COMBI: Communication for Behavioural Impact: COMBI: Communication for Behavioural Impact Linda S. Lloyd, Dr.P.H. Consultant, WHO/WMC
WHO, UNICEF, MOH-Maldives Male’, Maldives March 2006 What is COMBI?: What is COMBI? A dynamic approach to behaviour change that utilizes:
Strategic Social Mobilization Social Communication + = Measurable changes in behaviour! Why do we need a new approach?: Why do we need a new approach? Although there are good examples of IEC (Information, Education, Communication) programs that have improved knowledge and attitudes, there are few good examples of communications programs with measurable changes in behaviour
It is critical to measure actual changes in behaviour, not just assume it has occurred COMBI: based on theory and practice: COMBI: based on theory and practice
Behaviour change theories
Points in common among behaviour change theories: Points in common among behaviour change theories The person or community should have:
a positive intention toward the new behaviour
a minimum of barriers to achieve the behaviour
sufficient ability to carry out the behaviour
encounter messages that serve as reminders
Believe that the actions will have positive
results and benefits Elder, J. et al. 1998. Strategies for Health Education:Theoretical Models.
In Handbook of Immigrant Health, Sana Loue (Ed). New York:Plenum Press COMBI is different because: COMBI is different because
it is a methodology for planning sustained actions in communication and social mobilization.
COMBI focuses on measurable changes in behaviour,
changes in knowledge or attitude. History of COMBI: History of COMBI 1994: Dr. Everold Hosein offers the first 'Integrated marketing communication for behavioural impact in health and social development' course at New York University
2000: WHO promotes the COMBI methodology for planning communication and social mobilization actions History of COMBI: History of COMBI 2003: The Regional Dengue Program of the Pan American Health Organization (PAHO/WHO) promotes COMBI as an integral part of the Framework for a New Generation of Dengue Prevention and Control Programs in the Americas (EGI-Dengue, Strategy for Integrated Management for Dengue Programs)
(http://www.paho.org/english/ad/dpc/cd/dengue-nueva-generacion.htm) Slide10: 2004: publication of the COMBI guide for dengue (WHO,TDR,PAHO):
Planning social mobilization and communication for dengue fever prevention and control: a step-by-step guide.
http://www.who.int/tdr/publications/publications/planificacion_dengue.htm Slide11: 2000 – 2005: WHO and UNICEF use COMBI for leprosy, malaria, filariasis, TB, HIV/AIDS
2003 – 2005: WHO, PAHO and CDC implement a COMBI initiative for the prevention and control of dengue COMBI in action: COMBI in action HIV/AIDS:
Republic of Moldova, Ukraine, Kenya, Sudan, Bolivia
India, Kenya, Sri Lanka, Zanzibar, Myanmar, Nepal Slide13: Malaria:
Afghanistan, Sudan, Ghana, Bolivia
Kenya, India, Bangladesh COMBI in action - Dengue: COMBI in action - Dengue the Americas:
Barbados, Bolivia, Brazil, Colombia, Costa Rica, Dominican Republic Ecuador, El Salvador, Guatemala, Honduras, Nicaragua
Cambodia, Laos, Malaysia Slide15: HICDARM Achieving behavioural results Hear about the new behaviour Inform yourself about it
Convince yourself that it is worthwhile IEC programs focus on HIC Decide to do something about it
Act on this decision
Reconfirm that your action has had a positive result
Maintain the behaviour COMBI focuses on DARM
guide , pg. 5
©Hosein What do we hope to achieve through our communication programs?: What do we hope to achieve through our communication programs? We want to
Influence a decision/behaviour/social norm
Reinforce a decision/behaviour/social norm What do we hope to achieve through our social mobilization programs?: What do we hope to achieve through our social mobilization programs? We hope to
Mobilize various sectors of society to take action on a common issue
Create a sense of shared responsibility The 15 steps for COMBI planning:: The 15 steps for COMBI planning:
1. Assemble a multidisciplinary planning team: 1. Assemble a multidisciplinary planning team to:
determine the behavioural objetives
review the formative research results COMBI Team
Male’, Maldives Slide20: direct the pre-testing of the behaviour, the message(s) and the materials design the communication and social mobilization strategy evaluate implementation of the strategy COMBI poster Nicaragua 2. Establish preliminary behavioural objetives.: 2. Establish preliminary behavioural objetives.
COMBI Mantra #1
Do nothing – produce no T-shirts, no posters, no leaflets, no videos - do nothing until you have a specific behavioural objective! Step-by-step guide, pg. 10 Analytical methods for setting behavioural objetives : Analytical methods for setting behavioural objetives
Risk factor analysis
BEHAVE framework analysis
SMART objective analysis
(Specific, Measurable, Appropriate, Reasonable, Time-limited)
Step-by-step guide, Tool #4. Example: “SMART” Objectives: Example: 'SMART' Objectives Specific: based on priority behaviours
Measurable: you can measure the adoption, or not, of the behaviour
Appropriate: your target audience understands what the behaviour is, the behaviour is culturally acceptable
Reasonable: the objective can be achieved given existing resources
Time: within a specified time period Step-by-step guide, 'Step 2' and 'Tool 4' Slide24: Plastic containers and miscellany on roof tops, Male’, Maldives Open water storage container, Male’, Maldives Oil containers storage in back yard,
Himmafushi Slide25: Possible Objective for Plastic containers/miscellany:
Current message: Turn over or throw away.
COMBI Objective: Challenges –
what is trash, what is useful?
use roof for storage: 'out of sight, out of mind'
who is responsible for checking the roof? Slide26: Rooftop Garden, Male’ Water plants, Male’ Rooftop garden shop, Male’ Slide27: Possible Objective for Water Plants:
Current message: Change the water two times a week.
