EFFECTIVENESS OF SOCIAL MARKETING ON KNOWLEDGE, ATTITUDE AND PRACTICE ON CHILD NUTRITION BY WOMEN IN SOUTH-WEST NIGERIA

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EFFECTIVENESS OF SOCIAL MARKETING ON KNOWLEDGE, ATTITUDE AND PRACTICE ON CHILD NUTRITION BY WOMEN IN SOUTH-WEST NIGERIA

ABSTRACT

Despite intervention programmes aimed at improving child nutrition in Nigeria, the number of children with poor nutrition has consistently increased over the years. The usual top-down management approach to execution of intervention is contributory to this problem. Social marketing, a bottom-up and effective approach to intervention, has not been well studied in Nigeria. The effectiveness of social marketing on knowledge, attitude and practice of child nutrition by women in South-West Nigeria was therefore investigated.

The study was carried out using quasi-experimental research approach and Focus Group Discussion (FGD). Two hundred and forty women were selected by systematic random sampling from ante-natal clinic in primary health centres in selected 10 local government areas in Oyo (4), Ekiti (3) and Osun state (3) based on probability proportionate sample to size with 90, 75, and 75 women interviewed from each of the states respectively. Data were collected from the two groups using structured questionnaire which included 50 points-knowledge, 17 points-practice and 5-points Likert-attitudinal scales before and after exposure to nutrition messages. In addition, one FGD each was conducted among women in each of the 10 LGAs. Fifty percent (experimental group) were exposed to nutrition messages for 12 weeks with emphasis on social marketing techniques, while the remaining served as control. Parameters assessed were women‟s personal characteristics, knowledge, attitude and practice with respect to child nutrition. Data were analysed using descriptive statistics, problem tree analysis, Pearson Product Moment Correlation, Chi square and t-test at p = 0.05.

Mean age of women was 33 ± 7.7 years, 69.6% were married, mean household size was 5.10 ± 2.4 and mean number of children under-five was 2.90 ± 1.49. Half (50.4%) were educated and majority (67.5%) engaged in petty trading. The mean monthly income wasN20, 330 ± 17,052. At baseline, information sources included radio (75.4%) and television

(54.2%). Attitude to nutrition messages revealed favourable disposition to communication

channels/promotion (53.8%), environment/ place (58.8%), nutrition messages/ product (53.0%) and abandonment of previous nutrition behavior/price (64.2%). The discussants stated that child nutrition was affected by income, cultural preference and nutritional knowledge. Post-intervention evaluation showed that the experimental group manifested an increase in knowledge from 50.4% to 90.2%, favourable attitude from 47.8% to 68.9% and nutrition practice from 58.3% to 75.5% when compared to increase in knowledge 50.6% to 57.2%, favourable attitude 48.6% to 50.4% and nutrition practice 49.7% to 52.8% of the control group. Marital status (χ2=16.94), family size (r = 0.26), education (χ2= 44.45), occupation (χ2=21.00), and communication channel (r = 0.23) were significantly related to nutrition behaviour. Knowledge was significantly different in Oyo (t = 2.93) and Ekiti (t = 2.29), while attitude was significantly different in Oyo (t = 4.23) and Osun (t = 3.99) before and after exposure to nutrition messages. Respondents exhibited significant difference in nutrition behavioural (t = 2.62) before and after the intervention.

Social marketing using nutritional messages in audio, video and chart improved women‟s knowledge, attitude and practice of child nutrition. Adoption of the strategy for effective nutrition intervention programmes should be encouraged.

Keywords: Social marketing, Women behavioral change, Child nutrition, South-west Nigeria

