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R E S E A R C H A R T I C L E Open Access
Social value of a nutritional counselling and
support program for breastfeeding in
urban poor settings, Nairobi
Sophie Goudet
1*
, Paula L. Griffiths
1
, Caroline W. Wainaina
2
, Teresia N. Macharia
2
, Frederick M. Wekesah
2
,
Milka Wanjohi
2
, Peter Muriuki
2
and Elizabeth Kimani-Murage
2
Abstract
Background: In Kenya, poor maternal nutrition, suboptimal infant and young child feeding practices and high
levels of malnutrition have been shown among the urban poor. An intervention aimed at promoting optimal
maternal infant and young child nutrition (MIYCN) practices in urban poor settings in Nairobi, Kenya was
implemented. The intervention involved home-based counselling of pregnant and breastfeeding women and
mothers of young children by community health volunteers (CHVs) on optimal MIYCN practices. This study assesses
the social impact of the intervention using a Social Return on Investment (SROI) approach.
Methods: Data collection was based on SROI methods and used a mixed methods approach (focus group
discussions, key informant interviews, in-depth interviews, quantitative stakeholder surveys, and revealed preference
approach for outcomes using value games).
Results: The SROI analysis revealed that the MIYCN intervention was assessed to be highly effective and created
social value, particularly for mothers and their children. Positive changes that participants experienced included
mothers being more confident in child care and children and mothers being healthier. Overall, the intervention had
a negative social impact on daycare centers and on health care providers, by putting too much pressure on them
to provide care without providing extra support. The study calculated that, after accounting for discounting factors,
the input ($USD 419,716) generated $USD 8 million of social value at the end of the project. The net present value
created by the project was estimated at $USD 29.5 million. $USD 1 invested in the project was estimated to bring
USD$ 71 (sensitivity analysis: USD$ 34–136) of social value for the stakeholders.
Conclusion: The MIYCN intervention showed an important social impact in which mothers and children benefited
the most. The intervention resulted in better perceived health of mothers and children and increased confidence of
mothers to provide care for their children, while it resulted in negative impacts for day care center owners and
health care providers.
Keywords: Social return on investment, Exclusive breastfeeding, Community health volunteers, Intervention, Urban
poor, Nairobi, Kenya
* Correspondence: s.goudet@lboro.ac.uk
1
Loughborough University School of Sport Exercise and Health Sciences,
Loughborough, UK
Full list of author information is available at the end of the article
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Goudet et al. BMC Public Health (2018) 18:424
https://doi.org/10.1186/s12889-018-5334-8
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Background
In Kenya, sub-optimal maternal, infant and young child
nutrition practices are documented, with consequent
high levels of child malnutrition. The levels of malnutri-
tion have gone down, for stunting from 35% in 2008 to
26% in 2014 [1]. Likewise in poor urban areas, inappro-
priate maternal nutrition, suboptimal infant and young
child feeding practices and high levels of undernutrition
have been shown while exclusive breastfeeding for six
months is almost non-existent [2,3]. This means that
most children are failing to meet their nutritional re-
quirements for optimal growth during infancy, and the
development and health based on the WHO recommen-
dation to exclusive breastfeeding in the first six months
of a child’s life. Complementary feeding practices are
suboptimal, especially with regard to the nutrient density
of the foods fed to children under two years of age [3]
and hence, fail to meet the nutritional requirement of
growing infants. Poor breastfeeding and complementary
feeding practices are immediate causes of undernutri-
tion. In this poor urban setting in Nairobi, stunting, a
form of undernutrition, stands at between 47% and
50% [4,5]. Stunting is a major risk factor for morbid-
ity and mortality and is also associated with adverse
outcomes including compromised cognitive develop-
ment, scholarly achievement and future economic
productivity.
Interventions promoting optimal breastfeeding can re-
duce morbidity and mortality in children [6]. The baby
friendly community initiative (BFCI) is a multifaceted pro-
gram for promotion of optimal breastfeeding and infant
and young child nutrition, and other practices including
maternal nutrition in the community. BFCI is a comple-
mentary program to the Baby-Friendly Hospital Initiative
developed by the World Health Organization and the
United Nations Children’s Fund (UNICEF), with the aim
of promoting breastfeeding in maternity facilities world-
wide, and adopted in Kenya [7]. Given that many births
(close to 40%) take place at home in Kenya [1], and also
recognizing the need for continuum of care at the com-
munity even for those who deliver in hospital, the Minis-
try of Health has proposed the adoption of BFCI to bring
breastfeeding counselling and support to the community
as outlined in the country’s 2012–2017 Nutrition Action
Plan (https://scalingupnutrition.org/wp-content/uploads/
2013/10/Kenya-National-Nutrition-Action-Plan-2012-2017-
final.pdf). The BFCI package (unpublished) adapted for
implementation in Kenya involves an 8-step plan (the 8
steps are included in the Additional file 1:TableS1).
BFCI relies on a network of community health volun-
teers (CHVs) to reach mothers in their homes. In
Kenya, CHVs are part of the Community Health Strat-
egy, a government initiative that aims at using CHVs to
promote health in the community.
The African Population and Health Research Center
(APHRC) with the support of the Ministry of Health in
Kenya implemented a pilot project of the BFCI called
Maternal Infant and Young Child Nutrition (MIYCN)
project to assess effectiveness of the community health
volunteer element of the program to inform implemen-
tation of the BFCI in Kenya. The intervention aimed to
improve breastfeeding and other infant feeding practices,
and consequently nutritional and health outcomes of
children in urban poor settings in Nairobi. The pilot
study, employing a cluster-randomized study design, was
conducted in two slums where 14 community units (de-
fined by the Government’s health care system) formed
the unit of randomization (http://aphrc.org/wp-content/up-
loads/2016/03/FINAL-FILE-Design-draft-4-Social-return-
on-investments-evaluation-report-31st-Mar-2016.pdf). A
total of 1100 pregnant women and their respective babies
were recruited and randomly allocated into the intervention
and control groups and followed up. The community was
mobilized and promotion on the proposed intervention
was organized within the communities. CHVs were trained
on standard care, maternal nutrition, breastfeeding and
complementary feeding; deployed, supervised and in-
centivized. The mothers received regular, personalized,
home-based counselling by trained CHVs on breast-
feeding and complementary feeding and encouraged to
comply for antenatal and postnatal (ANC/PNC) visits,
birth planning, immunization, water and sanitation and
hygiene (WASH) practices in relation to the child (the
content of the counselling messages are in the Additional
file 1: Table S2). At national to county level, policy and de-
cision makers were engaged via stakeholder meetings.
