Social behavior change (SBC) programs are the key to addressing complex nutrition behaviors. By digging deeply into the hows and whys of these behaviors, particularly through close engagement with mothers, fathers, other family members and community members, nutrition programs can meaningfully impact them. 

But the capacity to implement nutrition programs using an SBC lens is limited – and managers of government nutrition programs in West and Central Africa were interested in building their skills to apply the SBC approach systematically to their efforts.

“We have seen in communities in Togo that exclusive breastfeeding will increase while a project is implemented but then decrease after the project ends,” said Dapou Tchapo, a community health nutritionist in Togo’s Ministry of Health. “We need to achieve a change in behavior and social norms so that the rate becomes stable. 

“Many projects simply raise awareness – they just share the information to mothers – but that is not enough,” she continued. “We need to understand why mothers may not exclusively breastfeed, and we must dig deeper and address the barriers or challenges that influence her behavior.”

“Social norms and behaviors underpin almost all nutrition behaviors, especially around maternal, infant and young child nutrition (MIYCN) practices,” explained Nathalie Likhite, regional SBC advisor for Alive & Thrive’s West Africa regional initiative. “The capacity to build nutrition program with a strong foundation in SBC requires specialist knowledge and activities. 

“We learned that program managers struggle to apply an SBC lens to their nutrition programs – and greatly wanted support to do so.”

That support debuted in August 2021 when Alive & Thrive, UNICEF and WHO, launched a program a year in the making, comprising a rigorous online course (complete with videos, animations, readings and quizzes), coaching support from SBC experts, and live lectures from outside specialists. It's referred to as the "blended learning program."

“The program is training a critical mass of people at the country level, providing them important SBC knowledge and insights – but that alone will not do the job,” said Simeon Nanama, UNICEF West and Central Africa’s Regional Nutrition Advisor. “That’s why the outcome is to develop a costed SBC plan for each country that would then be rolled out so that the majority of health workers are reached with these ideas.”

“Pre-service training in the region has not really taken nutrition into consideration, and health workers need to be equipped to deliver services but also to provide counseling to mothers,” he added. 

The course has two goals. First, it aims to build the capacity of managers to integrate SBC into nutrition programs; and second, using the example of the Stronger With Breastmilk Only initiative, it seeks to help countries develop costed SBC action plans to tackle exclusive breastfeeding issues. Stronger With Breastmilk Only was launched in 2019 by UNICEF, the World Health Organization, and Alive & Thrive.

“Developing SBC strategic plans is a very tangible outcome and makes the program quite unique," said Manisha Tharaney, director of the Alive & Thrive West Africa regional initiative.

Those plans will then help the region build capacity among all health workers as the insights and ideas provided in the blended learning program are cascaded across the countries via various interventions, Nanama said.

Working with a learning designer at Octo D, a firm based in Montreal, Alive & Thrive’s West Africa regional team, in collaboration with UNICEF and WHO, developed the 13-week program. The first cohort of learners will complete the program in March and includes 56 participants from six countries: Benin (12), Cameroon (8), Chad (8), Democratic Republic of Congo (8), Guinea (10), and Togo (10).

“We had great interest in the program and had to limit the number of countries,” Likhite said. “We're excited to share that a second cohort will be starting the course in April.”

The course begins with the basics of SBC and then covers important steps in developing an SBC strategic plan: clarifying the problem, using data to analyze the situation, determining appropriate SBC activities and audiences, formulating key messages, preparing a logic frame and indicators to monitor implementation of activities, and, finally, assembling an action plan.

“It was very useful and well done,” said Tchapo, of Togo, who participated with a team from the Togo Ministry of Health. “The coaches were very experienced. The experience itself was very useful and interesting.”

Engaging learners

“By blended, what we actually mean is that the program is asynchronous – you and your team can work on the modules at any time – and synchronous – you participate in live group activities, such as a weekly videoconference,” said Helene Caura, a learning designer at Octo D. 