TABLE OF CONTENTS

DEDICATION—- ——- ——- ——- ——— ——– —— —– —– —- ii

ABSTRACT—— ——– ——– ——— ——– ——— ——- ——- —— —- iii

ACKNOWLEDGEMENTS—— ——- ——- —— —— —— —– —- v

CERTIFICATION—– ——- ——- ——– ——- ——- —– —- — viii

TABLE OF CONTENTS—— — ix

LIST OF TABLES——- — xiii

LIST OF FIGURES—— xiiv

LIST OF PLATES—– —- xvi

LIST OF ACRONYMS—– — xvii

CHAPTER ONE

INTRODUCTION

1.1 Background to the Study — —- — — — — 1

1.2 Statement of the Problem — —- — — — — 7

1.3 Objective of the Study — —- — — — — 8

1.4 Research Hypotheses — —- — — — — 9

1.5 Justification of the Study — — — — — 10

1.6 Operational Definition of Terms — — — — — 11

CHAPTER TWO

LITERATURE REVIEW

2.1 Evolution of Social Marketing Concept — — — — 14

2.2 What is “Social Marketing?” — — — — 15

2.3 Marketing Concepts — — — — 15

2.4 Social Marketing versus Product Marketing — — — — 17

2.5 Social Marketing and Other Related Approaches — — — 19

2.6 Extension Teaching Methods — — — 20

2.7 Childhood Nutrition and Malnutrition in Nigeria —— — — 25

2.8 Infant and Child Feeding Patterns — — — — — 25

2.9 Types of Malnutrition —– —- —– —— —– —– — 26

2.10 The Challenge of Under-Nutrition — — — — — 29

2.11 Current Status of Nutrition in Developing Countries — — — 32

2.12 Coverage of Interventions to Improve Nutrition — — — 35

2.13 Effective Interventions to Improve Nutrition — — — 40

2.14 Underlying Causes of Under-Nutrition: Poverty, Disparities and

Other Social Factors — — — 42

2.15 Factors for Good Nutrition Programme — 45

2.16 Programme Success Factors — — — 46

2.17 Global Trends in Social Marketing Applications 49

2.18 A Review of the Effectiveness of Social Marketing Nutrition

Interventions — — — — — — — 51

2.19 Nutrition Interventions – Overview of Characteristics and Results — 52

2.20 Social Marketing of Vitamin ‘A’ Fortified Foods in Nigeria — — 82

2.21 The Social Marketing Methodology — — — — — 88

CHAPTER THREE

CONCEPTUAL AND THEORETICAL FRAMEWORK

FOR THE STUDY

3.1 Conceptual Orientation — — — — — — 90

3.2 Theoretical Framework — — — — — — 90

CHAPTER FOUR

METHODOLOGY

4.1 Study Area — — — — — — — 98

4.2 Research Design — — — — — — — 101

4.3 Study Population — — — — — — — 101

4.4 Sampling Procedure and Sample Size — — — — 101

4.5 Source of Data — — — — — — — 103

4.6 Instrument for Data Collection — — — — — 103

4.7 Measurement of Variables — — — — — — 104

4.8 Social Marketing Intervention — — — — — 110

4.9 Data Analysis — — — — — — — 111

CHAPTER FIVE

RESULTS AND DISCUSSION

5.1 Introduction – — — — — — — 112

5.2 Importance of Baseline Survey — — — 112

5.3 Descriptive Reports of Respondents‟ Background Information

On The Socio-economic Characteristics of Women — 112

5.4 Respondents‟ Sources of Information of Child Nutrition—— 118

5.5 Respondents‟ Awareness to Childs Distribution Programme/Messages 120

5.6 Respondents‟ Knowledge of Child Nutrition before and

After Social Marketing Intervention- – — — — — 123

5.7 Respondents‟ Child Nutrition Attitude Before and after

Social Marketing —– — —- —- —– —– —- —- 126

5.8 Respondents‟ Child Nutrition Practices Before and After

Social Marketing — — — — — — — — ——– — 128

5.9 Changes in Respondents‟ Knowledge, Attitude and Practice of

Child Nutrition as a Result of Social Marketing Intervention — — 130

5.10 Testing of Research Hypotheses — — — — 134

5.11 Discriptive Results of Focus Group Discussion

Conducted During the Study — — — ——— — — 150

CHAPTER SIX

6.1 Summary — — — — — — — 165

6.2 Conclusions — — — — — — — — 169

6.3 Recommendations — — — — — — — 170

CHAPTER ONE

INTRODUCTION

1.1 BACKGROUND TO THE STUDY

The concept of social marketing stemmed out of development communication. It is an approach that builds on diffusion of innovation and behavioural change models. Since 1970s, social marketing has been one of the most influential strategies in the field of development communication and it centres on behavioural change, understanding of communication as a persuasion tool and educating people in order to enhance and facilitate changes in different stages of pro-social behaviour (knowledge, attitude and practice). According to Novelli (2000), the social marketing process is circular. This explains why input gathered through qualitative and quantitative methods is fundamental for designing intervention programmes (activities and content). Social marketing is premised on the idea of mutual exchange for a perceived benefit derivable from any intervention. It takes a consumer orientation by assuming that the success of any intervention results from an accurate evaluation of the perception and needs of the target audience, which informs the design, communication, pricing and appropriate offering. The process is consumer-driven and is an audience-centred approach which features multiple reinforcing channels of communication along with public policy and environmental changes to influence behaviour.

