NNCC Model and Lessons Learned 2014 – 2018 Contents

05...... Acronyms

IMA WORLD HEALTH 06...... Stunting in Indonesia — A Brief Overview National Nutrition Communication Campaign Gedung Wirausaha, 7th Floor, Jl HR Rasuna Said Kav. C-5, 12 ...... The Need for a National Nutrition Communication Jakarta 12940, Indonesia Campaign on Stunting — the CBHN response

22...... Designing the NNCC — Following a Proven Model

26 ...... The NNCC Campaign Design Proces

34 ...... A Summary of Lessons Learned 4 NNCC Model and Lessons Learned 2014 - 2018 5

Acronyms

ADVISE Applied Data Vehicle for IMA Support and Evaluation ANC Antenatal care Bappeda Badan Perencanaan Pembangunan Daerah Kota Lhokseumawe (Regional Development Planning Board) BCC Behavior Change Communication CHNP Community–based Health and Nutrition to Reduce Stunting Project CSO Civil Society Organization DHIS2 District Health Information System 2 DHO District Health Office EBF Exclusive Breastfeeding EIB Early Initiation of Breastfeeding FBO Faith Based Organization GAIN Global Alliance for Improved Nutrition GSC Generasi Sehat Cerdas HPK Hari Pertama Kehidupan IEC Information, Education, Communication IMA Interchurch Medical Assistance/IMA World Health IPC Interpersonal Communication IYCF Infant and Young Child Feeding KAP Knowledge, Attitude, Practice M&E Monitoring and Evaluation MCA Millennium Challenge Account MCC Millennium Challenge Corporation MOH Ministry of Health NNCC National Nutrition Communication Campaign NTT Nusa Tenggara Timur ODF Open–Defecation Free PERSAGI Persatuan Ahli Gizi Indonesia (Indonesian Nutritionist Association) PKK Pemberdayaan Kesejahteraan Keluarga (Empowerment Family Welfare) Posyandu Pos Pelayanan Terpadu (Health Post) PSA Public Service Announcement Puskesmas Pusat Kesehatan Masyarakat (Community Health Clinic) RAD–PG Rencana Aksi Daerah Pangan dan Gizi (Local Action Plans for Food and Nutrition) SBCC Social and Behavior Change Communication SMART Specific, Measurable, Achievable, Realistic and Time–specific

© IMA/Achmad Ibrahim USG United States Government WASH Water, Sanitation and Hygiene WHO World Health Organization 6 Stunting in Indonesia — A Brief Overview NNCC Model and Lessons Learned 2014 - 2018 7

Stunting in Indonesia — A Brief Overview

“Of the 24.5 million children under 5 years of age in Indonesia, approximately 9.2 million (37%) are stunted.”

Over the years considerable progress has been made in the health and social development sectors in Indonesia. Still, the problem of stunting caused by malnutrition remains significant. Of the 24.5 million children under 5 years of age in Indonesia, approximately 9.2 million (37%) are stunted.1

Childhood stunting, a condition that often goes unrecognized, increases the risk of mortality, illness and infections, delayed development, cognitive deficits, poor school performance, and fewer years in school. Stunting is the result of chronic and often intergenerational under–nutrition, coupled with frequent illness, and is the hallmark of endemic poverty.

The high childhood stunting rate in Indonesia is associated with a combination of factors, including nutrition, hygiene, and childcare practices characterized by: 2

» Poor dietary diversity

» Poor feeding practices

» Inadequate maternal nutrition

» Insufficient birth spacing

» Low levels of exclusive breastfeeding

» Open defecation

» Unsafe drinking water

» Insufficient hygiene practices, and

» Household food insecurity

Stunting is reduced when women and young children are fed properly; when communities practice good hygiene, use improved latrines and © IMA/Achmad Ibrahim clean water, and keep environments sanitary; and when people receive the health care they need. © IMA/Achmad Ibrahim 8 The Need for a National Nutrition Communication Campaign on Stunting — the CBHN response NNCC Model and Lessons Learned 2014 - 2018 9

The Need for a National “Reaching 2.9 million children in 5,400 villages Nutrition Communication in 11 eleven provinces, the CBHN project helped Campaign on Stunting — to increase household income through savings the CBHN response in health expenditure and increase in productivity.”

To assist Indonesia to achieve its target for stunting reduction, the United States Government (USG) committed assistance through the Millennium Challenge Corporation (MCC) to implement the “Community Based Health and Nutrition to Reduce Stunting Project” (CBHN). The objectives of the CBHN are to reduce the number of, and prevent, low birth weight newborns, stunted children, and undernourished children in project locations. Reaching 2.9 million children in 5,400 villages in 11 provinces, the project helped to increase household income through savings in health expenditure and increase in productivity.

To meet these objectives, CBHN implemented activities aimed at improving maternal nutrition and children through enhancing community participation, increasing nutritional intake, reducing diarrheal incidence, improving availability of affordable nutritious food and increasing awareness about stunting among health workers, government officials and community. CBHN’s strategic components include community empowerment, improvement of service capacity, and behavior change communication, management and evaluation practices.

Component 1: Community Empowerment.

The Community Empowerment component was implemented through the Community Empowerment National Program for a Healthy and Intelligent Generation (PNPM Generasi, now Generasi Sehat Cerdas or GSC) that is intended to empower and facilitate the community to access education and health services. This activity consisted of participative planning, distribution of grants directly to the community, and technical assistance.

Component 2: Supply Strengthening.

This component included support for capacity building of health care providers and private sector interventions aimed at strengthening the capacity of officials, and improving health and © IMA/Achmad Ibrahim © IMA/Achmad Ibrahim nutritional facilities, in order to provide better service coverage. 10 Overview NNCC Model and Lessons Learned 2014 - 2018 11

This component trained midwives and » Many health workers lack the necessary Posyandu cadres, expanded sanitation and knowledge and skills to provide appropriate hygiene activities, distributed micro–nutrient and effective counseling and interpersonal supplements for pregnant women and children communication (IPC) interventions. And between the ages of 6–24 months and provided very few health workers are adequately instruments to measure child growth, weight equipped with appropriate IPC resources and height, intensive workshops for health care (e.g., flipcharts, posters, leaflets). workers and cadres, as well and private sector » Many parents, guardians and caregivers in interventions. Indonesia may not be aware of, or clearly Component 3: Communication, understand, the importance of proper Management, and Evaluation Practices. nutrition during pregnancy, and nutrition and sanitation for their children. They are The Government of Indonesia, with support unaware of the role that poor nutrition and from the Millennium Challenge Account– sanitation plays in stunting. Indonesia (MCA–Indonesia) and IMA World Health (IMA), identified the need for a » Community institutions, such as Posyandu coordinated and targeted Social and Behavior (Health Post) and mothers’ groups, on Change Communication Campaign (SBCC), which many IPC approaches are reliant, are that would apply a mix of mass media and often not in place, or are not functioning. interpersonal communication interventions to » Highest–risk populations are spread across promote and support improved nutrition and wide geographic areas, requiring significant sanitation among the families of Indonesia, human and financial resources and frequent ultimately leading to a reduction of stunting. outreach by health workers. The result was the 2014–2018 National Nutrition Communication Campaign (NNCC), a key » Environmental, behavioral, and social element of the CHNP. The NNCC was designed practices that impact nutrition in Indonesia to assist in achieving the CBHN program’s target vary widely across regions; ecologies, through communication interventions that behaviors, food taboos, and beliefs about promoted behaviors that both prevent stunting the best ways to raise children vary and encourage a healthy lifestyle that will considerably from one region to another. ensure the optimal growth of the child. Planning and design for the NNCC began in In designing a national level campaign targeting 2014, with campaign mass media, interpersonal malnutrition and stunting, MCA–Indonesia, communication and advocacy interventions government partners, and IMA acknowledged getting underway in 2015 in three districts that there were substantial challenges to be in South Sumatra, and Central and West addressed. “The Government of Indonesia, with support from the Millennium Kalimantan. Due to the success of the project, Challenge Account–Indonesia (MCA–Indonesia) and IMA World These included: MCA–Indonesia expanded the NNCC in May 2017. This expansion included eight additional Health (IMA), identified the need for a coordinated and targeted » Stunting results from a range of complex districts within the same three provinces where Social and Behavior Change Communication Campaign (SBCC), that behaviors and circumstances involving the project began. A total of 688 new villages a wide range of actors and social and were involved in the project from the districts would apply a mix of mass media and interpersonal communication environmental factors.3 interventions to promote and support improved nutrition and of Banyuasin, Musi Banyuasin, Gunung Mas, » Many civil, religious, formal, and informal Katingan, Pulang Pisau, Kapuas Hulu, Sintang sanitation among the families of Indonesia, ultimately leading to a leaders along with the media and private and Kubu Raya. reduction of stunting.” industry are unaware of the long term social and economic effects of stunting. 12 Designing the NNCC — Following a Proven Model NNCC Model and Lessons Learned 2014 - 2018 13

Designing the NNCC “ The NNCC was an evidence–based — Following a Proven campaign, designed to improve the knowledge, Model attitudes, and practices necessary to contribute to reducing the high levels of stunting in

The NNCC, designed and implemented by IMA from 2014–2018, Indonesia.” emphasized community–based behavior change communication (BCC) approaches, including simultaneous bottom–up and top– down interventions to reach diverse target groups and stakeholders. The NNCC helped to influence a shift in thinking among Indonesian policymakers and caretakers of children, increasing their under- standing of the importance of nutrition in child health, the threat of childhood stunting, and the importance of supporting improved infant and young child feeding (IYCF), hygiene, and health care practices. The campaign also helped to improve maternal health and nutrition, especially during pregnancy and breastfeeding, promoting breastfeeding exclusively for six months and continuing with solid food up to 24 months.

The NNCC was an evidence–based campaign, designed to improve the knowledge, attitudes, and practices necessary to contribute to reducing the high levels of stunting in Indonesia. Because stunting is caused by a range of diverse factors, the interventions developed were multi–sectoral, requiring actions at multiple levels and by a va- riety of actors in health, agriculture, social and political sectors, and at different levels of society. The NNCC used four major strategies to promote awareness of stunting and address child feeding practices, sanitation, and hygiene:

1. Encourage families, communities and policy–makers to prioritize stunting reduction and improved nutrition, using mass media and digital media platforms.

