Strategy for Addressing Behavior Change Communication in IRC Health Programs
Strategy for Addressing Behavior Change Communication in IRC Health Programs
Behavior is a key determinant of health and is influenced by a dynamic mix of internal and external factors. For many years IRC health staff have implemented various activities to promote healthy behaviors by communicating educational messages to individuals and communities. Whatever the thematic focus, we generally undertake these interventions with the goal of improved health outcomes. Our assumptions have been that the provision of resources such as medicines, condoms and water infrastructures along with increasing knowledge of the diseases associated with lack of those resources will lead beneficiaries to adopt new behaviors. Yet, while we have been able to observe increases in health-related knowledge among the people we serve, we have not been able to assess the effects our programs have on changing behavior.
With recognition of the significance of behavior change for IRC health programs and the limits of messaging, comes the need for a thoughtful approach. This requires an in-depth analysis not only of determinants and outcomes of behavior but our approach, as health professionals, to this complex issue. This strategy document aims to address the latter by combining what we know from experience, the current needs of staff and where we would like to be. As these factors inform the model for addressing behavior change communication in IRC health programs, the model in turn guides training and tool development.
A recent survey of IRC health staff provided insight into how behavior change communication programs are being implemented. The results indicated that a plethora of messages and communication methods are currently in use without evidence of a systematic approach to identifying target groups, key practices, barriers and enabling factors for behavior change, appropriate communication channels and targeted messages for BCC programs. There was no indication that messages were standardized and it was unclear whether materials in use matched the visual and verbal literacy of the audience, or whether the needs and desires of the audience had been considered in the design of the messages and materials.
The survey also attempted to discern approaches to monitoring and evaluating BCC activities. While there was some qualitative and quantitative evidence to suggest an association between approaches in use and increases in knowledge and practice of key health behaviors, the majority of programs responding to the survey were unable to demonstrate evidence of an effective BCC intervention. Furthermore, there was confusion over qualitative and quantitative indicators. In general, the survey results indicate a dire need for improvement in monitoring and evaluating IRC’s BCC programs.
In conjunction to the survey, a literature review of BCC theories, models and approaches was conducted. The documents reviewed examined models and approaches in isolation and often with the aim of endorsing a particular approach. Few trials have been conducted to compare the efficacy of different approaches within a population or the same approach in different populations. Thus, the data gathered from literature review proved insufficient in establishing an evidence base by which a particular approach could be endorsed as the IRC approach to behavior change communication.
The survey and literature review proved effective in helping to determine a guiding model for IRC’s BCC interventions. While they did not point to one particular approach as most effective, they both spoke to core elements found in a variety of approaches that constitute a comprehensive process, namely problem identification, formative assessment, design, pre-testing, implementation, monitoring and evaluation. The conclusion is therefore to focus on building our skills in these core elements by taking a process oriented approach to behavior change communication in IRC health programs. Training and tools will aim to build capacity around these core elements in a model that coincides with IRC program cycles.
Monitoring should be incorporated into every step of a BCC program, from formative research to evaluation. At each step, monitoring can be approached as keeping a journal of what was done where, when and what may or may not have happened as a result. Once the BCC intervention is underway, monitoring will include tracking established qualitative and quantitative indicators. When possible the attitudes of health staff implementing a BCC intervention should also be included in the scope of monitoring. Time-bound documentation of change is key to monitoring.
A formative assessment serves as the basis for any BCC intervention. The process of formative assessment begins with identifying the problem we want to address, including its prevalence and severity and progresses to gathering data on those affected by the problem. Questions concerning affected groups should aim to identify target audiences and learning as much as possible about their common practices, barriers and enabling factors for behavior change. Tools such as key informant interviews, focus group discussions, structured observations and population surveys are essential for gathering formative assessment data. When used complimentary, these tools should provide a reliable picture what people say that they do and what they are observed to do. The information in turn determines appropriate messages and communication channels for a BCC intervention. The keys to formative assessment are an interest in learning about people and an open mind. The process of formative assessment should result in problem identification and learning both about issues surrounding the behavior in question, as well as about the preferred communication methods of the target group.
