COMBI - a toolkit for social communication in fighting NCDs

COMBI: A TOOLKIT FOR SOCIAL COMMUNICATION IN FIGHTING NCDs

DR AZIZAH AB MANAN Public Health Physician

Senior Principal Assistant Director Of Health (Non Communicable Disease Control)

Penang State Health Department

8th National Public Health Conference, 2- 4th August 2016 , Hotel Equatorial, Melaka

COMBI TRAINING IN PENANG, 23rd Sept– 2nd Oct 2015Facilitator: Dr Everold Hosein (Ph.D), WHO Consultant

Outline

Trend Of NCDs & its Challenges What is COMBI Why Do We Need COMBI Is COMBI a Good investment ?

8th National Public Health Conference

Introduction

Non Communicable diseases account for a growing number of health burdens on families, communities and governments in Malaysia.

NHMS(up to 2015) reported increasing in NCDs trend over the years

11.6

15.2

17.5

7.0

7.28.3

4.5

8.09.2

4.24.9 4.7

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

20.0

NHMS III (2006) NHMS 2011 NHMS 2015

Pre

vale

nce

(%)

Prevalence of Diabetes, ≥18 years (2006, 2011, 2015)

Total diabetes Known Undiagnosed IFG


Prevalence of obesity and overweight, ≥18 years

4.5

1415.1

17.716.6

29.1 29.4 30

0

5

10

15

20

25

30

35

1996 2006 2011 2015

Pre

vale

nce

(%)

obesity overweight


NCDs burden responsible for up to 60% of all deaths, 80% are in low- and middle-income countries

4 major noncommunicable diseases: Cardiovascular disease Cancer Chronic Respiratory disease Diabetes

5 shared preventable risk factors: Tobacco use Obesity Unhealthy diet Physical inactivity Harmful use of alcohol

Chronic Respiratory

DiseasesCardiovascular

Disease

Diabetes Cancer

Harmful use of alcoholObesity

Unhealthydiets

Smoking

Physical inactivity

Other NCDs


NCDs Burden

Prevention and Control of NCDs Many different approaches have been useful in the past, ranging from health

education to development support communication for social mobilization

Numerous health campaigns over the years ( eg: healthy lifestyles campaign including anti smoking, 10 thousand steps etc)

While there have been some successes, there also been enormous frustration at not being able to achieve more at a faster rate

As a consequences, public health programmes struggle along -with minimal behavioural impact


Life and ‘style’ of millions is pushed like powerful flood waters

Our response is like a broken canoe with 3 people trying to stop the Tsunami – the risk behaviours

Sporadic small initiatives


Challenges in Reducing NCDs burdenAre we in the right tract?

NCD prevention and control depends on people carrying out very specific behaviours: putting less salt in the food one eats,

exercising at least three times per week,

eating a balanced diet, eating less,

checking one’s blood pressure, checking one’s diabetes status, not smoking, and the list goes on.

If we fail to get people adopting and carrying out these behaviours, we will fail to make a difference to NCD.

We cannot get people adopting and carrying out these behaviours unless we intimately and purposefully engage them in considering the merits of recommended behaviours.

Someone has to Do something; it is not enough to be aware, or motivated, or persuaded. Knowing what to do and actually doing it are quite different things.

We need to now not only focus on giving awareness and knowledge , need to do more!

Was adopted by WHO since 2000, Has its roots in private sector consumer communication and Integrated Marketing Communication

COMBI emphasises on : Sharp focus on achieving specific behavioural outcomes and not only informing and educating the

public. Go beyond increasing awareness and knowledge

Offers a 10-Step process Begins with community-based behavioural research or known as situational market analysis for

communication keys (SMA-CK) and then applies a synchronised, integrated blend of communication actions to the task of engaging people about the merits of recommended behaviours.

Social mobilization with a behavioural bite: Mobilization directed at the task of mobilizing all societal and personal influences with the aim

of prompting individual and family action with respect to specific healthy behaviours.

What is Communication for Behavioural Impact- COMBI?


COMBICOM= Communication, B –Behavioural, I=Impact

(Not Behavioural Change –but Behavioural Maintenance as ultimate result)

COMBI QUERY

HOW COME PEOPLE KNOW BUT DON’T ACT?

HOW COME WE BUILD SERVICES BUTPEOPLE DON’T COME?

THE REALISATION:

KNOWING WHAT TO DO IS DIFFERENT FROM DOING IT (yet we persist with communication for awareness and education.)