Andreasen, (1995) defines social marketing as the application of commercial marketing strategies which include market research, mixed media and advertising or consumer-based communication to analyse, plan, execute and evaluate programmes designed to influence the voluntary behaviours of the target audience in order to improve their personal welfare and that of the society. This submission emphasises the importance of keeping the target audience involved in need assessment, message development, refinement of messages and delivery strategies. It also involves segmentation of audience needs analysis, and use of multiple communication channels such as television, print, interpersonal communication to reach a large number of people.

In the United States, social marketing has been extensively applied in public information campaigns were targeted at various social problems such as smoking,

alcoholism, seat-belt use, drug abuse, eating habits, venereal diseases, littering and protection of forest. The Stanford Prevention Research Center (SPRC) an interdisciplinary research center involving several departments in the School of Medicine. The Center conducts problem-focused research, using observational and experimental methods, to test and disseminate disease prevention and control programs. The SPRC involves collaboration among a broad array of health professionals and social and behavioral scientists who share public health and population perspectives in planning and conducting research. The Stanford Three-Community Study of Heart Disease is frequently mentioned as one of the most fully documented applications of the use of social marketing strategies. This offers evidence that it is possible to change behaviour through the use of social marketing methodologies.

The campaign of Stanford Three-Community Study of Heart Disease included television programmes, radio programmes, newspaper advertisements, billboard messages and direct mails. In one of the towns, the media campaign was supplemented by interpersonal communication, with random groups of individuals at risk of acquiring heart diseases. Comparing the result among control and experimental communities, the research concluded that the media could be a powerful instrument of change, especially when aligned with interpersonal activities of community groups (Flora, Maccoby & Farquhar, 1989). Social marketing has been used in developing countries like Nigeria and Ghana where interventions like condom use; breast feeding and immunisation programmes have recorded a huge success. According to Chapman (1994), early health applications of social marketing emerged as part of the international development efforts and were implemented in the third world during the 1960s and 1970s. Programmes promoting immunization, family planning, various agricultural reforms and nutrition were conducted in numerous countries of Africa, Asia and South America.

1.1.1 SUCCESSFUL NUTRITION PROGRAMMES USING SOCIAL MARKETING STRATEGY

A number of programmes using social marketing approach have succeeded in improving nutritional status of the masses. Social marketing strategies involving market research, mixed media and advertising or consumer-based communication were used to facilitate adoption of better nutrition behaviour. In the Dominican Republic, the prevalence of malnutrition among 4000 rural children under the age of five fell from 12.2% to 6.9% and breast-feeding practices improved using social marketing. Feeding of newborns on demand rose from 35% in 1983-84 to 63% in 1986 (USAID, 1988).

Community nutrition education through individual counseling, print and audiovisual materials and use of mass media were among the key elements in Thailand’s Nutrition and Primary Health Care Programme. This programme reduced the prevalence of severe malnutrition among children under five in rural areas from 36% in 1982 to 20% by 1989

(INPF, 1989). After a national breast-feeding campaign which was carried out in Jordan from 1988 to 1990, 94% of the women interviewed recalled that the song used in radio and television programmes elicited behavioural change towards exclusive breast- feeding among nursing mothers. The proportion who knew about the appropriate time to initiate breastfeeding rose from 41% to 74%, while the proportion having knowledge regarding delayed supplementation grew from 36% to 61%. The proportion of mothers initiating breast-feeding within six hours of birth increased from 38% to 56% (McDivitt & Ayman, 1991 and Seidel, 1992).

