Introduction

Malnutrition remains a concern for vulnerable populations globally, and improving nutrition is critical in achieving the Sustainable Development Goals (SDGs). Globally, millions of people depend on social protection programs (SPPs) to meet their basic needs while safeguarding their food security. While “nutrition-specific” interventions can address the immediate determinants of child and maternal nutrition and development—adequate food and nutrient intake, feeding, caregiving and parenting practices, and lower the burden of infectious diseases, “nutrition-sensitive” interventions for social protection are those that address the underlying determinants of malnutrition, and often aim to promote behaviours conducive to nutrition through social and behaviour change communication (SBCC) while incorporating specific nutrition goals and actions. A growing body of evidence shows that nutrition-sensitive programs that include SBCC can lead to improved maternal and infant health and nutrition outcomes [1,2]. SBCC aims to improve behaviours of individuals through dialogues and processes that strengthen social contexts and systems [3].

Nutrition-sensitive SBCC interventions can also improve feeding practices for infants and young children early initiation while emphasizing the importance of exclusive breastfeeding and adequate complementary feeding practices, along with water and sanitation hygiene practices [4]. Cash transfer programs in social protection focus strongly on outcomes linked with the SDGs and are therefore important as they provide a crucial safety-net to children and their caregivers to alleviate poverty and address the key determinants of malnutrition [5]. However, despite the potential for integrating nutrition-sensitive SBCC interventions into SPPs, there is mixed evidence on the extent to which these interventions may deliver improved nutrition outcomes. To date, systematic reviews and meta-analyses have tended to focus on the importance of cash transfer programs for improvement in nutritional outcomes [6,7] or the added impact of SBCC interventions in communities to achieve optimal indicators for nutrition [6,8]. Yet to be answered systematically is how nutrition-sensitive SBCC can best be integrated within social protection programs to achieve the optimal behavioural impact in the context of low -and middle-income countries like Bangladesh and Pakistan [9]. Emerging evidence identifies the importance of integrating co-design approaches with those targeted by SBCC interventions to ensure the optimal development of SBCC program components [10,11].

The objective of this needs assessment study was to pilot an improved formative research method to integrate co-design approaches with program beneficiaries to enhance the findings of a systematic review [12]. Study objectives included the following: 1. Identify stakeholder and beneficiary current knowledge, attitudes and practices (KAP) in relation to nutrition-sensitive SPPs in Bangladesh and Pakistan; 2. Identify opportunities for the SBCC program moving forward – key messages, actors and communication channels and SBCC entry points for continuous program improvement; 3. Identify optimal monitoring and evaluation components of the SBCC nutrition-sensitive SPPs, including inputs, outputs, outcomes and impact.

Methods

A landscape analysis and systematic review of the literature was conducted exploring the effectiveness of nutrition-sensitive SBCC approaches in the context of SPPs in Bangladesh and Pakistan, with the review methodology and findings reported [13] elsewhere. To provide a more culturally nuanced understanding of the nutrition social protection issues, to supplement the systematic review, a needs assessment was conducted with program stakeholders and beneficiaries in both countries. The recruitment of participants for this study commenced on 2^nd August (Pakistan) and 20^th November (Bangladesh) with the participant recruitment period ending in both countries on 14^th December 2023. Co-design workshops of approximately 30 mins each were incorporated within research approaches. An interpretive descriptive method was adopted to the qualitative research to explore attitudes and opinions of supply-side and demand-side participants most invested in achieving successful program outcomes [14]. Semi-structured interviews (SSIs) were the preferred approach for working with SPP stakeholders given these key informants are often in senior professional roles with busy schedules. The approach is effective in gaining insights into problems that are not immediately perceptible and provides flexibility to probe for specific organisational and program challenges as well as opportunities for program improvement [15].

