Lesson 2 Handout 3: Examples of Completed Designing for Behavior Change Frameworks Example 1: Agriculture and Natural Resources (ANR) Programs: Poultry Management Behavior Priority Group or Influencing Groups Determinants Bridges to Activities Activities Targeted adult men and women who raise chickens keep them enclosed (penned up) at all times. Demographics: Adult men and women from families who raise chickens. These families all have children under 2 years of age or a pregnant or lactating woman at program start-up. Both men and women have attended some school. Speak and read Swahili Big Desires They all want food security, well-being and education for their children. Current Practices/Beliefs They live in rural villages and own small numbers of chickens, which currently wander freely and sleep in trees. They think chickens will not have enough to eat if they are penned up, Perceived negative consequences: Belief that chickens will stop laying Belief that it will be more effort and more expensive to give chickens food and water Perceived positive consequences: They will not lose chickens to wild animals Less loss due to illness Chickens will not damage crops and gardens It is easy to capture chickens for vaccinating Farmers can use Reduce the perception that chickens will stop laying eggs if they are penned up. Reduce the perception that it takes more effort/expense to care for penned up chickens. Increase the perception that it will be economically beneficial (less loss, less damage to crops, more fertilizer etc.) to keep chickens penned up. Increase access to fencing materials and skills for adapting local materials. Increase the perception that there are inexpensive ways to feed penned up 1. Create one demonstration site per village where families can observe the survival of penned chickens and the ability of chickens to adapt to the enclosed environment with displayed. 2. Meanwhile, start promoting the provision of improved feed, clean water and vaccine to all poultry. 1 and 2. Train agriculture volunteer promoters in poultry care (feed, water, vaccine) and construction of pens and cages using locally available materials. Monitor and reinforce their ability to transmit skills to others. 2. Reinforce the benefits of enclosing poultry by distributing a calendar with one benefit shown per month. cost
they do not know affordable ways to make chicken coops. Stage of Change Most of the Priority Group is in the aware-ness (or “contemplation”) stage of behavior change. Gender Role Both men and women keep chickens and each is free to decide to pen them or not. Women may need financial assistance to buy fencing manure for fertilizer Access: Lack of materials to build a fence or cage Cost of chicken feed chickens. 3. Provide technical assistance and a small loan to one entrepreneur per village to produce and sell quality, affordable chicken feed, and water and feed containers made of local or recycled materials. 3. As demand increases, program agronomists will work with local vendors to sell wire mesh. Outcome Indicator: Percentage of households that keep their chickens penned up/ enclosed at all times Process Indicators: Number of successful demonstration sites implemented Number of visitors to demonstration sites Number of families adopting one or more improved poultry care practices aside from enclosing poultry Number of entrepreneurs selling chicken feed
Example 2: WASH Programs: Hand washing with soap Behavior Priority Group Or Influencing Group Determinants Bridges to Activities Activities Targeted mothers of children U5 wash their hands with soap at the five* critical times each day. -after defecating; -after cleaning a child who has defecated; -before preparing food; -before eating; -before feeding a child. 1.Demographic Mothers of children 0 – 59 months of age Rural area of Saut d’ Eau in Haiti Cannot easily read Creole Speak Haitian Creole only Low income 2. Daily Routine Farm; raise Animals Gather at market Go to church on Sunday Practice open defecation 3. Common Desires Avoid catching cholera Education for kids 4. Current Practices related to the Behavior Only wash hands after they defecate; Vaguely aware of the link between hand washing and cholera 5. Common Barriers to the Behavior Access Having soap makes it easy Having access to water right where/ when you need it Perceived Negative Consequences Spending money on soap Action efficacy avoids getting cholera Cue for action Very difficult to remember Increase access to soap and water at the places where hand washing takes place Increase the perception that money spent on soap for hand washing prevents cholera and expenditures on health care Reinforce the perception that washing hands with soap and water is the most (cost) effective way to avoid cholera Increase the ability to remember to wash hands with soap and water 1 & 2. Organize soap making classes for mothers interested in earning extra money; sell/distribute soap in the community at low prices; 1. Train caregivers to make and install simple hand washing facility (tippy tap) nearer to the kitchen, toilet, churches and market. 2 & 3. Organize discussion groups in neighborhoods of target group, to discuss the cost/benefit of hand washing (i.e. hand washing costs less than medical care and loss of time due to illness) 4. develop /distribute/display Cue Cards (action reminders) and put them near toilet, kitchen and dining area of each target
