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BEHAVIOR CHANGETHE KEY TO EFFECTIVE RELIEF AND DEVELOPMENT PROGRAMS

Training Program Staff to Design Behavior Change Strategies

SAV E T H E C H I L D R E N F E D E R AT I O N, I N C.

Training Manual

Ashley Aakesson, Behavior Change SpecialistSave the Children Federation, Inc.

Ethiopia Field OfficeP.O. Box 387

Addis Ababa, Ethiopia2005

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AcknowledgementsThis manual has attempted to incorporate approaches, methods, and tools for changing behaviors from a wide variety of sources. The author is especially indebted to the CHANGE and Linkages projects at AED, and the Manoff Group, Inc. for developing many of the concepts and tools utilized in the manual. Thanks also to various Save the Children US departments and projects, including the Food Security Unit and Saving Newborn Lives staff in Washington DC, the DAP staff in Ethiopia, Haiti, and Mozambique, and the Behavior Change Working Group in Ethiopia for supporting the development of this manual.

Special thanks to Elizabeth Bunde, Michigan State Population Fellow, who initially formatted the manual and developed the “Wall of Barriers” and “Continuum of Behaviors” Exercises.

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Table of ContentsPage

Notes to Trainer: Introduction and Training Principles 4

Unit 1. How and Why People Change Behaviors 9

Unit 2. Putting Behavior Change at the Center of Our Programs 25

Unit 3. Situational Assessment and Formative Research 49

Unit 4. Field Exercise 62

Unit 5. Developing Effective Strategies to Change Behaviors through Programs

71

Unit 6. Monitoring and Evaluating the Impact of Behavior Change

85

Unit 7. Planning the Behavior Centered Approach for Programs 91

Annex 1. Examples of Behavior Change Strategies Resulting from the Behavior Centered Approach

96

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Notes to Trainer: Introduction and Training PrinciplesHow to use this manual This manual is intended to be used for training technical program planners and implementers. The authors have attempted to bring together proven tools and methods from many sources into one effective system for changing behaviors through programs. The approach to changing behaviors described in the manual can be used in every sector of emergency and development programs, including health, education, and food security. Each training unit includes content, learning objectives, key messages, exercises, instructions, and time and materials needed to complete the unit. The manual also includes case studies detailing the process as Save the Children/US has used it in actual programs. These case studies include challenges to implementation, strategies to overcome them, and the results achieved by this approach in changing behaviors on the ground.

A note on materialsThis manual was designed so that it can be used for a training with a range of technologies available. In a low technology setting, the trainer can present the content on flipcharts, printing out just the Participant Handouts to distribute to participants at the appropriate times. If an overhead or LCD projector is available, the trainer may use power point presentations to present the content. In any case, the trainer may want to print all of the content as power point handout pages, in addition to the Participant Handouts.

Training methods and principles employed in this manualOne goal of this manual is to utilize adult learning methods when training staff about designing and implementing behavior change strategies. People tend to train others in the way they have been trained, so it is important to employ adult learning methods when using this manual to train staff. See Table 1 for a summary of adult learning principles, adapted from J. Vella, 1994, Learning to Listen, Learning to Teach.

Effective trainers respect and build on the knowledge and experience that training participants bring with them. They use a mixture of teaching methods for the concepts and skills they want trainees to retain and apply. These methods include presenting to a large group, small group work and discussion, demonstration, role plays, and practicing new skills with feedback and discussion after. Teaching new skills effectively requires giving the learners opportunity to practice the skills in the context of the training, so that they can gain confidence in their ability to use the skill when they have returned to their jobs.

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Planning a training using this manualLinkages, in their manual, Behaviour Change Communication for Improved Infant Feeding: Training of Trainers for Negotiating Sustainable Behavior Change, January 2003, has defined six areas that should be addressed when planning a training. They are as follows:

Who: The learners (what are their skills, needs, and resources) and the trainer (s). Why: The overall purpose of the training and why it is needed.What: The skills, knowledge, and attitudes that learners are expected to learn. The

content of the training (keep in mind the length of the training when deciding on the amount of content).

What for: The achievement based objectives-what will participants be able to do after completing the training?

How: The learning tasks or activities that will enable participants to accomplish the “what for”.

Where: The location, including details of available resources and equipment, and how the venue will be arranged.

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Table 1: Adult Learning Principles

Needs Assessment: Determine what learners need to learn. Learning should address their needs and interests.

Safety in Environment and Process: Make people feel comfortable making mistakes.

Sequence and Reinforcement: Start with the easiest ideas or skills and build on them. Introduce the most important ones first. Reinforce key ideas and skills repeatedly.

Practice: Practice first in a safe place, then in a real setting.

Respect: Appreciate learners’ contributions and life experience.

Ideas, Feelings, Actions: Remember that learning takes place through thinking, feeling, and doing. Learning is most effective when it occurs across all three.

Immediate Relevance: Remember that learners should see how to use what they have learned in their job or life.

Teamwork: Help people learn from each other and solve problems together. This makes learning easier to apply in real life.

Engagement: Involve learners’ emotions and intellect.

Accountability: Deliver quality training and ensure that learners understand and know how to put what they have learned into practice.

6

Below is a sample schedule for a training using this manual:

Day 1Introduction to the Behavior Centered Approach to Programming 9:00-9:45 Participant Introductions

Review of AgendaEXERCISE 1.1: Training Goals and Expectations

9:45-10:45 PRESENTATION 1.1: Introduction to Theories of Behavior Change EXERCISE 1.2: What Are Behaviors?

10:45-11:00

Break

11:00-12:00

EXERCISE 1.3: Internal and External Determinants of Behaviors

12:00-12:30

EXERCISE 1.4: The Wall of Barriers

12:30-2:00 Lunch2:00-2:30 EXERCISE 2.1: Participant Experiences with Behavior Change

Interventions2:30-3:15 PRESENTATION 2.1: Approaches to Behavior Change

PRESENTATION 2.2: Focusing programs on behaviors using The Behavior Centered Approach

3:15-3:30 Break3:30-4:15 EXERCISE 2.2: The Continuum of Behaviors4:15-5:00 PRESENTATION 2.3 : The Behavior Centered Approach to

Programming5:00-5:15 Review and Questions

Day 2Designing and Implementing Strategies for Behavior Change 9:00-9:30 Review of Day 1 and Agenda for Day 29:30-10:30 PRESENTATION 3.1: Situational Assessment

EXERCISE 3.1: Activities to Behaviors 10:30-10:45

Break

10:45-11:30

PRESENTATION 3.2: Introduction to Formative Research and Methodologies

11:30-12:30

PRESENTATION 3.3: Formative Research Form FIELD EXERCISE 4.1: Preparing for the Field Exercise

12:30-2:00 Lunch2:00-3:15 EXERCISE 3.2: Planning Formative Research for Priority

Behaviors3:15-3:30 Break

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3:30-4:00 PRESENTATION 5.1: Developing a Behavior Change Strategy 4:00-4:30 EXERCISE 5.1: The BEHAVE Framework 4:30-5:00 PRESENTATION 5.2: Developing a Communications Plan5:00-5:15 Review and Questions

Day 3Field Exercise: Focus Group Discussions 8:30-9:00 Assembly and Review of the Day9:00-11:00 FIELD EXERCISE 4.2: Focus Group Discussions 11:00-11:30

Reassembly/Break

11:30-12:30 FIELD EXERCISE 4.3: Research Groups Report Key Findings

12:30-2:00 Lunch2:00-3:00 FIELD EXERCISE 4.4: Drafting Strategies Based on Key

Findings3:00-3:30 PRESENTATION 6.1 : Monitoring and Evaluation 3:30-3:45 Break3:45-4:30 EXERCISE 6.1: Incorporating Behavioral Indicators4:30-5:00 Review and Questions

Day 4

Planning the Behavior Centered Approach for Programs9:00-10:00 Review and Discussion of Behavior Centered Approach:

Opportunities and Challenges 10:00-11:00

EXERCISE 7.1: Situational Assessment for the Program: Prioritizing Behaviors

11:00-11:15

Break

11:15-1:00 EXERCISE 7.2: Assessing Gaps in Our Knowledge: Key Barriers, Motivating Factors, Feasible Practices for Priority Behaviors

1:00-2:00 Lunch2:00-3:00 EXERCISE 7.2 (cont’d.): Planning Formative Research to Fill the

Gaps3:00-3:30 EXERCISE 7.3: Planning the next steps after returning to the job3:30-4:00 Break4:00-5:00 Review and Questions

Training Evaluation

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Notes on the Field ExerciseAn important part of this training is the field exercise. Unit 4 describes the field exercise and subsequent training activities in detail. The exercise consists of splitting the group up into research teams, and giving each team the opportunity to conduct a focus group discussion, fill out the formative research form, and present results back to the main group. Participants can then use the results from the field exercise to practice designing a behavior change strategy.

The nature of the field exercise will depend on the purpose and context of the training. The trainer should work out the details of the exercise before hand, particularly as transportation and other logistics might be involved. Also, the trainer will need to notify the groups that the “research teams” will be talking to in advance. The trainer should draft some simple question guides in advance, which the research teams can help to modify as appropriate as part of Presentation 3. 3.

One example of a field exercise is breaking the group into two health teams (one to talk with women and one with men), and two agriculture teams (one to talk with women and one with men). The teams go into nearby communities for brief (one hour) focus group discussions on any topic related to their project. For example, “Using bed nets” for the health team, and “Soil conservation techniques” for the agriculture team.

If it is not feasible to go into the community to do the focus groups, research teams can talk to colleagues not participating in the training, or they can practice with the other participants, taking turns being the research team. These options will be less realistic as an exercise. In such a case the topic could be, “Starting a company exercise program”, or “Increasing savings in the provident fund”. If participants conduct focus group discussions with other participants or colleagues, it is important to note that they should not do “role plays”, responding as they think community members might respond, but that they participate as themselves, speaking from their own beliefs and experiences.

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Why and How People Change BehaviorsIntroduction

IN order to understand how to develop and integrate behavior change strategies into your program, it is important to first develop a basic understanding of the theories behind behavior change, the nature of behaviors, and the factors that influence behaviors. This unit is designed to provide a basic background in these issues.

Learning ObjectivesThe learning objectives of Unit 1 are:

To reach agreement on the goals of the training. To understand theories about behavior change and what they

have in common. To understand the characteristics of behaviors. To understand some factors (determinants) that influence

behaviors at the individual and group level.

MaterialsThe materials needed for this unit are:

Flipcharts Overhead Projector Markers Masking Tape

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Unit

1

10

Note cards or ½ sheets of paper

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Unit ContentExercise 1.1: Training Goals and Expectations

Presentation 1.1: Introduction to Theories of Behavior Change

Exercise 1.2: What Are Behaviors?

Exercise 1.3: Personal Experiences With Behavior Change/Determinants of Individual Behavior

Exercise 1.4: The Wall of Barriers

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EXERCISE 1.1: TRAINING GOALS AND EXPECTATIONSKey Messages: Understanding the goals of the training and sharing participant expectations.

Materials: Overhead Projector or Flip Chart Markers

Time: 15 minutes

FACILITATOR STEPS

Go around in a circle, asking each participant to say what she or he hopes or expects to gain from participating in this training. Give plenty of time for each person to answer. Ask if anyone would like to add anything.

Uncover a pre-written flip chart or transparency stating the goals of the training:

By the end of the training participants will: Understand theories about how and why people change behaviors Share personal and professional experiences with behavior change Know about “best practices” in programs to change behavior Know a process for developing, implementing, and monitoring

effective Behavior Change strategies Be familiar with some of the tools and methodologies in this process Plan how to use this approach to Behavior Change in their program

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Reflect on how the trainer’s and participants’ goals and expectations overlap or differ. Keep both lists of expectations/goals displayed throughout the training.

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PRESENTATION 1.1: INTRODUCTION TO THEORIES OF BEHAVIOR CHANGE Key Messages: Theories of behavior change help programmers understand how and why people change their behaviors. There are several models of behavior change. They share common elements. We can use these common elements to think about how programs can enable change in beneficiary communities.

Materials: Overhead Projector or Flip Chart and Markers

Handouts: Participant’s Handout 1.1: Common Theoretical Factors Participant’s Handout 1.2: Stages of Change Model

Time: 30 minutes

FACILITATOR STEPS

I. Behavior Change Theories

Theories developed by social and behavioral sciences about how and why people change behaviors include :

A. Health Belief Theory, B. Theory of Reasoned Action C. Trans-theoretical Model (also called the Stages of Change

Model).