2. Partner with health workers, cadres, and communities to support families to improve child feeding and hygiene.

3. Empower families to make choices that improve their quality of life.

4. Engage stakeholders to create a positive climate for stunting reduction. © IMA/Achmad Ibrahim © IMA/Achmad Ibrahim 14 Designing the NNCC — Following a Proven Model NNCC Model and Lessons Learned 2014 - 2018 15

IMA’s design of the NNCC was based on a In planning and designing NNCC interventions Based upon NNCC formative research results, The NNCC used a combination of “on–air” and proven Behavior Change Communication and messaging, IMA kept in mind the five stages the design and application of targeted “off–air” approaches—a mix of mass media (BCC) model, the “Transtheoretical Model,” also of decision making in the behavior change mass media, advocacy, and interpersonal communication and social media coupled referred to as the “Stages of Behavior Change process. These include: communication activities were carried out to with interpersonal and group communication, Model” (Figure 1).4 This is an integrative, respond specifically to the information needs for such as mothers’ group discussions, Posyandu 1. Pre–contemplation biopsychosocial model used to conceptualize individuals at each of the five stages. With such activation, and community events, to increase the process of intentional behavior change. 2. Contemplation specific messaging, targeting specific audiences, community members’ knowledge, change The model seeks to include and integrate there is a greater chance to stimulate behavior norms, and encourage the adoption of 3. Decision Making key constructs from other theories into a change and lobby for stakeholder support. behaviors known to be associated with stunting. comprehensive theory of change that can be 4. Action This multi–layered approach proved to be NNCC discovered from formative research applied to a variety of behaviors, populations, effective in penetrating all layers of target that the majority of target groups members, and settings—hence, the name Transtheoretical. 5. Maintenance communities. both caregivers and government stakeholders, were at the pre–contemplation stage. Most The selected channels of communication for were unware of, or had never heard of or specific target audiences, shown in Figure 2,

Figure 1 — Stages of Behavior Change Model considered, stunting as a serious health issue. included mass media outlets, interpersonal Hereditary factors were mentioned by nearly communication and community activation 70% of respondents as a cause of stunting.5 and collaboration with influential individuals. Stages of Action to take Change Characteristic Communication However, on other behaviors, such as hygiene Training and capacity building activities Interventions and sanitation, most were at the contemplation targeting influential individuals including, or decision making stage. However, while caregivers, relatives, peers, and religious leaders Pre-contemplation Unaware of problem of Increase awareness of problem; » Mass Media most acknowledged that hand washing was was designed and delivered to ensure the NNCC stunting, poor nutrition, personalize information about » Community Mobilization poor sanitation » Advocacy targeting important, most people didn’t practice it implementing partners were able to effectively policymakers regularly. deliver campaign messages.

Contemplation More aware of the problem; Motivate; encourage making » Mass Media thinking about change » Community Mobilization Figure 2 — NNCC Communication Framework » Advocacy targeting policymakers

Decision making Making a commitment to Assist with developing and » Community Mobilization change implementing concrete plans; » Interpersonal help set realistic, achievable goals

TV Spots Radio Jingles Action Assist with feedback, problem » Community Mobilization plans; trying promoted solving, social support, and » Interpersonal behavior for less than six reinforcement Radio Website & Discussion Facebook months INTERPERSONAL COMMUNICATION & COMMUNITY ACTIVATION Maintenance Continuation, adoption of Assist with coping, reminders, » Community Mobilization Telephone Community Religious behavior as regular activity » Interpersonal follow-up Relatives Based for more than six months slips or relapses leaders Forums

Local Posters Newspapers Husbands Parents Group Home Meetings Visits INFLUENTIAL INDIVIDUALS Posyandu Religious Banners Activation Gatherings

Community Gatherings 16 The NNCC Campaign Design Process NNCC Model and Lessons Learned 2014 - 2018 17

The NNCC Campaign 1 Assess the problem & identify possible solutions: conduct formative research and baseline survey

Define realistic communication objectives: state who will make what change, by how much, Design Process 2 where and by when

Define & prioritize target groups: identify specific sub–groups among the larger target Figure 3 — Steps in Campaign Design 3 group for tailored interventions

Define behaviors & messages to be promoted: behaviors must be realistic, achievable 1. 4 and specific to target groups

Define communication approaches & interventions: complementary approaches 5 and interventions should be included for impact Formative Research

Design, pretest & revise communication materials: ensure that materials are 6 understood, appealing, acceptable, and promote an action

5. 2. Define M&E requirements & processes: ensure that the campaign is on 7 track and having the expected impact

The NNCC Project Is Broken Down Into Lessons Learned Campaign Development And Design Dissemination 5 Phases The NNCC team followed a systematic and The IMA team operated from the logical sequence of seven steps in the design of knowledge that a well–designed, targeted campaign interventions. As shown in Figure 3 communications campaign can: this included in identifying problems, specifying » Increase the target group’s knowledge target audiences, developing effective and awareness of problems and solutions 4. 3. interventions, crafting appealing messages, and related to malnutrition. selecting realistic behaviors to be promoted. » Counter misconceptions and myths The NNCC team was aware from the beginning regarding nutrition, sanitation, and hygiene. Implementation Monitoring and that as the campaign was only one of three Evaluation Framework CBHN components (and had no control over the » Prompt individuals and communities to Development implementation of the other two components), take action, and to seek support in taking the campaign could only impact certain action. communication problems impacting stunting » Reinforce existing correct knowledge, and nutrition. For example, the NNCC could Development and implementation of the NNCC was accomplished over five attitudes, and behaviors regarding increase the knowledge of health workers and broad phases. These included: nutrition. caregivers regarding improved nutrition, and 1. Formative research training in proper handwashing, However, it » Demonstrate good nutrition, sanitation, 2. Campaign design could not provide commodities necessary for and hygiene practices—and, in the process, improved nutrition and handwashing. Nor 3. Monitoring & Evaluation Framework Development demonstrate the value of adopting those could it could not contribute to an improved practices. 4. Implementation health infrastructure. Those issues were to be 5. Lessons learned development & dissemination addressed by the other CBHN components. 18 The NNCC Campaign Design Process NNCC Model and Lessons Learned 2014 - 2018 19

» Advocate for action by national, provincial, » Produce sustained change in complex » Will the target group accept the promoted monitoring and promotion are poorly executed; and community leaders to design and enact health behaviors without providing behaviors—do any social or economic mothers understand that declining weight policies that have a positive impact on necessary support, including health care obstacles exist? over time is bad but do not fully comprehend nutrition. services, technology, supporting policy, and the importance of stunting; mothers often » Are services or commodities supportive of provision of necessary commodities. “eat down” (deliberately eat less food) in the However, a communication campaign cannot: behavior change available and accessible first month of pregnancy because of morning » Be equally effective in addressing all issues by the target group? » Replace health services, compensate for sickness; there is almost no nutrition counseling or relaying all messages, because the topic an inadequate or substandard health care during antenatal care; many mothers have or suggested behavior change may be system, or ensure access to health care unwanted pregnancies; benign neglect of complex; because the intended audience Answering these and other questions gave a services. children is common; and while fathers are may have preconceptions about the topic or clear understanding of the target audience— interested in helping out around the house, » Directly influence some food availability message sender; and/or because the topic their behaviors, attitudes, knowledge and long work hours keep them from doing so. issues—while a campaign can influence may be controversial. preferred information delivery channels. This caregivers’ feeding practices, it will not data enabled the NNCC to precisely tailor and The seven steps in the NNCC design process are directly address food production or target different elements of the campaign— discussed below. Others can apply these steps in Some of the more significant findings revealed underlying poverty. realistic behaviors to be promoted, messages, the design of SBCC campaigns across all health the following: materials, delivery methods, etc. Awareness of Stunting Through a combination of surveys, focus group patterns of media consumption, including discussions (FGD) and in–depth interviews (IDI), » Recognition of stunting as a serious public access and preferences, and barriers and data were collected from pregnant women, health problem was very limited, including promoting factors of effective communication mothers of children under two years and their among community leaders and health among targeted populations, i.e., parents family members, health workers, informal workers. Stunting was seen primarily as (mothers and fathers), other caregivers, the 1. Formative Research — leaders and district officials in 11 districts in the being caused by heredity and genetics community, health personnel, and government provinces of South Sumatra, West Java, East (Figure 4) and was often considered a Assess the Problem and officers (see Table 1). Identify Solutions Java, West Kalimantan, Central Kalimantan, West normal state for Indonesians. Only 20 IMA, in coordination with the University of Nusa Tenggara, East Nusa Tenggara, Maluku, percent of respondents recognized any Indonesia, designed research to answer the North Sulawesi, and Gorontalo. The selection negative impact from stunting. following questions: was based on the prevalence of stunting MCA–Indonesia and IMA acknowledged that » Most people, including health workers, among children under 5 years of age, cultural for the NNCC to have the greatest potential were not aware of stunting as a public representativeness, and accessibility. for positive impact, media resources and SBBC health problem. However, employees and » What is the nutrition problem, and what are interventions and messages would need to be Findings from formative research indicated officials of health–related institutions such the causes? based on a clear understanding of the needs, that prevalence of exclusive breastfeeding is as the District Health Office (DHO), family perceptions and current knowledge of the » How serious is the problem? low6; feeding with infant formula is common7, planning unit, Puskesmas, and village different audiences. Formative research was partly because mothers work outside the midwives were more knowledgeable about » Who is most affected by the problem? the key first step in the development of the home; households lack information about stunting than employees or officials outside NNCC. » Why are they most affected? breastfeeding; families introduce solid foods the health sector. early; the foods children eat are not diverse The objective of research was to understand » Some linked stunting with nutrition » What is their knowledge of the problem? and children do not eat as frequently as they knowledge, attitudes, and practices surrounding intake or types of food, family economic should; unhealthy snacks before meals are nutrition–related issues, especially those » What are the specific unhealthy behaviors condition, purchasing power, and mothers’ common; parents demonstrate a laissez faire involving stunting, in order to select priority that lead to the problem? knowledge. attitude toward caregiving (for example, behaviors to be promoted. This included 1) food » Who influences the behavior? children do not like their mothers’ cooking consumption patterns of pregnant women, and are often given inferior foods); soap and lactating mothers, and children under two; » Is it possible to change the behavior(s)? improved water are rarely available; growth 2) patterns of child care practices; 3) patterns » Is the target group able and amenable to of hygiene and sanitation practices; and 4) change? After defecation - 34%

After child’s defecation - 29%

Before a meal - 73%

After a meal - 60%

After defecation - 34% Ate more food - 42% After child’s defecation - 29% 20 The NNCC CampaignAte less Design food Process- 35% NNCC Model and Lessons Learned 2014 - 2018 21 Before a meal - 73% Ate same amount of food - 23% After a meal - 60%

