BEHAVIOR CHANGE COMMUNICATION AS AN INTERVENTION TO IMPROVE FAMILY HEALTH OUTCOMES

Transcription

1 BEHAVIOR CHANGE COMMUNICATION AS AN INTERVENTION TO IMPROVE FAMILY HEALTH OUTCOMES GARY L. DARMSTADT AND USHA KIRAN TARIGOPULA Low coverage of life-saving preventive health interventions stemming from unhealthful social norms, attitudes and practices, and lack of knowledge among key population groups and healthcare providers in both the public and private sector contribute to maternal, newborn and child mortality and morbidity in India. Specifically, lack of family planning leading to suboptimal birth spacing and to young maternal age at first pregnancy; lack of routine antenatal care or skilled attendance at delivery, including poor hygiene practices; lack of early and exclusive breastfeeding, newborn thermal care and clean cord care; poor infant and young child feeding practices; and poor demand for preventive child health measures, such as immunizations, all result in avertable morbidity and death. Although solutions to these problems are available, the uptake of interventions to improve family health outcomes remains unacceptably low. Evidence suggests, however, that social norms and practices can be changed through the communication of culturally contextualized messages designed to support families in modifying high risk practices and delivered through a combination of mass media and mid media, coupled with improved interpersonal interactions involving reasoning and negotiation between frontline healthcare workers and target populations at the family and community level. While there have been many standalone initiatives to shape demand and practices in rural settings in the past, they have suffered from three major limitations. First, they have not always been scientifically developed so as to systematically target risk factors and address social and structural barriers to behavior change, or have not focused on a manageable list of proven interventions Gary L. Darmstadt, Director, Family Health Division, Global Health Program, the Bill and Melinda Gates Foundation, Seattle, USA, and Usha Kiran Tarigopula, Deputy Director, Global Health, India Country Office, the Bill and Melinda Gates Foundation, New Delhi. Vol. 56, Special Issue

2 and a key mix of stakeholders and health providers involved in sanctioning and supporting the uptake of the new behaviors. Second, even interventions that have adopted these approaches have not integrated, aligned and synergized communications using multiple channels, particularly new and innovative communication technology applications and partnerships, especially with the private sector. Finally, these elements necessary for success have not been comprehensively implemented and demonstrated at scale. In short, the success of these interventions ultimately requires reaching a large number of stakeholders and key behavioral targets, particularly the poorest and most disadvantaged groups, with a limited number of culturally appropriate and aligned messages. In this way, the capacity of families and communities to take the risk of adopting a modified or new behavior, and to be producers of good health, is increased. To achieve this long-term goal, the Population Council was awarded a landscaping grant to conduct an analysis in rural Uttar Pradesh (UP) to inform the development of a comprehensive behavior change communication (BCC) strategy to shape demand and practices that could contribute to reduced maternal, neonatal and under-5 mortality and improved nutrition and reproductive health outcomes, particularly in UP, Bihar and throughout northern India. This special issue of The Journal of Family Welfare provides a synthesis of the existing literature, as well as the results of a number of comprehensive, original formative studies and analysis of diverse datasets carried out by the Population Council and its six consortium members. a This exercise has generated a vast amount of useful information on family dynamics that could be effectively used to develop a comprehensive BCC strategy for shaping demand and practices that would have a direct bearing on family health. Several key issues were addressed in this study, including identification of the barriers to the uptake of proven preventive interventions; analysis of successful approaches and strategies that have worked, those that have not, and reasons why or why not; identification of the partners working in the area of family health preventive care; and emerging new and innovative opportunities and approaches. Specific behaviors that were studied in detail included care seeking for essential maternal health services such as antenatal care and skilled attendance at delivery; clean delivery; early and exclusive breastfeeding; newborn thermal care including skin-to-skin care; clean cord care; appropriate complementary feeding (quantity, frequency, diversity of foods) of young children aged 6-23 months; routine immunization, in particular measles immunization; and birth spacing methods. These interventions were chosen on the basis of their potential impact on maternal, neonatal and child mortality using projections for UP, modeled through use of the Lives Saved (LiST) tool. 1 The landscaping and formative research exercise carried out by the Population Council and its consortium members is unique in many respects. For the first time in India, the development of a BCC strategy has been viewed from a wider perspective that has not only tried to identify and understand the barriers and facilitating factors for eight target behaviors in rural UP, but in addition a systematic effort has been made to identify possible partners who could a Abt Associates Inc., RKSWAMY BBDO, Confederation of Indian Industry (CII), Ideosync Media Combine, International Institute of Population Studies (IIPS), Indian Clinical Epidemiology Network (INDIACLEN). 2 The Journal of Family Welfare

