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Achieving and Documenting
Impact at Scale
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
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
Study Population
General Population in 27 districts
• Women, 15-49 years old
• Men, 15-54 years old
• Multistage random sampling
• Covered all intervention areas
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
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
Achieving impact at scale:
Reach
Dose Response
Behavior Change Theory
Measurement
The Communication Pyramid
Awareness
Comprehension
Motivation
Intention
Action
Attenuation of
effects at each
stage
The Communication Pyramid
Awareness
Comprehension
Motivation
Intention
More reach at
the top means
more impact at
the bottom
Awareness
Comprehension
Motivation
Action
Intention
Action
The Communication Pyramid
for Family Planning Use
SURVEY SAMPLE
(n=7542)
EXPOSURE
(71% of sample, n=5387)
KNOWLEDGE
(96% of exposed, n=5153)
ATTITUDES
(48% of exposed, n=2609)
DISCUSSION
(33% of exposed,
n=1781)
Heard any of 4
FP campaigns
Knows at least one
modern method
Ideal number of
children is ≤ 4
Talked to partner
re: FP
BEHAVIOR
(25% of
exposed,
n=1335)
Using a modern
method
Source: UHMG/AFFORD/JHU∙CCP Joint BCC Survey, Oct-Nov 2012, n=7542
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
Safe Motherhood
Saving Mothers,
Giving Life
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%
Saving Mothers
Those exposed were more
likely…
• to think home delivery
was risky
• to deliver in a health
facility
Belief that NOT delivering health facility is
very risky
100
Percent
80
74
60
40
58
20
0
Not exposed (n=130)
Exposed (n=549)
*Men & women, 15-54 years old, in
Kyenjojo, Kabarole and Kamwenge,
n=679, p< .001
* Exact p-value = .043, N=379
Last birth delivered in health facility
100
Percent
80
60
40
66
77
20
0
Not exposed (n=58)
Exposed (n=321)
Saving Mothers
Odds Ratios for Key Outcomes by Exposure and Gender
Outcome
Knowledge of
need to go to a
heath facility
in case of
danger signs
Delivered at a
health facility
All
respondents
Men
Women
2.67*
3.10*
2.66*
-
-
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.
Saving Mothers
Self-reported actions as a result of exposure to the
Saving Mothers campaign, n=581
Arranged for transportation
3
Prepared maama kit or supplies
4
Put aside money to use for delivery
7
Talked to wife/partner about HF delivery
11
Planned to deliver at health facility
46
At least one action
70
0
20
40
60
Percent
80
100
HIV Prevention
Get Off the
Sexual Network
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%
Sexual Network
Unexposed
Exposed
100
Percent
80
60
44.8
46.5
40
14.7
20
18.3
0
Tested for HIV in past 12
months*
Used condom at last sex**
(n=2458/5083)
(n=2746/5623)
Note: Among sexually active persons, 15-54 years
* p<.182; ** p<.001
Sexual Network
Odds Ratios for Key Outcomes by Exposure and Gender
Outcome
Intention to
get HIV test
(self)
Sex with only
one partner in
past 12
months
All
respondents
Men
Women
1.32*
1.37*
1.39*
1.04
0.96
1.31*
*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.