Example 3: Maternal and Child Health and Nutrition (MCHN) Programs: Exclusive Breastfeeding (EBF) Behavior Priority Group or Influencing Groups Determinants Bridges to Activities Activities Mothers only give breast milk to their children from birth to 6 months of age. Priority Group: Burundian mothers with children 0–6 months of age Live in rural setting Majority are illiterate Go to church on Sunday morning Are busy with daily household chores Want to be perceived as good mothers and wives After 3 months, they think they do not have enough milk to breastfeed Exclusively breastfeed until 4 months, but give other foods at that time Majority are in partial action stage Influencing Groups: Mothers-in-law Perceived action- efficacy Mothers don’t know the relationship between EBF and malnutrition Perceived Divine will: Mothers question whether their religious leaders/ traditions support this Behavior Perceived social norms: Mothers believe that their mothers, mothers-in-law do not approve 1. Increase the perception exclusively breastfeeding a child will help prevent malnutrition. 2. Increase the perception that religious leaders approve of EBF and that their religious tradition is supportive of EBF. 3. Increase the perception that their mothers approve of EBF. 4. Decrease the perception that a child will be hungry or lacking in nutrition if they are exclusively breastfed. 1. Record/write stories about mothers with children with good health/weight who do EBF and believe in EBF. Play the recording/read the testimonials on EBF at meetings in the community/ health facilities (following postnatal care and growth monitoring and promotion sessions). 2. In household meetings, use growth charts to show the difference between several children growing well who are exclusively breastfeeding and contrast them to other children who are losing weight who are not EBF. 3. Give pastors/priests/imams sermon guides on EBF and train them in their use. 4. Have Care Group Volunteers (CGVs) include mothers-in-law when teaching mothers of young children about EBF. 5. Explain to mothers (via CGVs and household visits) that children cry for many reasons, and crying does not always mean the child is hungry. Use growth charts to show mothers that many children who cry a lot (identify cases ahead of time) are still growing well and therefore are not lacking law,
of EBF) Perceived negative consequences: Mothers believe that the child will be hungry if not fed other foods at 4 months of age adequate nutrition. Teach mothers a step-by-step process for comforting a crying baby (). Outcome Indicator: Percentage of targeted mothers who only give breast milk to their infants from birth to 6 months of age Process Indicators: Number of women who heard testimonials Number of pastors trained Number of CGV and household visits that included the mother/grandmother Number of mothers trained to comfort a crying child
Other Key Determinants 5. Access Includes the degree of availability (to a particular Priority Group) of the needed products (e.g., fertilizer, soap, condoms) or services (e.g., veterinary services, immunizations) required to adopt a given Behavior Includes barriers related to cost, geography, distance, language, cultural issues, and gender Access issues can also be revealed by responses given to the Self-Efficacy question – What makes it difficult? Not having improved seeds or the health center is too far away. 6. Cues for action The perception of the Priority Group that they can remember to do a particular Behavior The perception of the Priority Group that they can remember how (the steps required) to do a particular Behavior Key powerful events that triggered a behavior change in a person (e.g., there was a fatal road accident here, so I remember that I should slow down when I get to this part of the road) 7. Perceived susceptibility/risk The Priority Group member’s perception of how vulnerable or at-risk s/he feels to the problem (e.g., how likely is it that my crop will get cassava wilt? How likely is it that my child will become malnourished?) 8. Perceived severity The Priority Group member’s belief that the problem (which the Behavior can prevent) is serious (e.g., Is soil erosion a serious problem for me? How serious is diarrhea? ) 9. Perceived action efficacy The belief that by practicing the Behavior one will avoid the problem; that the Behavior is effective in avoiding the problem (e.g., if I sleep under a mosquito net, I won’t get malaria) There is an overlap between Action Efficacy and Positive Consequences when the Priority Group cites as an advantage that doing the Behavior will prevent the problem. Note: Perceived susceptibility/risk and perceived severity relate to the problem. Perceived action efficacy links the problem to the Behavior. In order to study issues around susceptibility, severity, and action efficacy, you must know what the problems are that the Behavior addresses. Divine will can sometime also be about the problem, depending on how you phrase the question (e.g., Does God cause children to become malnourished?).
