The formative research method used for the development of the BCC 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 program intelligence to support the development of BCC plans8,9,10. 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 security for field teams. Despite the challenges, a best practice approach to designing effective behavioural change interventions was embarked upon, including an assessment of participants' health behaviours and examination of the type of BCC resources and actions needed, with the objective of tailoring the interventions to best meet participant needs11.
The RAR method included academically robust, qualitative approaches, including: semi-structured interviews (SSIs), Focus Group Discussions (FGDs), observational research, and case study approaches and narratives, which are seen to have generally been underutilised 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 regarding food, dietary practices and nutrition education challenges in Baluchistan13.
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 using a rapid review procedure in line with WHO recommendations for swift knowledge generation for priority health issues in resource limited settings14. A broad number of online databases were utilised 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 FGD agenda. Behavioural theories most relevant to the nutrition project included Health Belief Model which explores variables of target audience perceived susceptibility, severity, barriers and benefits15; Theory of Planned Behaviour and Social Cognitive Theory which explore variables of perceived behavioral control, self-efficacy, outcome expectancy and environmental influences16, 17; Diffusion of Innovations which examines the role of local opinion leaders in the diffusion of new agricultural practices18; and Nudge Theory which posits the importance of providing incentives to elicit greater engagement in health programs to influence dietary behaviours19. BCC program objectives emanating from the behavioural theories included increasing target audience awareness and knowledge about the risks of malnutrition; changing attitudes, beliefs and self-efficacy 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 behavioural intentions toward establishing KGs to grow nutritious, protein dense, produce.
Fieldwork approaches included the development of tailored discussion agenda for the SSIs. Given the ongoing insecurity in the Province a small field team of three staff was deployed to travel to the capital city of Quetta to conduct the SSIs, and travel onward to project intervention Districts of Kharan and Nushki. The fieldwork was conducted over 12 consecutive days.
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 experience20. 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 well as Trainers from the Food and Agriculture donor agency, as well as representatives from UNICEF, World Food Program, and the World Health Organisation.
Insights from the SSIs and the literature review informed the development of discussion agenda for 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 say21. 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 (see Table 1). All study methods were carried out in accordance with relevant guidelines and regulations with reporting experiments on humans. Participants under 18 yrs of age were excluded from the discussion groups, while informed consent was obtained from all other participants through the FGD screening instrument, prior to taking part in the study.
A total of 124 participants took part in FGDs with 8-19 participants attending each of the groups. Male and female group moderators were trained to facilitate like-minded gender groups in local language, with each FGD taking approximately 60-75 minutes to complete. Data collection involved recording of all discussions and then compiling of the recordings into Word format. Recordings were supplemented through dialogue between team members, immediately following each group discussion. Notes were compiled in a question-by-question format to capture what the individuals had to say in regard to each topic with the notes from the SSIs and FGDs totalling 48 single-spaced, A4 pages.
Data analysis was conducted using NVivo software to uncover the most significant themes and issues related to the behavioural theories. Software analysis was supplemented with grounded theory approaches which use open, axial and selective coding to identify and categorizing the relationships of various categories as well using selective coding to identify other categories which may be part of the core categories22. Data from the literature review, the SSIs and FGDs was triangulated to provide a rich data-source for comparative analysis23.