We are going to examine the common elements among all of these theories as well as exploring one model a bit further in order to better understand the processes that happen in behavior change.

II. Common Theoretical Elements

Place a copy of Handout 1.1 on an overhead projector or a piece of flip chart paper at the front of the room. Different theoretical models of how and why people change behaviors have many factors in common. Interventions in relief and development programs which are intended to bring about behavior change are more effective if they draw on these factors.

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Ask participants to volunteer to read one row of the Common Theoretical Factors table out loud, and to try to explain in their own words what it might mean. Make sure to praise each attempt, then give additional explanation if needed.

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III. Trans-theoretical or Stages of Change ModelPlace a copy of the Trans-theoretical or Stages of Change Model in the front of the room (using an overhead projector or on a flipchart). Review the Theory as follows. The Stages of Change Model represents:

A. A process that an individual goes through when changing a behavior

B. Individuals may progress through some stages faster than othersC. Individuals may move back and forth between stages rather than

moving in the same direction along the scale

Different types of behavior change interventions or messages are more effective than others depending on where the majority of the audience (those groups whose behavior they aim to change) is along the scale.

There are 6 phases in the scale:1. Pre-contemplation: People in this stage have no intention to

change behavior in the foreseeable future, are unaware of the risk, or deny the consequences of risk behavior.

2. Contemplation: People are aware that a problem exists, are seriously thinking about overcoming it, but have not yet made a commitment to take action.

3. Intention: People intend to take action in the near future.

4. Trial: People are taking inconsistent action to modify behaviors or environment.

5. Action: People modify their behavior or environment to overcome their problems; the behavior change is relatively recent.

6. Maintenance: People work to prevent relapse and maintain the behavior change over a long period of time.Source: Adapted from Prochaska and DiClemente, 1986.

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Ask for questions from participants. Participants will look at the stages of change model again related to specific behaviors.

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EXERCISE 1.2: WHAT ARE BEHAVIORS?Key Message: Understanding of the characteristics of behaviors creates a common language to discuss what changes are desirable and how program activities affect behaviors.

Materials: Overhead Projector Note Cards Markers Flipchart Paper Masking Tape

Handouts: Participant’s Handout 1.3: What Are Behaviors?

Time: 30 minutes

Facilitator Steps

Ask participants to tell you what the characteristics of behaviors are; list responses on a large piece of flipchart paper. After participants have provided responses, distribute Handout 1.3: What are Behaviors?, and read it out loud. Draw comparisons between the participant list and the Handout.

Pass out a note card to each participant and markers. Ask participants to think of a time in their life when they or a loved one have successfully changed a behavior and write the behavior on the card. Examples could include starting an exercise program, changing a work habit, or saving a certain amount of money each week. Be sure to tell participants that these behaviors will be discussed among the group, so they may not want to use a very private example.

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Collect the cards, mix them up and read each one out loud. Post each one as it is read in the front of the room (grouping any that may be the same or similar). Choose some behaviors and review the list behavior characteristics with participants: How is this behavior an action? Is it an observable or hidden action? How is it specific, measurable and feasible?

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EXERCISE 1.3: INTERNAL AND EXTERNAL DETERMINANTS OF BEHAVIORS Key Message: The ability of individuals and groups to adopt new behaviors is influenced by internal factors (personal beliefs, attitudes) and external factors (access to resources, social norms). These factors are called determinants and can either support or discourage change. Behavior change interventions must build on positive determinants and reduce negative ones in order to be effective.

Materials:

Cards from previous exercise with examples of personal BC

Flip Chart

Markers

Masking Tape

Handouts and Tools:

Participant’s Handout 1.4: Some Determinants that Influence Behaviors

Time: 60 minutes

Facilitator Steps

Refer back to the personal examples of behavior change from the last exercise. Ask for volunteers to discuss their or their loved one’s experience with changing a behavior. To get the discussion going it may be helpful if the facilitator has an example ready. The answers to the following questions can lead into a discussion of internal and external determinants of behaviors.

1. Why did you or your loved one want to change?2. What things helped you or your loved one to change? (Facilitator may

probe for internal or external determinants.)3. What things made it difficult for you or your loved one to change?

(Facilitator may probe for internal or external determinants.)4. Did the change happen all at once? How long did it take? Did you or

your loved one go through different “stages” on the way to change?

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5. How would you advise or help others to make a similar change?Facilitator should discuss each question separately and summarize responses to each question on separate flip chart pages taped at the front of the room.

Introducing the topic of Key Determinants: The goal of most program interventions is ultimately to change behaviors at individual or household levels. But individuals do not act in a vacuum. Their ability to adopt new behaviors is influenced by internal factors (the forces inside an individual’s head that affect how he or she thinks or feels about a behavior) like personal beliefs and attitudes, and external factors (those

forces outside the individual that affect his or her performance of a behavior) like access to resources or social norms. These influencing factors are called Determinants. The most influential factors for a behavior are Key Determinants. In order to change behaviors, programs have to address these Key Determinants.

Point out to participants that the factors they discussed related to their own experiences with BC are Determinants.

Label the responses to questions 1-5 on the flip chart pages “Motivations” “Positive Factors” “Barriers/Negative Factors” “Stages of Change”, and “Strategies for Change”. Usually some factors will show up as both positive factors and barriers.

Discuss how things like “family”, “friends”, “social norms”, can be either positive or negative determinants.

Pass out Handout 1.4: Some Determinants that Influence Behaviors. Briefly review the list with participants. Then ask them if they can think of any additional factors that can be added to the list.

Conclude the exercise by suggesting that, as programmers, we will be more effective at enabling positive behavior change if we remember our personal experiences with changing behaviors.

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EXERCISE 1.4: THE WALL OF BARRIERS Key Message: Programs seeking to change behaviors must determine where barriers to change lie and where positive factors exist that can be strengthened.

Materials: Flipchart sign: Individual, family, community level Flipchart sign: Institutional, policy level Sheets of paper Flipchart Paper Markers Masking Tape

Handouts: Participant’s Handout 1.4: Levels of Actors that Influence

Behaviors

Time: 30 minutes

Facilitator Steps

Introduce the topic: We have just learned about theories of behavior change that describe the factors which contribute to or inhibit adoption of new behaviors, as well as phases that individuals pass through when changing behaviors. We have also outlined internal and external factors (determinants) that influence the ability of individuals and groups to adopt new behaviors.

As well as being internal and external, determinants may exist at several levels. Programs seeking to change behaviors must determine where barriers to change lie at every level.

Handout Participant’s Handout 1.4. Ask participants to think about internal and external determinants that could operate at different levels.

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Ask participants to think of a behavior that they are trying to change through their program. Agree on one behavior as a group. Write that on a piece of flipchart paper and post it in the front of the room.

Pass out several half sheets of paper and a marker to each participant and ask participants to write down a reason why many people don’t change that behavior (what would a “barrier” to changing that behavior be?). Ask participants to think of internal and external barriers, as well as barriers that exist at different levels. Tell participants to write only one barrier per

sheet of paper. Allow approximately 10 minutes for participants to respond.

Collect the papers from participants. On one side of the wall, put up the side that reads “individual, family, community level”. On the other side of the wall, put up the sign that reads “institutional and policy level”.

Refer to the sheets of paper collected from participants. Read each one aloud and ask participants if they believe that it is an “individual, family and community level” barrier or an “institutional and policy level”. After the group agrees, place that sheet of paper under the corresponding banner and create a “wall” of the individual barriers.

Review the following with participants: Before an individual undertakes a new behavior, a person usually needs to:

Perceive a reason to do it Know what to do Know how to do it Not have too many negative beliefs/expectations

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Have the means (time, money, enabling environment, etc)

Be confident that he or she can do it and that his or her family and community won’t disapprove or punish

Expect that benefits will outweigh obstacles Expect social approval

For a person to repeat a new behavior, s/he usually needs to: Have a positive experience the first time Perceive sufficient benefit and lack of negative

consequences from her/himself and significant others.

Ask participants, “Can you think of anything that would reduce or eliminate each one of these barriers?” As each “brick” is addressed, remove it from the “wall” to demonstrate how we can reduce barriers in our program interventions.

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UNIT 1 Handouts1.1: Common Theoretical Factors

1.2: Diagram of the Stages of Change Model

1.3: What Are Behaviors?

1.4: Some Determinants that Influence Behaviors

1.5: Levels of Actors that Influence Behaviors

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Handout 1.1: Common Theoretical Factors

The Target Population Must: Factor:1. Believe the advantages of performing the behavior (benefits) exceed the disadvantages

Expected Outcomes (attitude)

2. Have formed a strong positive intention or be committed to perform a behavior

Intention

3. Possess the skills to perform a behavior Skills 4. Believe that they can perform a behavior Self-Efficacy5. Believe that the performance of a behavior will more likely produce a positive than a negative emotional response

Emotion

6. Believe that the performance of a behavior is consistent with their self-image

Self-Standards

7. Perceive greater social pressure to perform a behavior than not to perform it

Perceived social norms

8. Experience fewer environmental constraints to perform a behavior than not to perform it

Barriers

Adapted from National Commission on AIDS, 1993

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Handout 1.2: Diagram of the Stages of Change Model

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Pre Awareness

TrialIntention

Contemplation

Adoption

Awareness

Maintenance

Telling Others

Stages of Change ModelSteps for a person or group in changing behaviors

Praise

Support

Discuss Benefits

Negotiate

Encourage

Persuade

Inform

Appropriate Communication

Handout 1.3 What Are Behaviors?

BEHAVIORS ARE…

Concrete ACTIONS

Can be OBSERVABLE or HIDDEN

SPECIFIC

MEASURABLE

FEASIBLE

Have a DIRECT LINK to the desired outcome

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Handout 1.4: Some Determinants that Influence Behavior

EXTERNAL DETERMINANTS - those forces outside the individual that affect his or her performance of a behavior.

Access: encompasses the existence of services and products, such as condoms and needles, their availability to an audience and an audience's comfort in accessing desired types of products or using a service.

Policy: laws and regulations that affect behaviors and access to products and services. Policies affecting HIV include those regulating needle exchange; products or services to minors without parental permission; partner notification; domestic partners regulations, etc.

Culture: the set of history, customs, lifestyles, values and practices within a selfdefined group. May be associated with ethnicity or with lifestyle, "youth" culture.

Actual Consequences: what actually happens after performing a particular behavior.

Relationship Status: type of relationship, as categorized by the sexual partners and their community. Common categories areshort-term/long-term;casual/serious; monogamous/ multiple partners.

© 1998 The Academy for Educational Development

INTERNAL DETERMINANTS - the forces inside an individual's head that affect how he or she thinks or feels about a behavior.

Skills: the set of abilities necessary to perform a particular behavior. Key skills for protective HIV behaviors include communication, negotiation, sexual refusal, condom use skills, cleaning needles, etc.

Self-efficacy: an individual's belief that he or she can do a particular behavior.

Perceived Social Norms: perception that people important to an individual think that s/he should do the behavior; norms have two parts: who matters most to the person on a particular issue, and what s/he perceives those people think s/he should do.

Perceived Consequences: what a person thinks will happen, either positive or negative, as a result of performing a behavior.

Knowledge: basic factual knowledge about transmission of HIV, how to protect oneself from transmission, what test results mean, where to get services, etc.

Attitudes: a wide-ranging category for what an individual thinks or feels about a variety of issues. This over-arching category would include self-efficacy, perceived risk and other attitudinal factors.

Perceived Risk: a person's perception of how vulnerable they feel (to HIV, STDs, etc.)

Intentions: what an individual plans or projects s/he will do in the future; commitment to a future act. Future intention to perform a behavior is highly associated with actually performing that behavior.

Fun, Easy, Popular!

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Handout 1.5: Levels of Actors that Influence Behaviors

Policy Makers

Health, Education, Financial, Other Service Providers

Community Leaders and CBOs

Family

Individual

Target Groups to Create an Enabling Environment for Change

© Linkages

Putting Behavior Change at the Center of our ProgramsIntroductionWe have reached a common understanding of behaviors, models of how behaviors change, and key determinants that enable or prevent individuals from changing behaviors. In this Unit we will introduce the Behavior Centered Approach, which is an effective methodology for incorporating what we know about changing behaviors into our programs.


To share successful and unsuccessful experiences attempting to change behaviors through programs

To develop an understanding of a more successful model of incorporating behavior change into programs.


