Theory-based Approaches to Formative Approaches: translating observations into research questions/possible techniques Basil Safi, MPH, PE, CHES Kathmandu,

Theory-based Approaches to

Formative Approaches: translating

observations into research

questions/possible techniquesBasil Safi, MPH, PE, CHES

Kathmandu, Nov 8, 2011

Overall ApproachOverall Approach

• Defining strategic health communication

• Why formative evaluation?• Why “theory-based”?• Important concepts from social &

behavioral design and implementation

• Group exercise

Strategic CommunicationStrategic 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 We need to recognize the multiple layers that influence multiple layers that influence individual behaviorindividual behavior

SocialEcologicalFramework

Engaging Communities for Healthy Engaging Communities for Healthy Nutrition BehaviorsNutrition Behaviors

• Mass media

• Community mobilization

• Interpersonal communication and counseling

• Capacity building

• Advocacy

Working at Multiple Levels for Greatest ImpactWorking at Multiple Levels for Greatest Impact

Why Formative Why Formative Evaluation?Evaluation?

• Central tenet of behavior change interventions: KNOW YOUR AUDIENCE

• Demographically– Age– Education– Gender– Religion– Political views– Residence– Health literacy

Knowing your AudienceKnowing your Audience

• Psycho-graphical profile (KAP)– Prevailing attitude– Knowledge– Risk perceptions– Efficacy beliefs– Perceived barriers– Priorities

• Communication profile– Interpersonal ties– Media use patterns– New technology adoption– Access to information

Knowing your AudienceKnowing your Audience

• Behaviorally– Prior behaviors (attempted change

before?)– Readiness for adoption of new behaviors

• Culturally– Social norms– Social support (vs. isolation)– Cultural traditions– Obligations

• Structurally– Environmental facilitators and constraints– Access to services

Exposure to CBAIC TV spots increases Exposure to CBAIC TV spots increases level of perceived social influence and level of perceived social influence and interactioninteraction

KAP 2009 Household SurveyBase: All respondents*Unpaired t-tests, p<.0001

Presence of Team Flu Burung in Presence of Team Flu Burung in community increases perceived social community increases perceived social influenceinfluence

KAP 2009 Household SurveyBase: All respondents*Unpaired t-tests, p<.0001

Reach & TouchReach & 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 Reduction in early childhood mortality and childhood mortality and stuntingstunting

Baseline trend

Current direction

Reduction in early Reduction in early childhood mortality and childhood mortality and stunting with Suaahara stunting with Suaahara interventionintervention

Baseline trend

With health intervention

Reduction in early childhood Reduction in early childhood mortality and stunting through mortality and stunting through health intervention and current health intervention and current direction meeting at later pointdirection meeting at later point

Baseline trend

With health intervention

Zero nutrition related infant deaths

Shared vision

Awareness

Putting theories to workPutting theories to work

ActionAction

ComprehensionComprehension& Risk Perception& Risk Perception

Decision-Decision-makingmaking

IntentionIntention

Where is your audience with respect to the desired action?What information or messages do they need at that stage?

MaintenanceMaintenance

Stages of Behavior ChangeStages of Behavior ChangeWhere is your audience with respect to the desired action?What information or messages do they need at that stage?

Awareness of H1N1 flu

VaccinationVaccination

Knowledge of Knowledge of transmission modes & transmission modes & realistic risk perceptionrealistic risk perception

Considering Considering vaccinating herselfvaccinating herself

Intention to make Intention to make an appointmentan appointment

Takes her Takes her husband and 3 yr husband and 3 yr old daughter for old daughter for vaccination and vaccination and

advocates to advocates to family/friendsfamily/friends

AudienceAudience: : 30 yr old 30 yr old pregnant womanpregnant woman

Formative Evaluation Formative Evaluation Questions in the Suaahara Questions in the Suaahara CampaignCampaign

• Targeting Question: What salient communication channels need to be employed?– Radio, mobile phones, interpersonal sources?

• Segmentation Question: Who are the primary audiences?– Pregnant women– illiterate moms– Fathers– Others?– Who influences them (secondary audiences)?

• Tailoring Question: What messages will be designed?

E.g. of a Spacing E.g. of a Spacing CampaignCampaign

The same message is crafted differently for different audiences, while retaining its essence

TV Spots, Radio spots,Billboards, Poster and wall paintings

Regional VariationsRegional Variations

• E.g. Urban/Rural; East/West• Pretesting visuals and content is

critical– Appeal, Comprehension, Intent to

Act, Culturally appropriateness

Design guidelinesDesign guidelines1. 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 How Does Communication Affect Intention?Intention?

Enabling

Enabling

??

CCOOMMMMUUNNIICCAATTIIOONN

KnowledgeKnowledge& Skills& Skills

IntentionIntention

EnvironmentalEnvironmentalConstraintsConstraints

BehaviorBehavior

Reinforcement

Reinforcement

AdvocacyAdvocacy

PromotionPromotion

InstructionInstruction

How Does Communication Affect How Does Communication Affect Intention?Intention?

Enabling

Enabling

Ideation



IntentionIntention


BehaviorBehavior

Reinforcement

Reinforcement

AdvocacyAdvocacy

PromotionPromotion


Defining IdeationDefining 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 CommunicationIdeation Theory of Communication

KnowledgeKnowledge

AttitudesAttitudes

Self-Self-ImageImage

Perceived Perceived RiskRisk

Perceived Perceived EfficacyEfficacy

NormsNorms

EmotionEmotion

Social Social InfluenceInfluence

Personal Personal Advocacy Advocacy

BEHAVIORBEHAVIOR

Implies simultaneous effect of all influences.

Implies that communication can affect all of these factors.

(Kincaid, Figueroa, Storey, & Underwood, 2001)

E.g. Perceptions of E.g. Perceptions of DiarrheaDiarrhea

• 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 Other perceived causes of diarrheaof 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 Perceptions of Water TreatmentTreatment

• 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 Case Study: Aman TitraTitra

• 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 Boiling as the main treatment methodtreatment method


Boiling perceptionsBoiling 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 Are there other ways to make water as safe as it is after water as safe as it is after boiling?boiling?


Percentage of households with Percentage of households with E.coli contaminated boiled, ready E.coli contaminated boiled, ready to drink waterto drink water


Why would people try Why would people try it?it?

• Economical, Practical• Media ads enhanced the credibility of

the product the product• Registered/approved product

3 Components of Ideation3 Components of Ideation

Enabling

Enabling

Cognitive Beliefs/Values Perceived Risk Subjective Norms Self-Image Emotional Emotional Response Empathy Self-EfficacySocial Support & Influence Personal Advocacy



IntentionIntention


BehaviorBehavior

Reinforcement

Reinforcement

AdvocacyAdvocacy

PromotionPromotion


Factors Influencing Factors Influencing BehaviorsBehaviors

• 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, Group Exercise: The “Yes, but…” Gamebut…” 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, Example 2: The “Yes, but…” Gamebut…” 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


• 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


• 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


• 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

Theory-based Approaches to Formative Approaches: translating observations into research questions/possible techniques Basil Safi, MPH, PE, CHES Kathmandu,

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