social and behavior change communication approach in public health

sbcc in public health

1. Social and Behavior Change Communication approach in Public Health Dr. Aleena Maskey JR 2019 SPH&CM 9 th November 2020 1

2. CONTENT Introduction Social and behavior change communication (SBCC) Theories of SBCC Importance of SBCC SBCC Strategy approaches Steps of SBCC SBCC Strategy Shape-up Somerville SBCC initiative Conclusion References 2

3. Introduction Behavior is a complex phenomenon, influenced by factors within the individual and beyond. The Social Ecological Model, recognizes four levels of influence that interact to affect behavior: individual, family and peer networks, community and social/structural. Behavior determines whether a person is at risk or not. 3

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5. Smoking A lco h ol Diet a ry Physical Activity Non communicable diseases such as (NCDs) Diabetes Obesity Hypertension, Cancers, etc. Sexual Activity Substance abuse HIV, STD, Hepatitis Rash Driving Road Traffic Accidents Mental Disorders Healthy life Behaviour Public Health 5

6. INTRODUCTION Emphasis in public health interventions have been on changing behaviors or intervening early on to decrease the negative impacts that come with these behaviors. With successful intervention, there is possibility of decreasing healthcare costs, as well as general costs to society (morbidity and mortality). 6

7. INTRODUCTION Behavior change , in context of public health, refers to efforts put in place to change people's personal habits and attitudes, to prevent disease.  Behavior change in public health is also known as social and behavior change communication (SBCC). More and more, efforts focus on prevention of disease to save healthcare care costs.  This is particularly important in low and middle income countries where health interventions have come under increased scrutiny because of the cost. 7

8. Social and behavior change communication (SBCC) Previously known as behavior change communication (BCC), SBCC is an interactive process for developing messages and approaches using a strategic mix of communication channels to reach multiple levels of society in order to encourage and sustain positive and appropriate behavior . BCC was first employed in HIV and TB prevention projects. More recently, SBCC has grown to encompass any communication activity whose goal is to help individuals and communities select and practice behavior that will positively impact their health, such as immunization, cervical cancer check up, employing single-use syringes, etc. 8

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10. A key element of behavior change interventions involves negotiation with the individual or community for behavior change. Ultimately it involves negotiation with ‘Self’ to practice desired behavior. It uses dialogue, messages, persuasion, interpersonal and group communication to exchange information, ideas, skills and values aimed at bringing about behavior change. It employs a systematic process beginning with formative research and behavior analysis and is based on the communication, planning, implementation, monitoring and evaluation. 10

11. SBCC is a Process 11

12. Programs are designed on the basis of existing data, analyzing the problem in order to define barriers and motivators to change, and design a comprehensive set of tailored interventions that promote the desired behaviors. An SBCC strategy is the document that guides the design of interventions, establishing intended audiences, setting behavioral communication objectives and determining consistent messages, materials and activities across channels. 12

13. Participation of the stakeholders are vital at every steps of planning and implementation of the behavior change programs to ensure sustainable change in attitude and behavior. SBCC has proven effective in several health areas, such as increasing the use of family planning methods, preventing HIV and AIDS, reducing the spread of malaria and other infectious diseases, and improving newborn and maternal health. 13

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15. Effective SBCC interventions should aim to develop messages and activities that influence all four levels of the Social-Ecological Model, maximizing the facilitators and limiting the barriers. It is important to recognize, however, that it is unlikely for one single organization to be able to operate at all four levels, as these often require different skills, strategies and approaches. Coordination and partnerships with institutions and organization that operate at different levels are therefore necessary for a comprehensive SBCC approach. 15

16. Social norms and public policies influence behavior change. A strategic shift must be also be attempted simultaneously. Behavior change communication is not a stand alone strategy. It has to be used in conjunction with other strategies such as for HIV prevention campaigns medical treatment i.e. STD treatment and creation of enabling environment should be used along with SBCC approach. BCC often complements and supports other prevention strategies and approaches. 16

17. Behavior Change Theories SBCC and communication theories provide researchers and practitioners with frameworks for understanding human behavior, potential for change and how changes in behavior may happen over time. Theory can guide the design, implementation of evidence-based programs, and evaluations. Adequately addressing an issue may require more than one theory, and no one theory is suitable for all cases. They are therefore useful tools to inform SBCC program design and to highlight areas on which to focus. 17