Regular assessment of knowledge, attitudes and practices
on MIYCN was done, coupled with assessments of nutri-
tional status of the mother-child pairs and diarrhea mor-
bidity for their children. Children with severe acute
malnutrition (SAM) were referred to therapeutic feeding
centers. Sick children were referred to health facilities in
the community. These children had increased home visits
by CHVs. As opposed to the intervention group, the con-
trol group was not counseled by CHVs trained on MIYCN
but those trained on standard care only, with distribution
of standard MIYCN leaflets. The RCT findings showed
that the MIYCN potentially had an impact on exclusive
breastfeeding and stunting. The rate of exclusive breast-
feeding for six months increased from about 2% at base-
line (before the intervention) to approximately 55% for
both intervention and control group [8]. The prevalence
of stunting for children aged 6–12 months reduced from
about 33% at baseline to about 30% in the intervention
group, but increased to 38% in the control group. The lack
of significant difference in exclusive breastfeeding rates
between the two groups was considered to be due to po-
tential contamination between them [8]. It is possible that
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the CHVs in the control group may have obtained know-
ledge on MIYCN from the standard training given to them
(as it also includes messages on exclusive breastfeeding)
or from other sources e.g. other NGOs and from the
CHVs in the intervention group with whom they were
interacting with. More MIYCN knowledge may have been
obtained from the information materials that were pro-
vided to the CHVs in both arms.
The analysis presented here using a Social Return on
Investment (SROI) approach aimed to quantify the social
value created by the MIYCN intervention. [9]. In this
paper, stakeholders; i.e. people who have been impacted
by the intervention, were central in assessing and valu-
ing the impact of the intervention.
Methods
The methods used were based upon the SROI principles
and steps as presented in the SROI guide [10] and in the
practical guide for international cooperation [9]. The
methodology used is described in the paper by Goudet et
al. 2016 [10] and thus is not explained here. Data collec-
tion used a mixed methods approach (qualitatively using
focus group discussions, key informant interviews, in-
depth interviews, and quantitative stakeholder surveys,
and revealed preference approach using value games [11]).
The stakeholders included individuals or organizations
that were directly or indirectly impacted by the MIYCN
intervention and as a result experienced a change that
matters socially or economically. The research team elic-
ited a potential stakeholder list. During the study’s incep-
tion meeting held in June 2015 in Nairobi, representatives
from the Ministry of Health (at the county and national
levels), UNICEF, USAID, Non-Governmental Organiza-
tions, research organizations and academic institutions
contributed to firming up the identification of stake-
holders. An influence and importance matrix was used to
identify and select stakeholders (Additional file 1).
Mothers who participated in the intervention, their chil-
dren, the fathers, the grandmothers, the community
health volunteers, the health care centers, the data collec-
tors and the day care centers were identified(the list of
stakeholders are included in the Additional file 1:Table
S4). Children were too young to be interviewed thus the
researchers relied on mothers to report their outcomes.
Some identified stakeholders (grandfathers, other relatives,
neighbors and media) were excluded from the data collec-
tion by the research team as the material impact as a re-
sult of the activities was assessed to be minor by the
research team during the ‘identification of stakeholders’
phase. Some stakeholders were included in the data col-
lection (shop owners, traditional birth attendants) but ex-
cluded in the final analysis by the research team as the
impact on them was not tangible based on their responses.
For example one shopkeeper kept mentioning how she
had been advised on the use of the aqua tabs (tablets for
sterilizing water) and how his business had increased as a
result of stocking the aqua tabs and people buying. The
MIYCN project did not counsel mothers on sterilizing
water using aqua tabs but general hygiene including wash-
ing hands, boiling water for drinking.
Qualitative component
The main objective of the qualitative work was to gain a
general understanding of changes observed or experienced
as a result of the intervention. The qualitative approach
explored the impact of the intervention per stakeholder
using data from eight focus group discussions (FGDs), 15
key informant interviews (KIIs) and 14 in-depth inter-
views (IDIs) involving 161 participants. Qualitative data
collection was done through In-depth interviews (20) Key
Informant Interviews (28) and Focus Group Discussions
(19) with the potential stakeholders. A total of 162 partici-
pants, representing each stakeholder group were selected
purposively from the study community to participate in
the qualitative interviews. The selection process took into
account their religion, ethnicity and village of residence to
minimise bias. A pilot activity was conducted to pre-test
the question guide and feedback from the pilot was used
to review tools accordingly. The teams were trained on
the qualitative tools during the 7 days trainings on the
SROI approach, study objectives, quantitative data collec-
tion methods and the study’s data collection tools. The
questions used were the generic questions from the SROI
guide [11] and included:
–What has changed for you or your organization as a
result of the MIYCN project activities?
–Has all the change been positive? Were some of the
changes negative?
–Has anything changed that you were not expecting?
–Would the changes you have mentioned happen if
the project had not been there?
–How much of a difference will each of these changes
make to you or your organization?
–Was anyone else involved in making these changes
happen? If so, who were they and how much change
would you say was due to them?
The question guides were translated into Swahili, the
most commonly-used language in the study setting. The
Swahili questionnaires were not back translated but the
field workers were asked to confirm if the Swahili ver-
sion was the right translation of the English version. The
English and Swahili guides were then reviewed by the
field workers during training to confirm on the right
translations to ensure that no information was missed
out during the translation.
