90284 Strategic Communication for Development Projects A Toolkit For Task Team Leaders External Affairs & World Bank Learning Network Strategic Communication for Development Projects By Cecilia Cabañero-Verzosa 1 Copyright©2003 The International Bank for Reconstruction and Development/THE WORLD BANK 1818 H Street, N.W. Washington, D.C., 20433, U.S.A. All rights reserved Manufactured in the United States of America Third printing June 2003 This Toolkit was first published in 1996 by the World Bank’s Human Development Network under the title Communication for Behavior Change: A Toolkit for Task Managers. It is now offered as part of the World Bank Institute’s Distance Learning Course on Strategic Communication and has been reprinted by the World Bank Learning Network. Cover design and layout were designed by Jeeyeon Seo. 2 Foreword Bank task managers, division chiefs, and country department directors have strongly urged that communication be an integral part of operational work from early in program development. Governments too have recognized the importance of communication in helping to build broadly based support for policies and programs. Sociocultural barriers and inadequate information make it difficult for people to understand the benefits of change and the adverse consequences of maintaining the status quo. Communication can play a major role in providing an opportunity for informed choice. Increasing people’s access to information, discussing benefits as well as consequences, encouraging dialogue among leaders and their constituents – these are ways of using communication to support change. This effort of the Human Development Department to strengthen the design and monitoring of communication activities in lending programs in education, health, nutrition and population supports the Bank’s overall strategy of using communication for development. We hope that this toolkit will help task managers use communication not only as a means to disseminate information but also as a tool to facilitate adoption of new behaviors consistent with reform measures and public health goals. Mark Malloch Brown Vice President for External Affairs 3 Preface Investing in health is a high priority for the World Bank and its borrowers. Yet efforts to improve health systems will have little effect on health if these systems are not used. Because human behavior is a major factor in health outcomes, investments in health must focus on behaviors as well as heath facilities and service provision. Solving health problems requires that people understand and are motivated to adopt or change certain behaviors. Thus effective communication must be a part of any health investment strategy. Efforts to promote general awareness of public health issues – the traditional goal of information, education, and communication (IEC) programs – have built a good foundation for population, health and nutrition (PHN) activities. But they are not enough. Research into the effect individual and group behaviors have on the outcomes and costs of PHN interventions has recalibrated the targets of IEC. The new thinking is that communication programs must be designed first and foremost to support behavior change in key constituencies – delivering the message not just to potential clients, but to health providers as well. The ultimate goal is to get at-risk populations to adopt behaviors that in the aggregate will improve the health of the community and lower the costs of health care. Seeking health care, complying with treatment regimens, reducing health risks, and taking positive actions for health will reduce the frequency, severity and cost of disease to individuals and their communities. This document accompanies a toolkit designed to help Bank task managers plan and supervise the implementation of communications activities in PHN projects. It reviews the basic principles of communication for behavior change, presenting a step-by-stop guide to planning and implementing communication activities and linking those steps to the Bank’s project cycle. The toolkit itself contains a set of practical modules, including: · Communication research approaches for bank projects · A guide to communication indicators · Sample terms of reference for Bank and Borrower consultants · Guide questions for assessing organizational capacity · Sample budget and implementation plan · Case studies of best practice in behavior change communication. The toolkit was prepared by Cecilia Cabañero-Verzosa under the general direction of Thomas Merrick, population adviser of the Human Development Department. We are grateful for the guidance and support provided by the Bank’s task managers and staff who participated in the 1994 and 1995 workshops on communication for PHN projects as well as those who constituted the World Bank review 4 group. Comments on earlier drafts were provided by Anwar Bach-Baouab, Jorge Barrientos, Mariam Claeson, Xavier Coll, Edward A. Elmendorf, Catherine H. Fogle, Helen Garcia, Marito Garcia, Salim Habayeb, Keith Hansen, Richard Heaver, Teresa Ho, Richard Hoffman, Janet Hohnen, Evangeline Javier, Kees Kostermans, Rama Lakshiminarayanan, Maria MacDonald, Jo M. Martins, Ernest Massiah, Judith McGuire, P.C. Mohan, Indra Pathmanathan, Michael Porter, David Radel, Stanley Scheyer, Richard Seifman, Barbara Thomas, Jagadish Upadhyay, Paula Valad, Juliana Weissman, and Mary Eming Young. We especially thank Michele Lioy of the Central Africa and Indian Ocean Department’s Population and Human Resources Division, who in her dual roles as task manager of PHN projects and communication specialist provided valuable insight on how to bridge both works. She facilitated the communication workshops with Ms. Verzosa and provided materials drawn from work on bank projects. We also appreciate the support of Jill Wilkins, communication specialist in the Office of the Vice President of External Affairs, who field tested the toolkit with Ms. Verzosa during the Communication Planning Workshop for China’s Disease Prevention Project in May 1996. Robert C. Hornik of the Center for International Health and Development Communication at the Annenberg School of Communication at the University of Pennsylvania wrote the module Communication Research Approaches for Bank Projects. An outside panel of experts in communication, social marketing, and health promotion reviewed draft versions of the overview. This group consisted of Margaret Parlato, Beverly Schwartz, Renata Seidel, and William A. Smith (Academy for Educational Development), Phyllis T. Piotrow and Sung Hee Yun (Center for Communication Programs, Johns Hopkins University), Rose Mary Romano (Consultant, New Delhi Resident Misson, World Bank), Sandy Granzow (Granzow Communications), Marcia Griffiths and Michael Favin (Manoff Group, Inc.), Renee Wessels (Population Services International), Carol Corso, Joan Haffey, and Elaine Murphy (Program for Appropriate Technology in Health), Warren Feek (United Nations Children’s Fund), Sylvie Cohen (United Nations Fund for Population Activities), and Cathy Wolfheim (World Health Organization). Cover design, layout and editing were done by the American Writing Corporation. Philippa Shepherd edited the overview. In addition, the following Human Development Department staff helped produce the manuscript: Laura Coronel, Vivian Jackson, Edward Kelley, Amelia V. Menciano, JoAnn Stephens, and Ruth Utz. As the toolkit is used on the ground, we look forward to receiving feedback to help us refine, update and modify its various modules. David de Ferranti Director Human Development Department 5 Strategic Communication for Development Projects Contents 6 Module One | An Over view ... 9 Module Two | Communication Research Approaches for Bank Projects ... 31 Module Three | Indicators ... 47 Module Four | Terms of Reference for Bank Consultants ...59 Module Five | Terms of Reference for Borrower Consultants ... 71 Module Six | Qualitative and Quantitative Research ... 83 Module Seven | Guide Questions for Assessing Organizational Capacity ... 137 Module Eight | Implementation Plan ... 143 Module Nine | Timeline ... 161 Module Ten | Budget ... 167 Module Eleven | Best Practices ... 173 7 8 Module One Strategic Communication for Development Projects An Overview 9 Module One: Strategic Communication for Development Projects: An Overview Contents CHAPTER 1 Why Communication to Change Behavior Is Important ... 11 CHAPTER 2 Designing a Communication Plan ... 13 CHAPTER 3 Communication Activities in Bank Projects ... 19 CHAPTER 4 Implications for Action ... 28 References ... 29 10 CHAPTER 1 Why Communication to Change Behavior is Important For many of the interventions identified in the World Bank’s than the location or physical accessibility of services. 1993 World Development Report—oral rehydration, For example, in a country where high maternal mortality immunization, family planning, and safe motherhood are rates persist despite improvements in other health examples—providing access to medical technology and indicators, efforts to encourage referral of obstetric health services is not sufficient. For such interventions to emergencies may need to be complemented by efforts be effective, public health programs need to influence to change underlying cultural attitudes that view the clients and providers to modify their behaviors in ways death of a mother in childbirth with resigned acceptance. that will promote healthier lives. In particular, programs must work to influence individuals to take preventive The individual whose behavior most needs to change may action at the household level, to build effective community not be the only or even the primary audience for the support for health-seeking behaviors, and to change the message. Often, it is the people who influence that attitudes and behaviors of providers in ways that reinforce person’s behavior—the “influencers”—who most need to the desired healthy behaviors of their clients. be informed, and to change their attitudes and practices. Thus, if getting children immunized or monitoring their Effective health interventions require growth depends on their mothers then communication changed behavior may need to target traditional birth attendants and others Preventive action at the household level can reduce the in the community to whom mothers turn for guidance on severity and duration of illness, provided that people are child care. Effective communication programs need to motivated and know what actions to take. For example, target “influencers” —whether they be health providers, mothers can be taught to prevent the severe dehydration village elders, or members of a person’s family—since they resulting from diarrhea by using simple home-based fluid all affect the environment in which healthy behaviors are preparations. The timing of decisions to seek care is often promoted and sustained. crucial for survival, especially when health facilities are a long distance away. Correctly identifying the symptoms Providers of health services may also need to change of pneumonia in infants with respiratory infection or signs their behavior, devoting more effort to informing and of a mother’s hemorrhage during delivery may spell the influencing people through targeted messages and difference between life and death. through their own example. For instance, people otherwise inclined toward immunization or family Generating demand for health services is not just a planning may have been inhibited from adopting these matter of announcing their availability. Consumer positive practices because of worries about the safety attitudes often turn out to be more important influences of vaccines and contraceptives. 11 Box 1 Health providers need to get the word out to these Behavior Change Success: An potential users that the products are indeed safe and Example from the Expanded effective. And, since actions sometimes speak louder than Programme on Immunization words, providers may need to modify their behavior to avoid sending conflicting signals: the cause of In the Philippines, a six-month nationwide urban communi- cation campaign to promote measles immunizations, breastfeeding will not be well served, for example, if infant increased age-appropriate completion of the series of formula is routinely used in hospitals. immunizations: n The coverage of children aged 12-23 months in- Effective communication can change behaviors creased from 54% to 65%, and the proportion of nine to eleven-month-old children who were fully immu- Communication programs have a proven track record in nized increased from 32% to 56%, during the project bringing about behavior change in population health and period (1989-1990). nutrition (PHN) projects. Examples of communication n Exposure to the mass media message was related to projects that have successfully targeted specific behaviors increased knowledge about when to bring a child for measles immunization. The change in knowledge can be found in the fields of family planning, nutrition, about the appropriate age for measles vaccination maternal and child health, HIV/AIDs and sexually increased timeliness of vaccination. transmitted diseases (STDs). Box 1 presents an example. What explains the improved knowledge and its effect on behavior? Changes in service delivery were ruled out A global project, Health Communication for Child Survival since most program factors remained stable before and after the mass media activities. Nor did mothers learn (HEALTHCOM); implemented communication programs to about vaccinations during visits to the health centers. promote child care practices in developing countries. Of Both the household survey and exit interview data show that there was little change in the nature of the interaction sixteen behavior change outcomes of interventions carried between health workers and their clients or in the level of out under the HEALTHCOM Project, nine showed absolute accurate knowledge that mothers took away from their increases in recommended practices ranging from 10 to health center visit (Zimicki, et al., 1994). 26 percent (Hornik, 1995). Rather, the evidence points to the successful nationwide mass media effort which used three essential elements of the strategy tested during the Metro Manila pilot cam- Several elements contribute to successful commu- paign. The strategy focused on measles as a “hook” to get nication programs; identifying reasons why a program mothers to bring their child to the health center; empha- works is often difficult. A set of practical corollaries for sized logistic knowledge in the mass media messages, in particular promoting a single day of the week as “vaccina- successful communication programs, based on cross- tion day,” and giving clear information about the age for cultural research, is described in Chapter 3. measles vaccination; and targeted urban areas which had lower vaccination rates than rural areas. Immunizations were provided at health centers where routine vaccination services were available throughout the week. Popularizing a single day for measles vaccination addressed the concern of health workers about vaccine wastage since the mass media campaign was expected to increase demand. Mass media messages reassured mothers that health centers were ready to provide service. Zimicki, et al., (1994) concluded that: when countries meet certain conditions - a high level of access to the media, sufficient expertise and funds available to develop and produce high-quality radio and television advertisements, and a routine system that is able to serve the increased demand- a mass communica- tion campaign can significantly improve vaccination coverage. (p. 409) 12 CHAPTER 2 Designing a Communication Plan Communication activities involve an iterative process that Decisions on these guide formulation of an implementation can be divided into five important steps: (1) assessment, plan that describes the communication strategy and the (2) planning, (3) material development and pretesting, supporting elements—a budget, a timeline, a communication (4) implementation, and (5) monitoring and evaluation. research plan, and a capacity-building component—that will The last stage feeds back into the first in a continuous make that strategy feasible. cycle of reassessment and refinement. The process is audience-centered, beginning with observation of The scope of activities is an important consideration in audience behaviors and what causes them, and going planning a communication strategy. Behavior change is on to develop a strategy that will communicate perceived a long-term process, so task managers need to set realistic benefits and reduce perceived barriers to healthier goals. At the inception of a program, the prospective behaviors (Figure 1). audience will often be distributed across the “stages of change” continuum (Figure 2), from those who are ignorant Five-step process for planning and that a public health problem exists, through those who implementing communication activities are aware, concerned, knowledgeable, motivated to try Central to the assessment stage is obtaining information to a new behavior, finally to those already engaged in the guide the communication strategy. The assessment identifies recommended behavior. The distribution of the audience behaviors that should be encouraged or discouraged, along that continuum at the outset will strongly influence messages to convey, audiences to be reached, the both the goals of the campaign and the length of time it communication channels to be used to reach them, and units will take to be effective. suitable for undertaking the communication activities. Figure 1: At the planning stage a clear course of action is devised Planning and Implementing a Communication Program on the basis of this information. The results of the social assessments are sifted to single out: Assess Plan n The behavior that will lead to a substantial health benefit if adopted by a large segment of a given population, Monitor and n The message concepts that will promote evaluate Develop and perceived benefits of the new behavior, and Pretest material n The communication channels that will reach the audience as often and affordably as possible. Implement 13 Figure 2: In situations where most members of the target audience Audiences Along a Behavior Change Continuum— are already at an advanced stage in the continuum— Possible Communication Strategies aware and motivated—a five-year period of Bank support can be an effective inducement to adopt the desired behavior change. Immunization programs, for example, • Raise awareness Unaware • Recommend a solution have shown large effects in relatively short times, perhaps because many of the people targeted by the campaign were favorably inclined and already getting some vaccinations—only one stage away from adoption at the Aware, concerned, • Identify perceived barriers and outset of the program. But in situations where many knowledgeable benefits to behavior change members of the audience may be at very early stages of the continuum, quite unconvinced about the need for • Provide logistical information change (about using condoms with spouses, for example) Motivated to change • Use community groups to counsel or very resistant to change (giving up smoking, for and motivate instance), a project is unlikely to move the majority of the target audience to sustained behavior change in the five- • Provide information on correct use • Encourage continued use year Bank cycle. A more realistic goal would be a positive Tries new behavior by emphasizing benefits shift in distribution: fewer people at the unaware or • Reduce barriers through problem solving • Build skills through behavior trials thinking-about-it stages, a majority at the ready-for-action • Social support and trial stages, and a few at the consistent behavior stage. Figure 3 illustrates realistic goal setting for behavior • Remind them of benefits of new behavior Sustains new behavior • Assure them of their ability to sustain change in a hypothetical three-year diarrheal disease behavior control program. • Social support Material development and pretesting entail working with Figure 3: Behavior Change Goals for a Hypothetical Diarrheal the target audience to develop messages that will be Disease Control Program effective with that audience. To persuade the target Audience: audience that the new behavior has clear benefits for them, Women with Children under five years of age messages must be easy to understand and culturally Behavior: Giving oral rehydration therapy (ORT) sensitive. For example, the slogan “zero grazing”—a phrase from farming jargon meant to encourage single-partner 80 % relationships—was used in two million leaflets and posters printed for an AIDS campaign in an African country. But a 60 % survey showed that only 5 percent of respondents understood what “zero grazing” meant. Such problems can be avoided 40 % through pretesting (Starrs and Rizzuto, 1995). Year 3 20 % Implementation of communication activities typically Year 2 involves distributing print material, broadcasting radio and Year 1 television messages, and conducting community-based 0% group and interpersonal communication sessions. The Aware Motivated Tries new Sustains new Have Intend to use ORT behavior behavior effectiveness of these messages depends not only on their heard for child’s Gave ORT during Have given ORT during quality and timely delivery, but also on the availability of of ORT diarrhea child’s last all of the child’s diarrhea Know where diarrhea episode episode in the last year good supporting health services. Health service delivery is to go not the primary concern of communication staff, but they 14 do need to provide feedback on audiences’ perceptions of measles as the “hook” to get mothers to bring their service quality and, if necessary, to work with health children to health centers, this being a disease that mothers were most worried about. providers to resolve service delivery issues. (3) Material Development and Pretesting (two months): Research singled out TV and radio as the most accessible Monitoring and Evaluation are carried out simultaneously media for the message, with print materials as a follow up. with implementation when programs are monitored to Materials were presented to the health providers during gather information systematically about audience orientation sessions held before launching the communica- tion campaign. response to the messages, and subsequent changes in knowledge, attitudes, beliefs, and practices (KABP) (4) Implementation (three months) began with an announce- ment by the Secretary of Health in February 1988 of an associated with the intervention. Monitoring and making intensive effort to promote measles immunizations. Mass mid-course corrections is a self-reinforcing process: the media material released twice a week for three months, goal is to identify and capitalize on new opportunities to promoted free immunizations on a particular day of the week. Service providers were mobilized to provide daily improve the communication component. A final immunization services, with special provisions for staffing evaluation follows completion of the project, to provide to meet demand on “Immunization Day”. lessons for future communication programs. Box 2 (5) Monitoring and Evaluation (three months): Monitoring shows the five-step process for planning and enabled program managers to adjust tactics according to implementing a communication program in action, as audience response. For instance, extended hours (to 8:00 p.m.) for health centers were cancelled when it was illustrated by the campaign launched by the Philippine discovered that mothers did not come to the centers after Department of Health (DOH) to promote timely measles 5:00 p.m., and messages were then modified accordingly. Other examples were routine monitoring to make sure that immunization as part of its broader immunization print material remained available at the centers, that mass program. The success of that campaign (described in media material was aired, and that promotional material Box 1 above) illustrates the advantages of the iterative such as T-shirts and banners were in evidence during Immunization Day. cycle of evaluation and action incorporated into the program’s activities. Source: Verzosa, et al. (1989) Box 2 Practical corollaries The principle of specificity—of audience and of context— The Five-Step Program in Action: embedded in the five-step process leads to some practical The Philippine Expanded Programme on corollaries essential for an effective communication program. Immunization (EPI) Six such imperatives emerge from the evaluation data (1) Assessment (three months): DOH staff reviewed coverage surveys that showed immunization rates lagging gathered on the HEALTHCOM project (see Graeff et al., 1993; in urban areas, and on the basis of their findings conducted Hornik, 1995; and McDivitt et al, 1991, 1995). That project’s a Communication Planning workshop. Here, key questions were raised whose answers would determine the communi- extensive experience highlights the importance of: cation strategy: What health practice should be promoted? • Defining and segmenting the audience to be reached, To whom should the health message be directed? What channels would be most effective in reaching those • Identifying behaviors feasible for the identified particular people with that particular message? Adequate answers were not forthcoming from the workshop, so DOH audience, subcontracted research to obtain data on urban audiences’ “KABP” (knowledge, attitudes, beliefs and practices) • Ensuring that health services are in sync with regarding immunization. the strategy, (2) Planning (one month): Results of the study on KABP • Tailoring strategy and messages to audiences, among low-income women with children under two years old were used to formulate the communication strategy for • Ensuring adequate exposure for intended a Metro Manila pilot campaign: to emphasize the message audiences, and that children should be immunized against measles at 9-12 months old, to provide information about where and when • Building institutional capacity for communication work. immunizations could be obtained, and to single out 15 Defining and segmenting audiences Ensuring that services are In sync with the The primary audience for a communication strategy is the strategy population whose behavior puts them and others at risk, Obviously, communication efforts are worse than useless initially identified on the basis of data from sources such if client audiences cannot act on the message because as the Demographic and Health Surveys, sentinel the necessary services or medicines are inadequate to surveillance systems, anthropological research, or support the recommended behavior. Promoting a new qualitative assessments such as focus groups and depth contraceptive method or oral rehydration packet will only interviews. Once such research has identified this target bring frustration if consumers are unable to obtain them, population, the characteristics of the audience that will be or if poor quality of service delivery undermines the relevant to the campaign need to be identified. And since positive messages of the promotional campaign. In the population at risk may not be homogeneous, different Papua New Guinea, a video presented correct and segments will require different messages. A useful way of incorrect ways of communicating with mothers to improve segmenting audiences is by their readiness to change (See healthworkers’ counseling skills thus ensuring clients of Figure 2 above). quality services. The record of a 1988-89 campaign to promote Vitamin A Identifying feasible behaviors capsules in Indonesia illustrates the point: the reason In practice, the ideal behavior for solving a health problem is that progress was disappointing in some intervention not always feasible for a given population. Once the target areas was not the ineffectiveness of the communication population has been defined, communication components activities, but lack of access to the capsules. For precincts must be realistic and selective in focusing on behaviors that where it was easier to obtain capsules, the results were will be feasible for them to adopt. Selecting feasible quite different. Control communities with similar pre- behaviors involves, first, separating people who practice the campaign rates remained unchanged during the recommended behavior from those who do not as a basis campaign, while use increased sharply, from 24 percent for investigating the practical reasons for those different to 40 percent, in communities exposed to the campaign behaviors, and second, testing which behaviors are feasible (McDivitt et al., 1991). given available resources and structural conditions. Another example of a communication effort hampered by An example of the type of basic data that need to be a service deficiency is Jordan’s mass media campaign to investigated in establishing feasibility is afforded by a promote breast feeding within six hours after delivery. The project to promote handwashing in Guatemala. If mothers program had some success: about 20 percent more were to follow the program’s recommendations on mothers reported early initiation of breast feeding after handwashing, it would involve forty-six discrete behavioral the program than before. But results differed significantly steps such as fetching more water, storing water and for women giving birth in private hospitals from those who washing hands throughout the day. Clearly, the behavior had their babies in public hospitals or at home: most of was unfeasible for mothers to perform. To meet the the increase was observed in the public hospitals or at objective of reducing diarrheal disease morbidity by home; in private hospitals, early initiation increased only promoting new behaviors, the program reduced target slightly after the communication program. Other factors, behaviors to two: handwashing before preparing meals such as the social position of mothers in private hospitals, and before administering foods to children under three years may have inhibited them from adopting breast feeding, old (Graeff, Elder & Booth, 1993). but the evidence points to the lack of rooming-in facilities for newborns in private hospitals as a major deterrent (McDivitt et al., 1995). 16 Tailoring the strategy solve problems that audiences recognize. Messages and messages to the audience must fit into the mental and cultural context of people’s Once the target audience has been defined and lives and the frameworks that audiences use to characterized, and goals identified that are feasible given understand and define their actions concerning a the constraints that audiences face and the availability problem. Much of the formative research that precedes of supporting services, communication programs can development of a communication strategy involves begin to shape an appropriate strategy. Messages need elucidating (a) what behavior-related actions are already to be created and fine-tuned to be understandable and being taken by potential audience segments in the acceptable to their audiences, and geared to their “stage population at risk, and, (b) what leads populations to of behavior change” (Prochaska et al., 1992). Box 3 take certain actions, in particular what keeps them from illustrates how this kind of research can help shape the acting in the recommended way. communication strategy. Box 3 Developing messages based on an audience’s readiness to change calls for a specific strategy and message Exploratory Audience Research: emphasis for each type of audience. Messages to an Family Planning in India uninformed public will aim to raise awareness of a public Despite the success of the national family planning health issue and recommend a solution. Messages to program in India in increasing awareness of modern those who are already aware, concerned, and contraception among 96 percent of married women, only 42 percent of couples had ever used modern methods. knowledgeable need to focus on information to help them Thirty-one percent of women who stated that they did not evaluate the benefits and costs of the new behavior. For want any more children were not using contraception, people who are already motivated to change behavior, according to the 1992-1993 National Family Health Survey. The survey found that over 60 percent of the women not messages need to provide logistical information—where using contraception who could benefit from family to obtain supplies and services, how to use them. For those planning were not using it because of misconceptions, misinformation, and poor understanding of methods. Only who have tried the new behavior, messages need to 6 percent said that they were deterred by the difficulty of provide them encouragement to continue: guidance to obtaining products and services. correct use, reassurance on the benefits, and information Future communication would concentrate on filling the on how to overcome perceived obstacles. Finally, people audience’s need for specific information about correct who have been successful in adopting the new behavior usage and management of side effects, rather than consciousness raising messages about the benefits of need messages to reinforce their efforts—reminding them family planning. Source: World Bank (1995) of the advantages of the new behavior and reassuring them about their own ability to sustain the behavior. Zaire’s promotion of oral rehydration therapy (ORT) is a Messages that provide people a strong sense that there case in point. Zairians gave six different disease names is a social norm supporting their actions will facilitate for illnesses involving loose stools, and used different adoption of new behaviors, regardless of people’s position treatments for each. More than half of the respondents on a behavior change continuum. said they used ORT for the disease called “kuhara”, but fewer than one-sixth of the respondents reported treating Effective messages are not merely what is medically two other diseases—“lukungga” and “kilonde ntumbo”— correct, nor are a program’s objectives necessarily with ORT. Communication messages therefore, synonymous with the content of messages that might recommended the use of ORT for each of these diseases promote the behaviors needed to achieve those separately, rather than using a general term like diarrhea objectives. Good communication creates messages that (Hornik, 1995). 