18. Several commonly used theories exist; however, this section describes few that are most important : The Health Belief Model (Becker 1974) The Theory of Reasoned Action ( Ajzen & Fishbein 1980) The Theory of Planned Behaviour ( Ajzen 1991) The Stages of Change Model ( Prochaska & DiClemente 1984) 18

19. The Health Belief Model ( Rosenstock 1966; Becker 1974) Used to predict protective health behavior like vaccination uptake and compliance with medical advice. For behavior change to take place, individuals must have an incentive to change , feel threatened by their current behavior , f eel a change would be beneficial in some way and have few adverse consequences and must feel competent to carry out the change. 19

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21. The Theory of Reasoned Action ( Ajzen & Fishbein 1980) Behavior is dependent on 2 variables. Attitudes – beliefs about consequences of behavior and evaluating positive and negative aspects of making a change Subjective norms – what ‘significant others’ do and expect and the degree to which person wants to conform & be like others 21

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23. The Stages of Change Model ( Prochaska & DiClemente 1984) 23

24. The Behavior Change Spiral in the context of the Enabling Environment Social features eg nature of personal relationships; expectations of class, position, age, gender; access to knowledge, i n f o rmati on . Cultural features - the behaviors and attitudes considered acceptable in given contexts - eg relating to sex, gender, drugs, leisure, Ethical and spiritual features - influence of personal and shared values and discussion about moral systems from which those are derived - can include rituals, religion and rights of passage Legal Features - laws determining what people can do and activities to encourage observance of those laws Political features - systems of governance in which change will have to take place - can, for example, limit access to information and involvement in social acti o n Resource features - affect what is required to make things happen - covers human, financial and material resources; community knowledge and skills; and items for exchange 6 Features of the Enabling Environment 24

25. Audiences along a Behavior Change Continuum: Possible Communication Strategies Una w a r e Aware, concerned, knowledgeable Motivated to Change Tries New Behavior Sustains New Behavior Raise awareness Recommend a solution Identify perceived barriers and benefits to behavior change Provide logistical information Use community groups to counsel and motivate Provide information on correct use Encourage continued use by emphasising benefits Reduce barriers through problem solving Build skills through behavioral trials Social support Remind them of benefits of new behavior Assure them of their ability to sustain new behavior Social support 25

26. Importance of SBCC Increase in knowledge and attitude of the people. It helps to trigger and stimulate people for adopting positive behavioral approaches. It promotes appropriate and essential attitude change. As BCC strategies and messages are tailored for specific target groups, these strategies are efficient and effective. BCC approaches are more sustainable and acceptable. It helps to increase learning and skills. It improves aptitudes and feeling of self-adequacy. 26

27. Percentage CSWs having knowledge, intent, trial and maintainence for use of condom- Bangladesh 37 . 8 27 . 8 14 . 6 6.3 40 35 30 25 20 15 10 5 Knowledge Intent Trial Maintenance Knowledge= knows about use of condoms prevent STD; Intent=desire to use condom; Trial= tried condom at aleast once in last 24 hrs; Maintanence= used condom>50% of all last sexual encounter in last 24 hrs www.drjayeshpatidar.blogspot.in 27

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30. Evidence for SBCC as high impact practice 1 for F amily Planning : a review of 49 articles,1980-2009 Strong association of use of contraceptives to communication program exposure Both direct and indirect exposure contributes to increased use of modern contraceptives Exposure to multi-media has a greater impact: increase in odds ratio from1.6 to 10.2 by dose of exposure Ma s s med i a program s are foun d t o b e cos t eff e ct iv e : cost per new adopter ranges from USD 1.57 to USD 17.72. 1 Johns Hopkins Center for Communication Programs. SUMMARY REPORT : reviewing existing evidence on the contribution of communication interventions to increasing family planning use, January 2010. Source: Arzum Ciologlu, JHU-CCP, ppt with C-Change, URC on SBCC as High Impact Practice for USAID 30

31. SBCC strategy approaches Using a thoughtful blend of multiple approaches increases an audience’s exposure to messages. It also increases repetition of the message, allowing different channels to reinforce meaning. Repeat exposure improves the likelihood that a message will be understood, accepted and acted upon. 31

32. A combination of approaches, which include: Advocacy Mass Media Support Media/Mid-Media Community-Based Media Community Mobilization Social Mobilization Counseling Interpersonal Communication/Peer Communication Distance Learning Information and Communication Technology 32

