Introducing FOAM: Focus, Opportunity, Ability, Motivation A draft behavior change model for HW programs Dakar, May 29, 2007

2 Overview of Presentation  Background  Behavior change models  The Hanoi Workshop  Next steps

3 Background  Many tools available (eg. Handwashing Handbook)  All stress audience-centered programming  Lack of holistic model to explain all factors influencing HW  Global Scaling Up HW Project presents an opportunity  Learning objective  Common framework

4 What is a BC Model  Diagram that represents the various “determinants” of behavior change  “Determinants” are internal or external factors that influence an individual to perform a behavior

5 Advantages of a BC Model  Provides a common language  Identifies critical linkages  Informs M&E  Enables evidence-based and comprehensive programming  Can be adapted across populations

6 Foundations of BC Models  Draw on disciplines such as public health, marketing, communication, advertising, business, social psychology and consumer behavior  Foundations include Health Belief Model, Theory of Reasoned Action and The Stages of Change which have been studied extensively

7 Two Examples of BC Models  WB’s BC continuum  PSI’s PERForM

8 World Bank BC Continuum

9 PSI’s PERFORM 4 USERISK-REDUCING BEHAVIOR HEALTH STATUSQUALITY OF LIFE OPPORTUNITYABILITY MOTIVATION POPULATION CHARACTERISTICS SOCIAL MARKETING INTERVENTION PRODUCTPLACEPRICEPROMOTION AT RISK Attitudes Belief Subjective Norm KnowledgeAvailabilityBrand Appeal Quality of Care Threat Outcome Expectation IntentionLocus of Control Willingness to Pay Self Efficacy Social Support Social Norm Brand Attributes

10 Examples of PERForM Applications in Cambodia  Data:  2003 sero-surveillance: 42% new HIV/AIDS cases from husband to wife  Formative research: low condom use with trusted partner due to 1) low perceived risk and 2) low social support – confirmed later through TRaC survey  Number One: widely available (over 95% of brothels) and affordable but associated with commercial sex

11 Examples of PERForM Applications in Cambodia (2)  Program responses:  launch of OK Condom  “Klahan” (Be brave) BCC campaign

12 OK Condom  Marketing strategy:  Different product launched with family planning positioning in 2004  Differentiated distribution channels from Number One condom  Advertising and promotion includes mass media and sponsorships  Key results:  Total condom sales in Cambodia grew from 20 million in 2004 to over 25 million in 2006  OK Condom’s share at 10% of total sales

13 Klahan BCC Campaign  Aimed at building social support and improving personal risk perception among trusting couples  Integrates mass media (8 TV and radio spots), mobile video units, website and outreach through NGO peer-educator networks  Key determinants and exposure tracked through TRaC annual surveys

14 Spots

15 Generic Vs Branded  Generic (BCC) campaigns aim to change knowledge, attitudes and beliefs related to intended behavior and/or build “primary” demand for product category  Branded build “secondary” demand for product

16 Generic Vs Branded (2)  PSI generally does not put product brand on “generic” or BCC campaigns:  Enhances credibility  Facilitates stakeholder buy-in  Facilitates use by partners

17 PERForM and M&E  TRaC = annual targeted KAP-type surveys  Compares those who perform the desired behavior to those who do not  Identifies key determinants correlated to desired behavior  Establishes dashboards, allows for monitoring and campaign impact evaluation

18 The Hanoi Workshop  Held April 24-27, 2007  Participants included HW Coordinators, GoV/MoH and Global team  Facilitated by a communication consultant  Key objective: develop a global behavior change model for the “Scaling up HW Behavior Change” project

19 Process 1.Agreement on expectations and parameters 2.Review of existing frameworks 3.Overview of research and theories on change 4.Country/regional presentations 5.Identification of relevant determinants for HW 6.Decision to group determinants under opportunity, ability and motivation 7.Development of draft BC model FOAM

20 F in FOAM  Focus:  desired behavior (consistent HW at critical times)  target populations

21 O A M  Opportunity: institutional or structural factors that influence an individual’s chance to perform a behavior  Ability: individual’s skills and proficiency to perform a behavior  Motivation: drives, wishes, urges, or desires that influence an individual to perform a behavior

22 Access/availability Product attributes Social norms Knowledge Social Support Attitudes & beliefs Intention Expectations Threat Focus Opportunity Ability Motivation

23 Opportunity  Availability/access: ease of obtaining the cluster of goods and services needed for the behavior  Can I get water/soap when I need it?  How far to go to get it?  Is there water and soap when I wash hands?  What is the price?  Can I buy it when I need it?  Am I able to make the decision to buy soap?  Who makes the decision to buy soap?

24 Opportunity (2)  Product attributes: perceived or actual characteristics of goods and services  Does soap smell good?  Does water look clean?  Is the color (soap or water) nice?  Is it anti-bacterial?  Is the soap agent I have at home appropriate for all critical times?

25 Opportunity (3)  Social norms: behavioral standards which exist in the community for an individual to follow  Are people around me washing their hands with soap?  Who around me is washing hands?

26 Ability  Knowledge: true facts accumulated through learning about objects, actions, and events  Do I know why HW is important?  Do I know that washing with water is not good enough?  Do I know when to do it?  Do I know that germs that are invisible can make me or my child sick?  Do I know that HW can prevent my child from getting diarrheal disease and ARIs?

27 Ability (2)  Social support: Physical, emotional, or informational assistance an individual or community gives or receives for a behavior  Has anyone talked to me about HW?  Has anyone helped me to HW?  Has anyone made me feel good about HW or rewarded me?

28 Motivation  Attitudes and beliefs: perceptions or mental positions about a product or behavior. Evaluations or assessment of a product or behavior which may or may not be true.  Do I believe that HW is necessary?  Do I believe that HW improve my child’s health?  Do I think that all soaps the same and equally effective?

29 Motivation (2)  Expectations: what an individual thinks will happen as a result of performing the behavior.  Will washing my hands reduce my child’s immunity?  What will others think of me if I HW? How much do I care what they think (subjective norms)?  What do I think could happen if I HW? What if I do not HW?  Does God/fate decide whether my child will suffer from diarrhea or ARI (locus of control)?

30 Motivation (3)  Threat: perceived danger or harm associated with performing or not performing the behavior  How likely is my child to get diarrhea or ARI (susceptibility)?  How dangerous is diarrhea or ARI for my child (severity)?

31 Motivation (4)  Intention: individual’s plan to perform or facilitate the behavior  Am I planning to install a HW station?  Next time I go to the toilet/feed my baby am I going to washing your hands with soap?  How much am I willing pay?

32 From Model to Practice  FOAM can be integrated into existing tools and frameworks  Enables full marketing mix vision  Informs monitoring/MIS  Informs the formulation of communication objectives in the advertising brief  FOAM Operational Matrix (FOM) can be used for planning purposes

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34 FOAM Operational Matrix (FOM) from VN

35 Next Steps  Feedback from PPPHW BCC sub-working group and SC  Country-level validation/training workshops  Vietnam workshop tentatively planned early July  Tanzania FOAM workshop planned for mid July  Identification of key determinants to be tracked in household surveys based on formative research  Inclusion of FOAM communication objectives in advertising agency briefs and spot formative research  Training or TA on application of FOAM for HWTM