Qualitative approaches with program beneficiaries from the two countries took the form of focus group discussions (FGDs) as the approach provides for a non-threatening environment in which a moderator can explore knowledge, attitudes and practices (KAP) in relation to nutrition-sensitive SPPs with like-minded groups of 8–12 community participants. The methodological guidelines for FGDs included training of highly skilled, local moderators (MPHs, PhDs), the use of a standardised discussion agenda exploring a range of KAP indicators; probing with all respondents, avoiding any ‘leading’ of the groups, and close monitoring of the groups to identify potential positivity bias and dominant respondent bias [16]. Given the desire for greater integration of participatory approaches with the FGDs, a workshop session of Co-Design/Co-Creation [17] of approximately 30 mins duration, was incorporated into the group moderation to allow for greater collaboration from community members most affected by poor nutrition outcomes and multiple vulnerabilities. A 32-item COREQ (COnsolidated criteria for REporting Qualitative research) checklist [18] was used to ensure best practice approaches in the qualitative study design for conducting the SSIs and FGDs (see Supplementary Files).

Data analysis utilised Grounded Theory given the approaches ability to develop SBCC theory ‘grounded’ in data that has been systematically collected and analysed [19] and its ability to uncover issues related to social relationships/social processes and group behaviours [20]. Furthermore, thematic analysis was adopted for the analysis as the process allows for the formation of themes, in this case related to nutrition KAP, from participant transcripts and responses, to open-ended questions on a range of issues of interest. NVIVO 14 data analysis software was used to support the thematic analysis with the systematic review of secondary data sources supporting in-field findings. Ethics approval for the research was provided by the National Heart Foundation Hospital and Research Institute (Bangladesh) IRB clearance NHFH&R1 4/19/7-AD/2369, and Dow University of Health Sciences (Pakistan), Internal Review Board: IRB-3123/DUHS/Approval/2023/276.

Results

Findings from the SSIs and FGDs identified a number of similar themes and sub-themes emanating from the thematic analyses. A thematic analysis coding table identified four organising themes, and 21 sub-themes emerging under the overarching theme under investigation – Nutrition Sensitive SBCC in Social Protection (see Fig 1).

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Fig 1. Thematic Analysis Coding Table: Nutrition-Sensitive SBCC in Social Protection Programs in Bangladesh and Pakistan.

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The four organising themes related to Barriers to Program Engagement, Opportunities for Program Improvement, Knowledge Attitudes and Practices (KAP), and Target Groups, Messaging and SBCC Entry-Points. Of the 21 sub-themes, data analysis identified the most predominant theme identified by stakeholders and a number of beneficiaries within the Barrier’s organising theme was Resource Constraints, with this issue achieving data saturation before the SSI and FGD data analysis was completed. The most commonly cited resource constraints included the insufficient level of financial support/food support provided by most SPPs and the inequitable allocation of placements within the programs, which greatly exceeded supply. The second most cited barrier, which also achieved data-saturation before completion of the analysis, was Corruption and Nepotism within the administration of SPPs. Attitudes toward maladministration of SPPs were prevalent in both countries. Many vulnerable community members who were not able to enrol into SPPs had poorer attitudes and perceptions toward the selection processes.

The third most cited barrier was the Stigma and Discrimination sub-theme, where beneficiaries claimed they had been humiliated through the process of applying for aid, or feared being labelled as destitute by other community members. A fourth sub-theme to emerge was the lack of strategic approaches, which prevented the attainment of well designed, evidence-based SBCC programs with the collaboration of all stakeholders Other barriers mentioned by beneficiaries and stakeholders included poverty, widespread inequity, and gender issues including ‘gatekeepers’, predominantly the husbands of women who impeded their wives ability to successfully engage in social protection cash transfer and food programs as a result of distrust of any programs which may take their wives out of the household. Other sub-themes emerging that were seen to hinder program uptake were policy inertia, low literacy, substance abuse, and the distances and time required to travel to SPP recruitment offices/distribution hubs and access points (see Table 1. Barriers to Program Engagement).

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Table 1. Organising Theme – Barriers to Program Engagement.

https://doi.org/10.1371/journal.pone.0310288.t001

When examining the Opportunities organising theme for program improvement, several sub-themes emerged. The first is the sub-theme of Integration of nutrition-sensitive SBCC into SPPs which was identified as one of the study objectives. Feedback from the supply and demand sides identified that a number of food programs are already being trialled in both countries, with opportunities to integrate approaches more fully with cash transfers.