WAYS OF BRIDGING THIS KNOWELDGE/ACTION GAP

10 STEPS : COMBI10 step process for developing an integrated and synchronized communication

plan aiming to achieve significant behavior impact

Implementation, Monitoring And Evaluation, Budgeting Step 6: Management And Implementation

Of COMBIStep 7: Monitoring Implementation

Step 8: Assessment Of Behavioural Impact

Step 9: Implementation Plan

Schedule Step 10 :The Budget

The Communication Strategy and COMBI Plan of Action

Step 4: The Overall Strategy For Achieving The Stated Behavioural

Result (Restate the SBO) Step 5: The COMBI INTEGRATED PLAN

Identifying The Behavioural Objectives ( Critical Steps )

Step 1: The Overall Goal Step 2: The BehaviouralObjectives

Step 3: Conduct Situational Market Analysis for

CK(SMACK)

3 IMPORTANT PRINCIPLES IN COMBI (Three life episodes and lessons learned by the COMBI founder )

3 COMBI foundational

principles

CONNECT

MINDFUL OF THE

COMPETITOR LISTEN


Connect

Connect to the individual’s need, want, or desire and not focus

just on the technical merits of recommended

behaviours

Our recommended behaviours may be technically fantastic but

unless individuals see these behaviours as connected to

what is of value to them, they will remain understood but not

adopted.


The public is thinking: What's in it for me?

One of the most important aspects of marketing is togive your customers a reason to buy your products / services


Deep understanding of why the competitor is preferable

More sensitive engagement with people as we offer the value of recommended behaviours

What are your products and services? What are their benefits? How do they differ from competitors’ product and services ?


Mindful of the CompetitorWho are the Competitor??

The alternative behaviour or non-behaviour (no action)

more appeal to the individual than what we are recommending!

LISTEN :Listening to individuals, families and the community Tells us whether our behavioural recommendations are realistic and appropriate.

It is in listening to people that we Learn !

-how they wish to be engaged -how to connect the action to their life -how to offer in a more realistic way what at first seems unrealistic

Listen


Do nothing…. make no posters/phamplets , no t-shirts, no videos, etc… do nothing,

until one has set out sharp, specific, precise behaviouralgoals or objectives

Prevents the rush into the production of “IEC” (information-education-communication) materials such as T-shirts and posters and pamphlets, without first thinking through the relevance of these materials to the behavioural outcome desired.

These materials may or may not be needed; but this decision turns on how these items serve the behavioural objective(s). And that calls for a clear statement of expected behavioural results at the very start.

To make it precise and sharp , apply:• The 4 + 1 WsWho will do What, Where, When,….and, by the way, Why?

• SMARTS = SpecificM= MeasurableA= AppropriateR= RealisticT= Time-bound


Planning Principle 1: COMBI Mantra #1:

Penang COMBI KOSPEN: Step 1: Overall Goal

To decrease morbidity and mortality due to chronic non-communicable diseases (primarily cardiovascular

diseases, hypertension, diabetes), linked to obesity, poor nutrition, and inadequate physical activity in Penang

STEP 2: STATE TENTATIVE SPECIFIC BEHAVIOURAL OBJECTIVE(SBOS)

The entire COMBI Plan turns on this specification of expected

behavioural outcomes It would be best to limit our

focus and restrict oneself to one fundamental behavioural

objective at a time. At most, no more than three

related behavioural goals . The more precise and specific the behavioural objective, the better

the impact

In tackling too many desired behavioural outcomes, we may very well end up, like butterflies, flitting from one flower to the next, but not accomplishing very much by the end of a year . We would have worked hard and have been well intentioned but in attempting to do too much, we achieve little.

Research over the years have shown that people have enormous difficulty in recalling more than three themes or messages from a communication presentation


Do nothing…. make no posters, no t-shirts, no videos, etc…do nothing …until one has carried out a Situational “market” analysis (SMA) in relation to preliminary behavioural goals/objectives.

Why the Situational Market Analysis (SMA)?To discover the Communication Keys (CK) which would enable

engaged communication with the “consumer” to facilitate consideration of the suggested behaviour.

SMA = LISTEN TO THE CUSTOMER


Planning Principle 2: COMBI Mantra #2:

The Situational “Market” Analysis for Communication Keys (SMACK)

SMACK is essential to understand the desired behaviour from the perspectives of the “consumer”.

