Acknowledgements A Practical Guide to Conducting a Barrier Analysis draws heavily on both the 2011 version of the Designing for Behavior Change (DBC) Curriculum developed through the TOPS Project by Linda Morales, Judiann McNulty, Tom Davis, and Bonnie Kittle and the 2004 Barrier Analysis Facilitator’s Guide written by Tom Davis. The creative skills of Tom Davis, Linda Morales, and Judiann McNulty are amply reflected in this guide. The following people shared their insights into their experiences in organizing and conducting Doer/Non-Doer Studies and Barrier Analyses and made suggestions for what to include in this guide: Justin Colvard, Lotta Adelstal and Lucky Kalisya (Mercy Corps); Andrea Cuthrell and Jean Pierre Okitakoy (Food for the Hungry); Bernad Ochieng and Andy Melendez (American Red Cross); Erica Phillips (Cornel University); Sarah Bauler (Samaritan’s Purse); Lael Kucera (Water for Life); Franck Flachenberg (Concern Worldwide); and Marjolein Moreaux and Judiann McNulty (independent consultants). I am grateful for the support of Mitzi Hanold (Food for the Hungry) for sharing ideas on how to teach coding and of the participants in my October 2012 DBC course for providing responses that allowed me to design the coding game. The quality improvement verification checklist (QIVC) is based on one initially developed by Food for the Hungry. Many thanks to Tom Davis, Mitzi Hanold, and Mary DeCoster (Food for the Hungry); Justin Colvard (Mercy Corps); and Jennifer Nielsen (Helen Keller International) who took time from their busy schedules to review the draft curriculum and make very helpful recommendations. Also, thanks to CORE Group for assisting with the final formatting of the curriculum and for disseminating it throughout the CORE Group Community Health Network. Finally, I appreciate the opportunity that Helen Keller International/Democratic Republic of Congo afforded me to develop this practical guide because it will not only support their work, but will be used by scores of other organizations to improve social and behavior change (SBC) programming around the world. Bonnie Kittle April 2013
Bridges to activities (which used to be called key factors): Bridges to activities are based on the responses given by the priority group during the formative research and are more-specific descriptions of a change one should make to address the issue revealed by the research. A bridge to activity usually begins with a directional verb (e.g., increase, decrease, improve, reinforce) and often proposes to change the perception of the priority group. It is not expressed in percentages. The bridges to activities are always about the priority group, so it is not necessary to mention the priority group in the wording. There is always at least one bridge to activity written for each determinant found to be important to the chosen behavior (e.g., “increase the perception that diarrhea could cause a child to become malnourished”). Activities: Activities are a series of tasks that program implementers plan, organize, and/or conduct usually with the priority group or influencing groups to address bridges to activities. Activity descriptions start with an action verb. For example, “offer a small loan to one entrepreneur per village to produce and sell quality, affordable chicken feed” or “set up additional sale points of wire mesh”. 2d. Distribute Lesson 2 Handout 3: Examples of Completed Designing for Behavior Change Frameworks. Ask participants to refer to one of the examples, walk them through it, and address any questions. 2e. Distribute Lesson 2 Handout 4: Planning Guide: Steps in the Designing for Behavior Change Process and review it with participants. Address participants’ questions about each step. 3. Summary 3a. Summarize the lesson by discussing Lesson 2 Handout 5: The Five Principles. Answer any questions.
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. 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. They live in rural villages and own small numbers of chickens, which currently wander freely and sleep in trees. Both men and women have attended some school. They all want food security, well-being and education for their children. They think chickens will not have enough to eat if they are penned up, or they do not know affordable ways to make chicken coops. Most of the Priority Group is in the aware-ness (or “contemplation”) stage of behavior change. 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 manure for 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 to keep chickens penned up. Increase access to fencing materials and skills for adapting local materials. 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 cost-benefits 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. 3. Provide technical assistance and a small loan to one entrepreneur per village to cost
Example 2: ANR Programs: Reforestation Behavior Priority Group Or Influencing Group Determinants Bridges To Activities Activities Targeted farmers farming on sloped land plant trees on the hillsides of their land. Priority Group: Adult farmers, men and women, who farm on hilly land Minimal literacy Make their living from subsistence farming and seasonal migration to labor on plantations of export crops Own less than 4 hectares of land, but some of it is hilly and some of the land is eroded Want their children to have a better life and work off the farm Want to end the seasonal migration Want stable supply of staple foods Believe that it will take too long to see the fruits of their labor if they spend the time to plant trees Know that their farms are providing fewer harvest results each year Some have planted trees, but most feel it is a waste of time, effort and resources Perceived positive consequence: Believe that planting trees leads to future firewood and building material, controls erosion and landslides, prevents climate change, and can increase fruit production Perceived negative consequences: Believe they will lose investment of time and effort because saplings die Believe tree planting diverts time from planting food crops Believe the trees will hinder crop production by making shade and taking water 1. Reinforce the perception that the eventual benefits of planting trees are worth the effort today. 2. Increase the perception that if they know how to properly plant and care for trees that they will not die. 3. Decrease the individual time needed to plant trees 4. Reduce the threat to crop production by identifying other places to plant trees. 1. Work with municipal officials to begin promoting fruit trees rather than Neem trees; provide awards to families who plant/maintain a certain number of trees until they are (also could be done at the community level); and assure there is a long-range plan for financing and maintaining the municipal tree nurseries that provide free or low-cost seedlings, including those for fruit trees. 2. Conduct short demonstrations on tree planting in each sector, including appropriate technology containers for drip irrigation. Repeat the demonstrations in the schools when they plant trees. 3. Mobilize families to spend one day a year planting on