Second, are opportunities for Capacity Building/Empowerment of program beneficiaries and other community members, including key influencers, with the approaches potential to build ownership and social mobilization of the whole community. Next, is the potential for Co-Design/Co-Creation which was articulated through the participatory workshop exercises embarked upon with program beneficiaries as a component of the FGDs. The approach assumed that it’s those who are most vulnerable who may also be best placed to express their specific needs and wants in relation to SBCC, nutrition and social protection. Next, are opportunities for Improved Community Engagement to ensure that those in most need are provided for in safety-nets, and any gaps or leakages can be addressed in conjunction with empowered community representatives and groups.

Last, are Opportunities afforded by Continuous Improvement practices which include exploring innovations, improved integration through multisectoral approaches toward nutrition, agriculture, microfinance and SBCC programming with SPPs in both country settings. Additionally, monitoring and evaluation was cited by stakeholders with research expertise as an area which could demonstrate to government and donors the potential for SBCC to achieve improved behavioural impact. Other Opportunities identified included schools’ programs, nutrition microfinance or ‘kitchen gardens’ agri-business incentive opportunities (see Table 2. Opportunities for Program Improvement).

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Table 2. Organising Theme – Opportunities for Program Improvement.

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Given the importance of understanding current awareness and attitudes toward SPPs and nutrition related support programs, an important thematic investigation related to beneficiaries Knowledge, Attitudes, and Practices (KAP). KAP sub-themes of program Awareness/Knowledge identified challenges on where SPPs were located, what services are provided, what documentation is required to apply, and how applications need to be processed. Similar concerns about poor knowledge on nutrition were demonstrated including understanding of what types of food to eat, meal frequency, the need for dietary diversity, and what specific infant and young child feeding practices should be followed.

The second KAP organizing theme, sub-theme—Attitudes and Perceptions included investigation on important behavioural determinants of self-efficacy perceptions [23] and perceived behavioural control [24] emanating from the behavioural literature. While stakeholders working to improve nutrition outcomes have emphasised the importance of greater integration of nutrition-sensitive SBCC interventions with SPPs, the feedback from a number of beneficiaries of SPPs highlights their preference for cash transfers with the money received providing discretionary spending for the limited funds provided. However, other feedback from stakeholders indicates that cash transfers may often be spent by male, heads of households, on items that may not benefit women and children’s nutritional needs.

Other feedback from stakeholders emphasises that Attitudes which lead to Intentions and Behavioural Change are likely more important determinants to shift people along the behaviour change continuum, than simply awareness or knowledge on their own.

The Social and Cultural Norms, originally emanating from constructs of “Subjective Norms”, identified as “a function of the normative beliefs of a society and the motivation for someone to comply with each important person in someone’s life” [25] emerged as an important behavioural determinant. Feedback from stakeholders and beneficiaries emphasises the social and cultural barriers that impede vulnerable groups –mostly women– to achieve behavioural control. Motivation [26], which can lead to Social Mobilization, was another important sub-theme of KAP determinants that can be more fully impacted through greater participation by community influencers, with the subsequent skills and confidence that can evolve from participant engagement in SBCC including the reshaping of negative social and cultural norms.

The final sub-theme relating to KAP is Intentions and Behaviours, which includes Trialling Behaviours. The range of behavioural determinants highlights the often-long journey to move individuals and communities from Awareness of specific programs to Intentions to engage in activities, Trial the recommended behaviours, and finally Adopt and become Advocates for the behaviours (see Table 3. Knowledge Attitudes and Practices [KAP] Indicators).

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Table 3. Organising Theme - Knowledge Attitudes and Practices (KAP) Indicators.

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The last area emerging from the thematic analysis under the organising themes of Target Groups, Messaging and SBCC Entry-Points highlights a number of sub-themes emerging, which are key to the development of an evidence-based Theory of Change on SBCC in nutrition-sensitive SPPs. The first sub-theme in this area relates to target group selection and the fact that both Demand and Supply-Side groups will need to be considered. A number of priority target groups were highlighted including targeting to those already engaged with SPPs, as well as those currently not on the programs. Second, is the need to prioritise particularly vulnerable groups including pregnant, lactating or non-lactating mothers, and vulnerable youth. Next, is the need to also target –as a lower priority– supply-side groups including key influencers from community organizations, SPP staff, community health center staff, NGO staff, and voluntary health workers, including lady health workers prevalent in Pakistan. Other important influencers could include community leaders, religious leaders and teachers.