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Quantitative component.
Quantitative methods were used to assess the level of im-
pact experienced or observed by the project participants
and the frequency of participants reporting the changes in
terms of nutrition, health and hygiene practices or other
outcomes whether positive or negative as a result of the
project. These included the perceived benefits and losses
incurred as a result of the project and the estimated
changes in expenditure resulting from the intervention.
The questionnaires were designed by the research team
under guidance from SROI experts. A pilot activity was
conducted to pre-test the questionnaires, feedback from
the pilot was used to review tools accordingly. Question-
naire data were collected using electronic data capture de-
vices by a team of 10 field interviewers. The team were
trained for 7 days on the SROI approach, study objectives,
quantitative data collection methods and the study’sdata
collection tools. During the data collection process, two
field supervisors were involved in supervision of the data
collection process and 100% data editing to ensure high
quality data.
The quantitative stakeholder survey assessed the level
of impact using a Likert scale, and explored costs, dur-
ation and comparison with if the project had not taken
place. The questionnaires were developed by the re-
searchers based on the generic questions from the SROI
guide [11] and were pilot tested and adjusted. For ex-
ample, during the pilot the mother questionnaire had a
few questions like did you participate in the project, how
was it for you to participate, this was changed to “do
you know about the project mentioned, did you partici-
pate and how did you find your participation”?, this was
decided on after realizing that there were mothers who
did not seem to know about the project. We also added
a question on “who the participant had received the
MIYCN information from”, this came as a result of
mothers indicating that they had information and who
they had received it from. This clarification was helpful
in finding out if she actually participated in the project.
The changes assessed included the perceived benefits
and losses incurred as a result of the project and the es-
timated variation in expenditure resulting from the
intervention. The generic questions and areas that were
explored during consultation included:
–Using the Likert scale of 5 levels, please show me
the level of change?
–How long do you think this change will last?
–Inwhatotherwaysmightthechangehavecomeabout?
–What would have happened if you hadn’t been able
to benefit from the MIYCN activities?
The sample of mothers was randomly obtained based
on 10% in each group (intervention and control). An
additional group from another study which recruited
women not involved in the MIYCN study) was included
to allow for comparison, as a proper counterfactual. The
other stakeholders were purposefully sampled from the
community. Data were collected for 281 participants, se-
lected to represent the different stakeholders (separate
questionnaire for mothers, CHVs, grandmothers, day
care centers, business community, health care providers
and data collection team).
Other SROI components
Value games were used to place financial values on out-
comes which did not have a market value (e.g. happier
mothers). This provided a practical approach to valuing
outcomes and involving stakeholders. It showed how
stakeholders valued the outcomes they experienced rela-
tive to other products they also valued that have market
place values (prices). Stakeholders were consulted through
focus group interviews and key informant interviews. In
total 16 Focus Group Discussions were conducted; 4 with
mothers, 4 with fathers, 4 with grandmothers, 3 with
CHWs and 1 with data collectors who were involved in
the Main MIYCN study. The key informant interviews
were with 3 health care providers and 3 day care center
managers. The monetisation/valuation was done by carry-
ing out a value game for each of the outcomes the partici-
pants experienced as a result of the intervention.
During value games, participants were asked to list
items they also valued that have market values (prices)
and to place the outcome of interest relative to these other
items with market value. The average of the highest and
lowest cost item was used to assess the market value of
the outcome. For example, grandmothers placed the out-
come ‘less burden of care’between ‘food for one year paid’
and ‘rent for one year paid’in terms of importance (for
more information on value game, refer to [10]).
The inputs / costs that stakeholders contributed in
order to make the activities possible were identified via
the stakeholder questionnaire. In addition, the total
intervention and research cost was estimated at using
data generated by the APHRC financial system.
The SROI ratio was calculated by comparing the invest-
ments (inputs) and the financial, social and environmental
returns (outcomes and impact of an intervention) based
on assumptions (the assumptions are included in the Add-
itional file 1: Table S5) as follows: SROI ratio = Total (ad-
justed) value of results / Total value of inputs OR SROI
ratio = Total results x deadweight x attribution x inflation
adjustment / Total value of inputs. Details of calculation
can be found in the Additional file 1. Only final results
and assumptions are presented here.
The results were reduced to recognize the influence of
external influences (attribution, displacement, drop off and
deadweight). Attribution was used to recognize that some
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of the changes were not due to the intervention only. The
changes could have occurred due to other organizational
influences and/or persons working together. We assessed
displacement by exploring how much of the outcomes from
MIYCN have displaced other outcomes that were likely to
happen. Deadweight was explored in the questionnaire by
asking participants to rate the likelihood of an outcome if
the intervention had not taken place. Drop off was used to
recognize that the effect of the outcome will decrease over
time and outcomes are likely to be influenced by other fac-
tors. Finally, a discount rate was utilized to recognize that
people generally prefer to receive money today rather than
tomorrow which discounts the value of future benefits. Dis-
counting was applied to the values that have duration of
more than one year.
Data analysis
Qualitative component
Thequalitativedatawereanalyzedthroughuseofathe-
matic analysis method. A code book was developed from
important areas (themes and sub themes) arising from the
data and objectives of the project. The data was then coded
using NVIVO qualitative software. The topics of the the-
matic analysis were guided and developed from the inter-
view guides and also the recurrent and emerging
information collected from the participants’data. The path-
ways were identified by linking outcomes to understand the
change that occurred. For example, the theory of change
outcome 1.10 Healthier mother was built by creating the
following pathway: Counselling on health seeking by
CHWs - > Knowledge on importance of health care- > in-
creased confidence in seeking health care- > increased child
checkups- > birth at health facility- > normal birth weight-
> reduced complications- > mother and baby healthy.
Quantitative component
The quantitative data were analyzed by use of STATA
software and descriptive results were generated for each
question; the frequency of a reported outcome, the aver-
age duration of a reported outcome, the average value of a
reported outcome, the quantity of changes that would
have occurred anyway even if the project was not imple-
mented. In cases where comparison before and after the
intervention was required, variables based on the 5-point
Likert scale were regrouped into three levels of change.