3 collaborate, complement and leverage the implementation of the BCC strategy. Potential partners were explored from the communication sector as well as other sectors including advertising and media agencies, entertainment, new and emerging information communication technologies (ICT), public and private health sector providers including frontline health workers, and medical professionals bodies such as the Federation of Obstetric and Gynecological Societies of India (FOGSI), the Indian Academy of Pediatrics (IAP) and the National Neonatology Forum (NNF). The study also explored the possibility of leveraging the implementation of the BCC strategy under corporate social responsibility (CSR). Importantly, the study took the view that families and communities themselves are key producers of good health, and must be supported and equipped by a variety of actors to do this more effectively. Prior to planning and initiating the landscaping exercise, staff from the Population Council (M.E Khan, John Townsend and Katherine Williams), the Bill and Melinda Gates Foundation (Gary L. Darmstadt and Usha Kiran Tarigopula), and the Johns Hopkins University Center for Communication Programs (JHUCCP) (Douglas Storey) and a well-known medical anthropologist with vast experience in India and South Asia (Bert Pelto) held several meetings to select the target behaviors that could have the greatest impact on family health and to develop a pathways model that could provide the framework for research, data collection and ultimately the development of a comprehensive BCC strategy. The pathways model, originally developed by JHUCCP, was adapted and designed to help guide research to understand the barriers and facilitating factors in adopting healthy behaviors, and during the course of the research was continuously reviewed, modified and found to be highly useful for informing the study design, and data collection, analysis and synthesis (Figure 1). 2 The articles included in this issue of The Journal of Family Welfare provide crucial leads regarding the barriers and facilitating factors that have a significant bearing on the various target behaviors. Key findings and observations of these studies have been presented in articles 2-8 included in this volume, while detailed information is presented elsewhere. 3,4 Detailed findings from the analysis of potential partnerships are also included in a forthcoming volume. 5 The study found that three or more antenatal check-ups seem to be a catalyst for several targeted behaviors, including institutional delivery, early breastfeeding, postnatal care within 7 days of delivery, full immunization of children aged months and postpartum contraception for birth spacing. 6 Similarly, the article on immunization identifies several programmatic factors that facilitate the adoption of full childhood immunization, such as providing families information about the next immunization date, the consistent presence of the ANM to provide services on the scheduled immunization day and advice by frontline health workers or a medical doctor to all stakeholders in the family particularly mothers- in-law, about the risks children face if not fully vaccinated against preventable diseases. 7 It is also important to note that pervasive lack of knowledge that breast milk is comprised mostly of water, that exclusive breastfeeding means not feeding anything, even water, until the child is 6 months of age, and improper breastfeeding skills are major reasons for the inappropriate early initiation of supplementary feeds such as animal and/or formula milk to the child. 8 Moreover, women, husbands and mothers-in-law are not aware of the importance of postnatal check-ups for the mother and newborn within 7 days of delivery and have poor knowledge Vol. 56, Special Issue

4 Source: Modified and adopted from Health Communication Partnership Conceptual Framework: Pathways towards social and behavioral change in HIV/ AIDS. Health Communication Partnership, based at Johns Hopkins Bloomberg School of Public Health. Center for Communication Programs. 4 The Journal of Family Welfare

5 of postnatal danger signs that signal the need for medical care among mothers and newborns. 9 Notably, less than 1 percent of women in rural UP are aware of the lactational amenorrhea method (LAM), and 73 percent of women with a child less than 6 months and 53 percent of women with a child more than 6 months were exposed to the risk of unwanted pregnancy. 10 The formative study repeatedly underscores equity issues; that the poor, scheduled castes, scheduled tribes and non-literate segments of the population receive neither adequate information nor health services. The article on the reach of different media clearly indicates that interpersonal communication channels must take the lead role in behavior change while mass media could provide a supportive role in disseminating knowledge and bringing about the desired behavioral and social change. 11 The majority of rural women in UP (58 percent) have no exposure to any media and the percentage with access to any media varies from a mere 9 percent to 87 percent depending on the woman s background characteristics like caste, class, education and village size. Similarly, the perspectives of senior program managers from the media (press, radio, and TV) and advertising agencies on the proposed BCC strategy highlight the challenges in partnering with them in this effort. 12 The article on emerging information and communications technologies (ICTs) and their possible role provides leads on how mobile technology could be leveraged to communicate with families and improve the functioning of frontline health workers. 13 These cues need careful analysis for future action and research. Similarly, the study of the corporate sector provides a clear indication that under CSR, a substantial amount of funds are available, which is likely to further increase as the new directives of the government on CSR are implemented. 14 The willingness of the corporate sector to partner in the BCC strategy and their articulated need for assistance in capacity building for staff who plan and manage their CSR activities provides an important opportunity to further leverage the impact of the corporate sector. The information provided in the present issue of the journal and the BCC plan developed by the Population Council 15 and its partners, listing key barriers to uptake of proven behaviors, possible messages and the optimal media mix to promote behavior change, and measurable indicators to assess the impact could be immediately used to develop the BCC strategy. However, there is scope for further data analysis and to undertake rapid assessments to generate complementary information to answer key related questions that will enhance the utilization of findings and facilitate the acceleration of desired behavior change. Some questions that need further attention include: What are the points of engagement from which key behaviors are addressed? Antenatal care involves several contacts and seems to be a powerful mechanism to impart knowledge and motivate desired behavior change. How many such contacts are required to increase knowledge and change behavior? How can one be strategic about contacts and how much content can be packed into a contact? How can programs be best designed to achieve the desired number and quality of contacts? What do we know about how behaviors are linked or clustered together? Are there key behaviors from which other behaviors flow? For example, women who undergo three or more antenatal check-ups often adopt other targeted behaviors as well. How do the Village Health and Sanitation Committees at the village level, and the Rogi Kalyan Samiti (Patient Welfare Committee) at Vol. 56, Special Issue