Less than 3 times/day - 41% » Many civil, religious, and formal and Sanitation workers focused on safe delivery and did 3 times/day - 56% Ate more food - 42% informal leaders are not aware of stunting not provide breastfeeding or nutrition More than 3 times/day - 3% Ate less food - 35% » Although 75 percent of households and its long–term consequences. Because counseling. Ate same amount of food - 23% reported having access to latrines many Indonesians have a small physique, (including public facilities), open defecation » Televisions were present in most “shortness”TV in household- is often 80 %considered normal. Figure 5 — Food Consumption During Pregnancy was still common. Only one–third of households (80 percent), and cell phone EvenCell phone/mothers the Indonesian - 69% term for stunting Less than 3 times/day - 41% mothers reported using latrines. Open ownership was high (69 percent of mothers, C(orangell phone/husbands pendek), -means 76% “short person.” 3 times/day - 56% defecation was condoned as acceptable 76 percent of fathers); few households Additionally,Radio listening malnutrition - 8% is often invisible Infant andMore thanYoung 3 times/day Child - 3% Feeding behavior, especially for those who live reported listening to the radio (8 percent). to policymakersInternet access - until <5 % it becomes a critical along rivers, where flowing water is part of Internet access was found to be available to and highly acute issue. » Breastfeeding practices were sub–optimal. TV in household- 80% less than 5 percent of mothers (Figure 8). Almost all babies were breastfed, but only the cleansing process. After defecation - 34% Cell phone/mothers - 69% 46 percent of mothers reported six–month Hereditary - 68% » Among households in the study, only » AfterPreferred child’s def ecationmedia - 29or% source of nutrition exclusiveCell phone/husbands breastfeeding, - 76% and 60.4 percent 34.6 percent were observed to have soap informationBefore a meal among - 73% the primary target Lack of activity - 7.7%Frequently ill - Lack of food intake - 38.9% used infantRadio formula. listening -Challenges 8% to optimal available for handwashing and only 23.6 groupAf waster a asmeal follows, - 60% in order of preference: 8.7%Others - 9.3%Lack of food intake Others - 9.3% breastfeedingInternet access included - <5 % the common percent had running water in the home. direct communication with health workers, - 38.9%Hereditary - 68% Frequently ill - 8.7% perceptions that breast milk is insufficient, However, over 80 percent reported having television, Posyandu, internet, and radio. Lack of activity - 7.7% and that supplementary food is needed; soap, indicating knowledge of the benefits The AtPosyandue more food mothers’ - 42% class, usually mothers mustHereditar work;y - 68%and infant formula is Figure 4 — Community Knowledge on Causes of Stunting of handwashing with soap, but actual deliveredAte less by fo aod midwife, - 35% was also a preferred believedLack of tofood be intake equally - 38.9% good. After defecation - 34% practice is low. Handwashing at critical Ate samesource amount of ofinformation. food - 23% In remote, difficult– Others - 9.3% » AfFrequencyter child’s def ofecation child - 29feeding% and diversity times was also not optimal: 34 percent to–reach areas, the classes were held once Maternal Nutrition Frequently ill - 8.7% of diet Bewerefore asub–optimal; meal - 73% 41 percent of washed hands after defecation; 29 percent Lessevery than two3 times/day months. - 41% The media used in the Lack of activity - 7.7% » Respondents reported changes in food childrenAf under–twoter a meal - 60% ate less than three after child’s defecation; 73 percent before a classes3 times/dayincluded - 56%flipcharts and videos, consumption during pregnancy. The foods times a day (Figure 6). Half of the mothers meal; and 60 percent after a meal (Figure 7). Mofollowedre than 3 times/day by discussion - 3% sessions. that were consumed most frequently reported to feed only on demand, rather According to the World Health Organization by pregnant women were cereals (99.2 than activelyAte more ensuring food - 42% consumption. (WHO), there are five critical hand washing TV in household- 80% percent), followed by vitamin A–rich plants MothersAt weree less fo alsood - 35reluctant% to force–feed times: 1) before eating, 2) after defecating, Cell phone/mothers - 69% (73.2 percent), and meat, fish, poultry, and Atetheir same children,amount of fo asod doing - 23% so caused crying. 3) before breastfeeding, 4) before preparing Cell phone/husbands - 76% offal (72.6 percent). food, and 5) after touching an animal. Radio listening - 8% Less than 3 times/day - 41% » Overall, 42 percent of mothers ate more Internet access - <5 % 3 times/day - 56% After defecation - 34% foods and in greater quantities during

pregnancy (Figure 5). They felt hungrier More than 3 times/day - 3% After child’s defecation - 29% Before a meal - 73% Figure 8 — Communication Channels sooner after eating, which they perceived Hereditary - 68% Figure 6 — Daily Frequency of Meals for Children Under–Two TV in household- 80% After a meal - 60% as the infant’s demand. However, during the Lack of food intake - 38.9% first trimester, they felt sick more easily and Cell phone/mothers - 69% The NNCC design team also reviewed data from Figure 7 — Handwashing Behavior Others - 9.3% ate less than normal. The survey revealed » MothersCell phone/husbands were not - the76% only ones in the the baseline survey commissioned by MCA– Ate more food - 42% Frequently ill - 8.7% that 35 percent of respondents ate less food homes Radiowho list determinedening - 8% what children Indonesia in three provinces: South Sumatera, Ate less food - 35% Lack of activity - 7.7% compared to their non–pregnancy diet. consumed.Internet Men access often - <5 % controlled family Communication Channels West Kalimantan, and Central Kalimantan. Ate same amount of food - 23% finances and household decisions; they » Only 64 percent of women received iron » Most women (82 percent) reported Key findings included: influenced food purchase choices and tablets, and only 55 percent of these attending the last Posyandu session, with time–use issues that impact on child health Less than 3 times/day - 41% » Mothers knowledge on breastfeeding is completed the recommended 90 tablets Hereditary - 68% somewhat higher attendance among and welfare. Key influencers of child feeding 3 times/day - 56% low, and the exclusive breastfeeding rate is regimen. Poor compliance was related to Lack of food intake - 38.9% pregnant women (84 percent) compared behaviors included fathers, grandmothers, More than 3 times/day - 3% low. side effects and a common misperception Others - 9.3% to mothers of under–two year olds (81 midwives, community health volunteers, that the iron tablets—or tablet tambah Frequently ill - 8.7% percent). However, only half of respondents » Classes for pregnant women and mothers peers, and community leaders such as TV in household- 80% darah (“pill that adds blood”)—is only Lack of activity - 7.7% reported receiving information on nutrition with under–five children rarely exist, and religious leaders, chief of adat, etc. needed to treat low blood pressure. in theCell pastphone/mothers three months. - 69% Antenatal care attendance in these classes is low. Cell phone/husbands - 76%

Radio listening - 8%

Internet access - <5 %

Hereditary - 68%

Lack of food intake - 38.9%

Others - 9.3%

Frequently ill - 8.7%

Lack of activity - 7.7% 22 The NNCC Campaign Design Process NNCC Model and Lessons Learned 2014 - 2018 23

» Severe and moderate stunting rate among Table 1 — Analysis of Behavior Related to the Prevention of Stunting 0–5 month babies is 18 percent. Low birth weight rate, based on mothers’ reports, is Behavior Problem/ Current Practices Cause/Reason 40 percent among children 0–35 months. Stunting rates remain at 18 percent until 12 months of age, then increase as children get 2. Define Realistic older. Severe and moderate underweight Stunting rate among 0–5 month babies is 12 percent Communication Objectives

and increases as children get older. Communities do not understand the problem of • Stunting is a new problem for the community. There have yet to be stunting. any campaigns that deliver information on stunting. » Anemia rates were high among mothers The NNCC’s objectives, as established by MCA– (55 percent) and children 6–35 months (61 Indonesia in consultation with government A child’s height is considered to be caused by • The community is not aware of the role of nutrition in child percent). Pregnant mothers are found to partners, were as follows: genetics. growth. Lack of activity - 7.7%Frequently ill - have consumed diverse diets, but it is not 8.7%Others - 9.3%Lack of food intake clear whether in adequate quantity. » Increase awareness and understanding Very few stakeholders in the health sector have • Stakeholders do not give serious attention to nutrition and health of the causes, symptoms, long–term knowledge of stunting. This is also the case with problems. - 38.9%Hereditary - 68% non–health sector stakeholders. » Sanitation is very poor. Less than 2 percent implications and need for active prevention • There is the perception that malnutrition is a problem only when it of villages are open–defecation free (ODF). of stunting among parents, community is severe wasting. Only three of 379 control villages and eight members, Ministry of Health (MOH) • There is limited distribution of information, training, and advocacy regarding stunting. of 380 treatment villages are ODF. Children’s personnel, government officials, and the feces is disposed of in the open. public.

The information collected from the formative » Gain commitment from a broad array of Maternal Nutrition research and baseline survey provided the stakeholders in the public and private NNCC design team with a clear understanding sectors to tackle the problem of stunting.

of the attitudes, behaviors, and influencing Pregnant women reduce eating and eat less than • Lack of awareness regarding the importance of maternal nutrition. factors among the target groups with respect to » Foster individual and community behavior three times a day. change related to health and nutrition • Pregnant women may feel nauseous, especially during the first nutrition and stunting issues. Table 1 summarizes trimester. behaviors, practices, and beliefs related to among parents, other caregivers, and MOH personnel who deliver community health/ stunting revealed by research. Low consumption of animal protein. • Fathers do not provide extra money to buy nutritious food for their nutrition services. pregnant wives. In addition to the causes and reasons for current With knowledge gained from formative behavior and practice problems listed above, Belief in several myths regarding “taboo food” • The role of grandmothers that preserve and instill these myths to the there are other underlying causes that the research, IMA was able to conceptualize and during pregnancy. mothers. NNCC was unable to address via communication design diverse communications interventions to respond to these objectives that could be Pregnant women do not complete iron • Pregnant women claim to be lazy or nauseous as a result of taking interventions. These other underlying causes supplement tablets dosage. iron supplement tablets. implemented within the NNCC time frame include such issues as systemic poverty, • A lack of counseling regarding iron supplements by health workers inadequate financial, human, physical and (November 2015–March 2018) and with available social capital, and lack of access to resources financial, human, and material resources. 8 such as land, education and employment. The By working to achieve these objectives, the two other CBHN components (Component 1: NNCC served to strengthen the foundation Community Empowerment, and Component 2: necessary to move Indonesia towards the overall Supply Strengthening) responded to these other goal of improved nutrition and a reduction in underlying causes. stunting. 24 The NNCC Campaign Design Process NNCC Model and Lessons Learned 2014 - 2018 25

Table 1 — Analysis of Behavior Related to the Prevention of Stunting

At the same time the NNCC messaging delivered This audience segmentation helped to ensure Behavior Problem/ Current Practices Cause/Reason via mass media, interpersonal communication, that NNCC messages, materials, and advocacy and advocacy targeting stakeholders and and interpersonal communication activities decision makers supported the other two were relevant and appealing to the intended Early and exclusive Breast feeding components of the project—the “Community groups. Segmentation also helped to identify Project Activity at the Demand Side” and the the best channels for reaching each group.

Low rate of Early Initiation of Breastfeeding (EIB) • Birth attendants are not yet trained on EIB. “Supply Side Activity”—helping to strengthen practices and EIB malpractice. • EIB is not discussed during antenatal visits. the overall impact of the CBHN. NNCC target groups included the following: The NNCC was designed to reach and influence parents and caregivers of children, but an The infant is fed with breastmilk substitute food and • Lack of knowledge surrounding exclusive breastfeeding. Primary liquids during the first three days, including milk additional key goal was to impact the thinking formulas, and is introduced to foods and liquids other • Skepticism that breastmilk alone is sufficient during the first six As the main actors in childbearing and child than breastmilk before six months. months. Concern that the infant will remain hungry. Feeding and action of Indonesian policymakers feeding, and as those who are most affected by additional food is meant to pacify the infant, lessen tantrums, and by increasing their understanding of the increase sleeping. the health problems related to nutrition and importance of nutrition in child health. By • A widespread belief of virtues of honey for the infant. stunting, women were the primary target of the realizing the real threat of stunting to the NNCC activities. Among women, critical sub– individual as well as national development, groups for targeting messages included: these policymakers will ultimately influence Complementary Feeding social norms on how infants and young are » Pregnant women. properly fed. » Mothers or caregivers of children under–five

Children eat less than three times a day and are given food • Caregivers’ knowledge and competence regarding complementary years of age. only when they demand it. Breakfast is not a daily habit. Fed food is inadequate. only two food groups, grains (typically rice) and vegetables. Animal protein is very rare. • Reluctance to stimulate children to eat when they are refusing food.

