by women (FR)
• Common understanding among women and men that pregnancy requires better
nutrition but in practice women eat the same (FR)
• When families eat together, no preference for who eats what. When families eat at
different times mindful of leaving some for others (FR)
Module AYAHASI (Breastfeeding fathers) module 5 “What Can Father do?” only
covers bullet point no.3. Gender analysis needs to be sharpened here (?)
Infant and Young Child Care & Feeding
• Early initiation of breastfeeding
• More than half of all babies are breastfed in the first hour (61% WJ,
58% NTT) (Riskesdas 2018) not in terms of skin to skin and minimum 1
hr of contact
• In BISA areas, EIBF is much higher in NTT (90-91%) than in West
Java (52-57%) (BISA Baseline)
• Unlike studies some years ago, almost nobody adhering to the notion
that colostrum was ‘dirty’ (Formative Research)
• Persistent notion among some health staff and families that babies
often do not take breast milk in the first two days, so formula is
needed (Formative Research) breastmilk is not enough – can be part
of EBF
Infant and Young Child Care & Feeding
• Breastfeed exclusively for 6 months Policy makers: feel sufficient if
national target EBF 60% is achieved
• Note EBF is associated with stunting (Beal et al. 2017)
• EBF is low nationally (37%, Riskesdas 2018). More than half of
children are EBF in BISA areas, higher in NTT (64, 74%) than WJ
(52%, 57%) (BISA Baseline)
• Most women knew the meaning of EBF and more than half (52-74%)
of women know at least one benefit of EBF (BISA Baseline)
• Key barriers to EBF are lack of skills and confidence, family member
influence, work and promotion of BMS (Alive & Thrive 2018);
Barriers may include perception of mothers that BF is not pleasant, not
enjoying BF, grand mothers perceived young parents give up too
easily.
• Widespread assumption that a crying baby means they are hungry and
need more than breastmilk to be ‘full’ (Formative Research)
• Apart from one location in WJ, very few breastfeeding mothers were
also working. Norm is for mothers to breastfeed and remain at home for
first two years (Formative Research).
Infant and Young Child Care & Feeding
• Introduce foods at 6 months of age
• Most 6-8 month olds are receiving complementary foods (80-91%)
(BISA Baseline)
• Feed children frequently with adequate quality and quantity
• MDD is low, worse in NTT (35%, 51%) than WJ (52%, 78%) (BISA
Baseline) (26% v 55% Riskesdas 2018). But FR suggest DD slightly
better in NTT.
• Less than three-quarters of young children meet MMF (62-72%)
(BISA Baseline)
• Most young children in West Java receive junk foods (71%, 90%)
compared to fewer in NTT (25%, 33%) (BISA Baseline)
• Time given to breastfeeding once food introduced is short (FR)
• Little given other than plain rice porridge between 6-8m (FR)
• Children are often fed food only on demand, leading either to
infrequent meals or frequent snacks to appease them (FR)
• Fears of choking on meat, fish bones, eggs acceptable due to recent
feeding programmes. If ASF/iron-rich plant foods given in very
small amounts (FR)
Infant and Young Child Care & Feeding cont.
• Family support to child care and feeding Gender,
• The role of family is key and can be both a support and a barrier to
child feeding practices (Alive & Thrive 2018)
• Generally the care of infants is regarded as the ‘women’s
responsibility’. But fathers help by holding babies while the mother
eats, and trying to pacify crying babies. Fathers see their role as
protective rather than caring (FR).
• Although mothers described as the main caregivers, grandmothers
take much of the care responsibility for infants under 1 year (FR).
• When others caring for young children, found they are often given
formula milk and packaged baby foods. In some locations they
endorse delay of CF to 6 months, in others they encourage food early
(Formative Research).
• Grandmothers in most locations don’t support the increased use of
formula milk and packaged baby food (F\R)
• Little culture of mothers or fathers playing games and stimulating
young infants (FR).
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Infant and Young Child Care & Feeding cont.

• The proportion of children who met MAD was generally low (22%-
55%) across the four BISA surveyed districts.
• BISA will need to address the improvement of mothers' knowledge
on how to prepare a variety of foods and frequently feed their child
to ensure nutrient adequacy.