These levels are ‘no change’,‘changed up the scale’and
‘changed down the scale’. Changed up the scale is when an
individual was at a lower level on the Likert scale at base-
line but moved to a higher level after the intervention.
The changed down the scale is the vice versa, while no
change corresponds to an individual staying at the same
level after the intervention as was at baseline. After deriv-
ing these three categories we computed frequencies for
each category. Whether the change up or down a scale
was a desirable or negative outcome depended on the par-
ticular question.
Other component of SROI
To estimate the cost of the intervention, assumptions were
made to include 33% of the salaries of the research team
based on time diaries because their time was spent partly on
intervention delivery and partly on other activities such as
rigorous research activities, research capacity building for the
principal investigator as the original grant was for a training
fellowship and academic paper writing. In addition to the
APHRC costs, the mothers and grandmothers time spent
during counselling sessions was estimated using what activity
they could have done in the time they spent being counselled
and how much income they could have made from the activ-
ity. The input value for health care providers also needed to
be estimated based on the number of referrals and how
much time each referral took. The time spent was then con-
verted to how much money (salary for staff for that time/
treatment). The salary costs for CHVs, and data collectors
were already included in the total intervention cost.
An average of the higher and lower cost items was
used to assess the market value of the outcome. For ex-
ample, grandmothers placed the outcome ‘reduced bur-
den of care’between ‘food paid for one year costed at
Ksh 365,000 for a year ’and ‘rent paid for one year
costed at 90,000 for a year’in terms of importance. The
value of reduced burden of care in terms of cost was
then estimated at 365,000+ 90,000/2 = Ksh 227,500.
Ethical approval
Ethical approval for this study was obtained from the
Kenya Medical Research Institute (KEMRI) ethical re-
view committee in June 2015. Written consent and per-
mission to participate in the study and to record the
qualitative interviews was sought from each study par-
ticipant following full disclosure of the study objectives
and procedures before every interview.
Results
SROI measures the value of social benefits created by an
organization, in relation to the relative cost of achieving
those benefits, expressed in a SROI ratio [9–11]. The re-
sults section presents, the benefits expressed by stake-
holders, the costs identified and the SROI ratio. The
benefits were assessed by the combined results of the
qualitative, quantitative and other component; the qualita-
tive work identified the changes observed or experienced
as a result of the intervention; the quantitative analysis
assessed the level of impact experienced or observed by
the project participants and the frequency of the change
and the value games were used to place financial values
on outcomes which did not have a market value.
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Qualitative results
The outcomes identified were in total 34 and included 3 ex-
pected (e.g. healthier children), 20 positive but not expected
(e.g. mothers received more support from fathers) and 11
negative ones (e.g. increased level of worry for mothers due
to challenges in introducing complementary feeding after
prolonged exclusive breastfeeding) (Table 1).
This section focuses on the most important drivers in
terms of social value to conceptualize a theory of
change. Using the outcomes identified, pathways were
explored to create a theory of change. The intervention
contributed to the improved health of mothers and their
children. Participants’narratives are demonstrative that
mothers have very well understood the MICYN, ANC/
PNC and WASH messages and have changed behaviors
towards optimal practices.
Mothers felt that due to use of ANC and PNC ser-
vices, they faced less complications at birth and did not
have to experience caesarian section deliveries. This was
in comparison with the births of their other children.
They knew better what to eat during pregnancy and felt
stronger from it. Harmful behaviors such as use of drugs
were also stopped or reduced during pregnancy resulting
in normal weight babies at birth. The knowledge gained
in family planning helped mothers to avoid a pregnancy
soon after birth and thus to breastfeed for longer which
resulted in reported better growth and health of chil-
dren. Participants also reported that they exclusively
breastfed for six months and extended breastfeeding to
two years as counselled by CHVs in line with policy
guidelines, and for some this meant stopping work to do
so as their working environment was not conducive to
breastfeeding. For some of the mothers, breastfeeding
contributed to more relaxed babies but some also felt
that introduction of complementary feeding after six
months exclusive breastfeeding was challenging and
meant that children lost weight during the time of
introduction. For previous children born before the
intervention, they were started on foods early even be-
fore they were aged one month, so they got used to
food early.
Having more relaxed children who can sleep well
meant having more time to carry on household chores.
This time available was associated with employment of
optimal practices with regards to hygiene within the
household. Mothers also reported improving hygiene
practices related to a child’s care. As a result, mothers
recognized a decrease in diarrhea incidence and better
weight gain of their child compared to their other chil-
dren. Overall they felt more confident to seek appropri-
ate health care for themselves and their children. They
paid more attention to their children’s nutrition and re-
quested improved nutrition and hygiene practices when
leaving their children at the day care center.
The intervention created a more peaceful and support-
ive environment for child growth. Mothers were less
stressed around birth and breastfeeding times because of
the personalized counselling and care received. Fathers
recognized the benefit of counselling towards mothers
and children’s wellbeing. They were themselves happier
and reported being more willing to contribute financially
to the children’s needs. As children were less often sick,
fathers were able to miss less days at work and thus
bring more income home. Overall the relationships at
home benefited from a less ‘stressed’atmosphere.
Siblings of the children in the study also gained from
this situation and received more attention from their
mothers with regards to their education. Mothers had
more free time resulting from healthier and happier ba-
bies and were therefore able to attend school activities.
The grandmothers who were involved in looking after
children, were also more relaxed and happier as the bur-
den of care was lighter due to mothers caring for their
children and healthier children.
The MIYCN intervention led to change in spending
and earnings for the household. Mothers who had to
stop working to exclusively breastfeed lost their income
for several months and were not guaranteed to find
work again. Mothers and grandmothers reported savings
on health care expenditure as the child was less sick,
and on maternal milk substitutes as they breastfed more.