Caregivers do not provide responsive active IYCF practices. • Mothers yield to the child’s demands to prevent tantrums. Secondary Children are given snacks too close to meal time, thus reducing their appetite • It was evident that mothers who followed poor feeding practices This group included those who had the greatest lacked family support, particularly from fathers; women carry the 3. Define and Prioritize greater share of domestic work. Target Groups/Audience potential for influencing change: • Beliefs (myths regarding taboo food), self–confidence, and efficacy in performing IYCF. Segmentation » Fathers, grandmothers, and other family members. To ensure that the communications campaign would be effective, IMA and MCA–Indonesia » Peers, especially other mothers in the community. Sanitation and Hygiene knew that interventions needed to be crafted to precisely target specific primary target » Community leaders. groups. In addition, it was agreed that the Many still perform open defecation, particularly in • Use of latrine is not yet a desired practice due to several factors: » Males, between 20–40 years of age, living in the river. campaign had to reach out to secondary • Supply of clean water is limited. Its availability is necessary in the target groups who were able to influence rural areas, and with lower socio–economic construction and use of a latrine. status. • There is a widespread perception that building a latrine is government policy as well as the adoption expensive. • Low level of technical support to assist families in constructing of promoted behaviors by the primary target » Health workers. latrines. groups. » Policymakers, including national and district The practice of hand–washing at critical times is not • Hand–washing facilities with flowing water and soap are very an established habit. limited and are often located outside the house. level authorities.

• A lack of knowledge regarding the critical times to use soap when hand–washing, although value of hand–washing was generally well understood. 26 The NNCC Campaign Design Process NNCC Model and Lessons Learned 2014 - 2018 27

Table 2 — Key Behaviors/Messages and Approach/Channels for NNCC Target Audiences the campaign with too many behaviors and messages. In the case of stunting, a campaign could potentially focus on: 1) diet; 2) agriculture; Message Development 3) early childhood development; 4) water, sanitation, and hygiene; 5) gender; poverty; and 4. Define Behaviors and other issues. Target Audience Behaviors/Messages Approach/Channels

Messages to be Promoted IMA felt that overloading a campaign with • Pregnant women should consume 90 tablets • Antenatal care (ANC) visits. such a wide range of behaviors and messages of iron supplements during pregnancy. • Women’s groups and maternal classes. would lead to confusion and misunderstanding Behaviors to be promoted by the NNCC among the primary target audiences. Moreover, • Pregnant women should eat at least eat four • One–on–one counseling during follow–up. needed to be realistic and achievable. IMA times a day with sufficient animal protein. a potential consequence of focusing on so Pregnant mothers • TV public service announcement (PSA). knew that the campaign would lose credibility many behaviors and messages is that program if people were asked to do things they would implementers, including government workers, be unable to do, whether for social or economic • Caregivers, family members and health • Women’s groups and maternal classes. might not clearly understand program workers should avoid giving food other reasons. The behaviors to be promoted were than breast milk to the infant during the first • Posyandu, classes, and seek assistance for interventions and, as a consequence, not carry three days following childbirth and persist in challenges to IYCF. selected based on the social, economic, exclusive breastfeeding. out activities as planned. • TV PSA. attitudinal, and behavioral information collected • Women should give only breastmilk for infants • Posyandu Activation. though IMA formative research. For IPC interventions, IMA chose to focus on Mothers with child under six months. under–two behaviors and messages for mothers and • Mothers and caregivers should provide Behaviors to be promoted, and messages to other caregivers with regards to 1) nutrition complementary food, in accordance with age deliver and encourage those behaviors, were and in a sufficient amount and frequency, (maternal and child/baby, complementary both solid foods and semi–solid foods, agreed in close consultation and numerous consisting of at least four food groups, for feeding); 2) IYCF (improved feeding practices children aged 6–24 months. discussions with MCA-Indonesia and MOH. Their and promotion of exclusive breastfeeding); and • Mothers and caregivers should provide animal experience in health, sanitation, and nutrition in 3) sanitation and hygiene (latrine usage and protein for children aged 6–24 months. Indonesia as well as their experience in dealing handwashing promotion). • Mothers and caregivers should wash their with mass media in public health campaigns, hands with soap before preparing food, An overview of the key behaviors/messages feeding children, changing baby’s diaper, and provided valuable insight into the selection of after going to the toilet. the most important behaviors and messaging to increase awareness among adolescent girls, for mass media platforms. mothers, and caregivers about stunting, and to educate and motivate actors and influencers is • Every family should own and use a latrine. • TV PSA. The information collected from formative shown in Table 2. research and the baseline survey (step 1) • Fathers and other family members need to • Entertainment education. understand the importance of breastfeeding, identified a wide range of crucial behaviors. and support mothers in breastfeeding. • Religious forums. IMA was careful, however, to avoid overloading Father, family (mothers • Family should promote practices that are or mothers in–law) beneficial to children’s nutritional status.

• Families must support and facilitate improved nutrition for adolescent girls.

Communities need to come to a better • Religious forums. understanding and general agreement on a redefined social norm for how to feed babies • Community gatherings. and small children, and ensure a clean and healthy environment. • Community–led total sanitation.

Community & informal leaders 28 The NNCC Campaign Design Process NNCC Model and Lessons Learned 2014 - 2018 29

Table 2 — Key Behaviors/Messages and Approach/Channels for NNCC Target Audiences Table 3 — Priority Behaviors and Messages in TV Spots

Priority Behavior Why Selected Key Message Points Message Development

• Stunting prevalence for infants under 6 • Initiate early and exclusive breastfeeding. months is 19%; while for those 6–11 months is Target Audience Behaviors/Messages Approach/Channels 18 %. For children between 12–23 months, the • Continue exclusive breastfeeding until six months prevalence is at 35%.11 and continue breastfeeding through 2 years.

• Wasting prevalence for infants under 6 • After six months, introduce nutritious foods to • Engage mothers and their families in a • Nutrition training and IPC skills included in health Active feeding months is 5%; while for those 6–11 months is children in addition to breastfeeding. dialogue to discuss the messages and be worker training. 10%. For children between 12–23 months, the prepared to answer questions, and reinforce prevalence is at 11%.12 • Mothers must eat nutritious foods to be able to the messages. • Information, education and communication (IEC) breastfeed. tools to assist health workers in counseling. • Underweight prevalence for infants under 6 • Health workers should assist mothers months is 13%; while for those 6–11 months is • Children under–two years need four or more Health workers to perform proper early initiation of • One–on–one counseling during follow–up visits. 19%. For children between 12–23 months, the nutritious meals per day. breastfeeding within an hour of childbirth. prevalence is at 26%.13 • Active feeding to ensure consumption is necessary • Suboptimal complementary feeding in to ensure that under–two year olds eat the right combination with decreasing frequency of foods. • Stunting is a serious problem and results in • Talk shows on mass media and events. breastfeeding as the infant ages causes the poorer cognitive and educational outcomes nutritional status of the infant to deteriorate later in life, and lower productivity and • Stakeholder meetings. drastically. 14 prosperity. • Public hearing with parliamentarians. • NNCC will complement the existing GAIN • Reducing stunting is a national priority and (Global Alliance for Improved Nutrition) Policymakers and requires a multi–sectoral approach. • Journalist orientation. campaign, focusing primarily on active stakeholders feeding, the right frequency and diversity. • District level government must prioritize • Media visits. nutrition, by coordinating the multiple sectors that contribute to reduction of stunting.

• The nutritional status of women, starting from • The rate of diarrhea is 66% higher among • Treat water for making it safe for consumption. adolescence through child–bearing years, is infants whose family practices open defection critical for good birth outcomes and well– when compared to infants whose family owns • Defecating in the open is shameful and makes nourished children. a latrine with a septic tank. 15 people sick.

• Proven interventions for women include • Stunting prevalence rates are higher among • It is time for every family to own and use a latrine. iron supplementation and a diet rich in Sanitation and Hygiene children who often contract diarrhea. It is comfortable and safe. micronutrients. — latrine ownership and handwashing • No existing significant campaign on latrine • Wash hands with soap especially after toilet use, • Improving the nutritional status of girls and promotion use. and before preparing food and feeding children. women is good for babies and for Indonesia. • Dispose of child feces in latrine. • Interventions to reduce stunting by 20% are estimated to increase national income by 11%.9

• The return on investment could be up to US$48 per dollar, for every dollar invested to reduce stunting.10

Concerning mass media, NNCC was concerned some programs, investment in mass media may that trying to include all messages into be beyond their financial resources. For these television spots would be too complex for reasons, it was decided to limit production the target audience (given the short duration to two television spots (with 30 second and of each spot — 30 and 15 seconds), and 15 second versions each) focusing on two problematic for media production teams. key behaviors—improved active feeding and Moreover, while television is one of the improved sanitation and hygiene—as shown most cost–effective means of transmitting in Table 3. Messages on active feeding and information—based on cost per person improved sanitation and hygiene were also reached—the absolute cost to produce and included in IPC materials. broadcast television spots can be high. For 30 The NNCC Campaign Design Process NNCC Model and Lessons Learned 2014 - 2018 31

Figure 9 — Pros and Cons of Mass Media and IPC

Mass Media Interpersonal Communication (electronic, print & digital media) 5. Define Communication Experience repeatedly shows that individuals tend to get most of their information on Approaches and issues related to health through interpersonal Interventions communications. NNCC behavior change Pros Large coverage Direct to the target group interventions emphasized IPC interventions Attractive Personal To effectively deliver targeted messaging, Quickly builds awarness Messages eaisly adjusted focusing on mothers and other caregivers, and promote sustained behavior change, a Contributes to knowledge Influential among peers along with their peers and other influencers variety of complementary approaches and Low cost (e.g., grandmothers, fathers) to ensure that interventions were included in the campaign caregivers were empowered to make the proper design. Recognizing the pros and cons of choices. This approach was supported by a mass different media (Figure 9), the NNCC devised a Pros Reaches non-target groups Time intensive media campaign that reinforced key messages, Expensive Labor intensive diverse media mix including electronic (TV and educated the general population and increased Adjusting messages difficult Training may be required radio) and print mass media, and digital media. their awareness of the importance of reducing and costly Must tailor to local cultures This media mix complemented and increased stunting. In addition, advocacy to increase the credibility of messages delivered through awareness and understanding of the causes, interpersonal communication activities carried symptoms, and long–term social and economic out at the community level that were tailored to implications of malnutrition and stunting specific audiences. among leadership and influential groups was essential to help move the issue to the forefront and stimulate action. Figure 10 — NNCC Conceptual Framework for Stunting Reduction

NNCC Objectives

Interpersonal Communication Objective 1: Advocacy Increase awareness and & Social Mobilization understanding of the causes, symptoms, long- term implications, and prevention of stunting. Mass & Digital Media

Objective 2: Improved Gain commitment from maternal a broad array of Policy Public & Community Health Family Mothers nutrition, stakeholders in the Reduced makers & private leaders & workers IYCF, public and private sanitation Stunting legislators sectors, media & cadrers sectors to tackle the & hygiene CSOs problem of stunting. practices

Objective 3: Foster individual and community behavior change related to health and nutrition.

