Designing school-based nutrition education interventions using social and behavior change principles to improve dietary practices of adolescent girls in Ethiopia

Background and objectives: Large-scale interventions implemented through schools have the potential to reach over seventy percent of adolescent girls in Ethiopia. Promotion of healthy food consumption practices among adolescent girls should address their motivations, barriers, and influencing factors. We designed and facilitated the implementation of nutrition interventions delivered through government primary schools to improve the diet of adolescent girls. Methods: We applied the socio-ecological model of social and behavior change (SBC) to develop an effective strategy for adolescent nutrition in SNNP (Southern Nations, Nationalities and Peoples) (agrarian) and Somali (pastoralist) regions. Gaps in dietary practices, barriers and motivations, roles of influential persons, and channels of communication were identified. Context-specific intervention models were developed for each region using multiple sources of information and data. Interventions were implemented by school principals, supervisors, teachers, student leaders, community leaders and health extension workers. Program monitoring and participatory problem-solving sessions helped to adapt the interventions, and informed and refined the implementation process. Results: School teachers and parents had good knowledge about nutrition prior to interventions, but they were not addressing the drivers of adolescents' dietary behaviors. Interventions were developed to improve adolescent girls' knowledge, self-efficacy, social norms, and beliefs by engaging parents, teachers, and peers in interactive dialogue conducted through multiple existing school-based activities that were streamlined to easily integrate into existing events such as flag ceremonies, school clubs/peer to peer sessions, and classroom lessons. Hands-on, participatory, face to face communication aided by audiovisual materials were used. Student take-home materials were used to reach parents; contacts were expanded through parent-teacher meetings, health worker visits and community events to encourage parents to provide an enabling home food environment. Repeated training, supervision and monitoring were key to solving operational constraints. Conclusions: Social and behavior-change principles may be needed to design nutrition education activities for improving dietary practices of adolescent girls. Primary schools can be effective channels for scaling up interventions to improve adolescent nutrition.