Actions first boosting impact of community health programs. september 26, 2012


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Peter Gottert, our long-time (25 years for some of us....) colleague specializing in community-based strategies to health-related behavior change, will share some basic principles from his own experiences in the field--particularly in Africa. Peter says "Many community programs are simply too complicated to be scaled up." His presentation will include a series of “observations and practical tips that focus on how to streamline the design of community-based strategies in order to dramatically improve results."

Note that Peter has developed the presentation along with Mary Carnell, JSI (with whom he has worked on many USAID projects), and plans to give the presentation with her again at JSI on September 21. (This presentation does not focus specifically on Alive & Thrive activities.)

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  • Actions First
  • Observations & practical tips
  • to boost impact
  • of community health programs
  • Here is the take home message of this presentation: Streamline. Most community programs are too complicated… and as such cannot be taken to scale.
  • Switch has given me the courage to hit the road again – Why? Because Chip and Dan Heath have written a best selling book that makes behavior change completely understandable by left handed people, like myself and I dare say, by country teams.
  • Switch employs understandable terms and concepts. The BCC framework they propose is built around 3 components: Direct the Rider – what our mind tells us - what we think. Motivate the elephant: what our heart tells us – what we feel. Shape the path – how to change the situation I’ve used this slide in dozens of presentations to district level officials and they all get it. When I ask: If the rider wants to go in one direction and the elephant in another, who will win? Usually one person’s hand shoots up as he says “the rider.” Then there is silence and gradually others say, “No, no it’s the elephant that will win.” And so right there a team captures a huge concept in behavior change: Emotion trumps rational thought.
  • Let’s start with the easy part – what doesn’t work. Up on the top right corner – that poster which 8 people have looked at in the last 15 years – it’s still there I’m sure. That’s my work. We thought it was wonderful. Like many BCC field technicians, I fell in love with it.
  • Observation #1: The trusted messenger…
  • Observation #2: “You must streamline in order to successfully scale-up.”
  • Streamline at every turn. Streamline research, the design of frontline tools, training and targets. Everything that follows in this presentation is related, directly or indirectly, to streamlining.
  • We all love to load our programs with bells and whistles. It’s hard to avoid. Funders encourage it. But if you don’t streamline you can’t scale them up. And No Scale, No Public Health Impact.
  • This one page strategy literally says it all – it describes a streamlined strategy. Community leaders easily understand their role and see how each component fits with the others. I’ve been using this strategy, in one form or another, for 15 years. If you’ve ever written a 65 page communication strategy that never left the top shelf, your appreciate this.
  • The remaining 7 Observations in this presentation relate to components of this strategy.
  • Observation #3 : R esearch: Let’s be smart. The 1 st smart thing you can do with respect to research is put Actions First In other words, prioritize the behaviors that project is all about – prioritize the indicators you need to change.
  • I dentify up to 10 Small Do-able Actions
  • But how can we just jump into actions, you ask? Let’s look at the danger of not starting with Actions First. Some years ago I worked with the Nutrition Communication Project. We carried out a study on the infant feeding behaviors and traditions in Mali.   The results of this research were fascinating. Each stage of the child’s development was linked to an intricate tradition. Amazing. We were spell bound as the results were presented.
  • What happened next? And we ran straight into something the Health brothers warn us about in “Switch:” The rider is prone to Analysis Paralysis. We had too much information.
  • What did we do? We very quietly adopted 4 breastfeeding behaviors that UNICEF recommends in “Facts for Life.”   For example, “Mothers, exclusively breast feed your baby for the first 6 months.” This is one of many universal evidenced-based actions. This behavior is not going to change anytime soon.
  • There are a surprising number of universal actions. In Ethiopia, at a stakeholders workshop, the C-Change project used a series of VIPP exercises to identify 8 essential malaria actions. Another VIPP exercise took the Alive and Thrive team 85% of the way towards its “7 Excellent Feeding Actions.” This is the “Wisdom of the Stakeholders” at work.
  • What is the advantage of starting with actions? It focuses research on the essentials: the behaviors you need to change for public health impact. This image from the Madagascar BASICS project, shows a field agent learning about benefits and barriers related to specific IMCI actions- such as giving fluids to babies with diarrhea. Projects all to frequently, neglect existing studies and cast a research net that is designed to catch every fish in the sea.
  • Some of you are wondering, d on’t we need an in-depth study in order to segment our audiences, understand the causes and effects of the core problem, carryout a people analysis, a context analysis, gender analysis and dig into the barriers and obstacles? Not surprisingly, my humble observation is No you don’t. Let the trusted messengers do their job. Here are two neighbors. One young mother is a community volunteer. The second mother’s baby has had diarrhea for 2 days. Together they are discussing the importance of giving extra fluids to the baby. They negotiate which fluids, when, how, how long and what to say to the mother-in-law. Arriving at these personalized solutions is what the trusted messenger does so well.
  • Being smart about research is often an easy way to boost impact. Look at this graph: the X axis measures time and the Y axis measures percentage of target audience reached.
  • Let’s look at a project I worked on several years ago in Burkina Faso. After carrying out qualitative research and carefully designing our communication strategy we launched at the beginning of Year 3.