Once a comprehensive formative assessment is complete, the results should be used to define priority groups and priority behavior change objectives. A creative strategy for achieving the goal of behavior change can then be designed with input from the target group. The strategy for a behavior change program should be justified by the information gathered from a formative assessment. Examples of strategy justification based on formative assessments are: “In order to help [primary school children] to [wash their hands after using the latrine] we will focus on [making the practice of hand washing something fun to do] through [songs, games, colorful posters and drama]” and “In order to help [female childcare givers] to [carry out safe food preparation and storage practices] we will focus on [practically demonstrating good food preparation and storage practice] through [the creation of mother and toddler playgroups as a place care takers can entertain children and learn good childcare skills].” Both statements indicate that an intervention choice was made according to information regarding the practices of the target population. The process of creating a communication plan should result in a stated goal, a choice of intervention, the justification for this intervention and a work plan with time-bound activities, responsible persons, means of verification.
Messages & Materials Development
As a communication plan answers the question of how we go about a BCC intervention, message and materials development answer the question of what will be used to implement BCC activities. It should be possible to determine the messages and materials needed to conduct each activity after a communication plan. Message design is the essence of a BCC intervention as it requires a combination of what we know people are doing (formative assessment) and what we want them to do. Considerations for message design include claiming the attention of the target audience in an appropriate way, the comprehension of the message by the target audience and the accuracy and consistency of the message. Materials development take the mode of message communication into highest consideration. For instance, a message designed for a radio broadcast may use more phonetically pleasing words than a message designed for a poster or board.
It is import to test the proposed intervention with a selection of people from the target group before wider implementation. The visual and verbal messages conveyed by posters, flyers, billboards, radio spots and dramas must be tested to ensure that the target audience interprets the message as intended and that the messages are appealing, acceptable and appropriate to the audience. Pre-testing can be time-consuming so adequate time should be allocated to this step of the cycle, which may have to be repeated several times, as the messages are adapted, based on feedback from the target audience. Pre-testing may also mean testing the responsiveness of a group to a particular participatory rural appraisal exercises. Time should be allocated in the BCC intervention timeline for incorporating pre-testing results into intervention. Pre-testing must be followed by a revision of the materials based on feedback received.
The implementation phase of a BCC program involves conducting the activities of the communication plan with the target audience using pretested materials for a given period of time and monitoring progress.
An evaluation should tell us whether or not our intervention had an effect on the behavior of the target group, and why or why not. It should also tell us whether the intervention could have been done more effectively and/or efficiently. An evaluation not be seen as the end of a BCC intervention. A solid evaluation should build on the behaviors that have been impacted by the original BCC campaign serve as the means by which a more effective BCC intervention can be conducted with the same group and/or a key aspect of formative research for a new intervention.
Principles of the Model
1- A comprehensive formative assessment is the foundation for any BCC intervention.
2- An effective communication approach is a creative endeavor involving members of the target audience and is based on the formative assessment.
3. Pre-testing is a critical part of this development process. No BCC intervention should be conducted without pre-testing with a subset of the target group
4- Monitoring should be incorporated into every aspect of the BCC program.
5- An evaluation begins formative assessment.
The Way Forward
IRC’s Health Unit is dedicated to understanding the challenges to addressing behavior change in our health and hygiene promotion programs. This strategy document is, in essence, a problem identification exercise with a hypothesis on how to proceed. We have concluded that we will proceed to address our needs in this area via tools and training development centered on building capacity on monitoring, formative assessment, communication planning, message and materials development, pre-testing, implementation, and evaluation of BCC interventions.
We will continue with this strategy with the input of other IRC Technical Units and health and hygiene promotion experts. Ultimately, however, we realize that this strategy is the beginning of a process that feeds into an organization-wide strategy and contributes to a unique understanding of health behavior in emergencies in particular and conflict-affected populations in general