A. Understanding how to change what and how people eat

Eating habits of persons cannot be changed without understanding their eating behaviour: (a) capabilities, (b) opportunities, and (c) motivation factors of persons must be well understood to explain their behavioural traits (see figure below). So, when aiming to improve nutrition behaviour, a thorough assessment is needed on these aspects to explain existing behaviour and to assess how capabilities and opportunities can be developed such that they contribute to stimulate a behavioural change. But since behaviour traits relate to well-established conducts that somehow have proven satisfactory over time, interventions are required that target very efficiently the motivation of a person to pursue a behavioural change.

Source: adapted from Michie et al. (2011)

When assessing the different aspects that contribute essentially to a change in behaviour in regard to nutrition, the following is crucial:

• Capabilities – Understanding the physical and psychological limitations that explain the most relevant abilities that have an impact on the nutritional status of the person itself and others. Here, the role and capacities of women is of greatest relevance, as they have a strong impact on the family’s diet not only through cooking but also through food production and purchasing, food storage, and processing. All these activities may be constrained by physical, monetary, or educational shortcomings – or through beliefs and perceptions.
   
• Opportunities – Especially in poor rural areas, opportunities may be heavily constrained in regard to production and technology options (e.g. access to certain crops, irrigation and greenhouse facilities) and appropriate storage, processing and cooking facilities etc. Also, market access is likely to be constrained. At the same time, opportunities are not always fully utilized, e.g. green leafy vegetables are in many cases available but often not eaten! Overall, an in-depth understanding of the magnitude and scope of existing opportunities and constraints is absolutely crucial to anticipate changes in this regard with corresponding measures.
   
• Motivation – Capabilities and opportunities will certainly influence attitude and motivation towards change. Nevertheless, personal convictions and objectives, social pressure and potential reputation gains etc. may even be more important as factors driving motivation. A thorough understanding of the most important aspects that influence motivation is absolutely essential prior to design action towards improving nutrition outcomes!
   

B. Nutrition education as part of project design

How to convince farmers not to sell their vegetables, which are potentially well-priced, but eating them instead? How to give useful advice to people in a deprived situation to eat food of better quality, but which costs more? How to change the diet of people who are used and thus prefer unhealthy over healthy food?

These are the questions raised in many projects, while knowing by experience that it is very difficult to change nutrition behaviour. The following methods have proven promising and successful in the context of improving nutrition in rural areas. However, these are no blue prints; their efficacy depends on a sound initial assessment (see above) and the quality of project implementation – especially in regard to successful involvement of stakeholders based on trust and respect.

As the degree of education is especially low in rural areas, nutrition and health education is of primary importance, particularly targeting women – but not only. Such type of education is often provided by the health sector (government and NGOs) as part of “mother and child programs”, with special emphasis on the “first thousand days” (from pregnancy till child is 2 years), aiming to reach pregnant women, where nutrition quality is of particular importance for them and their babies. For that purpose, usually locally adapted nutrition education material is made available, produced by the Ministry of Health, local NGOs or partner organizations of UNICEF.

Nevertheless, in many cases, such education alone is often not translating into action and changes in regard to food production, as health experts are not linked to the field of agriculture. Therefore, projects should ideally have an approach that bring health and agricultural extension agents together to discuss with local stakeholders options how to improve their nutrition situation. Important is that through such project work, not only information is shared, but tangible improvements are suggested – ideally by stakeholders themselves – which are introduced and jointly monitored and evaluated. By going beyond “simple information sharing”, the success rate drastically improves!