Sexual Network
Odds of Testing for HIV by Number of Get off the Sexual
Network channels recalled
1.3*
Odds Ratio
1.2
1.2
1.0
0.8
0.4
0.0
Not exposed (N=983)
* p<.05
1 Channel (N=2,056)
2+ Channels (N=793)
Sexual Network
Self-reported actions as a result of exposure to Sexual
Networks campaign
Stop seeing a "side dish" and became faithful
to regular partner
8
Started using condoms
8
Went for HIV testing with my partner
11
Talked to someone about the Sexual Network
11
Discussed HIV prevention with my
spouse/partner
34
42
Reduced the number of sexual partners
66
Took at least one action
0
20
40
60
Percent
80
100
N = 3362 sexually active adults aged 15-54 years
Malaria
The Power of Day One
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%
The Power of Day One
Percent
Exposed
100
90
80
70
60
50
40
30
20
10
0
78
69
Unexposed
74
46
HH member treated within 24 HH member received blood test
hours for fever in past two
for fever in past two weeks**
weeks*
Note: n=269 in 3 districts; *p<.175, ** p<.001
The Power of Day One
Self-reported actions taken as a result of exposure to
Power of Day One campaign
Took my child for treatment within 24
hours of fever onset
Talked to someone about early testing
for malaria
Took my child for testing within 24 hours
of fever onset
Tested for malaria within 24 hours of
fever onset
14
22
31
52
Took at least one action
64
0
20
40
60
Percent
80
100
Note: Adults age 15-54 years exposed to Power of Day One
in 3 districts, n=394
Careseeking and testing for malaria by gender
and combined exposure to malaria campaigns
Treatment Group (Exposed)
Matched Control Group (Unexposed)
Net Difference
60
Percent
26
26
21
19
20
10
46
40
40
30
49
48
50
5
7
8
4
0
MEN
WOMEN
Average effect on CARESEEKING
for HH member with fever in
past two weeks
MEN
WOMEN
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.
Family Planning
Smart Choices
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
Smart Choices
Percent
Unexposed
100
90
80
70
60
50
40
30
20
10
0
52.3
31.3
58.4
38.6
Discussed FP with
partner**
(n=5136)
Exposed
35.6
41.7
Discussed ideal family
Current use of
size with partner** modern FP method*
(n=5235)
(n=3640)
Note: Among sexually experienced persons, 15-54 years
* p<.05; ** p<.002
Smart Choices
Odds Ratios for Key Outcomes by Exposure and Gender
All
respondents
Men
Women
Current use of a
modern FP
method
1.26*
1.30*
1.34*
Discussed FP with
partner
1.12
1.40*
0.98
Ideal family size is
≤ 4 children
1.11
1.23*
0.97
Outcome
*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.
Smart Choices
Self-reported actions as a result of exposure to
Smart Choices (n=786)
Started using condom
3
Started using implant
3
Started using Injectaplan
5
Started using pills
8
Started using IUD
10
Talked to friend about FP use
16
Talked to provider about FP use
19
Talked to partner about FP use
24
Took at least one action
55
0
20
40
60
Percent
80
100
Smart Choices
Odds Ratios—Current Use of Modern FP by
Number of Smart Choices Channels
Recalled
2.0
1.6
1.2
1.8*
1.9*
1 Channel
(N=643)
2+ Channels
(N=108)
Greater impact occurred
with exposure to more
channels of communication
1.0
0.8
0.4
0.0
Not exposed
(N=1,565)
Odds Ratios—Discussion of FP with Partner
by number of Smart Choices Channels
Recalled
4.0
3.6*
3.2
Note: Among sexually active individuals
* p<.05
2.4
1.6
1.8*
1.0
0.8
0.0
Not exposed (N=1,565)
1 Channel (N=643)
2+ Channels (108)
Modern FP use, ideal family size and partner
approval of FP by combined exposure
to FP campaigns
Treatment Group (Exposed)
Matched Control Group (Unexposed)
Net Difference
80
70
69.5
63.1
62.9
Percent
60
50.7
50
36.0
40
30.3
30
20
10
6.4
12.2
5.7
0
Ideal family size ≤ 4
children
Perceived partner
approval of FP
Current use of modern
FP
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.
Impact of combined exposure to FP campaigns
on key ideational variables (ideal family size
and partner approval of FP) by gender
Treatment Group (Exposed)
80
70
Percent
60
Matched Control Group (Unexposed)
71.9
67.4
65.3
56.4
62.8
50
Net Difference
62.5
55.6
44.7
40
30
20
10
18
8.9
7
4.5
0
MEN
WOMEN
Average effect on perceived
ideal family size of ≤ 4 children
MEN
WOMEN
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.
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
Thank you…and have a