Formative Research Monitoring & Lessons Learned 32 The NNCC Campaign Design Process NNCC Model and Lessons Learned 2014 - 2018 33

As illustrated in the NNCC Conceptual At the community level, the NNCC supported It also resulted in print and electronic media This advocacy effort ensured that NNCC Framework for Stunting Reduction (Figure 10), and worked with government and community journalists paying more attention to the messaging and promoted behaviors were the campaign applied three approaches to structures and facilities such as the district stunting issue and doing in–depth reporting. included in local action plans. Overall, this influence target audience behavior. These are: health office (DHO), Bappeda (Regional advocacy approach was highly effective District level advocacy involved forming local Development Planning Board), Puskesmas at increasing awareness, commitment, multi–stakeholder forums to mobilize support, (sub–district health center), and Posyandu to and ownership by local stakeholders, and media advocacy to raise stunting as a public Interpersonal Communication and Social organize multi–stakeholder meetings involving it produced innovative, responsive local issue, and engaging key stakeholders and Mobilization relevant government and non–government interventions. policymakers in policy dialogue on stunting actors working in nutrition, WASH, agriculture, Experience shows that interpersonal reduction. The NNCC gained leverage by taking and infrastructure sectors. communication interventions—face–to–face the lead in organizing stakeholder collaboration verbal or non–verbal exchange of information Engagement with multiple stakeholders in the development of the Rencana Aksi Daerah and feelings between two or more people— at the community level was a continuous Pangan dan Gizi (Local Action Plans for Food are highly effective in delivering complex process throughout the life of the NNCC. This and Nutrition), or RAD–PG (Figure 11). information and stimulating and sustaining multi–sector approach ensured that behavior behavior change. IPC is not just about what change was sustained during and beyond the is said, but how it is said and the non–verbal campaign. Figure 11 — NNCC Advocacy Process in Developing RAD–PG messages sent through tone of voice, facial expressions, gestures and body language. It is about developing a trusting relationship Advocacy 1. between the health worker and the client. MCA–Indonesia, government counterparts, For NNCC to successfully apply an IPC approach and IMA recognized that increasing awareness at the community level, IMA designed a training and understanding among leadership and Stakeholder to improve health workers’ and cadres’ IPC and influential groups of the causes, symptoms, and Mapping facilitation skills. This enabled NNCC field level long–term social and economic implications of partners to provide more effective face–to– malnutrition and stunting was essential to help face dialogue with and support to caregivers. move the issue to the forefront and stimulate Messages promoted through IPC interventions action. Therefore, NNCC targeted community 5. 2. were related to maternal and child nutrition, leaders, journalist associations, MOH personnel, including IYCF, and sanitation and hygiene. government officials, and policymakers with Social mobilization—which entailed engaging tailored information designed to move them to and supporting the participation of institutions, action. Adoption and Identify and community networks, social/civic organizations, implementation of partner with Personal outreach, from small group meetings Rencana Aksi Daerah CSOs and two of the largest faith–based organizations NNCC Advocacy Process in to large–scale workshops, encouraged Pangan dan Gizi: in Indonesia, Fatayat Nahdlatul Ulama (Fatayat Bupati issues decree Developing RAD–PG participation by top–level staff in the launch NU) and Nasyiatul Aisyiyah, to help shift and roll–out of the campaign. At the district attitudes, structures, and norms to better level, NNCC increased awareness and support priority practices—resulted in the understanding, especially among non–health implementation of district and village level sector government officials, local stakeholders, activities. These included community–based 4. 3. and journalists, of the causes, symptoms, and IPC through Posyandu, mothers’ classes, and long–term implications of stunting and how community gatherings. This approach ensured it can be prevented. This effort helped to gain that key individuals, religious leaders, and local policymakers’ and stakeholders’ support Collaborative development Organize Multi- community groups supported the delivery of of Rencana Aksi Daerah stakeholder to address stunting through integrated multi– campaign messages, stimulated interest in the Pangan dan Gizi Forums sector interventions and encouraged the proposed behaviors, and helped to sustain the inclusion of integrated stunting prevention in behavior change process. local development programs. 34 The NNCC Campaign Design Process NNCC Model and Lessons Learned 2014 - 2018 35

Featuring messages on stunting, exclusive Mass & Digital Media children could get information about IYCF, breastfeeding, child nutrition, sanitation The NNCC used mass media platforms sanitation, and proper hand–washing and hand–washing with soap on local radio (television, radio, social media, and website) to techniques. Health workers were able to stations in each of the NNCC supported reinforce and popularize key behaviors related download various tools. Stakeholders, districts. to improved nutrition and latrine use. Mass such as regional officials, could access and 6. Campaign Material Design media resources delivered messages on IYCF Social media may not seem the most likely download reference documents such as and sanitation and hygiene. The mass media choice for NNCC health messages, but Indonesia advocacy materials that explain the policies and Pre–testing messaging focused on increasing parents’ desire ranks fourth in the world for the number of and programs needed to reduce stunting. To ensure the production of high quality NNCC for their children to reach their full potential, Facebook users—that is more than 76 million Partner organizations and their cadres in materials, and to compete with professionally both in terms of physical growth and life people. Considering this number, and the the regions downloaded various advocacy developed media resources that dominate the achievement. continued rapid growth of internet connectivity and IPC tools to aid them in implementing print and electronic markets, creative and media and social media in Indonesia, NNCC invested the NNCC campaign. At the end of February agencies were contracted to carry out material Campaign messages were broadcast on in digital media as an effective way to deliver 2018 over 150,000 people had visited the design and production. The communication television stations that the formative research messages in Indonesia. By doing this, the NNCC website, generating nearly 530,000 materials developed included television spots, showed were most popular among the NNCC NNCC became the first nutrition campaign in pageviews. posters, banners, and various print resources for target audiences. The campaign purchased air Indonesia to invest in social media. This was IPC and advocacy. time on programming that was most popular »» NNCC Facebook Page: From the launch considered a logical choice as NNCC formative among the target audiences. NNCC mass media of the NNCC Facebook page it continued research showed that a significant percentage Campaign materials that have not been pre– activities consisted of: to show a steady and upward trend, from of the campaigns target groups use the internet. tested with the various target groups may have merely thousands of impressions in 2015 to Moreover, it is likely that internet use among mistakes, may not appeal to the target group, 8,640,412 impressions by the end of 2018, target group members will rapidly increase or may contain information or behavior change reaching a total of 6,117,686 Facebook »» Public Service Announcements (PSAs): given growth of internet connection and messages that are not practical, effective or Promoting active and responsive users, having 209,060 engagement, and culturally appropriate. Pre–testing is essential proliferation of devices (smart phones, tablets). .16 This was not only due to complementary feeding, latrine ownership 53,459 “Likes” to ensure that resources are easily understood, Among government officials from the national the Facebook advertising but more to and use, and consistent hand washing are appealing and acceptable, and promote to district levels, access to internet is almost continuous content development and with soap, aired on national level television a behavior change action with respect to the universal, providing an excellent platform to continual posts by the NNCC team. across Indonesia. reach with advocacy messaging. issues of nutrition, sanitation, and stunting. If resources are not easily understood, or do not »» Fillers and Built–in Segments: Fillers are »» Webtorial (tutorial provided on the Through digital media, users can comment, generate enthusiasm, they should be discarded one–minute broadcasts that featured a project website): This channel was directed ask questions, share opinions, promote others’ or revised. report of an event or activity that required towards several of the campaign’s target posts, and transmit to other digital platforms. audiences, particularly stakeholders and media amplification. Fillers and built–in IMA ensured that all key NNCC materials were Effective communication forums such as health workers, to increase public dialogue segments allowed key campaign messages, pre–tested with the target audiences. Pre– personal testimonies and public dialog are about the importance of child growth and especially regarding the role of men and testing of materials was conducted through made possible, enabling users to reach leaders nutrition. family in supporting mothers in childcare, and decision–makers more easily. focus group discussions in three provinces: to be inserted into popular programs such »» YouTube TrueView Ads: These were South Sumatra, West Kalimantan, and as religious programs. The NNCC provided information and support designed to create a viral effect and extend Central Kalimantan. Focus group discussions through a variety of digital platforms, were conducted with mothers, fathers, and »» Regional and National TV and Radio Talk target audiences’ exposure to key NNCC including: grandmothers/caregivers. The pre–test assessed Shows: Regional TV station talk shows messages, especially health workers, the levels of comprehension, attractiveness, featuring locally recognized health and »» NNCC website (www.gizitinggi.org): policymakers, and mothers/families with acceptability, and persuasiveness of the nutrition specialists and stakeholders from The NNCC website provided a reference Internet access. messages. the region were used to highlight the for people seeking information about »» Facebook Social Ads: This increased NNCC’s importance of stunting reduction. stunting prevention. It remains the only coverage encouraging webpage visitors Pre–testing assessed the content and Indonesian website dedicated to stunting acceptance of posters and banners (for »» Radio Adlibs (improvised delivery and allowing information to be shared with reduction. Parents with infants or young promotion of IYCF, latrine usage, appropriate of messages by radio broadcaster): other users. In this way the campaign could become a word–of–mouth campaign. hygiene practices, and maternal nutrition 36 The NNCC Campaign Design Process NNCC Model and Lessons Learned 2014 - 2018 37

practices) and jingles to be aired at community had a shared responsibility to monitor activities events (e.g., at Posyandu) and on local radio rather than be imposed only for particular unit / about IYCF practices and latrine usage. Pre– person. Additionally, a protocol was developed testing also compared preferences between to ensure data quality and timeliness at two versions of TV commercials about IYCF and periodic and routine time intervals. The project latrine usage. Results demonstrated that all collected a range of quantitative and qualitative campaign materials were well accepted. information. Quantitative information was collected through IMA World Health’s health management information system (HMIS)— Applied Data Vehicle for IMA Support and Evaluation (ADVISE)—a customized version of the widely used District Health Information System 2 (DHIS2)17.

7. Monitoring and The project’s indicators were mainly output and process level, and were collected using built in Evaluation — Keeping the data validation checks to minimize data entry Campaign on Track errors along with other data cleaning exercises. At the national and district levels, routine data analyses were conducted to show whether the The need to invest in a well–functioning campaign activities were being conducted as monitoring and evaluation (M&E) system is planned. Output and process indicators were widely recognized. An M&E system provides discussed against campaign targets by essential data for routine tracking of project aggregating data and displaying them in “easy– activities, guides the planning, coordination to–digest” tables, graphs and maps on ADVISE and implementation of a program and rapidly users’ customized dashboard showing progress identifies problems for course correction, against targets. Furthermore, the project sustained program improvement and rational conducted a data quality assessment (DQA) to resource allocation. assess the project’s data in terms of accuracy, timeliness and completion at the various project NNCC’s M&E framework was based around levels. Whenever a data gap or emerged or building a cycle of routine data collection, underperformance was identified, root cause management, analysis and use/interpretation analyses were performed to identify possible throughout the various levels of the project. solutions to improve implementation quality. Starting with harmonized SMART indicators that directly measured project outputs and NNCC’s monitoring system also facilitated the outcomes, the framework facilitated the collection of qualitative data through narrative creation of a monitoring system that made reports consisting of descriptions of challenges data gathering easy and facilitated information and successes during project implementation. use in a timely manner. This included agreed These were reported through success stories upon business processes for data flow from and other project learning documents. the village, sub–district, district and national levels. This approach ensured that all project implementers, regardless of their project role, 38 A Summary of Lessons Learned NNCC Model and Lessons Learned 2014 - 2018 39

A Summary “ Some of the more significant lessons learned of Lessons Learned while implementing the campaign are presented below, to provide guidance for others in the design and implementation of effective nutrition campaign

Throughout the life of the NNCC project, IMA identified challenges, activities and resources, and obstacles, and successes. During the life of the campaign, this to potentially inform other information served as a means of monitoring strengths and public health activities.” weaknesses, and it allowed the project team to adjust the campaign design and delivery as needed in order to maximize impact.

Some of the more significant lessons learned while implementing the campaign are presented below, to provide guidance for others in the design and implementation of effective nutrition campaign activities and resources, and to potentially inform other public health activities.

