The principles and practices of nutrition advocacy: evidence, experience and the way forward for stunting reduction

Abstract

Advocacy represents an intervention into complex, dynamic and highly contextual socio‐political systems, in which strategies and tactics must be adjusted on a continual basis in light of rapidly changing conditions, reactions from actors and feedback. For this reason, the practice of advocacy is often considered more art than science. However, capacities and practices for advocacy can be strengthened by sharing and analysing experiences in varying contexts, deriving general principles and learning to adapt these principles to new contexts. Nutrition is a particular context for advocacy, but to date, there has been little systematic analysis of experiences. The purpose of this paper is to illustrate and draw lessons from the practice of nutrition advocacy, especially in relation to stunting and complementary feeding, and suggest ways to strengthen capacities and practices in the future. The strategies and tactics, achievements and lessons learnt are described for three case studies: Uganda, Vietnam and Bangladesh. These cases, and experience from elsewhere, demonstrate that concerted, well‐planned and well‐implemented advocacy can bring significant achievements, even in short period of time. In light of the global and national attention being given to stunting reduction through the SUN (Scaling Up Nutrition) movement and other initiatives, there is now a need for much stronger investments in strategic and operational capacities for advocacy, including the human, organisational and financial resources for the advocacy and strategic communication themselves, as well as for monitoring and evaluation, supportive research and institutional capacity‐building.

Introduction

Global estimates of under‐five malnutrition indicate that in 2011, 165 million children were stunted, of whom 90% live in developing countries (UNICEF et al. 2012). Stunting is not only an issue of physical growth, but also of child survival, cognitive development, worker productivity, health consequences in adulthood, national financial burden and economic growth (Pelletier, et al. 1993; Jones et al. 2003; Engle et al. 2007; Black et al. 2008; Bryce et al. 2008; UNICEF 2009). This evidence has contributed to a widely shared understanding that reducing stunting can contribute to human capital formation, can help break the inter‐generational transmission of poverty, deprivation and inequity, and that cost‐effective interventions are available (World Bank 2006; Hoddinott et al. 2008; Horton 2010). In other words, the accumulated scientific evidence has documented wide range of consequences of chronic malnutrition and, in principle, should concern and motivate a wide range of policy‐makers and civil society organisations at many levels. From an advocacy perspective, this is an asset that many other issues do not possess.

As this evidence has been accumulating and becoming distilled within the technical nutrition community, there have also been encouraging developments in the last decade in advocacy, commitment‐building and partner alignment for young child nutrition at the global level. Specifically, through initiatives such as SUN (Scaling Up Nutrition; http://scalingupnutrition.org/), REACH (Renewed Efforts Against Child Hunger; http://www.reachpartnership.org/home) and Thousand Days (1000 Days Partnership; http://www.thousanddays.org/), the global nutrition community has been converging on a broadly common agenda of goals, strategies and interventions to tackle undernutrition. These initiatives have built upon previously separate efforts related to micronutrient deficiencies, breastfeeding promotion, complementary feeding and others in order to form a more coherent agenda. The core elements of the agenda are a focus on the most vulnerable time for undernutrition (the first 1000 days of life – from conception to 2 years of age); the use of stunting as a central focus and indicator (to replace the composite indicator of weight‐for‐age which underestimates undernutrition when overweight or obesity is present); the promotion of a life‐cycle approach (thereby including maternal nutrition); and a focus on nutrition‐specific as well as nutrition‐sensitive actions (to ensure attention to broader underlying causes and multi‐sectoral strategies in addition to child‐focused public health interventions). More fundamentally, these global initiatives all aspire to support country‐owned, country‐led strategies for addressing undernutrition in a sustainable fashion with an emphasis on results, transparency and accountability.

As a result of these initiatives, many international organisations, donors and governments have become more active in nutrition efforts and become strong advocates at global and/or national levels for greater attention and resources to undernutrition. For instance, over 100 organisations were signatories to the SUN Framework for Action in the development phase in 2010 and over 30 countries had joined the SUN movement by the end of 2012 (http://scalingupnutrition.org/countries-involved). In addition to the countries that have officially joined the SUN movement, there are dozens of other countries that have recognised malnutrition as a development problem and are in various stages of policy development and implementation. To be successful, these country‐level efforts will require sustained political and systems‐level commitment, appropriate financing, effective multi‐sectoral, multi‐stakeholder and multi‐level governance, and strong technical, managerial and implementation capacities. Advocacy and other forms of strategic communication are essential for strengthening and supporting actions, and as such, an examination of current advocacy capacities and practices is warranted.

The purpose of this paper is to strengthen the understanding and the practice of advocacy in relation to stunting in support of the current global and national efforts. The paper first clarifies the landscape of actors for advocacy and the role of advocacy within the larger domain of strategic communication. It then illustrates the practice of advocacy and emergent lessons from several recent country experiences. The paper concludes with suggestions on how advocacy capacities, practices and supportive research could be strengthened in the future.

Key messages

• Effective advocacy is essential for meeting global targets for stunting reduction and other nutritional problems.

• Concerted, well‐planned and well‐implemented advocacy can bring significant achievements, even in short period of time.

• There is a need for much stronger investments in strategic and operational capacities for advocacy, including the human, organisational and financial resources.

The landscape for advocacy and strategic communication

The permanent elimination of stunting in a country requires changes on the part of many actors and institutions. At the outset, it is useful to ask ‘who needs to do what’ if this goal is to be achieved. Using the widely recognised UNICEF Conceptual Framework (UNICEF 1991) or the stunting conceptual framework as a guide (Stewart et al. 2013, an extensive list of actors can be identified. Both of these frameworks highlight the multi‐sectoral causes of malnutrition (including food security, health, household behaviour, the roles and status of women) and the need for action at all levels from national through community and household. As such, the implicated actors include those with primary or secondary roles at household level (e.g. mothers, fathers, older siblings, grandmothers) and at community level (e.g. health workers, traditional birth attendants, local leaders, teachers, agricultural and community extension agents, community development councils, civil society actors and organisations); actors at district and regional levels [e.g. staff and managers in various government ministries and non‐governmental organisations (NGOs), elected officials, coordinating bodies at those levels and potentially private sector actors]; policy elites at the national level (and sometimes their equivalents at sub‐national levels) such as technical, managerial and senior administrative staff in the sectoral ministries (health, agriculture, finance, trade, industry, labour and justice); multi‐sectoral coordinating bodies, NGOs and donor organisations, parliamentarians and heads of state. It may also involve advocacy with private sector, academia, research and training centres, statistical offices and the media.

