Theory-based
Approaches to
Formative Approaches:
translating
observations into
research
questions/possible
techniques
Basil Safi, MPH, PE, CHES
Kathmandu, Nov 8, 2011
Overall Approach
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Defining strategic health communication
Why formative evaluation?
Why “theory-based”?
Important concepts from social &
behavioral design and implementation
• Group exercise
Strategic Communication
Strategic communication is a process carried
out with the active participation of
stakeholders and beneficiaries that addresses
a long-term vision and affects the causes of
as well as the barriers to behavior change.
We need to recognize the multiple layers
that influence individual behavior
Social
Ecological
Framework
Engaging Communities for Healthy
Nutrition Behaviors
Working at Multiple Levels for Greatest Impact
• Mass media
• Community mobilization
• Interpersonal communication
and counseling
• Capacity building
• Advocacy
Why Formative Evaluation?
• Central tenet of behavior change
interventions: KNOW YOUR AUDIENCE
• Demographically
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Age
Education
Gender
Religion
Political views
Residence
Health literacy
Knowing your Audience
• Psycho-graphical profile (KAP)
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Prevailing attitude
Knowledge
Risk perceptions
Efficacy beliefs
Perceived barriers
Priorities
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Interpersonal ties
Media use patterns
New technology adoption
Access to information
• Communication profile
Knowing your Audience
• Behaviorally
– Prior behaviors (attempted change before?)
– Readiness for adoption of new behaviors
• Culturally
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Social norms
Social support (vs. isolation)
Cultural traditions
Obligations
• Structurally
– Environmental facilitators and constraints
– Access to services
Exposure to CBAIC TV spots increases level of
perceived social influence and interaction
KAP 2009 Household Survey
Base: All respondents
*Unpaired t-tests, p<.0001
Presence of Team Flu Burung in community
increases perceived social influence
KAP 2009 Household Survey
Base: All respondents
*Unpaired t-tests, p<.0001
Reach & Touch
• Targeting
– Reaching the audience “where they live”
– Tapping into the appropriate communication
channel or venue
– Purpose: to enhance exposure
• Tailoring: Crafting persuasive messages that
– Resonate
– Inspire
– Motivate
Reduction in early childhood
mortality and stunting
Baseline trend
Current direction
Reduction in early childhood
mortality and stunting with
Suaahara intervention
Baseline trend
With health
intervention
Reduction in early childhood mortality and
stunting through health intervention and
current direction meeting at later point
Baseline trend
With health
intervention
Shared vision
Zero nutrition
related infant
deaths
Putting theories to work
Where is your audience with respect to the desired action?
What information or messages do they need at that stage?
Maintenance
Action
Intention
Decisionmaking
Comprehension
& Risk Perception
Awareness
Stages of Behavior Change
Where is your audience with respect to the desired action?
What information or messages do they need at that stage?
Audience: 30 yr old
pregnant woman
Vaccination
Intention to make an
appointment
Considering
vaccinating herself
Knowledge of
transmission modes &
realistic risk perception
Awareness of
H1N1 flu
Takes her
husband and 3 yr
old daughter for
vaccination and
advocates to
family/friends
Formative Evaluation Questions
in the Suaahara Campaign
• Targeting Question: What salient communication
channels need to be employed?
– Radio, mobile phones, interpersonal sources?
• Segmentation Question: Who are the primary
audiences?
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Pregnant women
illiterate moms
Fathers
Others?
Who influences them (secondary audiences)?
• Tailoring Question: What messages will be
designed?
E.g. of a Spacing Campaign
The same message is crafted differently for different
audiences, while retaining its essence
TV Spots, Radio spots,
Billboards, Poster and wall paintings
Regional Variations
• E.g. Urban/Rural; East/West
• Pretesting visuals and content is critical
– Appeal, Comprehension, Intent to Act,
Culturally appropriateness
Design guidelines
1.
What are the various levels of knowledge we need the
intended audience to acquire?
2.
What attitudes or perceptions need to be shifted to facilitate
to social and behavioral change?
1.
What are the general practices that we should promote
(adopting)?
2.
What are the specific practices that we should enhance,
modify and / or change?
3.
What is our definition of high risk practices?
4.
What should be the indicators above ? How to go about the
measurement?
How Does Communication Affect
Intention?
C
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T
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Instruction
Knowledge
& Skills
Promotion
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Advocacy
Environmental
Constraints
Intention
Behavior
How Does Communication Affect
Intention?
C
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Instruction
Knowledge
& Skills
Promotion
Ideation
Advocacy
Environmental
Constraints
Intention
Behavior
Defining Ideation
Ideation is defined as new ways of thinking
and the diffusion of those ways of thinking by
means of communication and social interaction
in local, culturally homogeneous communities.
Ideation Theory of Communication
Knowledge
Personal
Advocacy
Attitudes
Social
Influence
Implies
simultaneous
effect of all
influences.