1. Understanding the Audience and their Social Environment Formative Research is Essential

Considering the importance of developing evidence–based interventions and media resources, initial formative research should be part of a larger data management component of a communications campaign. Such a component should include the cleaning, storing, and planned analysis of findings for use in publications. An appropriate budget should be allocated to engage a professional research agency to design, carryout and analyze research, and support data management during the campaign “Reaching 2.9 million children period. Regarding the design of formative research, a simultaneously mixed qualitative and quantitative approach should be applied. in 5,400 villages in 11 eleven In addition, an additional qualitative study should be considered provinces, the project helped to gain more insights into the initial results collected through to increase household income the mixed method. Time for implementing formative research through savings in health should be extended as to allow flexibility in design. In addition, the expenditure and increase in involvement of MOH in the beginning phase of formative study productivity.”© IMA/Achmad Ibrahim © IMA/Achmad Ibrahim should be encouraged and structured for adequate efficiency. 40 A Summary of Lessons Learned NNCC Model and Lessons Learned 2014 - 2018 41

2. Mass Media Broadcast Intensity is Key Humorous, Fun Messaging To ensure high views and ratings for television Humorous PSAs can be more effective at spots, selecting the right channel and the right engaging the target audience than spots which television program and maintaining broadcast simply convey technical information. To counter intensity is an important consideration. challenges with some of the complex, less Although airtime on high–rated television emotionally engaging messages that fill the programs is expensive, the cost per contact is airwaves, NNCC developed and aired comical lower and therefore more efficient, as long as spots—which contained, for example, toilets it is reaching the target audience. As people’s and toilet humor—to generate excitement viewing habits and program preferences about the topic and to encourage behavior change, the media landscape needs to be change. There was widespread agreement continuously evaluated in order to invest in the that the more humorous PSAs (particularly most effective and efficient time slots. From the related to latrine use) were more popular. In the NNCC experience, television genres such as local case of the first PSA about feeding frequently soap operas on RCTI and imported soap operas and responsively, the complex nature of on ANTV were very popular among the NNCC the message proved problematic for media target groups. Campaigns should strive to utilize production teams, frontline health workers, relevant and popular television programs, and informal community leaders, and health facility invest in a high intensity of airtime, to further workers. disseminate information on stunting issues. Working with Professional Media Agencies Concise, Focused Messaging In order to ensure continuity in media resource Television spots and video filler messages design, messaging and output quality—and must be concise and, preferably, focused to compete with the abundance of advertising on a single topic. Incorporating too many currently saturating the media landscape of messages and ideas into a 30– or 60–second Indonesia—it is essential to work with a Media spot can complicate the message and Production/Creative Agency be to develop compromise effectiveness. Development mass media and interpersonal communication and production processes may also be more resources. A professional agency will be able complex, as materials may require input to provide an outside perspective for ways to from more reviewers, which not only slows engage the target groups that may otherwise the production process but also may end up be overlooked by in–house teams. They offer “diluting” the messages and result in an overall experience and lessons learned from applying negative impact on the final product. While different media strategies across many clients the involvement of a wide range of partners and can come up with new outside–the–box and stakeholders is generally considered to creative ideas. be a positive approach in designing SBCC interventions, streamlining the review processes is a critical consideration. 42 A Summary of Lessons Learned NNCC Model and Lessons Learned 2014 - 2018 43

visits and to follow–up by phone. Utilizing media environment. For example, the webtorial Mass Media Featuring Recognized Leaders Radio in the Digital Age midwives and volunteers—including through “Dirjen Kesmas: Untuk Kurangi Gizi Kronis has Impact Although more and more people are accessing phone calls to mothers—removed some of the Jangan Abaikan Kehamilan” (“Director General Through mass media, community leaders, information through the internet, radio can still financial barriers that kept service providers of Community Health, MOH: To Reduce Chronic including civil and religious leaders, can be an effective component of a multichannel from conducting home–based counselling. Malnutrition Don’t Neglect the Pregnancy”) was effectively and efficiently influence opinions campaign. The NNCC radio campaign, Elsewhere, similar programs might incorporate published on January 25, 2017 on Detik.com. and attitudes towards positive behaviors as comprised of adlibs and talk shows, reached phones and other inexpensive outreach into It generated only 2,412 views and attracted well as provide models for the behaviors. an estimated 72,000 listeners. Radio messages their communications strategy. just 1,118 visitors. Each visitor spent only one minute viewing the page—well below NNCC The use of prominent and influential public reinforced the information delivered through Allocate Adequate Time and Budget for expectations. figures can boost the recall of campaign interpersonal and group communications such Digital Media Development messages an increase their credibility. NNCC as a combination of mother group discussions, Based on the NNCC’s experience, it is strongly worked closely with two of the largest faith– Posyandu activation, and community events. The NNCC team learned that a digital campaign recommended that info–graphics and audio based organizations in Indonesia Nahdlatul The combination of interpersonal interventions with multiple platforms (such as a website visuals be used to communicate issues more Ulama (NU) and Aisyiyah, to reach target and radio messaging can help to penetrate all and Facebook page), demands a significant concisely, quickly, and attractively. As much of audiences through TV programming through layers of communities, and to reach those who amount of time and human resources. To attract the digital media audience consists of mothers their endorsement of key maternal and child are not using the internet. and keep the interest of targeted viewers, and caregivers, content needs to be responsive nutrition and sanitation and hygiene messages. stories and editorials/opinion pieces need and relevant to their information needs. Simple Dr. Said Aqil Siradj, chair of NU, and Aisyiyah‘s to be frequently re–conceptualized, drafted, and practical tips on feeding, supplemental chair, Mrs. Siti Noorjannah, participated in edited, and finalized for posting. Appropriate 3. Digital Media feeding, immunization, draws their attention. videos produced by and aired on ANTV, the visuals, such as photos, infographics, and other Social Media is Appropriate and Effective Detailed content and messages on government second largest television channel in Indonesia. illustrations need to be prepared. This is a policies has no value. Mothers and caregivers time–consuming process that relies on skilled Strategic Placement Increases Viewership The use of social media is appropriate are more interested in visuals and info graphics, writers and graphic designers. Investment in and effective in Indonesia, because 1) it is not long, text–heavy articles. The strategic placement of TV fillers during extremely popular, 2) it is cost effective, and 3) a dedicated digital team was required, due important holidays, festivals, and “health events” it extends program reach to rural areas, where to the specialized nature of digital media Moreover, an increasing number of decision– (e.g., Global Handwashing Day), and featuring social media can complement interpersonal formatting and content. Additionally, linking makers are using Twitter to engage with the use of prominent and respected figures, can communications interventions. If social media the multiple platforms was a critical step in their audiences. Through connecting with ensure increased views of campaign broadcast channels are used, however, governments and creating a snowball effect. Audiences were relevant Twitter accounts, the delivery of materials. For example, NNCC fillers aired during NGOs should consider capitalizing on other drawn to content presented through banners, succinct campaign advocacy messaging can Ramadhan were timed for broadcast a few media channels as well, because multiple media infographics and interactive photos. These be amplified and reach a wider, and more minutes before the call to prayer at the end of channels that link to each other and to other visually appealing formats allow the user to scan influential, audience. information quickly, and to easily access and the day—the time to break the daily fast. The websites with similar content can reinforce Increase Traffic via Facebook Ads timing effectively linked these important social messages. Implementing organizations should read campaign messages on stunting, nutrition, and religious events with NNCC’s messages, and also ensure that social media complements and sanitation. However, creating attractive, NNCC found that Facebook ads were a they reached a total of 17,482,400 television other communication interventions. NNCC informative, and effective visual content cost–effective way of increasing traffic on its viewers (33 percent of all television viewers). The found that while social media made it easy to requires skilled design staff. Facebook page (Gizi Tinggi). Buying Facebook ads is essential to driving higher traffic and Ramadan fillers were also placed on www.viva. improve norms and increase knowledge in Avoid “Text–Heavy” Formats co.id (1,726,492 visitors) and ANTV‘s YouTube easy–to–reach sub–districts, in less accessible generating “likes.” According to the latest media channel (74,102 subscribers and 40,000 views). regions, it alone was not sufficient. To address Lengthy, text–heavy webtorial formats were not data, people in Indonesia increasingly get their this limitation, NNCC provided incentives to suitable for the media environment, in which information from Facebook thanks to improved midwives and volunteers to conduct home audiences have a wide range of content to Internet access through mobile devices such as choose from. What was suitable to conventional smartphones and tablets. print media did not necessarily transfer well to the digital format. Digital content must be concise and attractive to compete in the social 44 A Summary of Lessons Learned NNCC Model and Lessons Learned 2014 - 2018 45

4. Print Media reporters and editors, nutrition experts and decision makers to discuss stunting issues. This Build Partnerships with Journalists (print & NNCC involvement with journalists helped to electronic) raise the visibility of stunting in the national Journalists play an important role in media. Between November 2015 and February disseminating correct information about topics 2018, 543 articles were published in both print that are poorly understood, provided they have and digital media outlets. a clear understanding of the issues. Therefore, Throughout the campaign period, the NNCC establishing good relationships and engaging organized media engagement activities journalists early on is necessary to increase their such as campaign media visits by print (and knowledge and awareness about stunting, and electronic media) representatives. These proved the importance of nutrition, sanitation and to be a cost–effective way to engage national hygiene, and keeping these issues high in the and regional media, build relationships with media agenda. Orientation and training for journalists, and generate national and regional journalists is necessary so they can correctly, news and in–depth articles on stunting issues, effectively and ethically report on stunting and at the same time highlight campaign issues, and to ensure an increased frequency of activities. NNCC conducted site visits for electronic and print media coverage. journalists and took part in journalist forums Ensure Adequate Budget for Print Media Collaborating with health works, cadres and At the provincial level the NNCC provided over to keep stunting high on their agenda. This community members was expedited by forming Purchased advertisements placed in regional 209 journalists with a two–day orientation proactive approach in engaging with journalist partnerships with local CSOs. Partnering with daily media can reach a large number of readers. on stunting issues, ensuring they had associations, and meeting on a regular basis CSOs is a recommended approach as they are However, this requires resources to support a basic understanding of stunting and with editors of major news outlets, can help well rooted in districts, have good networks the conceptualization, research, and writing the importance of sanitation in stunting influence public opinion, which can in turn within the health sector, and maintain a of advertorials and placement into popular reduction. The orientation allowed journalists influence the policy and decision–making consistent and dependable presence within the dailies. The NNCC learned that working with to visit Posyandu and see Mother Groups process. communities they serve. Moreover, their good local experts and government counterparts in action and engage with health workers. relations with local government officers and who have connections to regional media is an The NNCC also held Editorial Meetings with decision makers helps to move advocacy efforts effective, economical approach to accessing free forward. media in the form of free opinion editorials. Selection of CSOs was a formal process entailing the review and assessment of 5. Partnering with health workers, proposals submitted by CSO, site visits, and cadres and communities interviews with CSO staff. The NNCC views their relationship with CSOs not as subcontractors, Building trust and social connection is critical but as full partners in the campaign effort. This to ensure the success of communication relationship have them a sense of ownership in interventions at the community level. If those the campaign. Not only did the NNCC benefit at the community level trust the program, and from working with the CSO, the NNCC also the program’s messages, the more effective helped to build their capacity by increasing their the program can be. With this in mid the NNCC knowledge on stunting, and skills development worked to build strong relationships with health in programme management, finance, and works, cadres and community leaders and monitoring and evaluation. The campaign influential individuals. This involved training also provided them with communication, and up and supporting health workers, helping monitoring and evaluation tools. Coordination to make a Posyandu visit more appealing among CSOs was carried out by NNCC Provincial and worthwhile, and supporting the work of Coordinators. respected community health workers such as cadre and bidan. 46 A Summary of Lessons Learned NNCC Model and Lessons Learned 2014 - 2018 47

“This is the way….”, a more effective approach is to ask mothers “How do you….”, or “What do you….”. With this engaging approach, mothers feel their opinions and ideas are being respected which contributes to the learning process.”

