Improving childhood nutrition in Indonesia through an innovative behavioural change programme

Preventing malnutrition is meaningful to me. In Indonesia, in 2018, 31% of children under five were stunted [1]. As a trained medical doctor working in one of the poorest areas in Indonesia, I saw first-hand that emergency assistance and one healthy meal per day schemes did not go far enough to change people's behaviour. Once the intervention was gone, so were the new habits. I wanted to find another way to prevent illnesses and serve the community. Learning from HIV initiatives focusing on changes in behaviour, I became interested in the intersection between behavioural change and nutrition.

How parents feed their children is influenced by socio-cultural factors in Indonesia. We have a strong communal culture, where status and reputation affect how parents feed their children under two years old, who are referred to in Bahasa Indonesia as "Bawah Dua Tahun" or “Baduta”. With this in mind, Global Alliance for Improved Nutrition (GAIN) developed The Baduta programme in 2013 [2]. This programme uses an approach based on behaviour-centred design which was developed by the London School of Hygiene and Tropical Medicine to improve maternal and infant nutrition [3]. As senior programme manager, I have been involved in this project from the design phase in 2014; now, it has been adopted and scaled-up in more than 50 districts in Indonesia.

The programme targets four behaviours: exclusive breastfeeding, complementary feeding, eating healthy snacks and encouraging nutrient-rich diets for expectant mothers. It uses emotional demonstrations or ‘emo-demos’ and is complemented with health system strengthening activities, including the revival of the Baby Friendly Hospital Initiative, a global effort launched in 1991 by WHO and UNICEF to implement practices that protect, promote and support breastfeeding in maternity facilities.

The ‘Emo-demos’ use elements from evolutionary psychology, commercial marketing, and neuroscience, to engage mothers and trigger their different emotions such as nurture, love, kinship in fun and creative ways, rather than telling them what to do. Translating the nutrition information into relevant analogies of everyday situations, removing jargon and using simple language is leading to improved understanding in a fun and relaxing way and retains the messages longer than an instructive format. The intervention was an improvement of the existing education/counselling sessions for mothers on infant and young child feeding practices, that usually just instruct mothers on what to do in one-way communication with limited engagement. During this time, the breastfeeding rate has increased by 14% among mothers with infants less than six months, and consumption of iron-rich foods has increased 12% for children 6–23 months [3].

Having treated patients with diverse backgrounds and having worked in some of the poorest areas of Indonesia, I am proud that mothers, regardless of educational or social background, can relate to the programme. This fostered understanding makes it widely accepted across different cultures. I joined the field of nutrition to prevent illnesses and help more people. As this pilot programme [4] indicates positive effects on infant and young children's feeding practices, it is being scaled up to more areas in Indonesia, showing its replicability in different contexts, and that behavioural centred design has the potential to contribute to ending malnutrition.

Declaration of Competing Interest

None to declare. AM is alone responsible for the views expressed in the letter.