33. S BCC Operates Through Three Key Strategies 33

34. 1.Advocacy Advocacy is the act of putting a case persuasively before a target audience. It is a set of targeted actions, which aim to ensure support for program implementation at all levels. Types of Advocacy: Policy Brief Media advocacy Lobbying Three stages: Information gathering, strategizing and action 34

35. 2.Social Mobilization Social mobilization is the process of bringing together all societal and personal influences to raise awareness of and demand for health care, assist in the delivery of resources and services, and cultivate sustainable individual and community involvement. In order to employ social mobilization, members of institutions, community partners and organizations, and others collaborate to reach specific groups of people for intentional dialogue. Social mobilization aims to facilitate change through an interdisciplinary approach. 35

36. 36 3. BCC approaches

37.  The approaches chosen drive the SBCC program and help ensure consistency and coordination among partners and synergy across program interventions. The strategic approaches can be incorporated into a goal-oriented  campaign . Campaigns include a combination of approaches (usually including mass media in addition to community-based approaches) and provide multiple opportunities for exposure through a consistent theme that links program activities together. 37

38. A campaign provides benefits to the individual and/or society, typically within a given time period, by means of organized communication activities . Strategic approaches are often depicted through a  strategic framework , which shows how activities will contribute to objectives. 38

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40. Steps of Social and Behavior Change Communication (SBCC) 40

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43. Communication Strategy Health communication in the 1990s to the present has evolved into what may be called the “strategic era,” characterized by multichannel integration, multiplicity of stakeholders, increased attention to evaluation and evidence- based programming, large-scale impact at the national level, more pervasive use of mass media, and a communication process in which participants (“senders and receivers”) both create and share together . Communication strategy involves steps to develop need-based messages that are more likely to influence audience . 43

44. Steps in Communication Strategy Situation Analysis Audience Segmentation Determining Barriers BCC Objectives Effective Message Channels & Tools 44

45. 1. Situation Analysis Defining Purpose (Health situation that the program is trying to improve) Key Health Issue (Behavior or change that needs to occur to improve the health situation) Context (Strengths, Weaknesses, Opportunities, and Threats that affect the health situation) Gaps in information that limit the program’s ability to develop sound strategy. Formative Research to address gaps 45

46. 2. Audience Segmentation Which group of people is most affected by the problem (primary audience)? Which group of people influence the primary audience and to what extent? Addressing which group will provide the “tipping point” to change? How are the power dynamics between the people we will be dealing with? 46

47. 3. Determining Barriers Facilitating behaviour change requires that the barriers to change should be reduced so that people can try out and adopt new and useful behaviours . 47

48. Poor knowledge of cord care Poor knowledge of skin-to-skin care New born believed as impure unless bathed Early discharge leading to low postnatal checkups Lack of knowledge about danger signals for mother and child after delivery Poor advice by health workers coupled with lack of perceived need in families for post-natal care Barriers to new-born care 48

49. 4. Behaviour Change Communication Objectives Communication objectives should be more than just the specific behaviours that we want to change. They should address barriers that people experience in performing a specific behaviour Objectives will clarify the following: What changes in policies, service delivery, and social norms d oes one expect? What changes in knowledge, attitudes and behaviour of each audience segment d oes one expect BCC objectives should focus on motivation and the ability to act 49

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51. Types of Communication One way Two way Verbal Non-verbal Formal and informal Visual Telecommunication and internet 51

52. Seven Cs of effective communication Command attention Cater to the heart and head Clarify the message Communicate a benefit Create trust Convey a consistent message Call for action 5. Effective Message 52

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54. 6. Channels and Tools Use a mix of interpersonal, community media and mass media channels to achieve better results rather than use any single medium Different channels should be chosen based on the issue & target audience to be addressed 54

55. Channels Tools Activities / materials Interpersonal channels provide for face-to-face interaction and instant feedback Training, flipcharts , BCC t o o lk i t , supervision kit One-to–one interaction between health worker and woman, between ANM, physician and woman, family; counselling, group meetings with women, parents-in- law, community leaders Community channels reach a wider audience within the region and can be used to change social norms and create positive support for each other’s behaviour Community P art ic i p a t i o n a n d community media Community discussions to garner support of women’s groups, youth groups, street plays, community health charts, health melas, saas bahu melas, community felicitations and events Mass media reach large audience in a shorter period and can be used to reinforce messages Advertising, adv o c ac y , h e a l t h promotion Press releases, TV talk shows, radio shows, CD spots, health SM S t o w om e n , men and health providers. 55