  • By the end of Year 4 our “the impact year” our program had scaled up to 50% of its intended audience.
  • At the end of Year 5 we had only just completed scale up and were praying for an extension.
  • But what if our project in Burkina had been smarter about research and launched field activities at the beginning of Year 2.
  • Observation 4 : Frontline tools: clarity is half the battle. Can you imagine a carpenter who comes to your house to repair a cabinet with no tools? Or an electrician without pliers? Impossible: the same applies to health agents and community workers. We must equip them with easy-to-use frontline teaching tools.
  • A Good Tool: Shapes the Path
  • Meet Rova: a kind, hardworking community volunteer. She is using a good example of frontline teaching tool: the Counseling Card. Notice how simple it is – one image. It’s the most concise expression of an action Yet what happens if Rova’s program violates the principle of streamlining and develops 20, 25, 30 CCs? Rova becomes confused and begins to specialize in themes she is comfortable with like BF and drops more difficult themes like FP. Impact suffers
  • Alive &Thrive’s Child Nutrition Card clarifies actions and helps parents track their progress Without clarity as programs scale up, frequently they experience “message drift” – proposed behaviors are modified, dropped or become fused one into another.
  • Although the Family Health Card has 50 actions it helps achieve clarity.
  • Why, because it brings order what is often a chaotic health communication universe. Think of this from the families point of view. The new IYCF program starts, while the WASH project is in full swing. Then there is a vitamin A campaign and FP is always important, and don’t forget growth monitoring and immunization and deworming and safe sex.
  • This mother knows that when her child is 6 months old she focus on 5 priority actions. She is checking a box – by herself - after successfully carrying out an action. This is the definition of empowerment.
  • The Family Planning Invitation Card is a good example of clarity – it turns satisfied users into FP promoters
  • and of course, there’s the king of clarity, the Red Card.
  • One of the “three surprises about change” mentioned in “Switch” is: “ What looks like resistance is often a lack of clarity.” Achieving clarity is half the battle
  • What about different tools for different audiences? Here’s a five star Streamlining Opportunity: use the same tool for community volunteers and
  • health workers.
  • Observation #5: Short Skill-based workshops are win-win. There is no question that training is important, but training often soaks up project funds. Evaluation forms tell us that workshops are never long enough. In reality, most workshops are too long.
  • Observation #6: Targets boost impact :
  • Community activity has a half life - groups tend to flag after 3 months. Targets help maintain momentum –. Targets help them go wire to wire.
  • Communities in Ethiopia’s Alive and Thrive project has only one target Earn Smart and Strong Certificates. Each certificate is awarded to families carrying out 7 behaviors
  • A community can manage up to 5 targets, but not 8, 12 or 15. This is a Champion Community celebration in Madagascar. The local official could not possibly be prouder that his community reached all 5 of its targets.   The Champion Community model was designed to streamline – to focus community activity of broad integrated child survival and FP programs on key indicators that USAID was measuring.
  • Observation #7: Energize activities with demonstrations, skits and students OK, here’s a sad truth: Many community programs flag because they are too boring. We all have experienced the 35 -13- 3 syndrome. 35 participants come to the first meeting, 13 and the second and 3 to the third.
  • The home visit by the trusted messenger is the starting point of community activities. This trusted messenger – a young mother – is speaking to her husband.
  • Group activities are an equally important but a separate, complementary channel to home visits.
  • Groups facilitate experience sharing
  • and provide social support,
  • 3 effective way to liven up community activities are: Demonstrations, village theater and engaging students. Here is a thick porridge demonstration with a twist – its carried out by men.
  • Village theater is highly participatory. Think of drama as a demonstration on how to overcome barriers.
  • Drama allows community members to see how an obstacle is negotiated, and successfully carried out It’s hard to believe that this husband in Niger playing the role of a woman could ever be the same detached, distant father tomorrow.
  • Village theater is entertainment-education by the community for the community.
  • Finally, let students to energize your program.
  • Youth are powerful messengers on any health topic.
  • Here in rural Ethiopia, students combined a demonstration with village theater. And guess what …. they absolutely stole the show.
  • Observation #8: C lone early adopters.
  • Meet Awa, a Burkinabe mother of 4. She’s personable, full of life, an early adopter. When Awa tells her story about how she carried out new health behaviors, everyone listens - they know Awa faces the same daily challenges they do.
  • Too often community programs let achievement go unrecognized. Certificates are the most cost-effective BCC tool. They publically bring early adopters inside the “health doers” tent. This, by itself, makes sustainability of new behaviors more likely.
  • When community members proudly display their certificates, what happens? The early adopters clone their success. This is the power of the community. Let it work for your program.
  • The same principle applies to local leaders. Public recognition provides a surge of collective efficacy. Leaders believe in themselves and know “ We can do this !!”
  • Gradually social norms shift
  • Observation #9: Capture the community pulse with media
  • Let mass media drive your program. You can’t afford not to use mass-media – it’s too powerful. This good-father, bad father skit was recorded by local radio and TV. What better way to “capture the pulse” of community activities and reinforce achievement?
