Barriers to nutrition are often systemic, but individual behaviours and attitudes can also play a role. Understanding these behaviours was the first step of the BISA programme, which completed its first phase in the midst of the COVID-19 pandemic. Using a novel form of immersive formative research, living with families to assess their behaviours and attitudes to nutrition, the programme provides solutions to the supply and demand for quality nutrition – including a game of snakes and ladders.

Indonesia is the world’s fourth most populous country. It is also home to over 8 million stunted children*.

Stunting is the cumulative effect of the irreversible physical and cognitive damage caused by chronic undernutrition, repeated infections and inadequate childcare and feeding practices. With 31% of all Indonesian children suffering from this condition, the country requires robust intervention to improve the health and nutrition status of women and children in the first 1,000 days of life and through adolescence, in order to break the intergenerational cycle of undernutrition and ensure children grow into healthier, more resilient and productive adults.

The Government of Indonesia takes the issue seriously, implementing a bold national strategy called ‘StraNas’ to reduce stunting by 17% by 2025. In 2019, The Power of Nutrition convened a multi-sectoral partnership with Save the Children, Nutrition International, Asia Philanthropy Circle, DFAT, Unilever’s leading soap brand, Lifebuoy and Global Affairs Canada, to support this strategy. The partnership is called Better Investment for Stunting Alleviation programme, or ‘BISA’ – which translates to ‘we can’ in Bahasa Indonesia.

BISA is a US$10 million programme working to improve nutrition outcomes for children, pregnant women, and adolescent girls, targeting districts in the provinces of West Java and East Nusa Tenggara, where the prevalence of stunting is high. BISA is using existing resources and working at the sub-national level: with provincial and district governments, health workers, high school leaders, and village leaders including human development workers, youth cadres, family welfare empowerment groups and religious leaders. They will work to improve the access and quality of critical nutrition services.

The programme is also implementing a social behaviour change communications (SBCC) strategy to empower caregivers to practice optimal maternal, infant, and young child nutrition behaviours. The BISA team has completed the first phase alongside a quantitative baseline study and a qualitative formative research, designed to deepen understanding of community perceptions towards nutrition.

As part of the formative analysis, researchers lived with families in the targeted communities for five days, understanding their day-to-day lives and forming personal connections to gain first-hand insights into the barriers faced in accessing optimal nutrition.

The BISA team worked with families participating in the research to help them recognise solutions to overcome the barriers in their communities, and explored best approaches to:

• help babies and young children to play and get fed in a clean and hygienic way in the home
• address iron deficiency in adolescent girls sustainably
• ensure optimal breastfeeding
• make nutrition counselling effective (building confidence and skills of cadres)
• promote handwashing with soap

For example, to ensure clean and hygienic play spaces for babies and reduce germ contamination, members of the community built safety gates out of locally available materials to separate livestock from other spaces. Adequate water, sanitation and hygiene conditions and practices are a prerequisite for good nutrition, and can contribute to reductions in stunting.

Adolescent girls also designed a version of snakes and ladders to play with peers in school, with winning points gained from ‘iron positive’ actions and losing points from sub-optimal nutrition behaviours. The girls arranged to trial their game with a group of their peers and facilitated the entire session themselves. The quiz they conducted after the game demonstrated that the students had remembered the information well; and that the activity was more fun than the methods used to teach these messages in school.

Findings from this research have informed the social behaviour change communication strategy to ensure that SBCC approaches are relevant, culturally responsive, and addressing identified community needs. A key lesson was the importance of empowering community members to co-create solutions to improve behaviours that reflect the realities of the contexts in which they live. The approaches included in the behaviour change campaign represent multiple reinforcing levels of support to improve nutrition behaviours, including:

1. Interpersonal communication
2. Community engagement and mobilisation
3. Service strengthening & capacity-building
4. Digital & mass communications
5. Advocacy

These interventions will help to reinforce multiple positive nutrition behaviour changes, such as attending antenatal care as early as possible and minimum six times during pregnancy, taking recommended supplements, exclusive breastfeeding and hygiene.

In parallel to the social behaviour change campaign, the programme is also addressing the supply side of nutrition through partnerships with local government stakeholders. Besides addressing issues around COVID-19, BISA is working collaboratively with District Trainers, local and school facilitators, Village Chiefs, and high school youth groups to promote public health and hygiene for the improvement of the nutritional status of mothers, young children and adolescents. This represents a sustainable approach to programming; building experience and knowledge of nutrition among stakeholders who in turn will encourage better nutrition and hygiene behaviours in their communities.

This collaborative and holistic approach will enable programme stakeholders to understand first-hand the unique, context-specific challenges and opportunities for improved nutrition, and will contribute to the development of best-practices to be replicated elsewhere.

“We appreciate BISA supporting the Local Government in educating and elevating the Infant and Young Children Feeding practice within communities. This activity should be carried out simultaneously in all Integrated Service Unit as a social movement to prevent stunting during the first 1,000 days” said Josefa Rosela, an Infant and Young Children Feeding facilitator.

Another facilitator, Imelda Banase, said “The Complementary Food for Breastfeeding demonstration is important and good so that people will understand, and be motivated to adopt hygiene best-practices when preparing food, such as washing their hands and giving complementary foods to children aged 6 months.”

The foundations are in place for this critically important programme to assist the Government of Indonesia in their mission to improve nutrition outcomes for mothers and children, a mission made even more urgent by the pandemic.

It is estimated that BISA will enable 3.3 million people, including over 700,000 women, almost 490,000 children under two, and 1.45 million adolescent girls, to access high impact nutrition services, contributing to an additional 4,800 lives saved, 6,300 cases of stunting averted, and over 161,000 cases of anaemia averted.

We are excited to contribute to achieve this transformational change in the country, and we are thankful for the support of our partners, without whom this would not be possible.

*RISKESDAS 2018.

This blog by The Power of Nutrition, Save the Children and Nutrition International was originally published on The Power of Nutrition’s website on May 6, 2021.
Authors: Tatum Summers, Programme Manager, The Power of Nutrition; Prima Setiawan, Chief of Party of BISA, Save the Children; Donatus Klaudius Marut, Deputy Chief of Party, Nutrition International

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