Series J, Number 56
Family Planning Programs

CONTENTS

Home (Key Points)

Communication Motivates Behavior Change
Figure 1. Family Planning Communication Evolves

Spotlight: Ethiopian Radio Serial Follows Process to Success

Box: Theories Inform Behavior Change Communication

Communication—A Process, Not a Product
Figure 2. Defining SMART Objectives
Figure 3. Elements of a BCC Conceptual Framework
Table 1. Many Choices for Behavior Change Communication Programs

Box: Egyptian Project Combines Channels to Reach Families

Planning for the Future

Box: Participatory Approaches Empower Communities

Bibliography

Credits

• Model for a Creative Brief
• INFO Reports: “Tools for Behavior Change Communication”

• What BCC Programs Can Achieve
• Characteristics of Effective BCC Programs
• Planning Documents That Help Guide Implementation

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See companion INFO Reports, "Tools for Behavior Change Communication"
See companion INFO Reports, "Entertainment-Education for Better Health"
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Communication— A Process, Not A Product

Successful BCC programs follow a systematic process. For programs addressing individual behavior, the process usually consists of four or five major steps. Different organizations have different names for these steps. Still, they all involve analysis, strategic design, development and pretesting of messages and materials, implementation and monitoring, and evaluation1* (30, 74, 79, 137, 139, 189, 196, 201, 225). The process guides planning and implementation (see Spotlight: Ethiopian Radio Serial Follows Process to Success). Following a proven process helps programs to work efficiently and to avoid mistakes. Programs with limited BCC budgets can adapt the steps to suit their scope (136) (see box, right). For help with following the steps in this process, see the tools in the companion INFO Reports: “Tools for Behavior Change Communication” (see Tools Available for BCC Programs).

Other models and processes focus more on affecting social change in a community, so as to improve the health and welfare of all its members (47, 60, 87). These models follow a different process. They focus on participatory communication that enables people and communities to define who they are, what they want, and how they can achieve the desired change (47). Key principles include empowering individuals and communities and engaging people in making decisions that improve their lives (see Participatory Approaches Empower Communities). Objectives and outcomes also differ from the conventional BCC model. For example, social change models value the communication process, such as expanding dialogue and debate and increasing community leadership, not only as a means to achieve health or community development outcomes. They also value the participatory communication process as an end in itself (47, 60).

The gap between BCC for individual behavior change and BCC for social change is narrowing (60, 128, 211). The conventional BCC model for individual behavior change has evolved in a participatory direction and some conventional BCC programs address both individual behavior change and social change (see Participatory Approaches Empower Communities). Similarly, participatory programs involve some elements of information transfer from programmers to communities in order to achieve underlying behavior change objectives (128, 211).

Step 1 : Analysis

Analysis provides the foundation for the BCC program. Analysis involves defining the health problem, the intended audience, and communication needs. Some of this information will already be available. For example, the Ministry of Health usually collects information about the extent and severity of health problems. Epidemiological data help to identify the primary audience of the program—that is, who is at risk of or is suffering from the health problem (136, 139, 201). To gain insight into the health problem, potential solutions, and the audience, programs can contact other organizations who are addressing the problem through communication and other approaches. These organizations can explain what they have learned and what remains to be done (136).

Programs often also conduct their own in-depth audience research. Formative research (also called formative evaluation) provides that understanding. Formative research takes place before any program design or implementation. It collects information about the audience; their knowledge, attitudes, and beliefs about health; and the factors that affect their health behavior. Formative research also can discover the intended audience’s media habits (for example, how much they listen to the radio and at what times of day). Research can assess the audience’s access to information, services, social support, and other resources (16, 68, 136). Thus it helps programs to address their audiences effectively. Formative research also contributes to the conceptual framework. The conceptual framework describes how the BCC program expects to influence health behavior (see Step 2).

A thorough analysis of the audience identifies different groups of people based on such characteristics as age, sex, place of residence, values, and stage of behavior change (see illustration). Most BCC programs customize messages to suit subgroups of people who have similar needs, preferences, and characteristics (30, 139, 201). This audience segmentation can help to make programs more efficient and effective. It is efficient because it allows the program to direct its limited resources to those most in need or most likely to change. It is effective because message content, form, and style can be tailored more closely to the needs and abilities of more cohesive groups (5). Of course, when a medium such as radio reaches large populations, even a well-defined subgroup can amount to millions of people.

In addition, analysis identifies secondary audiences—that is, people who influence the health behaviors of the primary audience (136, 139, 201). Examples include family, friends, and local opinion leaders. The program may need different messages to reach these secondary audiences.