Overhead or LCD Projector (if available) Flipchart Markers Masking Tape

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Unit

2

32

Unit ContentExercise 2.1: Participant Experiences with Behavior Change Interventions

Presentation 2.1: Approaches to Behavior Change

Presentation 2.2: Focusing Programs on Behaviors Using the Behavior Centered Approach

Exercise 2.2: Continuum of Behaviors

Presentation 2.3: The Behavior Centered Approach to Programming

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EXERCISE 2.1: PARTICIPANT EXPERIENCES WITH BEHAVIOR CHANGE INTERVENTIONS Key Message: Our experience with successful and unsuccessful programs demonstrates that programs which successfully change behaviors at the individual, community, or policy level, share certain characteristics.

Materials: Flip chart and markers

Handouts: Handout 2.1: Programmatic Behavior Change Experience

Time: 30 minutes

Facilitator Steps

Break the group into small groups of three or four. Explain that this exercise is to encourage participants to reflect on and share their past experiences with programs that succeeded in changing key behaviors, as well as programs that did not succeed.

Distribute Handout 2.1: Programmatic Behavior Change Experience to each participant and review the form. Ask each group to fill out the form using one example of a successful program and one example of an unsuccessful program that members of the group have worked on. Each group should pick a reporter who will report back to the main group.

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After the small groups have finished, asked each group to briefly report the success and the failure to the large group. Ask participants to name the characteristics that the successful programs had in common, or that the failed programs lacked. List the answers on a flip chart at the front of the room.

Conclude the exercise by saying that you’ll be introducing an approach to designing Behavior Change strategies that incorporate the characteristics essential for successful programs.

PRESENTATION 2.1: APPROACHES TO BEHAVIOR CHANGEKey Message: Learning about different approaches to behavior change can help us to identify successful approaches that can be incorporated into our own programming.

Materials: Flipchart and markers

Handouts: Handout 2.2: Less Successful Approaches to Behavior Change Participant’s Handout 2.3: More Successful Approaches to

Behavior Change

Time: 30 minutes

Facilitator Steps

Distribute Handout 2.2: Less Successful Approaches. Discuss how often programs try to address through an approach that they think addresses the

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problem, such as a new technology or service, education, or a combination of both. Ask participants: why do you think these approaches might be less successful?

Distribute Handout 2.3: More Successful Approaches. Discuss the process of the behavior-centered approach from the diagram. Ask participants: what do you think are the advantages to this approach? Why might this approach be more successful? Record the responses on a flipchart. Possible responses – helps solve problems; ensures that activities are designed to meet the stated objectives; makes existing activities

more focused, effective and efficient.

Explain that there are five steps in this process:

1) Situational Assessment2) Formative Research3) Strategy Formulation4) Implementation5) Monitoring and Evaluation

These steps are a way to integrate behavior change into every aspect of the program, rather than having “behavior change communication” as an activity running parallel to other activities.

Conclude by saying that for the rest of the training, we are going to develop skills and learn how to use the tools that will enable us to apply the behavior centered approach to our own work.

PRESENTATION 2.2 : FOCUSING PROGRAMS ON BEHAVIORS USING THE BEHAVIOR CENTERED APPROACH Key Message: Focusing program activities on changing key behaviors at the individual, household, or community level will lead to achieving program objectives and goals.

Materials: Overhead/LCD projector OR Flip chart and Markers

Handouts:

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Presentation Content in Outline or Power Point Handout Form Handout 2.4: The 5 BEHAVE Principles

Time: 15 minutes

Facilitator Steps

Distribute the outline of the following presentation and Handout 2.4 so that participants can follow along and make notes. Explain that in this presentation you will be introducing the behavior centered approach, and reviewing what we know about how behaviors change. Encourage participants to ask questions at any time. Present the following material:

I. IntroductionTopics covered in this presentation An introduction to the behavior centered approach A review of what behaviors are and how they change

II. The Behavior Centered Approach to Programming A systematic process with five steps:

1. Situational Assessment2. Formative Research3. Strategy Development4. Implementation5. Monitoring and Evaluation

Each step has its own tools and methodologies to take you through the process

III. How does this approach fit with ongoing and new programs ? Improve existing program or activity Help design effective new program/activity Ensures that activities are designed to meet the stated objectives Makes activities more targeted, effective, and efficient Focuses all program activities on changing key behaviors

IV. Why focus on behaviors? ACTION IS WHAT COUNTS! Positive behaviors impact households and community, improving

outcomes Improved outcomes=achieving program objectives and goals

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V. Results of Similar Approaches Linkages in Ghana

Control Program Program

2000 2001 2002

Initiated breastfeeding in 1st hr after birth

14% 32% 62%

Exclusive breastfeeding until 6 mos

44% 68% 78%

Truth Campaign in Florida, USo Reduced new smokers among adolescents by 30% in one year

VI. What are behaviors? Concrete ACTIONS Can be Observable or Hidden Specific Time, place, quantity, duration frequency Measurable Feasible DIRECT LINK TO THE DESIRED OUTCOME

VII. Which Behaviors? Considerations:

o Not just a few “right” behaviorso Most “ideal behaviors” are actually clusters of behaviors

Find “key” behaviors that:o impact the problemo are feasible to achieve

VIII. How Behaviors Change Many determinants

o Changing knowledge and attitudes is usually not enougho Improving or increasing access to service or technology is

usually not enough FUN, EASY, POPULAR

o Perceive that positive consequences of doing the behavior outweigh the negative

o Believe that he/she has the knowledge, ability, and resources to do the behavior

o Believe that the behavior is accepted, supported in his/her family and community

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IX. The 5 BEHAVE Principles (refer to Handout 2.4)1. Know exactly who your audience is and look at everything from

their point of view.2. Your bottom line: the audience’s action is what counts.3. People take action when it benefits them. Barriers keep them

from acting.4. All your activities should MAXIMIZE THE BENEFITS and

MINIMIZE THE BARRIERS that matter to the target audience.5. Base decisions on evidence and keep checking in.

X. Behavior change involves multiple levels Behavior change strategies have to address the context that individuals

act within (refer back to Handout 1:5):o individualo familyo community o facility/service providerso policy

XI. Interventions to Change Behaviors NOT just communications! May include:

o Service Delivery (and Improvement)o Precise communicationso Trainingo Community mobilizationo New technology or producto Infrastructureo New Social Normso Advocacy & policy change

XII. Summary Points• The Behavior Centered Approach is a strategic process that assesses the

context of a problem and current behaviors, and identifies key behaviors for change can greatly increase the effectiveness of programs

• Focusing program activities on behaviors from the beginning ensures desirable impact

• Key behaviors are ones that will impact the problem AND are feasible to change

Encourage the participants to ask questions.

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EXERCISE 2.2: THE CONTINUUM OF BEHAVIORSKey Message: The continuum of behaviors helps us to understand that behavior change can be gradual and happen in different stages. It enables us to set reasonable and reachable behavior change goals for our programs .

Materials: Flipchart paper Markers Masking Tape

Handouts: Handout 2.5: Continuum of Behaviors

Time: 45 minutes

Facilitator Steps

It is useful to think about changing behaviors not as flicking on a switch, but rather as moving down a road. It may not be possible for programs to immediately change behaviors to the “perfect behavior” or the “gold standard”.

Programmers may feel frustrated if they do not see changes in the “ideal behavior”. However, behavior change happens in stages, moving from less desirable to more desirable behaviors. Program activities can be tailored and targeted to help beneficiaries move “along the behavior change road” from less desirable to more desirable behaviors.

Distribute Handout 2.5: Continuum of Behaviors. Explain how the behavior change process can happen along a continuum of change. An individual can move forward, step by step, along the continuum toward more desirable behaviors. At other times, an individual may move back and forth along the continuum.

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Ask participants to divide up into smaller groups (4-5 per group). Pass out a sheet of flipchart paper and a marker to each group. Ask each group to select one behavior their program seeks to change. It is fine if more than one group chooses the same behavior.

Ask each group to develop a continuum of change for that behavior (at least 4 stages). They will decide which are the most and least desirable behaviors, putting those at opposite ends of the “continuum” on the flipchart. Have the group think of steps or stages an individual could take to move toward the most desirable behavior.

After each group has completed their continuum, ask a representative from each group to present their continuum. After each group presents the continuum, ask participants if they can think of interventions that might help an individual move along each stage of that continuum. Repeat with each group until all have presented.

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PRESENTATION 2.3 : THE BEHAVIOR CENTERED APPROACH TO PROGRAMMING Key Message: The Behavior Centered Approach is a systematic process with tools and methodologies to help programmers design and implement communications and program activities that will successfully change key behaviors among individuals and communities.


Handouts: Presentation Content in Outline or Power Point Handout Form Handout 2.6-2.12: Forms for the Behavior Centered Approach

Time: 45 minutes

Facilitator Steps

Distribute the outline of the following presentation so that participants can follow along and make notes. Explain that in this presentation you will be discussing each step in the behavior centered approach in detail. Reassure participants that in the next three days they will be working through the process using exercises and real world examples. Encourage participants to ask questions at any time.

Distribute Handouts 2.6-2.12 and review each Form as you come to the corresponding Step in the presentation.

Present the following material:I. Steps in Behavior Centered Approach

o Situational Assessmento Formative Research o Strategy Formulation o Implementationo Monitoring and Evaluation

BC activities don’t run parallel to implementation of proposed activities. These steps are a way to integrate BC into every aspect of program.

II. Forms: Tools to take you through the processo Situational Assessment

Activities to Behaviors

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o Formative Researcho BEHAVE Form (strategy formulation)

Communications Plan o Implementation Plano Monitoring and Evaluation

Fill out the form(s) at the beginning of each step helps you see gaps in your knowledge. Then you can plan to fill the gaps.

By the end of each step, form should be complete enough to help you plan the next step.

III. Step 1: Situational Assessment This step helps you to:

o Plan programs by looking at the program goals and activities in terms of specific behavioral objectives;

o Place the program in a wider context of resources, partners, and policies;

o Prioritize and sequence activities over the life of the project. It involves restating SOs, IRs, and activities in behavioral terms, then

breaking those behaviors down further into small, concrete actions.

IV. Step 2: Formative Research Key step to designing activities that have sustainable impact on concrete

actions of priority groups Research based on behavioral objectives of the program: FOCUSED

AND SPECIFIC Through FR you can work with target groups in the community to find

feasible, specific changes that they can make to achieve behavioral objectives

V. Step 2: Formative Research (cont’d) First must review previous data and assess remaining gaps in your

knowledge Sources include baseline surveys, DAP surveys, EWS data, KPC data,

positive deviance study, gender relations analysis, evaluations Form helps to identify gaps in knowledge, current practices,

barriers/motivations, and target groups Plan and carry out research to fill the gaps and clarify previous data

VI. Step 2: Formative Research (cont’d) After analyzing info gathered through preliminary FR, you’ll have a more

clear idea of priority groups, supporting groups, barriers and motivations for specific behaviors

You’ll be able to work with target groups to learn what behaviors they are most able and willing to try to change, through a method we’ll discuss tomorrow

Consultative Research: can be used periodically to check impact of activities on behavioral objectives for target groups. More timely and useful feedback than evaluations.

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VII. Step 3: Strategy Formulation By now you have found specific, feasible changes, determined who in the

community to target, and the main barriers to and motivations for change.

At this step you plan how to design or refine activities to focus on key behaviors and groups

Communications plan to focus on messages, materials, time and place of delivery

VIII. Step 4: Implementation After planning how to refine activities to focus on specific behavioral

objectives and priority groups, then can plan specific action steps and timeline, including:

o Staff responsibilitieso Training staff, partners, community volunteers in new focus, new

messages, new skillso Sequence and schedule of activitieso Plan for technical support and consultative research

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IX. Step 5: Monitoring and Evaluation Track proposal indicators, incorporate ways to capture change in the

specific behaviors for different target groups, and changes in key determinants

If no change is occurring, conduct consultative research to learn why. Don’t wait until midterm and final evaluations to see what’s working and what’s not. “Feed-forward, not feed-back”.

X. Recap: Process and Tools Steps in the Process

o Situational Assessmento Formative Researcho Strategy Formulationo Implementationo Monitoring and Evaluation

Formso Situational Assessment

Activities to Behaviorso Formative Researcho BEHAVE Form

Communications Plano Implementation Plano Monitoring and Evaluation Plan

Encourage the participants to ask questions.