Each of these actors controls or influences decisions and actions that can have a positive or negative influence on the food, health, care and feeding of children, the status and roles of women and/or the allocation of human, economic, organisational resources at household, community and societal levels. Thus, each has particular role(s) to play in reducing or eliminating stunting. The role they are currently playing is shaped by their particular perspectives, norms and interests, which, in turn, are a function of their location in the system and the particular social, organisational, political, economic and professional incentives, opportunities and constraints.

Given this diversity, many forms of strategic communication are needed to improve the alignment of perspective, norms, interests, incentives, opportunities and constraints of these diverse actors in favour of improved food, health and care. Although terminology is far from being standardised in this area (Servaes & Malikhao 2010), three broad and overlapping forms of strategic communication are advocacy, social mobilisation and behaviour change (or programme) communications (Box 1) (UNICEF 2005). The primary focus of this paper is advocacy, especially targeted to policy elites as detailed above, but with the explicit recognition of the distinctive role that this plays and the need to complement this with other forms of strategic communication in the interest of creating broad and lasting change in the conditions that create stunting.

Box 1. The forms of strategic communication.

Strategic communication is an evidence‐based, results‐orientated process, undertaken in consultation with the participant group(s), intrinsically linked to other programme elements, cognizant of the local context and favouring a multiplicity of communication approaches, to stimulate positive and measurable behaviour and social change. Three forms include:

Programme communication or behaviour change communication is a research‐based consultative process of addressing knowledge, attitudes and practices through identifying, analysing and segmenting audiences and participants in programmes by providing them with relevant information and motivation through well‐defined strategies, using an audience‐appropriate mix of interpersonal, group and mass‐media channels, including participatory methods.

Advocacy is a continuous and adaptive process of gathering, organising and formulating information into argument, to be communicated to decision‐makers (often policy elites) through various interpersonal and media channels, with a view to influencing their decision towards raising resources or political and social leadership acceptance and commitment for a development programme, thereby preparing a society for its acceptance.

Social mobilisation is a process of bringing together all feasible and practical intersectoral social partners and allies to determine felt‐need and raise awareness of, and demand for, a particular development objective. It involves enlisting the participation of such actors, including institutions, groups, networks and communities, in identifying, raising and managing human and material resources, thereby increasing and strengthening self‐reliance and sustainability of achievements.

Source: Adapted from UNICEF 2005

The practice of advocacy

Advocacy has been described as an activity conducted on the basis of experience and tacit knowledge (Figueroa et al. 2002), as opposed to a more codified, evidence‐based and prescriptive approach seen in other professional domains (e.g. accounting, logistics planning and treating disease). In large part, this is because advocacy represents an intervention into complex, dynamic and highly contextual socio‐political systems, in which the strategies and tactics must be adjusted on a continual basis in light of rapidly changing conditions, reactions from actors and feedback.

In situations such as this, capacities and practices can be strengthened by sharing and analysing experiences in varying contexts, deriving general principles and learning to adapt these principles to new contexts. The following examples are provided to illustrate the insights to be gained by examining the practice of advocacy at a fine‐grain level of detail and sharing the principles more widely. Two of the cases described here focus on improving complementary feeding, which is a key issue for stunting prevention and has not received as much attention as breastfeeding in recent years (Piwoz et al. 2003).

Case study: Uganda

Context

Although high levels of stunting had been reported in Uganda in previous national surveys (up to 2006), little had been done to make stunting a national issue. Coordination mechanisms were sector led and had not succeeded to mobilise different actors to address the issue. Previous advocacy efforts had not been sustained nor reached the key policy‐/decision‐makers as they involved only technical staff.

In 2009, an Advocacy Working Group (under the Uganda Nutrition Society) was established at the request of the World Food Programme (WFP). The initial objectives were to establish a multi‐sectoral national and district coordination mechanism for nutrition, have food and nutrition legislation in place and generate increased resources for nutrition. An additional objective early in the process was to have the leadership for nutrition placed under one of the government departments, but this was abandoned based on unfavourable response from some of the departments. An advocacy concept paper was developed and milestones were defined by the Advocacy Working Group. The USAID‐funded Food and Nutrition Technical Assistance (FANTA) project trained national and district level advocates, including academics and (media) reporters, on the key targets, messages and channels to reach the different target audiences. A mechanism for review of the milestones was also agreed upon.

Achievements

The outcomes from this work cannot be fully attributed to the Advocacy Working Group because there were many other actors and activities taking place at the same time. Nonetheless, after 2 years of advocacy, there were some significant changes: (1) nutrition was explicitly included as a key issue in development and interventions were identified in the National Development Plan (2010–2015); (2) food security and nutrition became a key issue in the political manifestos of most political parties including that of the current government; (3) the Uganda Nutrition Action Plan was formulated and launched jointly by the President and the Prime Minister; and (4) a multi‐sectoral coordination mechanism in the Office of the Prime Minister was created by a Cabinet Memo.

Strategies/tactics used

The Advocacy Working Group, with technical support from WFP and FANTA, produced brochures for policy‐makers, a (generic) PowerPoint presentation on the quantified functional consequences of undernutrition on education, agriculture, health/survival and development. Workshops were organised in Kampala and in two of the sub‐regions for leaders to discuss these consequences. Newspaper articles were run with vivid case studies and a commitment note signed by key leaders was printed by main national newspapers immediately after the last elections. A documentary – targeted at leaders and donors – on the effect of undernutrition on development with a call for action (including coordination of nutrition interventions in the country) was aired in one of the TV stations in the country. Radio discussions with call‐ins were held in several parts of the country.

Additional strategies involved the use of champions and informal meetings. Over time the Chairman of the National Planning Authority agreed to be ‘the Champion for improved nutrition’, while the First Lady served as the patron of the Uganda Action for Nutrition. The Chairman was provided with essential data on the role of nutrition in the sectors of health, education, agriculture and development, was periodically briefed and had access to technical experts to respond to his questions or information needs. He convened meetings and motivated members of the nutrition community to develop the first multi‐sectoral nutrition action plan for the country, taking advantage of the global SUN movement. By virtue of his position, he convened meetings with key people in the government (e.g. Ministers) and convinced the President of Uganda to launch the Uganda National Action Plan 2011–2016. In addition, he represented Uganda at international forums on nutrition and SUN meetings.