(Perceived Self-efficacy) 2a. Doers: What makes it difficult for you to treat your drinking water? 2b. Non-Doers: What would make it difficult for you to treat your drinking water? [Write all responses below. Probe with “What else?”] (Perceived Positive Consequences) 3a. Doers: What are the advantages of treating your drinking water? 3b. Non-Doers: What would be the advantages of treating your drinking water? [Write all responses below. Probe with “What else?”] (Perceived Negative Consequences) 4a. Doers: What are the disadvantages of treating your drinking water? 4b. Non-Doers: What would be the disadvantages of treating your drinking water? [Write all responses below. Probe with “What else?”] (Perceived Social Norms) 5a. Doers: Who are the people that approve of you treating your drinking water? 5b. Non-Doers: Who are the people that would approve of you treating your drinking water? [Write all responses below. Probe with “What else?”] (Perceived Social Norms) 6a. Doers: Who are the people that disapprove of you treating your drinking water? 6b. Non-Doers: Who are the people that would disapprove of you treating your drinking water? [Write all responses below. Probe with “What else?”]
Sometimes when I travel, I don't have access to clean water, so I can't brush my teeth. I am too busy when I’m at work. It’s gross to brush your teeth in a public place where people will see you. I don’t have time to brush when I’m at work. I don’t have a tooth brush at work. The quality of the water at work is questionable. I go to bed late and am too tired to brush my teeth before bed. It is difficult to brush my teeth in the middle of the day because I am at work. I'm often rushed in the mornings and don't have a lot of extra time to brush my teeth. Sometimes I just forget to brush my teeth. It’s difficult to brush three times a day because if you carry around a toothbrush in your bag it gets covered in fluff and the toothpaste can burst in your bag. I would have to carry my toothbrush and toothpaste around with me during the day. I don't think I would be able to remember to do it given how busy I am during the day. I do not have time during work to brush my teeth. I likely will not remember to do it each day during the middle of the day. It would require brushing while at work and all of the inconveniences associated (bringing brush and paste to work, brushing in front of colleagues in men’s room, etc.). 17. Not having a personal sink at work makes it difficult to brush my teeth with toothpaste three times a day. Lesson 12 Flip Chart 2: Example Coding Guide/Tally Sheets of Results for Doer/Non-Doer Study Responses #Doers % Doers # % Perceived positive consequences: What are the advantages of doing the Behavior?
Lesson 13 Handout 1: Writing Bridges to Activities Instructions: For each response code write at least one Bridge to Activity related to the selected Behavior. Responses/Codes from Formative Research Determinant Bridge to Activity Doesn’t know how to plant on the contour Perceived Farmer thinks father-in-law doesn’t appreciate use of fertilizer (not worth the money and effort) Perceived social norms More insects if fields aren’t burned Perceived negative consequences Clinic staff are mean (care seeking) Access Perceived negative consequences Can’t breastfeed while working outside the home Perceived Can’t recognize the weeds Perceived Forgot the date of the distribution (improved seed use) Cue to action/ reminders Birth weight predicts nutritional outcomes (good birth weight = no risk of malnutrition) Perceived susceptibility Bible approved of covering feces/latrine use Perceived divine will Took child to be vaccinated last week, but they said they cannot open up a vial of vaccine for just one child (10 kids needed to open a vaccine vial policy) Policy
Men and women don’t discuss family planning here Culture Fidelity is too hard Self-efficacy/ skills Husband wants to plant more cash crops (not veggies for home consumption) Perceived social norms Stock-outs of preferred contraceptives Access Silos prevent rat infestation Perceived positive consequences Vet nearby (animal traction) Access Can’t remember how to check breathing (acute respiratory infection [ARI]/care seeking) Cues to action/ reminders Complementary feeding takes too much time Perceived negative consequences Being underweight is not serious (I was underweight and I turned out OK) Perceived severity God is in control of the harvest Perceived divine will Stopped breastfeeding to qualify for food rations (only malnourished infants get rations) Policy or negative consequences
Agriculture and NRM Activities Activity Determinant Walk around the village to view what happened to the soil when all the trees were cut. Perceived self-efficacy Advocate for controls and regulations on pesticides that limit the import of illegal products; Perceived social norms Persuade local shops to sell seeds and implements. Ag volunteers buy quality seed in bulk to and sell to farmers in affordable quantities. Perceived positive Consequences Orient village elders and farmers’ wives to the benefits of adopting the new practices Perceived negative consequences Work with religious leaders to help farmers realize that the crop rotation and “resting the land” is in line with recommendations in their holy scriptures. Access Survey of farmers regarding the % of farmers who suffer land erosion problems. Cues for action/reminders Crops comparisons: one with new seeds and one without Perceived susceptibility/risk Demonstration and hands-on practice to apply new skills such as tree planting, installing drip irrigation, etc. Perceived severity Survey of farmers regarding the extent of erosion (what % of farmers suffer land erosion problems) Perceived action efficacy Convene a discussion with the old farmers of the community to identify all the changes they have experienced over the years and how they have adapted to the changes. Perceived divine will Memory aid showing the distance between planted rows Policy Case study of families who planted a home garden who not only had plenty of veggies to eat but also earned income from the sale. Culture
