1. Highlights from the USAID Joint Behavior Change Communication Survey Douglas Storey, PhD JHU∙CCP Director for Communication Science & Research UHMG Annual Event 4 June 2013 Kampala, Uganda Achieving and Documenting Impact at Scale

2. Purposes of survey Measure effectiveness of behavior change interventions implemented by partners with USG funds over the past two years Understand reasons for impact not available from other source (UDHS, MIS, AIS) Assess BCC strategies used Guide planning for future programs

3. Study Population General Population in 27 districts Women, 15-49 years old Men, 15-54 years old Multistage random sampling Covered all intervention areas

4. Study districts Apac Arua Bukwa Bushenyi Busia Dokolo Hoima Ibanda Isingiro Kabale Kabarole Kalangala Kampala Kamuli Kamwenge Kasese Masaka Kiruhura Kumi Kyenjojo Lira Mbale Mukono Sironko Soroti Rukungiri Wakiso

5. Health topics covered Exposure to BCC interventions and media Knowledge, attitudes and behavior related to family planning – Approval of FP – Spouse communication – Ideal family size Sexual behavior – Intentions and norms – Multiple partners Knowledge, attitudes and behaviors related to HIV – Perceived risk – Testing and counseling – Care, treatment and support for PLHIV – Stigma – Male circumcision – Prevention Knowledge, attitudes and behaviors related to malaria – Prevention and ITN use – Careseeking & testing – Treatment – Treatment during pregnancy Knowledge, attitudes and behavior related to maternal and child health – Antenatal care – Safe delivery Alcohol use Violence against women and gender norms

6. Achieving impact at scale: Reach Dose Response Behavior Change Theory Measurement

7. Awareness Comprehension Motivation Intention Action The Communication Pyramid Attenuation of effects at each stage

8. Awareness Comprehension Motivation Intention Action The Communication Pyramid More reach at the top means more impact at the bottom Awareness Comprehension Motivation Intention Action

9. SURVEY SAMPLE (n=7542) SURVEY SAMPLE (n=7542) EXPOSURE (71% of sample, n=5387) EXPOSURE (71% of sample, n=5387) ATTITUDES (48% of exposed, n=2609) ATTITUDES (48% of exposed, n=2609) KNOWLEDGE (96% of exposed, n=5153) KNOWLEDGE (96% of exposed, n=5153) DISCUSSION (33% of exposed, n=1781) DISCUSSION (33% of exposed, n=1781) BEHAVIOR (25% of exposed, n=1335) BEHAVIOR (25% of exposed, n=1335) Heard any of 4 FP campaigns Knows at least one modern method Talked to partner re: FP Using a modern method The Communication Pyramid for Family Planning Use Ideal number of children is ≤ 4 Source: UHMG/AFFORD/JHU∙CCP Joint BCC Survey, Oct-Nov 2012, n=7542

10. Health Impact Areas Safe Motherhood: Saving Mothers, Giving Life HIV Prevention: Get Off the Sexual Network Malaria: The Power of Day One Family Planning: Smart Choices

11. Safe Motherhood Saving Mothers, Giving Life

12. Saving Mothers Implementation began June 2012 in 4 districts – Kabarole, Kamwenge & Kyenjojo covered in survey Focal messages: – Danger signs during pregnancy – Expertise of health workers to save mother’s lives – Advantages of health facility deliveries Channels: – Interpersonal communication (clinic-based and outreach), radio, community drama OVERALL RECALL: 74%

13. Saving Mothers *Men & women, 15-54 years old, in Kyenjojo, Kabarole and Kamwenge, n=679, p<.001 * Exact p-value =.043, N=379 Those exposed were more likely… to think home delivery was risky to deliver in a health facility

14. Saving Mothers Outcome All respondentsMenWomen Knowledge of need to go to a heath facility in case of danger signs 2.67*3.10*2.66* Delivered at a health facility --2.34* *p<.05; odds ratios for exposed respondents compared to unexposed adjusted for age, sex, rural or urban residence, marital status, education level and wealth index. Odds Ratios for Key Outcomes by Exposure and Gender

