In a group setting, before rolling out the sick child consultation solutions, providers engage in reflection activities promoting them to reflect on Infant and Young Child Feeding (IYCF) guidelines for feeding sick and recovering children. They also  learn how to advise caregivers on the importance of food quantity during illness and recovery and the need to encourage children to eat when appetite is limited. 

Relevant Design Objectives

• Reset intentions for quality counseling during sick child consultation
• Boost providers’ confidence to help

In Practice

In practice, providers imagine a typical sick child consultation and what they say to the caregiver. Providers are prompted to notice that they often do not counsel carefully on feeding during sick visits, and to connect the remainder of the activity to a concrete scenario in their own practice. Providers reflect on IYCF guidelines for feeding sick and recovering children and on the challenges caregivers may face in putting those guidelines into practice. Providers learn how to counsel caregivers on the importance of food quantity during illness and recovery and the need to encourage children to eat when appetite is limited. A feeding prescription, counseling aids, and/or reminder stickers are introduced into providers’ counseling to integrate this guidance. Providers practice using the new materials and reflect on the consultation they discussed at the opening of the activity to think about what they might do differently.

The feeding prescription, counseling aids, and reminder stickers are described in greater detail later in this session.

A “prescription” for feeding is integrated into an existing consultation form next to the medical prescription prompting health providers to discuss feeding during all sick visits alongside medical care.

Relevant Design Objectives

• Elevate importance of feeding
• Motivate providers to counsel consistently

In Practice

In practice, during a sick child consultation, after prescribing medical treatment, providers use the notes printed in the feeding box to counsel the caregiver on how much to feed during and after illness. Providers can write down any additional notes on how to feed the child.

Two additional pages may also be  integrated in existing nutrition counseling aids, including a page to cover feeding during and after illness and another page for coaxing when appetite is limited.

Relevant Design Objectives

• Train and motivate providers to counsel consistently 
• Boost providers’ confidence to help caregivers
• Emphasize the importance of quantity over specific foods

In Practice

In practice, during sick child consultations, providers emphasize the benefit of food quantity for sick and recovering children. While providing feeding counseling to caregivers, providers refrain from recommending specific foods that may not be available. Counseling on quantity and discussing with caregivers what foods they can access prevents discouraging them by avoiding mention of what they cannot offer the child. When limited appetite presents a barrier to feeding the child, providers counsel caregivers on encouraging the child to eat. Caregivers often see a young child’s appetite as immovable, but providers are trusted authorities who can help them to re-envision what is within their control. Providers offer concrete tactics for encouraging a child to eat.

A small sticker is placed on items that providers see during consultations, reminding them of the key message that every bite counts. Providers see the sticker and it cues them to counsel on feeding during and after illness, to focus on quantity and reminding caregivers that every bite counts.

Relevant Design Objectives

• Identify achievable improvements
• Emphasize the importance of quantity over specific foods

In Practice

In practice, health providers who conduct sick child consultations receive a reminder sticker with instructions to place it in a strategic spot where they will see it during consultations. During sick child consultations, the provider sees the reminder sticker. The reminder sticker cues the provider to emphasize, “Every bite counts.”

Define: Why we do it and what it looks like

The first step is to define the problem you aim to solve in terms of specific behaviors. This offers a roadmap for what the eventual solution needs to achieve.

You may have many hunches about what is causing the problem, but it is important to remove those assumptions from your definition of the problem and open yourself up to the possibility of other causes, including those you might not expect.

Problem Definition Examples: Weak vs. Strong

Flip each problem definition card to reveal its weakness/strength

Define: How to prioritize among behaviors

For nutrition programs, there are many possible behaviors that might improve health and nutrition outcomes for children. They can range from farming practices, to hygienic food preparation, to infant and young child feeding practices, to accessing health services. Within each of these categories, there are many possible behaviors. While targeted programming that addresses specific behaviors is most impactful, it can be challenging to decide what to prioritize.