In Indonesia, social marketing strategy using radio, banners and outreach programmes by health workers and village health volunteers increased the proportion of young children who received vitamin A capsule from a health post from 24% to 51% in test areas (Seidel, 1992). A second project used radio announcement slots, promotional marketing activities and counseling materials for health workers to promote vitamin A-rich foods. With the use of radio spots, the daily consumption of dark-green leafy vegetables increased from 19% to 32% among pregnant women, from 14% to 33% among nursing mothers, from 10% to 21% among infants aged 5 to 12 months and from 17% to 27% among children aged 13 to 60 months (Favin & Griffiths, 1991).

In Peru, a new weaning food for children with diarrhea was developed, using recipe trials with mothers. It was promoted through radio programme, cooking demonstrations in mothers’ clubs and local markets, a flip chart, a calendar and training materials for health professionals. In the test area, 80% of the women interviewed had heard of the food, 16% had tried it and 12% said that they would continue using it (Johns Hopkins University, 1990).

1.1.2 SOCIAL MARKETING CHARACTERISTICS

In acknowledgment of the potency of social marketing at addressing varied social and developmental issues, Chapman (1994) summarises eight sterling characteristics of social marketing after three decades of research and interventions which make it relevant for communicating pro-social and development messages:

Persistence and long-term perspective: Only programmes with sustainable support and commitment have proven to have impact on diffusion of new ideas and practices, particularly in cases of complex behaviour patterns.

Segmentation of the audience is central: This ensures identification of the different needs of the target audience.

Mapping target groups is necessary.

Incentives foster motivation among all participants in interventions.

The teaching of skills is fundamental to support behavioural change.

Leadership support is essential for programmes‟ success.

Community participation builds local awareness and ownership.

Feedback makes it possible to improve and refine programmes.

1.1.3 SOCIAL MARKETING FOR BEHAVIOURAL CHANGE

Using social marketing for a variety of rural development projects and child malnutrition improvement in particular grew out of relatively consistent findings that extol the catalytic role of audience communication strategies in accelerating the rate of technology transfer. This is evident in the availability of relevant information on changing negative attitudes and capacity building among others. The need for knowledge and improved skills to increase food production and improved nutrition is essential in the quest for food security and poverty mitigation. Statistics shows that more than 65 million low income earners in developing countries of Asia and sub-Sahara Africa suffer from inadequate food security. This is associated with deprivation, undoubted risk of hunger and malnutrition which is a greater risk- a situation arising from deficiency in one or more nutrient essential for health. Usually, this is characterised by lack of micronutrients such as Vitamin A, Vitamin C, Iron,

Calcium and Zinc; or Amino Acids, which are regarded as the building blocks of protein. Malnutrition results in a reduced ability to work and increased susceptibility to diseases depending on the nutrients lacking. For instance, inadequate Vitamin E can cause anemia and blindness, which subsequently could even result in mental retardation or death. The problem of child malnutrition will not abate if conscious effort is not made towards addressing how predisposing factors or determinants of this syndrome (Child malnutrition) could be mitigated. Therefore, knowledge of parametres that expose the population to malnutrition may have profound effects on dietary intake such as adequate access to food, education, migration and cultural influences would become imperatives.

Agriculture and nutrition are linked in many ways. People have long recognised the most obvious connection between food security and good health. This increased attention to nutrition by the agricultural sector ensures a greater focus on the consumer as the unit of analysis could facilitate improved nutrition status, improved work capacity and productivity. It is therefore pertinent for policy makers in the agricultural sector to pay more attention to nutrition.

It is also well documented that income generation increases food consumption and improves the quality of diet for poorer households. Several patterns have emerged from research findings. As income rises, poorer households spend more on food, although proportionately less than as their income increases (Kennedy, 1989; Diskin, 1995 and Behrman, 1995). Food purchases of these households become more diverse with higher quality foods such as meat and fruits. This implies that diets become more diversified and the overall nutrient composition of the diet improves. However, it must be noted that the aforementioned submission is subject to provision of training on health and nutrition practices, particularly for women because they are primarily responsible for feeding their families (Diskin, 1995 and Marek, 1992). Corroborating this assertion, Praff, et al 1989) opined that, when agricultural programmes are combined with well designed health and nutrition education, using social marketing strategies, significant changes in participants‟ consumption behaviour are reported. For example, when gardening initiatives were used with nutrition education or training, it increased households consumption of vitamin A – rich foods and consequently child nutritional status improved.

