Highlights from the USAID Joint Behavior Change Communication Survey

Douglas Storey, PhDJHU CCP Director for Communication Science & Research∙

UHMG Annual Event4 June 2013

Kampala, Uganda

Achieving and Documenting Impact at Scale

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 ResponseBehavior Change Theory

Measurement

Awareness

Comprehension

Motivation

Intention

Action

The Communication Pyramid

Attenuation of effects at each stage

Awareness

Comprehension

Motivation

Intention

Action

The Communication Pyramid

More reach at the top

means more impact at the

bottomAwarenessComprehension

Motivation

Intention

Action

SURVEY SAMPLE(n=7542)

EXPOSURE(71% of sample, n=5387)

ATTITUDES(48% of exposed, n=2609)

KNOWLEDGE (96% of exposed, n=5153)

DISCUSSION(33% of exposed,

n=1781)

BEHAVIOR(25% of

exposed, n=1335)

Heard any of 4FP campaigns

Knows at least onemodern method

Talked to partnerre: FP

Using a modernmethod

The Communication Pyramidfor Family Planning Use

Ideal number ofchildren is ≤ 4

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

*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

Not exposed (n=58) Exposed (n=321)0

20

40

60

80

100

6677

Last birth delivered in health facilityPe

rcen

t

Not exposed (n=130)

Exposed (n=549)0

20

40

60

80

100

5874

Belief that NOT delivering health facility is very risky

Perc

ent

Saving Mothers

OutcomeAll

respondents Men WomenKnowledge 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

Saving Mothers

At least one action

Planned to deliver at health facility

Talked to wife/partner about HF delivery

Put aside money to use for delivery

Prepared maama kit or supplies

Arranged for transportation

0 10 20 30 40 50 60 70 80 90 100

70

46

11

7

4

3

Self-reported actions as a result of exposure to the Saving Mothers campaign, n=581

Percent

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

Tested for HIV in past 12 months*

Used condom at last sex**0

20

40

60

80

100

44.8

14.7

46.5

18.3

Unexposed Exposed

Perc

ent

Note: Among sexually active persons, 15-54 years* p<.182; ** p<.001

(n=2746/5623)(n=2458/5083)

Sexual Network

OutcomeAll

respondents Men WomenIntention to get HIV test (self)

1.32* 1.37* 1.39*

Sex with only one partner in past 12 months

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.

Odds Ratios for Key Outcomes by Exposure and Gender

Sexual Network

Not exposed (N=983) 1 Channel (N=2,056) 2+ Channels (N=793)0.0

0.4

0.8

1.21.0

1.3* 1.2

Odds of Testing for HIV by Number of Get off the Sexual Network channels recalled

Odd

s Ra

tio

* p<.05

Sexual Network

Took at least one action

Reduced the number of sexual partners

Discussed HIV prevention with my spouse/partner

Talked to someone about the Sexual Network

Went for HIV testing with my partner

Started using condoms

Stop seeing a "side dish" and became faithful to regular partner

0 10 20 30 40 50 60 70 80 90 100

66

42

34

11

11

8

8

Self-reported actions as a result of exposure to Sexual Networks campaign

Percent

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

Note: n=269 in 3 districts; *p<.175, ** p<.001

020406080

100

78 746946

Exposed Unexposed

Pe

rce

nt

The Power of Day One

Took at least one action

Tested for malaria within 24 hours of fever onset

Took my child for testing within 24 hours of fever onset

Talked to someone about early testing for malaria

Took my child for treatment within 24 hours of fever onset

0 20 40 60 80 100

64

52

31

22

14

Self-reported actions taken as a result of exposure to Power of Day One campaign

Percent

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

MEN WOMEN MEN WOMEN0

10

20

30

40

50

60

26 26

48 49

21 19

4046

5 7 84

Treatment Group (Exposed) Matched Control Group (Unexposed)Net Difference

Perc

ent

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.

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

020406080

100

31.352.3

35.638.658.4

41.7

Unexposed Exposed

Per

cen

t

Note: Among sexually experienced persons, 15-54 years* p<.05; ** p<.002

(n=5136) (n=5235) (n=3640)

Smart Choices

OutcomeAll

respondents Men WomenCurrent 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

*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

Smart Choices

Took at least one action

Talked to partner about FP use

Talked to provider about FP use

Talked to friend about FP use

Started using IUD

Started using pills

Started using Injectaplan

Started using implant

Started using condom

0 10 20 30 40 50 60 70 80 90 100

5524

1916

108

533

Self-reported actions as a result of exposure toSmart Choices (n=786)

Percent

Smart Choices

Not exposed (N=1,565)

1 Channel (N=643)

2+ Channels (N=108)

0.0

0.4

0.8

1.2

1.6

2.0

1.0

1.8* 1.9*

Odds Ratios—Current Use of Modern FP by Number of Smart Choices Channels Recalled

Not exposed (N=1,565)

1 Channel (N=643)

2+ Channels (108)

0.0

0.8

1.6

2.4

3.2

4.0

1.01.8*

3.6*

Odds Ratios—Discussion of FP with Partner by number of Smart Choices Channels Re-

called

Greater impact occurred with exposure to more channels of communication

Note: Among sexually active individuals* p<.05

Modern FP use, ideal family size and partner approval of FP by combined exposure

to FP campaigns

Ideal family size ≤ 4 children

Perceived partner approval of FP

Current use of modern FP

0

10

20

30

40

50

60

70

8069.5

62.9

36.0

63.1

50.7

30.3

6.412.2

5.7

Treatment Group (Exposed) Matched Control Group (Unexposed)Net Difference

Perc

ent

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

MEN WOMEN MEN WOMEN0

10

20

30

40

50

60

70

80

65.371.9

62.8 62.556.4

67.4

44.7

55.6

8.9 4.5

187

Treatment Group (Exposed) Matched Control Group (Unexposed)Net Difference

Perc

ent

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.

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