For example, rather than midwives and cadres ensures that IPC skills become second nature. In Interpersonal Communication Skills IPC training designed by the NNCC ensure that lecturing to mothers “This is the way….”, a more addition, funding should allow for a maximum Development five key topics were covered. These included: effective approach is to ask mothers “How do number of midwives and cadres, as well as Based on NNCC formative research, knowledge 1. Stunting and 1,000 HPK (First 1,000 you….”, or “What do you….”. With this engaging other health workers, to attend training. It is days of life, introduction on healthy approach, mothers feel their opinions and ideas important that training content and methods of stunting issues, and communication skills, behaviors that prevent stunting) specifically interpersonal skills, were seen to are being respected which contributes to the be customized to meet the needs, technical be limited among staff at Posyandu. Moreover, 2. Maternal nutrition — Frequency of learning process. This “non–lecture” approach level, and capacity of cadres and health workers. meals and consumption of iron tablets while most mothers attend Posyandu regularly, involves the mothers, encouraging them to Training design should ensure that content very few had ever received information on 3. Maternal nutrition — consuming ATIKA ask questions, and contemplate and process is more practical and less theoretical so it can (Liver, Fish, Eggs) stunting or nutrition. Thus, the NNCC realized the information provided by the midwives be easily applied by midwives and cadres, and that many health workers required IPC skills 4. Active feeding to motivate child to eat and cadres. Ultimately, an improved quality of other health workers his/her meal — IYCF communication and dialogue between health training to enable them to effectively deliver To Increase Posyandu Attendance, workers and mothers can lead to an increased campaign messaging including IYCF and 5. Sanitation (the use of latrines and hand Improve the Posyandu Experience sanitation messages, correctly use IEC materials, washing with soap) likelihood of behavior change. and increase their knowledge of stunting To increase the number of times mothers bring Training on IPC skills for midwives and cadres IPC skills training for midwives and cadres and nutrition to have a greater chance to their children to the Posyandu, the experience helps to improve the learning experience of the not only improves their ability to effectively influence behavior change among the target must be made fun, exciting and worthwhile mothers. Rather than delivering information communicate with and influence behavior groups. NNCC designed an IPC training prepare for the mother. Counseling sessions at the via a drab monologue, midwives and cadres change among caregivers, it also provides communicators at the community level— health centers should be followed by engaging with improved IPC skills can engage in lively, them with the capacity to transfer IPC skills to specifically midwives and cadres—in delivering and fun activities such as healthy cooking entertaining and engaging two–way dialogue their colleagues. However, a one–off training key nutrition messages and motivating mothers demonstrations, quizzes, games, discussions, with mothers. experience is not adequate; training needs to be and activities for children. Making a trip to the to focus on improved nutrition for their babies comprehensive. Midwives and cadres need to Posyandu a fun yet educational experience and during pregnancy. attend several training sessions to understand can lead to a stronger and more effective IPC concepts, practice group and one–on–one engagement between the health workers, communication skills and become proficient mothers, fathers, midwives, and cadres. at passing on those skills to their colleagues. Multiple trainings, and refresher training, 48 A Summary of Lessons Learned NNCC Model and Lessons Learned 2014 - 2018 49

A budget to support the purchase of “prizes” Diseases Disorders Prevention and Management (e.g., for mothers whose babies have improved program; Integrated Management of Childhood nutrition statistics) and simple “gifts” for Illnesses; and Family Planning and Reproductive attending the Posyandu (such as hand soap, Health Services. dishwashing liquid, etc.) for mothers will Link Campaign Activities with National be required. Improving the IPC skills of the Events Posyandu contributes to improving the activities carried out at the Posyandu, and in A campaign should conduct nutrition and turn helps to increase attendance. sanitation promotion events concurrently with national health and nutrition calendar events, Support Outreach such as World Breastfeeding Week and Global Midwives, cadres and health workers need Handwashing Day. By linking to and associating support to ensure an adequate frequency with ongoing activities, a campaign can benefit and intensity of message dissemination and, from media representatives in attendance, reach most importantly, to build genuine, trusting a broader range of participants, and minimize relationships with target audience members. the burden on local health staff. Improved outreach requires on enhanced Build Broad Partnerships provision of human resources, skills training for staff, and adequate funding. This can be A campaign must have broad partnerships and accomplished by working with local leadership proactively engage with informal and formal to ensure guidelines, interventions, and community leaders to ensure their support supporting budgets focusing on nutrition for the implementation and sustainability While government regulations prohibit Ria Masupa, a village in Mandau Telawang, and stunting are articulated in the RAD–PG. of activities. A campaign must use all deliveries without assistance from health requires a six–hour boat journey from the sub– Such an official commitment, in writing, can communication channels that are available professionals, not all areas in Kalimantan district capital at a cost of up to IDR 6 million help to improve access to healthcare services in communities, including sermons for use in have trained midwives. Consequently, the (US$450)—an immense obstacle for Posyandu for mothers and children, especially those mosques and churches and talks for pengajians services of bidan lewus are in high demand. workers. The NNCC facilitator organized a in remote villages who often lack access to (neighborhood religious gatherings). They not only ensure accessibility to remote community meeting to find a suitable solution. transportation to visit Posyandu or Puskesmas. locations, but they can also provide comfort The community came up with the idea to Collaborate with Bidan Lewu Supporting outreach through RAD–PG can help and companionship nearly 24 hours a day as develop a “floating Posyandu,” or Posyandu ensure that nutrition and stunting messages While the NNCC collaborated with a variety they live within the community they serve— Apung, which is supported by a local private reach all target groups through various of government and non–government something that no midwife can provide. The sector plantation company. The Posyandu methods and channels including interpersonal, stakeholders, the campaign also realized the NNCC involved bidan lewu in the stunting Apung conducts routine services every month small group, community, and mass and social high–value—and logistical necessity—of reduction campaign by providing them with IPC in which basic health and nutrition necessities media. partnering with bidan lewu (traditional healers/ capacity training and communication materials are delivered. Two midwives and cadres to promote good nutrition and stunting accompanied by facilitators from NNCC and GSC Capitalize on Existing Health Programs birth attendants), which are very popular in remote areas in Kalimantan. Collaborating with prevention. Their links and influence within the (Generasi Sehat Cerdas) now run the Posyandu Linking campaign activities with existing bidan lewu ensured that the promotion of community to promote good nutrition was very Apung, providing the same service as any other health programs can lead to a more efficient good nutrition and sanitation practices could useful to the campaign. Posyandu. In cases where access is extremely difficult, midwives and cadres can consider and effective dissemination of messages on effectively reach remote areas where access to Ensure Accessibility to Remote Locations stunting. These platforms include Maternal and health facilities and services is limited. carrying out counseling follow–up by phone. Neonatal Health Services; Water, Sanitation, Campaign design should consider access issues And, as previously mentioned, another way to and Hygiene interventions; the Diarrhoeal for remote locations and identify flexible, access remote locations is to partner with bidan innovative solutions. For example, reaching lewu. 50 A Summary of Lessons Learned NNCC Model and Lessons Learned 2014 - 2018 51

Advocacy Targeting Political Leaders is an feels comfortable discussing stunting and its Essential Step implications and is working to move stunting to the top of the health agenda. More importantly, Political commitment, from the national to in Landak and Kapuas, the district governments the local level, is key to successful campaign are in the process of issuing regulatory implementation and is generally correlated frameworks to accelerate stunting reduction, a to the relative success of the campaign. For major achievement for the NNCC effort. instance, in OKI the NNCC benefited from high–level support and involvement from the Establish a Synergy to Amplify Campaign DHO and district head. This resulted in close Impact collaboration with the DHO officials, which As part of the Community Based Health and aided the smooth implementation of activities. Nutrition to Reduce Stunting Project (CHNP), the Their appreciation of the urgency of the issue NNCC linked up with the other two components influenced the commitment of the district of the project—the “Community Project Activity government counterparts. Therefore, prior at the Demand Side” (financing of community to seeking participation from government block grants, and participatory planning and counterparts, advocacy—relying on accurate, technical assistance to communities) and the clear, easy to comprehend arguments—was an “Supply Side Activity” (financing of training to essential step toward building understanding service providers, and appreciation of the issues surrounding 6. Empowering Families to Improve 7. Engaging Multi–Stakeholders stunting. The importance of advocacy at all as well as private sector interventions. By taking Quality of Life to Create a Supportive Policy levels cannot be overemphasized. the lead in coordinating with other CHNP Environment components and including them in multi–sector Promote Male Involvement The NNCC engaged in continuous dialogue and forums, the NNCC helped to strengthen the Conduct Stakeholder Mapping advocacy with key district decision–makers, The role of men, especially fathers of young overall impact and improve program outcomes. including the head of the District Health Office, children, was found to be critical to To ensure appropriate campaign design and The three CHNP components working in the head of Bappeda, and the head of the efficient implementation, it’s essential to partner harmony created a synergy to support the decisions on health and nutrition care for the district. Advocacy interventions and media with influential local groups, both government Posyandu, mother groups, counseling, and male family and for improving child rearing practices. tools to increase awareness and enhance and non–government. Stakeholder mapping is participation. This synergy also helped to Male involvement should be a key element in outreach were particularly valuable. District a critical first step in identifying the best local clarify the role and value of the RAD–PG by community outreach. Special messages should level public discussions were conducted to implementing partners. Stakeholders include all stakeholders, including informal leaders, be developed targeting men to enhance their create and facilitate public discourse about all groups that can affect and have influence community members, and the private sector, understanding of the severe consequences stunting. The NNCC held meetings with district on the development, implementation and resulting in more inclusive and comprehensive of stunting and to encourage a more active parliamentarians to increase their awareness management of interventions focusing on plans. role in child nutrition. Topics of discussion and understanding on stunting prevention and nutrition and stunting, as well as those who most effective in increasing men’s interest to urge them to support stunting reduction Target Faith–Based Organizations in will be targeted by interventions. Stakeholder included the economic value of breastfeeding, policies and programs. The NNCC assisted Advocacy Interventions mapping involves identifying, analyzing and complementary foods made from cheaper local districts to develop district–level plans and prioritizing these groups and organizations. In Indonesia, it is highly effective to work produce, and monitoring a child’s development. to advocate for the use of village funds This effort will allow for the identification with and gain support from faith–based to reduce and prevent stunting. Through and selection of local implementing partners organizations (FBO) to deliver campaign this approach, government counterparts who are the most established, have the most messaging and support advocacy interventions. transformed from being the advocacy target influential political connections, and will be FBOs have well established, wide social and group to becoming advocates for stunting in the best position to collaborate effectively political networks that can be used as platforms reduction. These influential government staff with program coordinators. Taking the time to communicate stunting reduction messages became “Champions” for the NNCC effort. to identify local implementing partners at the and build capacity of their members, and For example, the head of Landak district now beginning of the campaign will help to ensure influence decision makers. Moreover, FBOs have the campaign has a greater chance of success. 52 A Summary of Lessons Learned NNCC Model and Lessons Learned 2014 - 2018 53