But other mothers recognized that following the MIYCN
messages meant more expenditure towards health care
(due to increased referrals by CHVs) and nutritious food
resulting from advice by the CHVs. Fathers were able to
work more and hence earned more and even reported
saving money to start businesses, as they saved time
otherwise used on health care for the child.
The MIYCN intervention put pressure on day care
centers and health care facilities. Day care centers had to
meet the requirement of mothers for better hygiene and
food without being able to increase fees. These increased
expenditures were not compensated for by the increased
income due to higher attendance of children (children
were reported to miss less days due to illnesses). In the
short run, health care centers faced increased referral of
malnourished and sick children and of children for
checkups from the community by CHVs, which posed a
heavier workload on health staff.. Nevertheless, in the
longer run, they expected a decrease in work load as
children in the community were healthier.
The MIYCN intervention built confidence and skills for
field staff but with increased stress. Field staff including
data collectors and CHVs felt better skilled due to the
training received and the working experience. These
placed them in a better social situation within the com-
munity and meant that their chances for future employ-
ment increased. CHVs felt empowered especially in being
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Table 1 Outcomes grouped per outputs and stakeholders with identification of the outcomes using value based on revealed preferences, generating the most and the less
social value
Stakeholders Outcomes Values in USD Outcome using value based on
revealed preferences approach
Outcomes that generated
the most social value
Outcomes that generated
the less social value
Mothers Outcome 1.1: Increased expenditure on nutritious
food and/or health care
−16,084
Outcome 1.2: More worried mother due to loss in
baby weight and poor health
−99,181 x x
Outcome 1.3: Less worried mother due to better
health of her children
1,378,419 x x
Outcome 1.4: Decreased expenditure on food
and/or healthcare
15,001
Outcome 1.5: Confident mother to overcome
family’s pressure
1,057,745 x x
Outcome 1.6: Having less burden of care 4923
Outcome 1.7: Improved relationship at home 1,008,474 x x
Outcome 1.8: Less stressed mother because
less dependent on others
349,645 x
Outcome 1.9: Less income due to job loss −14,747
Outcome 1.10: Healthier mother 1,677,133 x x
Outcome 1.11: Receiving more support
from father
1682
Total 5,363,010
Children Outcome 2.1: Healthier baby 803,371 x x
Outcome 2.2: Less healthy baby due to difficulty
in introducing complementary feeding
−308,231 x x
Outcome 2.3: Better Cognitive development 839,760 x x
Total 1,334,900
Siblings Outcome 3.1: Improved school performance
for siblings
156,069 x
Outcome 3.2: Healthier sibling 1,101,472 x x
Total 1,257,541
Fathers Outcome 4.1: Increased support to mother
and child
0 (already valued in
outcome 1.11)
Outcome 4.2: Increased labour participation 40,058
Outcome 4.3: Improved living standards at home 19,229
Total 59,287
Grandmothers Outcome 5.1: Reduced stress due to mother
caring better for her children
74,294 x
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Table 1 Outcomes grouped per outputs and stakeholders with identification of the outcomes using value based on revealed preferences, generating the most and the less
social value (Continued)
Stakeholders Outcomes Values in USD Outcome using value based on
revealed preferences approach
Outcomes that generated
the most social value
Outcomes that generated
the less social value
Outcome 5.2: Happier grandmother 32,270 x
Outcome 5.3: Decreased healthcare expenditure 4720
Total 111,284
Health care providers Outcome 6.1: Decrease in workload due to
healthier children in the community
44,279
Outcome 6.2: Increased workload due to
mothers seeking child checkups
−160,248 x
Total −4685
Community health volunteers Outcome 7.1: Financial gain vs strain
(salary vs own contribution to vulnerable children)
7376
Outcome 7.2: Increased stress due to the
difficulties posed by the work
−21,859 x
Outcome 7.3: Increased confidence 63,890 x
Total 49,407
Data collectors Outcome 8.1: Increased income 882
Outcome 8.2: Increased confidence 0 (valued in
outcome 10.1)
Outcome 8.3: Increased stress due to the
difficulties posed by the work
0
Total 882
Day-care centers Outcome 9.1: Increased stress due to increased
enrollment
−3684 x
Outcome 9.2: Increased in expenditure due to
improved hygiene and nutritious food provided
−6703
Outcome 9.3: Increased attendance of children 4041 x
Total −6346
Goudet et al. BMC Public Health (2018) 18:424 Page 8 of 14
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the link between the community and the health care ser-
vices. On the other hand, they faced a highly stressed situ-
ation in the communities being confronted by extreme
poverty and vulnerabilities without the adequate support .
Quantitative results
Costs / Inputs
The inputs were what stakeholders contributed in order
to make the activities possible. The total intervention and
research cost was estimated at USD$ 394,544 (Table 2).
In addition to the APHRC costs, the mothers and
grandmothers time spent during counselling sessions
was estimated to be up to USD$3087. The input value
for health care providers estimated based on the number
of referrals and how much time each referral took was
USD$21,180. The total input was USD$419,716.
Benefits
The SROI ratio was calculated using values placed by stake-
holders on the outcomes identified by themselves. The out-
comes that did not have market value (Table 1) were valued
by the stakeholders themselves through value games.
The total social value created by the project was USD$
8 million (this is the total for all stakeholders: mothers,
children, siblings, fathers, grandmothers, health care pro-
viders, CHVs, data collection team, day care centers). The
Total Present Value for the project for 5 years, at a dis-
count rate of 6.5%, was USD$ 29.8 m. The Net Present
Value was USD$ 21.7 m (the Total Present Value minus
the total of all inputs) (Table 3). Thus, the SROI ratio was
of USD$ 29.4 m / 0.4 m (Net Present Value / Input) =
USD$ 71: USD$ 1. This means for every dollar of invest-
ment in the MIYCN project, USD$ 71 of social value was
created.
