Caregiving Behaviors for Nutrition and Child Development in Malawi: Maziko Report on People-Driven Design

"The premise for PDD suggests that engaging people directly in the design of the behaviour change process enhances their motivation and confidence to change behaviour. Proposed change is consequently feasible, appropriate, meaningful and locally supported."

People-driven design (PDD) is based on the principles of human-centred design (HCD) and was first developed by Empatika and Alive and Thrive in 2019. Rather than placing people at the centre of an externally driven process, PDD makes explicit that people themselves drive the process by helping identify their own behaviour challenges, setting goals, and developing their own ideas to encourage positive behaviour change. This report describes a PDD process to identify small doable actions to improve child nutrition and development in Balaka and Ntcheu districts in Malawi.

The PDD process was used to guide the social and behaviour change (SBC) component of the Maziko - Integrated Maternal and Child Cash Grant pilot project. Maziko is co-funded by Power of Nutrition, Save the Children, and Give Directly, with contributions from the Conrad N. Hilton Foundation and the Foreign, Commonwealth and Development Office (FCDO). The project has three strategic objectives to support pregnant women, lactating mothers, and mothers of children under three years old, including:

1. Improved access (financial and physical) to nutritious foods;
2. Increased uptake of recommended behaviours, addressed through information, advice support, and motivation to adopt recommended behaviours; and
3. Improved national, district, and sub-district enabling environments for access to nutrition-sensitive social protection, nutrition, and early childhood development (ECD) services.

As part of Maziko's inception period, Empatika was commissioned to design and lead research to provide a deeper understanding of the behaviours that drive poor maternal and child nutrition outcomes, along with the barriers and entry points to shifting them. The findings of this research identified possible nutrition priorities that informed the subsequent PDD process.

PDD requires that the design process is facilitated directly with those whose behaviour change is desired, as well as their support network, so that products and processes developed to support behaviour change are locally relevant, relatable, and owned. The PDD process typically involves four steps, beginning with Step 1 (immersion). This step was carried out as Phase 1 of this research; click here for access to the formative research report. The immersion research involved trained members of the Maziko team living with community members for four days and four nights. Team members were trained in conducting immersion research by Empatika mentors during a 4-day training including core qualitative research skills and respectful ways of undertaking research with people. This hybrid training included online sessions supplemented with group activities and offline field practicum.

Step 2: Inspiration involved deliberate and deep engagement by the study team with the particular context and behavioural determinants of current behaviour in order to brainstorm solutions. It comprised three elements:

• Deep engagement with the immersion findings to build empathy with the local context and local social norms and behaviours;
• Identification of key behaviours that might be amenable to change and that are judged to likely have an impact on chronic malnutrition and poor ECD, which are formulated as "How might we...?" challenge statements to inspire the next step (the use of the word 'might' promotes creative thinking and ideation with the premise that even if it does not work out, we will have learned something useful); and
• Identification of a range of possible solutions through a brainstorming approach with Save the Children and other stakeholders.

This understanding of behaviours and behaviour change also drew on the COM-B framework (capabilities, motivation, and opportunity for behaviour change)¹, which helped in the identification of key behaviours to be supported along four key themes: (i) family nutrition; (ii) exclusive breastfeeding for six months; (iii) better hygiene for babies; and (iv) engaging in early stimulation activities for babies and young children (ECD). These four key behaviour themes and findings around these were shared with the Maziko project team, Save the Children Malawi, and government stakeholders involved with the project. The Empatika team then crafted these behaviours into the following challenge statement to guide the co-creation process in each community:

• "How might we...enhance growth and development of babies through involvement of family members?"
• "How might we...bring together family members to support breastfeeding mothers?"
• "How might we...make sure babies and infants have fewer diarrhoeal episodes and to manage it better?"
• "How might we...help families (with small children and pregnant women) get nutritious food?"

During the PDD phase planning workshop, the Empatika team and Maziko project team discussed some potential ideas that might help to address the desired behaviour change for each challenge. After as many ideas as possible were generated, the group identified those they thought might be doable (those that did not require policy change, change in supply chains or directives for health providers or additional monetary resources).

Step 3: Design involved four teams of two facilitators who had previously undertaken the immersion research returning to the four study communities in April 2022 for three days to facilitate co-creation workshops with community members. All participants were selected purposively and included people belonging to different age groups, literacy levels, and, where possible, gender. After discussing and reviewing some of the key insights from the research team's immersion visit, participants were then facilitated to brainstorm ideas and solutions to their location's challenge. Ideas from the PDD planning workshop were used to prompt the discussion as needed. Participants then chose those ideas they decided were doable. The report documents how each of these steps were implemented by the facilitators for the four design challenges.

Reflecting on the experience, Empatika notes that engagement and participation is a process, and the quality of that process is more important than exposure to SBC products or one-off events intended to promote behaviour change. However, below are examples of SBC entry points for two of the design challenges:

• "How might we...enhance growth and development of babies through involvement of family members?" - example: interactive stimulation of children under 2 years old by involving family members like mothers, fathers, grandmothers, siblings in designing toys for babies and toddlers with locally available materials.
• "How might we...bring together family members to support breastfeeding mothers?" - example: a lullaby promoting breastfeeding that mothers could also sing to their babies.

Lessons learned for supporting the PDD process include:

• Core skills required for PDD differ from those typically required for programme staff and require significant training and support to develop.
• Mentoring is valuable and requires more intensive engagement and support to prepare first-time facilitators.
• If feasible, deeper engagement between mentors and facilitators is needed while in the villages.
• It is important to ensure that "How might we...?" statements are sufficiently narrow and focused on small, doable changes.
• The PDD experience should conclude by agreeing on steps for community trialing, even if a trialing period is not included in the PDD process. (Traditional PDD and HCD processes include a trailing phase, which involves agreeing with the community on a solution that they are excited to try out, as well as a process to do so with regular check-ins from the facilitators/mentors over multiple weeks. This full process was not included in the scope of this particular project.)

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¹ Michie S, van Stralen MM, West R. The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6(1):42.