December 2017

  • Blog post December 12, 2017

    Stop the Guessing: Fighting Cholera through Better Formative Research

    Tom Davis, MPH

    Global Sector Lead for Sustainable Health, World Vision International
    Little girl practices safe hand washing
    Little girl practices safe hand washing

    In order to be successful in our efforts to stop cholera, we need to better understand why some people adopt behaviors that stop cholera, while others do not. Although we all have pet theories on why people decide to do things based on our own anecdotal experience, we can often be wrong. To decide if vaccines and antibiotics are effective, we don’t sit around a table and guess - we would consider this highly unethical and unscientific. Yet when it comes to promoting behaviors, that’s what many projects end up doing. We need to stop the guessing, and conduct better formative research on the behavioral determinants for WASH behaviors and cholera immunization.

    Among the more popular formative research methods for identifying behavioral determinants are Barrier Analysis, RANAS, and the Alive & Thrive methods. Barrier Analysis (BA) is a rapid formative research tool used to identify behavioral determinants associated with a particular behavior so that improved behavior change messages and support activities can be used to facilitate behavior change [1]. A key feature of BA is that it statistically compares responses of people doing a behavior (the “Doers”) with those who are not (“Non-doers”). While studying water treatment in the Dominican Republic in 1990, I developed Barrier Analysis based on the Health Belief Model [2] and the Theory of Reasoned Action, and subsequently revised it based on the doer/non-doer analysis approach. Since then, hundreds of BA studies have been conducted by at least 33 international non-governmental organizations in 33 countries to study determinants of behaviors related to water, sanitation and hygiene, and other sectors.

    The results of 150 BA studies are now posted online on the FSN Network’s Behavior Bank [3] and some are in the published peer-reviewed literature. Analyzing these 150 studies, the most common reasons why people adopt or don’t adopt behaviors – the behavioral determinants – were found to be:

    • Perceived Self-efficacy, found in 86% of the BA studies: the belief that one can do a particular behavior given his/her current knowledge, skills, and resources. (e.g. whether or not a person believes that s/he can make it to an immunization post where cholera vaccine is offered).

       
    • Perceived Social Norms, found in 77% of the studies: the perception that people important to an individual think that he/she should do the behavior (e.g., whether a person believes that his or her spouse or neighbors approve of getting the cholera vaccine).

       
    • Perceived positive and negative consequences, found in 75% of the studies: the positive and negative things a person thinks will happen as a result of their performing a behavior (e.g., whether a person believes that the vaccine will make him or her get sick, avoid getting cholera, or become healthier overall).

       
    • Perceived Susceptibility to a disease or problem, found in 45% of the studies: a person's perception of how at risk they feel to a given problem/disease (e.g., how likely a person believes it is that he or she will get cholera in the next six months).
    Children in Myanmar wash their hands with soap at a hand-washing station. Photo: UNICEF/NYHQ2012-2056/Dean
    Children in Myanmar wash their hands with soap at a hand-washing station. Photo: UNICEF/NYHQ2012-2056/Dean

    The behavioral determinants on hand-washing with soap found through 17 BA studies posted on the Behavior Bank found similar determinants. Having a good idea of these barriers and enablers [4] will be crucial in the battle to stop cholera. Projects that use good formative research often have excellent results. For example, a Curamericas Global project in Liberia used BA and achieved impressive results on WASH and nutrition behaviors, and possibly due to that, had one of the steepest declines in child underweight of any USAID project (44 percentage points over five years). The proportion of mothers who practiced appropriate handwashing increased from 5% at baseline to 93% five years later and proper disposal of child feces also increased from 4% to 93%.

    The results from these studies are often surprising. For example, in Curamericas’ BA study of child feces disposal, they found that one prevalent and erroneous belief was that diarrheal diseases were chiefly airborne, so going to a latrine with its bad smells was perceived to be a good place to contract diarrhea rather than to prevent it. Who would have guessed that? In order to stop cholera, we need to stop the guessing and use rigorous formative research.

    References:

    [1] For a full description of this method, see the latest Barrier Analysis guide, A Practical Guide to Conducting a Barrier Analysis in English, French, Spanish and Arabic (http://www.fsnnetwork.org/practical-guide-conducting-barrier-analysis) and the Designing for Behavior Change training manual (http://www.fsnnetwork.org/designing-behavior-change-agriculture-natural-resource-management-health-and-nutrition) which is now available in English, French, Spanish, and Bangla.

    [2] See for example Koyaté et al (2015): http://www.sciencedirect.com/science/article/pii/S014971891400130X. 

    [3] See www.fsnnetwork.org/behavior-bank

    [4] See the Ebola Barrier Analysis Compendium for more information on barriers and enablers to WASH behaviors: http://www.fsnnetwork.org/ebola-barrier-analysis-compendium-summary-barrier-analysis-studies-ebola-related-behaviors.  