The analysis step also involves assessing communication resources (30, 79, 136, 201). For example, can other organizations collaborate and share costs? What communication channels best reach the intended audience? What are the capabilities of the local media industry, such as broadcasting, printing, advertising, and audience research? Are qualified communication professionals available?

Step 2: Strategic Design

Strategic design creates the roadmap for the program. Information collected from formative research, along with relevant behavioral theories, guides strategic design. During strategic design the program establishes objectives, develops the conceptual framework, selects indicators, chooses communication channels, develops the creative brief (a document used to inform, or “brief,” the creative team), and builds an implementation plan.

Establish “SMART” objectives. Objectives should be SMART—that is, specific, Measurable, Appropriate, Realistic, and Timebound (see Figure 2, below). Objectives describe the intermediate steps that must be taken to achieve end goals (158). They help the program to choose which activities to undertake and to decide what outcomes to pursue and measure (136). Outcomes are the intended results or benefits for the audience during or after exposure to a program (18, 207).

BCC programs often define three levels of objectives:

1. Communication objectives describe sought-after improvements in the indirect influences on behavior, such as knowledge, attitudes, or social norms (see Theories Inform Behavior Change Communication). For example, a communication objective could focus on reducing barriers to contraceptive use in the community.
2. Behavior change objectives refer to the intended changes in actual behavior. A behavior change objective might focus on increasing contraceptive use among the intended audience.
3. Together, communication and behavior change objectives contribute to the overall program objective. Program objectives refer to anticipated results of the overarching health program in terms of outcomes, such as decreasing the fertility rate among women of reproductive age (56, 138).

Develop a conceptual framework. A conceptual framework shows how program activities are expected to contribute to objectives. Such frameworks outline the logical sequence of steps to achieve results (20, 66).

Figure 3, above, illustrates the conceptual framework for a program to reduce unintended or mistimed pregnancies and to increase birth spacing intervals to the recommended time frame of three to five years (169). One communication objective might be to increase knowledge of modern contraceptive methods among women ages 15 to 49 by 20% over the next five years. A related behavior change objective might be to increase use of modern contraceptives among this group of women by 10% over the next five years. To reach behavior change and program objectives, the BCC program needs to consider “contextual variables,” which relate to underlying social, political, and economic conditions (see Figure 3) (183). These underlying conditions, identified in the formative research, along with relevant theory, inform the specific communication activities to undertake.

Communication interventions take place in three mutually supportive domains: the social-political environment, the service delivery system, and among individuals and communities (see “Domains for Communication Interventions” in Figure 3). These efforts are intended to produce “initial outcomes” at different levels: the social and political environment, service delivery systems, the community, and the individual. At the level of the individual, communication activities are expected to improve knowledge, change attitudes, and influence other factors (see “Initial Outcomes” in Figure 3). Changes in these initial outcomes lead to increased adoption of the desired behaviors, including increased use of modern contraceptives (see “Behavioral Outcomes” in Figure 3). In turn, behavior change leads to achieving the overall program objectives, such as reducing unintended or mistimed pregnancies and increasing birth spacing intervals (see “Sustainable Health Outcomes” in Figure 3).

Select indicators. Conceptual frameworks also aid in the selection of appropriate indicators (66, 92). An indicator measures a single aspect of a program that contributes to meeting objectives (20, 66). For example, evaluators might choose to track the number of audience members who attend particular community mobilization events. This indicator assesses outreach activities. Evaluators try to choose indicators that are valid (measure the topic or issue that they are meant to reflect), reliable (produce consistent results when repeated over time), specific (measure a single topic or issue), sensitive (responsive to change), and operational (measurable) (19, 139).

Choose communication channels. Findings from formative research guide the choice of communication channels. Formative research can identify which channels best reach the audience and which channels the audience considers most credible concerning health topics. Combining the three types of channels—mass media, interpersonal communication, and/or community channels—can help maximize the effect of BCC programs (see Egyptian Project Combines Channels to Reach Families). To choose the appropriate mix of channels, the communication team should consider which channels will best deliver the message to the intended audience within the available budget.

Beyond choosing the three types of channels, BCC programs also need to select specific channels and devise activities. For example, which radio stations best reach youth in the cities? Information and communication technologies (ICTs) enable people to interact and participate in the BCC campaign, but which ones can the audience use (see Technology Shapes Behavior Change Communication)? Programs can choose from a variety of formats, materials, and venues within each type of communication channel (see Table 1).