17 Ensuring adequate exposure required to achieve sustained change. For example, only for the intended audience a small percentage of smokers targeted by a campaign However finely tuned the message, it will not be effective may quit each year, but the public health benefits of if it fails to be heard by the intended audience. Planners maintaining that percentage of reformed smokers over need to determine the level of exposure necessary—how many years can be enormous. Also, new objectives for often the audience needs to be reached and for how communication are likely to emerge which require that long—and how to achieve that level of exposure with capacity be in place to incorporate them. The budget and available resources. Often, the most effective strategy the level of professional skill demanded of staff need to will need to use a variety of channels—radio, television, match the outcomes they are expected to achieve. print, visits from paid and volunteer workers, group encounters—because multiple channels are more likely to convey the message to all segments of an audience, particularly in increasing the sense of broad social support for the message. Data support the importance of using multiple channels where possible. Of the nine “high exposure” sites in a global project, (those where as many channels were used as possible), seven (82 percent) produced a substantial change in behavior. In contrast, in the six ‘low exposure’ environments only two interventions (28 percent) were successful (Hornik, 1995). Building institutional capacity for communi- cation work Communication programs need to have a stable institutional base and reliable funding to meet the goals set for them. Existing health education units in ministries of health often lack the skills or experience, and almost never have the budget to support adequate communication programs. A short-term campaign to influence a particular behavior can sometimes be constructed even without a strong institutional base, but such efforts may not be sustainable. Building the capacity to manage communication programs is a complementary goal, and likely to be a necessary one. For many types of behavior, messages transmitted through several channels to reinforce those behaviors over the long term will be 18 CHAPTER 3 Communication Activities in Bank Projects Assess Plan Monitor and evaluate Develop and pretest material Implement Each of the five steps in designing and implementing Project identification communication activities supported under PHN projects From a communication standpoint, the most important (see Box 2 above) requires a series of tasks at different tasks during project identification are to determine stages of the World Bank’s project cycle: whether behavior changes are required to achieve the objectives of the proposed project and to begin assessing • Project Identification: focus on assessment tasks; which behaviors among which groups need to be • Project Preparation: focus on continued changed, and how to change them. It is also important to assessment and the initiation of the planning step; review existing communication activities in the country, • Pre-appraisal/Appraisal: completing the to ascertain whether they need strengthening, improving, planning step, in conjunction with material or reorienting toward behavior change goals. The two development and pretesting; questions guiding the assessments are: • Supervision: material pretesting continues, imple- 1. Which behaviors promoted among which au- mentation is under way, and continuing monitoring diences will help achieve the goals of the project? and evaluation is initiated and carried out; 2.Can these behaviors be influenced by changes in • Project Completion: final evaluation. knowledge, attitudes, beliefs, or social norms? The checklist below outlines a schedule and division of A communication component is called for when current labor that may serve as a guide to planning, recognizing practices of epidemiologically significant groups are at that the allocation of responsibility between Bank and variance with public health goals, and when knowledge, Borrower and the timing of tasks over the project cycle attitudes, beliefs and social norms are an important will vary somewhat depending on resource availability, influence in those practices. Some programs may seek institutional capacity, and the specific exigencies of the to accomplish their goals without emphasizing a voluntary local situation. Many of the tasks require technical skills change in behavior. For example, a health program that neither the Bank nor the Borrower will have in their seeking to curb teen smoking may increase the sales tax permanent staff, so that both may have to contract for on tobacco in preference to launching a communication the needed expertise with outside groups - academic campaign. Other programs may make voluntary behavior institutions, non-governmental organizations (NGOs), change the main focus of the intervention, and here a private sector communication companies, or individual communication component may be called for. An consultants. Model terms of reference for these example would be a program intervention centered on engagements are to be found in the toolkit. encouraging pregnant women to visit a health center within the first trimester of pregnancy. 19 Figure 4 Checklist For Task Managers Bank project cycle related Communication tasks Group with primary responsibility to the five-step process Identification: Determine if a communication component is needed Determine if the communication component is needed, on the basis of review of epidemiological Borrower and the World Bank data, economic and sector work reports, demographic and KABP surveys, discussions with key informants. Select organizational locus for communication activities. Differentiate the communication strat- egy development to be done by the government Assessment from work that may Involve outside groups. Borrower Select project site. Borrower-specialist through Hire communication specialist for project preparation. preparation stage. World Bank (may need specialist during preparation mission and either pre-appraisal or appraisal missions Preparation: Assess knowledge, attitudes, beliefs and practices (KABP) and organizational capacity Assessment Review client profile-secondary data on KABP. Prepare the communication research plan. Hire consultant for planning research. Borrower Conduct planning research as part of social assessment Assess organizational capacity for communication work. Planning Assess government's communication capacity-building proposal. The World Bank Review criteria and process for selection of outside consultants. Prepare a communication strategy. Borrower Initiate work on the implementation plan (strategy, research plan, budget, timeline, capacity-building component). 20 Checklist for Task Managers (cont.) Bank project cycle related to the five-step process Communication tasks Group with primary responsibility Pre-appraisal/appraisal: Reach agreement on a communication strategy and implementation plan Agree on purpose, content, methodology for a communication component. Borrower and the World Bank Agree on how decisions will be made about who is going to implement the communication strategies. Planning Finalize implementation plan. Borrower Prepare documents; negotiate loan approval. The World Bank Develop and pretest material. Material development Orient health workers. Borrower and pretesting Prepare for project launch. Supervision: Monitor communication inputs and outcomes Evaluate whether: Material development • Health communication activities are taking place; • Health communication materials are reaching The World Bank and pretesting target audiences; • Communication activities are associated with changes in knowledge-attitudes-beliefs-practices. Document lessons learned about audience Implementation response to the communication activities. Borrower and the World Bank Monitoring and Evaluating Review results of monitoring research and modify activities as appropriate. Submit annual work plan. Annually Borrower mid-term review Conduct communication planning sessions about every two years to update strategy. Completion: Summarize lessons learned Final evaluation Describe next step for communication. Borrower 21 At the identification stage, both the Bank and the issues involved. Obviously, the earlier things can be started Borrower should be investigating available sources for at this stage of the process, the better. information to guide them in deciding on the need for and role of communication activities in the proposed Assess Plan project, and on formulating strategy. Demographic and health surveys complemented by Knowledge, Attitudes, Monitor and evaluate Devel0p and Pretest Beliefs, and Practices (KABP) surveys are good sources material of such information. An important decision will be where audiences are on the behavior change continuum (Figure Implement 2 above)—whether they need to be made aware of the public health issue, or are already aware of it and ready Project preparation to try new behaviors (see Box 3 above.) During the preparation stage, work needs to be done on three main tasks: (a) completing the assessment of Other sources of information for such preliminary current KABP for potential audiences; (b) assessing assessments include: Borrower capacity; and (c) preparing the implementation • Epidemiological studies relevant to the scope plan for the communication component of the project. of the project. Audience assessment • Evaluation reports from earlier projects and The Borrower should move ahead with studies of relevant sector reviews. audience KABP as an important adjunct to a broader • Interviews and discussions with key informants— social assessment aimed to identify project health providers, opinion leaders, public officials. beneficiaries, to confirm their need for PHN services, and to note social factors that may influence the project’s Based on these reviews, a decision to include a success. Often, new research will be required to build communication component will lead to discussions about on preliminary KABP acquired during the project various activities that the Borrower could undertake in identification stage. anticipation of the project preparation mission. These activities include: Project beneficiaries identified during social • Selecting an organizational locus for and assessments will probably overlap with target audiences identifying a site for communication activities. for communication activities, but are not necessarily synonymous with them. Some target audiences for • Specifying the role of the government and that communication—defined as individuals whose of the private sector. behaviors the project would like to influence—may be • Hiring communication specialists to assist the other segments of the population: “influencers” rather Borrower throughout project preparation. than direct beneficiaries of the project. A project in Bangladesh to assist females in secondary schools, for The distribution and timing of these tasks over the Bank’s example, identified fathers of girls as the primary target identification process and among the Borrower’s for the communication component, although secondary preparation activities in the interval between the Bank’s school-aged girls were the intended beneficiaries. identification and preparation missions will vary according Another target audience other than beneficiaries may be to such factors as the availability of communication health providers: in Kenya’s immunization program, for specialists during preparation, whether the proposed instance, focus group discussions disclosed perceptions project is building on earlier operations that have among mothers of shabby treatment at the health centers communication activities, the quality of existing information, which made them reluctant to return to the centers for the capacity of the Borrower, and the complexity of the completion of the immunization series. 22 Assessment of current audience KABP will help the Assess project team determine if more research is needed to Plan evaluate audiences’ readiness to change behavior, and Monitor and to develop message concepts that these audiences may evaluate Develop and pretest find persuasive. It is important for stakeholders — material people who will benefit as well as staff who will implement and officials who will support the Implement intervention—to participate in these assessments, not only as information-gatherers but also in drawing Assessment of Borrower capacity conclusions based on results. A second important task during the preparation process is assessing the Borrower’s capacity for communication Technical consultants and health education staff in the work and what action may be taken to strengthen it. This borrowing country generally take responsibility for involves identifying potential in-country sources of reviewing past communication projects and assessing technical support, and developing a training plan for in- the communication needs of the ministry or department house staff (see the module on organizational responsible for the public health program (such as a assessments in the tool kit for a more detailed treatment Ministry of Health). The Borrower is also responsible for of these issues). assessing audience and provider KABP, developing a communication research plan, and hiring a subcontractor In-country capacity may need strengthening in: to undertake the research. • Communication planning and management. If further KABP research is required, a communication • Research for the planning phase, for material research plan needs to be prepared to determine the development and pretesting, and for monitoring scope of audience research—on beneficiaries, and evaluation. influencers, or health providers—and to prepare terms • Material production. of reference for research activities. In this context, • Liaison work with mass media organizations to research does not refer to large-scale, long-term studies, develop a media plan if mass media activities but to smaller scale, tightly focused activities designed are likely to be needed. to support the development of effective program operations. Three types of research are particularly • Liaison work with organizations with large- germane to communication activities for PHN projects: scale outreach networks, if these networks may be incorporated. 1. Research during the planning phase to guide decisions about behaviors, audiences, messages, Not all of these skills are necessarily available within and channels of communication. existing government health education units, so the assessment will need to look into non-governmental 2.Research during the material development capacity in communication work. Some core skills do phase to pretest material for comprehensibility, have to be available within the project health education relevance, and acceptability. unit: (a) communication strategy development, (b) 3.Research during implementation stages of the planning of activities that support the communication project to monitor audience response. strategy, and (c) management of activities, including Plans for all three types of research may best be drafted coordination with service delivery units. In sectoral during project preparation, even though only the first will projects, core skills would include capacity to plan and be carried out at this stage. (For more on research, refer manage a communication component addressing to the module on Communication Research Approaches multiple audiences and supporting several interventions. for Bank Projects in the accompanying toolkit). For other skills— such as planning research, material 23 Assess Plan Monitor and evaluate Develop and Pretest material Implement development, pretesting, and monitoring—in-house implementors from the national, regional, and district capacity may be developed over time; alternatively, a levels into the decision process, can use participatory scheme may be devised to tap resources from the private methods like the Appreciation-Influence-Control (AIC) sector, academia and NGOs. workshop to develop a communication strategy in collaboration with stakeholders (World Bank, 1996). In Thus the assessment of organizational capacity needs to such workshops, researchers summarize findings while extend beyond the current organizational structure and communication specialists and stakeholders discuss resources of the counterpart ministry, to identify other units ways of using communication to promote desired responsible for communication work within the government, behaviors. At this point, work can start on incorporating and to search the private sector for qualified advertising the strategy into an implementation plan (see Box 4) agencies, market research companies, and firms which can be finalized during the Pre-appraisal stage. specializing in media production and media-relations. In Box 4 the academic sector, schools of journalism or communication and schools of public health with Initial Elements of an departments that focus on health and education may be a Implementation Plan source of needed communication skills. Non-governmental Different interventions call for different organizations (NGOs) may have extensive experience in strategies. For example: designing and managing both mass media campaigns and n Interventions to promote immunizations or micronutri- community-based networks for health interventions. ents often emphasize compliance as a behavior change strategy. n Family planning programs often promote a variety of In tapping these resources, it is critical to be clear at the contraceptive methods to encourage behavior change by providing a choice. outset about division of responsibility: to specify which n Interventions to address AIDS/STDs as well as the use communication tasks are to be undertaken by in-house of tobacco, alcohol and drugs may call for changes in staff and which to be contracted to outside agencies, lifestyle behaviors. and, if more than one government unit is involved, to Communication strategies must match identify which unit will have management responsibility behavior change objectives: for the communication component. n Tactics to promote compliance would include provid- ing simple reminders of when and where products and services may be obtained; giving dosage and usage Beginning work on the implementation plan instructions; and providing cues for correct behavior, for the communication component such as a symbol on immunization cards to signify Formulating a communication strategy to support the completion of the series. n Choice may be encouraged by family planning goals of the PHN project, and working on a plan to communication activities that provide couples with implement that strategy, begins at project preparation detailed information about the various contraceptive methods available so that they can select those most stage and continues into pre-appraisal. suited to their needs. n To change lifestyle behaviors, a strategy that provides a In devising strategy, the Borrower should encourage compelling reward may be needed for changing a routine behavior that may be ingrained or even participation especially a sense of ownership among addictive, and promotes social support for the change stakeholders and groups responsible for implementation. through PHN education or provides specific skills training to overcome barriers. See Smith W.A. (1995). Communication planning workshops, bringing 24 Box 5 Project pre-appraisal/appraisal The Communication During this stage, the Bank and the Borrower should Implementation Plan finalize the communication strategy and implementation plan, and begin material pretesting. During pre- 1. A strategic approach defines the behavior change goal(s) identified as feasible and effective in support- appraisal, the implementation plan is drafted by the ing the project’s purpose, the type of response desired borrowing country staff. Ideally, results of planning to achieve that change, and the target audiences research should have been available at the time the (information, education, persuasion) and methods (print, mass media, group encounters, interpersonal communication strategy was formulated, so as to ground communication) that will be used. the strategy in reliable data complemented by field 2. A training scheme for health workers in skills needed to experience and judgment. (In the absence of planning carry out communication activities critical to the strategy research data, implementation planning could still go (for instance, counseling, group communication). forward on the basis of a tentative communication 3. Monitoring and evaluation activities are designed for strategy formulated on assumptions about KABP and continuous monitoring of communication strategy and subject to verification from field data.) activities, to provide timely information to improve judgments about action. Once a proposed strategy has been formulated and 4. Capacity Building Component is a plan to provide the communication activities have been identified, the project infrastructure, staffing and training on communication strategy development and management. Further- team needs to work out the nuts and bolts of the draft more, the plan could address the long-term goal of implementation plan, by incorporating in it: establishing a viable career track for health educators by investigating organizational systems, work • a scheme for training health workers in the skills performance indicators and staff development opportunities which affect the quality of communica- needed to carry out the strategy; tion work. • monitoring and evaluation indicators; 5. Budget line items for critical elements that affect the • a capacity-building component; and success of communication activities including funding for communication research during the planning, • a budget and a timeline for all of the above. material development and implementation phase as well as adequate funding for mass media dissemina- At appraisal, the project task manager and the commu- tion costs and group communication activities. nication specialist should review the communication 6. Timelines that allow for a participatory process of strategy and the draft implementation plan with staff in the planning, implementing and monitoring communica- borrowing country to ensure that (a) results from research tion activities. on communication conducted as part of the social assessment have been used effectively to decide on behavior, audiences, messages, and channels; (b) • Is the proposed communication strategy likely to whether the details of the plan are technically sound, produce the desired behavior change among the feasible to implement and sustain, and support the PHN target groups? project’s goals. • Will behavior change within these groups affect Key issues for review include: public health? • Is the proposed communication component • Is there a communication strategy to improve appropriate to the specified purpose (to generate the KABP of health workers (if this is required)? awareness, to initiate trial, or to promote • Is the proposed strategy feasible in light of the sustained behavior change)? organizational staffing, funding, and time available? 25 On the basis of this review, the specialist may suggest site visits and discussions with field staff, the task ways to improve its technical content, or anticipate manager, project planners, technical experts, and potential implementation problems. stakeholders should analyze and, where possible, resolve the operational problems uncovered. More At the conclusion of the appraisal mission, an agreement broadly, analysis of the results of monitoring may would have been reached by the Bank and partners in indicate that the communication strategy as a whole the borrowing country on the purpose, content, and needs to be modified to achieve the intended changes methodology of the communication component of the in behavior. Several key questions are at issue here. PHN project. The implementation plan is approved (see Box 5). The appraisal mission is followed by the internal Are communication activities taking place? Bank process of document preparation, negotiation, The entire communication campaign can founder if key Board approval and finally, loan effectiveness. During elements of its strategy have not been carried out—for this time, staff in the borrowing country may continue instance, when broadcast or print material have not been with material development and pretesting activities, as developed, produced, or disseminated because of such well as the orientation of health providers with regard to problems as lack of funds, non-approval by program purpose and processes for communication activities. managers, weak administrative systems that hamper contracting of research, or inability to secure air time. Assess Plan Are communication materials and messages Monitor and reaching target audiences? evaluate Develop and Pretest A second common problem to be looked for in monitoring material is poor dissemination: even if the materials are produced, they may not be reaching their intended audiences. Implement Sometimes they sit in regional offices or clinics without Supervision ever being seen by the people they were prepared for. During implementation, the Bank’s supervision activities Frequent exposure to a program’s messages is an should ensure that the strategy is proceeding according important predictor of a program’s success. to plan and making progress toward desired objectives. The main tasks are to ensure adequate monitoring of Are communication activities associated with inputs and outcomes of the project’s communication changes in KABP among target audiences? activities, and to make corrective changes either if This is the question that will determine the outcome of a activities are not promoting the goals of the communication component of a PHN project. A monitoring communication components, or to take account of system can be set up to track changes in KABP as changing conditions and additional information acquired expected and to determine whether behavior is changing. during implementation. Such monitoring and supervision should involve technical experts as well as stakeholders Of course, the budget for a PHN project often will not who participated in the communication planning permit exhaustive evaluations that can unequivocally workshop. The aim is to assess the effectiveness of the assign effects to a given communication effort. Nor does communication strategy in increasing awareness, the effectiveness of the communication activities depend encouraging trial, or promoting behavior change. During solely on the timely delivery of well designed messages. 26 Communication success will also rely heavily on the field activities. An updated workplan, based on the five- quality of health services required to support its goals, year implementation plan approved at appraisal, should and it will be affected by other program activities, such be submitted annually to the Bank. Communication as training or capacity building, which also influence planning sessions, conducted about every two years, behavior change. Thus, although health service delivery will revisit the communication strategy, using the and program activities other than communication are not assessments of the adoption of new behaviors by target strictly the responsibility of health education directors, populations as a basis for redefining goals for the next they do need to take them into account; if necessary, phase of activities. The communication re-planning working with health providers to resolve delivery system process can provide useful information for the Bank’s problems, and supervising the integration of mid-term review. communication activities with other program activities. If monitoring can establish that communication activities Project completion are being implemented, that people are exposed to their Here the task is to take stock of what was accomplished messages, and that knowledge and practices are and report on lessons learned. As the project nears improving at an acceptable rate, this will be sufficient to completion, reporting should focus on whether, how far, guide decision making. and in what ways communication activities supported achievement of the project’s goals, and how future Supervision also entails reviewing activities against the communication components could be improved. methodology, timelines, and budget outlined in the implementation plan to ensure that the plan is followed Monitoring results will indicate whether communication without shortcuts (such as skipping pretests or avoiding activities reached their target audience and produced the consultation with health providers) and that funds are desired changes in KABP. But establishing direct causal adequate and being used for the right purposes. Where linkages between communication activities and observed funds prove insufficient, project managers may consider changes in behavior requires more sophisticated research reducing the number of target audiences or geographic that would usually be beyond the financial resources of areas of intervention, rather than taking a percentage PHN projects supported by Bank loans. reduction across all line items—an option often chosen because it is the path of least resistance. Thus, project evaluations that focus on impact and rate- of-return issues are not dealt with in this tool kit. If an Along with the regular monitoring surveys involved in this evaluation of this kind is considered desirable, it might draw cycle of evaluation and adjustment, personnel on the on communication data gathered for implementation country’s implementation team will be responsible for support. But the additional collection and analysis of continuing development and pretesting of print and data likely be required—such as the location of audiovisual material; training of health providers in face- comparison groups with different levels of access to to-face and group communication skills; orientation of various project components—could be seen as an all levels of health workers to their role in promoting activity distinct from research to support communication behavior change; dissemination of material via print, operations under the project. broadcast, and interpersonal communication channels; and conduct of baseline research before launching the 27 CHAPTER 4 Implications for Action No longer is it adequate only to increase public awareness The Tool Kit for Communication that accompanies this of public health issues; it is also critical to use overview provides practical information—such as, communication to influence populations at risk to adopt consultant terms of reference, indicators, a sample healthier behaviors. Improvement of health status implementation plan—designed to help task managers depends on people’s voluntary adoption of behaviors that in supervising preparation and implementation of a benefit them and their communities. By articulating these communication component. new benchmarks for successful communication, task managers play a key role in improving the quality of communication components in PHN projects. They can translate them into action by: • Ensuring that the communication strategy is based on strong analytical work focused on audiences and behaviors; • Establishing a mechanism for monitoring changes in audience KABP, using the results to revise strategy and improve implementation of communication activities; • Assessing organizational capacity for communi- cation work in the country, and encouraging governments to tap resources in the private sector for specialized communication tasks; • Directing financial and technical support towards helping government health education units build their expertise in communication strategy development and management. 