Malnutrition: Scaling digital behaviour change interventions
This article is authored by Sharon Barnhardt and Pratyusha Govindraju, Centre for Social and Behaviour Change, Ashoka University.
Behavioural interventions on digital platforms have the potential to improve child malnutrition at a large scale in rural India right now. While this may seem like an indirect or simplistic approach to solving a complex nutrition problem, research from Africa and South Asia suggests that behavioural interventions are an inexpensive and scalable addition to the multi-pronged approach required to tackle malnutrition. Malnutrition is the top risk factor for death and disability in India. While malnutrition can adversely affect health at any stage in life, children are more vulnerable to malnourishment and its consequences. In children under the age of five years, malnutrition most seriously manifests as stunting, wasting, underweight and anaemia. Malnourished children are more susceptible to diarrhoea and are at greater risk of succumbing to pneumonia. With one-third of India's children stunted, and one-third underweight, addressing malnutrition is an urgent humanitarian and policy priority.
Poshan Abhiyaan, India's flagship holistic nutrition scheme for pregnant women, lactating mothers, children and adolescent girls, emphasises the need for behavioural change alongside material and structural interventions. Behavioural interventions target inadequate information and poor decision-making to improve nutritional outcomes. When designed thoughtfully and in collaboration with communities, behaviourally informed strategies are critical to the successful adoption of nutrition schemes.
A review of nearly 80 studies on improving maternal and child nutrition outcomes in sub-Saharan Africa found that nutrition interventions based on behaviour change theory, counselling and communication were more effective than nutritional interventions that did not include a behavioural component. For instance, nutrition interventions that used persuasive communication to make an emotional appeal increased mothers' confidence and capability to meet their children's nutritional needs. Further, evidence from a large-scale household study conducted in Bangladesh showed how an intensive behaviour change communication strategy involving interpersonal communication and community mobilisation increased household expenditure on key food groups, dietary intake of mothers and children, and women's employment and control over their income.
Studies across low and middle-income countries show that interpersonal counselling for individuals or groups, media use, and community mobilisation activities effectively improve stubborn indicators such as adherence to exclusive breastfeeding. Exclusive breastfeeding is one of eight core infant and young child feeding indicators defined by the World Health Organization (WHO) in 2008. It is an important indicator for nutrition in early life, especially in communities with poor access to hygiene and sanitation. Children are most vulnerable to undernutrition and low age-appropriate growth between ages six and 23 months when they are introduced to foods other than breast milk. Undernutrition may result from inappropriate feeding practices such as initiating complementary feeding too early or too late, feeding the child too much or too little food and not introducing the child to diverse food groups, leading to nutrient deficiencies. Some of these practices stem from a lack of knowledge, and some are due to cultural beliefs. Such barriers can be effectively addressed through behavioural interventions designed for caregivers, extended family and the community.
During the Covid-19 pandemic, the Centre for Social and Behaviour Change, Ashoka University, in partnership with Piramal Foundation, found that behaviour change interventions delivered to parents and caregivers on moderated Whatsapp groups effectively improved nutritional outcomes for children between ages six and 23 months. The messages from moderators leveraged behavioural principles to reduce cognitive load in understanding complementary feeding practices. They used simple mental models, commitment devices and feedback loops to facilitate discussion among caregivers. Moreover, the Whatsapp group created opportunities for peer interaction and established visible social norms about food practices usually limited to the household.
Accounting for behaviourally informed interventions in nutrition programmes is usually less resource-intensive. These often involve inexpensive tweaks to existing programs that can lead to large impacts at scale—for instance, using WhatsApp or community radio to deliver behavioural science-backed messaging, leveraging YouTube to provide content that is both educational and entertaining or modifying in-person counselling to include the technique of persuasion. Such messaging can complement traditional counselling with verified, standardised messaging shared through audio stories and video series. India is projected to have one billion smartphone users by 2026, with the growth in demand driven by users in rural India. However, the gender divide in digital access poses a significant barrier to digitally delivered nutritional interventions. While addressing the gender divide should be our goal, one solution to scale behavioural interventions for nutritional programmes in the short term would be to equip health workers with devices and internet subscription plans that they can use to counsel mothers and grandmothers about child-feeding practices. For those with access to smartphones, health workers can share information and engage with recipients remotely, thus reducing transaction costs of multiple in-person visits. For those who don't, health workers can share behaviourally informed audio-visual messages during in-person counselling sessions - thereby ensuring greater accuracy and effectiveness of the information delivered.
The case for incorporating behavioural interventions to improve nutritional outcomes is strong. Well-designed behavioural messaging and strategies motivate adoption and adherence to healthy food practices, acknowledge caregivers' agency in decision-making and secure their commitment to making healthy food choices for their children.
This article is authored by Sharon Barnhardt, director, research and Pratyusha Govindraju, senior research specialist (Lead—Experiments & Evaluation), Centre for Social and Behaviour Change, Ashoka University.