In Indonesia, 37% of children under the age of five are “stunted,” meaning they suffer from impaired early growth. Stunting can lead to a life sentence of poor health and low achievement. This has a huge national impact, costing Indonesia 10.5% of GDP due to its long-term impact on the workforce.

In response, the government has made a national commitment to reduce stunting. Every village, district and province reports on their progress to the Vice President’s office, said Ravi Menon, the Global Alliance for Improved Nutrition (GAIN).

Working in the East Java region, which is home to nearly 40 million people, GAIN has been trialling a new approach: games. Based on behavioural science, they are designed to improve nutritional outcomes for young children. At scale, they could be a vital new tool in the government’s anti-stunting strategy.

So how do these games work, and what impact can they have?

Lightbulb moment

Working with the government and the London School of Hygiene & Tropical Medicine (LSHTM), GAIN’s program focuses on improving nutritional problems linked to stunting, including low breastfeeding rates, poor diets for young children, and unhealthy snacking.

Formative research demonstrated that mothers, though primarily responsible for feeding their children, were heavily influenced by their mothers-in-law, husbands and others. They were receiving advice which was often unhelpful, such as mothers-in-law suggesting solid food too early. “Mothers were well educated,” said Sian White, a research fellow at the LSHTM, but “we needed a way to break out of that noise”.

So they created “emo-demos” (emotional demonstrations); fun games to persuade mothers to follow new behaviours, and equipping them to push back against negative social influences. Led by community health workers, groups of mothers would take part in the emo-demos as they waited for child growth monitoring appointments at the local health centre.

“It’s a really quick way to create that visual sense of disgust”

All of the 24 games try “to create that lightbulb moment,” said White, with “a clear metaphor or moral.” For example, one game aims to increase breastfeeding, which is under threat from aggressive marketing from formula milk companies. The community health worker tells one mother to pack her things for the day as if they will be breastfeeding, and another mother to pack for using formula milk. The latter has far more to pack, teaching the mothers a clear lesson about how breastfeeding can be easier.

Another game was designed to reduce unhealthy snacking. With popular, brightly-packaged snacks from a local shop, the health workers put the snacks in boiling water. After a few minutes the dye and oil begin to separate. The community health worker then asks them, somewhat rhetorically, if they would feed that to their child. “It’s a really quick way to create that visual sense of disgust,” White said.

Getting to scale

Early results are encouraging: an independent evaluation found that over two years the programme increased breastfeeding rates by 14%, and 13% more toddlers consumed diverse diets. One of the target behaviours, improving anaemia during pregnancy, did not show improvement in the evaluation, but had only been active for 12 months.

So far, the program has reached 250,000 women, while 300 master trainers, 10,000 community health workers and 18 universities have been trained in the methodology. They are now working to cover the whole province and are expanding into 10 more.

“We didn’t know it could work for nutrition — it clearly did”

The big challenge is that gathering and training all the health workers takes time and is highly expensive, said Menon. Changing behaviour needs people, which means it costs money to scale. GAIN are looking for affordable ways to scale training, such as by analysing the effectiveness of training videos and creating 2-page step-by-step guides which are easy to follow.

The holy grail, however, would be to get public national accreditation. Once accredited, community health workers — who are often burdened with several tasks at once — can get points when they do the training, which can be used to gain promotion and better remuneration. Most of the work is voluntary, and these incentives could make a huge difference to scaling up.

A promising future

The success so far of emo-demos in Indonesia points to the broader potential of behavioural science in improving public health around the world. Their main use so far has been in hygiene and sanitation, said White. LSHTM, for example, are already working on using them to improve hygiene in humanitarian crises, and to improve sanitation coverage in India and Tanzania.

“We didn’t know it could work for nutrition and it clearly did,” said Menon. As policymakers around the world look for answers to some of the biggest nutrition issues, such as childhood obesity, emo-demos could prove to be a vital tool. — Jack Graham

(Picture credit: Scott Kuo/Flickr)

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