As a follow-up, feedback on the organizing theme of Message Types highlights the importance of considering the sub-theme of Social and Cultural Norms and how they influence community beliefs, traditions, and dietary preferences. Next, was the organising theme to identify SBCC Entry-Points, including sub-themes of interpersonal communication (IPC) sources which were overwhelmingly preferred to deliver dietary advice and SBCC materials by vulnerable community members and many stakeholders in both country settings. This approach is seen to provide more personalized communication from local influencers, including community leaders, and other respected figures who are seen as highly credible message sources within their respective communities. As such, these individuals, if well trained on SBCC approaches and provided appropriate support materials, would likely be in the best position to address specific community concerns on SPPs and nutrition-sensitive SBCC. IPC approaches identified by some stakeholders and beneficiaries included door-to-door visits from influencers with the acknowledgement that this approach may not be economically viable at-scale. As such, greater integration could be considered in utilizing existing human resources for IPC, including voluntary health workers already operating in most village settings.

The next most popular sub-theme for the SBCC Entry-Points organising theme, popular in both countries was Mobile Messaging and Social Media, with the mobile application ‘WhatsApp’ being frequently seen as the predominant communication modality for health and other messages in rural areas of Pakistan. Given the relatively lower literacy rates in Pakistan, it was recommended that recorded oral messaging be used in place of text messaging, where-ever possible.

Another sub-theme of the Entry-Points organising theme, highlighted by a smaller number of respondents in the co-design sessions was Print Media and Community Media, acknowledging that some print community resources might require improvements to the design of the resources through message pre-testing. Print resources were also highlighted by supply-side stakeholders given their potential to support IPC delivery of purposive messages by opinion leaders in their communities. Next, was the sub-theme of Mass Media, which was often mentioned by both stakeholders and beneficiaries due to its national proliferation. Many other health issues were recalled via televised media while the considerable cost of purposive messaging on national TV channels was highlighted by country media communications specialists. Community and local radio stations were also occasionally mentioned while community ‘miking’ —recorded message played through loudspeakers on bicycles— was also mentioned in the Bangladesh context, given the long history of its use in rural village settings. Important to emphasise in terms of SBCC message Entry-Points was the general desire to include priority messages at every contact point, with expert advisors emphasising that messages needed to be workshopped and pre-tested with the communities most impacted by the program.

The last theme to emerge from the analysis was the issue of Incentives or NUDGES [27], with the sub-themes of Conditional Cash Transfers (CCTs) and the potential for improved food supplementation highlighted by a number of SPP stakeholders. Several existing programs in Bangladesh and Pakistan already appeared to be using food or cash incentives highlighting the potential to Nudge mothers with children to visit health facilities and access IPC health worker channels during their visits. Additionally, CCT NUDGES were also used to build nutrition knowledge with program beneficiaries through targeted community training sessions which were required as part of the CCT benefit (see Table 4. Target Groups, Messaging and SBCC Entry-Points).

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Table 4. Organising Themes- Target Groups, Messaging and SBCC Entry-Points.

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Discussion

This formative study integrating co-design has shed light on some of the key entry-points for nutrition SBCC interventions in SPP identified by the program beneficiaries. This includes the types of messages, advocacy approaches and dissemination channels most applicable for use in Bangladesh and Pakistan. The qualitative approaches to the needs assessment and more specific probing on barriers and challenges identified by participants during the co-design sessions enabled more in-depth investigation to achieve culturally appropriate SBCC solutions to support the findings of the systematic review [15].

A synthesis of the findings across groups identified a number of important KAP indicators: Poor knowledge about nutrition as well as how to enrol for the schemes, and poor attitudes and self-efficacy perceptions emanating from participants inability to successfully enrol or qualify for SPPs and achieve nutritional benefits offered. This is in line with other studies which have identified that households of marginalised groups may lack sufficient information and education to understand the value of early life nutrition [28,29]. Knowledge about the correct foods to eat and the importance of dietary diversity for better health was more apparent with Bangladeshi respondents than Pakistani beneficiaries. This possibly reflects the smaller geographic footprint of Bangladesh, and the proliferation of media and community information sources coupled with the greater efficiency in disseminating messages through mass media available in the country [30] vs Pakistan’s more expansive and remote, rural regions and the challenges in reaching remote tribal and religiously conservative populations.

