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
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:
Standardized format for strategic application of research results
to behavior change strategy development;
Consultative research that includes "concept testing" and negotiated
Use of community interviewers
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
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
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 a type of research that uses quick, interactive
information-gathering methods with key people who are likely to be program
participants. Important scientific information and key cultural
and personal concerns are examined, and changes in behavior are negotiated.
The goal is to identify feasible, acceptable, and effective strategies
to improve behaviors, with program participants playing an active role
in the process.
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
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
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
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