Improving Compliance to Complementary Feeding Practices

Complementary feeding is crucial for improving nutritional and growth outcomes for 6-23-month-old children. Complementary feeding recommendations include diet diversity, quantity, frequency, and consistency guidelines. Appropriate complementary feeding practices can substantially reduce malnutrition rates and related disease burdens and break intergenerational cycles of undernutrition.

We conducted a diagnostic to identify barriers to complementary feeding. Based on our diagnostic findings, we designed and evaluated behavioural interventions to improve complementary feeding practices among caregivers (primarily mothers) of 6-23-month-old children. The study was conducted in Barwani and Vidisha districts in Madhya Pradesh with 699 mothers with children between the ages of 6-23 months registered at Anganwadi Centres.

Introduction

Our diagnostic research revealed several barriers to mothers engaging in complementary feeding practices. Among the key barriers identified were:

1. Complementary feeding is a composite behaviour that requires compliance with multiple guidelines across diet diversity, frequency, quantity, and consistency. Understanding all the necessary components of complementary feeding is cognitively demanding.
2. The complexity of complementary feeding practices leads to the oversimplification of counselling messaging to caregivers.
3. Complementary feeding is a personal, intra-household activity. Hence, there is limited communication on complementary feeding outside the household other than from frontline health workers (FLHWs), leading to low visibility of social norms and the absence of fora for mothers to discuss complementary feeding practices/challenges actively.

Based on these findings, we conducted a lab-in-the-field experiment to evaluate the effectiveness of two interventions:

The first, Socialising Complementary Feeding (CF), was designed to facilitate discussions around complementary feeding among caregivers. The intervention aimed to make complementary feeding practice and discussion a visible and social activity and leverage peer effects of increasing knowledge and adoption of complementary feeding. We deployed the intervention on WhatsApp groups with 4-5 mothers, facilitated by trained moderators.

The second, Simplified CF Script via phone counselling, provided a simplified script for counselling on complementary feeding components and risks of non-compliance. The script used simple, relatable language to convey complementary feeding guidelines. The intervention was delivered through phone counselling by trained enumerators.

Key results

Socialising CF through moderated WhatsApp groups improved minimum meal frequency (MMF) and minimum adequate diet (MAD). Improvement in minimum diet diversity (MDD) alone was not statistically significant.

The use of Simplified CF Script for phone counselling produced no significant improvement in minimum meal frequency (MMF), minimum adequate diet (MAD) and minimum diet diversity (MDD).

Description and methodology

We recruited the sample with support from the Piramal Foundation, which provided contact details of Anganwadi Workers (AWWs) in the two districts. The AWWs, in turn, provided relevant information about mothers with children between the ages of 6-23 months. We received 5403 numbers from AWWs across both districts, of which we identified 4301 unique numbers to contact for the baseline survey. Of these, 699 completed baseline, and 328 completed endline.

Due to the COVID-19 pandemic, we deployed our treatment and collected data remotely to ensure a no-harm policy.

To assess the effectiveness of the interventions, we used a randomised experiment methodology. Randomisation ensures that systematic differences between groups do not drive differences in outcomes. We studied the causal effect of the interventions on identified outcomes.

Participants answered the baseline survey over the phone. Four weeks later, we randomly assigned participants to one of two treatment groups or the control group.

Participants in the Socialising CF treatment arm were sent regular messages on complementary feeding components and practices via a WhatsApp group. The messages used behavioural principles such as reducing cognitive load, simple mental models, commitment devices, and feedback loops.

Those in the Simplified CF Script treatment group received scripted phone counselling. In addition, we sent three text messages to this group on three consecutive days after the phone call to reinforce counselling.

We administered the endline survey two weeks after the intervention.

Results and highlights

CSBC examined the causal effect of the interventions on the following outcomes:

• Compliance to minimum diet diversity (MDD): Minimum 4 food groups a day
• Compliance to minimum meal frequency (MMF):
  • Breastfed children, age 6-11-months: Minimum 2 meals a day
  • Breastfed children, age 12-23-months: Minimum 3 meals a day
  • Non-breastfed children: Minimum 4 meals a day
• Compliance to minimum adequate diet (MAD): Meeting both MDD and MMF
• We also measured secondary outcomes such as knowledge, value perception, risk perception and intentionality.

The treatment Socialising CF has a significant positive effect on MMF and MAD. When looking at MDD alone, the treatment does not have a significant effect. Among secondary outcomes, the Socialising CF treatment had no significant effect on knowledge, attitude and intention measures.

The Simplified CF Script treatment produced no significant improvement in the odds of compliance with MMF, MDD, or MAD. Among secondary outcomes, the Simplified CF Script treatment significantly improved knowledge of food groups and beliefs around complementary feeding. The treatment did not show any significant effects on any other knowledge, attitude, or intention measures.

Experimental results

Discussion

Key takeaways from the study are:

• Socialising CF through moderated WhatsApp groups improves complementary feeding.

  This intervention is easy to scale and cost-effective. ASHAs and Anganwadi workers create WhatsApp groups for mothers (who have smartphone access) and share regular messaging on complementary feeding. The cost of implementation is minimal, as there are no additional procurement or distribution requirements.

• The behavioural architecture of each component of complementary feeding is different.

  The intervention Socialising CF is effective in moving MAD and MMF indicators, but the effect is not sustained for MDD alone. This suggests that behavioural factors that influence each complementary feeding component are different, and using one blanket approach for promoting different components of complementary feeding might not be effective.

• Phone calling (+ SMS) based messaging interventions have limited reach and impact.

  In the Simplified CF Script intervention, messaging using phone calls and SMS reached very few of the intended sample (25% received complete treatment), resulting in no change in complementary feeding practices. However, there was a significant increase in knowledge and beliefs around complementary feeding.

• Implications of using Whatsapp to deploy the Socialising CF intervention

  WhatsApp has high penetration, usage and familiarity. Its group feature allows interactions in intimate, personalised groups. It allows sharing content in multiple formats (audio, video, images) and access to shared content at all times. On other social media platforms, like Facebook, a specific group is likely to be drowned out by other notifications and posts. The group also tends to be less personalised and intimate. In this use-case, WhatsApp also has advantages over in-person interactions, where one cannot access the information shared during the meeting in the same manner at a later time. Further, the high transaction costs of meeting in-person result in lower compliance and higher attrition.

Research funders and other information

This study was funded by a grant from Bill and Melinda Gates Foundation. The Institutional Review Board at Ashoka University approved the study.