Table 3 Summary findings of impact by stakeholder group in USD (discount rate: 6.5%)
Total impact Year 0 Year 1 Year 2 Year 3 Year 4 Year 5 Total Present value Net Present Value
Mothers 5,363,010 5,363,010 5,035,690 3,797,333 2,176,684 1,636,006 1,227,893 19,236,616 19,233,529
Children 1,334,900 1,334,900 1,253,428 941,542 707,261 531,276 399,081 5,167,488 5,167,488
Siblings 1,257,541 1,257,541 1,180,790 886,978 666,275 500,488 375,954 4,868,026 4,868,026
Fathers 59,287 59,287 55,669 41,817 31,412 23,596 17,725 229,506 229,506
Grandmothers 111,284 111,284 104,492 78,492 58,961 44,290 33,270 430,789 429,884
Healthcare providers −115,969 −115,969 −108,891 −81,796 23,460 17,623 13,238 −252,336 −273,516
CHVs 49,407 49,407 46,392 34,848 33,850 25,427 19,100 209,025 209,025
Data collection team 857 857 804 604 467 351 264 3347 3347
Day care −6346 −6346 −5958 −4476 −1410 −1059 1208 −18,042 −18,042
APHRC 394,544
Total 8,053,972 29,874,419 29,454,703
SROI ratio per
amount invested
71
Table 2 APHRC intervention and research costs for MIYCN intervention
Period of Report: March 01, 2012 - October 31, 2014
Cumulative Expenditure Cumulative Expenditure
Cost item To Date (Ksh) To Date (US$)
Salaries and consultant fees 19,994,314 231,936
Training workshop, Meetings, Workshops, travel and accommodation 2,333,722 27,000
Telephone, email, internet and bank charges, 400,884 4661
Printing & Stationery 640,300 7492
Motor Vehicle Running Costs 1,636,534 18,934
Non-Capital Office Equip & Tools and others 478,641 5531
Training Expenses 2,017,102 23,600
Other Program Expenses 243,145 2852
Field Office Expense 6,232,483 72,539
TOTAL 33,977,127 394,544
Goudet et al. BMC Public Health (2018) 18:424 Page 9 of 14
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Mothers, children and siblings were the stakeholder
groups that benefited the most with mothers representing
67%, children 17% and siblings 16% of the impact (Fig. 1).
The other stakeholders, including grandmothers,
fathers, health care centers, and day care centers
benefited from 1% of the social value generated. All
stakeholder groups had a positive impact except for
health care provider and day care centers (Table 3).
The outcomes that generated the most social value to
mothers and children were ‘healthier mother’and ‘less
worried mother due to better health’(Table 1).
The most important negative outcomes (with the most
value lost) were ‘less healthy baby due to difficulty in
introducing complementary feeding after exclusive
breastfeeding’and ‘Increased workload for health
workers due to more referrals by CHVs and mothers
seeking child checkups’(Table 1).
Sensitivity analysis
Sensitivity analysis was used to test the variables and as-
sumptions used based on base and new scenarios. We
checked changes for estimates of deadweight, attribu-
tion, displacement, drop-off and discount rate, the fre-
quency of the outcome and the value of outcomes,
where we used value games. The sensitivity analysis
showed that the ratio (71) can fluctuate from 34 to 136
depending on new case values (Table 4). The SROI ratio
is most sensitive to variation in value of outcomes that
were based on value game exercises, deadweight and fre-
quency used in key outcomes.
Discussion
This paper presents the social value of a community-
based nutrition intervention aimed at counselling and
supporting mothers for optimal infant and young children
feeding practices. Results showed that the intervention
created a theory of change in the community regarding
children and mother’s improved health and generated an
important social value, mostly towards mothers and chil-
dren, who were the primary beneficiaries.
A comparison of the SROI ratio with other interven-
tions in health and nutrition shows that this MIYCN
intervention had the largest ratio [12]. In Banke-Thomas
Table 4 Base and new case scenarios
Sensitivity analysis Base case New case New ratio
Attribution 0–25% 50% USD$ 44:1
Deadweight 5 –100% 50% USD$ 47:1
Displacement No displacement 25% USD$ 51:1
Drop-off 20% 50% USD$50:1
Discount rate 6.50% 3.30% USD$72:1
Outcome frequency use
Healthier baby 99% 50% USD$56:1
Healthier sibling 59% 50%
Outcome frequency use
Healthier baby 99% 50% USD$47:1
Healthier sibling 59% 0%
Outcome frequency use
Healthier mother 97% 48.50% USD$60:1
Value of the outcome using value game On average USD$ 2150 Value divided by 2 USD$34:1
Value of the outcome using value game On average USD$ 2150 Value multiplied by 2 USD$136:1
Fig. 1 SROI ratio breakdown per stakeholder group
Goudet et al. BMC Public Health (2018) 18:424 Page 10 of 14
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et al. (2015) [12] systematic review on SROI, 12 studies
were identified in health promotion [13–24], four in child
health [25–28] and three in nutrition [15,29,30]. The re-
ported SROI ratios varied from 1.1:1 to 65:1. There were
two studies from Kenya that used SROI, one on repro-
ductive health and one on water interventions [31,32]
with lower SROI ratios of respectively, 1:25 and 1:8. The
fact that the SROI ratio calculated in our study was the
highest may be due to the lack of comparison basis as
SROI is still a relatively new method. It is also possible
that SROI was used in other nutrition promotion inter-
ventions but that the findings were not published in peer
reviewed journals as so far most the studies using SROI
arein grey literature.
The findings here add evidence to previous results on ef-
fectiveness and impact of preventive nutrition programs on
children’s nutritional status in LMICs as presented in the
Lancet series on Maternal and Child Undernutrition [6].
The series showed that there was extremely limited evi-
dence of breastfeeding promotion impacting on children’s
nutritional status; the limited number of studies that
assessed nutritional status did not show an impact on
weight nor length of infants [6].Thefindingsherewere
able to confirm the potential effectiveness of MIYCN re-
ported in Kimani-Murage et al. (2016) [8] on optimal infant
feeding practices and improved child health. Furthermore,
thisstudyhasaddedtopreviousfindingsbycreatingathe-
ory of change that explains how the intervention activities
ledtothesepositiveoutcomesbutalsotonegativeones.