A tool developed by USAID Advancing Nutrition guides programmers to select behaviors based on the following considerations. Flip each consideration to learn more.

Behavior Gap

Relatively few people in the target population are currently practicing the behavior.

Potential to Impact Results

Addressing the gap will contribute greatly to program outcomes.

Potential Ability to Practice

The likelihood that the population will be able to practice the behavior, given their available resources, time, interest, and social support.

Case example: Define

In the DRC case example, the team identified two inter-related problem statements:

• Caregivers do not continue to breastfeed and feed their children aged 6-23 months during illness
• Caregivers do not give supplementary food to their children aged 6-23 months during the 2 weeks after illness.

In this example, we use the previously-presented prioritizing behaviors exercise to filter among several nutrition behaviors, and draw down lists of prioritized behaviors that the project would be working on. 

These behaviors were considered alongside five other complementary feeding behaviors, using the tool for prioritizing multi-sectoral nutrition behaviors.

Behavior Gap

Large gap between current practice and the optimal feeding behaviors. Prior research in the DRC suggested that most children receive less or no food during illness, few children are encouraged to eat during illness, and only a very small proportion of children receive more food than usual after illness.

Potential to Impact Results

Great potential to impact health and nutrition outcomes by improving the behavior, as childhood illness is very common.

Potential Ability to Practice

Relatively higher ability to practice compared to other complementary feeding behaviors, in a setting where families’ access to specific foods is routinely constrained.

Diagnose: Why we do it

The next step of the behavioral design process is diagnosis: identifying the most relevant drivers of the behavior of focus. As discussed earlier, context plays an extremely important role in behavior. The aim of diagnosis is to identify specific features of the context that influence the behavior, and that a solution might modify. Diagnosis offers direction on what a solution needs to achieve to successfully change behavior. 

Think back to the example of the pedestrian overpass you saw earlier in the session. Here are a few (of many) possible reasons why people might not be using the overpass:

• People might have been crossing the street here since long before the overpass was built. They might cross in the same place by habit, and it has not occurred to them to cross in a different way.
• The staircase of the overpass is dark and the steps are sometimes slippery. People might think more about these risks than the risk of crossing in front of traffic.
• Many other people are crossing in front of traffic. It might be tempting to follow the crowd.
• The overpass might not be inclusive for everyone. People might have physical challenges to get on the overpass. 

What would each of these imply for what a solution needs to achieve? Can you think of any other reasons people might not be using the overpass?

Diagnose: What it looks like

Diagnosis includes:

1. Generating hypotheses about what might be driving the problem. Prior behavioral science research offers clues about how people might respond to their context in predictable ways. It helps us predict, for example, when and why people might not make an active choice about something, or overweight certain options, or be deterred from following through on their intentions. 
2. Investigating hypotheses in-context. While prior research offers useful clues, it cannot tell us what is most relevant in the context where we are working and for the specific behaviors we are focused on. We investigate hypotheses through conversations with the actor whose behavior the program seeks to influence and with others who may have a different perspective on that behavior, and through observations of the physical settings and processes relevant to the behavior.
3. Analyzing the evidence, drawing conclusions about which hypotheses are confirmed, refuted, or changed, and identifying the barriers that are most relevant to your problem.

Because diagnosis is rooted in behavioral science research, completing it successfully requires knowledge of that research. In Session 2, you will learn about 3 behavioral science concepts that are particularly relevant to many nutrition challenges : scarcity, limited attention and confirmation bias. We will also point you toward other resources where you can learn more about behavioral science.

Case example: Diagnose

Breakthrough ACTION and USAID Advancing Nutrition investigated hypotheses about what might impede caregivers from continuing to feed young children during illness and feeding them more after illness through conducting 58 qualitative interviews with caregivers, family members, health workers, and other community members, as well as observations of clinical consultations. The following is a summary of diagnosis findings and their implications for programming (Breakthrough ACTION & USAID Advancing Nutrition, 2022).

