Community can be defined as “symbolic units of collective identity”; it is important to consider this collective identity when examining theories of community-level behavior. As mentioned previously, the problem of childhood diarrhea in Indonesia is greatly influenced by the breastfeeding behaviors of mothers. Multiple studies have demonstrated the positive effect exclusive breastfeeding has in reducing diarrhea and malnutrition when it is done for the first six months of life. The WHO Collaborative Study Team on the Role of Breastfeeding on the Prevention of Infant Mortality found that in developing countries, “any breastfeeding is associated with more than two-fold protection against infant mortality compared with no breastfeeding in the first year of life”. An international recommendation to promote exclusive breastfeeding has led to policy changes in communities around the world, for example, the breastfeeding law implemented by the government of Indonesia. While individual feeding practices are important in this case, the major determinants of diarrheal disease in infants can be better addressed using a behavior change model focused on collective identity since community ideals are so important in Indonesia.
Exclusive breastfeeding is a good behavior to frame an intervention around as it has a largely positive impact on reducing diarrheal disease. Mixed feeding practices – the use of prelacteal and other foods – is one of the problems influencing disease in children. The use of unsanitary water during preparation of feeds can cause contamination and disease. The problem behavior of mixed feeding practices can be influenced by several different behavior theories mentioned below.
Community Mobilization involves a shared effort within a society to address the major issues affecting the community as a whole. The most successful behavior change comes from the formation of partnerships between community leaders, health care workers, and social support networks, such as women’s groups. By building such networks, a sustainable change can be made to address a problem behavior in the community, such as mixed breastfeeding practices. When there is an emphasis on strong community leadership and a focus on allowing community groups to implement, evaluate, and monitor programs that are formed specifically for their needs, there is a greater chance that the programs will work and that they will have a lasting effect. Regarding breastfeeding practices, studies in both Thailand and India have shown that integrative methods are often the most successful in producing a significant improvement.
In Thailand, in order to combat malnutrition in children, the government and society leaders used community-level methods to improve child health. District chiefs were chosen for each community and were trained to integrate long-term nutrition programs that were started by members of the community and could therefore be kept up locally. These programs focused on teaching members of the community ways to provide for their own basic needs with an emphasis on agriculture, health (including breastfeeding), and education. The main goal was to give responsibility to families to care for their ill children when possible, instead of placing the emphasis on health care workers. Some studies showed more than 95% of villages in Thailand were using the basic minimum needs approach to attempt to improve the health of their children.
In 1998, the World Health Organization funded a project to study child-feeding practices in India. They found that exclusive breastfeeding was uncommon and complementary feeding practices were poor. To address this problem, the study developers designed an intervention targeted at teaching nutrition recommendations to the community through communication materials. From the onset, community members were involved; they gave insight on appropriate themes for the communication materials so they could have the biggest possible impact. Community health workers were also used to travel to homes in the community, assessing current feeding practices and correcting and teaching good behaviors where needed. After intervention techniques were employed, the study results showed a decrease in prelacteal (mixed) feeding: 31% use in the intervention group vs. 75% use in the control group, and an increase in exclusive breastfeeding: 79% in the intervention group vs. 48% among the controls. This change can be seen in the graph below.
For the past few decades, the positive deviance approach has been used to successfully fight childhood malnutrition in developing countries, as seen in the study done in North Jakarta, Indonesia. This methodology is rooted at the community level and is based on the concept that the answers to health problems lie within the communities themselves. The term “positive deviants” refers to individuals identified within a community who, though they face the same socioeconomic and environmental circumstances, have a higher than normal degree of health. This theory is used to identify the positive behaviors of deviants and to help these individuals disseminate their behaviors with an aim at adoption of the positive behavior within the entire community.
Another positive deviance model is the Hearth Nutrition Model, a community-based program using concepts of positive deviance to promote child nutrition. Positive deviance inquiry is the first step of this model and is used to identify successful feeding and nutrition behaviors in families. Based on these inquiry findings, a Hearth nutrition program is designed by a community to target malnourished children. The program should have components including monthly weighing, education and rehab sessions, and community management and monitoring of progress, which should all be based on behavior identified through positive deviance. The use of positive deviance in combination with the Hearth Program has lead to measurable behavior change improving infant weaning practices and child nutrition.
An evaluation of the positive deviance/Hearth approach in North Jakarta, Indonesia showed a decrease in severe and moderate malnutrition in children after only 10 days of implementation. With the practice of this approach, the percentage of children exclusively breastfed from birth to 6 months increased two-fold, from a baseline percentage of 15% to 30.9% at conclusion of the intervention program. In many cases of major behavior chance, success is based on the application of positive deviance theory. In turn, this success supports the notion that communities already have the answers and abilities to address their own issues.