28 References Graeff, J.A. Elder, J.P., & Booth, E.M. (1993). Communication for Verzosa, C., Bernaje, M., de Guzman, E., Hernandez, J.R., Reodica, Health and Behavior Change: A Developing Country Perspective. C., Taguiwalo, M. (1989). Managing a communication program San Francisco: Jossey - Bass Publishers. on immunization: a decision-making guide. Washington, DC: Academy for Educational Development. Hornik, R. C. (1995). Communication for child survival: World Bank (1993). World development Report 1993: Investing in Explaining health communication success evidence from the Health. Washington, DC: Oxford University Press for the World ’HEALTHCOM’ program. Manuscript submitted for publication. Bank. Manoff, R.K., Griffiths, M. Cooke, T.M., & Zeitlin, M.F. (1984). World Bank (1995). India’s family welfare program: toward a Nutrition Communication and Behavior Change Component: reproductive and child health approach. (Report no. 14644-IN). Indonesian Nutrition Development Program. (Project Description). Washington, DC. Washington, D.C.: Manoff Group Inc. World Bank (1996). The World Bank participation source book. McDivitt, J., McDowell, J., Satoto, Palmer, A. (1991). Washington, DC. Results from the evaluation of the HEALTHCOM Project in Central Java: 1988-1989. (Technical Report). Philadelphia: Author. Zimicki, S., Hornik, R.C., Verzosa, C. C., Hernandez, J. R., de Guzman, E., Dayrit, M., Fausto, A., Lee, M. B.& Abad, M. (1994) McDivitt, J., Zimicki, S., Hornik, R. C, & Abulaban, A. (1995). Improving vaccination coverage in urban areas through a health The impact of the HEALTHCOM mass media campaign on communication campaign: the 1990 Philippine experience. timely initiation of breastfeeding in Jordan. Bulletin of the World Health Organization, 72(3), 409-422. Studies in Family Planning. 24, (5), 295-309. Prochaska, J. O., DiClemente, C. C., and Norcross, J.C. (1992) In search of how people change. American Psychologist. 47, (9), 1102-1114. Smith, W. A. (1995, June). Communication makes a difference, sometimes. Paper presented at the World Bank workshop on Designing and Supervising Communication Components of PHN Projects, Washington, D.C. Starrs, A. M. and Rizzuto, R. R. (1995). Pretesting and revision. In Getting the message out: Designing an information campaign on women’s health. New York: Family Care International, Inc. 29 30 Module Two Strategic Communication for Development Projects Communication Research Approaches for Bank Projects 31 Module Two: Strategic Communication for Development Projects: Communication Research Approaches for Bank Projects This module, written by Robert C. Hornik of the University of Pennsylvania Annenberg School of Communication, Center for International, Health and Development Communication, identifies three stages of a communication project where research will be particularly useful. It recommends the development of a minimum research capacity for any communication program and presents ideas for carrying out communication research. 32 Communication Research Approaches for Bank Projects Contents Introduction ... 34 CHAPTER 1 Research During the Planning Phase ... 35 CHAPTER 2 Research During the Material Development Phase ... 40 CHAPTER 3 Research to Monitor Implementation ... 42 33 Introduction Box 1-1 Health communication projects operate at a distance from their audiences. This contrasts with conventional Three Roles for Communication educational efforts. Teachers in a classroom can hear Research the questions and read the confused expressions of their students. If they choose to, clinic health workers can 1. At the planning phase, research will help direct basic decisions about the shape of the program—which ask their clients to repeat the recommendations for home behaviors to address, which audience segments to treatment of a diarrheal episode, and see whether or approach, which message strategies to emphasize, and which channels to use. not they have understood. Communication projects may reach much larger audiences and may be able to assure 2. At the material development phase, the capacity to higher fidelity of messages than can classroom teachers audience-test communication material (posters, radio spots, flyers, etc.) will be important. or clinic staff; however, they do not have such easy channels for feedback from their audiences. As a result 3. When the project begins implementation, monitoring of audience response becomes central: are the they have a special need for an effective research and audiences exposed to the messages as often as evaluation component. expected; are knowledge, attitudes, and behavior improving as was expected? In this document we describe a minimum research capacity that any communication program should incorporate, some ideas about how the basic version might be elaborated, and some suggestions about how the capacity might be realized in practice. The roles for communication research at three stages of the communication project are discussed. We also deal with a fourth type of research, summative evaluation, designed to permit confident attribution of influence to a particular communication intervention and to define the cost-effectiveness of the intervention, but will argue that it is appropriate to invest in such summative evaluation in only a few circumstances. 34 CHAPTER 1 Research During the Planning Phase In some ways this is the most important opportunity for a Epidemiological information research contribution to a project. It is the time when the If a specific behavior changed for a specific population, basic trajectory of a project is to be set, when there is the would it be of substantial health benefit? This information most flexibility in choosing a direction, and thus when should be available from outside the communication good information can best influence decision-making. It component of a project, based on epidemiological is also the time when the research task is the least routine. research. This epidemiological information should serve There are a limitless variety of questions that planning as the basis for planning a communication activity. researchers might address, many different methods that are appropriate to apply, and, unfortunately, the possibility Institutional context for the behavior of expanding into many years to gather the appropriate Is it possible for audiences to engage in a recommended information. There is a great risk that planning research behavior through existing structures and institutions if will absorb time and resources, but still end up they choose to do so? Public communication programs contributing little to project decisions. start with the assumption that it is possible for an audience to engage in a recommended behavior (to take During the planning phase the most difficult task is to a child for immunization, or locate a condom at an discipline the research activity. A priori, planners must affordable price) if an effective public communication be ready to specify the major decisions. They must be program stimulates demand for those services. Those willing to allocate research resources to answer most of assumptions ought not be made without good reason to the questions of importance, even if that means some believe them to be true. It may be possible to validate sacrifice in the methodological rigor with which they those assumptions through available archival answer a particular research question. information, or through the use of knowledgeable informants. On the other hand, validating these In this section we present what we believe to be the assumptions may require the use of original data crucial decisions to be made for a communication collection, for example undertaking surveys of a sample program, and the research activities which might of clinics where immunizations are to be offered, or support such decisions. We organize the decisions audits of local retail outlets (pharmacies or groceries) to under three broad questions to be addressed during see whether condoms can be found. this phase: Choosing appropriate audiences • Behavior and Audiences Which audiences are at a health risk from the behavior? • Channels Which audiences may influence those at risk? There is • Messages. the need for information about which audiences are appropriate for the program. Such audiences may Choosing behavior and audiences include those whose own behavior may put them at risk Determining an appropriate behavioral focus for a (men engaging in sex with multiple partners without using project requires three types of information (see box 2-2 condoms) and/or those whose actions might influence for a summary). those at immediate risk (those who communicate about 35 what is socially acceptable in a particular community). responsive. However, the possible disadvantages would Such information will be helpful in choosing channels to be a restriction of the audience which may lead to a loss reach the audiences, since the communication channels of general political support for a particular effort, and it which reach urban versus rural districts, or men versus may also lead to stigmatization of the target audience women, or the well-educated versus the poorly as the cause of a problem. educated, may be different. Information on the two types of audiences will also be helpful in choosing the Selecting communication channels appropriate messages. For example, the reasons that The main reason for which many communication programs influence married men with children to adopt condom fail is because they do not reach their audiences with use with extramarital partners may be quite different from sufficient frequency. It is crucial at the planning phase to those that influence young, unmarried women to insist make hard-nosed judgments about what channels can on condom use. be organized to reach the audience effectively and what channels can be maintained over time. Assume a The choice of audiences will be based partly on program requires that a mother be reminded of the need epidemiological information which indicates who is at to bring a child in for vaccination at one, two, three, and risk of a dangerous health outcome and who is not nine months of age. Ideally the decision about the set of engaging in the recommended behavior. Measles may channels to be incorporated will be based on a be a particular threat to the health of the malnourished consideration of each of these major factors: and perhaps, in a particular country, measles are • Reach: what proportion of the audience is exposed particularly common among urban children—a to the channel? population which is poorly vaccinated. All of these • Frequency: how often are the audiences exposed to conditions would form a basis for focusing on urban the channel? children. However, other types of evidence may also • Cost: how much will it cost to achieve each contact be relevant to audience choice. Institutional research with a member of the target audience? (described above) may indicate that an audience • Managerial feasibility: will it be possible for the simply cannot engage in the recommended behavior, project to manage the use of the channel over given the current structural context—that there is no time—supervising outreach workers, or preparing easy access to vaccination. These audiences should effective media material? not be the target of a communication campaign meant • Effectiveness per contact: how much effect on to accelerate demand for services. Channels research knowledge or behavior will each contact with the (described below) may indicate that a particular channel produce? audience is beyond the reach of the channels that this project can afford. Message research (described Ideally one should have answers to all of these questions below) may indicate that a particular audience has based on research at the planning phase, yet that rejected the recommended behavior for fundamental recommendation is unrealistic under most reasons, and there isn't much likelihood that a circumstances. Data about the potential reach and communication effort will influence those reasons. frequency of a channel for some audiences may be available from existing archives. Radio ownership and The advantage of choosing a primary target audience is listenership, or frequency of visits to public health clinics clear: the promise of more efficient use of resources if may be estimated from health surveys, for example. If there is a focus on persons at risk, on channels which not available from existing data sources, original data reach them, and on messages to which they will be collection will be required. Fortunately, behavior and 36 audience research may be combined with the message depends on their knowledge of the risk of such sex in research described below. However, for some channels transmitting HIV. Others may argue that condom use is which are not already in place (such as mobile film vans, a reflection of social expectations from peers—individual or community volunteer networks) only best guesses use will vary with perceived peer use of condoms. Still about potential reach may be possible. Budgetary cost others might suggest that overall attitude toward condom estimates may be calculable for most channels, which use, or skill in condom use, or partner’s expectations can be combined with the reach and frequency about condom use are important influences. All of these estimates. These will produce estimates of cost per hypotheses about what might determine condom use contact, as well as of total cost for reaching the entire carry with them ideas about message strategies. If target audience with the frequency thought to be transmission risk perception is key, then messages needed. Estimates of managerial feasibility and effect about the extent of risk might be expected to influence per contact estimates will not be based on new research, behavior. If perceptions of peer behavior are central and but on planners’ best judgment, and previous experience if others are, in fact, using condoms, messages in the country and elsewhere. emphasizing peer behavior would be appropriate. Once the range of possible influences and their implied Creating messages message strategies are laid out, the next step is to use Message research during the planning phase involves research to investigate and choose among them. two sequential tasks. The first is creating a range of possible message strategies from communication For each possible influence, the answers to three theory, key informant interviews, group discussions, or questions will help determine the extent to which they best judgment. Planners relying on available theory, or represent a promising path. Evidence about these on the best advice of informants, or on discussions with questions will most likely be answered through a sample groups representing the target audience, or on their own survey with the target population, although other judgment, suggest a range of possible message methods may be appropriate also. Tables 2-1 and 2-2 strategies that they think might influence audience represent hypothetical results from a survey used to behavior. For example, someone might suggest that develop message strategies. We use them to condom use among men during nonmarital intercourse demonstrate analyses of the three questions. Table 2-1 Condom Use and Belief that Unprotected Sex has Risk of HIV Use of condom during sex last intercourse Belief that unprotected has risk of HIV No Yes Number No 80% (8) 47% (42) 50 Yes 20% (2) 53% (48) 50 Number 10 90 100 37 Table 2-2 Condom Use and Belief that Peers Use Condoms for Sex with Nonmarital Partners Belief that peers use condoms for sex with Use of condom during sex last intercourse nonmarital partners No Yes Number No 63% (44) 20% (6) 50 Yes 37% (26) 80% (24) 50 Number 70 30 100 Is there a substantial number of people who are not in How hard will it be to move the audience on the predictor the desired position on the relevant variable? For variable? How hard will it be to convince those who are example, what proportion of the population does not saying that there is no risk of HIV transmission through believe that there is a high risk of HIV through unprotected sex that there is a risk? How hard will it be to move those sexual intercourse? If almost everyone already who do not think their peers are using condoms to a belief recognizes the threat, as in Table 2-1, where 90 percent that their peers are using condoms? In contrast to the do, then there is little to be gained from focusing on that analysis of the first two criteria, there are unlikely to be message. By contrast, in Table 2-2, where 70 percent data available to make this decision. In this case, the do not believe that their peers are using condoms planner’s judgment will come into play. Simple (although half are using condoms according to that table) knowledge (for example, of transmission risks) may be there is a good deal of room for movement. On this easier to influence through communication than more criterion, only the second message about peer behavior fundamental beliefs, or beliefs that reflect direct has much promise. experience (for example, peer use of condoms). If two message strategies are both promising according to the Is there a substantial relation between the predictor first two criteria, then the one which is judged more variable and the outcome variable? Do differences in the changeable would take priority. predictor variable predict who will and who will not engage in the desired behavior? In both Table 2-1 and Table 2-2 Of these two messages (unprotected sex has a risk of there are substantial relations between predictor (column) HIV, and peers use condoms for sex with nonmarital and outcome (row) variables. Those who have positive partners), this exercise would lead planners to prefer the beliefs are more than twice as likely to engage in the second. The first message strategy is disqualified on recommended behavior as those who do not. On this the basis of the first criterion. While the second message criterion both message strategies have promise. strategy may be harder to change, success in changing 38 Box 2-2 Planning Phase Research: A Summary Box 2-1 This is the most important phase of communication research, in that the trajectory of the project is set and Practicality in Message the variety of questions to be addressed is great. In addition, there is a great risk that planning research can Research: A Caveat absorb time and resources, but, because of poor In practice, message research and analysis will management, may contribute little to project decisions. rarely lead to a single definitive message strategy. It should be noted that, while planning research is imperative for honing the project’s communication strategy, planners will find that planning phase research 1 Multiple proposed approaches may show promise rarely results in a single definitive message strategy. against all three criteria cited previously and each The following summarizes the key decisions and will merit use. questions to be addressed during planning research. 2 Multiple strategies may be more effective than any one strategy, given that particular individuals may Which behavior(s) should be addressed and be vulnerable to more than one influence, and which audiences should be approached? different members of the audience are likely to be vulnerable to different strategies. • Epidemiological information: if a specific popula- tion changed a specific behavior, would it be of 3 While this data-informed strategy analysis should substantial health benefit? improve the process of strategy choice, it can offer • Institutional context for the behavior: is it possible no guarantees. The observed associations in for audiences to engage in a recommended Tables 2-1 and 2-2 are consistent with the claim behavior through existing structures and institu- that if the belief changes, the behavior will change. tions if they choose to do so? However, these associations are not definitive evidence of causality. That would only come from • Choosing appropriate audiences: which audi- actual piloting of a message strategy and evalua- ences are at a health risk from the uneducated tion of its effects, and that approach is unlikely to behavior? Which audiences may influence those be within the resource constraints of most projects. who are at risk? Given some uncertainty, judgment based on other criteria will play a role, and is unlikely to result in a Which communication channels should be used sole emphasis on a single message. Nonetheless this approach will probably both eliminate some to reach an audience? approaches as inappropriate (given failure against Decisions concerning choice of channels should be any of the three criteria) and guide planners to based on: favor some strategies. • Reach • Frequency • Managerial feasibility it promises a substantial shift in condom use, in that it is • Effectiveness per contact. a belief that is not currently widely shared, yet is highly What messages should be conveyed to target related to condom use. audiences? Steps in producing messages include creating a range of possible message strategies from communication Once the target behavior, audience, channels and theory, key informant interviews, group discussions, or message strategies are chosen, the project will turn to best judgment, and investigating message strategies using the questions below: implementation and a different role for research. Of course a project which is implemented and found to • Is there a substantial number of people who are not in the desired position on the relevant (i.e., at-risk) produce unsatisfactory results, or needs to move in a variable? new direction, may have to be cycled back to planning • Is there a substantial relation between predictor phase research. However, for this discussion, we treat and outcome variable? the process as sequential, and turn next to research • How hard will it be to move the audience on the approaches used at the implementation phase. predictor variable? 39 CHAPTER 2 Research During the Material Development Phase The second broad area of research particular to types of materials, then are asked not merely to show communication components of health projects is comprehension of the message but to report about the pretesting of materials. Message strategy development details of the material. Questions are asked such as: is discussed in the previous pages is distinct from the hairstyle appropriate? Is the background color material development. The former deals with the broad appealing? Are the words used offensive in any way? message approach, while material development Under such circumstances there can be little evidence research focuses on the usefulness of particular available about likely comprehension under realistic material. This is often the most accepted of all the sorts conditions; rather, the groups are being used as expert of research discussed here, perhaps because it is the informants, given their best judgments about the material. most concrete, and because it can be done with relatively little in the way of resources. Both of these approaches to pretesting can be valuable, so long as purposes are not confounded. Group expert The role of pretesting commentary may be helpful in guiding material design. Pretesting research typically involves showing either Often, direct comprehension testing will be a distinct and rough versions of materials, or sometimes finished crucial activity whose goal is not satisfied by focus group versions to small numbers of people representative of analysis of prototype materials. the target audience. Sometimes this is done one person at a time, and sometimes it is done in groups. To some Principles of material development extent, two distinct approaches to such research work and testing at cross-purposes. On the one hand, the fundamental Some general principles of material development goal of pretests is to know whether exposure to the research might include: material under normal circumstances (such as listening • Pretest with people representing the full range of the to a radio program at home, seeing a poster on the wall target audience. A material that works with the well- of the clinic, or referring to a take-home flyer after the educated may not work with the less educated. clinic health worker explained the content) will lead to comprehension of the intended message. For that goal, • Distinguish between expert informant testing and pretests of materials should take place under conditions group testing. If the purpose is to seek expert which resemble the real ones in which exposure occurs. informant judgment, then it is often useful to present a variety of materials presenting the same However, many material pretests are done under quite message, so respondents can make comparisons. different circumstances, and, de facto, have a different If the goal is to estimate likely comprehension, goal. Gathered into groups, people are shown multiple once one material is presented, estimates of 40 comprehension of additional materials are likely to be biased. • Strive for thorough pretesting, but remain realistic. In the ideal, projects ought to pretest every material that is produced. In reality, that is an unlikely event since a substantial project will produce many different materials and will not have the research resources or the time available to pretest every one of them. An alternative strategy may be to view pretesting primarily as a training activity. Its goal is to hone the judgments of materials writers and artists, so that they improve their judgment as to what will work with their target audience. This would suggest that early material development should invest heavily in pretesting, but that this investment be reduced over time. Pretesting will be less urgent when the degree of modification required as the result of pretests lessen as producers become more proficient. Then the pretesting function would be required for only a sample of materials to insure that the producers’ empathy with their audience would not be lost. Pretesting would also be required when either a new audience was being addressed or a major new message strategy was being introduced. 41 CHAPTER 3 Research to Monitor Implementation Once a communication component is launched, the encourage exclusive breastfeeding among urban research turns to monitoring indicators of process and women. At baseline, perhaps sixty sites would be effects. Again, for a project of great size with substantial randomly chosen, and then divided into four matched resources available for the communication component sets of fifteen sites. One set of fifteen sites would be (and with skilled researchers on its staff), research visited every three months and ten or twelve mothers of during implementation can be complex and thorough. babies under six months of age would be interviewed at However, most projects will find complex models each site, producing a total sample of 150 to 180 beyond their resources and skills. A simpler alternative mothers. Over the course of a year each set of sites would approach is presented here. be visited once. Assuming that six interviews could be completed per day per site, and each site required two Box 3-1 days of work, interviewing could be completed in thirty Three Questions For days of work; if coding and basic analysis of frequencies Communication Implementation required ten days, each round of data collection would A project which carefully chooses its indicators and monitors them frequently, over time, may still have require approximately forty days of work by one person. great a advantage over those which aspire to complex Four rounds per year would then require 160 days per implementation models but cannot produce timely year, about eight working months. feedback for decisions. Operating communication components of projects can be greatly helped by answering three basic questions: The survey instrument 1. Is the audience being exposed to the messages as The instrument would have a series of core questions intended? addressing process and effects of the project. One 2. Is the intended audience changing cognitions (knowl- section would address exposure to the major project edge, beliefs, attitudes) as expected? messages; if mothers were to have heard about exclusive 3. Is audience behavior changing? breastfeeding from hospital counselors (or from A basic research model midwives in their community, or from physicians at A model for research to be carried out during the prenatal visits, or from radio programs), carefully phrased implementation phase comprises three major questions would ask for reports of such exposure. A components: a sample of sites for monitoring, the survey second section would measure cognitions which the instrument, and the analysis. messages addressed: if a project focused on increasing a woman’s knowledge of what to do if she had problems A sample of sites for monitoring with breastfeeding, or on knowing the advantage of Depending on the behavior of interest, the choice of exclusive breastfeeding in avoiding diarrhea, questions sample sites and the size of needed samples will vary. would gauge her knowledge of those issues. A third However, as an example, assume that the goal is to section would assess adoption of recommended 42 behaviors, both precursor behaviors such as feeding on implemented. If only a few percentage increase in demand rather than on a schedule, and focus behaviors exposure can be achieved, the project is not succeeding. such as, delaying solid foods until 4–6 months. Similarly, if the cognitions are slow to change even over several waves of data collection, then skepticism about The analysis program success is also justified. Behavior changes will The first step in analysis would be simply to describe be most difficult to detect, since logically they will changes in the major indicators over time. Wall charts change at even a slower rate than cognitions. would graph changes in each of the indicators, such as Nonetheless, by accumulating behavioral data over the proportion of the sample recalling exposure to radio multiple waves it will be possible to make confident messages about breastfeeding. The absolute level of estimates as to whether behavior is improving or not. indicators would be important (such as whether 10 percent or 50 percent report such exposure), but the Maximizing the usefulness of direction of the change in indicators would be more research analysis important. (If 30 percent knew that exclusive The second part of the analysis is the follow-up to breastfeeding lowered the risk of diarrheal disease at observed results. If the indicators suggest that baseline, is it now up to 50 percent, or is it still close to improvements are occurring as expected, then 30 percent?) adjustments are unnecessary. However, these indicator data, by themselves, will not make it clear why any How much progress should be expected failures have occurred—why exposure falls short of Because the sample will be small, sampling errors projected levels, why good levels of exposure fail to be around particular point estimates will be large. (An associated with cognitive change, or why behavior indicator for which the sample mean was 50 percent and change lags behind cognitive change. If such failures for which there were 150 respondents would have a exist, then project staff will need to sort out the reasons confidence interval of at least plus or minus 9 percent). by examining the nature of project operations (for Thus only large changes from measurement wave to example, were radio messages actually broadcast?), by measurement wave will be detectable with confidence, interviewing or observing intermediaries (are hospital although the pattern over an entire year will be much staff providing counseling as indicated?), or by further more easily seen. interviewing intended beneficiaries who might provide insight as to why knowledge differed so much from For the process variables of exposure and cognitions, behavior. Many projects will prefer to build in an input this ability to detect only large changes should be monitoring system from the start, to know whether acceptable. Exposure to messages should be low at expected activities actually occur, rather than waiting for baseline and increase substantially as the program is evidence of failure to achieve expected levels of 43 exposure or knowledge. That system would document As a practical matter, for most projects, incontrovertible how many outreach volunteers were trained covering claims of causal influence are beyond their reach. The what proportion of the intended audience, how many cost of providing adequate information to make such messages were broadcast and how often, how many claims is often too high for an operating project, for the posters were distributed and to what geographic sites, following reasons: and so on. This evidence about the extent to which • The project cannot justify a control area needed to projected activity was realized will complement the support such claims. monitoring of exposure, cognitions, and behavior. Many will also wish to maintain the capacity to do follow-up • The sample sizes required to show effects will eat focused research to sort out the specific sources of up scarce resources. observed shortfalls—why outreach workers are not • The time frame of such studies produces feedback visiting the number of homes they were expected to, or too slowly for decisionmaking. why radio programs are not recalled by the audience even though they have been broadcast. The program Finding a set of trend lines which substantially match may also want to track budgetary costs of each expectations will be a hard enough criterion for most component of the communication system. When joined projects to meet; few will be troubled by insecurity about with the exposure evidence it will indicate cost per unit the attribution of good observed results. However, there of exposure, and that may be compared across channels are some times when external agencies want firmer and with projections at project start-up. justification for policy. They need more confident attribution of causal effects, and ideally want estimates The limits of monitoring research of the costs of projects per unit of effect. Such evaluation Monitoring research will indicate whether things are going research, known as summative evaluation research, is as projected. It is likely to be a sufficient basis for a not typical of loan-related documents and as such, is judgment as to whether the program is operating not dealt with in this document. adequately in most circumstances. Along with a complementary capacity to investigate why things are Internal versus external management not going as expected, it will serve the needs of an This document suggests that quite different research operating project well. However, on logical grounds, it needs to be done at the planning phase of a program does not permit attribution of observed changes to the than at later implementation phases. From the start, operation of the communication component. Other projects should be structured so that they include forces, whether part of the project or external to it, might substantial research capacity. However, the research also explain any observed changes in cognitions and in functions which are required evolve as projects mature. behavior. Much of the academic evaluation literature Projects may choose to undertake these research tasks deals with issues of inference of effects and makes it with their own staff or they may choose to manage the clear that such inference is often a difficult affair. research work of other institutions. 