Online courses are quite common and interest in them has grown, particularly during COVID-19. But most people do not complete them if they are entirely self-paced, without any guidance or support from a coach or teacher.

“Keeping people engaged is always the challenge,” Caura said. “Blended learning is proven to be the most effective – human interaction is crucial.”

The primary challenge in designing the course was aligning the content to the practical tasks and goals learners would be expected to do, she said.

“The course itself is super practical,” she said. Determining the course content was guided by a rigorous action mapping exercise, she said. The action map helped course designers look at the content through the eyes of learners and remain focused on the capabilities the program is trying to give them.

Learners access the course via an online platform that presents content modules on an attractive interface. The site also allows them to exchange ideas or ask questions in a discussion forum, engage in group assignments, and receive announcements from course administrators.

Each module is generally aligned with a calendar week. After completing reading assignments and quizzes on their own, complemented by video clips and animations, a learner then worked with her or his country team on various missions – for example, to collect data on a particular issue. Then, they participated in a weekly two-hour videoconference with additional presentations on the topics covered in the platform; the videoconferences also featured special guests who elaborated on the newly gained knowledge, and provided an opportunity to learners to ask clarifying questions.

The course incorporated elements of gamification (points gained after each completed activity, badges for different achievements) to give a learner a sense of progress and achievement and a “sane competition,” Caura said.

Building SBC skills

The essence of the program is SBC. Since its launch in 2019, 10 countries have launched Stronger With Breastmilk Only program, making it an ideal launching pad for the blended learning program.

“We used the Stronger With Breastmilk Only initiative as a case study to illustrate the types of exclusive breastfeeding activities a nutrition team could implement,” said Adam Aho, a nutrition officer at UNICEF Gabon who helped develop the course and co-facilitated the program for its first cohort of learners. 

“It’s very important to build SBC skills and knowledge,” he added. “Sometimes programs forget the importance of changing norms, habits and behavior – choosing to focus mainly on awareness raising. But we know knowledge itself does not change behavior.”

A number of lessons helped learners explore those influences and discuss various techniques to address them, she added.

“We discussed small doable actions,” Tchapo recalled. “That was very enlightening - we were not at all familiar with that concept.”

Proof of concept

The contributions of several specialists who presented during the course were particularly helpful, said Lanfia Toure, a nutrition program officer at UNICEF Guinea, as well as the support of program coaches. The main downsides were occasional connectivity issues and the volume of reading material.

“The case studies presented by experts were very helpful,” Toure said. “These presentations allowed us to learn new things and better understand how to implement interventions.”

Equally effective, he said, were the various “missions” teams undertook – “they built teamwork” – and the discussion forum on the online dashboard – “in this forum, the trainers, the participants, everyone shares their experiences and has them addressed – it was very informative.”
 
Perhaps most significantly, Toure said his team is very close to submitting a budgeted SBC action plan to the Ministry of Health’s directors – the goal of the program. 

“We have already written a first draft and shared it with our coach,” he said (the program's coaches are continuing to support the country teams even after they complete the program). “We identified all of the activities and have arranged them according to strategic axes. We’re just waiting for the inputs from our coach.”

The program also offered insights to those working with the national teams.

“The participants were a highlight of the course for me,” said Karen Greiner, UNICEF Regional SBC Advisor. “Hearing from government technical managers and experts from so many countries helped me understand the challenges, and also the resourceful solutions emerging from communities in the region. A colleague in Togo shared how leaders solved a cultural barrier to breastfeeding and that example was truly inspiring.”

The program is now being refined based on feedback from learners and with notes of various insights and ideas kept in a journal during the experience. 

“It’s a very innovative way that we can build skills in SBC for MIYCN programs – a very welcome way,” Likhite said. 

And, Aho added, the first cohort’s experience has shown interest in the content is high.

“This is a unique initiative in the region,” he said. “I’m sure it will really contribute to the improvement of MIYCN programs.”