Planning for the Future
Three factors determining the long-term success of behavior change communication are: (1) developing ongoing capacity to create high-quality BCC programs, (2) planning BCC programs with future expansion in mind, and (3) sustaining behavior change over time.
Develop and Sustain Capacity for High-Quality Programs
Over the last 20 years government agencies, private organizations, and some universities have strengthened the capacity to develop and conduct BCC programs. They have trained communication professionals. They have established independent communication organizations or units within larger organizations. They have joined in partnerships that bring together the many different skills needed for BCC. Such skills include communication planning, project management, audience research, development of messages and materials, media production, pretesting, public relations, and monitoring and evaluation (30). Each approach to capacity building has different merits. Pursuing all available approaches generally is the best strategy at the national level.
Training can develop some capacity quickly. People receive training in BCC at many levels and in many ways. Training can take place in classrooms, on the job, through self-instructional materials, or via distance-learning programs or Web-based technology (65, 135). To make the most out of investments in training, organizations should have clear policies and processes for deciding whom to train. Programs should select and train the staff members who will actually work on communication programs and who are likely to stay with the organization for a time (46).
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In Malawi workshop participants use interactive computer software called SCOPE to design an HIV/AIDS BCC program. Such workshops and tools help to develop local capacity for high-quality BCC programming. Photo: © 2002 Arzum Ciloglu/CCP, Courtesy of Photoshare
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The United Nations, international and in-country NGOs, some community-based organizations, and a small group of international consultants conduct a variety of communication training courses and workshops (43, 96). For example, the World Health Organization provides training on the COMBI (Communication for Behavioural Impact) Design Process, an approach for planning social mobilization and communication programs for a variety of health issues. Recently, the Namibian Ministry of Health and Social Services unveiled its plan for a nationwide HIV-prevention communication campaign based on the COMBI process (204, 205, 225). The Center for Communication Programs at the Johns Hopkins Bloomberg School of Public Health also conducts workshops to help health care professionals worldwide design strategic health communication programs. The workshops use an interactive software program called SCOPE (Strategic Communication Planning and Evaluation). SCOPE allows users to design, implement, and evaluate health communication programs directly on the computer (83).
Another training approach, called competency-based training, identifies the tasks required by a specific job and the skills needed to perform those tasks. Competence is about turning knowledge into action (96). The approach is commonly used to train health care providers in clinical skills (25, 99, 113, 164, 187). In 2002 a meeting of communication experts from various organizations and regions developed a preliminary set of key communication competencies (see http://www.changeproject.org/pubs/competenciesreport.pdf, p. 14). This set of competencies is the starting point for the development of accepted competency standards that universities and training programs worldwide can use to create competency-based curricula to educate and train communication professionals (96).
The competencies developed at the 2002 meeting informed a project already underway in Peru to develop the national capacity for health communication. Between 2002 and 2005 the USAID-funded CHANGE project, a consortium of Peruvian universities, and two Peruvian NGOs developed communication competencies for various health professionals. They identified specific health communication competencies for regional health authorities, physicians, nurses, health technicians, and health promoters. Project partners used the competencies to develop training modules and curricula for each profession. Then they held competency-based training workshops in six regions of Peru for nearly 1,000 health care professionals in the particular communication competencies appropriate to their specific jobs (33, 212).
Education develops capacity over the long term. Teaching students—the next generation of professionals—the basic competencies for BCC helps ensure capacity for the longer term. Around the world, academic institutions offer communication degrees, typically in schools of health, communication, agriculture, or education. Over 80 universities and other academic institutions offer postgraduate communication programs focused on improving people’s health and well-being. About one-third are in developing countries (44). For example, the College of Development Communication at the University of the Philippines Los Baños offers three postgraduate degree programs in development communication and also undertakes training, advisory, and action projects (208). (For a list of undergraduate and graduate communication courses that the college offers, see http://www.devcom.edu.ph/ver1/, under “Academic Programs” from the menu on the left side.)
Free-standing BCC organizations provide expertise. In some developing countries independent organizations have emerged to provide BCC services. Some of these organizations, such as the Communication for Development Foundation Uganda (CDFU) (http://www.cdfuug.co.ug/) and the Healthy Russia Foundation, are legacies of institutional capacity building by large nongovernmental health programs with BCC components (37, 100, 143). Others, such as Egypt’s Information, Education and Communication Center of the Ministry of Information’s State Information Service, grew out of partnerships between donor agencies and governments (40). Some were the field offices of global BCC technical assistance programs but became independent and self-sustaining (226). Through years of dedicated work to develop staff skills and strategic partnerships, these organizations have developed the expertise to respond to their countries’ unique health communication needs. They provide technical assistance and services in designing, implementing, and evaluating BCC programs.
Partnerships make use of existing capacity. More and more, experts point to the need to strengthen institutional partnerships and networks (46, 123, 193, 212). This approach to capacity development does not require one organization to develop all the skills and resources needed. Rather, a number of organizations collaborate, each contributing its specific capabilities—and strengthening them in the process. For example, a family planning program can join with a local university or research firm to conduct research and contract an advertising agency or media production firm to develop messages and materials.