Informal meetings (e.g. meal‐time and desk‐side meetings), site visits and seizing windows of opportunity can be powerful tactics. These were used when there was an outbreak of kwashiorkor in one of the districts and the media covered the issue for several days. A team of parliamentarians was taken for a field visit to the area to interact with parents of children with severe acute malnutrition in a local hospital. Parliamentarians were briefed on the importance of addressing undernutrition in their constituencies. Meal‐time meetings were held with selected parliamentarians who subsequently raised awareness in Parliament of the high levels of undernutrition.

Case study: Vietnam

Context

Maternity leave and workplace support, as key components of parental entitlements, are crucial to ensuring that babies are breastfed exclusively from the minute they are born to the time they are 6 months old, with continued breastfeeding up to 24 months or beyond. While over 98% of babies are breastfed in Vietnam, only 20% are breastfed exclusively for the first 6 months and a similar proportion (22%) continue to be breastfed up to 24 months (NIN et al. 2011). Women form a large part of the workforce (48%) in Vietnam (Ministry of Labour, Invalids and Social Affairs & ILO 2010), and returning to work is commonly cited by mothers as a barrier to optimal breastfeeding practice. Discussion and dialogue on the issue of extending maternity leave (along with extending the age of retirement for women in Vietnam) had been on‐going for some years. However, the process gained momentum in 2009–2010 when it was learnt that the labour code would undergo review and recommendations for change would be presented to the National Assembly's Standing Committee in 2011. In this context, UNICEF and Alive & Thrive (A&T)1 partnered with relevant government departments, including the Ministry of Health (MoH) and the Administration for the Protection and Care of Children of the Ministry of Labor, Invalids and Social Affairs (MoLISA), to initiate a process of dialogue and discussion to protect breastfeeding by extending paid maternity leave from 4 to 6 months.

Achievement

On 18 June 2012, Vietnam's National Assembly made a landmark decision to extend paid maternity leave from 4 to 6 months – a bold departure from other maternity leave policies in Southeast Asia. The decision passed with more than 90% of votes.

Strategies/tactics used

The process leading to this achievement was systematic, comprehensive and iterative, and the result of a close collaboration between a wide range of government, UN and non‐government agencies [Alive & Thrive (in preparation)]. The process began with the completion of Opinion Leader Research (A&T 2012) and stakeholder analysis in 2009–2010. These exercises helped identify key actors with the right influence and access to legislative audiences, and key messages for building consensus around policy decisions. Once this groundwork was complete, the broader strategy included four key components:

1. Developing and sustaining partnerships, including the media, to create pathways to policy change: While the initial partnership included departments of key line ministries plus UNICEF, WHO and A&T, the stakeholder analysis revealed the need to work with the Legislation Department of MoLISA as they were responsible for drafting the revised labour code. It was also deemed important to include the Vietnam Women's Union (VWU), the Vietnam General Confederation for Labour (VGCL), Vietnam Social Security (VSS) and finally the Institute of Legislative Studies (ILS) as follows:

   • The VSS played a critical role in completing financial analyses and endorsing that they had the capacity to cover costs for two additional months of paid maternity leave.

   • The VGCL played an important role by completing a survey that addressed the opinion of female labourers – critical actors in the process. The survey revealed that while 78% of female workers were aware of the importance of breastfeeding, 83% cited returning to work as the key barrier to optimal practice. In addition, the survey showed that 90% of female workers supported the extension of maternity leave over other parental entitlement options (Alive & Thrive, 2013).

   • The ILS – mandated by law to provide capacity development for members of parliament – facilitated access and information sharing with Vietnam's National Assembly.

2. The endorsement of the VSS, the survey results from VGCL and the support from ILS were crucial in building the case for and creating champions for policy change. As partnerships were developed, numerous print articles and media clips were placed during the process and events organised to generate public awareness and opinion on the issue. For example, at an event celebrating World Breastfeeding Week 2011, a banner was signed by over 300 mothers and other attendees in support of extending maternity leave.

3. A second strategy was to develop the evidence base in an ongoing manner to address key questions and concerns of partners and actors and to mitigate resistance: Evidence and arguments fell into four categories: (1) conventions and global recommendations (e.g. Convention on the Rights of the Child, WHO exclusive breastfeeding recommendation); (2) scientific evidence‐base (e.g. medical and scientific evidence on the benefits of exclusive breastfeeding); (3) socio‐economic and cultural aspects, including local, tailored research (e.g. to understand employee attitudes towards breastfeeding and maternity leave completed by VGCL); and (4) empirical experience and local application (e.g. experience from other countries with longer paid maternity leaves, how the law has been or will be implemented) (Alive and Thrive 2013).

4. A third strategy was to create compelling messages and strategic communication tools for use in a variety of settings and channels. Insights gathered through primary and secondary research and throughout the process were used to tailor messages to different audiences and a variety of print and electronic materials were developed and used, including booklets and policy briefs. These can be found on http://www.aliveandthrive.org or http://www.unicef.org/vietnam.

5. We conducted meetings, consultations and desk‐side briefings to build consensus among partners and targeted decision‐makers. Ultimately, any policy change process is dependent on actors coming to a common understanding of the issue. A variety of fora were used to engage actors and create ‘one voice’ on the issue. Champions, such as those within the VWU, UNICEF and the National Assembly, played a strategic role in helping to build consensus for extending paid maternity leave, resulting in an astounding 90% vote in favour of the extension. Resistance along the way was mitigated by addressing all concerns and arguments using evidence‐based information and research.

As noted, the process was iterative and emergent until critical momentum for policy change was achieved. Moreover, efforts to extend paid maternity leave were integrated with efforts to amend Decree 21 (Vietnam's iteration of the International Code) and the Advertisement Law. Both policy issues were presented under the umbrella of protecting the rights of the child and the role of legislators in protecting and supporting breastfeeding. This overarching umbrella provides the space in which to include several other related nutrition and health policy objectives (e.g. amendment of the health insurance law to include nutrition counselling and products) and it enables policy‐makers to view child health and nutrition as a holistic issue rather than a fragmented one.

Case study: Bangladesh

Context

National survey data in Bangladesh reveal that child stunting rates have been stagnant at roughly 40% over several years (BDHS 1995–2007) and there has been little change in the prevalence of exclusive breastfeeding or improved complementary feeding. Although nutrition has been cited as a government priority, there have not been specific or coordinated efforts to improve infant and young child feeding practices or to decrease stunting. The Alive & Thrive programme was designed to address these gaps in policy development and implementation.