  • Blog post December 12, 2017

    Stop Yelling: Using Neighbors to Mobilize Communities to Stop Cholera

    Tom Davis, MPH

    Global Sector Lead for Sustainable Health, World Vision International
    Man speaks into loudspeaker during vaccination campaign. Photo: WHO/C. Black
    Man speaks into loudspeaker during vaccination campaign. Photo: WHO/C. Black

    Achieving high levels of coverage of multiple-dose vaccines – such as the cholera vaccine – takes more than good logistics. Promoting turnout for immunization requires the use of evidence-based community mobilization methods. In 1983, I was involved with some of the early mass immunization efforts in Haiti while working for International Child Care, an organization that led the first mass immunization in Haiti years earlier.

    As Zone Coordinator, I would ride motorcycle or get around on horseback – and sometimes just hike Haiti’s endless mountains – with our vaccinators to remote locations of the country. We had to rely on the help of TB Agents, local government leaders, and vaccinators with megaphones to announce posts and to mobilize people to come to the posts.

    These were not sophisticated methods – it was more yelling at people to try to get them to do something. Rumors spread about vaccines, not everyone was reached with announcements, and even though vaccines were made available, not everyone turned out. Nowadays we realize that it takes a lot more than this to get the high immunization coverage that will save lives. It requires actively involving communities, gaining people’s trust, understanding how people think, and communicating messages through people that they trust – even people that they choose based on that trust.

    We need to move forward: Some community mobilization and behavior change approaches are proving themselves to work better than others, especially those where the person doing the mobilizing has a closer relationship and more frequent contact with the people being mobilized. For example, recent research found that immunization coverage for tetanus toxoid (TT2) and measles increased 16 points and 9 points more (respectively) in programs that used the Care Group approach versus those that used other behavior change and community mobilization approaches during the same years and countries [1].

    Why? Care Groups are based on peer-to-peer behavior change, and neighbors can be quite effective in persuading their closest neighbors to adopt a new behavior, to try out something new, and to shut down rumors. In many – if not most – Care Group projects, women in the community directly choose their peer educator rather than that person being chosen by an organization or community leaders. This assures that the person teaching them and promoting behaviors is someone that they know, trust, respect, and like. This is key to behavior change and to effective mobilization.

    Differences in health service utilization: care groups vs non-care groups
    Differences in health service utilization: care groups vs non-care groups

    Peer educators have also proven themselves to be effective in mobilizing parents to seek out care for sick children, well child care, and other health facility services. Evidence from a larger-scale Food for the Hungry Care Group project in Mozambique, for example, found that care seeking and use of clinical services increased much more in districts using Care Groups when compared with adjacent districts that did not use the approach [2]. Cost-effectiveness is another reason that more and more organizations are using peer-to-peer behavior promotion approaches. Studies have found low costs per life saved for Care Group projects [3, 4], and an unpublished analysis that I conducted recently found a cost per behavior adopted of only $4.18. Combining the interpersonal communication used in peer-to-peer behavior promotion with effective mass media can bring about even better results.

    Other community mobilization and behavior change approaches, such as Participatory Learning and Action Groups, have also been found to be effective for changing behaviors and improving care seeking. For that reason, they may be an effective avenue for mobilizing people for cholera immunization. In order to take advantage of these groups, Cindy Pfitzenmaier and I, along with other collaborators and with the support of the CORE Group, the TOPS Project, and CORE Group members, recently created the Cholera Disease Preparedness Community Group Module [5] which has been distributed through UNICEF and WHO for the recent Cholera outbreak in Yemen, and sent to over 16 countries through USAID’s Office of Food for Peace and The TOPS Program.

    It’s time for everyone to put down the megaphone, stop yelling, and start using the quiet power of persuasive neighbors and peer-to-peer communication to boost community turnout for cholera immunization.

    References:

    [1] See George et al. BMC Public Health (2015) 15:835 DOI 10.1186/s12889-015-2187, https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-015-2187-2.

    [2] Davis, T., Wetzel, C., Hernandez Avilan, E., de Mendoza Lopes, C., Chase, R.P., Winch, P.J., and Perry, H.B. (2013). Reducing Child Global Undernutrition at Scale in Sofala Province, Mozambique, Using Care Group Volunteers to Contact Mothers Frequently with Health Messages. Global Health Science and Practice 1(1): 35-51. http://www.ghspjournal.org/content/1/1/35.full.pdf

    [3] See Perry et al (2015a), http://www.ghspjournal.org/content/3/3/358 for details on the Care Group approach, and Perry et al (2015b), http://www.ghspjournal.org/content/3/3/370 for results of the approach.  The Care Group training manual and other CG resources are available at www.CareGroupInfo.org.   

    [4] Tripathy et al. (2010).  Effect of a participatory intervention with women’s groups on birth outcomes and maternal depression in Jharkhand and Orissa, India:  a cluster-randomised controlled trial.  Lancet 2010; 375: 1182-92.

    [5] Pfitzenmaier, C; Davis, T; Srinivasan, A; and McDaniel, S (2016). CORE Group Cholera Module. Washington, DC. Food for the Hungry (FH).  http://www.coregroup.org/resources/616-cholera-module