56. Major BCC Initiatives Sanitation and Hygiene Program Health and environment education Program for improving newborn and maternal health : Suaahara , a five year integrated nutrition program for women and children in Nepal Health Education for Adolescent Girls : HC3 Project in Nepal is a four-year , $5 million project that focuses on youth, adolescents, migrants and marginalized and disadvantaged groups. HIV prevention programs Malaria control programs and other infectious disease control programs Family planning services 56

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58. Major BCC Initiatives Sanitation and Hygiene Program Health and environment education  Nutrition Assessment and Gap Analysis (NAGA) from which a five-year multisectoral plan for nutrition was prepared. This included evidence-based interventions for the health, agriculture, education, WASH and welfare sectors. Program for improving newborn and maternal health : Suaahara , a five year integrated nutrition program for women and children in Nepal (2011-2016) HIV prevention programs Malaria control programs and other infectious disease control programs Family planning services 58

59. Shape-up Somerville Initiative 59

60. Stakeholder involvement Cambridge Health Alliance (CHA), members of the Tufts University Friedman School of Nutrition Science and Policy, an emerging community health research organization, the Institute for Community Health (ICH), Somerville Public Health Department. 60

61. Researchers from Tufts University received CDC funding for a Shape Up Somerville intervention, which included components designed to promote healthy eating and physical activity for children, at home, at school, and in the community. The primary focus of the grant was on students in grades 1-3 in the Somerville Public Schools. GOAL: to influence every part of an early elementary schoolchild’s day – before, during, and after- school to promote healthy eating and physical activity and improve children’s weight status. 61

62. INTERVENTION INCLUDED Food service enhancements to improve breakfast and lunch and staff professional development, food service infrastructure development, i.e. equipment and facility improvements Walk to school activities SUS classroom curriculum and professional development School wellness policy development SUS After-school curriculum and professional development Outreach and education to home through materials, forums, events “SUS approved” restaurants Community outreach and capacity building through policy development, trainings, media placements. 62

63. SUS After-school curriculum and professional development Outreach and education to home through materials, forums, events “SUS approved” restaurants Community outreach and capacity building through policy development, trainings, media placements, 63

64. Researchers from the Institute for Community Health received funding for “Growing Healthy” to support school-based vegetable gardens and fruit and vegetable promotion in the school cafeteria. GOAL: to increase the consumption of fruits and vegetables by school-aged children through experiential learning in the lunchroom and school gardens. INTERVENTIONS INCLUDED: Developed school-yard gardens and vegetable promotion curriculum Promoted usual and unusual fruits and vegetables through school food service using taste tests, fruit and vegetable of the month, and campaign materials Outreach and education home through newsletters to parents 64

65. Community applicants from Groundworks Somerville received funding to support city planning infrastructure and partnership development to improve walking and biking opportunities in Somerville. GOALS: to improve the infrastructure and capacity of Somerville to promote physical activity and active living for all residents through partnership development, programming, promotion of physical activity and opportunities for activity, developing policies and physical or “built” environment supportive of physical activity. 65

66. INTERVENTIONS INCLUDED: Advocacy for bicycle and pedestrian changes to the city Supporting SUS partnership activities Supporting immigrant community organizations active living activities 66

67. Guiding Principals First, the SUS community-based initiatives have explicitly targeted multiple sectors of the community. Second, SUS initiatives developed as a result of engaging community partners in the planning, implementation, and evaluation of the initiatives. This participatory approach to obesity prevention is a key ingredient to success and sustainability. Third, attention to applying theoretical models and evidence-based approaches has been a hallmark of the SUS approach to intervention development and achieving sustainability. 67

68. Core to its success has been the political will and leadership of the city of Somerville to prioritize childhood obesity prevention and wellness promotion for all Somerville residents. Leadership, engagement and support from the Mayor and many city departments/ program has been critical to institutionalization of the SUS mission and values – health is a priority in Somerville. Balance between program evolution and ongoing maintenance of the core components of SUS initiatives. Continued success came from innovative, new and sustained collaborations. 68

69. Diversified funding allowed for multi-level and multi-sector initiatives spanning from the school food service to parks and playgrounds. Sustained interest from original SUS developers and connection to new personnel was critical to maintain enthusiasm and seek new funding. External credibility from academic published articles as well as national recognition was a key ingredient to sustain interest, promote progressive thinking, assist in acquiring additional funding and encourage city level interest across multiple domains. 69