Achievements

In Bangladesh, as in the other Alive & Thrive (A&T) countries, the programme model was designed as an integrated approach recognising the interplay among multiple interventions. Thus, the achievements in this case represent progress in developing and implementing multiple forms of strategic communication (advocacy, social mobilisation and behaviour change communications):

• A National Infant and Young Child Feeding (IYCF) Alliance was formed under the leadership of the Institute of Public Health Nutrition and several training and communication materials were developed.

• In the programme areas, behaviour change communications are targeting mothers and families with messages that support optimal feeding practices. The community component (conducted by several members of National IYCF Alliance) hires and trains health care workers for service delivery at the community level, with the focus on counselling to improve IYCF practices and reduce stunting. Counselling starts for women in the last trimester of pregnancy and continues after delivery until the child is 2 years old. Social mobilisation is conducted through structured meetings with community leaders and influential persons such as imams, teachers, local government officers, adolescents, doctors, traditional birth attendants and others.

• A popular animated cartoon video series ‘Meena’ for children was modified to include IYCF.

• There has been a high uptake of messages and widespread use of these by actors in a variety of programmes. This has benefitted from rigorous field testing of all information, education, and communication and training tools.

• Private sector marketing approaches were successfully adapted for social marketing of IYCF in collaboration with media companies.

• The combination of interpersonal counselling and mass media along with social mobilisation is having an impact on improving IYCF practices. Recent surveys show a rise in exclusive breast feeding and, in intensive program areas, in complementary feeding practices.

Strategies/tactics

A systematic approach was taken to inform advocacy strategies and tactics, including opinion leader research, stakeholder analysis. The opinion leader research focused on the perceived importance, understanding and saliency among the target audiences. The research results revealed that neither influential policy‐makers nor the highly educated, non‐medical participants had much knowledge of the current status of IYCF and malnutrition in the country or about its implications. This highlighted the need to increase the understanding of the role that IYCF plays in nutrition and, ultimately, in the cycle of poverty and to increase its profile among competing priorities. The research also revealed the opportunity for specific media engagement and capacity building work that had never been conducted on the issue, despite many years of investment. The media was chosen as the primary intervention as one of the paths to reach policy‐ and decision‐makers as a way to generate and build momentum around policy decisions.

Before starting the community component, the earlier policy achievements in IYCF were reviewed and summarised. The areas covered were: national policies and strategies, including the IYCF Strategy and Plan of Action; formation of a national committee for IYCF; the status of the Code of Marketing of Breast Milk Substitutes; and legislation protecting and supporting breastfeeding among working mothers. Also noted were the status of the Baby‐friendly Hospital Initiative; attention to IYCF in the Newborn and Reproductive Health strategies; and in/pre‐service education for health care providers. Progress was also assessed in relation to community outreach and support, development of information, education, communication and behaviour change materials and media exposure. These desk reviews were followed by formative research with mothers to assess the current infant feeding practices, with a special focus on complementary feeding. Gaps in knowledge and practices were identified, which contributed to the development of advocacy materials and media messages as well as programmatic communications.

A summary of key advocacy lessons from the three case studies combined is provided in Box 2. Some of these confirm well‐established practices (such as tailoring messages, working in partnerships, media and champions). However, some of them require additional attention in future advocacy efforts, such as clear, time‐planned goals and greater use of formative, ongoing and evaluative research.

Box 2. Overall lessons from the case studies.

1. Strong leadership, especially government leadership driven by experienced and senior persons is critically important. Sustained negotiation, persuasion and mobilisation skills are key leadership capacities.

2. Broad, effective partnerships are critical to ensuring that all issues are addressed and leverage comparative advantages within partnerships to produce results. It is also a must for harmonising various stakeholder initiatives. The partnerships create ownership by all actors as well as shared responsibility and shared credit.

3. Development of clear goals, time‐bound objectives, processes and action plans, also integrated in other processes, are necessary. The agendas/objectives may change and need to be further fine‐tuned to fit with new needs and opportunities as they arise.

4. Thorough situation analysis and research are needed beforehand to identify the local advocacy needs and gaps and to inform advocacy strategies, tactics and interventions accordingly. Opinion leader research, stakeholder analysis and other methods should guide strategies.

5. Research is needed not only at the initiation of the process but also throughout the implementation. Developing the evidence base in an ongoing manner to address key questions and concerns of partners and actors and to mitigate resistance should be planned in advance.

6. Development of advocacy messages, channels and methods should be tailored to different audiences, sectors and contexts. Creating compelling messages and strategic communication tools for use in a variety of settings and channels brings more results. Insights gathered through primary and secondary research are especially useful to tailor messages to specific contexts.

7. Media and champions can play strong role in advocacy. At the same time, informal meetings, consultations and desk‐side briefings are useful to build consensus among partners and targeted decision‐makers. Site visits also have proven to be powerful.

8. Allocate sufficient resources to develop and support research, materials and events.

9. Monitor and evaluate progress and assess risks to inform further planning and implementation and make adjustments as needed to ensure further improvement and success.

Case study: a practitioner profile

The foregoing cases from Uganda, Vietnam and Bangladesh represent high‐level summaries of several years of advocacy work, with brief descriptions of the country context, advocacy objectives, strategies and tactics, achievements and practitioner reflections on lessons learnt for advocacy. Even as high‐level summaries they are quite useful in revealing the strategies and tactics that may be successful in various contexts. They represent a source of highly contextualised, experiential and qualitative data that, if extended to a much larger range of countries and contexts, could help strengthen the art and science of nutrition advocacy.

A complementary methodology for generating such data is the practitioner profile (http://courses2.cit.cornell.edu/fit117/). Such profiles are created by conducting and recording an in‐depth, semi‐structured interview with one advocacy practitioner at a time, concerning a particular experience or episode and then transcribing and thematically analysing the interview. This method can be one of the strategic tools for designing and initiating advocacy in a given country as well as for advancing the knowledge, practices and evidence‐base for advocacy more broadly.