Therefore, popularising child nutrition programmes using social marketing approach is a vital step towards enhancing the nutritional impact of agriculture intervention. This approach helps to harness the basic understanding of the most important determinant of child malnutrition. This is imperative if the current high number of malnutrition among children is to be reduced.

1.2 STATEMENT OF THE PROBLEM

Malnutrition is a complex problem with numerous political, economic, social and cultural causes. In 1992, a UNICEF causal model for under-nutrition gained widespread acceptance for its recognition of three underlying and immediate causes: food insecurity, poor health and inappropriate caring practices (UNICEF, 1992). The appropriate emphasis to address each cause varies by country and regions of a country. Severe malnutrition cannot be remedied without significant investments in distributing food, augmenting household income, or otherwise making food more available or accessible and/or improving the quality and availability of health care, while mild and moderate malnutrition can be eliminated or controlled through simple changes in dietary and food hygiene practices that are amenable to change through well-planned and executed behaviour-change strategies (UNICEF, 1992).

In Nigeria, child nutritional problem lies in mild and moderate malnutrition. Successive governments have introduced several child nutrition intervention programmes to combat child malnutrition. This includes school feeding programme, mineral fortification programme and vitamin A capsule supplement. Despite these concerted efforts, the cases of child malnutrition are on the increase. UNICEF, (2000) reported that the prevalence of malnutrition among children under 5 years of age in Nigeria is significantly higher than in most other developing countries. The major form of micronutrient malnutrition identified includes iron deficiency, vitamin „A‟ deficiency and iodine deficiency disorders. The strategy used by the government has not yielded the desired results, largely due to the associated institutional rigidity and over bureaucratization, top down management style and lack of coordination or linkage with other component of Attitude, Knowledge and Skill for Research and Development (AKIS/RD), particularly research and development (Farington et al, 2000, Rivera, 2001 and Beckman, 2002).

To this end, there is a need for an alternative extension delivery mechanism that will ensure people‟s participation and tailored to peoples‟ needs. Social marketing as an all inclusive approach seeks to influence social behaviour, not to the benefit of the marketer but the larger audience and the general society. The potency of social marketing strategy to influence trends in nutrition pattern among women with respect to increase in nutrition knowledge, better dietary practice and attitude for children cannot be overemphasised. It is against this background that the research attempts to determine the effectiveness of social marketing on knowledge, attitude and practice on child nutrition by women in South-western

Nigeria by providing answers to the following research questions:

What are the socio-economic characteristics of the child bearing women?

What is the level of awareness of child nutritional programme/ messages by the respondents before and after social marketing intervention in the study area?

What are the communication channels required to make child nutritional messages available to the respondents?

What is the respondents‟ knowledge of child nutrition before and after social

marketing intervention in the study area?

What is the respondents‟ attitude towards child nutrition messages before and after

social marketing intervention in the study area?

What is the respondents‟ child nutrition practice before and after social marketing intervention in the study area?

What are the constraints associated with good dietary intake by respondents in the study area?

1.3 OBJECTIVE OF THE STUDY

The general objective of the study is to determine the effectiveness of social marketing strategy in women behavioural change on child nutrition in Southwestern Nigeria.

The specific objectives of the study are to:

identify the socio-economic characteristics of the child bearing women in the study area.

determine the awareness of child nutrition programme/ messages of respondents in the study area.

determine the respondents‟ sources of information on child nutrition the study area.

There is no significant relationship between the selected socio-economic characteristics (education, age, family size, occupations, marital status, religion and income) and child nutrition behaviour.

There is no significant relationship between awareness of child nutrition messages and child nutrition behaviour.

There is no significant relationship between respondents‟ information sources and child nutrition behaviour.

There is no significant difference in respondents‟ child nutrition knowledge before

and after exposure to nutritional messages across the three states.