44 The extent to which research is done internally, or only managed internally, will probably vary with the stage of project evolution. For many projects, it may make sense to manage, but not undertake, the research at the planning stage. Contracting other researchers for a limited period to undertake such research under the guidance of project planners may be efficient. However, material pretesting and particularly the monitoring activity at the implementation phase are longer-term and even permanent components of project operations. For many projects it will prove less costly, and increase the likelihood that results will be integrated, if the research staff is in-house. 45 46 Module Three Strategic Communication for Development Projects Indicators 47 Module Three: Strategic Communication for Development Projects: Indicators This module contains a list of key indicators to help program managers measure the outcomes of communi- cation activities and track the inputs and processes that contribute to these outcomes. These indicators were adapted from the first edition of Handbook of Indicators for Family Planning Program Evaluation by J.T. Bertrand, R.J. Magnani and J.C. Knowles. New indicators developed for this module include the percentage of the target audience expressing knowledge, attitudes, and beliefs consistent with message(s), and the percentage of the target audience engaged in recommended practices. 48 Indicators Contents CHAPTER 1 Number of Communications Produced, by Type, during a Reference Period ... 50 CHAPTER 2 Number of Communications Disseminated, by Type, during a Reference Period ... 51 CHAPTER 3 Percentage of Target Audience Exposed to Program Messages, based on Respondent Recall ... 52 CHAPTER 4 Percentage of Target Audience who Correctly Comprehend a Given Message ... 53 CHAPTER 5 Percentage of Target Audience Expressing Knowledge, Attitudes, and Beliefs Consistent with Message ... 54 CHAPTER 6 Percentage of Audience who Acquire the Skills Recommended by the Message ... 55 CHAPTER 7 Percentage of Target Audience Who Discuss Message with Others, by Type of Person ... 56 CHAPTER 8 Percentage of Target Audience who Engage in Recommended Practices ... 57 49 CHAPTER 1 Number of Communications Produced, by Type, during a Reference Period A communication is defined as one or more messages Purpose and issues packaged as a single item on electronic, print, or other This listing constitutes an internal inventory for the media (e.g., radio spot, poster, brochure, video, etc.). program or project, and is generally organized by type of communication. It reflects the capacity of the program Data requirements to generate materials and thus serves the purpose of A list of items produced in a given period of time, such creating a sense of accountability among communication as one year, is required, and a comparison to what was staff responsible for production. However, it is a crude planned for the project. measure because it does not reflect the frequency or reach of the diffusion of each communication, nor does Data source it measure the quality of the items produced. Administrative records are used as the data source. 50 CHAPTER 2 Number of Communications Disseminated, by Type, during a Reference Period Dissemination is defined as the external transmission Purpose and issues or distribution of the communications produced via This indicator measures productivity of the Health electronic, print, or other media, as well as the Education Department, specifically the quantity and type interpersonal activities or public relations events of communications disseminated (irrespective of whether implemented. anyone sees or hears them, understands them, or acts on them). “Getting the message out” is a necessary Data requirements (though not sufficient) activity to initiate members of the A list is required of communication products target population into the program’s goals. disseminated and of activities conducted during a given period of time, such as a year. Well-planned information, education, and communication (IEC) programs generally have a strategy for the diffusion Data sources of communications that lists the types of communications Sources of data include log books of radio and TV stations and the number of each type to be disseminated. This regarding the number of broadcasts of each spot or plan serves as a target to be achieved during the reference program; records of the Health Education Department of period. It is particularly useful to interpret the number of the Ministry of Health (or other institutions implementing communications actually disseminated in relation to the communication activities) on the number of posters or number targeted. Ideally, one would then ask the question brochures distributed to service delivery points; and covered by the next indicator, “How successful were these program records at service delivery points regarding the messages in reaching the target population?” number of brochures distributed to clients, educational talks given, outreach visits by program staff, etc. 51 CHAPTER 3 Percentage of Target Audience Exposed to Program Messages, based on Respondent Recall Individuals exposed to messages are defined as those extent to which the public has been informed about who can recall seeing or hearing them disseminated by family planning via the mass media, whether through the communication program or other source via electronic promotional messages produced by the government or or print media or through interpersonal channels. The private family planning associations, or through news message may be either a specific phrase (e.g., the stories about specific methods. For example, from slogan of an ongoing campaign) or any mention of a Demographic and Health Survey (DHS) data, it is project on health, nutrition, or population. possible to calculate the percentage of the population exposed to any family planning message. Countries with Data requirements a systematic program to use multiple channels of To measure this indicator, one must count the channels communication, including aggressive media through which the individual has seen or heard either a programming, to reach target audiences tend to score specific message or any message about a project on high on this measure. By contrast, countries that limit health, nutrition, or population. dissemination of messages to a single channel such as interpersonal communication tend to score low. Data source Data are obtained by a survey (preferably with a random Two types of recall are frequently tested in surveys: sample) of the target population. spontaneous and aided (analogous to the questions on knowledge of family planning methods in the DHS). Purpose and issues Specifically, the respondent is asked whether he or she Recall of specific messages provides a measure of the has heard other messages not spontaneously reach of a given communication campaign. (“Exposure mentioned. Since there are usually several messages in to” and “reach of” a communications program are a communication campaign, the responses regarding equivalent concepts). specific messages are, in some cases, weighted more heavily for unaided versus aided recall, and then By contrast, exposure to “any message” about family summed to arrive at a continuous variable measuring planning provides a crude but useful measure of the the level of recall. 52 CHAPTER 4 Percentage of Target Audience who Correctly Comprehend a Given Message This indicator is defined as the percentage of persons on a small, nonrepresentative sample of the population, who, having heard a specific message, are able to it is useful to assess comprehension once the messages correctly paraphrase the main idea. are actually in circulation among the target audience. Data requirements It is important to collect this information by interviewing To measure this indicator one requires answers from a series of individuals in private (the usual format for a respondents to surveys made before and after diffusion survey). By contrast, focus groups are not a useful means of the message to determine a change in the level of of obtaining this information. If, for example, only one comprehension. person in the group knows the correct response and he or she gives it, this immediately contaminates the rest Data source of the data collection procedure. Data are obtained by a survey (preferably with a random sample) of the target population. Purpose and issues This indicator is useful in ensuring that the messages being disseminated are indeed comprehended by the target population. Ideally, all messages should be tested for comprehension (as well as other qualities) prior to final production. However, even if they pass a pretest based 53 CHAPTER 5 Percentage of Target Audience Expressing Knowledge, Attitudes and Beliefs Consistent with Message A communication campaign promotes specific Data requirements behaviors, the adoption of which are expected to lead To measure this indicator one requires answers from to a substantial health benefit. Based on research, respondents to survey questions dealing with project experience, and judgment, communication knowledge, attitudes, and beliefs. Surveys should be planners make assumptions about which types of made both before and after diffusion to provide a knowledge, attitudes, and beliefs contribute to the comparison. adoption of new behaviors. Communication material contain statements or messages that disseminate this Data source knowledge or portray an attitude or belief. Data are obtained by a survey (preferably with a random sample) of the target population. Knowledge is defined as a good understanding of why specific behavior contribute to good health. Attitudes Purpose and issues are defined as a positive or negative feeling towards an This indicator is useful for determining if message idea, person, or object. Beliefs are defined as a strategies are working, i.e., if the message’s content is framework of thinking about ideas, persons, or objects. understood and whether changes in knowledge, attitudes, and beliefs have any correlation with the program’s intended messages. 54 CHAPTER 6 Percentage of Audience who Acquire the Skills Recommended by the Message Individuals who acquire the skills necessary to perform Purpose and issues a task are defined as those who could not complete the This indicator is intended to measure the effectiveness task correctly prior to seeing or hearing the of a given communication in teaching a skill, assuming communication. A skill is defined as behavior needed that is the purpose of the communication. to correctly perform a given task. For a family planning program, for example, this might entail taking the pill in Ideally, the researcher will be able to observe members the correct way, putting on a condom, or checking the of the intended audience actually performing the task. strings of an IUD. Verbal reports are less reliable than direct observation. On the one hand, respondents might claim greater facility Data requirements at a skill than they actually have; on the other, less Definition of criteria for the correct demonstration of a articulate respondents might be better at doing a task given skill; verbal description of the skill or actual than explaining how it might be done. demonstration, before and after exposure to the communication. While this indicator is important as part of the overall effect of the program, it is among the most difficult to Data sources apply in practice. Even if the respondent is able to Data are obtained by interviewing members of the target demonstrate the skill in a simulated exercise, he or she population exposed to the messages or by observing may not apply it in everyday living. In addition, the field the skill being performed. team needed to assess whether an individual has acquired a given skill may require a higher level of training and/or clinical expertise than the typical interviewer would have. Collecting data on this indicator represents a special challenge, and thus it is not widely used at the field level. 55 CHAPTER 7 Percentage of Target Audience who Discuss Message with Others, by Type of Person Discussing the message refers to any conversation Purpose and issues subsequent to exposure to the communication in which This indicator measures the extent to which one or more the communication (radio/TV spot, brochure, song, etc.), messages from the mass media or from group its characters, or its messages are mentioned. Breakdown communication generate further interpersonal into type of person (such as spouse, partner, relative, communication. friend, etc.) is applicable under some conditions. Within the communication field, it is often stated that Data requirements mass media are useful for creating awareness and To measure this indicator one needs to know the number increase knowledge, but that interpersonal of persons who discussed the messages with others, communication plays a vital role in bringing about actual either as a percentage of those who heard or saw the behavioral change. Although it has been shown that messages, or as a percentage of those interviewed. media can have a direct effect on behavior, campaigns that generate substantial interpersonal communication Data source may result in an even greater level of behavioral change Data are obtained by a survey (preferably with a random (first, because of the social support that may be sample) of the target population. generated for the idea, and second, because the message may be transmitted to others who did not hear it from the original source). 56 CHAPTER 8 Percentage of Target Audience who Engage in Recommended Practices This indicator is defined as the percentage of persons Data source who understand and engage in practices recommended Data are obtained by a survey (preferably with a random by the communication program. A communication sample of the target population), which may be strategy should identify the behavior to be promoted combined with behavioral observations in service among a specific audience. facilities or in homes. Data requirements Purpose and issues To measure this indicator one needs to know the number This indicator is one of the more stringent measures of of persons who declare their use and intended continued success of the communication program. Monitoring use of the practice recommended by the communication research should attempt to determine if changes in program. In some cases, the observed use of the cognitions (knowledge, attitudes, and beliefs) correlate practice may be measured, such as in observing correct with changes in behavior. Admittedly, behavior change breastfeeding technique. In either case, these figures will be more difficult to track—it may take a while for would be stated either as a percentage of those who behavior to change in a given population, or behavior heard or saw the messages in question, or as a change trends may not be sustained. It would be useful percentage of those interviewed. to investigate communication program input over time to determine if messages are reaching audiences with adequate frequency for a sustained period. 57 58 Module Four Strategic Communication for Development Projects Terms of Reference for Bank Consultants 59 Module Four: Strategic Communication for Development Projects: Terms of Reference for Bank Consultants This module includes illustrative examples of terms of reference that described tasks undertaken by communi- cation consultants hired by the World Bank during project preparation and supervision. A brief project background provides the context for the task of each communication consultant. 60 Terms of Reference for Bank Consultants Content CHAPTER 1 Project Identification: Population and AIDS Control Project (Chad) ... 62 CHAPTER 2 Project Preparation: Women’s Health and Safe Motherhood Project (The Philippines) ... 64 CHAPTER 3 Project Preparation: Disease Prevention Project (China) ... 66 CHAPTER 4 Project Preparation, Appraisal, and Supervision: Health and Population Project One (Burundi) ... 68 61 CHAPTER 1 Project Identification: Population and AIDS Control Project (Chad) This chapter describes the terms of reference for a • To gather data through surveys on knowledge, communication/social marketing specialist hired by the attitudes, beliefs; focus group discussions, World Bank for the Population and AIDS Control Project (Chad). behavioral data on current practices and an assessment of skills needed to perform new Project background behaviors; and key informant interviews. The project aims to assist the Government in implementing its long-term strategy in population and • To assess availability of data on the following social family planning, (FP) and its medium-term plan for AIDS marketing issues: perceptions about the image of control. It will support policies and investments that the product (i.e., the condom); availability at costs strengthen institutional capacity for work in population, that are affordable to low income groups, family planning and AIDS control. Specific activities distribution systems (from manufacturer to national include implementing a community awareness program distribution center to retail outlets), pricing and and disseminating population policy; epidemiological, profit margin and its impact on the willingness of operational and socioeconomic research; promoting retailers to carry the product; and funds for condoms through social marketing; and increasing promotions. participation of the private sector and NGOs in population, family planning, and HIV/AIDS/STD • To assess the organizational systems for managing programs by setting up a social fund. the social marketing component: specifically, the agency (public, private, or a combination) which The key objectives for the consultant's work on the social will be responsible for overall management of the marketing component of the AIDS project are: elements needed in a successful social marketing program to promote condoms for AIDS/HIV • To assess the availability of research-based prevention; product distribution and sales information upon which a communication strategy organization; advertising and promotions; and will be developed. Data will be needed to answer product pricing structure. four questions: who is the target audience for this social marketing campaign? What behavior will be promoted? What message concepts will convince Based on the consultant's assessment of these issues, the target audience of the benefits of the new the consultant should submit recommendations relevant behavior? Which communication channels will be to the following: used to reach the target audience? 62 • Conduct of secondary analysis of existing data or The consultant will also review Bank documents regarding conduct of primary research to fill in key knowledge this proposed project, including the Initial Executive gaps on any of the issues identified above. Project Summary and the Project Identification Document, and suggest modifications as needed. • Conduct of an organizational study to determine the feasibility of various options for setting up an effective Prepare a master timeline and budget which incorporates organizational system for the social marketing the subactivity timelines and budgets listed above for use program. For example, one option may consist of by the task manager during project preparation. government oversight and day-to-day management by a subcontracted private sector group. • A pricing study to determine the retail price for condoms that will make them affordable to low- income groups and financially attractive to retailers and distributors. • Pretesting of message concepts that will help determine effective product positioning for condoms. Should condoms be positioned primarily for preventing STD/ AIDS/HIV, or should they be promoted using a combined family planning and STD/AIDS/HIV product positioning? • A market segmentation study to determine which group will serve as primary target audience. Recommendations should include the proposed terms of reference for subcontractors, a timeline, a budget estimate, and a list of possible subcontractors or government agencies or units that will undertake these activities. 63 CHAPTER 2 Project Preparation: Women’s Health and Safe Motherhood Project (The Philippines) This chapter describes the terms of reference for a consultant the appraisal mission, a budget for IEC/social marketing on communication/social marketing for the Women’s Health will be prepared based on this strategy. and Safe Motherhood Project (The Philippines). Scope of work Project background The consultant will undertake the following activities: The project aims to improve the health status of women, particularly women of reproductive age. Its specific 1. Review available secondary research data on topics objectives include (a) improving the quality and range of relevant to women’s health, such as formative women’s health and safe motherhood services (b) research and campaign tracking research, including strengthening the capacity of local government units studies on knowledge, attitudes, beliefs, and (LGUs) to manage these services and of the Department practices; focus group discussions; and campaign of Health to provide policy, technical, financial, and tracking surveys on family planning, micronutrients, logistical support (c) enhancing the participation of local AIDS/STDs, adolescent fertility, and cancer in communities and NGOs in the project; and (d) expanding women, as available. the knowledge base upon which to draw for policy and technical guidance for women’s health programs. 2.Conduct interviews with key officials of the Department of Health involved in family planning, To accomplish these objectives, the project will consist maternal and child health, and nutrition, to of (a) service delivery; (b) institutional development determine how their programs are addressing key including information, education, and communication issues that constrain the adoption of appropriate (IEC) programs to promote attitudes and practices that health practices, especially as they relate to would improve women’s health; (c) community women’s health. partnerships; and (d) policy and operations research. 3.Prepare a summary (3–5 pages) of issues that a Objective behavior change intervention promoting women’s This document describes the nature of the services that health should address. the consultant will provide to the World Bank in connection with the preparations for the appraisal 4.Prepare a draft communication strategy for the mission for the Women’s Health and Safe Motherhood promotion of key behaviors among specific target Project. The consultant’s activities are meant to provide audiences. This communication strategy should the research data and information upon which a draft answer the following questions: who is the target broad strategy for behavior change will be based. During audience for the behavior change intervention? 64 What behavior should be promoted? What message concepts will this target audience find appealing or compelling? What channels of communication will be used? 5. Identify the types of communication support materials that need to be produced and disseminated as part of the overall communication strategy. This preliminary list will be used primarily for budgeting purposes. Reports from tasks 3, 4 and 5 are due on May 30, 1994. 6. Brief the World Bank mission regarding these findings and recommendations during the June 1994 mission to the Philippines. 65 CHAPTER 3 Project Preparation: Disease Prevention Project (China) This chapter describes the terms of reference for The second stage is identifying the behavior the project would communication consultants for the Disease Prevention like to promote. Is this behavior easy to change or not? Are Project (China). there barriers such as the lack of knowledge, negative attitudes, or lack of access to the product (vaccines)? Project background The proposed project was designed to meet two distinct The third stage is describing the message concept that disease prevention objectives: (a) to improve the project staff believe will facilitate the change in immunization coverage to reduce vaccine-preventable behavior. Should the message be primarily informative? infectious diseases in poor areas of China; and (b) to This will be the case if project staff believe people are enhance China’s capacity to plan and implement convinced of the need for the behavior (immunization) programs to control the rising prevalence of and need is timely reminder on the age of the child noncommunicable diseases, STDs/ HIV, and injuries. needing immunization and the time and place where The first objective will be addressed through an immunizations are provided. This is very different from immunization component, which will improve access to a message concept requiring persuasion to help people and quality of immunization throughout ten of China’s see the benefits of the new behavior and the poorest provinces. The second objective will be consequences of current "unhealthy" behavior. addressed through an innovative health promotion component, which will be implemented in seven cities The fourth stage is determining the channels of and, to a more limited extent, in Yunnan Province. The communication that reach the specified target audiences. health promotion component involves communication Here, the goal is to use a mix of channels that will be activities aimed at influencing target populations to effective in reaching large groups of people with adopt healthy life-styles and behaviors. consistent messages. These include the use of interpersonal communication, group communication There are four key questions that the project will need networks, and mass media channels. to answer to be able to formulate the communication strategy. The first is determining who comprises the These decisions need to be made based on research target audience. It is useful to distinguish a primary information, either secondary data (if available) or a target audience—those people whose behavior the combination of primary and secondary data. project would like to influence, for example mothers. The secondary audience are those groups of people who Thus the communication consultants can be helpful in serve as influencers on our primary target audience, such the following ways: as husbands or the persons mothers consult regarding 1. Determining the availability of research data to help child health. answer these four questions. If secondary research 66 data are not available, then the consultant can capacity for communication work and develop a plan prepare the terms of reference for some formative for strengthening that capacity in specific areas, such research that can be done during project preparation. as strategy development, developing communication materials, and technical training for front-line workers in 2. Technical assistance in synthesizing the available interpersonal communication skills, monitoring, research data and making these available to the materials dissemination, etc. Dr. Y, as the sociologist government program managers so that they can on the team, may be able to provide assistance in make these four key decisions based on research. developing research protocols to assess client KABP. The Bank may wish to consider a communication These may be needed subject areas where there are no planning workshop where local or international available data. consultants can facilitate a two-day workshop aimed at generating the communication strategy for Dr. Z, because of her experience in launching the project. communication campaigns, may be able to assist in the 3. Identifying local agencies, individuals who have development of a communication timeline, a budget, the technical capacity to undertake the and, if some KABP data are available now, a matrix communication work for the project. containing various options for a draft communication 4. Developing a simple tracking system to monitor strategy. This matrix would show possible ways of changes in knowledge, attitudes, and practices. answering the four key questions—target audience, behavior to be promoted, message concepts and Further specific tasks that can be assigned to the various channels. The purpose of this draft matrix is to provide consultants include giving Dr. X responsibility for helping several alternatives. The Government of China staff can develop the overall behavior change intervention strategy then review the implementation implications of each of for the entire project. He would help the Government of these alternatives before the communication strategy China to answer the four questions mentioned above by workshop, where all the Government of China providing them with a synthesis of research-based stakeholders can participate in the final decision. information. In order to do this, he needs inputs from Dr. Y on chronic diseases and from Dr. Z on STDs, AIDS, Ideally, before the workshop the following steps would and EPI. They will investigate the availability of have been completed: information on people’s knowledge, attitudes, beliefs 1. All KABP data have been analyzed. and practices (KABP) and help identify perceived benefits 2. Implementation issues for each of the various options of the new behaviors being promoted. have been discussed, although not agreed upon. All three consultants may be able to jointly develop a 3. Budgets and timelines for the top two most favored simple monitoring and tracking system for changes in options for a behavior change strategy would be knowledge, attitudes, beliefs, and practices (KABP). available. They may also be able to determine they organizational 67 CHAPTER 4 Project Preparation, Appraisal, and Supervision: Health and Population Project One (Burundi) This chapter describes the terms of reference for communication activities in population and health. The consultants hired by the Bank for the Health and specialist will initiate discussions with all relevant Population Project I (Burundi). ministries and agencies about their possible contribution to the IEC program. Project background This project seeks to improve maternal and child health More specifically, the specialist will discuss with the (MCH) status by strengthening nationwide MCH services, Ministry of Education a strategy for a population including family planning (FP) and nutrition activities. It education program for school-aged children. The aims to increase contraceptive use rates to 14 percent specialist will review ongoing activities of the Ministry by 1992 and assist in controlling the AIDS epidemic. The of Heath’s Health Education Unit and assess the project has five components: (a) development of MCH requirements to implement a broad-based IEC program. and FP services; (b) development of an information, Furthermore, the specialist will work with government education, and communication (IEC) program; officials in outlining a strategy for a multisectoral IEC (c) support for the National AIDS Control Program; (d) program, including definition of specific audiences, institutional strengthening of the Ministry of Health; and development of targeted messages, and the balance (e) population data development. All components are between media and person-to-person communication. closely interrelated and aim at developing the population, health, and nutrition sector as a whole , in Terms of reference for project conjunction with the Bank-supported structural pre-appraisal mission adjustment program. The project is designed to be The communication specialist will assess the following implemented over a five-year period starting in January objectives of the proposed IEC component: (a) providing 1988. If the implementation proceeds on schedule, a general public information about the population second project will be prepared during the course of the problem and the health impact of closely spaced first project. pregnancies; (b) promoting a small family norm; and (c) promoting effective contraceptive methods. The Terms of reference for project specialist will review the proposed strategies, which preparation mission include (a) use of the mass media, with diversified The communication specialist will review the ongoing messages aimed at the main target groups; (b) person- information activities on population launched by the to-person approaches; and (c) intersectoral coordination Government and various ministries. The specialist will of the various IEC activities. The specialist will assess review the existing and potential demand for FP and the how major constraints have been addressed, including strategy required to initiate more effective and broader (a) the establishment of the IEC coordination unit and 68 its relationship with the health education unit; (b) the the Ministry of Health in drafting the related terms of government’s financial and managerial absorptive reference. capacity; (c) family planning service availability to respond to the increasing demand; and (d) shortage of Terms of reference for project trained manpower at various levels. Furthermore, the supervision specialist will (a) assess how the potential contribution The communication specialist will be responsible for to the IEC program of government, nongovernmental, and reviewing the IEC component of the ongoing project and donor agencies has been defined, and (b) finalize for identifying potential IEC activities and programs in a agreement on steps to be taken before appraisal. second population, health, and nutrition project. In particular, the specialist will examine the structure of the Terms of reference for project Ministry of Health’s Health Education Unit and the appraisal mission adequacy of its staffing, and identify future training and The communication specialist will be responsible for technical assistance needs. The specialist will also appraising the IEC program development component. review the following: (a) the appropriateness of IEC The specialist will pay particular attention to the tasks contained in the unit’s 1990 work plan; (b) the strengthening of the health education structure, including capacity of the Unit to carry out the proposed activities; staffing requirements, training, and technical assistance (c) the effectiveness of the materials already produced needs. The specialist will review the progress made in by the Unit, focusing primarily on family planning and finalizing the plan of action proposed during the pre- AIDS-related materials; (d) the content and development appraisal mission and its coordination with the maternal process of the past and future messages used to and child health and family planning component. The promote family planning and AIDS education; and (e) specialist will discuss the message content and the coordination mechanisms between the Health pretesting for the three priority IEC themes: Maternal and Education Unit and the other ministries (Interior, Social child health care, family planning, and nutrition Affairs, Women's Affairs, and Education) and UNICEF and education. The specialist will review the coordination UNFPA-funded projects involved in family planning and mechanisms between the Ministry of Health’s Health AIDS-related IEC activities. The specialist will also Education Unit and the various ministries (Interior, Social discuss with relevant authorities the need for expanding Affairs, Women's Affairs, and Education) involved in IEC IEC activities as part of a potential second population, activities. The specialist will also assess the potential health, and nutrition project and will identify specific for collaboration and coordination with UNICEF and areas of intervention. UNFPA-supported projects. Furthermore, the specialist will assess the need for technical assistance and help 69 70 Module Five Strategic Communication for Development Projects Terms of Reference for Borrower Consultants 71 Module Five: Strategic Communication for Development Projects: Terms of Reference for Borrower Consultants This module contains selected terms of reference for communication consultants hired by the Borrower country during project preparation and supervision. A brief background provides the context for the work of each communication consultant. 