An illustration of the granular insights that can be produced by a practitioner profile is provided in Boxes 3 and 4. This profile was conducted with the director of a large NGO nutrition project in one country, with a particular focus on reducing stunting. The interview was recorded, transcribed and thematically coded as shown in the Boxes, with the themes emerging from the data rather than being defined beforehand. Some of the results confirm the lessons identified in the Uganda and Vietnam case studies (e.g. the importance of informal meetings, credibility, flexible goals and objectives), but the profile also identifies a larger set of themes and, by virtue of the quotes, provides a more grounded understanding and ‘feeling’ for the strategies and tactics in that context. Of particular interest is that there were relatively few themes related to messaging compared to those related to organising (Box 3) and adapting to the national context (Box 4). This is noteworthy because of the exceptional time and resources that organisations devote to message development and, by comparison, the limited systematic training, skill‐building (and scientific literature) related to organising and adjusting to the national culture and context.

Box 3. Insights from practitioner profiles: organising.

Theme	Illustration
Networking	‘The importance of these social networks, getting to know people, just establishing personal contacts. You know, those are very important everywhere, I think particularly in some of these settings.’
Informal group	‘They referred to it as national coalition, but it is not really a formal entity at all. It is just a group who meets about every quarter, and who put together the national behavior change communications plan because the draw was that people wanted to have harmonized messaging. So this group was born, I think about 15–20 organizations and entities who continue to want to meet and compare notes and see how they're doing. We never said this was an official group. We never claimed it was anything. So it was not a threatening entity at all’.
Expanding the group	‘So right from the beginning it was finding who's on my side who is on the other side and who is on the fence? What will it take to move people one by one to our side?’
Formal group	‘[Initially some others] wanted to work mainly with the pre‐existing and formally recognized non‐governmental nutrition working group. And that's sort of the first reaction people have is, “Oh, we'll just work with the nutrition working group,” but that group does not involve government entities and is not a task oriented group in terms of taking steps to implement programs, it is simply a place to exchange information.’
Issue negotiation within the nutrition community	‘The first thing is to establish that nutrition is really important, again and again. And then within nutrition our particular issue is up against wasting and severely malnourished rehabilitation, micronutrients and maternal nutrition, and so on. You don't want them to say [about you]: “Oh these people have come here with a single agenda so, if you invite them they'll only speak about this.” So I was challenged over and over to make presentations on maternal nutrition and on anemia, etc. So that then one has the validity to be more credible and convincing about our issue and say, “Look, I've looked at the whole thing. This is where my issue fits in and why it is the most critical and do‐able right now.” ’
Sharing and reciprocation	‘It was like, “send me the latest references on hand washing before feeding children”, or “send me your power point presentation, I need to make one, I'm just going to use your slides”, or “have you seen the latest operational plan which is not yet public? I really need your feedback, can you do this for me?” or from various donors “Okay, I'm going to see somebody high up in the ministry, so why don't we say the same things so they hear it from 2 different people?” ’

Box 4. Insights from practitioner profiles: the national context.

Theme	Illustration
Credibility	‘We were the outsiders so we had to establish ourselves and people had to find value in what we had to offer; but once that developed and they test you to see if you're going to come through, once you're over that stage then it became quite easy’.
Scaling up	‘What is the role of advocacy in scaling up? To engage all those partners and people and forces at those intermediate and closer to the ground levels. You can't reach tens of millions of people yourself so you have to give it away to others. But then you make strategic decisions about how many people, how fast, and how easily and affordably can somebody take it forward for you; and then marketing and promoting that so they'll pick it up has been really where most of the advocacy has gone’.
National and cultural differences	Transparency: ‘A lot of stuff is going on at every meeting, they are not necessarily sharing information, lack of transparency, people holding things close to their chest, so you know, not necessarily wanting to share.’
	Taking Credit: ‘The other thing in this region is that the less you take credit, the more credit you get. And if you say “We did this work” and we put our logo on it, it's a loser. You have to do the opposite. You have to go out of your way to say, “I didn't do this. This is all your work. Remember? It was your idea!” All the time. In other countries, yeah, they can be much more straightforward and open: if you do it, you get credit. What the heck? You know? Don't be shy. And some donors demand credit.’
	Scientific credibility: ‘Having the scientific and technical side correct is very important. People here are very nitpicky and if they find any flaw in your science or findings they will rip you to pieces. In other places I've worked people don't care so much; it just has to make sense, it has to be down to earth and practical’.
Building government ownership and capacity; handing over	‘We very carefully cultivated a small core group that included the government focal point and institute director. [S/he could] call everybody together to develop harmonized messages, so people are not saying different things. [Before that] we always were being asked to present in meetings and conferences and so on. [But now] it is being led by the Director. And now this director with whom we've been working for 2 years has emerged as the front runner for higher leadership’. ‘At the last meeting we said we are not going to host these meetings. We are not even going to write the letter of invitation for the director. So we handed it over to another NGO. They are another one of our close core allies, so they took it over, they funded it, they put together this banner, they created the agenda, they issued the letters, did the follow up, all that stuff. So, we're trying to sort of get out of it more and more.’
The work: Meetings, visitors, transitions, vigilance, dynamic, opportunistic	‘It's meeting with people who are either coming to our office or going to somebody's place or to any of the other group meetings going on around town. And a lot of time in the field now, more and more out in rural areas, east, west, north and south. So that takes up quite a bit of time. We get a lot of people coming from overseas, a lot of traffic, a lot of people come here from various organizations. So it is chaos in that there are so many people who are doing something related to our area, or should be at any given time, and we're always finding some new group that's doing something else somewhere or who is interested, but maybe not producing correct materials or messages, so we have to deal with that. There's also a lot of transition. There are several people who came when I joined who have already left. Their replacements are coming in and now we have to start all over again with them. And then there will be a new issue suddenly surfacing and you don't know how real it is or how widespread, so you need to go out and try to figure that out and the strategy to deal with it. It's just being terribly opportunistic and you have to be on point and the message has to be very clear. So that's where most of the energy or effort in advocacy has gone.’
Stable goals with nimble strategies	‘The thing that doesn't change is at the end of 5 years we have to be at scale, we have to produce, and it has to be in a sustainable way. You have to always look for targets of opportunity but it is really very specific objectives and goals. The end point doesn't change’.

From policy elites to broader public engagement

Advancing infant and young child nutrition, and particularly the stunting prevention agenda, is socio‐politically complex. As noted, there is a vast array of actors involved in the development and implementation of nutrition policies and programmes, with varied viewpoints, perspectives, mandates and approaches. There are differing views as to what needs to be done, what works and what should be the priorities. There is urgent need to address this ‘fragmentation’, by building a wide‐scale and genuinely shared understanding of the stunting problem, its consequences and ways to tackle it. The cases presented above provide valuable insight concerning some of the strategies and tactics needed to accomplish this.