15. Saving Mothers

16. HIV Prevention Get Off the Sexual Network

17. Sexual Network Launched in September 2009 Focal messages: – increase practice of monogamy – consequences of multiple partnerships – Ways to get off the sexual network – HIV testing and counseling Channels: – TV and radio spots, billboards, local theatre, and call-in radio shows OVERALL RECALL: 52.9%

18. Sexual Network Note: Among sexually active persons, 15-54 years * p<.182; ** p<.001 (n=2746/5623) (n=2458/5083)

19. Sexual Network Outcome All respondentsMenWomen Intention to get HIV test (self) 1.32*1.37*1.39* Sex with only one partner in past 12 months 1.040.961.31* *p<.05; odds ratios for exposed respondents compared to unexposed adjusted for age, sex, rural or urban residence, marital status, education level and wealth index. Odds Ratios for Key Outcomes by Exposure and Gender

20. Sexual Network * p<.05

21. Sexual Network N = 3362 sexually active adults aged 15-54 years

22. Malaria The Power of Day One

23. The Power of Day One Launched June 2011 in six districts – Apac, Kumi, and Soroti districts covered in this survey) Focal messages: – Importance of rapid careseeking for fever – Testing for and treating malaria within 24 hours of fever onset – Emphasis on children and pregnant women Channels: – Radio spots & talk shows, community meetings, billboards, posters, point of service materials, telephone hotline and SMS platform OVERALL RECALL: 63.7%

24. The Power of Day One Note: n=269 in 3 districts; *p<.175, ** p<.001

25. The Power of Day One Note: Adults age 15-54 years exposed to Power of Day One in 3 districts, n=394

26. Careseeking and testing for malaria by gender and combined exposure to malaria campaigns Average effect on CARESEEKING for HH member with fever in past two weeks Average effect on receiving a malaria BLOOD TEST for HH member with fever in past two weeks Men (n=2038 exposed, 1204 unexposed) and women (n=1933, 1340 unexposed) aged 15-54; p<.0001 based on propensity score matching to estimate the average treatment effect, controlling for 20 socio-demographic and communication variables.

27. Family Planning Smart Choices

28. Smart Choices Launched August 2012 Focal messages: – Use modern FP methods to achieve your life goals – Methods available for various life stages and reproductive goals Channels: – radio, television, countrywide billboards, point of service materials. OVERALL RECALL: 35.7%* *Based on only the first three months of the campaign

29. Smart Choices Note: Among sexually experienced persons, 15-54 years * p<.05; ** p<.002 (n=5136)(n=5235)(n=3640)

30. Smart Choices Outcome All respondentsMenWomen Current use of a modern FP method 1.26*1.30*1.34* Discussed FP with partner 1.121.40*0.98 Ideal family size is ≤ 4 children 1.111.23*0.97 *p<.05; odds ratios for exposed respondents compared to unexposed adjusted for age, sex, rural or urban residence, marital status, education level and wealth index. Odds Ratios for Key Outcomes by Exposure and Gender

31. Smart Choices

32. Greater impact occurred with exposure to more channels of communication Note: Among sexually active individuals * p<.05

33. Modern FP use, ideal family size and partner approval of FP by combined exposure to FP campaigns Exposed (n=5269), unexposed (n=2007) men and women aged 15-54; p<.0001 based on propensity score matching to estimate the average treatment effect, controlling for 8 socio-demographic and communication variables.

34. Impact of combined exposure to FP campaigns on key ideational variables (ideal family size and partner approval of FP) by gender Average effect on perceived ideal family size of ≤ 4 children Average effect on perceived support of partner for FP Men (n=2024 exposed, 921 unexposed) and women (n=2574 exposed, 1052 unexposed) aged 15-54; p<.0001 based on propensity score matching to estimate the average treatment effect, controlling for 8 socio-demographic and communication variables.

35. Conclusion: How to achieve impact at scale Operate at Scale – Maximize reach Capitalize on dose effects – Use mutually reinforcing channels Use a theory-based strategy – Focus on drivers of behavior Research—Measure the right things – Test the behavioral strategy – Measure intermediate changes

36. Thank you…and have a