72 Terms of Reference for Borrower Consultants Contents CHAPTER 1 Project Identification: Basic Education Project (Niger) ... 74 CHAPTER 2 Project Implementation: National Health Sector Project (Madagascar) ...78 CHAPTER 3 Project Implementation: Primary School Development Project (Ghana)...80 73 CHAPTER 1 Project Identification: Basic Education Project (Niger) This chapter describes the terms of reference for raise the percentage of girls enrolled from 36 percent to communication consultants hired by the Government of 49 percent; and (c) reduce the percentage of repeaters Niger for the Basic Education Project (Niger). at the primary level-from 16 percent to 10 percent. It has been decided to make this a hybrid project, Project background comprising both a structural adjustment program and Niger is one of five countries in the world where fewer an investment program, because Niger’s rather low than one-third of children are enrolled in primary educational level and budgetary constraints make it education. What is more, girls account for only 36 percent impossible to accomplish the educational objectives of enrollments, which means that only about 10 percent without education policy reforms and the investments of girls attend primary school. Regional differences can needed to support these reforms. also be seen: the enrollment ratio is lower in rural areas, where long distances are involved and where people’s The objectives of the structural adjustment program will attitudes are less favorably inclined toward education be to (a) increase the cost-efficiency of resource for girls. Parents in rural communities do not believe that utilization in the education sector; (b) increase resource their daughters will be able to obtain employment in the allocations to primary education; and (c) promote more modern sector and they consequently fail to see the equitable access to primary education. advantage of educating them. Incomes are also low in rural areas, which adversely affects the demand for The objectives of the investment program will be to make education in general, and for girls’ education in primary education more accessible and equitable and particular. The fact is that if money is short parents will improve its quality and management. The first objective send their sons to school rather than their daughters. To will be accomplished by (a) constructing 1,170 primary remedy this situation the Government of Niger has school classrooms; (b) promoting the enrollment of girls developed an Emergency Education Rehabilitation Plan, in primary schools by conducting a national information, the aim of which is to overhaul the country’s education education, and communication (IEC) campaign and system, which is at present both costly and elitist, and carrying out administrative reforms involving resource to make it a more equitable system. This plan will give mobilization and literacy training for 16,000 women aged priority to (a) improving the quality of primary education; 15–25; (c) promoting the establishment of community (b) increasing the capacity of the system; and (c) schools by parent–student associations and other efficiently mobilizing and utilizing resources. The district-level organizations; and (d) purchasing and Government is preparing a basic education project to distributing micronutrients to 594,000 primary school implement this plan, which is to be financed by the students. International Development Association (IDA). The objectives of this project will be to (a) increase enrollment The investment program will improve the quality of in the first year of primary education by 40 percent; (b) primary education by (a) restructuring and improving 74 basic and continuing teacher training in order to upgrade ratio among girls; (b) encourage a change in attitude teacher competencies and increase the number of toward primary education and academic success of girls; teachers graduating each year from 400 to 720; (b) (c) publicize throughout the country, particularly in those providing about 1.6 million school textbooks, 1.2 million regions where primary school enrollment of girls is below exercise books for mathematics, and 51,000 teacher the national average, the educational and socioeconomic manuals; and (c) organizing projects to upgrade benefits of educating girls; (d) boost community support teaching methods in 200 schools. for primary education for girls to encourage communities to mobilize the resources needed in cash and in kind; (e) The investment program will improve the management inform parents and opinion leaders about improvements of the education system by (a) strengthening the in the education system designed to encourage the capacity of the Ministry of Education to manage enrollment of girls, such as more culturally acceptable resources and to carry out and evaluate programs aimed school environments, adapted programs of study, at improving education; and (b) improving the efficiency financial aid, and upgrading of teacher competencies; and of the decentralized management and planning of the (f) bring about a change in the behavior of parents in order education sector. to get them to send their daughters to primary school. The Government of Niger intends to hire consultants to Description of consultants’ responsibilities design, plan, and supervise the national information, The consulting services will be divided into two phases. education, and communication campaign, which is one First, during project preparation, the consultants will be of the components needed to accomplish the first responsible for preparing the IEC component; then, once objective of the investment program. The terms of the project is in effect, they will be responsible for helping reference for these consulting services are given below. to supervise the implementation of the component, in accordance with the plan prepared during the preparatory Terms of reference phase of the consulting services. The component will be The IEC program will be prepared and supervised by a prepared during an initial ten-week consulting phase, consulting firm to be selected by the Ministry of Education which will commence in November 1994, immediately following the issue of a bidding invitation to a shortlist of following completion of the study on the obstacles firms. The consultants provided by this firm will be involved in educating girls. During project implementation, required to work in close cooperation with the staff of supervision missions of two to three weeks each will be the Direction des Projets d’Education (DPE, Directorate conducted at regular intervals, in accordance with the of Education Projects), the Cellule Technique de schedule established during preparation of the IEC Promotion de la Scolarisation des Filles (CTPSF, Unit to component. The purpose of these missions will be to help Promote the School Enrollment of Girls) and the other the staff of DPE and CTPSF plan and implement the agencies involved, and with one or more qualified local communication activities. consultants to be selected by DPE and CTPSF. The preparation of the IEC component will be divided The objectives of the IEC component are to (a) make into three subphases: (a) review and evaluation of the parents, teachers, opinion leaders, and others aware of situation; (b) depth group interviews; and (c) preparation the obstacles that contribute to the low school enrollment of an action plan. 75 The first subphase, review and evaluation of the situation, sector and the public sector to develop, pretest, will help to answer important questions and identify and produce messages and materials. Recom- issues that still require clarification. The consulting mendations will be made to the appropriate services to be provided during this subphase will include ministries on the basis of this assessment. the following: In-depth group interviews will be needed to investigate • Evaluation of existing policies and programs more deeply any unresolved issues that were raised concerning the education of girls. during the study of obstacles to girls’ education and that need further research. This subphase should begin as • Review of relevant studies on attitudes, soon as the review and analysis of the studies of girls’ experiences, and practices concerning the education have been completed, and should be carried education of girls. One particular in-depth analysis out in parallel with evaluation of the situation (above). It of the reasons for the low enrollment of girls in will include the following: Niger, which will have been carried out as part of the project preparation and completed by • Preparing guidelines for in-depth interviews on November 1994, will be used to identify issues that issues identified as requiring further research and still require clarification. selecting the groups to be interviewed. These activities will be influenced by the findings of the • Evaluation of communication media — both modern review and analysis of the studies mentioned and traditional, mass and interpersonal — and of above, particularly the study carried out as part of lessons learned from education campaigns the project preparation. conducted in social sectors such as the health sector. A decision about whether supplementary studies on • Training group facilitators to lead the groups. media are needed will be based on this evaluation; if • Conducting depth group interviews. they are needed, the terms of reference will be prepared during the consulting period, and • Analyzing the data collected during the group individuals and/or organizations capable of carrying interviews and identifying topics on which the out these studies will be identified. communication activities will have to focus, as well as identifying the segments of the public to be • Evaluation of existing organizational capability to targeted by the IEC messages. carry out communication activities and prepare, pretest, and produce the communications An action plan will then be prepared on the basis of the materials at central and local levels in order to preceding subphases. This will comprise the following: identify both local and international technical assistance and training requirements. The • Identifying the specific and measurable consultants will also examine the potential role of communication objectives and describing the NGOs at the community level and their possibilities expected results of this component. for liaison with the ministries involved, such as the • Formulating a communication strategy that will Ministry of Communication. specify, for each communication objective, the • Cost-benefit assessment of using the private segments of the public to be targeted; the 76 advantages to be emphasized to bring about Hiring procedures changes in attitude and behavior; the messages The Government of Niger will invite bids from a shortlist and strategy to be used in communicating these of three to six consulting firms specializing in advantages; and the media that will be used to communication. The technical bids received by the convey these messages. deadline will be analyzed according to predetermined • Preparing a detailed list of activities planned for criteria and the contract will be awarded to the firm that implementing this strategy, including the individuals submits the best technical bid. A memorandum of understanding will be signed between the Government responsible for each activity, and a budget and a timetable for implementing these activities. of Niger and the selected firm for a period of five years (1994-99). • Formulating a training plan for central and local personnel; a technical assistance plan (including In their bids, the consulting firms will be required to terms of reference) for local consultants and demonstrate their experience in the field of planning, supervision missions; a plan for monitoring the implementing, and managing communication programs, project with specific indicators for assessing the particularly in Sub-Saharan Africa, and to offer progress of this project component; and an prospective consultants capable of performing the tasks evaluation plan. described. In addition to the capabilities required to perform each of the specific tasks identified in the terms After the preparation phase comes the project of reference and in the plan of action, consultants must implementation phase. The role of the consultants during have at least the following qualifications: this phase will be to assist the staff of DPE and CTPSF and other personnel involved in planning and carrying • A Diplome d’Etudes Superieures (a university out the communication activities of the project. The degree equivalent to a master’s) in communication. supervision missions will be conducted in accordance with the timetable in the technical assistance plan, and • At least five years’ experience in the area of will enable the consultants to help the local staff perform communication in Sub-Saharan Africa, and the annual planning activities, provide training, plan the preferably in the Sahel region countries. IEC campaigns, and carry out the communications activities for which no local expertise exists as yet. It is • A good knowledge of written and spoken French. estimated that these missions will be needed about three times a year during the first two years of the project • An aptitude for team work. and twice a year during the last three years. Before each mission, the terms of reference in the technical assistance plan will be reviewed and revised, if necessary, by the DPE and CTPSF. The consulting firm will, on the basis of these terms of reference, select the consultant who will conduct the mission. 77 CHAPTER 2 Project Implementation: National Health Sector Project (Madagascar) This chapter described the terms of reference for Terms of reference communication consultants hired by the Government of The communication consultant will be expected to assist Madagascar for the National Health Sector Project the government’s Information, Documentation, and (Madagascar). Education Service (SIDES) to: Project background • Decide on its objectives, its functions, and its The project will provide flexible support towards organizational structure at both the central and implementation of the Health Sector Project over a five- provincial levels. year period (1992—96). It will support the national • Write a job description for each position on the objectives of reducing mortality and morbidity, central organization chart. moderating fertility levels, and improving the efficiency • Assess its central staffing needs. and sustainability of public health expenditures. It would also contribute significantly to implementation of the • Define the role of the provincial IEC units and National Population Law (NPL) adopted in 1991. identify the tasks for which they should be responsible. The project will finance (a) comprehensive communicable • Write a job description for each position proposed disease programs to control malaria, tuberculosis, at the regional level. leprosy, sexually transmitted diseases (including AIDS), • Assess staffing needs at the faritany level. and the plague; (b) the establishment of a communicable disease monitoring system; (c) introduction or upgrading • Draw up an implementation schedule for of family planning services as an integral component of establishment of SIDES and its provincial IEC units. maternal and child health care in at least 500 Ministry of This should indicate dates for recruitment of staff at Health clinics; (d) improved delivery of primary health central and regional levels, assessment of staff care services, including reasonable access to essential training needs, and design of a training plan drugs in all Ministry of Health outpatient facilities; and covering the different categories of personnel. If it (e) the first phase of a long-term institutional is recommended that SIDES and the provincial development program. This program aims to units be set up in stages, the implementation progressively restructure and strengthen the Ministry of schedule should also indicate the proposed date Health’s policy on popular and community participation; for each stage. strengthen the Ministry’s policy formulation and • Determine what equipment and consumable goods programming, monitoring and evaluation capacity; and SIDES headquarters and provincial units will need broaden the financing base and improve the to carry out their tasks. sustainability of public health expenditures. 78 • Specify office needs (security, air conditioning, floor areas, etc.) for both SIDES and the provincial units. The consultant should work closely with the relevant staff of the Ministry of Health (particularly his or her own counterpart, the Secretary General), and should inform donors who are financing health, family planning, and nutrition projects of recommendations. Lastly, the consultant is asked to identify what technical assistance will be needed to ensure that SIDES and its provincial IEC units are established successfully. The consultant should: • Be experienced in setting up communication programs in nonindustrialized countries. • Possess at least a master's degree and five years' professional field experience. • Be able to write and speak fluent French. Previous experience in Niger would be desirable. The consultant’s appointment will be for a period of six weeks. 79 CHAPTER 3 Project Implementation: Primary School Development Project (Ghana) This chapter describes the terms of reference for The development and implementation of the IEC program consultants designing the communication strategy and will be undertaken in four phases, briefly outlined as follows. plan for the Primary School Development Project (Ghana). Phase One will involve the review of available data and, as Project background needed, communication research on knowledge, attitudes, The Primary School Development Project (Ghana) seeks beliefs, and practices (KABP) that influence enrollment in to increase communities’ sense of ownership of primary primary schools and completion of primary schooling with schools and enhance their role in increasing primary adequate educational achievements. The results of this school enrollment, strengthening the capacity of the research will be critical in the development of a schools to provide a good education, and improving the communication strategy. learning achievements of children in primary schools. In order to achieve these objectives, the midterm review Phase Two will involve the development of a of the project in November 1995 recommended the comprehensive communication strategy to address the design and implementation of an information, education, information needs of various audiences and encourage and communication (IEC) program to promote broad- behavior change. The communication strategy should based support for educational policies and programs. be feasible to implement nationwide. Specifically, the An effective IEC strategy is also considered crucial to the communication strategy will identify: success of Ghana’s basic education sector improvement • Audiences to approach. program, the first phase of which will be carried out by the Government in 1996-2000. • Behaviors to promote. • Messages to disseminate. It is envisaged that a comprehensive communication • Channels of communication to use to reach strategy will be developed to address the information audiences with adequate frequency. needs of various audiences and encourage behavior change supportive of the goals of the Ministry of • Organizational units to undertake communication Education regarding basic education. Various types of activities, as well as the primary unit responsible communication materials and channels will be used to for managing the communication program. target different groups of audiences, including parents, community leaders, headmasters and headmistresses, Phase Three will involve the development and pretesting and teachers. A monitoring and evaluation system will of communication materials for radio, TV, print, or be established to provide prompt feedback on the cinema, depending on the communication strategy effectiveness of the communication strategy so that agreed upon; and the launch of communication activities timely modifications can be made. The communication in project sites. strategy will seek to coordinate with and give support to the activities planned for the basic education sector over Phase Four, which will be concurrent with Phase Three the next few years. activities, will involve the development of a system for 80 monitoring and evaluation of communication activities IEC activities at the national, regional, and and using monitoring data to make midcourse corrections community level, and describing roles and and update the communication strategy. responsibilities at each level. In the second stage, the consultant will organize and co- Terms of reference facilitate a communication planning workshop after The Ministry of Education would like to engage the research is completed to enable project staff and services of consultants to assist in carrying out the IEC stakeholders to utilize the data in developing the program in the various phases described above. The communication strategy, and implementation plan for following sample terms of reference deal with the work the IEC program. Ideally, the person responsible for required during the first and second phases. research will be the co-facilitator of the workshop. If this is not feasible, the researcher should be present during Scope of work the workshop. The implementation plan will identify the The consultant will assist the Ministry of Education in specific issues that need to be addressed, the attitudes designing an IEC strategy and plan in two stages, a review and behaviors that need to be changed, the target groups of available data and a communication planning workshop. most crucial to effecting such changes, the essential messages that need to be conveyed to particular groups, The review of available data may indicate that formative the most effective means of delivering these messages, KABP research is needed for key audiences, including the relative timing of each activity, and the costs. The parents, community-based influentials, district education plan will also include mechanisms for monitoring and officers, headmasters and headmistresses, and teachers. evaluating the impact of the activities so that appropriate The consultant will plan and carry out this research. Results and timely adjustments can be made to the IEC strategy will be used to develop a communication strategy to guide and its implementation. IEC activities. Schedule As a first step, the consultant will gather available research The research activities should be completed in three on knowledge, attitudes, beliefs, and practices of key months. The review of available research data will be audiences mentioned above and send these to the undertaken in July and August and a report sent to the Ministry of Education and the World Bank with a Ministry of Education and the World Bank by the end of recommendation on the need for further research to fill in August. The communication planning workshop may be gaps. (For example, there may be inadequate data from held mid- to late October, depending on the completion some regions.) of a new KABP study using rapid appraisal methods, if needed. The draft implementation plan should be If further research is needed, the consultant will prepare a proposal for a study, for example, using rapid appraisal completed within a month after the workshop. methods, and submit this to the Ministry of Education and the World Bank. Such research should be completed Reporting before the communication planning workshop. The consultant will be responsible to the Ministry of Education on this assignment and will work directly The consultant will also undertake the following tasks: under the supervision of ___. • Reviewing past communication activities in Ghana, Qualifications such as campaigns about family planning, The consultant should have experience and an academic nutrition, and maternal and child health, to background in social science research. A graduate determine channels of communication available degree in the social sciences with at least five years of and accessible to low-income populations, and to research experience will be preferred. Experience in the identify the impact of communication activities. field of information, education, and communication will • Identifying existing infrastructure and resources for be an advantage. 81 82 Module Six Strategic Communication for Development Projects Qualitative and Quantitative Research 83 Module Six: Strategic Communication for Development Projects: Qualitative and Quantitative Research This module contains examples of qualitative and quantitative research used in developing communication strategies and in tracking changes in knowledge, attitudes, beliefs, and practices. The description of when qualitative and quantitative research techniques are used was reprinted from Methodological Review: A Handbook for Excellence in Focus Group Research by Mary Debus. This is followed by an article on Using Focus Groups to Develop and Promote an Improved Weaning Food Product by Cecilia Cabañero-Verzosa, Cecile M. Johnston and Olabode Kayode. The final piece is a sample methodology with questionnaire for a study on knowledge, attitude, beliefs and practices study developed by Susan Middlestadt of the Academy for Educational Development and the Agency for Communication Options of Bangladesh for a World Bank- supported project on female education. 84 Qualitative and Quantitative Research Contents An Overview of Qualitative Research ...86 CHAPTER 1 Using Focus Groups to Develop and Promote an Improved Weaning Food Product ... 94 CHAPTER 2 Knowledge, Attitude, Beliefs, and Practices Survey Used by the Female Education Awareness Program (Bangladesh) ... 106 85 An Overview of Qualitative Research The following overview of qualitative research aims to The two primary qualitative research techniques are (1) clarify what it is and what information it provides, and to individual depth interviews and (2) focus group give guidance about when to use it by providing some discussions. These will be discussed in greater detail in concrete examples of its applications and highlighting later sections of this document. Emphasis will be placed its distinctions from quantitative research. on focus group research. What is qualitative research? What are the roots of qualitative research? Qualitative research is a type of formative research that Historically, qualitative research grew out of several offers specialized techniques for obtaining in-depth disciplines: literary criticisms, social sciences and responses about what people think and how they feel. psychoanalytic theory. The nature of qualitative analysis It enables program management to gain insight into is tied to literary criticism and to the social sciences. The attitudes, beliefs, motives and behaviors of the target interpretation and synthesis of ideas and concepts has population. When applied properly, qualitative always been part of literary criticism, and the type of techniques are used along with quantitative techniques qualitative analysis that requires insight and illumination in an interrelated, complementary manner. For example, is part of sociological tradition. The interviewing the qualitative approach provides depth of techniques of qualitative research grew largely out of understanding about consumer responses, whereas the psychoanalytic theory. These techniques were then quantitative approach provides a measurement of applied to the marketing field in what was known as consumer responses. By its very nature, qualitative motivational research, research that used highly research deals with the emotional and contextual aspects intensive, in-depth, individual interviews supplemented of human response rather than with objective, by projective and other psychological tests. These measurable behavior and attitudes. It adds "feel," techniques were aimed at understanding the motivations "texture" and nuance to quantitative findings. Qualitative and reasoning behind the verbal responses, and they research is conducted to answer the question why, required an extremely high level of professional skill to whereas quantitative research addresses questions of both implement and evaluate. how many or how often. The qualitative research process is one of discovery, the quantitative research process Motivational research as it was practiced in the 1930s is pursues proof. no longer in use today. However, qualitative research continues to play a very important role in the field of Additionally, the qualitative nature of this research marketing, and the qualitative techniques employed applies not only to the techniques for eliciting responses, have been continuously refined and developed. Despite but also to the qualitative nature of the analysis. this evolution, it is important to recognize the roots of Qualitative research is interpretative rather than qualitative research in order to understand the basic descriptive. It involves small numbers of respondents premises upon which it is built. If a researcher is not who are not generally sampled on a probability basis. applying some aspects of these original disciplines, he/ No attempt is made to draw firm conclusions or to she is not conducting true qualitative research. generalize results to the population at large. 