An important finding was that the intervention created a
favorable environment towards child’s health where im-
proved MICYN, WASH and family planning practices were
employed and where mothers, fathers and grandmothers
were less stressed about the child’s health. This is an envir-
onment where a couple agrees for the mother to stop work-
ing in order to exclusively breastfeed their baby as her
working environment was not conducive to do so; or where
fathers were willing to provide additional financial support
towards child’s growth. This supportive environment lead-
ing to confident, less worried and less stressed mothers is
recognized to be extremely important to successfully
breastfeed children [33]. The intervention also reduced the
burden of care for the grandmothers, who were often the
caregivers of children born to young mothers. Previous re-
search found that child care by young mothers was com-
promised due to limited knowledge and competence of the
young mothers on child care, leading to dependence on
their own mothers and mothers-in-law (grandmothers of
the children), and also lack of commitment [34]. Lower
burden of child care on the grandmothers freed their time
for labor force participation. Interventions that aim to
counsel on breastfeeding exist [6] but the MIYCN study
was slightly different in the design; the timing was different
as counselling started when women were pregnant and the
topics of counselling were not focused only on MIYCN but
included ANC/PNC, WASH and family planning. Findings
showed that these differences were important and contrib-
uted to positive outcomes for maternal and child health
and wellbeing. The children were shown by this method to
have less SROI than mothers despite the intervention being
targeted at them. It could be hypothesized that because
they were too young to be given their own voice in this type
of evaluation (mothers had to report on both their own and
their children’s benefits). Other SROI assessments did in-
clude children as stakeholders (4 studies in child health)
but the children were older [26–28]andwereabletobe
interviewed or the study was evaluative and did not inter-
view children [25]. Nevertheless, it is interesting to note
that in Biswas et al.’study (2010) [26], parents/caregivers
benefited significantly more than the children in terms of
value created. Whilst this appearedtobeanunexpectedre-
sult as in the MIYCN program children were the primary
beneficiaries, it was due to the high financial value gener-
ated by tangible improvements in livelihood status through
income-generating or increased wage earning opportunity
for their parents. The authors noted that the benefits of im-
proved parent/caregiver income would positively impact
children. Similarly, here, it is expected that the social value
gained by parents will benefit the children as identified
already in the theory of change; more confident mothers
can use optimal IYCF practices. Additionally, benefits to
child health and development are long-term, and may not
have been fully captured in our assessment.
The social value generated by the intervention brings
new evidence on the potential impact of the proposed
BFCI in Kenya. This is key information as the existing
evidence so far is extremely limited on effectiveness of
such a program [8]. In addition, this is the first study ex-
ploring impact from the stakeholder point of view from
their personal experience, which resulted in their own
evaluation of the intervention. This is useful in scaling
up the intervention with regard to the proposed national
BFCI program in Kenya as policy engagement has
already been established through the pilot design and
the involvement of the national MIYCN steering com-
mittee formed by representatives of Ministry of health
(Unit of Nutrition & Dietetics), UNICEF and relevant
NGOs. While the intervention led mostly to positive
outcomes, negative outcomes were also identified. The
fact that negative outcomes were identified and pre-
sented is demonstrative of the approach taken of not
limiting the assessment to ‘positive outcomes’only. This
is new knowledge as the Lancet systematic review of
current evidence on maternal and child undernutrition
did not include a review of the negative outcomes [6].
We suggest here some programmatic recommendations
to minimize these negative outcomes in future BFCI
programs in Kenya (Table 5).
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The knowledge shared here from applying SROI to a
nutrition intervention with scientific rigor and research
expertise could be useful material for future use through-
out the nutrition sector, and can provide practical refer-
ence materials to other SROI practitioners implementing
such studies in developing country contexts.
The recommendations for future programming or
scale up were for National and County Governments to
roll out the BFCI program as a health promotion tool,
and to support the community health strategy through
funding CHVs as an essential component of the BFCI
program. BFCI has positive impacts on mother and child
health as well as the health and wellbeing of other family
and community members including fathers and grand-
mothers. Incentives for community health volunteers to
motivate them should be provided combined with ad-
equately training them on handling psychosocial issues.
The health facilities in the community should be rein-
forced to face the change in workload and increased re-
ferrals. Day care centers are places where children’s
nutrition and growth could be put at risk. Subsidies or
contribution towards ‘child friendly’day care centers that
promote child health would likely result in positive
changes for children. The community should be empow-
ered economically through social protection measures
and empowerment programs such as job creation and
support of mothers who wish to successfully combine
work with breastfeeding as some mothers had to stop
working to breastfeed. Men (fathers) should be included
in BFCI interventions as they contribute to its success
and positive outcomes by supporting their wives and
children financially and beyond. Finally, for researchers,
NGOs, and donors the SROI approach should be more
widely used in evaluation of interventions in order to
identify negative outcomes and value social outcomes.
Limitations
The limitations were related to the complexity of asses-
sing future health benefits of a current intervention and
the challenges in valuing non-market valued outcomes.
We decided therefore not to value future health benefits
and to limit the duration of impact to not more than
5 years. We feel that this may underestimate the social
value of the intervention but without data on how to
evaluate these, we preferred not to include them. We
used willingness to pay via value games to monetize out-
comes without market value such as confidence, burden
of care, worry, happiness etc. While value games exer-
cises were done to minimize subjectivity and to reach a
consensus per stakeholder group, sensitivity analysis
showed that the SROI ratio was mostly sensitive to
these. Although in Banke-Thomas (2015) [11], there is
an agreement that primary beneficiaries are best placed
to identify and value the outcomes themselves, it was
suggested in order to make the process more robust,
that the financial proxies described by beneficiaries
should be tested through further research for appropri-
ateness and relevance. A proxy verification process could
be integrated into monitoring and evaluation procedures
Table 5 Programmatic recommendations to minimize negative outcomes in future BFCI programs
Stakeholder Outcome Recommendations
Mothers Outcome 1.1: Increased expenditure on
nutritious food and/or health care
Provide social protection measures or empowerment for
food and healthcare.
