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Suaahara - Building Strong and Smart Families

Suaahara - Building Strong and Smart Families

In an effort to improve the nutritional status of women and children in Nepal, the United States Agency for International Development (USAID), in consultation with the Ministry of Health and Population (MOH) and other partners, designed the five-year (August 2011 - August 2016) Suaahara (Good Nutrition) programme. Focusing on the 1,000 days from conception though the first two years of life, the programme relied on a multi-sectorial approach by addressing child sanitation, hygiene, access to food, child-feeding practices, and gender and social equity. It aimed to: improve reproductive health/family planning services; create awareness regarding sanitation and hygiene; improve access to clean water; and introduce home-based gardening as a way to encourage a balanced and healthy diet. Moreover, it also worked on influencing positive behavioural changes through planned communication campaigns in 41 underserved districts.

Communication Strategies: 

Suaahara means "a good balanced diet is the strong foundation protecting our lives." The project (Suaahara and Suaahara II) works with communities, government, and civil society organisations to provide women and their families with access to information and skills for better nutrition, hygiene, and health practices. For example, the project works with the government to build the capacity of Female Community Health Volunteers (FCHVs) and other Community Extension Workers, as well as staff from the Departments of Agriculture, Local Governance, Education, and Water. This creates multi-sectoral collaboration and synergy to address the pervasive problem of under-nutrition in Nepal. Project activities include:

  • Organise regular visits and follow-up by FCHVs of households, particularly those of disadvantaged groups who have children under two or pregnant women.
  • Organise and facilitate mothers' group interactions to promote dialogue and raise awareness regarding better health and nutrition practices for women and children.
  • Use smartphones to track coverage of disadvantaged households and monitor the degree to which Suaahara has reached these households with interventions.
  • Improve the survival of mothers and their children by providing effective counseling on healthy timing and spacing of pregnancies (HTSP).
  • Improve mothers' infant and young child feeding knowledge and behaviours.
  • Increase year-round access to nutritious foods to improve the nutritional status of children under two years of age and their mothers.
  • Enhance clean water, sanitation, and hygiene conditions by promoting household facilities and community sanitation norms.
  • Improve the food security of households by increasing the diversity of foods grown and consumed at home.
  • Use communication campaigns like Bhanchhin Aama, described below, to influence social and behavioural change in health and nutrition practices of 1,000-day mothers (pregnant and breastfeeding women, and mothers with children under two years of age).
  • Provide nutritional counseling to 1,000-day households.
  • Offer training to plant and maintain small, diversified gardens.
  • Offer support for poultry breeding to provide animal-source protein and increase incomes.
  • Offer training and support to build latrines, dispose of solid waste safely, and wash hands frequently.

One of the key social and behaviour change communication interventions is the Bhanchhin Aama or "mother knows best" integrated nutrition communication platform and campaign for mass and community media, which includes a popular radio drama, hoarding boards (billboards) that promote key messages and are community specific, and other support materials. Bhanchhin Aama is centred around the character of an Aama, a "normal" Nepali mother-in-law. The Aama appeasd as a character in a serial radio drama and as the host of a live recorded call-in show broadcast twice weekly in three different languages. The programmes cover a broad range of topics related to maternal and child health and nutrition, including infant and young child feeding (IYCF), hygiene and sanitation, agriculture, and family planning. A logo with Bhanchhin Aama's image appears on all of Suaahara's materials, including field activity guides, posters, pamphlets, billboards, games, toolkits, and videos - ensuring that the programme has a branded "look and feel". (Click here to access all the project videos.) According to organisers, the character has become a popular and trusted figure across Nepal, providing a role model for intended audiences, as well as delivering nutritional information in a credible, authentic, and persuasive way.

Social mobilisation activities reinforce the campaign's key messages and provide mothers and their families with a place to share experiences and discuss the campaign. Bhanchhin Aama community activities have included: more than 240 radio discussion groups among marginalised populations; celebration of key life events during 1,000 days, such as a rice feeding ceremony; cooking demonstrations; mothers' group meetings and school group activities; and national day celebrations (e.g., Breastfeeding Day) with songs and folk media. There was also media advocacy with journalists for increased quality reporting about nutrition issues.

To develop this evidence-based entertainment-education campaign, formative research was conducted to gain an in-depth understanding about the primary determinants of key behaviours related to infant and child care, including breastfeeding, complementary feeding, feeding practices, sanitation, and hand washing. Research methods included: focus group discussions among mothers, fathers, and mothers-in-law; in-depth interviews with traditional healers, community health workers, model farmers, and government officials; participant observations of public places and markets; and perceptual mapping techniques. The intervention was designed to respond to the findings of the formative research, including these insights:

  • Concerns about children's education and future prospects are important motivators. Education was also perceived to be related to agency, or the ability to make positive changes in one's life, including the adoption of nutritious food habits.
  • Higher educational levels were associated with the respondents' practice of more "progressive" behaviours, such as delivering a baby at a health centre, eating tastier foods, and aspiring for a better life for themselves and, especially, their children.
  • Mothers-in-law continue to play an important role in family life and seemed to welcome social changes that they noted were unfolding in their communities. They are a potential resource that can be tapped by providing positive role models of mothers-in-law in media programming and by including them in community mobilisation activities.