Annex 4: Answers for Lesson 4 Handout 3: Match the Determinant to the Question How easy is it to remember how to use the water filter? Cue for Action If you only gave breast milk to your baby, would that prevent her from getting diarrhea? Action Efficacy How difficult is it for you to get the soap you need to wash your hands every day? Self-Efficacy How likely is it that your child will become malnourished in the next year? Susceptibility What are the disadvantages of getting tested for HIV? Negative Consequences Are there any local customs or traditions against discussing how to use the household income with your wife? Culture Who would disapprove of you delivering at the health facility? Social Norms What are the advantages of keeping your animals penned up at all times? Positive Consequence What makes it difficult for you to use a condom every time you have sex with a non-regular partner? Self-Efficacy Do you think it’s God’s will that people get cholera? Divine Will How serious of a problem would it be if you contracted HIV? Severity
Annex 6: Answers for Lesson 6 Handout 2: Examine the Questionnaire Question Response Is this a Doer/Non-Doer questionnaire or a Barrier Analysis questionnaire? How do you know? Barrier Analysis – it studies more than 4 determinants. How many places on the questionnaire are there for classifying the respondent as a Doer or a Non-Doer using tick boxes? 2 – top of Page 1 and just after the Classification Table. What seems to be the purpose of the questions posed in Section A? To distinguish Doers from Non-Doers What do you think is the most important piece of information included in the demographics section? The Name of the Interviewer – so you can return the questionnaires that she did back to her for coding What is the purpose of the Behavior Explanation? To make sure the respondent understands what Behavior you will be talking about. How many open-ended questions are there in Section B? 7 if you include the last one on Universal Motivators How many questions on the questionnaire (Section B) are NOT related to the Behavior? 2 – susceptibility and severity – 3 if you include the universal motivator question What is the difference between how the Doer questions are asked and the Non-Doer questions? Doer questions are in present tense Non-Doer questions are in conditional tense (would) How many questions are posed to BOTH Doers and Non-Doers in the same way? 6 What is the purpose of the Classification Table? To help remember how specific screening questions should be answered to be classified as either a Doer or a Non-Doer or someone not to interview For the open-ended questions, what important instructions are included on the questionnaire? PROBE! Which determinants have more than one question? Self-Efficacy, Social Norms, and Cue for Action For which closed questions do you read the responses? #7, #8, #9, #10, #11, #12 --- The ones that include the responses in the question.
you use a condom? look for another respondent] Group: Doer Non-Doer Section B: Research Questions Perceived Self-Efficacy Doer: What makes it easy for you to use a condom every time you have sex? [probe at least three times] Non-Doer: What would make it easy for you to use a condom every time you have sex? [probe at least three times] Doer: What makes it difficult for you to use a condom every time you have sex? [probe three times] Non-Doer: What would make it difficult for you to use a condom every time you have sex? [probe three times] Perceived Social Norms Doer: Who are all the people who approve of you using a condom every time you have sex? [probe three times] Non-Doer: Who are all the people who would approve if you used a condom every time you have sex? [probe three times] Doer: Who are all the people who disapprove of you using a condom every time you have sex? [probe three times] Non-Doer who are all the people who would disapprove if you used a condom every time you had sex? [probe three times]
5. Yesterday in addition to water, did you use anything to wash your hands? with soap 6. If yes, what did you use? with soap 7. May I please see the soap you have in the house now? with soap Screening Questions Example 2: Care Seeking Instructions: Read the behavior statement, then read the screening questions. In the space provided write the part of the Behavior Statement that corresponds to the Screening Question. Behavior Statement (relaxed) Mothers of children under 5 years of age who have a fever seek medical treatment from a professionally trained provider within 48 hours of noticing the fever. Behavior Screening Questions Corresponding part of the Behavior Statement 1. How old is your youngest child? Mothers of children under 5 years of age 2. In the last 3 months did your youngest child have a fever? who have a fever 3. When your youngest child last had a fever did you seek medical care? seek medical treatment 4. Where exactly did you seek medical care when your child had a fever last? from a professionally trained provider 5. After noticing the fever, after how much time did you take the sick child to a clinic? within 48 hours of noticing the fever