“I got nutrition information from a doctor at a health complex, from community drama, from yard meetings. They delivered various nutrition related messages like how the baby will get nutrition, that we should eat milk, eggs, vegetables, fruits, and then the baby will be healthy: We got it from an NGO worker, through miking, through mobile phones, TV, News. Community clinics also provide these nutrition messages.”

Rural-Females-19-34 Years-CD-SES, Kurigram Co-Design Workshop, Bangladesh.

The lack of [23] perceived behavioural control by women, particularly in rural communities in Pakistan suggests the role of SBCC may be to subtly shift perceptions of social and cultural norms in strict conservative communities, to allow for greater agency by those most involved with the health of children and other family members. With poor self-efficacy [23] and perceived behavioural control comes poor motivation and social mobilization of most vulnerable groups. The findings indicate the need to consider more innovative ways to engage poorly motivated groups through incentives and other promotional benefits.

Five barriers to program engagement emerged from the analysis including resource constraints, corruption/nepotism in the administration of the programs, stigma and discrimination felt by a number of vulnerable applicants to the programs, and the role of gatekeepers -predominantly husbands of women- who prevented women’s access to the SPPs. The lack of strategic approaches were also seen as a major barrier to the successful administration and promotion of the program through SBCC.

The role of gatekeepers featured more so in Pakistan than in Bangladesh with the restrictive role of male gatekeepers emphasized in relation to family food decisions, with FGD moderators in Pakistan reporting that husbands and other family members also attended the FGDs with women respondents and had to be ushered into other areas while the groups were being conducted. This highlights current cultural and social norms which inhibit women’s agency to seek SPP and nutrition support, also reported from studies in other religiously conservative rural settings; alongside recommendations to also target men in these settings with nutrition-sensitive SBCC program messaging [31].

Issues of stigma and discrimination also need to be addressed with SPP providers given the competitiveness of people trying to access the schemes and the humiliation experienced by those who were rejected in favour of participants perceived to have familial ties or relationships with the administrators of the schemes. Along with the perceived poor administration of some SPPs, were often cited barriers to enrolment including the complex documentary requirements and online application procedures which many vulnerable respondents were not able to negotiate.

Furthermore, the co-design process conducted with program beneficiaries revealed that, across both countries, there were negative opinions of SPPs, funding levels to support adequate food supplementation, and other household expenses. This was coupled with the shame and humiliation reported by some applicants, and other poor customer experiences that in some cases, may have been designed to discourage engagement. The study findings confirm other studies of the limited coverage of SPPs, including weak and inadequate cash transfer coverage to poor women’s groups; the reinforcement of a cycle of privilege and disadvantage among socioeconomic classes, errors in distribution of existing schemes, and challenges faced by non-beneficiaries in gaining benefits [32–34].

With the challenges, five opportunities for program improvement were also identified including opportunities for improved integration of SPPs with nutrition programs and SBCC to promote the programs and address beneficiary concerns. Capacity building and empowerment of vulnerable groups, particularly women with young children, was identified as an important requirement, as well as opportunities for co-design of messages to facilitate greater community engagement and address social and cultural norms within a culture of continuous improvement. Program donors have highlighted the ability of well-designed SPPs to reduce women and girls vulnerability, improve nutrition, enhance education outcomes, protect livelihoods and facilitate women’s economic and social empowerment [35].

Discussion on the organising theme of knowledge, attitudes and practices (KAP) indicators, identifies the need to focus on key behavioural determinants to support and maintain behavioural change. This includes building awareness and knowledge about SPPs and access to services, changing attitudes and perceptions, both from the supply and demand sides, toward the optimal functioning of the programs, addressing social and cultural norms in messaging and promotional activities to motivate and mobilise populations toward greater behavioural intentions to get enrolled in the programs and improve nutrition outcomes.