a vast membership, giving them a strong and strengthened, messaging can reach a wider local stakeholders, and it produced innovative, activities were implemented on time and influential position in advocating for supportive audience, and target groups can be mobilized responsive local interventions. For example, as planned. In OKI, the best performing government policy and resource allocation to take action. Social mobilization can bring Desa Pematang Sukatani, Kecamatan Mesuji NNCC district for outreach activity, sub– to combat stunting. Because of their size and people together to work more effectively and Makmur, Kabupaten OKI, did not have any district facilitators with health and nutrition influence, FBOs can be effective partners in both ensure greater impact by the campaign. At the health facilities; community health activities backgrounds were recruited from local residents advocating for increased government support national level, the NNCC joined forces with three took place in the village office, school, or who had a strong sense of ownership of NNCC to stunting and nutrition interventions, as well agencies: 1) Nasyiatul ‘Aisyiyah; 2) Fatayat NU; in front of a house. Assisted by NNCC, the community–based interventions. as deliver messages and support down to the and 3) PERSAGI (Persatuan Ahli Gizi Indonesia — community held meetings and advocated for Engagement with government counterparts is village level. For the greatest effect, media Indonesian Nutritionist Association). Together use of village funds to build a Posyandu. By not only essential during the implementation resources developed should be tailored to with these partners the NNCC more effectively April 2017, an 11 x 7–meter building was ready of a campaign; government consultation appeal to the different characteristics of each planned and implemented advocacy and social for use, enhancing health service delivery. The and cooperation during the design phase is faith in terms of language and imagery. mobilization activities. community developed an understanding of a fundamental step that needs to be taken how village funds can be used for many sectors The NNCC advocacy partnership included Fatayat NU established the “Barisan Nasional before the campaign activities begin. Meetings including health and that allocation of funds several FBOs. These organizations have Cegah Stanting” (National Group on Stunting with high–ranking officials about planning will only happen if the community expresses strong and extensive networks from national Prevention). Mainstreaming of stunting and implementation of campaign activities their opinions and advocates directly with their to community levels, and they have strong prevention was also carried out by Nasyiatul were more productive and effective when leaders. political influence that can be used to reach ‘Aisyiyah. Being an organization under they included a limited number of appropriate key decision–makers. The NNCC conducted Muhammadiyah, Nasyiatul ‘Aisyiyah took steps Build Broad Partnerships and Coalitions participants. NNCC found that smaller meetings an Interfaith Discussion Forum to provide a to ensure that nutrition and stunting issues resulted greater government support, because Broad partnerships and coalitions made this platform for these FBOs to meet, communicate, were adopted by other organizations affiliated the more intimate forums were more personal nutrition campaign successful. Key stakeholders and network for stunting prevention initiatives. with Muhammadiyah. PERSAGI contributed to and open. Large meetings were less productive. in the Indonesian context included religious Attending the forum were representatives the stunting prevention movement through institutions, the local military and police from Fatayat, NU, Muhammadiyah, Nasyiatul organizing round table discussions with authorities, and the PKK (Pemberdayaan Aisyiyah, Pemuda Muhammadiyah, Pelkesi numerous health professional organizations and 8. Monitoring and Evaluation Kesejahteraan Keluarga). Involving key local and and the Salvation Army (Evangelical Christian various health education associations. regional decision–makers in television and radio The need to invest in a well–functioning and Protestant), Perdhaki and Konferensi Coordination with Field–Level talk shows helped to increase their concern monitoring and evaluation (M&E) system is Waligereja Indonesia (Catholic), Yayasan Implementers with stunting issues. Communicating with widely recognized. A well–functioning M&E Buddha Tzu Chi and Perwakilan Umat Buddha the public through the media increased their system should provide essential data for routine di Indonesia (Buddhist), Parisada Hindu Strong coordination among district level sense of accountability on addressing the issue. tracking of project activities, guide the planning, Dharma Indonesia (Hindu), and Majelis Tinggi implementers including GSC facilitators, Following participation in NNCC–supported coordination and implementation of a program Agama Khonghucu Indonesia (Confucian). The Puskesmas, and campaign facilitators was television and radio talk shows, government and rapidly identify problems for course leadership of these organizations agreed that critical to providing the necessary support for staff paid greater attention to stunting and took correction, sustained program improvement stunting is an important and relevant issue community behavior change for improved appropriate actions. One possible explanation and rational resource allocation. both for their members and their organizations. breastfeeding, ICYF, and sanitation practices. for their increased commitment may be that Leadership agreed to strengthen and maintain NNCC’s data generation, analysis and use was The RAD–PG, mandated by a Presidential Decree government staff felt compelled to address the interfaith network as the mandate of the a collaborative effort across the various project to accelerate and better coordinate stunting stunting because community members knew Interfaith Discussion Forum and to act as an levels and was aided by the use of technology. reduction programs at the sub–national level, about it as a result of the NNCC’s radio and advocacy group. Quantitative information was collected through was a successful approach to coordinating TV campaigns, and they demanded that IMA World Health’s health management Collaborate Existing Networks for Social community implementers. The RAD–PG process government respond to the issue. Creating information system (HMIS)—Applied Data Mobilization created concrete plans on food and nutrition, a dialogue between communities and the Vehicle for IMA Support and Evaluation including stunting reduction, to be executed government was an important result of the By collaborating with existing networks and (ADVISE)—a customized version of the widely by different multi–sectoral government offices. mass media approach. agencies working in the health, nutrition, used District Health Information System 2 This approach was highly effective at increasing and sanitation sectors, interventions to Locally recruited facilitators were effective at (DHIS2)18. While the NNCC project believes awareness, commitment, and ownership by improve nutrition and reduce stunting can be ensuring that community–based outreach that ADVISE was only one of the many tools 54 A Summary of Lessons Learned NNCC Model and Lessons Learned 2014 - 2018 55

to track project implementation, it was critical substantial training requirements for users. This also included stakeholders meetings, website as well as the IMA home website. IMA in ensuring the data quality, completeness, Additionally, project implementers need to project review meetings with provincial and is currently working with the MOH, MCA- timeliness as well as the data utilization for be sensitive to the fact that often refresher district stakeholders, as well as advocacy Indonesia and other stakeholders to place the project improvement. Through this iterative trainings are required to reinforce and meetings at all levels throughout the Lessons Learned Document on their websites process a few key lessons emerged: update users’ knowledge and skills. implementation. At the national level to promote wider distribution. meetings and/or dissemination of Lessons » The monitoring system encouraged data » Routine supportive supervision is vital to IMA has also compiled all materials produced Learned have have been provided to MCA- ownership and investment among all project success. Regular communication, for documenting and sharing lessons learned Indonesia, Bappenas, MOH, Ministry of Village project stakeholders. Each ADVISE user checklists, data quality assessments into a package to be used by policy makers, as well as national level partners including, could not only enter data from their and reporting were all various forms of program designers and academia for future PERSAGI, Fatayat NU, Nasyiatul Aisyiah, and own jurisdiction, they could also track supportive supervision that the project SBCC for stunting reduction activities and PELKESI. their progress in comparison to other used to demonstrate project effects. strategic planning. jurisdictions. As such project improvement In addition to distribution to relevant partners discussions and decision–making were held and stakeholders, IMA has uploaded an throughout the various levels of the project, 9. Dissemination of Lessons Learned electronic version to the GizziTinggi.com rather than only at the top. Over the life of the project IMA has worked » NNCC’s monitoring system facilitated with partners to collect lessons learned for continued quality improvement and real– inclusion in the NNCC website, Facebook page time performance tracking. Since ADVISE and regular progress reports (i.e., quarterly was available to all users 24/7, it would reports, annual reports). On a regular basis, become very clear which villages, sub– these reports have been used to share ideas and districts and/or districts were meeting or strategies that are working, and to strengthen exceeding their targets on a monthly basis. collaboration and communication among the This bred some informal competition to range of partners. out–perform each other. IMA has produced and shared with MCA- » Information is power. NNCC’s monitoring Indonesia a summary of these lessons learned system ensured data transparency and as well as a vidoand, after receiving inputs, has accountability. As ADVISE was accessible obtained permission to share more widely. to all project stakeholders, it was easy to identify jurisdictions that were not IMA recognizes that there is a need to promote sustainability of stunting activities 1. 2013 Riskesdas (Basic Health Survey), Indonesia’s Ministry of Health reporting completely and timely. 2. Ahmad Syafiq, Sandra Fikawati (2015). Various Paths To Stunting: Qualitative Finding In Indonesia; IMA World Health Indonesia, Center for Nutrition and Health at the national, provincial and district levels. Studies Faculty of Public Health Universitas Indonesia » Developing a comprehensive project This has, in part, been done through the 3. These include as eating practices during adolescence and pregnancy, exclusive breastfeeding, complementary feeding, sanitation and hygiene practices, infec- tious disease prevalence, health–seeking behavior, food access and availability, gender norms, and education levels. monitoring system is not a small task and project’s advocacy activities but is also being 4. Prochaska & DiClemente, 1983; Prochaska, DiClemente, & Norcross, 1992 5. Final Report of Formative Research, Phase 1 National Nutrition Communication Campaign, April 2015, IMA World Health needs to be thought out from the project strengthened by widely sharing our Lessons 6. Around 55% of respondents did not dedicate a full six months to exclusive breastfeeding. design stage. Furthermore, commensurate Learned documentation. In the final months 7. More than 40% of infants had been given food or beverages other than breastmilk (in the form of formula milk, water, or honey) within the first three days after birth. funding must be allocated to allow for the of the project, IMA conducted meetings at 8. United Nations Children’s Fund. UNICEF’s approach to scaling up nutrition for mothers and their children. Discussion paper. Programme Division, UNICEF, New York, June 2015. implementation of the various systems and the national and district levels to more widely 9. Hodinott, J., Alderman, H., & Behrman, J. (2013). The Economic Rationale for Investing in Stunting Reduction. GCC Working Paper Series, GCC 13–08 processes. share the lessons learned with counterparts 10. Hodinott, et. al.; Quershy, L., Alderman, H., Rokx, C., & et al. (2013). Positive returns: Cost benefit analysis of a stunting intervention in Indonesia. Journal of Devel- opment Effectiveness, Vol 5 pp 447–465. and stakeholders. This dissemination was 11. MCC Indonesia Nutrition Project, Preliminary Baseline Survey Results, 2015 » A comprehensive monitoring system held in close-out meetings at the district 12. Ibid relies on capable users, particularly when 13. Ibid level that included partners and government 14. Ibid. information technology is being used. 15. UNICEF Indonesia Issue Briefs, October 2012 counterparts involved in project activities. 16. An impression is the number of times a post from a Facebook page is displayed, whether the post is clicked on or not. People may see multiple impressions Therefore, project design and budgeting of the same post. For example, someone might see a Page update in News Feed once, and then a second time if their friend shares it. Reach is the number of need to accommodate the potentially people who received impressions of a Page post. Reach might be less than impressions since one person can see multiple impressions. Engagement is the number of people who saw a post that reacted to, shared, clicked or commented on the post. A page like is the total number of people who have clicked “like” on your Page. 17. DHIS2 (https://www.dhis2.org/) is a real time database system used for data entry, aggregation, analysis and reporting purposes. It can be operated using desk- top or smartphone (Android) devices and has both online and offline capabilities. 18. DHIS2 (https://www.dhis2.org/) is a real time database system used for data entry, aggregation, analysis and reporting purposes. It can be operated using desk- top or smartphone (Android) devices and has both online and offline capabilities. IMA WORLD HEALTH National Nutrition Communication Campaign Gedung Wirausaha, 7th Floor, Jl HR Rasuna Said Kav. C-5, Jakarta 12940, Indonesia