Outcome 1.2: More worried mother due
to loss in baby weight and poor health
Provide targeted counselling around complementary
feeding introduction.
Outcome 1.9: Less income due to job loss Provide small subsidy such as cash transfer or empowerment
of women for baby friendly income generating activities.
Advocate for maternity leave benefits.
Children Outcome 2.2: Less healthy baby due to
difficulty in introducing complementary feeding
Provide targeted counselling around complementary
feeding introduction.
Healthcare providers Outcome 6.2: Increased workload due to
increased referrals and mothers seeking
child checkups
Provide extra staff and support via Ministry of Health.
CHVs Outcome 7.2: Increased stress due to the
difficulties posed by the work
Provide support to vulnerable mothers and children
via social protection measure or financial empowerment.
Provide psycho social support to CHVs.
Data collectors Outcome 8.4: Financial strain due to financial
aid given to vulnerable mothers
Provide support to vulnerable mothers and children
via social protection measure or financial empowerment.
Provide psycho social support to data collectors.
Day care centers Outcome 9.1: Increased stress due to increased
enrollment without increased financial gains
Provide small subsidy for food and hygiene or
microfinance services.
Outcome 9.2: Increased in expenditure due to
improved hygiene and nutritious food provided
Provide small subsidy for food and hygiene or
microfinance services.
Goudet et al. BMC Public Health (2018) 18:424 Page 12 of 14
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
to ensure that financial proxies reflect current trends
and perceptions of beneficiaries.
Conclusion
The MIYCN intervention showed an important social
value with mothers and children benefiting the most.
Mothers and children reported better health, as well as
increased confidence of mothers. Overall, the interven-
tion had a negative social value on day care centers and
health care providers putting too much pressure on
them without providing extra support. These findings
can inform the design of future programming by maxi-
mizing the social value the intervention created towards
improving health of mothers and children, and by target-
ing resources to manage negative outcomes towards day
care centers and health care providers. The policy rec-
ommendations from this work are to roll out the BFCI
program as a priority health promotion tool, as it is
likely to have huge health and social benefits, and to
support the community health strategy through funding
CHVs as an important component of the BFCI program.
When implementing the BFCI, it is important to
recognize that there is a need to ensure that adequate
support for health service and day care provision is
available for the initiative to have a greater chance of
success in creating social outcomes.
Additional file
Additional file 1: Table S1.Steps in the proposed Baby Friendly
Community Initiative (BFCI) program in Kenya, Step Description, Table
S2. Content of counselling messages, Table S4.List of stakeholders,
Table S5. Assumptions for base case scenario variables. (DOCX 18 kb)
Abbreviations
APHRC: African Population and Health Research Center; BFCI: Baby Friendly
Community Initiative;; BFHI: Baby-friendly Hospital Initiative;; CHV: Community
Health Volunteer;; IYCF: Infant and young child feeding;; MIYCN: Maternal,
infant and young child nutrition
Acknowledgements
We thank the APHRC Research Staff, particularly Dr. Alex Ezeh and Dr.
Catherine Kyobutungi, for their technical support in the design of the MIYCN
Project. We are also grateful collaborators in the MIYCN Project, particularly
Prof Nyovani Madise of the University of Southampton, Prof Shane Norris of
the University of the Witwatersrand and Prof Rachel Musoke of the University
of Nairobi, for technical support in the design and implementation of the
study. The authors are also highly indebted to the data collection and
management team and the study participants. We acknowledge assistance
of Daniel Maina in data programming and Amos Thairu in data analysis. We
are also grateful to the Unit of Nutrition and Dietetics and the Unit of
Community Health Services of the Ministry of Health, Kenya, for their
guidance in the design of the MIYCN intervention and their support during
the implementation of the project. We would also like to thank UNICEF,
Concern World Wide, Makadara and Embakasi sub-County Health
Management Teams, the National Maternal Infant and Young Child Nutrition
Steering Committee, the Urban Nutrition Working Group, and the Nutrition
Information Working Group, among other agencies/NGOs/groups for their
contribution to the design and/or implementation of the program.
Funding
This work was supported by UKAID from the Department for International
Development (DFID) through the Transform Nutrition Research Consortium
(PO5243, Aries Code 201448) led by the International Food Policy Research
Institute (Grant # 2105X212.APH). The original MIYCN study was funded by
the Wellcome Trust, Grant # 097146/Z/11/Z. PG was supported by a British
Academy mid-career fellowship (Ref: MD120048). SG is beneficiary of an AXA
Research Fund postdoctoral grant.
Availability of data and materials
The data that support the findings of this study are available from APHRC
(APHRC Microdata Portal), in line with APHRC’s data sharing guidelines
(http://aphrc.org/wp-content/uploads/2014/05/GUIDELINES-ON-DATA-
ACCESS-AND-SHARING.pdf).
Authors’contributions
SG, EK, PLG, FW, CW, TM, MW and PM were involved in the conception, design
and collection of data. SG led the analysis and interpretation of the data. SG, EK,
CW, TM, and PLG contributed to the analysis and interpretation. All named
authors contributed to the drafting of the paper and all critically reviewed its
content and have approved the final version submitted for publication.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests
Ethics approval and consent to participate
Ethical approval for this study was obtained from the Kenya Medical
Research Institute (KEMRI) ethical review committee in June 2015. Written
consent and permission to record the qualitative interviews was sought from
each study participant following full disclosure of the study objectives and
procedures before every interview.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Loughborough University School of Sport Exercise and Health Sciences,
Loughborough, UK.
2
African Population and Health Research Center, Nairobi,
Kenya.
Received: 17 October 2017 Accepted: 19 March 2018
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