6 the Primary Health Center and/or Community Health Center level within a district, fit into the program? b,c What are the learnings from the pulse polio campaign that could be utilized in designing the BCC strategy for family health? What are the characteristics of villages that are not reached and covered by an Accredited Social Health Activist (ASHA) or Anganwadi Workers (AWW) in terms of population size, accessibility and caste structure? If BCC is dependent on these frontline health workers, how can programs reach out to them? How can ASHAs and other frontline health workers, including the AWW and ANM, be motivated to promote desired behavior change? While providing financial incentives is one method, what are other possible approaches? How should financial incentives be rationalized? Should each behavior or a package of behaviors be incentivized? How do two frontline health workers ASHAs from the health department and AWWs from the ICDS program collaborate and complement each other? Will task sharing among these workers make the program at the community level more comprehensive and sustainable? What do we know about the business plan for CSR? Individual companies are spending on CSR programs: how do we collectively organize and optimize these funds? What have we learned about how to engage with the corporate sector? What can we learn from their business practices that could be utilized to increase the effectiveness of public health programs? This timely publication of key findings from the formative studies will not only help in disseminating knowledge on behavior change in India, but is also aimed to generate further discussion and research on questions that remain unanswered and thus impede progress in this area globally. Most importantly, the information contained in this volume provides critically needed evidence on how to work with families, communities, the health system and the private sector to save the lives of women and children now. References 1. Johns Hopkins Bloomberg School. n.d. LiST: The Lives Saved Tool An evidence-based tool for estimating intervention impact< www. jhsph.edu/dept/ih/iip/list/index.html>. 2. Health Communication Partnership Conceptual Framework: Pathways towards social and behavioural change in HIV/AIDS. Health Communication Partnership, based at Johns Hopkins Bloomberg School of Public Health. Center for Communication Programs. b Village Health and Sanitation Committee is a village level accountability structure created under the National Rural Health Mission for planning and monitoring health activities including the development of village health plans. Committee members include panchayat representatives, ANMs, AWWs, teachers, community health volunteers and ASHAs. This committee has about `10,000 or $ 225 as untied funds for local problem solving. c Rogi Kalyan Samiti (Patient Welfare Committee) is an accountability structure created under the National Rural Health Mission at the level of a Community Health Center and at a district government hospital. This committee is an innovative mechanism to involve people s representatives in the management of public hospitals with a view to improve their functioning by levying user charges. This committee has annual flexible funding up to `100,000 or $2,250 for any services and equipment required locally. 6 The Journal of Family Welfare

7 3. Khan, M.E., Darmstadt, G.L., T. Usha Kiran and Ganju, D. (eds.) Shaping demand and practices to improve family health outcomes: A formative study in rural Uttar Pradesh. New Delhi. Population Council (forthcoming). 4. Khan, M.E., Darmstadt, G.L., T. Usha Kiran and Ganju, D. (eds.) Shaping demand and practices to improve family health outcomes in India: Synthesis of findings from the literature. New Delhi: Population Council (forthcoming). 14. Ahuja, R., Bhattacharya, D., Bhargava, R. and Ganju, D Role of the corporate sector in promoting family health in Uttar Pradesh. Journal of family welfare, Population Council Shaping demand and practices to improve family health outcomes in northern India: A framework for behavior change communication. New Delhi: Population Council (forthcoming). 5. Khan, M.E., Darmstadt, G.L., T. Usha Kiran and Ganju, D. (eds.) Shaping demand and practices to improve family health outcomes in northern India: Exploring partnerships. New Delhi: Population Council (forthcoming). 6. Khan, M.E., Hazra, A. and Bhatnagar, I Impact of Janani Suraksha Yojana (JSY) on selected family health behaviors in rural Uttar Pradesh. Journal of family welfare, Ahmad, J., Khan, M.E. and Hazra, A Increasing complete immunization in rural Uttar Pradesh. Journal of family welfare, Aruldas, K., Khan, M.E. and Hazra, A Increasing early and exclusive breastfeeding in rural Uttar Pradesh. Journal of family welfare, Varma, D.S., Khan, M.E. and Hazra, A Increasing postnatal care of mothers and newborns including follow-up cord care and thermal care in rural Uttar Pradesh. Journal of family welfare, Goel, S.,Bhatnagar, I., Khan, M.E. and Hazra, A Increasing postpartum contraception in rural Uttar Pradesh. Journal of family welfare, Ganju, D., Bhatnagar, I., Hazra, A., Jain, S. and Khan, M.E Reach if media and interpersonal communication in rural Uttar Pradesh. Journal of family welfare, Ramakrishnan, N. and Arora, V Media perspectives on partnerships to address family health in northern India. Journal of family welfare, Garai, A. and Ganesan, R Role of information and communication technologies in accelerating the adoption of healthy behaviors. Journal of family welfare, 56. Vol. 56, Special Issue

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