SMACK will prompt one to examine those reasons why people do or do not accept a recommended health behaviour

Critical step in acquiring an understanding of the desired behavioural result from the perspective of the “consumer


First, we Hear about the new behavior

then, we become Informed about it

and later Convinced that it is worthwhile.

__________________________________________________________________________________________________________

In time, we make the Decision to do something about our conviction

and later we take A ction on the new behavior

We await next Re-confirmation that our action was a good one

and if all is well, we M aintain the behavior

HIC-DARM Analysis: GETTING THE BEHAVIORAL RESULT

TO ASSESS THE CURRENT SITUATION : knowledge levels, attitudes, current behaviours, behavioural trends.

HOW COME PEOPLE KNOW BUT DON’T ACT? HOW COME WE BUILD SERVICES BUT PEOPLE DON’T COME?

KNOWING

DOING

Anthropological-type Research DILO (Day in the Life Of) Analysis MILO (Moment in the Life Of) Analysis TOMA (Top of the Mind) Analysis

Armchair—sit and think

Research by walking around, then sit and think

In-depth interviews

Focus Group Research: Homogeneous, small groups,

questionnaire guide, open-ended questions. Usually one issue – in private sector: shape of bottle; screw top. Bias in interviewers if health staff. Note non-verbal cues. Caution with focus groups

Force Field Analysis ,SWOT Analysis: Strengths, Weaknesses, Opportunities, Threats

Primary sources (Survey/ Quantitative/Qualitative Research)

Secondary sources/Secondary Analysis


SMA involves listening to people and learning about their perceptions on recommended behaviour(s) through tools such as :

Tools for the Situational Marketing Analysis-Market research

DILO (Day in the Life Of) Learn the behaviour of the day. To examine the daily activities of those we wish to engage to identify the communication contact points

MILO (Moment in the Life Of) Is the behaviour feasible, realistic, trial .To examine the difficulties/steps involved in carrying out the recommended behaviour

TOMA (Top of the Mind Analysis)What is the first thing they think / top of their mind that relate to the behavior. To explore people’s perception and immediate association with the behaviour


Tools for the Situational Marketing Analysis

PRODUCT C1 : Consumer’s

Need/Want/Desire

We do not sell a service/behaviour

We offer a solution to your Need/Want/Desire

We do not create Needs/Wants/Desires; We respond to what is

there; if latent, we bring to the top-of-the mind.

Explore TOMA

PRICEC 2 : Cost

in relation to benefit @ value and in relation to

the Competitors

Not just price; but time, effort, etc.

–Reducing cost by incentives affects cost/value ratio

–Increasing value by branding affects

cost/value

Explore MILO

PLACEMENTC 3 : Convenience

to get product or service or to carry out behaviour.

what alternative behaviours serve as competitors to the

recommended behaviour

Explore The DILO

PROMOTION C4: Communication

Integrated, Engaged Communication Using the Five-Point Star Blend of

Communication Interventions

Integrated Marketing Communication The 4 C’s – Consumer Need analysis to get the DARM

HICDARM confronts a major challenge in behaviour adoption: How come we know what to do but we don’t do?

The Four Cs offer some answers to that query: We fail to connect to the first C, the Consumer’s Need/Want/Desire We fail, with the second C, Cost, to engage the consumer in a fresh review of the

Costs vs. value calculation We fail, with the third C, Convenience, to show how feasible it is to carry out the

behaviour. We fail, with the fourth C, Communication, to engage via an integrated, synchronised,

blend of communication actions with regard to the first three Cs.

HICDARM AND THE FOUR Cs

“We have a great product/service/behaviour in response to your need/want/desire (C1) at a wonderful cost/value ratio (C2) and easily available (C3).”

Head Knowing

HIC

HeartDoingDARM

BehaviourChange

HICDARM – NEEDS & GOALS

Hear Informed

Convinced

Decision Action

Re-confirmationMaintenance


6%

9%

12%

13%

20%

16%

24%

Hear Informed Convinced Decision Action Re-confirm Maintain

Have heard but now needs to be informed

Now needs to be convinced-that is worthwhile

Need to be triggered/ encouraged to Decideto do something about the behaviour

Need to be prompted to Act

Have acted and now need to have action Re-confirmed

Need to be encouraged to maintain the behaviour

Psychographic market segmentation: NOSA analysis: target groups, priority market segments.