Help can come from other branches of the same program’s organization, universities, private firms, government agencies, NGOs, and community groups (96). Working with partners can offer greater credibility, new approaches and methodologies, and greater access to resources and skills and to the intended audience (46, 136, 153, 212).
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In Egypt agricultural extension workers conduct seminars on reproductive health. They encourage farmers to ensure their families’ reproductive health. Partnerships between different sectors are a good way to make use of existing capacity and resources. Photo: Pathfinder/Egypt Takamol Integrated Reproductive Health Services Project
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In some situations it may be helpful to involve partners in other sectors, such as the environment, education, or democracy and governance. For example, in Egypt the Takamol Integrated Reproductive Health Services Project uses agricultural and irrigation extension workers to inform farmers about reproductive health topics during routine outreach visits. They provide information on breastfeeding, child health, early marriage, healthy timing and spacing of pregnancies, antenatal care, maternal health, gender-based violence, and involving men in reproductive health decision-making. Farmers already accept these experts as credible information sources (195).
Plan for Large Scale
If BCC is worth doing, it is worth doing in a big way. Major improvements in public health often require the healthier behavior of many, many people (48, 54). The term “scaling up” typically refers to expanding program activities to reach more people and more areas, thus increasing impact (1, 29, 48, 87). This is also referred to as “going to scale.” Scaling up is done best by planning for it from the start, with vision and commitment. By looking ahead, program planners can build in the components needed for large scale. Such components are difficult to add or alter later (45, 177, 197). For example, a simple program is easier to scale up than a complex one. Therefore, programmers with scale in mind design a simple program rather than a more intensive approach envisioned just for a specific site (45, 87, 176, 177).
Programs can use a variety of strategies to scale up their activities and impact (35, 48, 51, 133). Strategies of BCC programs have included the following:
Testing and refining programs before expanding. Programs testing particular approaches or messages in pilot areas should choose sites with potential for high impact. Early success will build confidence among program staff and communities, attract more interest from other communities and policy makers, and encourage more support. Positive features to look for in a pilot site include dynamic leaders, existing community groups, and volunteers (177).
Assessing the costs and effectiveness of a program is essential before scaling it up (48, 177). Data from program monitoring and evaluation should provide this information. Program managers also should consider the key elements that made the program a success, simplify the program model to emphasize those elements, and assess whether those elements will be sustainable during scale up (45, 176, 177). If a program was not effective, it should be redesigned and retested before going to scale (177).
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Scaling up is done best by planning for it from the start. A simple program is easier to scale up than a complex one.
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The Madagascar Child Survival and Reproductive Health Program was designed from the start to improve breastfeeding practices rapidly and at scale. It started in two districts in 1996. The program worked with local radio stations to broadcast 6 to 10 breastfeeding promotion messages each day during the “mass campaign months,” which happened one month in every three. The program also distributed the messages on cassettes to bus and taxi drivers, who played them for passengers. Community-based group activities and interpersonal communication between health workers and mothers reinforced the messages (150). Over the next six years the program scaled up to reach nearly eight million people—about half of the nation’s population. In program sites breastfeeding within one hour after birth increased from 34% among new mothers to 76% in just two years, between 2000 and 2002. In comparable sites without the program, levels remained at about the national average of 35% (150, 177).
Partnering with other organizations to expand size and coverage. Solid partnerships can bring together the support, resources, credibility, and expertise needed for eventual expansion (30, 136, 177). Such partners may include community organizations, NGOs, commercial organizations, research institutions, government units, and communication media themselves such as radio or TV networks or production houses. Indeed, plans to scale up can influence the choice of partners at the start. For instance, the program may not need a particular organization at first, but that organization might contribute to scaling up later (87).
In 2001 the Romanian Family Health Initiative (RFHI) started a two-year pilot initiative in three districts, providing family planning through primary health care units. By 2007 RFHI had scaled up the pilot project to the national level. Key to this success was collaboration among the Romanian Ministry of Health and Family (MOHF), USAID, JSI Research and Training Institute, and local NGOs. Multisectoral working groups composed of staff from the MOHF, donors, NGOs, and other implementing partners developed supportive policies and draft legislation, standards, and protocols for key project components.
One component was a BCC campaign. The campaign sought to create awareness of family planning and reproductive health issues and raise demand for modern contraceptives. Coordination between stakeholders ensured that campaigns to build demand for contraceptives started in areas where providers had been trained and clinics had the necessary contraceptive supplies. The level of contraceptive use among married women of reproductive age in rural areas increased from 21% in 1999 to 33% in 2004. Over the same period the rate of abortions in these areas declined from 2.4 to 1.1 per 1,000 married women. Romanian policies now support provision of family planning at the primary health care level (71, 72).