While this shared understanding, mobilisation and commitment among policy elites is crucially important, a comprehensive and sustainable strategic communication initiative must go beyond this. Due to the large number and varied location of actors that make or influence decisions relevant to food, health and care, a more extensive, intensive and creative interaction with society at large may be needed. Such engagement can help building broad awareness, norms, social commitment and political accountability for reducing and preventing stunting. However, the engagement of society at large has received far less attention in nutrition advocacy initiatives, as ‘the public’ or communities are primarily viewed as targets or objects of behaviour change communication campaigns rather than change agents in their own right. Without strong and broad public recognition and concern for the stunting problem, political momentum for advancing nutrition may decline, and within a relatively short period.

The indicators for measuring social change communication and mobilisation developed by the Consortium for Communication for Social Change (http://www.communicationforsocialchange.org) can be adapted to the nutrition and stunting prevention context and offer insight into what would be required for a broad strategic communication initiative along these lines:

• Is there expanded public and private dialogue and debate on the consequences of childhood stunting?

• Is there increased accuracy of the information that people share in the dialogue/debate about the causes and consequences of childhood stunting?

• Do planned communication initiatives support people who are centrally affected by undernutrition to voice their perspectives in the debate and dialogue?

• Is there an increased leadership role being played by people disadvantaged by the issue of chronic undernutrition?

• Do debates and discussions on the reduction and prevention of childhood stunting resonate with major issues of interest to people's everyday interests?

• Do nutrition communication initiatives link people and groups with similar interests who might otherwise not be in contact?

These questions begin to suggest the goals and objectives for a broad and inclusive national strategic communication initiative for advancing the nutrition and stunting prevention agenda. Such an initiative would require a mix of different communication approaches (e.g. policy advocacy, communication for development, social mobilisation and behaviour change communication), rather than any one approach, and these should be planned, integrated and resourced as such. The advent of modern communication technologies is rapidly expanding the possibilities for broader public engagement, as illustrated in Uganda's U‐Report Initiative (Box 5). There is a need for global and national nutrition communities and leadership to embrace this broader view of advocacy and social change.

Box 5. Engaging the public: Uganda's U‐report initiative.

While a number of options exist for understanding public opinion and perceptions, they are more in the nature of monitoring or tracking trends through local and national news media, Internet and website traffic, and the occasional survey or focus group discussion. Although quite useful, most of these methods have not really offered an easy, regular, large‐scale and cost‐effective process for ‘listening through dialogue’. However, new opportunities exist through innovative uses of mobile telephony and strategic partnerships with telecom service providers. One such successful example is UNICEF Uganda's U‐Report initiative.2

In 2010, UNICEF Uganda trained 300 Boy Scouts from across Uganda as ‘social monitors’, and tasked them with reporting via SMS directly from their communities on issues important to their region. The trained adolescents then trained and signed up more social monitors, virally building a network of community level reporters. Simultaneously, UNICEF partnered with other NGOs such as BRAC Uganda, the Girls Education Movement, World Vision, as well as frontline workers of the government. Today, there are nearly 175 000 U‐reporters registered with UNICEF. This base of U‐reporters, by responding to weekly poll questions and spontaneously sending information or asking questions of immediate relevance, has catalysed a national level conversation on development issues starting from the grassroots.

U‐report is built on RapidSMS, an open‐source software framework (developed through a collaboration between UNICEF and Columbia University) for developing server‐side applications that work with any phone currently on the market. It is completely free, relatively easy to download, configure and quickly deploy at the grassroots. The U‐report ‘network’ generates systematic, light weight, low cost and real‐time information directly from the community level, using crowd‐sourcing methodologies.

The U‐reporters are providing with a ‘pulse’ from every area in the country. In mere minutes, they can find out how many youth are within a 10‐min walk of safe water, what issues are important to them, and where the disparities are the greatest. U‐report has allowed citizens to speak out on what is happening in their communities (e.g. new disease outbreaks) and amplify their voices through local and national media (e.g. opinions and observations on government programmes and activities). It allows local leaders to send alerts to key actors about the issues their constituents are facing (e.g. stock‐outs of medicines); and it allows information to be fed back to the U‐reporters (e.g. about health protection measures) so they are empowered to work for improvements in their localities themselves. Information is used to build a real‐time ‘accountability chain’, to ensure that bottlenecks are being addressed in a timely manner. It is also forwarded to high‐level policy‐makers and political leaders. The U‐report concept and system is now spreading to other countries in the region and is being used for a range of innovative actions, including nutrition surveillance and monitoring of child growth.

The way forward

The purpose of this paper is to strengthen the understanding and the practice of advocacy in relation to nutrition, in support of the current global and national efforts to reduce stunting and other nutrition problems. While there is a substantial grey and published literature with useful frameworks, principles and recommended practices for advocacy (Cohen et al. 2001; Christoffel 2000; Figueroa et al. 2002; ACTION Project 2007; Klugman 2011, Stachowiak undated), there has been relatively little systematic study in relation to stunting, or chronic undernutrition more broadly. The brief case studies presented in this paper make a contribution to that literature and illustrate the value in undertaking additional and more detailed studies in other contexts. However, in contemplating ‘the way forward’, this focus on the practice of advocacy needs to be broadened considerably. This final section outlines a number of issues needing attention in order to strengthen the practice, impact and sustainability of nutrition advocacy to prevent stunting.

Big picture issues

This paper and the others in the Supplement have focused on stunting as the central problem. However, stunting is but one of many issues seeking attention and resources in a given country and strategic decisions on how to frame the problem must take account of this competitive environment. Box 6 illustrates this competitive environment based on the country experiences described here and broader experiences (Milio 1990; Pelletier 2000; SCN 2002; Heaver 2005; World Bank 2006; Pelletier 2008; Natalicchio et al. 2009; Pelletier et al. 2012). This partial compilation highlights several important features. Firstly, stunting can be framed in many ways, depending upon the policy discourse, political and bureaucratic dynamics, windows of opportunity, partnership possibilities and other considerations. Secondly, competition can and often does exist even within the broader nutrition community. Thirdly, a great advantage of stunting or nutrition in general is its tremendous malleability or versatility with which it can be framed or constructed. All social and policy issues are socially constructed by design or default (Vaughan & Seifert 1992; Rochefort & Cobb 1994; Schneider & Ingram 1997; Stone 2002; Fischer 2003), but the multidimensional causality and consequences of stunting offers an unusual opportunity to align it with many other issues rather than compete with them in a zero‐sum fashion. This has been used to a great advantage in a number of countries (Pelletier et al. 2011) and seen most clearly in the Vietnam case where 6‐month maternity leave was framed as an investment in future human resources of the country.