SelfImage
BEHAVIOR
Perceived
Risk
Emotion
Perceived
Efficacy
Norms
Implies that
communication
can affect all of
these factors.
(Kincaid, Figueroa, Storey, & Underwood, 2001)
E.g. Perceptions of Diarrhea
• Diarrhea is not always seen as a significant
health threat
• Viewed as part of growing up and may even be
seen as beneficial for children, except during an
epidemic such as cholera
• Diarrhea is caused by many different exposure,
so it is perceived as something that is difficult to
control, especially by just boiling or treating
water
Other perceived causes of
diarrhea
• (1) infancy teething, (2) traumatic falls, (3)
inadequate care of children, (4) imbalance of
hot and cold foods or states, (5) improper
diet, such as, too much fruit, eating sweets or
overeating, (6) breastfeeding the child after
s/he has been hungry for a while, (7)
switching from treated drinking water to
non-treated drinking water, (8) evil eye, and
(9) mothers’ health behavior and emotional
state
(Nielsen et al., 2003; Goldman, Pebley, & Beckett, 2001; Iyun & Oke, 2000;
McLennan, 1998; McLennan, 2000a, Olango & Aboud, 1990; Ketsela, et al., 1991;
Kaba & Ayele, 2000; Jintrawet & Harrigan, 2003; Nichter, 1988)
Perceptions of Water Treatment
• Water treatment is not always perceived to
have compelling health benefits.
• Even if you treat water at home, you may still
get exposed to contaminants elsewhere
• Only for the weak, young, and frail
Case Study: Aman Titra
• Worked to develop a sustainable
commercial model for the production,
distribution and promotion of a POU
chlorination product (Air RahMat),
• Create an enabling environment to
increase access to POU products and
technologies.
Ati, A. Figueroa, ME, Ainslie, R., Making waves against the norm, 2009, APHA
Boiling as the main treatment
method
Ati, A. Figueroa, ME, Ainslie, R., Making waves against the norm, 2009, APHA
Boiling perceptions
• A tradition: “our parents, our ancestors boiled
their drinking water, and so do we. It’s a
tradition”
• Practical!
• For smart people: “people here are smart people
here are smart and knowledgeable, they know
that water and knowledgeable, they know that
water needs to be boiled”
Are there other ways to make water as
safe as it is after boiling?
Ati, A. Figueroa, ME, Ainslie, R., Making waves against the norm, 2009, APHA
Percentage of households with E.coli
contaminated boiled, ready to drink water
Ati, A. Figueroa, ME, Ainslie, R., Making waves against the norm, 2009, APHA
Why would people try it?
• Economical, Practical
• Media ads enhanced the credibility of the
product the product
• Registered/approved product
3 Components of Ideation
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Instruction
Knowledge
& Skills
Cognitive
Promotion
Beliefs/Values
Perceived Risk
Subjective Norms
Self-Image
Emotional
Emotional Response
Empathy
Self-Efficacy
Social
Support & Influence
Personal Advocacy
Advocacy
Environmental
Constraints
Intention
Behavior
Factors Influencing
Behaviors
• Intentions to perform the behavior
• Environmental constraints preventing the behavior
• Skills necessary to perform the behavior
• Behavioral beliefs and perceived consequences
(attitudes)
• Perceived normative pressure
• Self-image: self-standards and sanctions
• Emotional reactions
• Self-efficacy (perceived capability and confidence)
Group Exercise: The “Yes,
but…” Game
• Objectives
• To elicit significant barriers that impede ability to change
behaviors
• To categorize barriers into meaningful themes
• Assumption
– Sometimes, people may be reluctant to discuss their
barriers
– People may not be consciously aware about the
barriers
Example 2: The “Yes, but…”
Game
• Method
• Provide a sentence
• Ask audience to complete the sentence with the
phrase, “Yes, but….”
• Example
• “Always wash your hands before you eat”
• Yes, but……..
– …… the water is often dirtier than my hands
– ……. there is a severe water shortage
Example 2: The “Yes, but…”
Game
• Develop themes
• It may be possible to categorize barriers according to
levels. For example, barriers against breastfeeding:
• Individual level: lack of perceived importance
• Interpersonal level: family may not support
breastfeeding after child is a couple of months old
• Normative level: others may think I am weird
• Structural level: I am too far away from home in the
day time because I need to get firewood
Example 2: The “Yes, but…”
Game
• Develop themes
• It may be possible to categorize barriers according to
other factors. For example, barriers against
immunization of new-born babies
• Psychological: it is too traumatic
• Cost: it takes too much money to get on a bus and get
to the clinic
• Structural: clinic is too far away
• Social: no one else seems to be doing it
Example 2: The “Yes, but…”
Game
• Group Themes
1) Use of fertilizer for your crops
2) Build a village latrine
3) Exclusively breastfeed infant for first 6 months
4) Seek medical attention at the first signs of wasting
5) Raise chicken as family protein source