Develop a creative brief. The creative brief is a document that the communication team develops and shares with people and organizations involved in development of messages and materials, such as advertising agencies, public relations firms, or writers and designers. It provides all staff with the same direction for developing messages and materials. The creative brief includes a profile of the intended audience, audience actions expected (behavior change objectives), and the resulting benefits that the audience will appreciate. The creative brief should also include the key message points that will be conveyed in all messages, activities, and channels (136, 139). (For help with developing a creative brief, see Model for a Creative Brief.)

Build an implementation plan. The next step is an implementation plan, covering partners’ roles and responsibilities, activities, timeline, budget, and management. At this stage the program also should plan for monitoring and evaluation (also called process evaluation and summative evaluation, respectively). (For a summary of all the documents that should have been prepared by the end of this step, see Planning Documents That Help Guide Implementation.) Monitoring and evaluation should be planned for in every BCC program from the beginning, starting with formative research to inform the analysis stage, and then developed and used throughout the planning and implementation process. A monitoring plan should describe what aspects of the program will be monitored, how and how often, and what indicators will be used (66).

Monitoring enables managers to determine if the program is on track and to account for budget expenditures (see Step 4). An evaluation plan describes the research design, indicators, and methods used to determine if changes in outcomes have taken place and can be linked to the BCC program (see Step 5) (66).

There are a number of types of evaluation designs (see Examples of Evaluation Designs). The choice depends on the nature of the BCC program, the funds and expertise available for the evaluation, the duration of the program, and the information needs of stakeholders and decision-makers (136). Ideally, evaluations include measurements at the start and completion of a BCC program, so that they can be compared. Evaluation design should measure exposure to various BCC activities (66, 138). Developing a strong evaluation plan may require help from an evaluation expert who is familiar with research design, sampling, and advanced statistical analysis.

As a rule of thumb, it is advisable to allocate approximately 10% of a BCC program budget to monitoring and evaluation. A monitoring and evaluation budget may exceed 10%, however, particularly for pilot programs intended to determine whether the program is worth replicating or scaling up (142). For small programs with relatively small budgets, 10% represents a limited amount (142). Evaluation conducted on such a small scale usually cannot be expected to detect significant program results. Thus, the funds may be better spent on program activities and low-cost monitoring (94, 106, 142).

Step 3: Development and Pretesting

The analysis, conducted in Step 1, and the strategic plan, created in Step 2, guide the development of concepts, messages, and materials. The program should tailor its messages based on the audience’s position in the stages of behavior change (228). For example, research may find that most people are already aware of and concerned about the desired behavior, but they have not yet tried it. They may need messages that focus on the benefits of behavior change. Research may find, instead, that most people are already motivated to change their behavior. Then messages may need to provide practical information, such as where to obtain supplies and how to use them (see illustration).

For example, a study in southwestern Uganda found that adolescent girls were aware of HIV but underestimated their risk of infection. They distrusted condoms. Generally, they lacked a formal, culturally appropriate source of sexual and reproductive health information. Surveys of the community found that people were aware of the vulnerability of adolescent girls to HIV and other STIs. Also, people wanted adolescents to know more about reproductive health risks. Therefore, program staff worked with the community to revitalize and update a traditional channel of communication for adolescent girls about sex and marriage, the senga (meaning father’s sister). With training, sengas delivered messages about HIV and family planning that were both accurate and culturally appropriate. They also gave young women traditional information about sex and marriage (130–132).

Choose type of appeal and tone. Programs can use a number of different types of appeals in their messages, such as informing, entertaining, persuading, educating, or empowering (201). For example, entertainment-education approaches can educate and motivate people as they entertain them (175) (see Spotlight: Ethiopian Radio Serial Follows Process to Success). Messages also can vary in tone—for example, using humor or fear. Fear appeals both motivate behavior change and cause defensiveness and resistance to change. Which response dominates depends on whether the message proposes effective and feasible action to avoid the threat (222, 223).

Obtain creative talent. To develop effective materials, the program needs creative talent. This talent could come from within the organization. It also could come through partnerships or contracts with other organizations, such as advertising agencies, public relations firms, or NGOs with staff trained in communication (79, 136). The program should use the creative brief developed in Step 2 to explain the communication strategy to the creative staff and help them to understand the objectives and what the program has learned about the intended audience. A profile of a typical audience member can also help the creative staff to develop materials that are relevant and appealing to the audience. (For guidelines on managing the work of an ad agency, which can be adapted for working with other creative professionals, see the publication, “How to Select and Work With an Advertising Agency,” at http://www.jhuccp.org/pubs/fg/2/2.pdf.)

