Beyond Dialogue: Moving Toward Change of Behavior Strategic Behavior Change Communication in Public Health Beyond Dialogue: Moving Toward Change of Behavior DR G U AHSAN Chairman NORTH SOUTH UNIVERSITY

A predictive model of communication & change: Influence of ideational elements on behavior Knowledge Implies simultaneous effect of all influences. Personal Advocacy Attitudes Social Influence Self-Image BEHAVIOR Perceived Risk Emotion Self-Efficacy Norms Center for Communication Programs U N I V E R S I T Y OHNS HOPKINS J 854 PPT CCP 6/7/00 3

A Generation Ago . . . . Monologue: The “Medical Era” Expert (sender) sending messages to non-expert (receiver)

Doctor speaking to patients BCC Dr GU Ahsan

Moving from monologue to dialogue (both-way) The 70s: “Field Era” Moving from monologue to dialogue (both-way)

The 70s: “Field Era” • Need to reach people beyond the clinics • Derived from extension agent approach in agriculture • Field work supported by IEC materials, films and audio visuals • Mass media impact on behavior considered modest due to limited reach • Large volume IEC • SMCR(E) as dominant communication model

The 80s: “Social Marketing Era” Moving from non-paying clients to customers who ask and pay

Moving from dialogue to mutual adjustment and convergence The 90s to Present: “Strategic Era” Moving from dialogue to mutual adjustment and convergence

The 90s to Present: “Strategic Era” On the process side • Participants in the communication process create and share together • Distinction between “senders” and “receivers” begin to disappear • Communication not as a spare wheel

The 90s to Present: “Strategic Era” • Greater multi-channel integration • Multiplicity of stakeholders • Increased attention to evaluation and evidence- based programming • Increased sophistication in audience segmentation • Large scale impact at national and local level • Role of electronic media more pervasive

Developing World Radio and TV Receivers 2100 1800 Radio 1500 Television 1200 Thousands of Receivers 900 600 300 1955 1965 1975 1985 1995 2000 Year Source: International Broadcasting Audience Research Library/ British Broadcasting Company, 1996.

Strategic Communication Today Strategic communication is a process carried out with the active participation of stakeholders and beneficiaries that addresses a long-term vision and affects the causes of as well as the barriers to behavior change.

Strategic Communication Today Strategic communication includes many approaches such as: community mobilization, client-centered counseling, social network interventions, social marketing, entertainment-education, TV/radio spots, dramas and music, provider promotion, behavior change communication, public policy advocacy, media advocacy, personal and community empowerment, public relations, mass media dissemination...

12 Key Elements of Strategic Communication: Making Evaluation More Complex Results-oriented Science-based Client-centered Participatory Benefit-oriented Service-linked Multi-channeled Technically high quality Advocacy-related Expanding to scale Programmatically sustainable Cost-effective

Strategic Directions in HIV/AIDS Behavior Change Communication More applications of theory-driven communication and behavior change at multiple levels

Theory Driven Behavior Change Communication Ideation is defined as new ways of thinking and the spread of those ways of thinking by means of communication and social interaction in local, culturally homogeneous communities. Cleland & Wilson, 1987

Ideational Factors Related to Condom Use (Zambia) • Perceives self to be at a moderate-to-high risk of contracting HIV/AIDS • Knows at least three ways to protect self from HIV/AIDS • Has talked with at least three people about safe sex • Has a positive attitude towards people who use condoms • Knows where to purchase condoms • Has an above-average sense of efficacy regarding ability to use condoms even when facing opposition from partner

Cumulative Effect of Ideational Factors on Condom Use among Male Adolescents, Zambia 2000

Cumulative Effect of Ideational Factors on Condom Use among Female Adolescents, Zambia 2000

Odds of Condom Use by Ideation and Exposure, Zambia Youth Survey, 2000 Controlling for TV use, sex, age, educational attainment, residence

Theory Driven Behavior Change Communication Ideation Need to Identify causal (proven) factors related to desired behaviors • Abstinence • Being faithful to one partner • Consistent condom use • Delaying sexual debut • Seeking treatment for STIs • Seeking VCT (Voluntary Counseling and Testing) • Preventing MTCT (Mother-to Child transmission)

Theory Driven Behavior Change Communication Social acceptance: improving social environment • Breaking the silence • Improving policy environment/strengthening political will • Overcoming stigma • Agenda priority setting • Increasing public understanding of HIV impact

Theory Driven Behavior Change Communication Social network • Stimulating couple & community discussions • Influencing community norms • Developing community capacities

Theory Driven Behavior Change Communication Social learning/modeling • Modeling individual and collective self- efficacy • Modeling health provider behaviors • Scaling up Enter-educate (education through entertainment) programming

The Individual - Social Continuum HIV/AIDS - related behaviors Collective Behavior Change Individual Behavior Change Couple Community (e.g.) Consistent condom use (e.g.) Reducing stigma HIV/AIDS - related behaviors 854 PPT CCP 6/7/00 26

Indicators for Community Empowerment and Change Leadership Degree & Equity of Participation Information Equity Collective Self-Efficacy Sense of Ownership Social Cohesion Social Norms Adapted from draft Rockefeller/JHU document

Zambia Nicaragua Uganda Ghana 854 PPT CCP 6/7/00 28

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