  • These youth recently adopted several potentially life-saving behaviors. Local radio lets them tell their story of the personal strategies they have developed to resist peer pressure.
  • Broadcasting success. What better way to engage local leaders than to tell the world about the achievements of the village down the road.
  • Communities on the move provide source material for media – and the media, in turn drives community activities.
  • Thank you
  • Actions first boosting impact of community health programs. september 26, 2012

    1. 1. Actions First: Boosting Impact of Community Health Programs Brownbag , September 30, 2012 FHI 360 Peter Gottert 1
    2. 2. • PresenterPeter Gottert ( Presenter) Alive & Thrive , GHPN 2
    3. 3. Actions First: 3
    4. 4. Observations & practical tips 4
    5. 5. to boost impact 5
    6. 6. of community health programs 6
    7. 7. Streamline 7
    8. 8. 8
    9. 9. Direct the Rider: What our mind tells us - what we think. Motivate the Elephant: What our heart tells us – what we feel. Shape the Path: Change the9 situation
    10. 10. 10
    11. 11. 9 Observations1. Trusted messengers: Gold standard2. Streamline for scale3. Research: Let’s be smart4. Frontline tools: Clarity is ½ the battle 11
    12. 12. 9 Observations (con’t)5. Short workshops: Win-win6. Targets boost impact7. Boredom is bad8. Clone early adopters.9. Media: Capture the pulse 12
    13. 13. Observation #1 The trusted messenger 13
    14. 14. Observation #2 StreamlineScale Up 14
    15. 15. Streamline ResearchTools Training Targets 15
    16. 16. No ScaleNo Impact 16
    17. 17. Community StrategyOne pagestrategy 17
    18. 18. Community Strategy #3 Research #4 Tools #5 Training #6 Targets#7 Boring is bad #9 Media #8 Clone early adopters 18
    19. 19. Observation #3 Research: Let’s be smart Actions First 19
    20. 20. Small Do-ableActions 20
    21. 21. Fascinatinginfantfeedingtraditionsin Mali. 21
    22. 22. Analysis Paralysis 22
    23. 23. Mothers,Give onlybreast milkto your babyfor the first6 months 23
    24. 24. 24
    25. 25. 25
    26. 26. No you don’tLet the trusted messengers do their job 26
    27. 27. Boost ImpactReach Year 1 Year 2 Year 3 Year 4 Year 5100%80%60%40%20% 27
    28. 28. Reach Year 1 Year 2 Year 3 Year 4 Year 5100%80%60%40%20% 28
    29. 29. Reach Year 1 Year 2 Year 3 Year 4 Year 5100%80%60%40%20% 29
    30. 30. Reach Year 1 Year 2 Year 3 Year 4 Year 5100%80%60%40%20% 30
    31. 31. Reach Year 1 Year 2 Year 3 Year 4 Year 5100%80%60%40%20% 31
    32. 32. Observation #4 Frontline Tools: Clarity is 1/2 the battle 32
    33. 33. A Good Tool:33 Shapes the Path
    34. 34. 34
    35. 35. Child Nutrition Card• Clarifies actions• Helps parents track progress 35
    36. 36. Family-friendlyhealthcard… 36
    37. 37. 37
    38. 38. 38
    39. 39. 39
    40. 40. King of clarity 40
    41. 41. What looks like resistance is oftena lack of clarity 41
    42. 42. 2 Streamlining Opportunity 42
    43. 43. 43
    44. 44. Observation #5Short workshops: Win-win 44
    45. 45. Observation #6 Targets boost impact 45
    46. 46. Targets maintain momentum 46
    47. 47. Ethiopia – typical target:Earn ~200 Smart and Strong Certificates 47
    48. 48. 48
    49. 49. Observation #7 Boring is Bad 49
    50. 50. Home Visits 50
    51. 51. 51
    52. 52. Facilitate experience sharing 52
    53. 53. Provide social support 53
    54. 54. 54
    55. 55. 55
    56. 56. Howbehaviorsarenegotiated 56
    57. 57. 57
    58. 58. Lessons Learned Working with partners is an efficient way of expanding programs. 58
    59. 59. Powerful messengers 59
    60. 60. 60
    61. 61. Observation #8 Clone early adopters 61
    62. 62. 62
    63. 63. 63
    64. 64. 64
    65. 65. We can do this !! 65
    66. 66. Social norms shift 66
    67. 67. Observation #9Capturethe pulse 67
    68. 68. Drive theprogram 68
    69. 69. 69
    70. 70. 70
    71. 71. 71
    72. 72. USAID BASICS Madagascar Project Immunization Coverage100 94 90 78 80 70 60 50 1996 baseline 40 1998 non-intensive 30 1998 IMCI 20 10 0 BCG Completely vaccinated Directory/Presenter/Filename 72
    73. 73. Essential Services in Ethiopia Project Directory/Presenter/Filename 73
    74. 74. Figure 12. Percentage of Respondents with‘High’ Social Support, Group Cohesion and Collective Efficacy Time Since Certification 74
    75. 75. Thank You 75
    76. 76. Discussion 76