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Unit 2 Handouts

2.1: Programmatic Behavior Change Experience 2.2: Less Successful Approaches to Behavior Change

2.3: Behavior Centered Approach to Programming

2.4: The 5 BEHAVE Principles

2.5: Continuum of Behaviors

2.6: Situational Assessment

2.7: Activities to Behaviors

2.8: Formative Research

2.9: BEHAVE Framework (Strategy)

2.10: Communications Plan

2.11: Implementation

2.12: Monitoring and Evaluation

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Handout 2.1: Programmatic Behavior Change Experience

Program/ Targeted Behaviors

Why was it a Success or a Failure?

How did we know?

What did we measure?

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Handout 2.2: Less Successful Approaches to Behavior Change

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Problem

Problem

Problem

Technologies or services to address the problem

Education

Technologies or services to address the problem

Education

Handout 2.3: Behavior Centered Approach to Programming

Example:

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Problem

Epidemiology (Situational

Assessment)

Identify key behaviors

that impact the problem

Behavioral Analysis:

Barriers and Motivations

Strategy (Program): Communications,

Training,CommunityMobilization,

New or ImprovedServices,

Technology, Product(s)

& PolicyTo Support Behavior

Improvements

30% of deaths Under 5 due

to diarrhea

Caretakers wash hands at appropriate timesTreating drinking waterwith chlorineAppropriate disposal of waste and fecesGood food hygiene

Belief that Diarrheais caused by teething:it is inevitableChlorine not availableor very expensive

49

High mortality due to DD

StrategyExamples:• Increase knowledge (men and women) that microbes cause diarrhea

• Teach appropriate disposal and food hygiene

• Distribute chlorine with food and train how to use

Handout 2.4: The 5 BEHAVE Principles

1. Know exactly who your audience is and look at everything from their point of view.

2. Your bottom line: the audience’s action is what counts.

3. People take action when it benefits them. Barriers keep them from acting.

4. All your activities should MAXIMIZE THE BENEFITS and MINIMIZE THE BARRIERS that matter to the target audience.

5. Base decisions on evidence and keep checking in.

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Handout 2.5: Continuum of Behaviors

Less Desirable More Desirable

Example 1:

Let child feed self from family dish

Let older child feed child from family dish

Let child feed self from own bowl

Care provider feeds young child from own bowl

Example 2:

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Sell cattle only when emergency strikes

Use early warning information to sell some cattle at first sign of emergency

Regularly sell older cattle before dry season

Use market information to buy when prices low and sell when prices high

This and the next six pages are Handouts 2.6-2.12:1. Situational Assessment

INTERMEDIATE RESULT:

Severity and Nature of Problem

Partners Related Policies

Available Resources

Communication Resources

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1.a. Activities to Behaviors

What Activity? Intermediate Result Ideal behaviors Behavioral components of ideal behaviors

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2. Formative Research

Activity Ideal practice Current practices Feasible practices

Primary/Supporting Group Barriers Main motivations

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3. BEHAVE Framework ©

Priority Group Behavior Key Factors Activities

In order to help: to: we will focus on: through:

Indicators: Copyright AED and the CHANGE Project

3.a. Communications Strategy

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Participant Group Supporting Groups

Message Media and Materials (radio, posters, drama, counseling aids, etc)Behavioral Content Motivation Barriers

4. Implementation Planning Table

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Intermediate Result:

Activities & Steps

Staff needed Partners Approximate Dates

Resources Technical Assistance

Needed

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5. Monitoring & Evaluation Planning Table

Key Determinants:

Indicators KEY BEHAVIORS: Changes in actions

Baseline Current Baseline Current

Next Steps:

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Situational Assessment and Formative Research IntroductionIn the last Unit we introduced the Behavior Centered Approach to programs. In this Unit we look in more depth at the first two steps in the BCA process: Situational Assessment and Formative Research.


To understand the process of the Situational Assessment and Formative Research, and where they fit in the overall Behavior Centered Approach

To be comfortable with the Forms for the Situational Assessment and Formative Research

To be able to look at program activities in terms of what key behaviors they seek to change

To be able to plan a Situational Assessment and Formative Research


Overhead or LCD Projector (if available) Flipchart Markers Extra Handout 2.7: Activities to Behaviors and 2.8: Formative

Research Forms for Exercises Masking Tape

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Unit ContentPresentation 3.1: Situational Assessment

Exercise 3.1: Activities to Behaviors

Presentation 3.2: Introduction to Formative Research and Methodologies

Presentation 3.3: Formative Research Form and Preparing for Field Exercise

Exercise 3.2: Planning Formative Research for Priority Behaviors

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PRESENTATION 3.1: SITUATIONAL ASSESSMENT Key Message: The Situational Assessment answers the same questions we ask anytime we are designing a new intervention. What are the main problems facing the population? What are the scope, nature, and context of the problems? What resources are available in and outside of the community to address the problems?

Materials: Overhead/LCD Projector OR Flip chart and Markers

Handouts: Handout 2.6: Situational Assessment Form Handout 2.7: Activities to Behaviors Form Handout 3.1: Selecting/Prioritizing Behaviors

Time: 15 minutes

Facilitator Steps

Distribute the outline of the following presentation so that participants can follow along and make notes. Refer to Handouts 2.6 and 2.7 which participants should have already. Explain that in this presentation you will be describing in depth the first step in the Behavior Centered Approach, the Situational Assessment. Encourage participants to ask questions at any time. Present the following material:

I. Steps in the Behavior Centered Approach1. Situational Assessment2. Formative Research 3. Strategy Formulation 4. Implementation5. Monitoring and Evaluation

II. This step helps you to: Plan programs by looking at the program goals and activities in terms

of specific behavioral objectives Place the program in a wider context of resources, partners, and

policies Prioritize and sequence activities over the life of the project

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In an ongoing program, it involves restating SOs, IRs, and activities in behavioral terms, then breaking those behaviors down further into small, concrete actions.

Review Handouts 2.6 and 2.7 column by column with participants to make sure the forms are clearly understood. For each column in Handout 2.6: Situational Assessment Form, ask participants where they can find out the information required. Can be project documents, secondary sources, government offices, the community, etc.

Distribute Handout 3.1 and review it with participants. This is a useful tool when planning new interventions. It helps to determine what problems are feasible to address given the time, resources, and mandate of the program.

Encourage participants to ask questions.

EXERCISE 3.1: ACTIVITIES TO BEHAVIORSKey Message: Looking at program activities in terms of behaviors they seek to change can help make existing activities more effective. It is also useful for planning new activities. It is also important to consider that each priority behavior we ask beneficiaries to change may consist of many smaller behaviors.

Materials: Flipchart and markers Masking tape

Handouts: Extra copies of Handout 2.7: Activities to Behaviors

Time: 45 minutes

Facilitator Steps

Ask participants to divide into small groups according to program sector. If all training participants belong to the same sector, ask them to divide into

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groups of 3 or 4. Distribute extra copies of Handout 2.7: Activities to Behaviors to each participant. Distribute flip chart paper and markers to each group

Ask each group to fill out the form for one type of program activity within their sector. Ask the group to transfer the form onto a flip chart when they are finished filling it out. The first step of the form is breaking the activity into behaviors that activity is seeking to promote or change. The second step is to

take each behavior, and break it down further, if appropriate, into its behavioral components. Go around the room as groups work to clarify questions and encourage them.

When the groups have finished, ask each group to share the results with the large group. Discuss the exercise:

o Did participants find the task easy or difficult and why?o Did it help them to see their program any differently? In what way?o Would anyone make any suggestions or comments about to the other groups’ forms?

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PRESENTATION 3.2 : INTRODUCTION TO FORMATIVE RESEARCH AND METHODOLOGIES Key Message: The role of formative research in the Behavior Centered Approach is to use familiar qualitative research techniques to learn about current practices, barriers, motivating factors, and positive practices existing in program communities. Using information learned through formative research, programmers can develop effective behavior change strategies.


Handouts: Presentation Content in Outline or Power Point Handout Form

Time: 45 minutes

Facilitator Steps

Distribute the outline of the following presentation so that participants can follow along and make notes. Explain that in this presentation you will be discussing how formative research fits into the behavior centered approach, and introducing formative research methodologies.

Participants will be able to practice some formative research planning and skills during the field exercise. Encourage participants to ask questions at any time. Present the following material:

I. Steps in the Process1. Situational Assessment2. Formative Research 3. Strategy Formulation 4. Implementation5. Monitoring and Evaluation

II. Where does Formative Research Fit in the Process? In Step 1 you have looked at your planned activities in terms of the

behaviors they seek to change We have seen that even straightforward behaviors, like exclusive

breastfeeding, are actually made up of many smaller, specific actions

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Research has shown that communicating a list of ideal behaviors to community members is not an effective way to help people change their behaviors

III. The Role of Formative Research in Behavior Change The role of formative research is to help you work with priority groups

for each behavior to find small, specific actions that people are able to change and that will help achieve a project goal (IR).

These small specific actions will form the basis for your Behavior Change Strategy (Step 3)

IV. Assessing gaps in your knowledge Before you can determine what formative research you need to carry

out, you must first review previous data and assess remaining gaps in your knowledge

Sources include baseline surveys, DAP surveys, EWS data, KPC data, positive deviance study, gender relations analysis, evaluations

The Formative Research Form (Handout 2.8) is useful to identify gaps in knowledge, current practices, barriers/motivations, and priority groups

V. Planning Formative Research Formative Research is not general and exploratory, but based on the

behavioral objectives of the program. It is focused and specific Once you have assessed current data and knowledge gaps, you can

plan and carry out research to fill the gaps and clarify previous data

VI. Formative Research Methods Methods for formative research include:

o Observationo In-depth interviewso Focus group discussionso Participatory methods (mapping, seasonal calendars, time

diaries, food recall)o Positive Deviance Inquirieso Trials of Improved Practices (TIPS)

Most of these methods will be familiar to SC program staff and managers

VII. FR Methods: Observations Structured or unstructured

o Verify informationo See behaviors in contexto Ask for demonstration (example, preparing ORS, or correctly

using pesticide for ticks)

VIII. FR Methods: Focus Group Discussions Group discussion with

o 6-12 participants

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o 1 moderatoro 1-2 note takers

Exchange of ideas among participantso To explore the variety of attitudes and practiceso To explore the variety of barriers and motivationso To learn about social norms

Good for checking preliminary research results Probing questions are key!

IX. FR Methods: Doer/Non Doer Analysis Ask a sample group specific questions to determine whether they are

likely to do a specific behavior After analysis, split the group into two based on who is more and less

likely to do the behavior Identify factors that differentiate between “doers” and “non-doers”

X. Outcomes of Preliminary FR Actual current practices Resources and possible specific behaviors to field test through TIPS Barriers and Motivations Attitudes of priority and supporting or influencing groups

XI. FR Methods: Trials of Improved Practices Any program that promotes improved behaviors should test

recommendations for changing behaviors Through field test, can see response to recommendations and know

which are most feasible

XII. How are TIPS conducted? An initial visit A counseling visit A follow-up visit

Counseling and negotiation are key Small number of representative people

XIII. TIPS: Initial visit Background information Current practices

XIV. TIPS: Counseling Visit Feedback on practices Recommendations and initial response Negotiation and motivation Discussion with others if needed Agreement on specific practices to try

XV. TIPS: Follow-Up Visit Changes since last visit

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New practices (ex 24 hr food recall) Outcome and response to trial Modifications people made Adoption of practice How they would explain or recommend to others

XVI. Analysing TIPS Results Summaries of common problems Most acceptable recommendations Strategies people use to make agreed changes Motivations and Barriers

XVII. Outcome of FR and TIPS By the end of Step 2, you’ll know:

o Ideal situationo Real situationo Feasible specific changeso Barrierso Motivationso Resources

Ask participants whether they have had any training or experience using any of the FR methodologies you have presented. Write answers on a flip chart. Point out that these methods are familiar to many development workers. In the Behavior Centered Approach they are just a bit more focused.

Encourage participants to ask questions about the presentation.

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PRESENTATION 3.3: FORMATIVE RESEARCH FORM AND PREPARING FOR FIELD EXERCISEKey Message: The Formative Research form can help you assess your current knowledge, plan to fill the gaps in your knowledge, and analyze the results of formative research. The field exercise will help you to practice some new skills, and will give us some “real world” examples to work with for the rest of the training.