There is no significant difference in respondents‟ child nutrition attitude before

and after exposure to nutritional messages across the three states.

There is no significant difference in respondents‟ child nutrition practice before and after exposure to nutritional messages across the three states.

There is no significant difference in respondents‟ behavioural change (knowledge, attitude and practice) before and after exposure to nutritional messages.

1.5 JUSTIFICATION FOR THE STUDY

The study is borne out of the concern to reduce the cases of child malnutrition in Nigeria. Despite several efforts made by Nigeria government and non-governmental organisation to combat child malnutrition, chronic vitamin and mineral deficiency, also known as ‘Hidden Hunger’ still poses serious health problems confronting developing nations, especially Nigeria.

The evolution of Millennium Development Goals is partly to eliminate hunger and malnutrition. This is the 8th year into the millennium and Nigeria is still far from realising the goal of food sufficiency and nutrition security, expected to be achieved by the year 2015 by the United Nations. Therefore, there is need to adopt a proven communication development initiative that will ensure behavioural changes and community participation that is consumer driven.

Considering the foregoing therefore, the use of social marketing strategies to reduce child malnutrition will serve the following important functions. First, it will assist in providing feedback for government and non-governmental agencies to support continuing improvement of nutrition activities among women particularly on the issue of child nutrition and will serve as a guideline for dietary intake that will enhance growth and development among children. Secondly, social marketing will help to establish the importance of child nutrition education campaign for research institutes government and non-governmental agencies to improve child nutrition and combat other related micro nutrient deficiencies among children under 5 years old in Nigeria.

Consequently, the result of this study could be used as a basis for creating a more sustainable nutrition programme by providing concrete guideline for the use of social marketing as a tool to enhance knowledge, attitude and practice of child nutrition. Results from this study will also provide information on what should be taught in future mothers’ classes in order to better convey the message of nutrition across to the members of the community. It will also generate information that will provide guidance for programme planners and policy makers on how to design suitable interventions to reverse the trend of increasing child malnutrition in the Nigeria. The study will also be useful for researchers and students who will like to conduct research in social marketing with respect to agricultural extension.

1.6 OPERATIONAL DEFINITION OF TERMS

Social Marketing: This is the use of multiple communication channels to influence the voluntary behaviour of the target audience in order to improve their personal welfare and that of their society.

Malnutrition: Deficiency in one or more nutrients essential for health. Usually, the nutrient lacking are micronutrients such as Vitamin A, Vitamin C, Iron, Calcium, Zinc or Amino Acid- the building block of protein. Malnutrition results in anemia, blindness, mental retardation or death.

Dietary Intake: Refers to the type of food taken by individuals or household.

Household: One person who lives alone or group of persons, related or unrelated, who share food or make common provision for food and possibly other essentials for living.

Nutrition Behaviour: Constitutes knowledge, attitude and practice of nutrition habit that determines adequate food intake required for normal growth and development.

Knowledge: Refers to the factual background on which to base decisions, such as knowledge about the relationship of eating and health and about planning for healthy nutrition, using assessments and nutritional guidelines.

Attitudes: Personal perceptions for decisions, such as feeling responsible for one‟s own health and the health of others.

Practice: Practical basis for mastering tasks and procedures related to healthy eating, such as skills for selecting and preparing healthy meals and practising food safety.

Place: The distribution channels used to make the product available to target audience.

Promotion: This describes the appropriate communication channels to reach the target audience that will produce the desired change in behaviour.

Products: Refers to the behaviour, or nutrition/health idea that the campaign planners would like the target individuals or groups (consumers) to adopt.

Price: The cost associated with “buying” the product. Cost can involve sacrifice related to psychological wellbeing of the target audience (e.g. increased anxiety), sociality (e.g. possibility of ostracism), and economics (e.g. financial sacrifice, or time inconvenience).

Nutrition education: This involves providing consumers with the information about food and nutrients needed to make decision about what to eat to enhance growth and development.

Vitamin „A‟ Mineral fortification: This describes inclusion of vitamin A mineral in food like flour and vegetable oil which is branded with an” eye” logo.

Iodize salt: This describes the inclusion of iodine in table salt in order to prevent iodine deficiency disorder (IDD) in children.

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