COMBI Objective: Challenges –
number of water plants in house
may not be in clear container so can’t see water has organic material
cost of rooting gel as substitute for water? Slide28: Open well, Male’ Abandoned open well, Himmafushi Partially covered open well, Male’ Slide29: Possible Objective for open wells:
Current message: Clean open wells
COMBI Objective: Challenges –
reported reluctance to use fish in open wells by residents in Male’
'clean' well not a clear behavior, time intensive
covering is problematic Slide30: Construction site, Male’ Water in foundation at construction site, Male Water on slab, construction site, Male’ Slide31: Possible Objective for construction sites:
Current message: Remove standing water – depends upon what is found holding water
COMBI Objective: Challenges –
hard to standardize
enforcing regulations may be difficult
The 4 Cs of Marketing: The 4 Cs of Marketing Consumer:
Is the cost of the behaviour worth the
investment [time, effort, financial]?
The 4 Cs of Marketing: The 4 Cs of Marketing Convenience:
Service, location, hours of service,
sensitivity of the provider, behavioral
Focus on integrated communications
3. Plan and conduct formative research/situation analysis: 3. Plan and conduct formative research/situation analysis COMBI Mantra #2
Do nothing – produce no T-shirts, no posters, no leaflets, no videos – do nothing until you have conducted the formative research needed to determine whether the behavioural objective is feasible! Step-by-step guide, pg. 28 COMBI Team,
Male’, Maldives 4. Invite feedback on the formative research.: 4. Invite feedback on the formative research. Present and disseminate the formative research results so they can be used by other groups in the integrated dengue program (e.g., epidemiology, laboratory, entomology, communication, training). Slide36: 5. Analyze, prioritize and finalize the behavioural objectives – not more than 3!
Using a comprehensive analysis of the results of Steps 3 and 4, it is necessary to:
identify the most important breeding sites
identify the behaviours that can be 'improved' or 'changed' with greatest success Slide37:
Segment target groups.
age, sex, educational level, place of residence (urban/rural)
need (e.g., families who need to store water, families with tires in their patio)
stage of change in which the target population can be found Slide38:
7. Develop your strategy.
Setting Step-by-step guide, pg. 45 The five integrated communication actions : The five integrated communication actions 1. Advocacy/public
relations/management 2. Social mobilization 3. Publicity All actions M-RIP: massive,
repeated, intense, and persistent 4. Interpersonal
communication 5. Point-of-service
promotion Step-by-step guide, pg. 8 Communication challenges: Communication challenges
Slide41: Benefits to dengue program managers: Benefits to dengue program managers COMBI provides a comprehensive guide to:
Develop a strategy for communication and social mobilization actions
implementation of the strategy
the behavioural impact of the actions Slide43: 8. Pre-test behaviours, messages and materials
probability that the
behaviour will be accepted
ensure that the messages and materials
are understandable and will result in the desired impact. COMBI Project Ibirité, Brazil 9. Establish a monitoring system.: 9. Establish a monitoring system.
The focus of the monitoring system is the adoption of the behaviour, not the presence of larvae.
CHALLENGE A lack of indicators that more truly reflect the behaviour. 10. Strengthen staff skills.: 10. Strengthen staff skills.
If there isn’t the capacity to plan, administer, implement and monitor this process at all levels, there will be no sustainability.
Slide46: Implementation of the behavioural objective with the community,
Ibirité, Brazil 11. Set up systems to manage and share information. : 11. Set up systems to manage and share information.
Exchange of information among the different dengue program components is essential for good decision-making. Slide48: Flow of information
Managua, Nicaragua Slide49: Flow of information
São Luís, Brazil 12. Structure your program. : 12. Structure your program.
Include personnel with experience in behaviour change, communication and social mobilization.
Designate budget funds annually to sustain communications and mobilization actions. 13. Write a strategic plan (a COMBI plan). : 13. Write a strategic plan (a COMBI plan).
The COMBI plan describes in detail:
the combination of communication actions that will be used
all the steps needed to implement the strategy Step-by-step guide, pg. 78 14. Determine your budget. : 14. Determine your budget.
A specific budget for the COMBI plan should be developed based upon the reality of available funding for dengue and the financial situation of the country. 15. Conduct a pilot test and revise your COMBI plan. : 15. Conduct a pilot test and revise your COMBI plan. Ensure that the strategy does not have critical deficiencies
Refine the approach Preliminary results of the external evaluation of the CDC/WHO/PAHO dengue COMBI initiative:: Preliminary results of the external evaluation of the CDC/WHO/PAHO dengue COMBI initiative: It is a pragmatic approach that has resulted in behaviourally-focused messages. Countries visited: Barbados (Island-wide), Brazil (4 sites), Guatemala (1 program w/multiple sites), Laos (1 site), Malaysia (2 sites), Nicaragua (1 site)
Slide55: COMBI has created enthusiasm and commitment at various program management levels and the community
There are positive tendencies in the measurement of behavioural changes, but more still needs to be done to refine behavioural indicators.
(e.g., the use of entomological indicators not appropriate for the behaviour being promoted) Slide56: Why commit yourself to COMBI? To have a greater behavioural impact
To get the most out of your budget
To stimulate greater collaboration among the community, health volunteers and the health sector
To motivate your target population
Because it is good program management! Formative research on open wells, Male’, Maldives Documents of interest: Documents of interest Elder, J. (2005). Evaluation of Communication for Behavioural Impact ('COMBI') Efforts to Control Aedes aegypti Breeding Sites in Six Countries. Tunis:WHO Mediterranean Centre for Vulnerability Reduction (WMC).
WHO/PAHO (2004). Planning social mobilization and communication for dengue fever prevention and control: a step-by-step guide. Geneva:WHO.