Handouts: Refer to Handout 2.8: Formative Research Form

Time: 15 minutes

Facilitator Steps

Make sure that participants have Handout 2.8 in front of them. For each column on the form, ask a participant to volunteer what s/he thinks it means in terms of developing a behavior change strategy. Ask others in the group to add to the first idea. Below are the main ideas that should come out for each column.

Activity-the program activity, such as “Health education talks given by community health workers”, or “farmer demonstration plots”, or “non-formal education given by para-professional teachers”

Ideal practice-the “perfect” behavior that the activity is meant to help individuals or communities to do. Examples would be “Feeding 12 month-olds appropriate quantity and quality of meals per day”, or “families send girls to school and keep them there for the whole school year”

Current practices-what individuals or communities are doing now. It’s important to get this information directly from the community through formative research, not based only on what project staff think current practices are. Examples would be “feeding 12 month-olds only 2 meals of starchy food per day”, or “families send one younger girl to school, but take her out during heavy farming seasons”.

Feasible practices-what can individuals or communities do given current barriers, motivations, and the scope of our program to help? This may be

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different from the Ideal practice. Finding feasible practices is important after preliminary formative research has shown the barriers and motivations. One way to find out what practices are feasible is Trials of Improved Practices (TIPS). An example of a feasible practice for complementary feeding of 12 month-olds could be “give one extra snack of fruit or and egg per day, plus adding oil to the starchy food at each meal”.

Primary and Supporting Group-The primary group is the group who does the behavior (the mother for feeding, or the farmer for agricultural practices). The supporting group influences the primary group. For example, mothers-in-law often influence mothers to do certain health behaviors for children. Or community leaders might influence farmers to use certain technologies.

Barriers and Main motivations-these are the Key Determinants we have talked about for the last couple of days. Barriers keep people from doing a behavior, motivators help them to do a behavior. A barrier for adequate feeding of 12 month-olds could be “fruit is expensive, and not available for part of the year”. A motivator for adequate feeding of 12 month-olds could be “part of being a good father is providing the right kinds of food for your family”.

PLANNING THE FIELD EXERCISE At this time the Trainer should do Exercise 4.1 from Unit 4, before proceeding to Exercise 3.3 below.

EXERCISE 3.2: PLANNING FORMATIVE RESEARCH FOR PRIORITY BEHAVIORSKey Message: To plan Formative Research it is important to find out what you know already (for example by reviewing baseline surveys or secondary documents), and what you still need to find out. It is also important to know whether you have the capacity to do the research needed, or whether you will need outside technical assistance.


Handouts: Extra copies of Handout 2.8: Formative Research Form

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Time: 75 minutes

Facilitator Steps

Ask participants to divide into small groups according to program sector. If all training participants belong to the same sector, ask them to divide into groups of 3 or 4. Distribute extra copies of Handout 2.8: Formative Research to each participant. Distribute flip chart paper and markers to each group.

Ask each group to fill out the form for one type of program activity within their sector. Ask the group to transfer the form onto a flip chart when they are finished filling it out.

It is important in this exercise that participants only fill out information that they know-not just what they think. If they do not know something, they should write that they don’t know on the form.

The next step for groups is to plan how to fill the gaps on the form. What areas would they like to know more about? How will they get the information they need? Who will they need to talk to? What methods could they use? How long do they think it might take? What resources will they need?

Go around the room as groups work to clarify questions and encourage them.

When the groups have finished, ask each group to present their formative research form, and to share their plan for filling in the gaps.

Discuss the exercise: Did participants find the task easy or difficult and why? Did it help them to see their program any differently? In what way?

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Would anyone make any suggestions or comments about the other groups’ forms or plans?

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Unit 3 Handouts

3.1: Questions to Consider in Selecting and Prioritizing Behaviors

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Handout 3.1: Questions to Consider in Selecting and Prioritizing Behaviors

Scope of the Problem How harmful are current behaviors/lack of improved behaviors to an important group's well being (economically, or in terms of health or education)?

Likely ImpactHow great an impact is adoption of the new behavior(s) likely to have?Are there: (a) multiple new behaviors that mothers/families can adopt that will have a significant impact (i.e., can the program negotiate one or more of several useful actions with mothers?); or (b) is there one specific behavior that everyone needs to follow?

Primary AudienceHow feasible is it to successfully motivate people to adopt the new behavior(s)?

Are people aware of the problem or need? Are people already interested in doing something about it? How strong are the positive consequences/perceived benefits? Can people see immediate benefits, or only longer-term and/or vague ones?

How difficult is the new behavior(s} to carry out? What are the potential costs? How compatible is it with common beliefs and perceptions? How similar is it to current practices? How difficult is it to do well enough? How often and for how long do people need to do it? Does the primary audience have the confidence and social approval to adopt

the new behavior(s)? If not, how difficult would it be to build up these supports?

Barriers to ChangeHow strong are the barriers to adopting the new practice(s)?

Internal barriers (customs, beliefs, perceptions, real or perceived lack of self-efficacy, social norms), and

External barriers (lack of time and money; lack of transportation; health service deficiencies in cultural sensitivity, quality, convenience, and reliability; health workers' treatment of mothers; policies that need to be changed; lack of new or improved products, etc.

How feasible is it to reduce these barriers through efforts of the program, communities, and other collaborating groups?

© CHANGE Project, April 2001

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Field Exercise

IntroductionIn Units 1-3, we have learned about how and why people change behaviors. We have learned about the Behavior Centered Approach to Programming, and have looked in depth at the first two steps in the Approach, the Situational Assessment, and Formative Research. This Unit takes participants through a Field Exercise where they will be able to practice conducting formative research, analyzing data, and developing a Behavior Change Strategy based on formative research results.

SEE HANDOUT 4.1 for Sample Field Exercise Question Guides.


To practice conducting a focus group discussion To practice analyzing data from formative research To practice developing BC strategies based on formative research

results


Overhead or LCD Projector (if available) Flipchart, Markers, and Masking Tape Question Guides for Focus Group Discussions Notebooks and pens (if participants don’t have them) for note

taking during Focus Group Discussions Extra Handout 2.8: Formative Research and Handout 2.9: The

BEHAVE Framework Forms for Exercises

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Unit ContentField Exercise 4.1: Preparing for the Field Exercise Field Exercise 4.2: Focus Group Discussions Field Exercise 4.3: Research Teams Present Key Findings Field Exercise 4.4: Developing Behavior Change Strategies Based on Key Findings

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FIELD EXERCISE 4.1: PREPARING FOR THE FIELD EXERCISE Key Message: The field exercise will help you to practice some new skills, and will give us some “real world” examples to work with for the rest of the training.


Handouts: Draft Question Guides for Focus Group Discussions

Time: 45 minutes

Facilitator Steps

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Explain that participants will have a chance to practice the Focus Group Discussion methodology, and to try to fill out this form, during the Field Exercise. The goal of the field exercise is for participants to have a chance to practice new skills, and to raise questions about the process in a safe environment.

A. Review the basics of conducting a Focus Group Discussion, including:

respecting confidentiality, non judgmental communication, active facililitation, good time management, and

good note taking.

B. Review the question guides, giving participants a chance to make changes or additions.

C. Divide participants into research teams, according to sector, if appropriate. Ask for a volunteer from each team to facilitate the focus group discussion. All other members of the team will be note-takers/observers.

C. Review the logistics: what is the schedule for the exercise, what are arrangements for transportation (if any), and where will the discussions take place.

Encourage questions from participants. Make sure that participants understand this is just an exercise. It is a chance to try new things, to learn from mistakes.

FIELD EXERCISE 4.2: CONDUCTING FOCUS GROUP DISCUSSIONSHandouts:

Revised Question Guides for Focus Group Discussions

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Time: 120 minutes, including a 45 minute to 1 hour focus group discussion, and travel time if any

Facilitator Steps

Meet briefly to make sure that participants have the revised question guides, and that everyone understands their responsibilities during the focus group discussions. Remind everyone of the time to meet back at the training venue. Remind everyone to have a good time!

Depending on whether the field exercise is taking place in the community or with other participants, or with colleagues outside the training, the trainer may choose to go with one research team, to check in on all the teams, or to stay at the venue and prepare the next exercises.

Meet back at the training venue at the agreed time. Ask participants to share, informally, what they thought of the exercise. What was positive about it? What was challenging? What would they do differently next time?

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FIELD EXERCISE 4.3: RESEARCH TEAMS PRESENT KEY FINDINGS Key Message: After formative research has been conducted, programmers will analyse the data to find current practices, key barriers, motivating factors, and other information that will be used to develop a strategy for behavior change.

Materials: Flip chart and Markers Masking tape

Handouts: Extra Copies of Handout 2.7 Formative Research

Time: 60 minutes

Facilitator Steps

Ask research teams to review their notes from the focus group discussions and try to fill out the formative research form based on their findings. Remind them that this is an exercise, there are no right or wrong answers. Tell them that they will be asked to share their most important findings with the large group.

Move from group to group to encourage them. At this point, it is not important that they extract the “right” information from their data, but that they are practicing new skills. Ask each group to write on the flip chart the findings that they think would be most important in terms of designing a behavior change strategy for a program.

Ask each research team to present their key findings to the large group. Encourage other teams to ask questions, give comments, or make suggestions.

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FIELD EXERCISE 4.4: DEVELOPING BEHAVIOR CHANGE STRATEGIES BASED ON KEY FINDINGSKey Message: Behavior Change Strategies are a Bridge from Formative Research to Action. They help guide your program activities so that they are REDUCING BARRIERS and MAXIMIZING BENEFITS for target groups to practice positive behaviors.

Materials: Flip chart and Markers Masking Tape

Handouts: Extra Copies of Handout 2.9: The BEHAVE Framework

Time: 60 minutes

Facilitator Steps

Ask each research team to begin drafting a behavior change strategy, based on the findings from their focus group discussion. The BEHAVE framework acts as a guide to developing a strategy, as they fill out each column.

Move from group to group to encourage them. At this point, they should feel free to be creative. The important thing is that they are practicing new skills. Ask each group to write their BC strategy on the flip chart in the form of The BEHAVE Framework.

Ask each research team to present their key findings to the large group. Encourage other teams to ask questions, give comments, or make suggestions.

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Ask participants to comment on the Field Exercise overall. What did they like about it? What was challenging? How would the process be different if they were doing it within their program?

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Unit 4 Handouts

4.1: Sample Question Guides for Field Exercise Focus Group Discussions

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Handout 4.1: Sample Question GuidesFormative Research Field ExerciseExpanded Program on Immunization Focus Group Discussion Guide

Instructions for facilitator1. Thank people for taking time to talk to us2. Have each member of the research team introduce themselves3. Say something like: “We would like to talk to you today about immunizations for children and women in your community. The discussion won’t take more than an hour or so. Your participation is voluntary, and you don’t have to answer any questions you don’t want to. Save the Children and the District Health Office will use the information you give us to improve the immunization program here. Thanks again for talking with us today.”4. As you ask the questions, encourage all participants to share their ideas-some people may need more encouragement to speak. Treat participants respectfully, and do not show any reaction, positive or negative, to their answers.

Are you talking with a women’s group or men’s group? _________

How many participants are there? __________

Instructions for note takers/observers1. Do not try to write down word for word what everyone says. Instead, summarize each person’s contribution. If a phrase is repeated often, or a local word for something is used, then it is good to get the exact words.2. Try to record whether the group agrees with a person’s statement, or whether there is disagreement and discussion in the group of a point. 3. After the group has finished, it’s good to go back through your notes soon after (the same day when possible) to fill in gaps or clarify notes from your memory.

Questions for Participants1. Is it important for children to be immunized? Why or why not?

2. What is the best age for children to be fully immunized?

3. Is it important for women to be immunized against tetanus? Why or why not?

4. Where can women and children get immunized in your community?

5. When can women and children get immunized in your community? Are there special

times when they can get immunized?

6. Doctors tell us that children need to go for immunization five times in order to get full

protection against disease. But many mothers in Nakasongala bring their child for only

one or two immunizations and then stop coming. What do you think are some reasons for

this?

a. After they have given some answers, you can probe for issues like shortage

of time, beliefs about immunization, distance to or quality of services

7. (ask only the men) As fathers, what can you do to support your wives to make sure

that they come for all immunizations needed by your children?