86 Why use qualitative research? • Direct link with target public: qualitative There are both conceptual and practical reasons for using techniques give program management the qualitative research. The primary conceptual reason for opportunity to view and experience the target using qualitative research is that it provides greater groups directly. depth of response and, therefore, greater consequent • Technical facilities are unnecessary: qualitative understanding than can be acquired through quantitative research can be conducted in areas where no techniques. In addition, qualitative techniques, computer or other technical facilities are available. particularly one-on-one interviews, enable the researcher to tie together clusters of behavior that relate to a given Problems with qualitative research consumer decision or action. For example, a program One major problem exists with qualitative research: it is manager may want to understand in greater detail the often applied inappropriately. In other words, qualitative chain of decisions that leads to trial of an oral rehydration research will sometimes be used when a quantitative salt (ORS) product. In a qualitative study, the program technique is more appropriate. Or, qualitative research will manager can identify the relationship of all of the various be analyzed as if it were a quantitative study, drawing hard decisions at an individual level, getting a clear picture of and fast conclusions or projecting responses instead of the complete adoption process. A quantitative study developing hypotheses and gaining insights. Another would instead provide data on individual steps within problem with qualitative research is related to its the process—for example, the number of outlets visited, subjectivity. Since it is highly dependent upon insight and the price consumers are willing to pay, the level of product interpretation, qualitative research is highly susceptible to awareness, and so forth. subjective bias on the part of the researcher or observer. Because no hard data analysis is conducted, it is very Another conceptual reason for using qualitative difficult to verify whether the analysis of qualitative data is techniques has to do with the nature of qualitative correct. And, because of the nature of qualitative research itself and how it relates to the decision process techniques themselves, it is even difficult to determine in research. It can be argued that both the qualitative whether the research is being conducted properly. As a research process and the broader formative process result, many qualitative researchers in the field today have retain major subjective or intuitive elements. The initial only marginal or mediocre experience. Finally, because steps in the formative research process—that is, defining qualitative research has a high degree of flexibility and does the problem and information needs, formulating not require a highly structured questionnaire format, it is hypotheses, and defining variables—are all essentially possible for the researcher or program manager to be intuitive and therefore qualitative in nature. In addition undisciplined and not fully think through the research issue. to the above, there are many pragmatic reasons for using qualitative research methods. Much controversy has been associated with qualitative • Cost: in general, qualitative research is more research because of its potential pitfalls. A good deal of economical than quantitative research. discussion in the research field centers on how to ensure the quality of qualitative research, yet users and • Timing: some qualitative techniques, particularly practitioners still do not agree on many of the aspects of focus groups, can be executed and analyzed good qualitative research. quickly in the absence of data processing capabilities. How is qualitative research used? • Flexibility: the study design can be modified while Qualitative research is used largely in four general ways: it is in progress. (1) as a tool to generate ideas; (2) as a step in developing 87 a quantitative study; (3) as an aid in evaluating a example, to develop hypotheses about the reasons quantitative study; and (4) on occasion, as the primary for a sudden drop in usage of a particular product, data collection method for a research topic. or discontinuance of a particular practice • Select and refine materials for a larger quantitative As a tool to generate ideas, qualitative research can: study—for example, qualitative research can be • Stimulate ideas by providing program management used to reduce the number of advertising concepts with firsthand experience in observing and hearing being evaluated or to refine the concepts prior to the target population, observing them interacting going into a quantitative test. with the product, discussing the practice, or listening to their language about the issues. This behavior As a way to help understand the results of a quantitative and language may be quite different from that used study, it can: or imagined by the program manager. • Explain, expand and illuminate quantitative data— • Develop new ideas for the communications strategy, for example, to help understand the reasons for an the product positioning, or creative execution. unexpected finding • Explore the ideas and messages the target population • Gain some understanding about the reasons for perceives in visual or verbal stimuli such as advertising, certain trends—for example, to understand why brand names, packaging, and posters. mothers who have tried ORT (oral rehydration therapy) are not reusing it • Explore a product or behavior category that is relatively unknown and for which the researcher is • Describe the factors that are affecting an attitude not yet able to provide the specifics required to change—for example, to illuminate why one conduct a quantitative study. particular piece of advertising or promotion is more persuasive than another to the target audience. As a preliminary step to aid in developing a quantitative study, it can: Some research problems do not lend themselves easily • Develop hypotheses about the thought and to a quantified approach and, therefore, qualitative research may be used as the primary data collection decisionmaking processes of the target population as they relate to the product, practice, or issue strategy. For example, when a bank wants to understand being researched how its pension and trust department would be marketed to large corporations, a quantitative technique • Specify particular information needs for the would be inappropriate for such a small sample and quantitative study detailed topic. The best approach in this case might be • Help identify the types of people to be interviewed to conduct a series of one-on-one interviews with chief in the quantitative study—for example, the primary financial officers from twenty firms in the market. and secondary target populations and the relevant decision-makers Three keys to successful qualitative research There are three keys to conducting good qualitative • Aid in the development of question wording and research. First, the research must develop the art of sequencing—for example, to identify all of the asking “Why?" Second, the researcher must develop attributes of a particular product that should be the art of listening. Third, the researcher must approach included in the quantitative questionnaire the research as a creative process of investigation. • Assist in problem identification and definition—for The art of asking "Why?" 88 Qualitative researchers have been developing the art of suspected criminal why he murdered the victim. A good asking "Why?" for many years. Paul Lazarsfeld wrote an detective, like a good researcher, will use indirect article on the issue in 1934 pointing out that simply questions, projective techniques, observation, body listening to the answers to an open-ended question language, symbolism and experimentation. could result in a confusing overlap of various influences, product attributes, and individual motivations. He urged The art of listening the following: The art of listening takes time and practice to develop fully. Qualitative researchers must be acutely aware of • That "why?" questions be given specificity so that the fact that accurate listening is extremely difficult and these elements can be untangled that listeners often make unconscious errors. Truly • That questions be specifically tailored to fit the creative listening requires a high degree of sensitivity, experience of the respondents intuition and reflection, as well as accuracy. Some things • That we recognize the biases or assumptions made to keep in mind about listening include: by every researcher so that we are in fact asking • Active listening is closely related to empathy, one's what we really want to know. ability to identify with another in terms of the way that person would feel or act. To dramatize these three points, Lazarsfeld quoted from • The way things are said may reveal more of the a G. K. Chesterton detective story: intended meaning than the words that are spoken. Have you ever noticed this: that people never answer • Good listening requires hearing what is meant as what you say? They answer what you mean or what they well as what is said. This means picking up on think you mean. Suppose one lady says to another in a nonverbal clues—indicators of anxiety and country house, "Is anyone staying with you?" The lady uncertainty, of confidence and assertiveness. does not answer, “Yes; the butler, the three footmen, Hesitations, silences and variations in word choice the parlor-maid, and so on," though the parlor maid may are also relevant. be in the room or the butler behind her chair. She says, ''There is nobody staying with us,'' meaning "Nobody of Research as a creative process of investigation the sort you mean." But suppose a doctor inquiring into Qualitative research, then, is very, much like the an epidemic asks, "Who is staying in the house?" Then investigatory process that would be carried out by a the lady will remember the butler, the parlor maid and detective. Although some specific techniques and all the rest. All language is used like that; you never get standard questions are almost always applied, the key a question answered literally, even when you get it to getting the right answers is to adapt and create the answered truly. process to suit the specific research issue. It generally does not work to apply an "off-the-shelf" approach. Just In asking "Why?" the experienced qualitative researcher as no two crimes are alike, no two qualitative research will be careful to: (1) ask in a neutral manner; (2) avoid projects are alike. A high level of creative thinking must leading the respondent; (3) ask only one question at a be applied to each new situation if the qualitative time; and (4) note verbal and nonverbal clues of confusion research process is to be truly successful. or evasion from the respondent. Therefore, when applied, the art of asking ''Why?'' is like the workings of a detective who is trying to uncover the perpetrator of a crime. The last thing the detective will do is ask the 89 Table 1-1. Two leading qualitative methods: individual Distinctions Between depth interviews and focus groups Qualitative and Quantitative The following section aims to provide: Research 1. An understanding of the basic characteristics of focus groups and individual depth interviews Qualitative Quantitative 2. Guidelines for selecting the appropriate technique Provides depth of by highlighting the strengths and weaknesses of understanding Measures level of occurrence each technique Asks “Why?” Asks “How many?” and 3. Specific examples of how each technique might be “How often?” applied to a research issue. Studies motivations Individual depth interviews and focus groups are two Studies actions leading qualitative research techniques. Focus groups Is subjective capitalize on group dynamics and allow a small group Is objective of respondents to be guided by a skilled moderator into increasing levels of focus and depth on the key issues Enables discovery Provides proof of the research topic. They are by far the most widely used qualitative technique. Individual depth interviews, Is exploratory Is definitive like focus groups, are characterized by extensive probing and open-ended questions, but they are conducted on Allows insights into Measures level of a one-on-one basis between the respondent and a highly behavior, trends, and so on actions, trends, and so on skilled interviewer. Interprets Describes When to use individual depth interviews Although individual depth interviews are less widely used, there are specific circumstances for which they are Box 1-1. particularly appropriate. These include: Qualitative Research • Complex subject matter and knowledgeable Illuminates Quantitative respondents: for example, a study among phar- Findings: macists or physicians on their attitudes and practices An Example regarding the treatment of a particular disease A manufacturer of 35mm cameras conducted a • Highly sensitive subject matter: for example, a study national advertising campaign designed to illus- among women who have had an abortion regarding trate the simplicity of the product. A quantitative evaluation of the campaign indicated that there was their feelings about sexuality and family planning very high awareness of the product and of the campaign, but that there continued to be a percep- • Geographically dispersed respondents: for tion among the non-35mm users that the product example a study among population policymakers was too complicated for them to use. In order to in eight countries regarding their reactions to a identify more clearly the reasons for this perception, the manufacturer could put together several focus document on child spacing and maternal health groups composed of those individuals who had been exposed to and remembered the advertising, but • Peer pressure, in studies among consumers to who were not convinced of the basic copy platform obtain their reactions to a potentially controversial that the camera was simple enough for them to use. Focus groups would give the manufacturer the advertisement where a "social desirability" ability to listen in detail to the consumers' reasons response might cloud the real persuasive power of for feeling this way about the product. the message; for example, a study of male teenagers to explore their attitudes about sexually responsible behavior. 90 Figure 1-1. Qualitative Research Applications Early exploration for idea generation and direct experience of target population Pilot for quantitative study: Explain, understand, and exploration, hypothesis illuminate quantitative development, language behavioral and attitude data Identify information needs of Understand trends in potential target segments Qualitative behavior or attitude shifts research applications Help develop communication, Problem identification and definition strategies, concepts, and treatments Tie together clusters of behavior Obtain information from on an individual basis small, "elite" samples completely familiar with the pertinent social or cultural When individual depth interviews are being considered context. Therefore, some of the responses may not be as the research technique, it is important to keep several correctly understood or reported, particularly in the case potential pitfalls or problems in mind. of the "elite" respondent. The respondent may have a desire to speak beyond the limits imposed by the There may be substantial variation in the interview interviewer and to seek more interaction with the setting. Depth interviews generally take place in a wide interviewer, widening the “knowledge gap” even further. range of settings; this limits the interviewer's control over the environment. Interviews conducted in a hospital or The potential for management observation and feedback at a store may have to contend with many disruptions, is limited. Because a program manager generally does all of which inhibit the acquisition of information and limit not observe the interviews, the feedback procedure the comparability of interviews. either does not exist or takes considerably longer to conduct. It is time-consuming to debrief the interviewer There may be a large gap between the respondent’s after each of the initial interviews is conducted (so that knowledge and that of the interviewer. Individual depth changes can be made). interviews are often conducted with knowledgeable respondents (such as physicians) yet administered by Additionally, some key interviewer behaviors are less knowledgeable interviewers, or by interviewers not important to the success of conducting depth interviews 91 and should be kept in mind. It is important that the • Group interaction. Interaction of respondents will interviewer be able to: (1) accurately receive the generally stimulate richer responses and allow new information; (2) accurately recall the information; (3) and valuable thoughts to emerge. critically evaluate the information; and (4) act upon the • Observation. The sponsor can observe the information as it is received in order to regulate the discussion and gain firsthand insights into the interview process. respondents' behaviors, attitudes, language and feelings. This is particularly important in the early, Accurately receiving the information can be inhibited by “creative” stages of program development. interviewer fatigue, interviewer boredom, interviewer bias or expectation of answers, interviewer • Cost and timing. Focus groups can be completed preoccupation with taking notes, and technical language more quickly and generally less expensively than a foreign to the interviewer. Steps should be taken to avoid series of depth interviews. these problems if possible. Examples of when the above factors might be important are provided in the following specific applications of Accurately recalling the information can be inhibited by focus group research: a confusion of content between interviews, selective • Idea generation. A group discussion is conducted retention on the part of the interviewer, and the among pharmacists or physicians to generate new interviewer’s attempt to retain too much information. ideas for an improved ORS product (food additives, vitamin A additives, flavor additives, etc.). A group Critically evaluating information during the interview is a works best to build on ideas generated. function of the interviewer’s ability to identify the actual level of richness of the content being provided. It is • Package design screening. Alternative package important that the interviewer steer the respondent away designs, either in concept or in prototype form, are from irrelevant information and induce richness when presented to potential user groups to reduce the superficial answers are being provided. number of concepts for a quantitative test. A group works best because design personnel can be Acting upon the information being received and altering present to view the group and get ideas. the interview as it takes place is important both within a • Evaluation of message concepts. Messages in given interview as well as across the series of interviews. some rough, pre-production form are presented to The ability of the interviewer to regulate the information potential target audience groups for evaluation and within a given interview is really an issue of probing, refinement. A group works best because creative focusing, and staying on track with respect to the personnel can be present to view the group. interview objective. Regulating or altering the process across a series of interviews is a matter of assessing • Problem identification and definition. A group information that has been accumulated from one discussion is conducted among condom users to interview to the next in order to refine the interview guide generate hypotheses about why a successful and make it more responsive to the overall objectives of condom brand failed when introduced into a new the research. region. Groups work best to get a quick reading before planning a quantitative study. When to use focus groups Focus groups are far more widely used than individual A more complete breakdown of issues to consider when depth interviews. The main reasons focus groups are choosing between focus groups or depth interviews is selected more often as the qualitative technique include: included in Table 1-2. 92 TABLE 1-2 Which To Use: Focus Groups Or Individual Depth Interviews? Use individual depth Issue to consider Use focus groups when... interviews when.... Interaction of respondents may stimulate a richer Group interaction is likely Group interaction response or new and valuable thoughts limited or nonproductive. Group/peer pressure will be valuable in challenging Group/peer pressure would inhibit the thinking of respondents and illuminating responses and cloud the meaning of Group/peer pressure conflicting opinions. results. Subject matter is so sensitive that respon- Sensitivity of subject Subject matter is not so sensitive that respondents dents would be unwilling to talk openly in a matter will temper responses or withhold information. group. The topic is such that a greater depth of The topic is such that most respondents can say all response per individual is desirable, as Depth of individual that is relevant or all that they know in less than with complex subject matter and very responses ten minutes. knowledgeable respondents. It is desirable to have numerous interviews It is desirable to have one interviewer conduct the on the project. One interviewer would Interviewer fatigue research; several groups will not create interviewer become fatigued or bored conducting the fatigue or boredom. interviews. A larger amount of stimulus material Stimulus materials The volume of stimulus material is not extensive. must be evaluated. A single subject area is being examined in depth and It is necessary to understand how attitudes Continuity of information strings of behaviors are less relevant. and behaviors link together on an indi- vidual pattern basis. Experimentation with Enough is known to establish a meaningful topic guide. It may be necessary to develop the interview guide interview guide by altering it after each of the initial interviews. It is possible and desirable for key decision makers “First-hand” consumer information is Observation to observe “first-hand” consumer information. not critical or observation is not logistically possible. An acceptable number of target respondents can be Logistics assembled in one location. Respondents are geographically dispersed or not easily assembled for other reasons. Cost and timing Quick turnaround is critical, and funds are limited. Quick turnaround is not critical, and budget will permit higher cost. 93 CHAPTER 1 Using Focus Groups to Develop and Promote an Improved Weaning Food Product As discussed in Chapter 1, the focus group discussion suggested that the improved weaning food could be has emerged as one of the innovative information- better marketed as a food for a healthy child, rather than gathering methods being used in development settings. as a “medicinal” food for a sick one, and that the In this chapter, Cabañero-Verzosa, Johnston, and Kayode additional ingredients to be added in the old variety illustrate the use of this method to assess mothers' should be sold separately so that mothers could fortify reactions to an improved variety of weaning food the food themselves. designed to improve infant nutrition and develop effective communication strategies to market the weaning food as In Nigeria, as in other developing countries, poor nutrition part of a health intervention in Nigeria. often predisposes young children to diarrhea and other childhood illnesses. When the Dietary Management of This chapter describes the various steps—the Diarrhea (DMD) Project 1 got under way in Nigeria, the composition of focus groups, locations of discussions, team uncovered a pattern of feeding during the weaning selection of participants, discussion guides, group period that seemed to exacerbate infant susceptibility discussions, and data analysis—involved in the to diseases, including diarrhea. implementation of this component of a larger research project. More important, it also discusses a few changes Traditionally, Nigerian infants begin the weaning process that the investigators made in the standard focus group at four to six months. Their first weaning food, called methodology to make it more suitable for a developing eko, is a very watery concoction made from a maize or country setting. For example, permission of the village guinea corn pap called ogi. Infants are given eko daily chief was sought to interview female participants for focus and are introduced to more nutritious solid foods only at groups. Pre- and post-focus groups were also conducted. a much later date. In fact, the research data indicate First, mothers were taught an improved recipe for a that at twelve months of age only half the children are commonly used weaning food in a focus group context. consuming solid foods as part of their regular diets. Later, after the mothers had tried the recipe at home for Families also take ogi as a daily breakfast and snack some time, their preferences and suggestions were food. The mixture often contains as much as 70 percent discussed in another set of focus groups. water and, needless to say, is not very nutritious. It can also be a carrier of the water bacteria that cause diarrhea. The focus groups generated useful information about both product-related and communication-related questions, Project overview which was ultimately used in the final decisionmaking This paper describes how focus groups were used in related to the more widespread introduction of the conjunction with quantitative research techniques to nutritionally improved weaning food. For example, the develop and promote a new, enriched weaning food to groups indicated that roasted cowpea flour was most Nigerian mothers as a means of improving both the acceptable to mothers as a fortifying ingredient; that nutritional and health status of their babies. The chapter mothers could easily prepare the improved food; and that provides background on the use and mechanics of focus an additional preparation step—the addition of malted groups as a rapid appraisal method, and explains how flour—was acceptable to mothers. The focus groups also the group discussions for the present project were 94 planned. The chapter then discusses the specific focus mixing of the eko ilera. The second dealt with the nature group methodology used in this project and the analysis of communication support needed to effectively of results, and finally highlights how the study results encourage the acceptance of eko ilera among mothers. were used. The four sets of product-related questions that had to The intervention be answered were: A DMD project team of medical and public health • Is fortification of the traditional ogi acceptable to professionals and social scientists reasoned that eko mothers and eko sellers? What fortifying could be fortified to create a new weaning food that ingredients are acceptable? Why? would help to improve the nutritional status of these children. Cowpea flour, red palm oil, and sugar were • Can mothers learn the recipe? Can they teach eventually chosen as fortifying ingredients—items that others? are all readily available in the community and provide • What product characteristics are important to the required nutrients for weaning-age children. The new mothers? Is the addition of malt flour to maintain product came to be known as “eko ilera”, or “eko for the desired liquid consistency an additional step in health”. The fortified eko ilera is much more nutritionally the cooking process that would be tolerated? sound than the traditional watery eko2. • Will mothers prepare the new eko Ilera at home? The improved weaning food was introduced in two local The communications-related questions included such government areas, Asa and Oyun, in the Kwara state of issues as: Nigeria. This area offers a good mix of urban and rural communities and mostly comprises the Yoruba ethnic • What communication strategy is appropriate? Is group. This environment provided a homogeneous there an audience other than mothers? What benefit audience for the project's communication component can be identified for the target audience—the and for its research component as well. mother—and for the ultimate beneficiary—the child? • What materials will be effective in teaching the During the last stage of the intervention, health care mothers to use eko ilera? workers at each of twelve sites trained ten mother leaders who in turn were each responsible for training ten Focus groups were the research vehicle used to answer neighbors in the preparation and feeding of the new eko these questions. The qualitative, exploratory nature of ilera. Training materials included flipcharts, flyers, and focus groups seemed ideal for examining reactions to a product samples. Mothers were taught how to prepare new product that deviated from traditional methods. the new eko ilera during cooking demonstrations held Because group discussions lend themselves to probing in the community and in public places such as markets. and uncovering perceptions, attitudes, and feelings, it In all, approximately 1,200 mothers from Kwara State was believed useful for gauging mothers' impressions were trained during the intervention. about a new food. Because eko ilera deviated from conventional practices, focus groups were an ideal The research issues format to informally explore possible resistance and to This project was based on research related to two basic learn what appeals might prove persuasive to the areas of decisionmaking. The first were product Nigerian mothers. decisions dealing with the specific composition and 95 However, the focus groups were only part of an overall discussions and cooking demonstrations to research program of the DMD project that included in- determine the acceptability of these fortifying depth interviews, ethnographic assessments, options and the food preparation procedures. A observational studies, cost monitoring, clinical studies, second set of recipe trials occurred at the individual and surveys. The focus groups, with their opportunities homes of mothers who volunteered to try two for group dynamics and consensus-building, functioned recipes that affected the liquid consistency of eko. very effectively as a complement to these other types of • Clinical trials. Clinical trials assessed the research. While the more quantitative studies were acceptability, safety, and nutritional quality of the objective, definitive, descriptive, and measurement- maize-cowpea weaning diet in children with acute oriented, the focus groups were subjective, exploratory, diarrhea. A total of sixty children aged 6–24 and interpretive. months were randomly treated with either the DMD candidate diet or a commercial soy protein isolate, To summarize, in addition to the focus groups, the following lactose-free infant formula immediately following research studies were undertaken in the effort to effectively rehydration therapy. introduce the new weaning food to Nigerian families: • Ethnographic studies. Key informants provided Focus group planning and methodology information on infant feeding, diarrhea taxonomy, and Focus group interviews offer a means of obtaining in-depth household feeding and treatment patterns during information on a specific topic through a discussion group. diarrheal episodes. At the time that the project team The underlying premise is that people who share common was trying to reach a decision on whether to fortify an experiences, problems, or concerns are willing to reveal existing watery pap used as weaning food, or to them in a group atmosphere. Focus group interviews are introduce solid foods earlier, ethnographic interviews not simply individual interviews conducted in a group were also conducted to assess which option mothers setting; the moderator does not ask the same question of would find more acceptable. all respondents. Rather, focus group interviews represent • Surveys. A representative sample of 2,655 mothers a situation in which the participants are stimulated to talk of children less than three years of age provided with each other on the chosen topic under the guidance information on child feeding practices and provided of a moderator. The primary role of the moderator is to anthropometric assessments of targeted children. promote group discussion. • Food price monitoring. Quarterly market surveys were carried out in both urban and rural markets to Focus groups can be carried out in developing country establish the cheapest sources of energy and protein. settings, but because developing country conditions often present constraints, researchers must take steps • Longitudinal household treatment studies. Laduba, a rural village near the city of Ilorin, was to ensure the quality of the research data. These quality chosen as the site for conducting dietary intake assurance steps may include ensuring that: the studies and diarrheal epidemiology among forty- recruitment process brings qualified participants into the five children aged 5–30 months. discussions; the moderator functions as a facilitator rather than as an authority figure on the issue under • Recipe trials. Recipe trials provided mothers with discussion; and the results of group discussions are firsthand experience in the preparation of the new adequately recorded and analyzed by someone who has food. A list of possible ingredients for fortification a clear understanding of the goals of the research. was compiled. Mothers were invited to focus group 96 Box 2-1. The Use of Focus Groups in Developing the Product and the There are other, indirect advantages to using focus Communications Effort groups as a research tool in developing countries. They Product questions: Focus groups to respond provide a mechanism through which the researcher and the community cooperate in the solution of the Is fortification of Initial groups—mothers eko acceptable? Initial groups—eko sellers community’s problem. Focus groups also provide a means for researchers to work with the project Can mothers learn recipe, Recipe trial groups beneficiary—the community itself—in all phases of then teach others? project work from identifying issues, to developing and Is the use of malt Pre and post groups with in- testing solutions, to preparing communication materials, flour acceptable? home product use test and finally, to introducing an intervention. Will mothers prepare Post groups with in-home new eko at home? test To explore the questions concerning product and communication strategies vis-à-vis the new weaning Communication questions: food, four sets of focus groups were conducted as What communication indicated in Box 2-1. strategy will work? Initial groups—mothers Initial groups—EKO sellers Materials pretesting groups The first set of focus groups was held with two different What materials will be audiences: mothers, and women who were active in the effective teaching aids? Materials pretesting groups cottage industry of making and selling eko. These initial groups were exploratory in scope. With mothers, the discussions turned to feeding practices with eko and preference for two recipes that affected the liquid reactions to the addition of fortifying ingredients. Among consistency of eko. One recipe included malt; the eko sellers, the groups examined cooking procedures second had no malt. The discussions were held at a and selling practices. With regard to the seller groups, central location within each community, and mothers there was keen interest as to whether these women could discussed their perceptions of the two pap products. serve as agents for making a fortified version of their product or participate in the intervention in some other Finally, focus groups with mothers were used in way. As a second goal, these initial groups examined pretesting graphic materials. A flipchart describing the possible messages and communication strategies for food, the ingredients, and the cooking process was the intervention. developed, along with a scaled-down version in a flyer that mothers could take home. Focus groups gauged The second set of focus groups was conducted with reactions to the print materials and also proved useful mothers in conjunction with recipe trials. Several for finalizing the product name and the final positioning fortifying options and cooking procedures were of the new, fortified eko as a weaning food. illustrated during the recipe demonstrations. The focus groups provided a format for testing mothers' reactions Group composition and size to the new ingredients and the resulting products. In general, each group discussion included six to ten individuals. Group members were homogeneous with A third set of pre- and post-focus groups wrapped, like respect to two different characteristics: nursing mothers who bookends, around an in-home product use test. The test currently gave their children traditional eko, or eko sellers took place in four communities and determined who made and marketed the product in their communities. 