Using Formative Research to Inform a BCC Strategy to Increase Food Security and Dietary Diversity in Low-Income Rural Communities

Research Article

Int J Nutr Sci. 2021; 6(3): 1055.

Using Formative Research to Inform a BCC Strategy to Increase Food Security and Dietary Diversity in Low-Income Rural Communities

Turk T1,2*, Safdar NF3, Hashmi S4, Shah N5 and Zaheer S5

1Communication Partners International (CPI), Springfield, NSW, Australia

2Adjunct Professor, School of Public Health, Dow University of Health Sciences, Karachi, Pakistan

3Adjunct Associate Professor, School of Public Health, Dow University of Health Sciences, Karachi, Pakistan

4Assistant Professor, School of Public Health, Dow University of Health Sciences, Karachi, Pakistan

5Senior Lecturer, School of Public Health, Dow University of Health Sciences, Karachi, Pakistan

*Corresponding author: Tahir Turk, Communication Partners International (CPI), 24 Dulwich Road, Springfield, NSW, Australia

Received: May 28, 2021; Accepted: June 22, 2021; Published: June 29, 2021


Background: Adequate nutrition is a public health priority, particularly in low-income rural areas where there is a high prevalence of malnutrition and stunting. Baluchistan is an arid desert and mountainous province with the worst health indicators in Pakistan. The objective of this research study was to identify current knowledge, attitudes and practices of vulnerable women with young children residing in remote areas of Baluchistan and assess their information needs to guide the development of a BCC nutrition strategy materials and activities.

Methods: This study design incorporated formative research via eight focus group discussions with demand and supply-side program beneficiaries (n=124) to assess current nutrition knowledge, attitudes and beliefs toward kitchen gardens and proposed nutrition resources. Semi-structured interviews (n=16) were also conducted to provide program intelligence from key informants. A literature review supported the development of discussion agenda based on predominant behavioral theories. Data analysis was conducted with in vivo qualitative software coupled with grounded theory with qualitative findings triangulated.

Results: The study identified important factors for the development of BCC resources and activities. Opportunities included effective nutrition education, improved income and livelihoods from kitchen gardens, women’s empowerment and gender equality. Challenges included traditional cultural practices, entrenched food preparation behaviour, environmental and infrastructural constraints.

Conclusions: Lessons learned highlight the benefits of integrating formative research methods with a comprehensive literature review and behavioural theories for the development of BCC resources for nutrition programs in insecure and resource-constrained settings.

Keywords: Behavior Change Communication, Nutrition, Food Insecurity, Needs Assessment, Formative Research


AusABBA: Australia Baluchistan Agri Business Programme; BCC: Behaviour Change Communication: BNPMC: Baluchistan Nutrition Project for Mothers and Children; FAO: Food and Agriculture Organization; FGDs: Focus Group Discussions; KGP: Kitchen Gardens Project; RAR: Rapid Assessment and Response; SSIs: Semi-Structured Interviews; UN: United Nations; UNICEF: United Nations Children’s Fund


WHO estimates that globally, 2 million children under 5 years of age are wasted, 17 million are severely wasted and 155 million are stunted, with around 45% of deaths among children under 5 years of age linked to undernutrition [1], which mostly occurs in Low and Middle Income Countries (LMICs) [2]. Child stunting and malnutrition is also associated with lower dietary diversity with food insecurity and poor household food choices contributing to the lack in meeting children’s nutrient requirements [1,2]. Additionally, malnutrition is seen to predominantly occur in regions where there is limited access to high protein foods, poor vegetation cover and a proxy of rainfall or drought [3]. Socioeconomic determinants also play a significant role in food insecurity and diversity of food choices, which lead to childhood and maternal malnutrition [4].

Baluchistan is an arid and remote province situated in the South West of Pakistan. The Province covers around 44% of the total land mass of Pakistan, making it the largest of the four Provinces in the region. Health and nutrition are a major problem in Baluchistan, which has the worst health indicators of all other Provinces in Pakistan.

Many districts in Baluchistan are food insecure with women and children being most affected by food insecurity and malnutrition. As a result, the Province has the highest prevalence of malnutrition with a globally critical level of stunting of 47% in children under the age of five [5].

There are multiple determinants of stunting and malnutrition that pose challenges toward improved nutrition in Pakistan. Recommendations on strategies to improve nutrition outcomes include a greater focus on poverty alleviation, improvement of mother’s health literacy including community-based education and targeted nutritional interventions, and accessibility to health care facilities. Furthermore, behavioural interventions that can address the limited exposure to information and geographical isolation of most vulnerable groups are seen as being much needed in the Baluchistan context [6].