Behavior insights and implications for programming

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Flip each behavior insight card to reveal the implications

Poverty and scarcity impose practical constraints and a cognitive burden

Identify achievable improvements

Refocus attention on what caregivers are able to do

Child feeding needs are not addressed during sick visits due to divided attention and doubts

Elevate importance of feeding

Train and motivate providers to counsel consistently

Boost providers’ confidence to help

The focus on quality over quantity obscures the benefits of feeding greater amounts of available foods

Emphasize the importance of quantity over specific foods

Guide health workers and caregivers to recognize locally available and affordable options

Perceptions of good and bad foods further limit the choice set

Counter misconceptions about which foods are good for children over six months

Teach baby-friendly preparations of foods that are not commonly considered

Deference to limited appetite leads to missed opportunities to coax

Inspire caregivers to view their child’s appetite as moveable

Build skills and confidence to overcome limited appetite

In Session 2, we will return to these findings and you will learn more about some of the specific behavioral science concepts that underlie them. You will also practice thinking about how those concepts might translate to your context and programs.

Design: Why we do it

After diagnosing the drivers of the behavioral problem, the next step is to design solutions that address those barriers. While it can sometimes be tempting to skip directly to this step, steps 1 and 2 of the behavioral design process help us to ensure we are identifying a solution that is appropriate for the problem. Successful designs will reshape the context to positively influence behavior, overcoming barriers that impede the behavior and harnessing features of the context that encourage and facilitate the behavior. This might mean, for example, changing something in the physical environment, offering a person a new experience, or making positive behaviors and opinions of other people more visible to them. Sometimes, designs can encourage people to reflect differently on the choices they make and to be more intentional about those choices or consider things they may have overlooked before. Developing designs together with the people who will use them allows you to tailor them so they are acceptable to users and received and understood in a way that is likely to change behavior positively.

Think back once more to the pedestrian overpass. Imagine that you conducted a behavioral diagnosis and found that one reason people do not use the overpass is that they find the dark staircase unpleasant and are thinking more about tripping on the slippery stairs than about the (probably greater) risk of crossing in front of traffic. Can you think of two different ways a design might address this? Tips: Consider changes to the staircase, but also consider ways to encourage people to think more about the risks of crossing in front of traffic.

Design: What it looks like

Design activities should:

• Involve a diverse group of stakeholders, including people who will ultimately use or interact with the designs. For nutrition designs, this might include caregivers, other family members, health workers, community leaders, Ministry of Health stakeholders, and others from your program team. 
• Generate many different ideas to address the barriers identified in diagnosis to help you move beyond the most obvious solutions. Using directing questions is helpful to think about solutions from different angles – for example, “how might we help people to see the longer-term consequences of a choice?” or “how might we encourage a caregiver to make a plan for how they will feed the child?” Combining individual brainstorming with group activities, and working with a diverse group are all ways to generate many different ideas. 
• Filter and prioritize ideas according to program goals.
• Build prototypes, test with users, and refine. This involves building “rough draft” versions of designs, giving prospective users an opportunity to interact with them and offer feedback, and refining and retesting often through multiple rounds.  In the pedestrian overpass example, a prototype might be a rough draft of new signs that could call attention to the overpass, or a model of a new overpass design.

Case example: Design

In the case example from the DRC, the design process led to a set of solutions delivered through three touch points to encourage caregivers to continue to feed their young children during illness and to feed more than usual in the two weeks following illness.

These behaviors were considered alongside five other complementary feeding behaviors, using the tool for prioritizing multi-sectoral nutrition behaviors.

Sick Child Consultation

A Reflection and Orientation to Solutions, Feeding Prescription, Counseling Aids, and Reminder Stickers support family-based health providers to counsel consistently and effectively on feeding sick and recovering children. → Providers feel confident in the value of counseling on feeding during sick visits and know how to counsel effectively.

Peer Exchange of Coaxing Strategies

A group actively facilitated by a community health worker builds caregivers’ skills and confidence to encourage young children to eat when their appetite is limited.