97 Group locations traditional pap, or being in the business of making and All group discussions were held in the community. Often selling eko. An example of such a screening questionnaire the village leader offered his residence as a venue for appears in Box 2-2. the group discussions. His home was often centrally located for participants and usually had a quiet, inside The focus group team room for the discussion. Because of the wide The focus group team consisted of three individuals: a discrepancy in maternal behavior patterns between lead moderator, a moderator’s assistant, and a urban and rural areas, it was important to hold groups in marketing specialist. The moderator (and observers and both venues. note-takers who also attended each focus group) were recruited largely from the corps of field researchers and Table 2-1 summarizes the composition, size, and supervisors who had worked on the baseline DMD locations for the four sets of focus groups. research projects. With few exceptions, none had previous experience with the focus group research Participant recruitment technique. Training for the staff included organized Recruiting mothers in Nigeria for focus groups posed some sessions and role-playing. unique challenges. The interviewing staff usually arrived in the village a week or so in advance of the focus groups. The lead moderator was a woman who had previously Nigerian women are often discouraged from talking to conducted individual interviews for the quantitative strangers, so permission to interview them was first surveys and the ethnographic studies for the DMD obtained from the village leader. Only then could project. She knew the Yoruba language and culture and interviewers visit the mothers to invite them to participate had the interpersonal skills of a good moderator. She in a group discussion. To determine whether a woman could put people at ease, offer unconditional positive qualified, potential candidates were contacted in person regard, withhold her own opinions, and encourage and then led through a structured sequence of questions. discussion. This person received on-the-job training that As previously stated, depending on the specific focus included organized sessions with role-playing and group, the women had to meet certain criteria, such as specific advice on topic sequencing and probing. She currently nursing a child and feeding the child the also received written guidelines on moderator Table 2-1. Composition and Location of the Focus Groups Groups Members No. of groups No. of members Rural locations Urban locations Initial Nursing mothers 7 88 Alapa, Ballah Otte Alanamu, Baboko aged 20-40 Erin-Ile, Offa Initial Eko sellers 6 51 Alanamu, Baboko aged 30-50 Ballah, Oke-Oye Otte Erin-Ile Mothers Alapa, Ballah Alanamu, Baboko Recipe trials 8 approx.60 Oke-Oye, Otte Erin-Ile, Offa Pre-in-home Mothers 4 approx.40 Oke-Oye, Otte Alanamu, Baboko aged 15-40 Post-in-home Mothers 4 approx.40 Oke-Oye, Otte Alanamu, Baboko aged 15-40 Material pre-test Mothers approx.12 approx.100 Oke-Oye, Otte Alanamu, Baboko 98 Box 2-2. Focus Group Screening Guide Good morning/good evening. We are from the University of Ilorin. We are in your village to meet with some mothers to discuss child care. We met your village chief and he has agreed to our talking with you—may we ask you a few questions? DATE: VILLAGE: Urban _____ Rural _____ HOUSEHOLD NAME: CHILD’S NAME: AGE OF YOUNGEST CHILD: _____Less than three years of age _____More than three years of age IS CHILD CURRENTLY BEING FED OGI/EKO? _____ NO _____ YES Note to interviewer: Ogi is a paste made from fermented and sieved maize or guinea corn. A pap called eko is prepared by adding some of the ogi paste to boiling water until it thickens. If the mother has a child less than three years of age who is currently fed ogi/eko, please invite the mother to a meeting to be held: Date_____________________ Time_____________________ Place_____________________ Otherwise, thank her for talking with you today. techniques and had a chance to try out her techniques with input from the multidisciplinary group. The guide in pilot groups held as a pretest for the topic guide. relied on input from baseline data and other ongoing research. This discussion guide was then pretested and The lead moderator was assisted by a professor of health revised in Nigeria prior to conducting the actual focus education from the University of Ilorin. He was the field groups. (The moderator was also trained during this manager for the communications component of the DMD pretest.) The first two focus groups in each set were used project and was well-versed in the rationale for the focus as a pilot. If it proved that major changes were needed in groups. He attended the groups as an observer and the discussion guide, the research team was prepared to prepared summary reports following each one. delete these first two pilot groups from the overall analysis. The marketing specialist, a U.S.-based consultant, also Excerpts from one of the focus group guides are shown joined the local team during the focus groups. This in Box 2-3. person worked with the U.S.-based multidisciplinary DMD team that prepared the discussion guide. Discussion guides Discussion guides for the four sets of focus groups were drafted in the United States by the marketing consultant 99 Box 2-3. Focus Group Discussion Guide For Mothers: Pre In-home Product Test The research plan aimed to determine overall consumer preference among three recipe variations: Ingredients/recipes 1. Ogi cooked with palm oil and roasted cowpea flour 2. Above with malt flour added before serving 3. Ogi cooked with palm oil and roasted cowpea flour, with malt flour mixture reboiled before serving Methodology The products will be tested in the home by mothers who have children between the ages of six and eighteen months who are fed ogi. Four sites, two urban and two rural, will be chosen and up to ten mothers will partici- pate in each group, for a total sample of forty mothers. Mothers will be taught the recipes in focus group discussions, to be held in a central location within their village or urban neighborhood. For the recipes containing malt, mothers will be permitted to choose the method of preparation they prefer; that is, whether to add the cowpea flour while cooking the pap, or to add the cowpea flour along with the malt after the cooked pap has cooled somewhat. Mothers will be given sufficient supplies of roasted cowpea flour and malt to last for ten days. They will test malted fortified ogi for five days and unmalted fortified ogi for five days. The order of testing will be varied between locations as follows: Malted Unmalted Location flour/ogi flour/ogi Urban 1 First 5 days Second 5 days Urban 2 Second 5 days First 5 days Rural 1 First 5 days Second 5 days Rural 2 Second 5 days Second 5 days Mothers will each be given a cup and spoon at the start of the testing period for this product in order to encour- age the desired behavior of spoon-feeding. Observers will be assigned to each test site in order to record data about in-home preparation and feeding practices of the test products, and to answer any questions the mothers may have. At the end of the testing period, the observers will complete an individual questionnaire with each mother before the final focus group discussion is held. A final focus group discussion (FGD) will be held with all participating mothers in each test location to determine overall product preference, method of preparation and feeding, quantity and frequency of feeding, and intent on the part of the mothers to adopt the new recipe. Below is an example of a focus group discussion guide used for both the recipe-teaching and materials-testing FGDs. Introduction A. Introduce team, purpose of visit. B. Positioning. We want to know what you think about a new way of making ogi to help make your baby strong to cope with diarrhea and other diseases. We are working on several ingredients and we want you to try the recipes in your home and tell us about your experience with them. Present ingredients (rotate order) A. Present roasted cowpea flour and explain how it is prepared. Ask: • Have you ever seen it in this form? • Have you ever used it? • What might it be used for? 100 Box 2-3 continued • Is it available in the market? • What do you think about adding it to ogi? B. Present malt flour and explain how it is prepared. Ask the same questions as above. Demonstrate recipes (rotate order) A. Get reactions to preparation steps/time/ingredients B. Reactions to appearance/consistency of finished ogi C. Taste of the finished ogi D. Overall impressions: • Would they give it to their child/family? • Would they add/omit anything? • Is this recipe better/worse/about the same as previous ones tried? Prepare a large enough quantity so that enough remains after tasting in order to make a comparison of the three recipes. Volunteer recipe demonstration A. Ask for a volunteer to choose one of the recipes and prepare it. B. Why did she choose that recipe? C. Reaction to preparation steps/time. D. Reaction of volunteer and group to finished product. E. How can she teach another mother to prepare the recipe. F. Problems expected. Overall preferences A. Rank overall preferences and reasons. B. Of the first preferences: • Is it liked a lot/a little/not much? • Is it for baby/family? • Problems expected. • Product test instruction. A. Introduce observer who will come to their homes. B. Instruct which recipe to try first. C. Distribute ingredients, cups, and spoons. D. Thank mothers for participating. 101 Conducting focus groups education after each group discussion. A report guide In general, a focus group moderator leads participants for this purpose is shown in Box 2-4. through a sequence of topics that reflects an inverted pyramid. Very general behavioral and attitudinal issues Labor-intensive tape transcriptions, often completed by are discussed first. These are followed by topics of ever- two independent listeners, were not undertaken for these increasing specificity, from child-rearing practices, to groups due to cost and time considerations. Although reactions, to concept statements and preferences the group discussions were taped, the team referred to among product options. For the DMD project, in the the tapes mainly to clarify points discussed. first set of groups, mothers began by discussing the food and methods of feeding for children under three. The Product findings discussion moved on to sources of ogi and reasons for The first round of focus groups revealed some key points use. Eventually, the conversation was guided to on how to go about fortifying the traditional eko. The reactions to a list of possible additives. Mothers eko sellers were reluctant to tamper with their successful completed the session by talking about credible sources recipe formulas unless there was a large-scale mass of new information. media campaign to support the introduction of the new food. Eko sellers were therefore eliminated as possible Whenever possible, the focus groups were held indoors, agents of change during the DMD research phase. with participants seated in chairs in a circle. Although Mothers, on the other hand, were already quite used to the home of the village leader was often pressed into fortifying the pap themselves after purchase to sweeten service for this purpose, on other occasions, the group it or add variety. For eko ilera, then, it was concluded discussions were held outdoors in some communal living that mothers accepted the concept of fortification and space. All sessions were audiotaped. should be responsible for fortifying the ogi themselves. Analysis of results Preferred ingredients were uncovered during focus groups When focus groups are conducted in the United States, held at the recipe trials. Of the four possible fortifying the moderator usually prepares the final report. This ingredients, roasted cowpea flour emerged the winner for approach poses a problem in developing countries, several reasons. Cowpea, a common household item, however, since few trained moderators are available who was readily available at the market and was affordable to know both the language and culture and who are villagers. The final roasted cowpea eko looked similar to sufficiently conversant with social marketing principles high-status infant foods like Cerelac Nan, and Similac. to understand how the focus groups can affect the Finally, mothers believed that by drying and roasting the program. Often, moderators are trained on-site from cowpea flour, its shelf life could be extended from two to among health workers or interviewers. Consequently, eight weeks. the task Of preparing the analysis gets divided among several persons. Learning and teaching the recipe Recipe-teaching trials showed that mothers could In this Nigerian project, a data plan was drafted prior to definitely learn the recipe and teach this skill to other each set of focus groups. It clearly delineated What types mothers. However, the teaching of a new recipe meant of information were needed and how they would affect that mothers would need to remember to add new the program. As soon as possible after each focus group, ingredients or modify the traditional cooking process. the staff of moderator, observers, and note-takers met The accompanying focus groups provided a chance to to discuss and concur on the key findings. A short clarify a few issues, including the following: that the summary report was prepared by a professor of health additional ingredients used in the new eko ilera are 102 readily available; that the food is easy to prepare; and feeding. The thick consistency would require spoon- that the cooking process entailed adding malt flour to feeding. Since hand-feeding is a deeply entrenched make the eko thin. practice, the DMD team decided that it would be beyond the time and financial resources of the project to promote Product characteristics a new fortified food and a new feeding mode at the same The ogi of cowpea flour, red palm oil, and sugar had a time. The nutritionists experimented with a solution very thick consistency. The DMD team was concerned commonplace in the beer industry, the addition of malt that this would make the product unacceptable to flour, which gave the final product a thin consistency. mothers, most of whom practiced hand-feeding and force- Box 2-4. Focus Group Report Guide: Mothers’ Groups Comment on place/date/ group (the mothers)/ moderator. Comment on composition of group, e.g., older/younger members, total number, changes during the course of the FGD, and special circumstances that may have affected the group, e.g. outside distractions, etc. Current feeding habits Summarize mothers’ description of child feeding practices. Describe the age of weaning; foods given; frequency of feeding. Probe their reasons for believing that current feeding practices are desirable. Determine their concept of the healthy child and the relationship between feeding and the child’s health. Ogi preferences Summarize their overall preference. Identify the reasons for their choice. Describe in detail food preparation and feeding of the various recipes. Probe their concept of the “cost” of the new recipe, in terms of monetary cost and other factors, including psychological resistance to change and time needed to prepare and feed the new weaning food. Describe mode of feeding, frequency, food handling, and food storage practices. Identify any negative perceptions about the recipe. Ogi additives Summarize answers and probe whether these additives are also good for children with diarrhea. Concept test (where applicable) Comment on reaction to concept(s) tested. The concepts introduced were: A. This new ogi will make your baby light and active, because it contains cowpea, which makes your baby strong. With this new ogi, your baby will be better able to cope with illness. B. This new ogi will make your baby light and active, because instead of taking too much water, the baby can take more ogi. With this new ogi, your baby will be stronger after being ill with diarrhea. C. Specifically comment on overall reaction (positive/negative), believability, and what was liked or disliked. Solid food introduction Summarize mothers’ practices regarding the feeding of solids. Probe beliefs about the feeding of solids during the first year of life. Sources of information Describe sources of information about child care, especially feeding. Who are credible authorities? Implications/forward action Indicate decisions made by the debriefing team as a result of the FGD regarding need (or no need) for additional FGDs, changes necessary in the moderator’s guide, and changes/new concepts to be tested in future FGDs. 103 This product modification meant an additional ingredient in three critical ways: they suggested positioning eko ilera in the recipe, and also an additional step in the cooking as a weaning food; they recommended mothers rather process. Furthermore, it meant teaching mothers how than eko sellers as the target audience; and they isolated to sprout, dry, and grind maize or guinea corn to produce a message for the campaign. malt flour. This product modification was introduced to mothers in the third round of focus groups. An in-home At the outset, the project faced a dilemma, in terms of how product use test was preceded and followed by focus to position eko ilera—as a food for diarrhea or as a weaning groups, which attempted to determine the acceptability, food. Focus groups with both eko sellers and mothers convenience, and feasibility of this additional step. supported the weaning food strategy. According to sellers, attempts to make eko “medicinal” by adding ingredients During the in-home test, mothers prepared the cowpea- for a child with diarrhea were old-fashioned and likely to fortified eko two ways: with malt and without malt. As detract from eko’s use as a family food. Positioning eko expressed in the post-focus groups, the malt recipe was ilera as a weaning food was judged to be consistent with well received by mothers. Reports that it produced mothers’ beliefs and behaviors, while maintaining the status healthy, strong babies, stopped diarrhea, and helped of eko as a food for the whole family. babies sleep and play well were commonplace. A second issue that was unresolved prior to the focus Preparation at home groups was what role the eko sellers would play in During the in-home trials, mothers were given enough distributing the fortified pap. Could they, for example, malt and cowpea flour to cook the new ogi in their homes revamp their cooking procedure, add the fortifying for ten days. They were visited daily by DMD staff to ingredient, and then market the product through their observe whether the food was prepared and how it was usual channels? The focus groups argued against this cooked, as well as to provide assistance for any tactic. Eko sellers were reluctant to tamper with their problems they encountered. At the post-focus group, a successful recipes or to add any ingredients that would drawback was identified. Would the addition of malt detract from eko’s status as a general family food. It prior to serving invite contamination? This problem was was further discovered that mothers already are quite eventually solved by a nutritionist who suggested used to fortifying the pap themselves. Consequently, it additional reboiling after adding the malt. On this basis, made sense to exclude eko sellers from the intervention the DMD team felt convinced that mothers could prepare and to make fortification the job of the mother. the product effectively in their homes. Lastly, the communication strategy required a promised Focus groups had been useful in moving a new product benefit of the new weaning food to encourage full from concept stage to final form. Mothers had supplied participation of the target audience. The mothers input on acceptability, preferred ingredients, texture, and welcomed a concept statement that promised that ease of preparation. fortified eko would strengthen a child to cope better with childhood diseases. The “healthy baby” promise, as Communications findings portrayed in the name eko ilera, became a message of The initial groups developed the communication strategy the final intervention. 104 Pretesting of communication materials The final contribution of the focus groups was the refinement of communication materials. The program planned to use a flipchart for teaching and a flyer that mothers could take home with them. Three versions were tested for comprehension in focus groups with nursing mothers. When mothers were able to enumerate the ingredients and follow the cooking process, the materials were printed and used in the intervention. Notes 1. The Dietary Management Project was funded by USAID between 1985 and 1989 for the purpose of developing practical methods for either reducing or eliminating the adverse nutritional effects of diarrhea in children. The project was carried out in Nigeria and Peru. The HEALTHCOM Project, also funded over five years by USAID, provided technical assistance to DMD in the development and pretesting of training materials. 2. Eko, a traditional weaning food, a maize or guinea corn pap, was fortified with toasted cowpea flour, red palm oil, sugar, and malt. The energy density of this recipe was 85 kca1 per 100 gram wet weight, a considerable increase over the traditional eko, with 25 kca1 per 100 grams. The protein density supplied by the recipe was 2.2 grams per 100 gram wet weight, compared to only 0.8 grams per 100 grams for traditional eko. 105 CHAPTER 2 Knowledge, Attitude, Beliefs, and Practices Survey Used by the Female Education Awareness Program, Bangladesh The preliminary specifications for formative research on The sample will be selected in stages: the Grade 8 to 9 transition for the Female Education Awareness Component of the Female Secondary School 1. Select thanas Assistance Project are described below. 2.Select secondary school in thana 3.Work with headmasters and teachers to select girls The goal is to provide formative research for a social attending Grade 8 marketing program to encourage guardians and their 4.Interview male guardian, female guardian, and daughters to enroll in secondary school (with particular Grade 8 girl emphasis on facilitating enrolling and sending girls to 5. Have household identify other influentials Grade 9). 6. Interview other influentials. The targets are male guardians, female guardians, girls, The questionnaire, based on established theories of and other influentials associated with girls currently in behavior and behavior change, will assess knowledge, Grade 8 considering Grade 9. attitudes, beliefs, and practices (KABP). It will be similar to the questionnaire used with guardians and influentials The objectives are to determine the advantages and in Appendix H, but focusing more specifically on sending disadvantages (benefits and constraints) perceived by daughters to Grade 9. The quantitative questionnaire rural girls in Grade 8 and their guardians of sending their (KABP) will be developed by content analysis of daughter to secondary school (particularly to Grade 9) responses to a qualitative questionnaire (pre-KABP). The and to identify which should be targeted in a campaign KABP questionnaire will include questions to obtain designed to keep girls in secondary school; to determine demographic information about the household, important social referents (people who approve or questions to guardians (father and mother) regarding disapprove) in terms of female secondary education their beliefs about the consequences of sending their through Grade 9 and to identify which should be used in daughter to Grade 9, and normative beliefs about the campaign as possible sources of communication, sending her, questions to girls regarding their beliefs normative pressure, or testimonials to facilitate about going to Grade 9, and questions to other enrollment in Grade 9; and to select marketing channels, influentials regarding their beliefs about having girls in mass and interpersonal. the village enrolled in and attending Grade 9. The method is face-to-face intensive interviews with four The pre-KABP stage will include qualitative research to members of rural households with Grade 8 girls. develop a quantitative questionnaire. The sampling plan will take four Phase I thanas, one from each of the 106 four divisions. Ten girls will be picked from each thana, Questions below would identify strategies to overcome as well as a male guardian, a female guardian, and an barriers and to facilitate sending a daughter to Grade 9: influential person in the community for each girl. The What would make it easier to send (NAME OF total sample size will be 160, consisting of forty male DAUGHTER) to Grade 9? guardians, forty female guardians, forty girls, and forty What makes it difficult to send (NAME OF others in the community. DAUGHTER) to Grade 9? Open-ended questions can be used to identify the The questions for the girls and the influentials should be consequences (advantages and disadvantages), salient parallel to the questions for the guardians, except the referents (people who approve and disapprove), and focus for the girls should be going to Grade 9 next year strategies (things to make it easier) with respect to and for the influentials, sending girls like (NAME OF GIRL) sending girls to Grade 9. to Grade 9. Guardians can be asked the following questions to The following steps will be needed for the pre-KABP: assess consequences (advantages and disadvantages) of sending their daughter/girl to Grade 9: 1. Ask question with probe Sometimes our actions have good consequences. 2.Record verbatim for open-ended questions Other times they have bad consequences. I would 3.Review after interview is complete like to ask you some questions about what might 4.Create coding categories for responses happen as a result of your sending (NAME OF DAUGHTER) to Grade 9. 5. Code full set of open-ended questions What do you see as the advantages of sending 6. Create data file of categories for open-ended (NAME OF DAUGHTER) to Grade 9? What good questions and of numeric codes for close-ended things might happen? and demographic information What do you see as the disadvantages of sending 7. Conduct frequency count of consequences, of (NAME OF DAUGHTER) to Grade 9? What bad referents, and of strategies to determine items things might happen? most frequently mentioned for inclusion in the quantitative KABP Other questions would identify salient referents, people 8. Conduct internal consistency analysis of close- who would approve or disapprove of their sending their ended questions to assess format daughter to Grade 9: 9. Report KABP questionnaire recommendations. People we know often have opinions about what we should or should not do. Some people approve The deliverables will be: and some people might disapprove. · Copies of questionnaires in both Bangla and English Who do you think would approve of your sending (NAME OF DAUGHTER) to Grade 9? · Copies of instruction/interview manuals Who would think you should send her? · Description of the survey methodology including the sampling plan Who do you think would disapprove of your sending (NAME OF DAUGHTER) to Grade 9? · Open-ended questions from pre-KABP translated verbatim response to open-ended questions in a Who would think you should not send her? word-processing file 107 · Raw quantitative data from pre-KABP on diskette in The deliverables for the KABP will be: SPSS/PC or IBM-compatible ASCII file · Copies of questionnaires in both Bangla and English · Codebook for data files · Copies of instruction/interview manuals · Final five-page report on content analysis of pre- · Description of the survey methodology including KABP with questionnaire recommendations as to the sampling plan the content of the quantitative questionnaire. · Raw quantitative data from KABP on diskette in SPSS/PC or IBM-compatible ASCII file The KABP stage itself will include a quantitative survey of samples from twelve thanas (four Phase I, four Phase · Codebooks for data files II, and four with no program). Twenty girls from each · Tables comparing senders and nonsenders thana will be surveyed, with their male and female guardians and influentials. Thus 240 male guardians, · Short management summary of KABP. 240 female guardians, 240 girls, and 240 others in the community will be surveyed. The questionnaire will be face-to-face and will take about 60 minutes to complete. The steps of the KABP will be to: 1. Design three questionnaires (mother/father, daughter, and influential) based on analysis of qualitative study 2.Pretest and revise questionnaires 3.Design sampling plan for survey 4.Train team of interviewers with study procedures, sampling plan, and questionnaire and coding 5. Code and enter data 6. Clean data 7. Carry out frequency analysis for each questionnaire 8. Prepare tables providing comparative analysis of senders (those guardians who intend to send their daughter to Grade 9) and nonsenders (those who do not) for each of the four populations 9. Write management summary report on KABP with recommendations for communication activities 10. Submit raw data on diskette with document outlining study procedures. 