Pretest messages and materials. During pretesting, typical members of the intended audience see or hear preliminary versions of the campaign materials. Then they are asked questions such as: What message does the TV spot convey? Are the characters in the radio drama believable? Is the information in the brochure easy to understand? What is attractive about the piece? What is unattractive about it? Is anything offensive? Answers to these and other questions may indicate the need for changes. Revisions may be minor or substantial, but the pretesters’ reactions should not be ignored (228).

There is no substitute for pretesting with the intended audience. Review by colleagues or experts will not reliably predict audience reaction. For example, in the Accelerating Contraceptive Use Project in Afghanistan, pretesting with community leaders at one site found that pictures in condom instructions would be unacceptable. In the two other sites pictures were acceptable if used only in counseling (88, 115).

Step 4: Implementation and Monitoring

During this step the manager of the BCC program makes sure that each program component is developed as planned and that each product reaches the correct destination on time. Implementation can typically involve distributing print materials, broadcasting radio and television messages, or conducting community meetings or individual counseling sessions (30).

When launching the program, program managers can engage the media to obtain maximum news coverage of the program. News coverage often is people’s first source of information (155). Kickoff events and press conferences are good ways to get the news media’s attention.

For example, Egypt’s Communication for Healthy Living project hosted group weddings that attracted hundreds of newlywed couples. Extensive news coverage of these receptions in national radio, television, and newspapers spread the message of the Sahatek, Sarwetek (“Your Health, Your Wealth”) campaign throughout Egypt (38, 81). specific messages focused on safe pregnancy and delivery, postpartum care, neonatal and infant care, and birth spacing. Developing an ongoing relationship with the news media helps ensure continuing coverage of the program.

Monitoring occurs during program implementation. It enables managers to track program activities, outputs, reach, and costs (16, 66, 159). For example, programs may monitor the quality, timing, frequency, and audience size of radio and television announcements or dramas. Programs may track print runs and distribution of print materials. They may conduct site visits—for example, to check if clinics have program materials and use them properly.

Program managers and evaluators can collect data from such sources as log books of TV or radio stations, program activity forms, and clinic registries (136). How often data are collected depends partly on how easy they are to collect. Existing data collection systems, such as service statistics, can be convenient. Usually, however, the program also must develop new data collection processes—for example, organizing staff to monitor television and radio broadcasts (66).

Program managers also should monitor the immediate reactions of the audience whenever possible. Program managers can create listener groups or conduct focus groups or short surveys to determine audience members’ understanding of and reactions to messages (11, 161, 209). That information helps managers and evaluators identify obstacles and opportunities and make midcourse corrections (see Spotlight: Ethiopian Radio Serial Follows Process to Success).

Step 5: Evaluation

Evaluation assesses program achievements and how well the program has met its objectives (66). It can measure the extent to which observed changes in outcomes can be linked to communication activities. That is, have audience members changed in the ways described by the communication and behavior change objectives? And is the BCC program responsible for these changes?

To assess whether the BCC program accounts for the observed change in outcomes, evaluators consider eight criteria: (1) observation of change in the outcome; (2) degree of relationship (correlation) between exposure to the program and the observed outcome; (3) evidence that exposure occurred before the observed change in the outcome; (4) lack of evidence suggesting that the observed change is due to other factors; (5) observation of a large, abrupt change over time in the outcome in the absence of other major influences; (6) evidence of a causal connection (consistent with theory); (7) evidence that the impact increases as the level or duration of exposure increases (dose response), and (8) consistency with findings of previous research (19, 59, 142). The more criteria that evaluation findings meet, the greater the confidence that the BCC program is responsible for the observed outcomes (142). A strong evaluation design will plan from the start to check many of these criteria.

Evaluations can provide valuable evidence to decision-makers, demonstrating that BCC programs contribute to health outcomes and justifying future investments (66, 92). A dissemination plan helps ensure that key stakeholders and decision-makers learn about program results. Different people prefer different formats for presentation of results. For example, busy policy makers usually appreciate a policy brief. A program manager may want a detailed report. Researchers tend to favor journal articles. The public and members of the audience may most appreciate a participatory presentation and discussion, with time for questions and answers (139, 142).

Information from evaluation often serves as part of the formative research findings for design of the next program. By identifying key factors that contributed to success, evaluation can facilitate sustainability and scale-up (54).

* Some processes include monitoring with evaluation rather than with implementation. This report includes monitoring with implementation because monitoring focuses on processes and tracking the production of materials during the implementation stage, whereas evaluation occurs at the end of the program.