The programme utilised these insights in activities targeting families' aspirations to improve health and nutrition behaviours at the household and community levels. The design was informed by behaviour change theories (stages of change, theory of reasoned action, and diffusion of innovation).

Click here [PDF] for a document describing the planned activities under Suaahara II.

Development Issues: 

Children, Nutrition

Key Points: 

In Nepal, 41% of the under-five children suffer from stunting, 13% suffer from wasting, and 39% are underweight. Moreover, the rate of stunting is found to be as high as 60% among disadvantaged groups. Due to the lack of awareness and poor access to health services, only 58% of women in Nepal receive antenatal care during pregnancy, and only 36% of deliveries are assisted by a skilled birth attendant (SBA). The low level of supervised antenatal and postnatal care and poor maternal nutrition directly contributes to higher maternal mortality rates. In addition, 44% of the population does not have access to toilets, and open defaecation contributes to higher diarrhoeal disease morbidity, with further detrimental effects on nutritional status. Socio-economic, geographic, and educational factors, along with regressive gender norms, contribute to the poor health status of Nepalis, particularly women and children.

Key takeaways for nutrition SBCC:

  • A unified-theme, "branded" campaign links community and household-level approaches and mass media to reinforce key attitudes and behaviours and enhance the enabling environment for change.
  • To help families makes changes to established cultural practices, it is critical to use a trusted information source, such the mother-in-law figure. For example, many nutrition behaviours in Nepal, such as very low rates of feeding eggs, meat/fish, or vegetables to children under two years, are guided by cultural practice - but the Bhanchhin Aama radio programming helped promote the idea of the mother-in-law persuading families to practice new behaviours that would strengthen children's health and benefit their futures.
  • Using personal communication technology can be critical to effectively engage priority audiences. Mobile phone ownership was high - over 80% - and many people listened to the radio via their phones. The Bhanchhin Aama intervention capitalised on this by incorporating a call-in radio show that made participation simple and convenient. This interactive element helped the programme make adjustments and strengthen its relevance to audience needs.
  • Getting all stakeholders onboard from the outset helps to ensure successful development and implementation of a multi-sectoral, multi-platform programme.
  • Ensuring the participation of male family members needs greater attention. The participation of men was relatively low, as a result of several factors, including travel for migrant work. However, the direct participation of males in activities can be essential to facilitating and continuing behaviour change, as males are typically key decision-makers at the household level.

According to a 2014 district-level study, four of every five people (81.7%) who listened to the Bhanchhin Aama programme (28% of the population or half of those who own a radio) self-reported taking an appropriate action related to IYCF, and more than half (53.3%) discussed the issues with their friends and families. In addition, an independent survey of 2,500 mothers found that their child's dietary diversity, consumption of food from four or more food groups, consumption of fruits and vegetables, and consumption of animal source foods were positively and significantly associated with the frequency of listening to the Bhanchhin Aama programme.

Sample results from Suaahara overall:

  • Increased prevalence of children of 6-23 months receiving a minimally acceptable diet from 23% to 59% in 2015.
  • Increased percentage of children 6-23 months of age receiving minimum dietary diversity (foods from >4 food groups) during the previous day from 47% to 60% in 2015.
  • Increased prevalence of exclusive breastfeeding of children under 6 months from 46% to 69% in 2015.
  • Supported establishment of Food Security and Nutrition Steering Committee, the Nepal Nutrition Group, the Nutrition Technical Committee, the Nutrition Advisory Committee, the Safe Motherhood sub-committee, the Family Planning Sub-committee, and the Reproductive Health Coordination for improved coordination between government and other stakeholders.
Partner Text: 

Suaahara is funded by USAID/Nepal and involves these partners: Save the Children, Helen Keller International, JHPIEGO, Johns Hopkins Center for Communication Programs, Nepali Technical Assistance Group, Nutrition Promotion and Consultancy Service, and Nepal Water for Health. The programme also works closely with the government's Child Health Division and National Health Education, Information and Communication Center as well as the Family Health Division and the National Health Training Center, Agriculture Department, Livestock Department, Department of Water Supply and Sewerage, and Ministry of Federal Affair and Local Development - from the central to the community level.

Contacts (user reference): 
See video

SPRING website, K4Health website, USAID website, Johns Hopkins Center for Communication Programs website, and Health COMpass website - all accessed on October 19 2017; and email from Caroline Jacoby to The Communication Initiative on October 30 2017. Image credit: Johns Hopkins Center for Communication Programs

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