C. Methods and tools

There are different methods and tools to get a handle on nutrition education, at different levels and through different means. The following are most relevant in the context of nutrition sensitive interventions:

1. Motivational Interviewing & Cognitive Behavioural Therapy – Motivational interviewing is a counselling approach that links interviewing with sharing of advice, being significantly more effective than traditional advice-giving. It is a directive, client-centred method for enhancing intrinsic motivation by exploring and resolving ambivalence and barriers to behaviour change. The main principles underpinning motivational interviewing are: (a) express empathy (through reflective listening), (b) develop discrepancy (between the individual’s goals and their current behaviour), (c) avoid argumentation, (d) roll with resistance (acknowledge and explore the individual’s resistance to change, rather than opposing it), and (e) support self-efficacy.

In situations where behavioural traits are very strong hampering nutrition (i.e. obesity, additions), motivational interviewing might be used in combination with Cognitive Behavioural Therapy (CBT), which aims to stimulate tangible behavioural change based on awareness in regard to dysfunctional thoughts, assumptions, and patterns of behaviour. It explores the range of factors that influence one’s behaviour, both external (e.g. environmental stimuli and reinforcement) and internal (e.g. thoughts). CBT also relies on techniques such as goal-setting and self-monitoring, based on presumption that behaviour can be learned (and unlearned).

2. Social marketing for improved nutrition – PR type of work might be interesting aiming to target a bigger number of stakeholders / beneficiaries. Yet, as information alone is in most of the cases not enough to change behaviour, such social marketing work must be based on a solid concept to somehow stimulate changes based on very strong and clear messages. Important is not only the message itself, but also who conveys it and what type of media is used. Interesting messages may relate to specific crops that are relevant to improve the diet (e.g. orange fleshed sweetpotato, coloured native potatoes, kale or other leafy vegetables). Interesting spokespersons may be successful sportsmen, doctors, or nutritionists. Especially in rural areas, radio might an ideal media to convey such message(s), or TV in case rural areas have access to it. Also printed material may be relevant. Here, the visualization of the messages must be well implemented, and the concept may follow the Brazilian example, which goes beyond conventional technical nutrition education leaflets, including recommendations like: “share your meal”, “eat together with friends and family”, “eat fresh and less packaged food”. Simple recipes may also be part of such social marketing material, which can also easily placed online and shared through Social Media.

3. Positive defiance – In contrast to approaches, where malnutrition and its causes are in the centre of attention (i.e. a negative situation), the Positive defiance method gives attention to situations and people where good nutrition prevails, despite of the same difficult circumstances. Thus, the approach builds on the experience of well-nourished persons, who share their “story” with others, and thus act as resource persons. This method is based on the presumption that the advice of outsiders is not as practical and useful as when it comes from own people. Consequently, this method is particularly promising in contexts where there are certain prejudices against outsiders.

4. Focus on “easy choices” – This approach aims to making healthier options easier, i.e. making them more attractive than unhealthy ones. Most of the times, this implies a change of the context / environment or the way how food items or food choices are presented, creating in some way also new social norms. Examples of interventions for such an approach are: putting fruits on tables in meetings instead of sweets, making salad the default side dish in social gatherings, improving the ingredients of processed products or recipes, banning the sale of soft drinks in schools, taxing of unhealthy food etc. Yet, as this approach in many cases results in confronting the consumer with a new situation where he or she has actually no “choice”, interventions should ideally involve some sort of communication that explains the reason relating to the “improved choice” – to enhance understanding and conviction.

Important: Projects must have a close look on own “easy choices”. Are soft drinks offered during meetings, or locally made (unsweetened) fruit juice? What are the criteria for caterers preparing the meals for project events?

5. Emphasis on “leverage technology” – This approach puts full attention on specific technologies and their potential impact to improve the nutrition situation in a given context. The underlying thinking and conviction of this approach is that certain technologies – i.e. being of great benefit for the target group – leverage nutrition outcomes through a shift of paradigm by changing fundamentally the way food is produced, processed or consumed. Examples may include access to: (a) irrigation technology (favouring the production of vegetables), (b) solar drier technology (favouring the conservation of fruits, herbs and other crops), (c) solar panels (favouring food processing), (d) internet (favouring online access to new recipes etc.).