Box 6. The competitive context for stunting advocacy.

Common sectors	Illustrative competing interests and priorities	Common narratives that favour competing interests	Potentially effective external frames for stunting advocacy
Within nutrition	Severe acute malnutrition (SAM), micronutrient malnutrition (MM), chronic diseases, health sector interventions, multi‐sectoral approaches, private sector solutions	Urgency of SAM, high cost‐effectiveness of MM interventions, complexity of multi‐sectoral approaches, efficiency of market‐based approaches	Cumulative burden of stunting greater than SAM and preventive approaches must accompany curative; optimal early nutrition helps prevent chronic diseases, multi‐sectoral approaches build long‐term capacity and sustainability
Within health	Child survival, neonatal survival, maternal and reproductive health, HIV, malaria, immunisations, non‐communicable diseases	High population burden, differentially affects children and the poor, evidence‐based cost‐effective solutions exist, health as a human right	Malnutrition has the highest burden of all these diseases among children, accounting for half of all child deaths, affects cognition and economic growth and low cost interventions can reduce national health care spending
Within agriculture	Maximise aggregate food production, productivity, high value export crops, value chains, political patronage	Agriculture as an engine for economic growth growth, rural incomes and employment, food security, lower food prices and nutrition improvement	Abundant evidence demonstrates that agriculture must be planned and implemented with a nutrition lens and must be complemented with other sectoral actions, if it is to enhance nutrition and avoid harm
Within labour	Minimise regulatory burdens on private sector, protect private sector interests	Promote efficiency and competitiveness in the private sector; avoid unintended consequences of regulation	Rights of the child and international norms; evidence of benefits of breastfeeding for child and maternal health, worker productivity and economic growth
Within finance	Allocate resources to established sectors according to political influence and/or narrowly calculated returns of investment	Given severe budget constraints, allocative efficiency and investment in public goods is the most sound public policy	Evidence and major international organisations support improving nutrition as an investment in human capital, social and economic development and reduced health care spending, with high returns
Among elected officials	Political patronage, electoral considerations and the desire for visible benefits (resulting in economic and development policies that harm or fail to improve nutrition)	Diverse narratives claim benefits for various social groups or public purposes and avoid discussion of opportunity costs, inequities and inefficiencies	Malnutrition as a moral, human rights, development and equity failure; can be a component of political platforms for promoting equity, social inclusion, investment in human capital, protection of human rights and social responsibilities of legislators

It follows that the circumstances in a given country may favour that ‘stunting’ be framed broadly (e.g. in relation to poverty reduction, equity and/or food security), in a middle range (e.g. in relation to IYCF, access to health services or water, sanitation and hygiene) or in a narrow range (e.g. IYCF alone). These decisions concerning the framing and inclusiveness of the problem will have a large bearing on the overall advocacy agenda, including scope, scale, architecture and issue focus. Specifically,

• sectoral scope refers to the range of public and private sectors and actors with whom to engage;

• administrative scale refers to the priority given to policy elites, system level actors (including implementers), sub‐national levels, communities and the public at large;

• institutional architecture refers to the formal and informal ways in which the advocacy actors engage and collaborate with one another; and

• issue focus refers to the framing and inclusiveness of the problem (e.g. undernutrition, stunting, severe acute malnutrition, micronutrients, food security, dual burden).

Despite the enormous strategic importance of issue focus and framing decisions, experience shows that these can be very difficult for the nutrition communities to agree upon (Garrett & Natalicchio 2011; Hill et al. 2011; Hoey & Pelletier 2011; Pelletier et al. 2011). The disagreements arise because of the differences in interests and perspectives among the nutrition actors and because there are technical (scientific), administrative and political dimensions to these decisions (Menon et al. 2011). Although these decisions related to framing and issue focus are complex and difficult, they are not intractable. They require strong collaborative leadership and strategic capacity and some positive examples exist in global health and nutrition (Shiffman 2007; Shiffman & Smith 2007; Garrett & Natalicchio 2011; Pelletier et al. 2011). Achieving this cohesion and agreement within nutrition policy communities is not something that comes naturally and will require forms of capacity‐building that are not common at present (Pelletier et al. 2011, 2012).

Capacity issues

It is common for capacity to be interpreted narrowly in terms training and individual capacities, e.g. the knowledge and skills to be a tactical and persuasive advocate. That certainly is one element of capacity in the context of nutritional advocacy but the needs are much greater. As indicated above, one of the most important capacities is at the level of the nutrition community: the ability to build and maintain effective working relationships, a coherent internal frame and cohesion within the advocacy coalition, i.e. strategic capacity (Pelletier et al. 2011). There also is a need for the capacity to plan and implement multi‐faceted advocacy and strategic communication that address policy elites, system actors (e.g. implementers), sub‐national levels, communities and/or the public at large, as appropriate for the context. This, in turn, requires that national or regional institutions possess the capacity to train and support these skills; that a set of advocacy competencies have been defined, along with curricula and models appropriate for pre‐ and in‐service training; and that on‐the‐job coaching, support and/or communities‐of‐practice are available. A related need is for a practical methodology for conducting an assessment of national capacities, needs and opportunities. And finally, since the nutrition community in a country typically involves members from government, donors, NGOs, civil society and academia, there is high member turnover and a need to ongoing recruitment, relationship‐building, orientation to the goals, strategies and norms of the advocacy coalition and leadership renewal.

Monitoring, evaluation and research

Advocacy initiatives need to be monitored and evaluated, as does any other development activity, but this has proven to be a challenging undertaking because of the nature of enterprise. Advocacy typically involves long time frames, many actors interacting with each other and the environment in complex ways, difficulties in attributing outcomes to advocacy activities, unpredictable and uncertain results, the need to frequently change objectives and strategies based on emergent dynamics and the usually poor documentation of inputs, outputs and outcomes (Mansfield 2010). That said, there now are several thoughtful frameworks that can be used for designing the monitoring and evaluation systems for advocacy and there is a need to develop prototypes and case examples for a wide range of advocacy initiatives and contexts (Guthrie et al. 2005; Weiss 2007; Mansfield 2010). For instance, the M&E approaches for a multi‐sectoral advocacy programme at national and sub‐national levels would look quite different from those tailored to strengthening national iterations of the International Code or advocacy for improved parental entitlements.