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Formative Research Field ExerciseUsing Improved Varieties of Crops Focus Group Discussion Guide

Instructions for facilitator1. Thank people for taking time to talk to us2. Have each member of the research team introduce themselves3. Say something like: “We would like to talk to you today about farming practices in

your community. The discussion won’t take more than an hour or so. Your participation is voluntary, and you don’t have to answer any questions you don’t want to. Save the Children will use the information you give us to improve our agricultural programs here. Thanks again for talking with us today.”

4. As you ask the questions, encourage all participants to share their ideas-some people may need more encouragement to speak. Treat participants respectfully, and do not show any reaction, positive or negative, to their answers.

Are you talking with a women’s group or men’s group? _________

How many participants are there? __________

Instructions for note takers/observers

1. Do not try to write down word for word what everyone says. Instead, summarize each person’s contribution. If a phrase is repeated often, or a local word for something is used, then it is good to get the exact words.

2. Try to record whether the group agrees with a person’s statement, or whether there is disagreement and discussion in the group of a point.

3. After the group has finished, it’s good to go back through your notes soon after (the same day when possible) to fill in gaps or clarify notes from your memory.

Questions for Participants

1. Is it important to sort seeds for planting after the harvest? Why or why not?

2. Which seeds are better to keep for planting?

3. Is it important to use improved varieties of seed for different crops? Why or why not?

4. Is it easy or difficult for farmers in this community to use improved varieties of seed?

What makes it difficult? (or easy if they say easy)

a. After they have given some answers, probe for accessibility of seeds, cost,

knowledge about which kinds to use

5. Is it more important to use improved varieties of some crops than others? Which crops

are more important? Why?

6. Tell us what is the best way to keep (store) seeds for planting? What is good about

this way? (or why is this way better than others?)

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Developing Effective Strategies to

Change Behaviors Through ProgramsIntroductionThis Unit looks in depth at how to develop strategies that will enable positive behavior change through programs. Effective strategies include program interventions like training, infrastructure development, or increasing access to resources, as well as multi-channel communications.


To understand the process of Strategy Development, and how it fits in the overall Behavior Centered Approach

To understand that any type of program intervention will be more effective if it is part of an overall Behavior Change Strategy

To understand how a Communications Plan is developed


Overhead or LCD Projector (if available) Flipchart, Markers, and Masking Tape Outlines of Presentation Content to hand out Extra Handout 2.9: The BEHAVE Framework Forms Handouts 5.1-5.4

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Unit ContentPresentation 5.1: Developing a Behavior Change Strategy

Exercise 5.1: The BEHAVE Framework

Presentation 5.2: Developing a Communications Plan

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PRESENTATION 5.1: DEVELOPING A BEHAVIOR CHANGE STRATEGY Key Message: The Behavior Change Strategy is the Bridge from Formative Research to Action. It is the guiding document that ensures that your program activities use the formative research results to REDUCE BARRIERS and MAXIMIZE BENEFITS so that target groups in the community can adopt positive behaviors.


Handouts: Presentation Content in Outline or Power Point Handout Form

Time: 30 minutes

Facilitator Steps

Distribute the outline of the following presentation so that participants can follow along and make notes. Explain that in this presentation you will be describing in depth the third step in the Behavior Centered Approach, Developing a Behavior Change Strategy. Encourage participants to ask questions at any time. Present the following material:

I. Behavior Change Strategy: the Bridge between Research and Programming Steps in the Process

6. Situational Assessment 7. Formative Research 8. Developing a Strategy 9. Implementation10. Monitoring and Evaluation

II. Step 3: Developing a StrategyThe Behavior Change Strategy will answer:

Who will participant groups be? What interventions and messages can reduce barriers and promote

feasible practices? How will participant groups be reached? Which media and materials to use? Where and when will they be distributed, broadcast or used?

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III. Strategy Development Workshop With all participant groups & partners Cornerstone of plan Decide how to design, or revise, interventions to address barriers and

promote feasible practices identified in the formative research

IV. Timing of the BC Strategy Design Process Situational Assessment (1-2 weeks) Formative Research (8-24 weeks) Strategy Development (2 weeks) Media & Material Design (2-4 weeks) Draft & Pretest (8-16 weeks) Production (8 weeks)


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EXERCISE 5.1: THE BEHAVE FRAMEWORKKey Message: The BEHAVE Framework is a tool to make sure that the Behavior Change Strategy addresses the right audiences, and uses the results of the formative research effectively. It is also a concise way to summarize the BC strategy.


Handouts: Extra Copies of Handout 2.9: The BEHAVE Framework

Time: 30 minutes

Facilitator Steps

Ask participants to divide into four groups. Distribute extra copies of Handout 2.9: The BEHAVE Framework to each participant. Distribute flip chart paper and markers to each group. Each group corresponds to one column in the BEHAVE Framework: Priority Group; Behavior; Key Factors; and Activities.

Ask each group to:

A. Brainstorm about the kind of information that might go into their column in the BEHAVE Framework, and give specific examples.

B. List how they would get the information for their column

Go around the room as groups work to clarify questions and encourage them.

When the groups have finished, ask each group to share the results with the large group, starting with Group 1 and ending with Group 4. Each group can tape their flip chart at the front of the room, next to the

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previous one, so that you end up with a BEHAVE Framework on the wall. Ask for comments and questions as each Group presents.

Discuss the following points:1. What do we mean when we say that the BC Strategy is the “Bridge”

between Research and Action?2. Review the sentence at the top of the BEHAVE Framework, “In order

to help ________ to __________ we will focus on ____________ through__________”.

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PRESENTATION 5.2 : DEVELOPING A COMMUNICATIONS PLAN Key Message: A well designed communications plan is a key element of any Behavior Change Strategy. Good communications ensure that your messages are reaching the key actors in the community, and that they understand them. Elements of a communications plan include the target and supporting audiences, the type of media used, the message content, and the channels through which the messages will be delivered.


Handouts: Presentation Content in Outline or Power Point Handout Form Handout 5.1-5.4

Time: 30 minutes

Facilitator Steps

Distribute the outline of the following presentation so that participants can follow along and make notes. Explain that in this presentation you will be discussing how to develop a multi-channel communication plan and effective behavior change communication materials. Encourage participants to ask questions at any time. Present the following material:

I. Developing a Communications Plan Behavior Change Communicaton is not the only intervention that you will use to change

behaviors, but it is an important part of any Behavior Change Strategy Make a materials list Draft materials

o Write a creative briefo Draft messages and materialso PRETESTo Revise

II. Segmenting the Audience The “audience” is the group of people whose behavior the project is seeking to change Segmentation is how to get from a group of people to exact target

o Different ways to segment: Demographics (age, household size) Location (sandy or clay soil, near or far to health center or market) Behavioral (people who already practice and people who don't)

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Much of this segmentation will have been done during the situational assessment and formative research steps

The communications plan is about how to reach those targets through messages, media, and materials

III. The 4 M's Media Materials Message Methods

IV. Media and Materials Interpersonal communication (health or extension workers) TV Radio Print materials (posters, counseling cards, newspapers) Theatre Other traditional forms

V. Selecting Appropriate Media and Materials Reach Frequency Appropriateness Credibility Cost What participants need, when & where they need it (seasons, during pregnancy)

VI. Designing Media and Materials Design materials suitable for available media Involve participants Have artist or script writer go to community 2 groups of 6-8 people for each segment of the audience

VII. Designing the Message KEY POINTS:

o Motivateo Address internal barriers to change o Other types of interventions can address external barriers, for example increasing

access to services or resources Content Design Persuasion Factors Memorability

VII. Making a Materials List Counseling cards or aids for one-on-one Counseling posters for groups Posters, signs, notes, or songs for reminders Radio, TV, or traditional media for motivation or creating an image

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VIII. Drafting Materials: The Creative BriefWrite a creative brief:

Background Participant groups Objectives Barriers Motivations Tone Media and materials Other considerations (language, literacy)

IX. Drafting Materials: Pretesting After drafting, PRETEST!

o Method to determine reactions before materials are producedo Very importanto Test all pieces of materials: text and visualso Test drafts with right colors, background images, sizeso Give participants 2 versions to choose

Begins after first draft of materials Do several times as you refine and revise drafts Bring artist to listen to hear directly from participants Ends when materials will work as desired

X. When are you finished pretesting? When MOST (70-80% of) participants:

o Understando Likeo Accepto Want to act!

People should identify with the pictureso Often prefer images they aspire too Usually prefer positive images (but can build on existing concern)o Avoid abstractions, body parts, depth

There should be changes! Can be difficult to decide what to do with feedback

XI. Managing the Materials Development Process Advisable to manage this process in house

o Use steering committees or advisory groups to: Provide technical review Support

Using outside firms or consultantso Find out who is availableo Be clear about expectationso Understand pricingo Establish a good working relationship

Difficulties with private sector firmso More clients to work witho Greater emphasis on technical accuracy

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Encourage participants to ask questions about the presentation. Ask participants to share their experiences with developing communication plans and materials. What made those experiences rewarding or frustrating?

Distribute Handouts 5.1-5.4 and briefly describe what they are. Participants may look them over on their own and ask questions at any time in the rest of the training if they need clarification.

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Unit 5 Handouts

5.1: Media and Materials Comparison Table 5.2: The Creative Brief5.3: Sample Pretest Guide for Print Material5.4: Example of Message Development and Pretesting

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Handout 5.1: Media and Materials Comparison Table Media & Materials

Advantages Disadvantages

Interpersonal Communication

Able to provide tailored information to individuals .

Can negotiate small improvements according to individual’s willingness and ability

Provides credibility to content

Provides detailed information

Can do demonstrations, modeling of complex skills

Discusses sensitive, personal topics

Creates support at the community-level for new behaviors, ideas, products

Allows for immediate feedback on new content

Time consuming

Reaches small numbers of individuals

Requires practical skills training

Requires supervision of field workers

Graphics & Print Materials

Provide timely reminders at key spots when and where people need them

Attract attention Provide basic,

standardized information (increase knowledge and raise awareness)

Are handy and reusable

Support interpersonal communication

May be locally produced

Give confidence and credibility to content

May not be cost-effective

Training necessary for proper use and display

(Posters) need to be changed routinely as they can become part of the background

Radio Reaches many people

Can create demand for a service or product Provides basic, standardized information (increases knowledge and raises awareness)

Can overcome internal resistances to trying something new

Can improve an image or social norm

Provides timely information

Supports interpersonal communication

May be locally produced

Gives confidence and credibility to content

Difficult to tailor to specific participant groups

Can be challenging to obtain feedback

Requires access to radio recording equipment or station

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TV & Film Reaches many people

Can create demand for a service or product

Can improve an image or social norm

Provides basic, standardized information(increases knowledge & raises awareness)

Can overcome internal resistances to trying something new

Provides timely information

Supports interpersonal communication

Gives confidence and credibility to content

Difficult to tailor to specific

participant groups

Can be challenging to obtain feed back

Requires access to TV station and TV in homes

Costs can be high

Traditional Uses traditionally acceptable forms

Puts new information in a familiar context

Uses local talent

Reaches small numbers of people

May not be available when needed

Requires training and support

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Handout 5.2: The Creative Brief

The Creative Brief1. Background

What is the background of this intervention? Why are you doing it?

2. Target Audiences

Who do you want to reach with your communication? Be specific.

3. Objectives

What do you want your target audience to do after they hear, watch, or experience this communication?

4. Obstacles

What beliefs, cultural practices, pressures, and misinformauon stand between your audience and the desired objectives?

5. Key Benefit

Select one single benefit that the audience will experience upon reading the objective(s) you have set

6.Support Statement, Reasons Why

These are the reasons why the key benefit outweighs the obstacles and the reasons that what you are promoting is beneficial These reasons often become messages.

7. Tone What feeling should your communication have? Should it be authoritative, light, or emotional? Pick a tone.

8. MediaWhat channel(s) or form will the communication take? Television? Radio? Newspaper? Poster?, Point-of-purchase? Flyer? All of the above?

9. Creative Considerations

Is there anything else the creative people should know? Will it be in more than one language? Should they make sure that all nationalities are represented?

© The Linkages Project, Academy of Educational Development

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Handout 5.3: Sample Pretest Guide for Print MaterialIntroduction

Greetings Presentation of participants and team Give objectives of the pretest Thank them in advance for their invaluable assistance. Remind them that participation

is voluntary, that there are no right or wrong answers, and that the opinions of every participant counts.

Show the material, pass around so each person can see well. Show one piece at a time, then discuss it before moving on to the next one.