Have yet to hear about the behavior eg: 10000 steps

SMACKing – Situational Market Analysis for Communication Keys(CK)

To have within a period of 12 months from the start of this COMBI

programme, 25% of individuals age 18 and older (approximately 330,000 of

1.3 million in this age group) who are not now engaged in “High Physical

Activity” (HPA) to carry out Brisk Meditative Walking” (BMW) every other

day for one session of 30 minutes (BMW 30) which is about 3000 steps

or an accumulated 30 minutes (meaning two 15-minute sessions

(approximately 1500 steps per session) or three 10- minute sessions,

approximately 1000 steps per session) for three separate periods of 21

days within the first year of this COMBI Plan, OR carrying out some

other kind of equivalent Vigorous Physical Activity of their choosing in

the same time period,

Step 4: Restate Specific BehaviouralObjective (SBOs)

Example : SBO To have 50% (800,000 women) of all women giving birth

in Vietnam during the 12 month period of December 2010 and November 2011 (projected to be 1.6 million women giving birth) “exclusively breast feed” their baby for a period of six months from within one hour of birth to the end of the first six months, meaning that they feed the baby nothing else but breast milk, not even water, no other liquids, no infant formula, and no other food but breast milk. This behaviour, for the moment, will be referred to as EB6 Behaviour. It will be later re-branded.


Behavioural ThemeBranding ✔ BMW 30

Brisk Meditative Walking Just 30 minutes. All at once. Or 3 x 10-minutes, Or 2 x 15 minutes Every other day – 21 days – Just 5 weeks And then add two more 21 day sessions Be Healthy, Look Good, Feel Good

Branding

✔ BMW 30

Rebranding: Cabaran AKTIF21 hari

Hanya 30 minit

Sekali gus atau 3 x 10-minit, atau 2 x 15 minit

Minima selang sehari selama – 21 hari – hanya 5 minggu

Ulangi sekurang kurangnya 2 lagi pusingan selama 21 hari

Cergas tubuh dan minda , lebih tenaga untuk segalanya….


1. Public Relation/Advocacy/Administrative Mobilization: Highlighting the particular behaviour on the public and administrative/programme management agenda via various key channels such as mass media, news coverage, official memoranda, community leaders agenda, capacity building etc…

2. Community Mobilization: group meeting, partnership, traditional media, road shows, leaflets, posters, home visits, community research etc

3. Sustained appropriate advertising: M-RIP-Massive, Repetitive, Intense, Persistent via mass media, engaging with people. Six Hits: To truly engage the consumer, strive for “six hits” per day for five days per week for three weeks. Six flights per year (minimum 3 x /year) – Key media channel

4. Personal Selling/Interpersonal communication/Counselling: At community level at service points, door to door. Use SHAPE to communicate ( sincere/sensitive, humorous/ honest , attentive/articulate, proficient, empathetic, enthusiatic) and other personal counselling principles.

5. Point of service promotion : Accessible and readily available solutions to health problems

Step5: The COMBI INTEGRATED PLAN (Using the Communication Keys – arising from the smacking activity and outline the communication strategy

COMBI’s Five Integrated Communication Actions

A COMMUNICATION MODEL: MS.CREFSM ESSAGE

S. OURCE

C HANNEL

R ECEIVER

E FFECT

FEEDBACK

SETTING

what media/channels are most popular and most influential; what traditional media are used; who would be credible sources of information; what media would provide useful triggers and prompts to action; how does information and influence flow in communities and families;

are there local marketing, advertising, public relations agencies, etc. Relating to MS.CREFS

Syncronised, Strategic, Integrated—everything with a behavioural hook.

M-RIP: Massive, Repetitive, Intense, Persistent

Six Hits: To truly engage the consumer, strive for “six hits” per day for five days per week for three weeks.

Six flights per year : minimum 3 x /year

Not Cheap

COMBI’s Five Integrated Communication Actions


Where is COMBI being Applied ( Ref: WHO,2004)

Health Programme

Countries Where COMBI Planning and Implementation are taking Place

Dengue Belize (planning), Brazil (planning), Cambodia (pre-implementation), Costa Rica (pre-implementation), Cuba (planning), Dominican Republic (pre-implementation), El Salvador (planning), Guatemala (implementing), Honduras (planning), Indonesia (pre-implementation), Lao People’s Democratic Republic (implementing), Malaysia (implemented 2001), Myanmar (pre-implementation), Nicaragua (implementing), Panama (planning), Philippines (planning), Thailand (planning)