Given these factors there is a considerable need for Behaviour Change Communication (BCC) programs to improve nutritional outcomes in the province and health seeking behaviour [7]. however, the nature and extent of behavior change activities is uncertain due to the current lack of understanding of the cultural dynamics that may affect dietary attitudes and practices in these areas. To support greater integration and institutionalizing of strategic, evidence based BCC approaches a Kitchen Gardens Project (KGP) was established to add value to the efforts of inter-sectoral integration of donor programs aiming to achieve improved nutrition outcomes.

The Baluchistan Nutrition Project for Mothers and Children is funded through the Australian Government under the World Bank’s Multi Donor Trust Fund for Nutrition. Project components are designed to address general malnutrition in women and children, micronutrient malnutrition, BCC and strengthening of institutional capacity. The initial BCC component was involved with assessing needs for the development and implementation of the KGP messages and a set of basic but innovative nutrition communication products to improve nutrition behaviour. Additionally, a training package to improve family dietary and child feeding practices of mothers with infants was also required to support greater participation in the KGP for improved nutrition to be implemented through a Pilot Project.


The formative research method used for the development of the Pilot Project Plan comprised of Rapid Assessment and Response (RAR) approach. RAR has been found to be a cost effective, pragmatic method of public health and social issues research allowing for rapid collection of programme intelligence to support the development of BCC plans [8-10]. The application of RAR was of particular importance in the resource constrained and insecure settings of Baluchistan with the fieldwork needing to be conducted in a short time period, while ensuring adequate levels of safety for field teams. Despite the limitations a best practice approach to designing effective behavioral change interventions was embarked upon, including an assessment of participants’ health behaviour and examination of the type of actions needed, with the objective of tailoring the interventions to best meet the participants’ needs [11].

The RAR method included academically robust, qualitative approaches, including Semi Structured Interviews (SSIs), Focus Group Discussions (FGDs), observational research, case study approaches and narratives, which are seen to have generally been underutilized in public health program research [12]. These qualitative methodological approaches to data collection were seen as potentially powerful tools for understanding the culturally specific influences exacerbating the challenges in Baluchistan [13]. An added innovation to the formative research, to garner additional insights for possible BCC messaging approaches, was the use of Photo voice participative research techniques [14]. Photo-voice was seen as having the potential to provide messaging from local opinion leaders, which could be used during the project implementation stage. Ethics approval for the study was obtained from Dow University of Health Sciences, Ethics Committee (Approval number: IRB-/399/DUHS/ Approval/2019).

The first step of the study involved an audit of existing nutrition resources in the Province with the intention of pretesting key resources as a component of the formative research. Next, was completion of a literature review to provide context for the program. International and national literature was sourced from 27 online databases as well as grey literature and internal reports sourced from provincial stakeholders. Predominant behavioural theories applicable to the study were also identified with key variables incorporated into the program logic framework, objectives, SSI and FG discussion agenda. Behavioural theories most relevant to the nutrition project included Health Belief Model which explores variables of target audience perceived susceptibility, severity, barriers and benefits [15]; Theory of Planned behavioural and Social Cognitive Theory which explore variables of perceived behavioral control, self-efficacy, outcome expectancy and environmental influences [16,17]; diffusion of Innovations which examines the role of local opinion leaders in the diffusion of new agricultural practices [18], and Nudge Theory which posits the importance of providing incentives to elicit greater engagement in health programs to influence dietary behaviour [19]. BCC program objectives emanating from the behavioural theories included increasing target audience awareness and knowledge about the risks of malnutrition; changing attitudes, beliefs and selfefficacy perceptions; shaping community social norms through influencers and other role models, increasing motivation to engage with the program through incentives, and building practical skills and behavioral intentions toward establishing KGs to grow nutritious, protein dense, produce.

Given the the ongoing insecurity concerns in the province, fieldwork approaches deployed a small field team of three staff to travel to the capital city of Quetta to conduct the SSIs and travel onward to project intervention districts of Kharan and Nushki.’ SSIs were facilitated with 16 key informants as the approach has been found to offer a flexible and powerful tool to capture local people’s voices and how they create meaning from their experience [20]. Key informants interviewed included Program Directors, Deputy Directors and Program Managers, Provincial BCC Consultants, District Nutrition Officer’s, the Head of the Lady Health Workers, and Provincial Nutrition Directorate staff working with at-risk groups.

Additionally, Technical Advisor’s and Team Leaders from the Women’s Economic Empowerment and Agri-Business Units were interviewed as were Trainers from the Food and Agriculture donor agency, representatives from UNICEF, World Food Program, and the World Health Organization.

Insights from the SSIs and the literature review informed the development of discussion agenda for the FGDs. Eight FGDs were conducted with program beneficiaries as the approach has been found to be a pragmatic method of formative research with community participants who, on their own, may be reluctant to be interviewed or who may feel they have nothing to say [21]. Convenience samples of participants for the FGDs were selected following training workshops and during the field visits. Group segmentation included demand and supply side participants segmented by gender, age, socioeconomic status and location. A structured screening instrument was used to screen participants prior to recruitment (Table 1).