This emphasises the importance for SBCC interventions that focus on achieving behavioural change among the most vulnerable, while also ensuring SBCC activities will move other participants at various stages of change, further along the behaviour change continuum [36]. This includes the need for pretested messages delivered through highly credible IPC message sources of key influencers and opinion leaders which have also been identified as key drivers for change in other development programs [37].

Possible solutions provided by respondents in both countries from the co-design sessions included the need to establish an independent complaints mechanism in the form of an Infoline, easily accessible by community members. This accords with recommendations from other studies for more “information-related channels” for nutrition and social protection available to the vulnerable [38,39]. Other feedback recommended more community awareness sessions be conducted, so community members were better informed about the nature of the SPPs, what benefits were provided, the level of the benefits, when the benefits would be received, and the assessment criteria for enrolment into the programs [39]. Barriers to improved nutrition within the communities of the poorest of the poor identified that the basic food packages provided with most food programs usually only addressed food hunger, rather than the provision of more nutrient-dense foods and adequate dietary diversity.

Opportunities for SBCC identified the greater need for program integration including CTTs linked to improved health outcomes, capacity building and empowerment of beneficiaries lacking in confidence and ability to effectively engage with the programs and resultant benefits to be accrued, and greater community engagement in the effective design and delivery of the programs including co-design opportunities at various stages of the program design, with the approach seen as most often used for nutrition intervention development [10].

The formative research and systematic review has highlighted the importance of addressing the barriers to improved nutrition through nutrition-sensitive SBCC approaches embedded within cash transfer programs. This could include building awareness and knowledge on local, culturally acceptable and affordable nutrient-dense foods, and the provision of child-appropriate recipes which were identified through the systematic review [40,6]. Opportunities to integrate nutrition with the conditional cash transfer programs also considered the role of NUDGES or incentives to qualify for the CCTs which were contingent on greater engagement by program beneficiaries to build knowledge and capacity for improved nutrition outcomes, particularly through trainings attended by women with young children. CCT NUDGES could also include beneficiaries taking their children for regular health checkups at Primary Health Centres (PHCs) to monitor growth and development. Similar approaches in providing cash alongside nutrition counselling, have been found to enable vulnerable populations to adopt more positive nutrition practices, and improve the diets of young children [39].

Food stamps/vouchers was another idea raised by stakeholders in Pakistan that is worth trialling in both countries, as it allows recipients to use a portion of funds provided in the form of food vouchers to purchase specific nutritious products, rather than using the funds for other discretionary spending. The approach, which has been adopted in a number of high-income country settings, testifies to the efficacy in channelling limited safety-net resources toward improved nutrition and health outcomes of the most vulnerable. Despite the reported improvements in dietary outcomes, the system will need careful planning due to reported unintended effects, due to purchasing restrictions applied to some food voucher programs [41].

Issues related to the range of SPP providers with different program branding indicate that many beneficiaries, particularly in Pakistan, are not aware of the term “social protection program”, despite many being enrolled in the programs. Additionally, the large number of SPPs operating in both countries (more than 100 SPPs identified in Bangladesh) are likely to create confusion among beneficiaries on where to enrol in the programs and what nutrition and cash benefits are provided. The politicisation of SPPs has also caused challenges in enrolment with these branding issues also highlighted in other country settings [42,43].

SBCC message dissemination

SBCC message dissemination is an important component of the SBCC Entry-Point Platform with the recommendation that the most preferred and impactful messages should be delivered by highly credible interpersonal communication (IPC) sources. These comprise –key influencers and opinion leaders including doctors/nurses, and other Government and NGO health workers, religious leaders, local leaders, community members (MPs), and allied health and agricultural professionals. Other credible IPC sources identified were friends, family members, youth, teachers and children in schools. This recommendation conforms to other study recommendations for key messages to be delivered through community mobilization processes, whereby community or social workers, health workers, peer educators and counsellors are trained and engaged for health promotion and education [53].