What are the disadvantages of getting tested for HIV? Cues for action/reminders Are there any local taboos or norms against discussion how to use the household income with your wife? Perceived susceptibility/risk Who would disapprove of you delivering at the health facility? Perceived severity What are the advantages of keeping your animals penned up at all times? Perceived action efficacy What makes it difficult for you to use a condom every time you have sex with a partner? Perceived divine will Do you think it’s God’s will that people get cholera? Policy How serious of a problem would it be if you contracted HIV? Culture regular
important barriers and enablers, it may not be enough to find what truly motivates people, including the “big benefits.” Therefore, it can be useful to follow up this approach with focus group discussions or a Participatory Learning and Action activity. (In the section on questionnaire development, however, we will mention a question that you can put at the end of your questionnaire to look into “big benefits”.) Also, using Trials of Improved Practices (TIPS), focus group discussions, Participatory Learning and Action (PLA), and other qualitative methods can be useful for studying enablers and barriers when a Barrier Analysis is not possible due to a lack of Doers. For example, when you are introducing a behavior that is new to an area (e.g., solar water disinfection, use of Zinc), you may not find any Doers at the beginning of the project. Is Barrier Analysis a quantitative method, qualitative method, or both? Barrier Analysis is both qualitative and quantitative. It has open-ended elements that help explore and describe how the two groups think (which makes them qualitative in nature), but it also has quantitative elements (e.g. the statistical comparison of Doers and that allow us to determine the important differences. Since Barrier Analysis does not measure prevalence of a particular belief, most people do not think of it as quantitative; however, quantitative information is being collected and analyzed (e.g., which group gave a particular response more often). Lesson 5 Handout 4: Barrier Analysis Game Questions and Correct Responses Questions Responses How is a Doer/Non-Doer Study different from a Barrier Analysis survey? Doer/Non-Doer Studies examine only four of 12 determinants How many determinants are explored in a Barrier Analysis? Up to 12 Which determinants are explored by both Doer/Non-Doer Studies and Barrier Analysis surveys? Perceived self-efficacy, perceived social norms, perceived positive consequences, and perceived negative consequences What data collection method is recommended? Individual interviews Who is usually interviewed in a Barrier Analysis? The priority group members Who interviews Doers and Non-Doers (in both Doer/Non-Doer Studies and Barrier Analyses)? Someone who has been trained in this interview technique Can the same person be interviewed concerning Not recommended Doers)
before and after the PD/Hearth. norms Work with Ministries of Industries to pass regulations requiring the fortification of cooking oil with vitamin A. Perceived positive consequences Tying soap from string next to tippy-tap Perceived negative consequences Survey the number of children who had to be taken to the clinic to receive treatment for diarrhea. Access Community growth monitoring showing the high percent of children who are malnourished Cues for action/reminders Gardening tools distribution Outreach growth monitoring and promotion activities Perceived susceptibility/risk Baby weighing at the end of the two-week PD/Hearth Perceived severity Invite fathers to the final session of the PD/Hearth to show them the results of proper feeding & gain support for continued feeding Perceived action efficacy Breastfeeding support groups where mothers help each other overcome BF difficulties Perceived divine will Convene discussions with older women about how mothers used to carry their babies with them everywhere to remind current mothers of the “old ways” Policy Work with religious leaders to gain support for equal feeding practices regardless of gender; produce sermon outlines. Culture Agriculture and Natural Resource Management (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. Perceived positive Consequences
Question 11 is posed as a closed question, but has several response choices. In this case, Question 13 mentions the behavior, which makes the determinant perceived action efficacy, not perceived susceptibility. Also, the question should not only be about their own risk to disease, but also that of their family. In Question 16, “more possible” needs to be reworded. Question 18 is not about the facility, but what they, the CBO members, want. There is no question about perceived action efficacy. Classification Exercise in Lesson 10 Handout 6: Practice Classifying Doers and Non-Doers 1 – Doer 2 – Non-Doer 3 – Do not interview 4 – Non-Doer 5 – Non-Doer 6 – Non-Doer 7 – Non-Doer 8 – Doer Lesson 13 Handout 1: Writing Bridges to Activities Responses/Codes from Formative Research Determinant Bridge to Activity Doesn’t know how to plant on the contour Perceived Increase the ability to plant on the contour efficacy
Doer: What makes it difficult for you to use a condom every time you have sex? [probe three times] Non-Doer: What makes it difficult for you to use a condom every time you have sex? [probe three times] 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] Access Doer: How difficult is it for you to obtain enough condoms so you can use them every time you have sex? [read all responses] A. Very difficult B. Somewhat difficult C. A little difficult D. Not difficult at all Non-Doer: How difficult would it be for you to obtain enough condoms so you could use them every time you have sex if you wanted to? [read all responses] A. Very difficult B. Somewhat difficult C. A little difficult D. Not difficult at all Cues for Action/Reminders Doer: How difficult is it to remember to use a condom every time you have sex? [read all responses] A. Very difficult B. Somewhat difficult Non-Doer: If you wanted to use a condom every time you had sex, how difficult would it be for you to remember to use it? [read all responses] A. Very difficult