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Infant and Young Child Care & Feeding cont.
• Giving children Vitamin A Supplementation
• Only around half of mothers (47-66%) describe months when VAS is
distributed (BISA Baseline).
• Very few mothers can answer at least two benefits of VAS (2-12%)
(BISA Baseline)
• Giving children and ORS and Zinc when sick
• Child diarrhoea is <10% but higher in West Java (9%,10%) than
NTT (3%,7%) (BISA Baseline)
• Very few mothers could mention at least one benefit of ORS and at
least one benefit of zinc for diarrhea (7-22%) (BISA Baseline)
• During/after illness give children additional fluids and food
• Very few children were fed more foods during/after illness (<4%)
(BISA Baseline).
• Families often withold food for sick babies, especially breastmilk
which they think is too much for the baby to manage (FR)
• More children were fed more liquids during/after illness, higher in
West Java (33%, 45%) than NTT (6%, 21%) (BISA Baseline)
Infant and Young Child Care & Feeding cont.

• The BISA baseline survey shows discrepancies between knowledge

and practices in the surveyed topic on VAS.
• The BISA baseline survey shows that although knowledge of the
benefits of VAS of the mothers is relatively low (only about half of
mothers had knowledge on the correct month for VAS distribution),
but the practice is high in all four districts (the proportion of children
6-23 months of age who received vitamin A ranged between 54.0%
to 72.7%, and higher in East Nusa Tenggara than in West Java).
(BISA Baseline)
• This might be due to the mother’s belief in the services of VAS
offered by cadres and health staff.
Infant and Young Child Care & Feeding cont.

• Mothers knowledge on the benefit of zinc and ORS for childhood

diarrhoea treatment were generally low. (BISA Baseline)
• Less than 10% of mothers in districts in West Java were able to mention
at least one benefit of Zinc/ORS for diarrhoea treatment, while in TTU
and Kupang it is 10.5% and 22.7, respectively. (BISA Baseline)
• The proportion of mothers or caregivers of children 0-23 months with
diarrhoea in the last month who received both ORS and Zinc for
diarrhoea treatment was less than 20%, while those who received either
ORS or Zinc alone range from 23.6% to 52.1%. (BISA Baseline)
• The BISA project will need to encourage the health care providers to use
both ORS and Zinc for diarrhoea treatment in children and to inform the
mothers on the benefit of zinc and ORS for childhood diarrhoea.
Infant & Young Child Care & Feeding cont.
• Handwashing with soap at critical times
• Proportion of households with a handwashing station with soap and
water higher in WJ than NTT (90% v 60%) (BISA Baseline)
• Proportion of mothers aware of handwashing at all critical times
very low (<20% in NTT and even lower in WJ <6%) (BISA
Baseline).
• Handwashing higher in WJ (57%) than NTT (20%) (Riskesdas
2018).
• No study households washed hands before preparing foods or eating
but washed after eating to remove food smells (FR)
• Often only practised when hands ‘appear dirty’ (FR)
• Separate young children from contaminants in the home and
communities (especially animals) can be included in critical times to
HWWS, now that we don’t do EED study, not sure if we can justify to include this in our
intervention-to be shared horizontally (except on HCD)
• More households in WJ (69%) had clean play spaces than those in
NTT (25%, 49%) (BISA Baseline).
• No concern regarding living in close proximity to animals, done
Use of Health & Nutrition Services
• Attendance at ANC during pregnancy –Covid 19 challenge
• Almost all mothers in NTT (>96%) attended 4+ ANC but around 20-
30% of mothers in West Java had not (BISA Baseline)
• ANC attendance during first trimester is low (Alive & Thrive 2018)
• Many women don’t see any need in attending ANC unless they feel
unwell (Formative Research)

• Attendance at child nutrition and health services?

• Attendance at posyandu in each study location varied, better
attended in NTT than WJ (FR)
• Fathers generally do not attend posyandu sessions which are deemed
women’s business (FR)
Provision of Nutrition Services for adolescent girls

• Provide quality counseling to adolescents at school on

WIFA, diet and WASH
• Education sessions for adolescent girls were conducted in most
schools (71-89%) (BISA Baseline).
• Few teachers could define anemia (11-22%) but almost all could
describe signs and symptoms. Teachers’ knowledge about WIFA
dosage and benefits varied, it was better in NTT (BISA Baseline).
• Health providers’ knowledge about WIFA was better in NTT than WJ
and almost all could describe 1 benefit, knowledge on dosage was
lower except in TTU (BISA Baseline)
• Teachers not considered as a good source of information, preferred
source is someone with experience. Want to learn in a fun way (FR).
Skin fairness is valued among adolescents especially in WJ-
implications in iron promotion (FR)
• Adolescent girls concerned about their skin and hair (FR)
• What about out-of-school girls?
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Provision of Nutrition Services for adolescent girls

• Provide WIFA for adolescent girls

• Similar to Riskesdas, 2018 in BISA areas 60-90% of in-school
adolescents receive any WIFA tablets but fewer receive a sufficient
amount, especially in NTT (<10%) (BISA Baseline).