Several forms of research are needed to assist the design and implementation of advocacy initiatives and to assist capacity‐building programmes. As illustrated by the A&T project in Ethiopia, Bangladesh and Vietnam (http://www.aliveandthrive.org/our-approach) this may include: formative and opinion leader research at an early stage of planning, to identify prevailing knowledge and beliefs among a potentially wide range of audiences (e.g. policy‐makers, implementers, professional groups, civil society actors, journalists); local, national or international data relevant to the focal problem or targeted policy (e.g. paid maternity leave); survey data on the views, preferences and priorities of the beneficiary population (e.g. employed mothers) and data for populating the PROFILES advocacy tool (Burkhalter et al. 1999). Given the central importance of building and maintaining cohesion and agreement on internal and external frames within the advocacy coalition, another important category of research could involve the coalition members themselves. For example, techniques such as practitioner profiles (http://courses2.cit.cornell.edu/fit117/), Q methodology (Brown 1980) and network mapping (http://netmap.wordpress.com/) could be used in a participatory manner for the coalition leaders to both gather insights into the perspectives, relationships and experiences among members and to feed the findings back to the members and stimulate reflection and discussion aimed at convergence. A variety of special studies may be necessary in the context of operations research (e.g. to assess and assist implementation of advocacy activities at sub‐national levels); as part of the advocacy evaluation (e.g. interviews with policy actors to assess their views of how and why a specific policy change did or did not happen in a given case and relate this to the advocacy efforts deployed in that case); and case studies or practitioner profiles of specific advocacy activities, episodes or programmes (such as those presented in this paper) to inform and improve future advocacy strategies, tactics and practices.

These M&E and research activities in support of a national advocacy initiative have their own capacity requirements and these should be addressed in the advocacy capacity‐building programme.

Resources

Advocacy activities tend to be under‐financed even with the highly targeted advocacy efforts that have been deployed in the past (i.e. targeted to policy elites). This is unfortunate since the return of investment from a well‐implemented advocacy effort can be substantial and the resources required are quite small compared to the resources invested in large‐scale intervention programmes. If the administrative scale of advocacy is to be broadened, to include sub‐national levels and society at large, the resource needs will be greater but so too will be the returns in relation to well‐implemented actions and a sustained focus on nutrition. This perspective deserves attention from global partners committed to stunting reduction.

A related problem is that financial resources are often not budgeted separately within programmes or organisations and typically there is a need for several organisations to contribute financial resources to the effort. However, for bureaucratic reasons (e.g. different per diem rates and other financial norms), it is very difficult to pool such resources. These seemingly mundane bureaucratic matters can become major impediments to nutrition advocacy and these problems will only increase as the scope and scale of advocacy increases. Again, creative reforms or agreements from the global level or agreements among partners at the country level would make a significant difference. Related to that, the development of practical advocacy costing models, based on country experiences, would greatly facilitate efforts to mobilise financial resources from governments and their partners. These should include not only resources for the advocacy initiative itself but also for training, building the training capacity, coaching, monitoring and evaluation of the advocacy and related research.

In addition to financial resources, there are important considerations related to human resources for advocacy. A well‐planned, medium‐scale advocacy initiative to address stunting (with multi‐sectoral and multi‐level components) will include some tasks that require dedicated and specialised staff (e.g. mass media, materials production, journalist training, training of sub‐national staff). Typically, these are drawn from donor, NGO or private sector organisations that partner with government staff in the implementation. In addition to these specialised tasks, advocacy initiatives that target policy elites typically require substantial investments from more senior staff, such as country directors or managers of country programmes, who are typically required to perform these functions in addition to their other administrative and programmatic duties. Their involvement is essential, for reasons of technical credibility, their embeddedness in the national nutrition community and access to policy‐makers and/or implementers, but the level of effort required of them is often underestimated. Their involvement can be facilitated by ensuring that their job descriptions include a formal and appropriate level of effort for advocacy and by allocating some of the strictly managerial or technical tasks to others in the organisation.

The central role that donors and NGO staff currently play in advocacy may be the most practical arrangement in the short/medium term, but in the longer term, efforts should be made to strengthen the advocacy capacity of government departments and other national organisations. This is essential if the goal of country‐owned, country‐led approaches is to become realised. In addition, much of the advocacy that currently takes place in a country occurs within the government, in conversations that do not involve external partners. Thus, a much greater investment is needed to develop capacity within the government itself as well as within national institutions (e.g. research centres, think tanks, academia) that are in a position to advice government.

Conclusion

The rapid and sustainable reduction of stunting on a national scale is a large undertaking involving nutrition‐specific and nutrition‐sensitive actions within multi‐sectoral policies, programmes and society at large, from national through community levels. These actions will only happen, and will only be sustained, in the presence of broad and effective advocacy combined with other forms of strategic communication. The cases reviewed here, and experience elsewhere, reveals that concerted, well‐planned and well‐implemented advocacy can bring significant achievements, even in short period of time. In light of the global and national attention being given to stunting reduction through SUN and other initiatives, there now is a need for much stronger investments in strategic and operational capacities for advocacy, including the human, organisational and financial resources for the advocacy and strategic communication themselves, as well as for monitoring and evaluation, supportive research and institutional capacity‐building. An important first step is for a global working group to develop and support a costed strategic plan for building these capacities at the national, regional and global levels.

Source of funding

The Bangladesh and Vietnam case studies are based on the Alive & Thrive Initiative funded by the Bill and Melinda Gates Foundation. The Uganda case study is based on a FHI 360 project funded by USAID.

Conflicts of interest

The authors declare that they have no conflicts of interest.

Contributions

Pelletier led the conceptualization, drafted several sections, integrated each co‐author's sections and managed the collaborative process. Haider, Hajeebhoy and Mwadime drafted the country case studies. Mangasaryan drafted portions of the Introduction and the case study summary. Sarkar drafted the U‐Report summary, public engagement and communications sections. All authors commented upon and approved the final content.