Background
A Behavior Change Approach: Overview

A behavior change approach is a process for planning and implementing a comprehensive, strategic set of interventions and activities to change behaviors at many levels to achieve a health objective.  A behavior change approach identifies priority behaviors for change, uses qualitative research among critical target audiences to define major factors influencing these behaviors and recommends a set of behavior change interventions.  Interventions may change behaviors or create a supportive community and policy environment for change. 

Behavior change does not result from increasing knowledge alone.  Many contextual factors, including the behaviors of family and the community, influence individual behavior change.  Therefore, the range of behavior change activities often extends beyond conventional communication, to link and coordinate communication activities with training, health systems support, product and service improvements, social norm change and even new or improved policies.   

The strategic selection and implementation of an appropriate set of behavior change interventions can help to directly improve skilled careseeking practices during and after childbirth and help to create a supportive, enabling environment at household, community, health facility and policy levels. 

One of the fundamental principles of the behavior change approach is promoting behavior change in the context of social change.  Community engagement, ownership and empowerment are key to sustained behavior change.  At the community level, a behavior change approach focuses on activities that create and sustain an enabling environment for behavior change and social change, building partnerships with communities and developing interventions considering the community's own assessment of their needs and priorities.  Community-centered behavior change interventions promote the empowerment of community partners and encourage collaborative design and implementation of local programs.   A community-oriented behavior change approach identifies people and communities as agents for their own change, placing information within the community for dialogue, debate and collective action and using available resources to overcome barriers.  An assets-based approach helps communities identify, strengthen and utilize resources and knowledge that exist within the community itself to support behavior change and improve health outcomes.

The CHANGE Project Approach

The initial step in applying a behavior change approach is to conceptualize health objectives in behavioral terms and develop a set of behavior change objectives for each health outcome.  The behaviors that influence healthy outcomes - individual, family, community, health system and policymakers - should then be assessed in their context and addressed for each health objective.

Several concepts underlie the CHANGE approach to developing behavior change interventions to improve maternal and newborn survival: 

• Behavior-based programming;

• Standardized format for strategic application of research results to behavior change strategy development;

• Consultative research that includes "concept testing" and negotiated behavior change;

• Localization; and

• Use of community interviewers

Behavior-Based Programming

Behavior-based programming is central to CHANGE's approach to improve maternal survival.  Behavior change is at the center of the program design process.  The first step is to clearly delineate ideal behaviors that would achieve the desired health outcomes.  A set of research objectives, based on the ideal behaviors, guides the systematic design of a qualitative research plan to document current behaviors and explore how they can be redirected, re-patterned or re-positioned toward the ideal.

CHANGE's qualitative research tools explore factors influencing use of skilled care.  The behavior-based tools were designed to document current behaviors, barriers, motivators, amenability to change, conditions of acceptability and "user characteristics."  Each element is essential to the design of behavior change interventions.

These guides emphasize skilled care for all births:

• The need to reposition TBAs as "links" to skilled care for all women, instead of their current role as care providers;

• The critical, lifesaving importance of use of skilled care during the early postpartum period; and

• The need to enable skilled maternity care providers to actively participate in provision of higher quality, more "caring" services for women.

Behavior Change Intervention Strategy Formulation Worksheet

One of the challenges that programs face is how to design behavior change interventions.  Qualitative research results are often not carried forward into the strategy.  CHANGE uses a standard  format to systematically apply qualitative research results to behavior change strategy development.  Over the past decade this tool has been applied successfully to a wide range of health programs. 

The left side of the behavior change strategy worksheet helps program planners to analyze current and feasible behaviors.  The right half of the worksheet suggests the interventions that may be needed to promote behaviors.  

Consultative Research: Concept Testing and Negotiated Behavior Change

Consultative research is most widely known through its application to child nutrition but it is also appropriate for promoting maternal and newborn survival.  Consultative research involves communities and households not only as respondents in the qualitative research but also in the design, testing and modification of new behaviors to increase acceptability and adoption.  For example, participants are asked for their opinion on concepts such as repositioning traditional birth attendants (TBAs) as "links to skilled care" instead of actual care providers.  Testing this concept on the ground with the people who must actually agree to try it is critical to assess the acceptability in the field.  

Negotiating behavior change involves talking with women, families and communities to develop recommendations that come as close to the "ideal" behaviors as local conditions permit.  This helps program planners to understand participants' "conditions of acceptability," in other words, what would make the new idea acceptable to them.  Testing and negotiating new behaviors before strategies are designed can help use resources efficiently by increasing the likelihood of success and sustained change.

Localization of Behavior Change Interventions

Another important aspect of the qualitative research process is the development of a local list of maternal health terms relevant to childbirth and early postpartum.  The purpose of this list is more than simple translation of medical terms and concepts into the local language.  The list also captures local usage and terms.  Many traditional cultures have a strong local oral tradition and there are also often proverbs and rhymes that are used to express concepts that are culturally sensitive.

Documenting the precise words, phrases and concepts that communities use allows them to be woven into behavior change materials and messages to increase local comprehension.  Too often, "messages" are not developed locally and may not retain the intended meaning once they reach families and communities.  Defining local cultural context and linguistic subtleties can make a message meaningful and actionable.  This localization process has been called the "house-to home" metaphor by UNAIDS.

Use of Community Interviewers

A unique element of the CHANGE approach is the use of community interviewers to conduct simple behavioral research that is conventionally performed by interviewers with medical or academic training.  The challenges associated with community-conducted research include the need for different interviewer training models and the additional time requirements for building basic skills and providing practical interview experience.  The benefits of using community interviewers include:  familiarity with the area, confidence of the community leaders and members and their knowledge of local language and culture.  

Interviewers are recruited from the local community and selected for appropriateness of age and gender per category of respondent.  When community interviewers keep personal journals of their interview experiences, their journal entries, along with notes kept by the trainers and community research coordinators, provide a unique perspective.  Community interviewers can work in pairs so that one person can interview and one person can record.  A supervisory "coach" can help increase interviewer confidence to work with the instruments and improve the quality of interviews and record keeping.

Community interviewers facilitate transfer of research results when they participate in community discussions and strategy workshops.  These discussions help to maximize the participation of key stakeholders in design of locally appropriate strategies to increase use of skilled care.