As seen in previous models, community level theories have thoroughly explained breastfeeding practices and have provided opportunities for addressing behavior change. The problem behavior of mixed feeding practices would be best addressed using the Community Mobilization Model; this model emphasizes the importance of empowering the mothers in the community and having them participate in the development and implementation of their own behavior change process. The Community Mobilization Model is also ideal for making social changes, for example, making exclusive breastfeeding the cultural norm. The steps in the Community Mobilization Model are designed to increase the efficacy of mothers in the community as a whole. Because breastfeeding is an individual-level behavior, it is important to integrate constructs from individual-level theories. The constructs we chose to include are from the Health Belief Model and Theory of Reasoned Action/Planned Behavior. By including these into an integrative model, we can address change at both the community and individual levels. The integrated model we constructed is specifically directed towards the desired behavior, exclusive breastfeeding, rather than the problem behavior in order to maintain uniformity and the possibility of change.
Community Mobilization Model Constructs:
The Community Mobilization Model includes concepts that describe the model, as well as key steps in the Community Action Cycle. The concepts of the model include:
• Empowerment - Empowerment is the process of allowing people to gain mastery over their lives and as a part of the community. With regards to exclusive breastfeeding, this is an important concept that allows mothers to actively participate in choosing to exclusively breastfeed over practicing mixed feeding.
• Critical Consciousness - Critical consciousness states that people have the ability to make conscious choices based on reflecting on the action. Although, in the case of exclusive breastfeeding, mothers do not have much of a choice based on the recently passed law that mandates exclusive breastfeeding, the community action cycle will allow mothers and members in the community to make conscious decisions in how they choose to exclusive breastfeed.
• Community Capacity - The community capacity refers to the resources and characteristics of the community that encourage or limit its ability to participate in the community action cycle. This concept is important in regards to analyzing and preparing the communities of North Jakarta for an intervention.
• Social Capital - This concept explains the importance of the relationships between community members in influencing its ability to make social change. In order to make exclusive breastfeeding a long-lasting change, all members of the community and within the household must work collaboratively and cooperatively.
• Issue Selection - Issue selection allows the community members to identify and set specific targets for change that strengthen the community. In the issue of exclusive breastfeeding, the community members are able to work together to set these goals that not only help mothers prevent their children from dying from diarrhea, but also help employers have better retention and production and benefit the overall community with healthier women and children.
• Participation and Relevance - Although exclusive breastfeeding has already been initiated as a change required by law, mothers and all members of the community (including employers) should be included in the process of the intervention in order to make a behavior change that is relevant to them.
The key steps in the Community Action Cycle are step-by-step instructions that allow community members to plan, carry out, and evaluate behavior change. The following are the key steps of the Community Action Cycle, which are further applied to exclusive breastfeeding as shown by the graphic model.
1. Prepare to Mobilize
2. Organize the Community for Action
3. Explore the Health Issues and Setting Priorities
4. Plan Together
5. Act Together
6. Evaluate Together
7. Prepare to Scale Up
Health Belief Model Constructs:
Perceived threat and outcome expectations are both individual-level constructs from the Health Belief Model that determine behavior. These constructs can be integrated into the process of the community action plan when the health issues of exclusive breastfeeding are explored and priorities are set. This will allow mothers to build their individual self-efficacy, while participating in the effort of behavior change as a community.
• Perceived Threat - The construct of perceived threat includes both the perceived susceptibility to the problem and perceived seriousness of the consequences of the problem. Mothers and community members who are in the process of exploring the health issues of exclusive breastfeeding should be able to identify their own individual perceptions of their child’s susceptibility to diarrhea and how seriously they view mixed feeding to result in threatening consequences.
• Outcome Expectations - The construct of outcome expectations is comprised of perceived benefits of adopting the new behavior and the perceived barriers to taking the action. Before taking community action, mothers should be able to identify the benefits of exclusive breastfeeding and the barriers that keep them from adopting the behavior.
Theory of Reasoned Action/Theory of Planned Behavior Constructs:
Because exclusive breastfeeding is the desired social change as a community, normative beliefs as well as attitudes should also be addressed during the community action cycle.
• Normative Beliefs - Normative beliefs are the approval or disapproval of the behavior by significant figures in the community. When preparing to mobilize, information on the approval and disapproval of exclusive breastfeeding of significant members of the community should be gathered in order to help with the mobilization plan. Ways to target those who disapprove and change their stance should also be discussed.
• Attitude - The attitude towards a behavior is governed by an overall evaluation of the behavior and the outcomes that result. During the evaluation process of the community action cycle, mothers should be able to discuss their attitudes of exclusive breastfeeding and make adjustments to improve their overall evaluation.
Comprehension of behavior theory at both the community and individual level is crucial in developing an effective intervention program. By following the appropriate steps outlined by the Community Action Cycle and including individual-level constructs, a behavioral intervention to promote exclusive breastfeeding can be created that instills community empowerment and individual self-efficacy. Community empowerment will ensure that mothers in the community are actively involved in setting goals and evaluating their own actions, and with increased self-efficacy, breastfeeding should be less of a “chore” and breastfeeding can instead be used as a bonding practice with the child.
By applying the Community Mobilization Model to address our problem behavior, we can break down the constructs of how people acquire and maintain the pattern of mixed breastfeeding practices and how mothers can adopt exclusive breastfeeding. Doing so provides a framework that can be used to design an effective program to change this behavior, which will have the greatest effect if implemented at the community level.