HIV/AIDS Moldova (planning), Sudan (planning), Ukraine (planning)

Leprosy India (implemented 2002), Mozambique (implementing)

Lymphatic Filariasis

India (implemented 2002,2003), Kenya (implemented 2002, 2003) Myanmar (planning), Nepal(implemented 2003), Philippines (implemented 2003), Sri Lanka (implemented 2002, 2003), Tanzania (planning), Uganda (planning), Zanzibar (implemented 2001, 2002, 2003)

Malaria Afghanistan (pre-implementation), Ghana (pre-planning), Sudan (pre-implementation), Uganda (planning)

TB Bangladesh (planning), India (implementation), Kenya (implementation)

How can one tell if COMBI works?

COMBI’s impact is defined by the behavioural results specified from the very outset. Once these have been established, the social science research methods of tracking surveys, sample surveys, field observation and in-depth interviewing allow for measuring the achievement of specific behavioural results

The essential pre-requisite, however, for measuring impact is having clear behavioural outcomes as programme goals

In Johor Bahru, Malaysia, a three-month COMBI Programme resulted in 85% of households in sampled areas carrying out the desired behavioural task over a 12-week period. Three months later, 70% were still maintaining the checks

COMBI has also supported over 40 million people to participate in Mass Drug Administrations, motivating over 75% of entire populations to prevent lymphatic filariasis in 6 COMBI-supported countries. Sri Lanka and Kenya both attained over 80% of the total populations, meaning that over 90% of those eligible for treatment had complied

In the state of Bihar, India, COMBI contributed to early case detection of leprosy through improving the number of people selfreporting at clinics. The proportion of skin cases attending clinics rose by 69% with the number of female skin cases rising by 73%

Leprosy: skin cases attending clinics increased by 69% Skin cases (women) attending clinics increased by 73%

Leprosy control, Bihar State, India Over 6,000,000 people targeted

Key behaviours: “Check your skin for early signs of leprosy” and “Seek early diagnosis”

Campaign was M-RIP: 200,000 posters, 84 radio spots, 41

newspaper advertisements (in concentrated flights)

68 vehicles used for community mobilisation over 3 days

400,000 school children took home worksheets

3,000 banners and dangler flags at service centres, 22,000 badges worn by staff


Moldova COMBI : To promote positive mother and child health @ antenatal/Child care behaviours as part of a United Nations Children's Fund (UNICEF)/Ministry of Health and Social Protection campaign

69%

32%

62% 59%

81%76%

88% 91%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Seeing a doctor in the first12 weeks of pregnancy

Taking folic acid in the first12 weeks of pregnancy

Taking iron tablets for atleast 2 months during

pregnancy

Knowledge of danger signs

Before

After


Is COMBI a good investment?


COMBI’s investment value lies in the following:

• Social mobilization will be strategically targeted

• Existing resources will be better utilized

• The true constraints and problems affecting behavioural outcomes will be in greater understanding

• Encouraging public-private sectors partnerships

• Give more value for money , should be able to sustained if done in a proper way …..

Conclusion COMBI incorporates the many lessons of the past 50 years of health education

and communication in behaviourally-focused, people–centered strategy

Its methodology effectively integrates health education, community mobilization, consumer communication techniques and market research, All directed sharply and smartly to specific, precise behavioural outcomes in health

It can be used as an effective communication tools to reduce NCDs and its risk factors

So remember …….Connect, listen, be mindful of the competitor and DO NOTHING


ACKNOWLEDGEMENT & References

Dr. Everold N. Hosein (Ph.D), Senior Communication Advisor-Consultant, World Health Organization (WHO) and Communication Consultant to UNICEF, UNFPA, and UNDP

Mobilizing For Action – COMBI , WHO Mediterranean Centre for Vulnerability Reduction(WMC), Tunis

National Health Morbidity Survey 2015 report , Institute for Public Health (IKU)

Training on Strategic Health Communication Planning: Applying WHO’s Communication for Behavioural Impact(COMBI) Planning Methodology for Behavioural Results in Health ( Focus on NCD), Penang 28th Sept – 2nd October 2015

COMBI – Sharing Countries initiative (internet link)

For more information on how COMBI may be applied to behavioural goals in promoting healthy behaviours, please contact email: [email protected]

mailto:[email protected]


Healthcare

COMBI - a toolkit for social communication in fighting NCDs