• Handwashing facilities at schools

• Only around half of schools had handwashing stations with soap and
running water in 3 BISA districts (59-65%) and was worst in
Sumedang (32%) (BISA Baseline).

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Provision of Nutrition Services for pregnant women
• Provide quality counseling maternal nutrition
• Counselling on MIYCN is often missing or substandard, particularly at sub-district
level (Aiming High Report)
• More mothers received counselling on breastfeeding than on maternal nutrition and
CF (BISA Baseline)
• Only half of mothers in NTT (44%, 60%) stated information delivered during
counselling was easy to understand and only three-quarters in WJ (77%, 79%)
(BISA Baseline)
• Few health providers (13-52%) and Posyandu cadres (12-29%) had knowledge on
all appropriate counselling methods (BISA Baseline).
• Only around half of Posyandu cadres reported availability of job aids (59-67%)
(BISA Baseline)
• Health providers’ knowledge about benefits of IFA is varied but most can describe
at least 1 benefit (88-98%). Dosage knowledge low (BISA baseline)
• Women describe having their weight taken and blood pressure checked during
ANC but received little advice about nutrition or care (FR)
• Focus for Posyandu cadre and staff is almost entirely on infants and not welfare of
new mothers (Formative Research)
• Cadre didnt mention Pink book or IYCF booklet/guideline as reference (FR-HCD)
• Cadre think that develop FAQ job aid and common home visit approach will boost
their confidence (BISA FR-HCD) 35
Provision of Nutrition Services for pregnant women

• Provide nutrition commodities for pregnant women

• Most women receive any IFA (87-96%) and, except in West Bandung (59%)
most receive 90+ IFA (76-93%) (BISA Baseline).

• What about services provided by TBAs?

• No standard, not included in counselling training as the national strategy is
to “eliminate” TBA
• TBA average age = Grand mothers. Grandmothers are key influencers for
family (BISA FR)

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Provision of Nutrition Services for infants and young children

• Provide quality counseling on IYCF and child health

• Counselling on MIYCN is often missing or substandard, particularly at sub-district level
(Aiming High Report)
• More mothers received counselling on breastfeeding than on maternal nutrition and CF (BISA
Baseline)
• Only half of mothers in NTT (44%, 60%) stated information delivered during counselling was
easy to understand and only three-quarters in NTT (77%, 79%) (BISA Baseline)
• Few health providers (13-52%) and Posyandu cadres (12-29%) had knowledge on all
appropriate counselling methods (BISA Baseline).
• Only around have of Posyandu cadres reported availability of job aids (59-67%) (BISA
Baseline)
• Provision of advice or opportunity to ask questions constrained in all Posyandu. Information
provided to a group in a didactic manner (FR).
• Cadres not confident in counselling, afraid of making mistakes, overwhelmed with RR, feel it
should be done by ‘experts’ (FR)

Policy: counselling training cascade down to cadres through health system-health workers, limited number
of “supervisors” AND limit opportunity for cross sectors-horizontal sharing eg to the HDW system,
religious groups who mainly fathers. Can non-health workers become skilled supervisors?….content
perceived to be “health owned”...every skills added to cadres follow traditional way of cascade training.
What about cadres’ basic set of competency in counselling?
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• Provide nutrition commodities for children
• Only around half to three-quarters of mothers received VAS for children in
the last 6 months (54-73%) (BISA Baseline)
• Few caregivers of children with diarrhea received ORS and zinc for treatment
(9-17%) (BISA Baseline)
• Health providers’ knowledge on VAS benefits for children varied, around
half could describe at least 2 benefits (52-65%). Except in Kupang, health
providers’ knowledge on zinc for diarrhea was low (BISA Baseline).

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Policy, Human Resources, Budget

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Click icon to add picture

WHAT DO WE
ALL THINK
NOW?
1. What other evidence or
insights are there around each
proposed behavioral
outcome?

2. What else do we need to know

about these behavioral
outcomes?

3. What is the low hanging fruit

out of the behavioral
outcomes?

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