Door-to-door dissemination of IPC messages was one approach recommended by many respondents, while stakeholders acknowledged the high costs involved with this form of message dissemination. Therefore, IPC delivered through community settings and purposive trainings would be more economical. Other preferred message dissemination methods included mobile media with recorded messages on WhatsApp (for illiterate community members) and community “miking” (Bangladesh only). Social media was also seen as a cost-effective and pervasive message source easily accessed by many people via their mobile phones, with Facebook and Tik Tok most frequently mentioned, alongside the use of local social influencers with large followings to front social media campaigns. Community radio/talkback radio, and community media such as posters and outdoor billboards should also be considered where budgets allow, with more costly purposive TV mass media messaging and news and current affairs programming considered when there is a strong buy-in to SPP and nutrition programs SBCC from government and donors.

Additionally, recommendations are to expand the application of NUDGES in the form of food incentives to empower community members and achieve a greater commitment to a range of health improvement behaviours:

“So, we are providing specialized nutritious food to the beneficiaries because we believe that the poorest of the poor families are facing this food insecurity issue. So, that is why we incorporated this specialized nutritious food in our model. Then we are also ensuring their immunization in the program. Then antenatal and postnatal care is one of the components in the program, and then awareness sessions: The beneficiaries must attend the awareness sessions by visiting our health facilities.”

Director General, of Government Cash Transfer Program, Pakistan.

Next, is the call for improved strategic planning through a nationally endorsed nutrition-sensitive SBCC strategy and action plan which includes Monitoring, Evaluation, Learning and Adaptation (MELA) components to measure program inputs, outputs, outcomes and impact, and use lessons learned to continually improve on interventions. A SBCC strategy endorsed by the government can also more clearly articulate key components required to achieve nutrition objectives and provide a practical stepwise approach to improve integration of nutrition-sensitive SBCC into SPPs. This would include more systematic, evidence-based activities for the design and pretesting of messages, with opportunities to scale-up messages which resonate with target groups and support nutrition behavioural change objectives.

“In Tawana, the concept was to promote local agriculture; the community was so happy because they could relate better diets with local foods and dishes. We didn’t talk about a ‘nutritious diet’, only ‘power giving foods’ with the pictures: They related to it very well. How do you translate it further?”

Former Director of donor funded school lunch project, Pakistan.

Last, is the importance of continuous program improvement which can only be achieved through well designed, nutrition-sensitive SBCC interventions which are effectively monitored for their impact with the view to scale-up approaches that are found to provide the greatest benefits and cost-efficiencies. As such, donors and governments should also be encouraged to provide adequate funds for MELA components of these programs to measure the effectiveness of SPPs on nutrition outcomes which require considerable investments over time. The recommendations emanating from the needs assessment and supporting systematic review have been articulated through the development of a SBCC Entry-Point Platform Spreadsheet and key components (see Table 5).

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Table 5. Nutrition-Sensitive SBCC Entry-Point Platform Spreadsheet.

https://doi.org/10.1371/journal.pone.0310288.t005

Conclusion

The integration of co-design into qualitative methods to supplement a systematic review of the literature has provided important program intelligence from which to design culturally appropriate, nutrition-sensitive SBCC interventions to support SPPs in Bangladesh and Pakistan. The iterative approach to program design has also provided lessons learned for other LMICs addressing malnutrition. However, integration of co-design into initial stages of formative research should not be seen as a substitute for well-designed needs assessments that explore participant barriers and benefits to effective program implementation. Rather, the approach should complement all stages of formative research by allowing participants to engage more purposively into identifying possible solutions to the key issues raised through the qualitative enquiry. The inclusion of co-design sessions into initial stages of program formative research should also not preclude more comprehensive co-design sessions taking place with program beneficiaries at evaluative research stages and pre-testing following development of SBC communication resources and approaches. This iterative process of learning can be seen to provide greater opportunities for culturally nuanced and more readily accepted behaviour change programs to improve nutrition with the poorest of the poor. In particular, the integrated approach to formative research was found to be efficient in the resource-constrained settings of the study countries with the methodology evolving from needs assessments conducted for SBCC strategies for a range of other priority health programs, in LMIC settings [54–56].

Lessons learned indicate that the consultative approach of needs assessment formative research integrated with co-design sessions can provide greater ownership, participation and engagement by program beneficiaries as well as identifying more pragmatic solutions to the current barriers to entry to nutrition-sensitive SPPs, identified by beneficiaries.

Supporting information