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In Cape Town, South Africa, some 20,000 people marched on parliament in February 2003 to call for universal access to antiretroviral (ARV) treatment for HIV. Later, the government agreed to provide ARV treatment through the public sector. Committed individuals and groups can influence politicians and policy makers to expand programs. Photo: © 2003 South Africa Treatment Action Campaign (TAC)
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Influencing policy or legislation to broaden the reach of programs. Working with the news media is one way to win support for expansion. News coverage can increase public understanding of a health issue and shape the public debate (91, 215-217). Also, individuals and groups can campaign for supportive policies and programs (5). Both the beneficiaries of programs— that is, the audience—and public interest organizations can influence policy.
In South Africa the Treatment Action Campaign (TAC), an activist AIDS organization, used the communication tools of advocacy, mass movement, and political pressure to lobby the government. The group sought universal access to antiretroviral (ARV) treatment through the government health care system (221). When TAC formed in 1988, ARV treatment was available only to a small minority of South Africans who could afford to pay for private health care (140). In February 2003 TAC organized a thousands-strong march on parliament. In March 2003 it began a civil disobedience campaign (69). On August 8, 2003, South Africa’s cabinet made a commitment to provide ARV treatment through the public sector (190).
Work Toward Social Change to Sustain Behaviors
To be most effective in the long term, programs must focus not only on motivating individual change. They also must change the social and cultural contexts that influence individuals (23, 60, 120, 121). BCC programs must broaden to include such approaches as advocacy, to strengthen political commitment, and community participation, to create a sense of ownership in the program (see Participatory Approaches Empower Communities).
When the expectations of their families, peers, and communities support healthy behavior, people are more likely to practice healthy behavior, even in difficult circumstances. In other words, changing social norms sustains behavior change over the long-term. The practice of contraception in Indonesia serves as an example. In 1967 less than 5% of Indonesian married women used modern contraceptive methods. The average woman gave birth to nearly six children over her reproductive lifetime. In contrast, in 2006 almost 60% of married women were using a modern contraceptive method. The total fertility rate had fallen by more than half (from 5.9 children per woman to 2.6) (125).
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Sustaining healthy behavior usually requires a continuing investment in BCC as part of an overall health program.
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Over the four decades the government family planning program, USAID, and other partners worked to create a strong enabling environment to support use of family planning services. This included having well-trained staff to provide services, creating new social norms that favored a small family size, cooperating with religious leaders, and developing government and political support. In particular, long-term BCC campaigns, with the slogan “Dua anak cukup” (“Two children are enough”), created a small family size norm, increased people’s interest in having fewer children, and generated demand for family planning services. Over the years the campaign used a variety of channels to promote the small family size norm. The communication strategy evolved as the situation in Indonesia changed—from reaching rural areas with grassroots participation and promoting smaller family norms, to building an independent private sector and improving quality of care (125).
Between 1997 and 2003 Indonesia experienced a political and economic crisis. Still, levels of contraceptive use continued to rise (7, 32, 67, 185). The new social norm seems to explain the sustained rate of use. A study found that the more widespread the small family size norm was in a particular Indonesian county, the more likely that levels of contraceptive use remained unchanged during the crisis. For example, in counties where one-third to two-thirds of women supported the small family norm, women were 1.5 times more likely to use contraception than in counties with low normative support for small family sizes (185). This suggests that BCC programs that change social norms to promote positive behaviors contribute to sustained individual and collective behavior change over time.
Social norms help to sustain individuals’ healthy behavior and may decrease the need for intensive BCC programs. Still, sustaining healthy behavior usually requires a continuing investment in BCC as part of an overall health program. People need to hear messages repeatedly—and often to discuss them with others—before they take action. Furthermore, as people go through the process of changing their behavior, they need to hear different messages (148). Also, every year young people reach adulthood and take on responsibility for their own health, including their reproductive health. Thus there are new audiences to reach. Even those who have adopted healthy behavior may need occasional reminders.
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In Indonesia long-term BCC campaigns with the slogan “Dua anak cukup” (“Two children are enough”) helped to create a small family size norm and sustain use of family planning services. This photo, titled “Rukun” (“Harmony”), won third place in a photo contest sponsored by BKKBN, Indonesia’s national family planning program. Photo: © Yudi Tirtajaya/ Yogyakarta and BKKBN
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Good reproductive health often requires healthy behavior. BCC programs in family planning, related reproductive health, HIV prevention, and other health and development areas have helped millions of people adopt healthier behavior. For example, BCC programs have helped to increase contraceptive use by increasing knowledge, addressing personal barriers such as worries about side effects, and improving attitudes about small family size and spacing children. BCC programs also are essential to changing the social contexts that influence individual behavior. For instance, many HIV prevention programs address social norms that foster the pandemic, such as norms that condone having multiple sex partners.
Thus, virtually all family planning and reproductive health programs benefit from a strong BCC component. The route to successful BCC is well-known. Proven processes, models, and theories help program managers develop effective BCC programs. BCC programs generally change health behavior at a low cost per person, particularly when they reach many people. Even small family planning programs can develop strategic BCC components. They can adapt and simplify BCC development processes to fit their overall program and budget. One communication product or approach will not be enough, however. To promote and sustain healthy behavior, BCC requires ongoing attention.
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