Conduct the focus group discussion: Proceed with the focus group session using the following questions. Do not tell the group our interpretation or goals for the material until the last question. You should ask these questions separately for each piece you are pretesting.

Comprehension and Cultural Appropriateness:1. In your opinion, what is the message of the item? What makes you think that?2. Is anything in the picture difficult to understand? What? 3. Are any words difficult to understand? Which ones? 4. Could you explain this message to someone else? How would you explain it? What might be difficult about explaining the message?5. In your opinion, are the picture and the words like your situation, or your neighbors in the community? What about them does or does not?6. Is there anything offensive or inappropriate in the picture or the words? What is it? Why is it offensive?7. Would other people in the community accept this picture and message? Why or why not?

Attractiveness:1. What do you like the most about the picture or the words? Why do you like it? 2. What do you dislike about the picture or the words? For what reason? How would you change that?

Involvement/Inducement to Action:1. Do this picture and words make you think about people like yourself? Why or why not?2. Does the item ask you to take any action? What action?4. Would you consider taking that action? What would be difficult about that? 5. How would you explain this message and its action to a friend? Would you encourage them to take action?

Suggestions for Changes:1. Explain the desired message and ask: What can we do to improve the picture or message to make it more understandable, more pleasing, more realistic? How? What would be better about that?

THANK THE GROUP FOR THEIR TIME AND ASSISTANCE AND ANY OTHER CLOSING REMARKS AND COMMENTS

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Handout 5.4: Example of Message Development and Pretesting

COMMUNICATIONS FOR VITAMIN A RICH FOODS: THE LEARNING PROCESS (INDONESIA 1986-1987)

Issues In-Depth Interviews& Focus GroupDiscussions

HouseholdTrials (TIPs)

Message Strategy Pretesting

Sources of vitamin-Arich foods

There was a lack of animal and fruit sources but green leafy vegetables readily available in markets andgrowing outside

No new findings In mass media, recommendseveral specific green leafyvegetables that were readilyavailable and acceptable; incounseling materials alsorecommend papaya &mango

This was wellaccepted, althoughmothers had troubledistinguishing greenleafy vegetables fromothers

Main motivation tomodify practices

There was no familiarity with vitamin A; some appreciation of vitamins as good for health andgreen leafy vegetables as good source of vitamins

Consuming vitamins for better health was an effective motivation for eating more green leafyvegetables

To improve the 'image' of green leafy vegetables, especially wild greens, as an absolutely essential food for good health

Image of vegetablesas full of vitamins andgood for health wellaccepted but not forwild, free vegetables

Authority figures /spokesperson

Doctors were well-accepted as authoritiesalthough others hadmore contact withmothers

Doctors were crediblesources of advice oneating more greenleafy vegetables

On radio and posters, usedoctor; nurse-midwife andothers can say, "doctorssay"'; use Elly Kasim, apopular regional singer, asspokesperson

Spokesperson wasexcellent to createinterest, but notcredible as a sourceof health / nutritionadvice; this shouldcome from doctor

Frequency ofConsumption

Families ate some greenleafy vegetables, but notenough

All groups except 5-12 month oldsincreased consumption

Recommend eating greenleafy vegetables "every day,every meal" in specific quantities for various audience segments

This concept was notwell communicated indraft radio spots; itwas decided to relyon counseling forcommunicatingspecific quantitativesuggestions

Children don't likeGreen leafyVegetables

Mothers claimed this forchildren under 1 year

Emerged as aconstraint for allchildren under 5months; reinforced bymothers' allowingchildren to choosetheir own food

For 5-12 month olds, agreethat it takes time for babiesto accept new foods butmothers must perseverebecause green leafyvegetables are so important

This claim in radiospot believed

© The CHANGE Project, Academy of Educational Development


Monitoring and Evaluating the

Impact of Behavior Change IntroductionThis Unit looks in depth at how ongoing program monitoring and periodic evaluations of changes in behavior can strengthen the implementation of strategies to change behavior through program interventions.


To understand methodologies used for monitoring and evaluating the impact of behavior change strategies

To understand indicators for ongoing monitoring and periodic evaluations that are more relevant to issues around behavior change than traditional program indicators

To understand the role of supportive supervision in implementing a behavior change strategy effectively


Overhead or LCD Projector (if available) Flipchart, Markers, and Masking Tape Outline of Presentation Content to hand out Extra Handout 2.12: Monitoring & Evaluation Planning Table

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Unit ContentPresentation 6.1: Monitoring and Evaluating Behavior Change Strategies

Exercise 6.1: Incorporating Behavioral Indicators into Program M & E


PRESENTATION 6.1: MONITORING AND EVALUATING BEHAVIOR CHANGE STRATEGIES Key Message: The Behavior Centered Approach incorporates behavioral indicators into ongoing monitoring and periodic assessments of programs. For example, rather than just monitoring the number of community members receiving health messages, the M & E system would capture whether barriers to change are being reduced, whether they are beliefs about a certain practice, or access to resources necessary to do the practice.


Handouts: Presentation Content in Outline or Power Point Handout

Form

Time: 30 minutes

Facilitator Steps

Distribute the outline of the following presentation so that participants can follow along and make notes. Explain that in this presentation you will be discussing how to develop a Monitoring and Evaluation Plan for Programs using the Behavior Centered Approach. Encourage participants to ask questions at any time. Present the following material:

I. Monitoring & EvaluationSteps in the Process

1. Situational Assessment 2. Formative Research 3. Developing a Strategy 4. Implementation5. Monitoring and Evaluation

II. Monitoring & EvaluationCurrently program monitoring routinely assesses:

Distribution of materials Whether events take place (trainings, EPI days) Number of participants

Evaluations assess: Recall, Use, Action

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Impact

III. Monitoring DataMonitoring data should help you:

Use information to make changes Keep up with changes in practices: As participants change, the activities and messages should change


IV. Monitoring Methods Can be done through:

reviewing reports self-monitoring/reporting direct observations (LQS) supervision guides spot checking distribution points periodic tracking studies

V. Monitoring and Evaluation Data Monitoring information falls into different categories:

Implementation Acceptance Behavior change Impact

VI. Monitoring Implementation Monitoring questions (implementation):

Have materials been distributed to users? Has training been conducted as planned? Are staff using materials? Are broadcasts on as planned? Are media reaching participant groups?

VII. Monitoring AcceptanceMonitoring questions (acceptance):

How do people feel about materials? Are they understood? Are participants receptive to information (do they believe & trust)? Is there any adverse reaction? For counseling materials: Do users believe and use the materials?

VIII. Monitoring & Evaluating ImpactMonitoring questions (behavior and impact):

Have people begun to follow actions? Has the new practice become a regular activity? Are concepts and practices spreading? Is there any evidence of impact?

IX. Indicators for Key Determinants If the determinant is Strength of Belief, a question can be :

“Taking my child to the health center the first day s/he has a fever is important.”

1-Strongly agree, 2-agree, 3-unsure, 4-disagree, 5-strongly disagree


X. Indicators for Key Determinants Additional Examples:

Norms: My mother-in-law thinks that babies need only breast milk until 6 months of age.


Self-efficacy: It is easy for me to use improved post harvest storage method X.


XI. Family/Community Indicators Our indicators and measurement tools can be focused on the multiple levels of determinants:

Examples of Family/Household Indicators % of families who have discussed improved complementary feeding

practices % of couples who have discussed FP methods in the last two weeks % of HHs who have improved crop storage facilities

Examples of Community Indicators % of mother's groups who have discussed exclusive BF % of villages with an HIV/AIDS committee % of farmers groups with "promising" market linkages

XII. Institutional and Policy Indicators Institutional System Indicators

% of health facilities that do not have a stock-out of essential medications in the last six months (availability)

% of agricultural extension agents who inform producers about specific pest management techniques (client communication)

Policy Indicators Tax incentives for post harvest processing Health Policy to immunize children at every available contact, not only on

EPI days

XIII. Evaluation Important to include specific behavioral indicators in surveys based on

research to show change Depending on the behaviors, sometimes change can occur very fast Generally one year is enough to show impact

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EXERCISE 6.1: INCORPORATING BEHAVIORAL INDICATORS INTO PROGRAM M & EKey Message: The Monitoring and Evaluation Planning Table helps teams to develop behavioral indicators to monitor in order to provide feedback to improve the program.


Handouts: Extra Copies of Handout 2.12: Monitoring and Evaluation

Planning Table Behavior Change Strategies Developed in the Field Exercise

Time: 45 minutes

Facilitator Steps

Ask participants to divide into the Field Exercise Research Teams. Distribute extra copies of Handout 2.12: Monitoring and Evaluation Planning Table to each participant. Distribute flip chart paper and markers to each group. Ask each group to plan how they would monitor the implementation of their BC strategy, and how they would evaluate its impact on actual behaviors and program results.

Their plan should include: indicators, methods timing who is responsible how would this be incorporated into current program M & E

systems?

Go around the room as groups work to clarify questions and encourage them. Remind participants that this is an exercise and there are no right or wrong answers.

Ask each research team to write the key parts of their monitoring and evaluation plan on a flip chart to present to the large group. Encourage other teams to ask questions, give comments, or make suggestions.

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Planning the Behavior Centered

Approach for Programs IntroductionThis Unit gives participants the opportunity to plan how to incorporate the Behavior Centered Approach into their Program.


Thinking through the implementation of the Behavior Centered Approach in terms of

o Timeo Human and Financial Resourceso Activitieso Roles and Responsibilitieso Technical Assistance Requirements


Flipchart, Markers, and Masking Tape Extra Copies of Handout 2.6-2.12 as needed by participants for

planning

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Unit ContentExercise 7.1: Situational Assessment for the Program: Prioritizing Behaviors Exercise 7.2: Assessing Gaps in Our Knowledge: Key Barriers, Motivating Factors, Feasible Practices for Priority Behaviors

Exercise 7.3: Planning the Next Steps


EXERCISE 7.1: SITUATIONAL ASSESSMENT FOR THE PROGRAM: PRIORITIZING BEHAVIORS Key Message: The first step in applying the Behavior Centered Approach within a program is to look at the program in terms of behaviors to promote or change, and planning to do a Situational Assessment for those behaviors.

Materials: Flip chart and Markers Masking Tape

Handouts: Refer to Handout 2.6 Situational Assessment and Handout 2.7

Activities to Behaviors Forms

Time: 60 minutes

Facilitator Steps

Ask participants to divide into small groups according to sector. If all participants are from the same sector, ask them to divide into groups according to different interventions, for example, Reproductive Health, Nutrition, and Child Survival.

Ask each group to brainstorm the behaviors that are most important to promote or change in order to achieve the program objectives for their sector or interventions. They can use Handout 2.7 Activities to Behaviors as a guide. When they have a list, they should prioritize those behaviors.

Ask the groups to look at their priority behaviors, and start to fill out the situational assessment form for them, using Handout 2.6 Situational Assessment . For the last 15 minutes of the session, they should plan how to complete a Situational Assessment for their sector or set of interventions.

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EXERCISE 7.2: PLANNING FORMATIVE RESEARCH TO FILL THE GAPS IN OUR KNOWLEDGEKey Message: A Key Step in the Behavior Centered Approach is Assessing what program staff know already about current practices and barriers to change. After assessing current knowledge, staff can plan to fill the gaps through formative research.


Handouts: Extra Copies of Handout 2.8 Formative Research

Time: 120 minutes

Facilitator Steps

The groups from the previous exercise should stay together for this exercise.

Ask each group to fill out the Formative Research form for their priority behaviors. The group should think carefully about what they know, where they know it from, and what they are not sure about. Encourage the groups, and remind them that these exercises are just the first steps in planning how to use the Behavior Centered Approach in their Program.

Ask each group to start planning how to fill the gaps in their knowledge about priority behaviors through formative research. Their formative research plan could include:

Who to talk to? What issues to explore? What methods to use? When to do it? What Technical Assistance, if any, they need to do it?

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Depending on how the exercise goes, groups can take the last 30 minutes to share their research plans. Encourage other groups to ask questions and make suggestions.

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EXERCISE 7.3: PLANNING THE NEXT STEPS Key Message: As the Training comes to a close, it is important for participants to plan the next steps once they are back at their jobs.


Time: 30 minutes

Facilitator Steps

It is up to the trainer to decide whether to conduct this exercise in plenary, or to ask the participants to divide into smaller groups according to sector or type of intervention.

Ask participants to brainstorm about next steps. Their plans should include: What needs to happen Who will take the lead When it should happen Resources needed Technical Assistance Needed

If time permits, small groups may share their plans. Encourage other groups to ask questions and make suggestions.