Home Visit

Families of sick children learn together to celebrate every bite and plan to overcome challenges to feeding during illness and recovery, including accessing affordable, nutritious foods for their children and overcoming limited appetite.

Test: Why we do it

This step refers to “country-based testing,” or actually implementing the designs and evaluating what happens. While gathering user feedback during step 3 is essential to build strong solutions, field testing allows us to understand what impact those solutions have (if any) on the behavior we sought to change. It can support us to further refine designs.

Test: What it looks like

A number of different approaches can be used, depending on program goals and constraints. Two commonly used approaches are:

• Randomized controlled trials (RCTs). These are considered the “gold standard” of rigorous evaluation, and help us to understand with confidence whether a solution caused the outcomes of interest. It involves randomly assigning some individuals (or groups) to receive the solution and some not to receive it, and comparing results between the two.
• Pre/post evaluation. This involves measuring changes that occur after the solution is implemented. It can offer useful insight, but it is very important to be attentive to any other changes that may have occurred alongside the solutions’ implementation that could also have influenced results.
• Using monitoring data. This helps to capture trends in information about how the solutions are implemented and (sometimes) behaviors. This can offer useful information on the solutions and the experiences of the people who use them, which can inform ongoing decisions and refinements. However, it generally does not offer conclusive information about the impact a solution has had on behavior.

Limited attention refers to the fact that we can only pay attention to a certain number of things at any given time (ideas42, n.d.). Our attention is much more limited than we often think, which means that we overestimate what we will notice and learn from. We can fail to notice something even when it matters a lot.

Watch this brief video for an illustration of limited attention (Simons, 2010).

How Does Limited Attention Impact Behavior?

• When we concentrate on one thing, we end up neglecting others. We can only respond to a given number of features of our environment at any point in time. Multitasking stretches our attention, making it hard to process information that we could easily process if we were focused on only one thing.
• Our attention is more limited than we might think it is, which means that we underestimate how much we miss.
• We do not notice what we do not expect, even if it is important.

Limited Attention in Real Life: Indonesian Seaweed Farmers

A study of seaweed farmers in Indonesia illustrates how limited attention can hold back a person’s ability to learn from the consequences of their actions. Seaweed farming is done by cutting raw seaweed from a previous harvest into pods and attaching them to lines in a shallow seabed near the shore. Farmers tend to these pods and harvest the seaweed after 30–45 days.

A large number of dimensions affect yield, and farmers in the study were quite knowledgeable about most of them. But most of them did not know what size the pods should be, and they were reluctant to even guess. 

The researchers conducted an experiment in which they varied the size of the pods (which farmers tend not to think about). This experience gave the farmers new information about what pod size is optimal, since some sizes led to better harvests. However, farmers did not change their farming techniques because they did not notice this variation–they were focused on all the other things they already knew affected yield.

However, when farmers were given concise summary information about their yields, broken down by pod size, they did change their behavior. They did not receive any new information, but their attention was brought to information they had access to all along (Hanna, et al., 2012).

Limited Attention in the DRC Case Example

Returning to the DRC example, it was found that when young children are sick, caregivers understandably prioritize medical care and medicines. Caregivers recognize the importance of nutrition, but it receives less of their attention and effort than medical care. Sick child consultations offer an opportune moment for providers to counsel caregivers on feeding while they are urgently attuned to ways to help their child recover, and counseling on feeding is a component of the Integrated Management of Childhood Illness protocol.

Image credit: Augustin Ngandu, Breakthrough ACTION DRC

However, health providers in the facilities studied often fail to bring up feeding at all during these visits. Research has shown how one urgent issue can crowd out attention to other issues, even if they are important. Caregivers are intently focused on seeking care, and, once at a clinic, receiving medicine. Health providers are likewise cued by their training, clinical forms, and caregivers’ questions and requests to focus on medical care (Breakthrough ACTION & USAID Advancing Nutrition, 2022).

In session 3, you will learn about how the solution designs redirect attention to feeding during sick child consultations.

Design Implications of Limited Attention