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ANNEX 1: EXAMPLES OF BEHAVIOR CHANGE STRATEGIES RESULTING FROM THE BEHAVIOR CENTERED APPROACH I. EXCLUSIVE BREASTFEEDING (EBF) FROM LIBEN, ETHIOPIA

PROBLEMIn an environment of high malnutrition and infant morbidity/mortality, a 2001 survey showed that exclusive breastfeeding rates were very low. By two to three months of age, 67% of children were being given animal milk, water, and/or tea.

BEHAVIORAL ANALYSIS The following results were elicited through focus group discussions and Trials of Improved Practices.

Current PracticesSupplementing with cow milk. Leaving babies for long periods of time with siblings or mothers-in-law, who give cow milk (often mixed with water).

Key Determinants (Barriers/Motivations)The barrier to exclusive breastfeeding that men and women both emphasized more than any other is the belief that EBF is too difficult for women, that it takes too much from them. Quotes included, “she will lose her strength”, and “the baby is just drinking her blood”. Giving cow milk or water is seen as giving the mother a needed rest from milk production. It was clear that some improved maternal nutrition practices would need to be included in the strategy.

A positive is that as pastoralists they believe that mother’s milk is very good for babies. They draw a parallel between cows and calves and human mothers and babies.

Another barrier is general lack of knowledge about optimum breastfeeding practices including how often to breastfeed, for how long at a time, and correct positioning that makes the BF more pleasant and efficient for baby and mother.

Feasible PracticesThe families who participated in the Trials of Improved Practices found it feasible to give longer, scheduled feedings with the mother in a comfortable position. They found it feasible for the mother to drink an extra serving of milk or yoghurt each day, plus water or milk each time she breastfed. The mothers could eat eggs more often, but they did not find it feasible to increase the mother’s intake of fruit and vegetables-they were not available locally. Mother’s did not find it feasible to express milk to leave with other caretakers.


Participants saw a change in the baby within two weeks-sleeping longer at a time, happier in general. Mothers felt physically much better, and able to do their work just as well or better.

STRATEGYTarget Audiences

Primarily mothers. Secondarily fathers, grandmothers, and community health workers.Communication Plan (Key Messages and Materials)The key messages are given by community health workers using counseling cards at small group talks with men and women, and at mother to mother support groups for breastfeeding mothers. Key messages include:

1. For fathers: God has made breast milk to be perfect food for babies. A wise father helps his wife to give only breast milk the first six months of life.

2. For mothers: Eat an egg every day to stay strong and healthy while pregnant and breastfeeding. Eggs are delicious, cheap, easy to cook, and make women strong.

3. For mothers: Feed from one breast until the breast is light and empty. Your baby will get fat, and will sleep a long time in between feedings. At the next feeding, feed from the other breast until the breast is light and empty.

Non Communication ActivitiesA non-communication activity which could reduce the barrier of poor maternal nutrition would be demonstration home gardens and poultry projects. This was beyond the scope of the program, however.

IMPLEMENTATIONStaff developed a schedule for training community health workers and support group facilitators on new materials and messages. A schedule for monitoring and supervision was also developed.

MONITORING AND EVALUATIONProcess indicators (changes in key determinants)

1. How many men who have participated in small group talks in the last quarter believe that babies should have only breastmilk for the first six months?

2. How many women who have participated in small group talks or mother to mother support groups in the last quarter :

a. feed each time until the breast is light and empty?b. drink water or milk each time they breastfeed?c. have eaten an egg in the past week?

Outcome indicators (changes in behaviors/in problem)1. Final evaluation survey: how many infants under 6 months were given water, animal milk, or tea in the last 24 hours? In the last week?


II. RANGE MANAGEMENT FROM LIBEN, ETHIOPIA

PROBLEMA breakdown of traditional mobility patterns and increase in herd sizes has led to overgrazing, especially around water points. In addition, previously high quality grazing land has been taken over by inedible thorny bush species that inhibit grass growth.

BEHAVIORAL ANALYSIS The following results were elicited through community meetings and in-depth interviews with key informants.

Current PracticesIncreased use of semi-private land for planting of crops and grazing livestock has led to less seasonal mobility.In some areas only, increased settlement has increased the distance to migrate to good grassland.Lack of a system for “rotating” grazing land, setting aside some land to rest so that grasses can regenerate.Some areas have had good experience with reclaiming grazing land from harmful species, but only through SC’s FFW program.

Key Determinants (Barriers/Motivations)Motivating factors include the strong desire to preserve the traditional pastoralist livelihood, and the positive experience in a few areas with reclamation and resting grassland. Another positive is the ability of traditional leaders to mobilize labor and other community resources.

The biggest barrier is the “tragedy of the commons”, with each household maximizing their good without regard to long term or group effects. Another barrier is the lack of official recognition of using semi-private land meant for planting for grazing livestock. A third barrier is lack of capacity among community leaders to plan annual grazing rotation and reclamation.

Feasible PracticesThese are untested, but according to community representatives at meetings and key informants, the following practices are feasible:

1. In sparsely populated areas, community mandated migration of livestock, with fees imposed for non-compliant households.

2. In more populated areas, setting aside grazing land each year that will be reclaimed and/or rested.

3. In all areas, mobilizing community labor and tools to reclaim some grazing land, or to maintain already reclaimed land.

STRATEGYTarget Audiences

Livestock owners (men and women), youth, and community leaders.

Communication Plan (Key Messages and Materials)


The key messages are given by community leaders and resource management committee members to individuals and at community meetings. In addition, in school youth are participating in environmental clubs where they are asked to talk to out of school youth about key messages. Key messages include:

1. For livestock owners: The earth doesn’t belong to us. It belongs to our children. Stop overgrazing in Liben to protect their future!

2. For livestock owners: Ask your local Resource Management Committee for the best ways to protect your land and water for the future.

3. For youth: You are the future! Learn to manage resources wisely to make your family and community strong.

4. For youth certificates or t-shirts: I am the future of pastoralism! Liben Environmental Youth Clubs

Non Communication ActivitiesSave the Children staff and appropriate local government representatives will meet with resource management committees from each PA (like a county) every six months to plan reclamation/maintenance/resting activities for the next year, to monitor achievement of previous plans, and to discuss challenges and solutions.

Ideally, a program to rationalize the use of semi-private land around water points for both planting and grazing would be useful to reduce competition for resources, and to prevent further degradation of resources. Unfortunately, the policy environment is such that it is not possible to address the issue.

IMPLEMENTATIONStaff developed a schedule for training resource management committees and youth group facilitators on new materials and messages. A schedule for monitoring and supervision was also developed.


Gathered through regular monitoring information:1. How many PA’s have met in the last six months to plan

reclamation/maintenance/resting activities?2. Are migration committees meeting regularly to determine

community mandated migration?Gathered at quarterly meetings with resource management committees in sparsely populated areas:

3. How many fees have been imposed for non-compliance with migration? How many collected?Have there been complaints about unfair implementation of the system?

Outcome indicators (changes in behaviors/in problem)


1. Final evaluation survey: How many hectares of grazing land has been reclaimed/maintained/rested over the life of the program? How many have been done without food or tool inputs from SC?

CHALLENGES IN ETHIOPIAChallenge: Conducting formative research, developing strategies, developing and testing materials with staff while other program activities were ongoing.How addressed: Staff believed in the approach, so were willing to keep working on it despite delays and other difficulties. The person coordinating the work had to be very persistent and keep lines of communication open.

Challenge: Using the strategy to make real changes in the way program activities were carried out. Focusing more on key messages and less on others.How addressed: Making specific modifications to training manuals and changing monitoring forms and routines.


III. COMPLEMENTARY FEEDING FROM MAISSADE AND DESSALINES, HAITIThanks to Marjolein Moreaux for providing the information

PROBLEMHigh rates of malnutrition among under 24 month children, increasing dramatically after six months.

BEHAVIORAL ANALYSIS The following results were elicited through a survey, focus group discussions, and Trials of Improved Practices.

Current PracticesBaseline survey results showed that:73.7 % of 6-9 month-olds are given # correct feedings (logical because 1-2 feedings is already correct)28.9% of 9-12 month-olds given # correct feedings 31.6% 12-24 month-olds given # correct feedingsThe periods of largest growth faltering in children 6-24 months are 6-9 months of age, and 12-24 months.

Key Determinants (Barriers/Motivations)FG results showed that Snacks are not considered as a food, not considered as something important for a child. At 9 months people leave their children more often with other caretakers, as snacks are not important often not leaving anything to eat Children are not fed after 4-5 o’ clock to prevent bloating Almost no recipes for special baby foods exist After 12 months a child is considered an adult and should eat what adults eat There is no knowledge at all about the feeding needs of children, the same for medical staff A mentioned barrier was “no money/time for cooking twice/3 times a day” (cost of charcoal/time)

Feasible PracticesDuring Trials of Improved Practices: Families were asked to prepare mashed baby foods (with recipes like purees and enriched porridge), and to leave a leftover for a few hours later (to overcome the barrier of charcoal/time). Families were asked to feed at nighttime before putting the child to bed.

Results showed that changes were all well accepted and mothers mentioned “baby fatter”, “baby healthier”, “will develop better” as motivators for them.

STRATEGY


Target AudiencesIn the case of feeding all caretakers of children are to be reached because in Haiti children are often left behind with fathers, grandmothers, or older siblings.

Communication Plan (Key Messages and Materials)The team decided that quality and frequency of feeding should be key messages for children. Growth faltering begins in children 6-9 months, even if frequency of feedings is enough, so we decided to stress the quality of baby foods for that age group, with examples of recipes. For the 9-24 months olds we decided to stress the importance of snacks.

Key messages include:1. Give children older than 6 months snacks in between meals during

the day. When you leave your child behind don’t forget to leave a snack for him

2. Children should not go to bed hungry, give them something to eat before putting them to bed.

The motivators in the materials are the ones mentioned by parentsThe barriers are being addressed by: giving cheap examples of good foods adding the sentence “When you leave your child behind don’t forget to leave a snack for him” (for the barrier leaving the child behind) adding the sentence “Children should not go to bed hungry, give them something to eat before putting them to bed.” (for the barrier “I don’t want my child to be bloated”) teaching about leaving a leftover as a feasible practice (found in TIP’s) using recipes tested in the TIPs

The chosen channels are the ones already existing in the different organizations, combined with some consciousness-raising (sensibilisation) days. On those days each dispensary will have a special day with music and food, working around the key messages. Community groups will be trained in theatre to spread messages in all areas. Radio messages and songs sung by a children’s choir will be broadcast by the community radio station.

The following materials were developed: Counseling boards, folder, and songs on a cassette to use with women’s groups, dispensaries, and youth groups Posters, enlarged counseling boards, folder, and songs on a cassette to use at rally posts, agriculture meetings, cock fighting points, food distribution points, and schools Counseling boards to use during individual growth monitoring (home visits or rally post)

To give a comprehensive, uniform feel to the campaign, all materials show a logo showing the three partners, a chain representing seven key


nutrition behaviors, and an overall message related to all seven key behaviors.


IMPLEMENTATION

Three members of the technical team involved in all stages have written the training manual. This training manual serves for training on the seven key messages but parts can be left out, depending on the level of people to be trained. In the case of feeding, a chapter on feeding of young children (6-9, 9-12, 12-24) is taught to the trainees. The next chapter explains the communication techniques with theory on how the learning process goes in stages, how to listen, how to speak to an adult, etc. Trainees practice using role plays using the new materials.

All trained staff have the agenda of messages to pass, following a monthly schedule. Messages passed, material used, materials in stock, posters in place, songs passed, etc. are being monitored in the regular monitoring forms in which these items were simply added.


To measure changes in knowledge a KAP study is done every six months, the same for a PRA to measure changes in practices, barriers and motivators. These studies will be done so that every three months one is being done. Five staff members will do the study with five beneficiaries regarding five different communication activities.

Outcome indicators (changes in behaviors/in problem)Annual (?) and final evaluation survey: Numbers of different age groups receiving correct number of feedings a day; rates of malnutrition among children under 24 months.

CHALLENGES IN HAITI

The need to remind staff and volunteers to stay within the key messages

Keeping the process participatory to make it sustainable Writing the training manual was time consuming, and it may be too

theoretical Practice through role plays is key, especially for front line workers

and volunteers Ongoing, quality supervision and monitoring


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