108 Baseline knowledge, attitude, beliefs and practices study: individual questionnaire for male and female guardians Background Characteristics 1. Name: 2. Address: 3. Record gender by observation: Male [1] Female [2] 4. How old are you? Age ...... (complete in years) 5. What is your primary occupation? 6. What is your secondary occupation? 7. Did you ever attend school? Yes [1] No [2] IF YES: What was the highest grade that you passed? Grade ...... 8. Do you know how to read a letter in Bangla? Yes [1] No [2] 9. Do you know how to write a letter in Bangla? Yes [1] No [2] 10. What is your religion? Muslim [1] Hindu [2] Christian [3] Buddhist [4] Other [5] 109 11. Do you pray or worship every day or less often? Every day [1] Less often [2] Others (specify) [3] Mass Media Exposure 12. Is there a radio in this house in good working order? Yes [1] No [2] 13. Is there any/another radio near here which you can listen to? Yes [1] No [2] 14. How many days during the last week (seven days) did you listen to the radio? ...... (number of days) 15. Is there a television in this house in good working order? Yes [1] No [2] 16. Is there any/another television near here which you can watch? Yes [1] No [2] 17. How many days/nights during the last week (seven days/ nights) did you watch television? ...... (number of days/nights) 18. How often do you usually read the newspapers to get news and information? About once a month [1] About once a week [2] Two to three times a week [3] Almost every day [4] Once a day or more [5] Never read them [6] Don’t know how to read [7] 110 19. Have you ever seen a video? Yes [1] No [2] 20. Would you please cite the single most serious problem people like you are facing in our country? (RECORD ONE RESPONSE—THE FIRST RESPONSE.) Education [1] Marriage of son [9] Education for women [2] Land problem [10] Economic [3] Housing problem [11] Food [4] Transportation [12] Health [5] Environment [13] Clothing [6] Employment [14] Population [7] Other (specify) [15] Marriage of daughter [8] 21. Think about the last piece of information you got about education. What was the content of that message? (RECORD THE FIRST RESPONSE.) Communication Channels: Frequency 22. These days information and messages about education come to us from many sources. We would like to know how you have received messages on education. Have you ever received messages on education through ......? Media/Source Yes No Don’t know Radio 1 2 3 TV 1 2 3 Video 1 2 3 Newspaper 1 2 3 Miking 1 2 3 Poster 1 2 3 Meeting at health center 1 2 3 Meeting at school 1 2 3 Folk song 1 2 3 Punthipath 1 2 3 Talk with teacher 1 2 3 Talk with UP chairman/member 1 2 3 Talk with VDP worker 1 2 3 Talk with neighbor 1 2 3 Talk with relative 1 2 3 Talk with field worker 1 2 3 IF YES TO FIELD WORKER: What type of field worker? 111 Awareness of FSSAP 23. In some areas of Bangladesh, the Government of Bangladesh has started a program to help girls go to high school. Girls can get money to go to high school. Have you ever heard of such a program? Yes [1] No [2] 24. Where did you hear about this? (RECORD ONE RESPONSE.) Radio [1] Folk song [9] TV [2] Punthipath [10] Video [3] Talk with teacher [11] Newspaper [4] Talk with UP chairman/member [12] Miking [5] Talk with VDP worker [13] Poster [6] Talk with neighbor [14] Meeting at health center [7] Talk with relative [15] Meeting at school [8] Talk with field worker [16] (IF YES: What type of field worker?) 25. What have you heard about such a program? (RECORD RESPONSE.) 26. Where would the guardians go for more information or to apply? 27. Are the girls in this thana eligible to get money to go to high school? Yes [1] No [2] 28. For which grades can girls get money? Sending a Daughter to High School: Intention, Attitude, Subjective Norm INTRODUCTION: Now I would like to ask you some questions about female education. In particular, we would like to know what you think about sending (NAME OF DAUGHTER) to high school for a few years. INSTRUCTION: Ask the questions first and then read out the responses. 29. If you could have the opportunity, will you send (NAME OF DAUGHTER) to high school for a few years? Do you think that you: Definitely will send her [1] Probably will send her [2] Don’t know; not sure (DO NOT READ) [3] Probably will not send her, or [4] Definitely will not send her? [5] 112 30. Is it good or bad for you to send your daughter to high school for a few years? Is it: Very good [1] Somewhat good [2] Don’t know; not sure (DO NOT READ) [3] Somewhat bad, or [4] Very bad? [5] 31. Is it easy or difficult for you to send your daughter to high school for a few years? Is it: Very easy [1] Somewhat easy [2] Don’t know; not sure (DO NOT READ) [3] Somewhat difficult, or [4] Very difficult? [5] 32. Is it useful or useless for you to send (NAME OF DAUGHTER) to high school for a few years? Is it: Very useful [1] Somewhat useful [2] Don’t know; not sure (DO NOT READ) [3] Somewhat useless, or [4] Very useless? [5] 33. Do most people who are important to you approve or disapprove of your sending your daughter to high school for a few years? Would you say they: Disapprove and discourage [1] Disapprove only [2] Don’t know or not sure (DO NOT READ) [3] Approve only, or [4] Approve and promote? [5] Consequences of Enrolling a Daughter in High School INTRODUCTION: Sometimes our actions have good consequences. Other times they have bad conse- quences. I would like to ask you some questions about what might happen as a result of action that you take. I will now ask you about the foreseeable consequences/effects of sending your daughter to high school for a few years. 34. What is the single most important advantage of your sending your daughter to high school for a few years? What is the one most important good thing that might happen? (RECORD ONE RESPONSE—THE FIRST RESPONSE.) 113 She can find job [1] She can earn money [2] She will help her family [3] She will bring fame to her family [4] She will have a better life; she will prosper [5] She will be self-sufficient, self-reliant [6] She will have enriched knowledge, know how to decide [7] She will be able to make decisions herself [8] She will be socially respected [9] She can give advice and counsel to others [10] The community will prosper [11] She will motivate others for education [12] She will educate younger brothers and sisters [13] She will educate her own children [14] She will be wedded to a good husband [15] She will be wedded to an educated man [16] She will mix with people from the community [17] No dowry will be required to marry her off [18] Others (specify) [19] 35. What is the single most important disadvantage of sending your daughter to high school for a few years? What is the one most important bad thing that might happen? (RECORD THE FIRST RESPONSE.) She needs more money; can’t afford it [1] She needs money for books, texts, and materials [2] She needs proper dresses [3] She will not be available for housework; she cannot help her mother at home [4] Villagers will say bad things [5] Boys will disturb/tease her on the way to school [6] The school is too far away; distance to school [7] Transportation problems [8] Prefer early marriage [9] More money will be required to marry her off [10] It would bring shame to the household [11] It will corrupt her [12] She will get married on her own [13] Others (specify) [14] Behavioral Beliefs for Sending a Daughter to High School 36a. Will sending (NAME OF DAUGHTER) to high school for a few years help educate the younger children in your family? It definitely will [1] It probably will [2] Don’t know; not sure (DO NOT READ) [3] It probably will not [4] It definitely will not [5] 114 Will sending your daughter to high school for a few years: It It It Don’t probably definitely definitely probably know will will will will It not not b. Bring shame to your family? 1 2 3 4 5 c. Motivate others for education? 1 2 3 4 5 d. Cause financial hardship? 1 2 3 4 5 e. Let boys tease her on the way to school? 1 2 3 4 5 f. Bring money to her husband’s family? 1 2 3 4 5 g. Bring money to your family? 1 2 3 4 5 h. Mean you will need more dowry to marry her off 1 2 3 4 5 i. Bring fame to your family? 1 2 3 4 5 j. Help her marry an educated man? 1 2 3 4 5 k. Help her educate her own children when she gets married? 1 2 3 4 5 l. Help her space her children properly? 1 2 3 4 5 m.Help her lead a better life? 1 2 3 4 5 n. Mean she can give advice and counsel to others? 1 2 3 4 5 Evaluation of Outcomes of Sending a Daughter to High School INSTRUCTION: We want to know how good or bad the respondents feel about each outcome of sending the daughter to high school for a few years. Be sure you find out if they think it is very or somewhat good or bad. INTRODUCTION: In this section, we will ask you whether some things are good or bad. Please tell us exactly how you feel, whether you feel something is very or just somewhat good or bad. 37a. Is it good or bad to educate the younger children in your family? Very good [1] Somewhat good [2] Don’t know; not sure (DO NOT READ) [3] Somewhat bad [4] Very bad [5] Is it very good, somewhat good, somewhat bad or very bad: Very Somewhat Don’t Somewhat Very good good know bad bad b. To bring shame to your family? 1 2 3 4 5 c. To motivate others for education? 1 2 3 4 5 d. To cause financial hardship? 1 2 3 4 5 e. To let boys tease her on the way to school? 1 2 3 4 5 f. To bring money to her husband’s family? 1 2 3 4 5 g. To bring money to your family? 1 2 3 4 5 h. To need more dowry to marry her off 1 2 3 4 5 i. To bring fame to your family? 1 2 3 4 5 j. To help her marry an educated man? 1 2 3 4 5 k. To help her educate her own children ? 1 2 3 4 5 l. To help her space her children properly? 1 2 3 4 5 m. To help her lead a better life? 1 2 3 4 5 n. For her to give advice and counsel to others? 1 2 3 4 5 115 Specific Normative Beliefs of Sending a Daughter to High School INTRODUCTION: People we know often have opinions about what we should or should not do. Sometimes they approve and promote, sometimes they promote only. Sometimes they disapprove and discourage, sometimes they disapprove only. 38a. Do your neighbors approve or disapprove of your sending your daughter to high school for a few years? They: Disapprove and discourage [1] Disapprove only [2] Don’t know or not sure (READ) [3] Approve only [4] Approve and promote [5] Do/does .........approve or disapprove of your sending your daughter to high school for a few years? Both disapprove Disapprove Don’t Approve Both approve and discourage only know only and promote b. Your daughter 1 2 3 4 5 c. Your husband/wife 1 2 3 4 5 d. Your father-in-law 1 2 3 4 5 e. Your mother-in-law 1 2 3 4 5 f. Your father 1 2 3 4 5 g. Your mother 1 2 3 4 5 h. The religious leaders 1 2 3 4 5 i. The village elders 1 2 3 4 5 j. Teachers 1 2 3 4 5 k. Field workers 1 2 3 4 5 Motivation to Comply With Specific Others 39a. When it comes to education and family matters, how often do you do what your neighbors think you should do? Almost always [1] Most of the time [2] Sometimes [3] Hardly ever [4] Never [5] b. When it comes to education and family matters, how often do you do what your daughter thinks you should do? Almost always [1] Most of the time [2] Sometimes [3] 116 Hardly ever [4] Never [5] c. When it comes to education and family matters, how often do you do what your husband/wife thinks you should do? Almost always [1] Most of the time [2] Sometimes [3] Hardly ever [4] Never [5] d. When it comes to education and family matters, how often do you do what your father-in-law thinks you should do? Almost always [1] Most of the time [2] Sometimes [3] Hardly ever [4] Never [5] e. When it comes to education and family matters, how often do you do what your mother-in-law thinks you should do? Almost always [1] Most of the time [2] Sometimes [3] Hardly ever [4] Never [5] f. When it comes to education and family matters, how often do you do what your father thinks you should do? Almost always [1] Most of the time [2] Sometimes [3] Hardly ever [4] Never [5] g. When it comes to education and family matters, how often do you do  what your mother thinks you should do? Almost always [1] Most of the time [2] Sometimes [3] Hardly ever [4] Never [5] 117 h. When it comes to education and family matters, how often do you do what your religious leaders think you should do? Almost always [1] Most of the time [2] Sometimes [3] Hardly ever [4] Never [5] i. When it comes to education and family matters, how often do you do what your village elders think you should do? Almost always [1] Most of the time [2] Sometimes [3] Hardly ever [4] Never [5] j. When it comes to education and family matters, how often do you do what your teachers think you should do? Almost always [1] Most of the time [2] Sometimes [3] Hardly ever [4] Never [5] k. When it comes to education and family matters, how often do you do what field workers think you should do? Almost always [1] Most of the time [2] Sometimes [3] Hardly ever [4] Never [5] To Elicit Influentials 40. Who do you consult in the community regarding decisions on issues like marriage and school enrollment (especially for girls)? Where does this person live? What is your relationship with this person? (PUT DOWN NAMES AND ADDRESSES OF THE PEOPLE THE RESPONDENT MENTIONS.) NAME ADDRESS RELATIONSHIP (i) (ii) 118 (iii) (iv) __________________________________________________________________ Codes for relationship: Parent [1] Parent-in-law [2] Uncle [3] Aunt [4] Brother [5] Sister [6] Neighbor [7] Teacher [8] Religious leader [9] Community leader [10] Government official [11] General Social Attitudes 41. FEMALE GUARDIAN: How often do you cover your head with your sari in the presence of outside males? MALE GUARDIAN: How often does your wife cover her head with sari in the presence of outside males? Almost always [1] Most of the time [2] Sometimes [3] Hardly ever [4] Never [5] 42. FEMALE GUARDIAN: Who decides on the following matters? You, your husband, or do you decide jointly? MALE GUARDIAN: Who decides on the following matters? You, your wife, or do you decide jointly? Husband Wife Joint NA a. Whether to buy land or cattle for the household 1 2 3 7 b. Whether to seek treatment for a sick family member 1 2 3 7 c. Whether sons should go to school 1 2 3 7 d. Whether daughters should go to school 1 2 3 7 119 43. What is the highest grade in school that you think your son(s) should complete? Grade ...... 44. What is the highest grade in school that you think your daughter should complete? Grade ...... 45. FEMALE GUARDIAN: Can you do the following things alone? MALE GUARDIAN: Can your wife do the following things alone? Yes No Don’t know a. Go to any part of the village 1 2 3 b. Go outside the village 1 2 3 c. Go to the marketplace 1 2 3 d. Go to a health center 1 2 3 e. Visit a primary school 1 2 3 f. Visit the closest secondary school 1 2 3 g. Visit a neighbor to watch TV 1 2 3 46. If you could choose, at what age would you like to see (NAME OF DAUGHTER) married? ........ years (in complete years) 47. Do educated girls require more, less, or the same amount of money to get married off? More [1] Less [2] The same [3] 48. Do girls in school spend more, less, about the same amount of time, or no time on domestic work? More [1] Less [2] The same [3] No time at all [4] General Attitudes Toward Education INTRODUCTION: Now I am going to read you some statements that you hear people saying these days. After I read each statement I would like you to tell me if you agree or disagree with it. Let me tell you how I would like you to answer each question. You might agree with a statement fully or not fully. You may agree with a statement 16 annas or 8 annas or 4 annas or 2 annas or none at all. 120 INSTRUCTION: Put the responses in terms of the degree—mentioning annas (16 annas, 12 annas, 8 annas, etc.)—in proper columns to indicate whether the respondent agrees or not. Statement Agree Disagree 49a. More all-girl schools are needed in this area. b. Grown-up girls should get married not attend schools. c. People in this community can help female education by donating time or labor to improve the school buildings. d. Girls will be housewives and do not need education. e. Educated girls will not respect their in-laws. f. It will be difficult to find an educated man for an educated girl. g. Some villagers disapprove of educating grown-up girls. h. Educated girls will be too proud to help with housework. i. People in this village should try to check boys from making comments to girls on their way to school. j. What my daughter learns in school is relevant to the things she needs to know to live in the village. k. Educating girls will provide them with a better life. l. Tuition is free for girls up to Grade 8. Facilitating Factors INTRODUCTION: The government can do things to improve female education. And people in villages can also help. We would like you to think about the past twelve months. Have you ever done any of the following activities in the past twelve months? 50. In the past twelve months, have you: Yes No a. Attended an event at the school? 1 2 b. Worked with the headmaster to improve the school? 1 2 c. Donated time to the school? 1 2 d. Donated money to the school? 1 2 e. Joined a parent/teacher association? 1 2 f. Worked with the school managing committee? 1 2 g. Encouraged other guardians to send their daughters to school? 1 2 51. How long does it take the girls of this village to go to high school? ...... minutes 52. How do the girls of this village get to high school? 53. In sending the girls in this village to high school, how much would it help if the school: 121 Not at all A little A lot a. Was closer? 1 2 3 b. Was just for girls? 1 2 3 c. Had more female teachers? 1 2 3 d. Had flexible hours? 1 2 3 e. Had better transportation? 1 2 3 f. Had better toilets? 1 2 3 Household Characteristics 54. Is this household a single or a joint household? 55. How many members are there in your family? 56. Do you, your husband/wife, or any member of the household own any agricultural land? Yes [1] No [2] 57. IF YES: How much land? (INSTRUCTION: Write down the response using units that can be converted into decimals.) 58. Is this dwelling owned by you or your husband/wife? Or is it owned by a relative or family member? Or is it rented from a nonrelative? Owned by self/husband/wife [1] Owned by relative [2] Rented from a nonrelative [3] Other [4] 59. RECORD CONSTRUCTION OF HOUSE. Roof: Concrete [1] Tin [2] Kuchha [3] Other (specify) [4] Walls: Brick [1] Tin [2] Kuchha/mud [3] Other (specify) [4] Floor: Concrete [1] Kuchha/mud [2] Other (specify) [3] 122 60. Does your household (or any members of your household) have any of the following? Yes No Number Almirah 1 2 Cot 1 2 Table/chair/bench 1 2 Watch/clock 1 2 Cycles 1 2 Chickens 1 2 Ducks 1 2 Goats 1 2 Cows 1 2 61. Was there any time in the last five years when your household had insufficient food to eat for several weeks running? Yes [1] No [2] Thank you for your time and cooperation. Interviewer: Date: 123 Baseline knowledge, attitude, beliefs and practices study: individual questionnaire for influentials Background Characteristics 1. Name: 2. Address: 3. Record gender by observation: Male [1] Female [2] 4. How old are you? Age .......(complete in years) 5. What is your primary occupation? 6. What is your secondary occupation? 7. Did you ever attend school? Yes [1] No [2] IF YES: What was the highest grade that you passed? Grade .......... 8. Do you know how to read a letter in Bangla? Yes [1] No [2] 9. Do you know how to write a letter in Bangla? Yes [1] No [2] 10. What is your religion? Muslim [1] Hindu [2] Christian [3] Buddhist [4] Other [5] 124 11. Do you pray or worship every day or less often? Every day [1] Less often [2] Others (specify) [3] Mass Media Exposure 12. Is there a radio in this house in good working order? Yes [1] No [2] 13. Is there any/another radio near here which you can listen to? Yes [1] No [2] 14. How many days during the last week (seven days) did you listen to the radio? ......... (number of days) 15. Is there a television in this house in good working order? Yes [1] No [2] 16. Is there any/another television near here which you can watch? Yes [1] No [2] 17. How many days/nights during the last week (seven days/nights) did you watch television? ........ (number of days/nights) 18. How often do you usually read the newspapers to get news and information? About once a month [1] About once a week [2] Two to three times a week [3] Almost every day [4] Once a day or more [5] Never read them [6] Don’t know how to read [7] 19. Have you ever seen a video? Yes [1] No [2] 125 20. Would you please cite the single most serious problem people like you are facing in our country? (RECORD ONE RESPONSE—THE FIRST RESPONSE.) Education [1] Education for women [2] Economic [3] Tood [4] Health [5] Clothing [6] Population [7] Marriage of daughter [8] Marriage of son [9] Land problem [10] Housing problem [11] Transportation [12] Environment [13] Employment [14] Other (specify) [15] 21. Think about the last piece of information you got about education. What was the content of that message? (RECORD THE FIRST RESPONSE.) Communication Channels: Frequency 22. These days information and messages about education come to us from many sources. We would like to know how you have received messages on education. Have you ever received a message on education through ......? Media/source Yes No Don’t know Radio 1 2 3 TV 1 2 3 Video 1 2 3 Newspaper 1 2 3 Miking 1 2 3 Poster 1 2 3 Meeting at health center 1 2 3 Meeting at school 1 2 3 Folk song 1 2 3 Punthipath 1 2 3 Talk with teacher 1 2 3 Talk with UP chairman/ member 1 2 3 Talk with VDP worker 1 2 3 Talk with neighbor 1 2 3 Talk with relative 1 2 3 Talk with field worker 1 2 3 IF YES TO FIELD WORKER: What type of field worker? 126 Awareness of FSSAP 23. In some areas of Bangladesh, the Government of Bangladesh has started a program to help girls go to high school. Girls can get money to go to high school. Have you ever heard of such a program? Yes [1] No [2] 24. Where did you hear about this? (RECORD ONE RESPONSE.) Radio [1] TV [2] Video [3] Newspaper [4] Miking [5] Poster [6] Meeting at health center [7] Meeting at school [8] Folk song [9] Punthipath [10] Talk with teacher [11] Talk with UP chairman/member [12] Talk with VDP worker [13] Talk with neighbor [14] Talk with relative [15] Talk with field worker [16] (IF YES: What type of field worker?) 25. What have you heard about such a program? (RECORD RESPONSE.) 26. Where would the guardians go for more information or to apply? 27. Are the girls in this thana eligible to get money to go to high school? Yes [1] No [2] 28. For which classes can girls get money? Sending Girls to High School: Intention, Attitude, Subjective Norm INTRODUCTION: Now I would like to ask you some questions about female education. In particular, we would like to know what you think about sending the girls in this village to high school for a few years. INSTRUCTION: Ask the questions first and then read out the responses. 127 29. Will you encourage guardians to send their girls to high school for a few years? Do you think that you: Definitely will encourage [1] Probably will encourage [2] Don’t know; not sure (DO NOT READ) [3] Probably will NOT encourage, or [4] Definitely will NOT encourage [5] 30. Is it good or bad for you to encourage guardians to send the girls in this village to high school for a few years? Is it: Very good [1] Somewhat good [2] Don’t know; not sure (DO NOT READ) [3] Somewhat bad [4] Very bad [5] 31. Is it easy or difficult for you to encourage guardians to send the girls in this village to high school for a few years? Is it: Very easy [1] Somewhat easy [2] Don’t know; not sure (DO NOT READ) [3] Somewhat difficult [4] Very difficult [5] 32. Is it useful or useless for you to encourage guardians to send the girls in this village to high school for a few years? Is it: Very useful [1] Somewhat useful [2] Don’t know; not sure (DO NOT READ) [3] Somewhat useless [4] Very useless [5] 33. Do most people who are important to you approve or disapprove of your encouraging guardians to send the girls in this village to high school for a few years? Would you say they: Disapprove and discourage [1] Disapprove only [2] Don’t know; not sure (DO NOT READ) [3] Approve only [4] Approve and promote [5] 128 Consequences of Sending Girls to High School INTRODUCTION: Sometimes our actions have good consequences. Other times they have bad consequences. I would like to ask you some questions about what might happen as a result of action that you take. I will now ask you about the foreseeable consequences/effects of sending the girls in this village to high school for a few years. 34. What is the single most important advantage of your sending the girls in this village to high school for a few years? What is the one most important good thing that might happen? (RECORD ONE RESPONSE—THE FIRST RESPONSE) They can find jobs [1] They can earn money [2] They will help their families [3] They will bring fame to their families [4] They will have a better life; they will prosper [5] They will be self-sufficient, self-reliant [6] They will have enriched knowledge, know how to decide [7] They will be able to make decisions themselves [8] They will be socially respected [9] They can give advice and counsel to others [10] The community will prosper [11] They will motivate others for education [12] They will educate younger brothers and sisters [13] They will educate their own children [14] They will be wedded to good husbands [15] They will be wedded to educated men [16] They will mix with people from the community [17] No dowry will be required to marry them off [18] Others (specify) [19] 35. What is the single most important disadvantages of sending the girls in this village to high school for a few years? What is the one most important bad thing that might happen? (RECORD THE FIRST RESPONSE.) They need more money; can’t afford it [1] They need money for books, texts, and materials [2] They need proper dresses [3] They will not be available for housework; they cannot help their mothers at home [4] Villagers will say bad things [5] Boys will disturb/tease them on the way to school [6] The school is too far away; distance to school [7] Transportation problems [8] Prefer early marriage [9] More money will be required to marry them off [10] It would bring shame to their households [11] It will corrupt them [12] They will get married on their own [13] Others (specify) [14] 129 Behavioral Beliefs for Sending Girls to High School 36a.Will sending the girls in this village to high school for a few years help educate the younger children in their families? It definitely will [1] It probably will [2] Don’t know; not sure (DO NOT READ) [3] It probably will not [4] It definitely will not [5] Will sending the girls in this village to high school for a few years: It It It probably probably will Don’t It know definitely definitely will not will will not b. Bring shame to their families? 1 2 3 4 5 c. Motivate others for education? 1 2 3 4 5 d. Cause financial hardship? 1 2 3 4 5 e. Let boys tease them on the way to school? 1 2 3 4 5 f. Bring money to her husband’s family? 1 2 3 4 5 g. Bring money to the father’s family? 1 2 3 4 5 h. Mean they will need more dowry to marry them off? 1 2 3 4 5 i. Bring fame to the father’s family? 1 2 3 4 5 j. Help them marry educated men? 1 2 3 4 5 k. Help them educate their own children when they get married? 1 2 3 4 5 l. Help them space their children properly? 1 2 3 4 5 m.Help them lead a better life? 1 2 3 4 5 n. Mean they can give advice and counsel to others? 1 2 3 4 5 Evaluation of Outcomes of Sending Girls to High School INSTRUCTION: We want to know how good or bad the respondents feel about each outcome of sending girls to high school for a few years. Be sure you find out if they think it is very or some what good or bad. INTRODUCTION: In this section, we will ask you whether some things are good or bad. Please tell us exactly how you feel, whether you feel something is very or just somewhat good or bad. 37a. Is it good or bad to educate the younger children in the family? Very good [1] Somewhat good [2] Don’t know; not sure (DO NOT READ) [3] Somewhat bad [4] Very bad [5] 130 Is it very good, somewhat good, somewhat bad or very bad: Very Somewhat Don’t Somewhat Very good good Know bad bad b. To bring shame to the family? 1 2 3 4 5 c. To motivate others for education? 1 2 3 4 5 d. To cause financial hardship? 1 2 3 4 5 e. To let boys tease them on the way to school? 1 2 3 4 5 f. To bring money to the husband’s family? 1 2 3 4 5 g. To bring money to the father’s family? 1 2 3 4 5 h. To need more dowry to marry them off? 1 2 3 4 5 i. To bring fame to the father’s family? 1 2 3 4 5 j. To help them marry an educated man? 1 2 3 4 5 k. To help them educate their own children ? 1 2 3 4 5 l. To help them space their children properly? 1 2 3 4 5 m.To help them lead a better life? 1 2 3 4 5 n. For them to give advice and counsel to others? 1 2 3 4 5 General Social Attitudes 38. How often do the wives of this village cover their heads with their sari in the presence of outside males? Almost always [1] Most of the time [2] Sometimes [3] Hardly ever [4] Never [5] 39. In most households in this village, who decides on the following matters? The husbands, the wives, or do they decide jointly? Husband Wife Joint NA a. Whether to buy land or cattle for the household 1 2 3 7 b. Whether to seek treatment for a sick family member 1 2 3 7 c. Whether sons should go to school 1 2 3 7 d. Whether daughters should go to school 1 2 3 7 40. What is the highest grade in school that you think the boys of this village should complete? Grade ........ 41. What is the highest grade in school that you think the girls of this village shouldcomplete? Grade ........ 131 42. Can the wives of this village do the following things alone? Yes No Don’t Know a. Go to any part of the village 1 2 3 b. Go outside the village 1 2 3 c. Go to the marketplace 1 2 3 d. Go to a health center 1 2 3 e. Visit a primary school 1 2 3 f. Visit the closest high school 1 2 3 g. Visit a neighbor to watch TV 1 2 3 43. If you could choose, at what age would you like to see the girls of this village married? .......... years (in complete years) 44. Do educated girls require more, less, or the same amount of money to get married off? More [1] Less [2] The same [3] 45. Do girls in school spend more, less, about the same amount of time, or no time on domestic work? More [1] Less [2] The same [3] No time at all [4] General Attitudes Toward Education INTRODUCTION: Now I am going to read you some statements that you hear people saying these days. After I read each statement I would like you to tell me if you agree or disagree with it. Let me tell you how I would like you to answer each question. You might agree with a statement fully or not fully. You may agree with a statement 16 annas or 8 annas or 4 annas or 2 annas or none at all. INSTRUCTION: Put the responses in terms of the degree—mentioning annas (16 annas, 12 annas, 8 annas, etc.)—in proper columns to indicate whether the respondent agrees or not. Statement Agree Disagree 46 a. More all-girl schools are needed in this area. b. Grown-up girls should get married not attend schools. c. People in this community can help female education 132 by donating time or labor to improve the school buildings. d. Girls will be housewives and do not need education. e. Educated girls will not respect their in-laws. f. It will be difficult to find an educated man for an educated girl. g. Some villagers disapprove of educating grown-up girls. h. Educated girls will be too proud to help with housework. i. People in this village should try to check boys from making comments to girls on their way to school. j. What my daughter learns in school is relevant to the things she needs to know to live in the village. k. Educating girls will provide them with a better life. l. Tuition is free for girls up to Grade 8. Facilitating Factors INTRODUCTION: The government can do things to improve female education. And people in villages can also help. We would like you to think about the past twelve months. Have you ever done any of the following activities in the past twelve months? 47. In the past twelve months, have you: Yes No a. Attended an event at the school? 1 2 b. Worked with the headmaster to improve the school? 1 2 c. Donated time to the school? 1 2 d. Donated money to the school? 1 2 e. Joined a parent/teacher association? 1 2 f. Worked with the school managing committee? 1 2 g. Encouraged other guardians to send their daughters to school? 1 2 48. How long does it take the girls of this village to go to high school? ........ minutes 49. How do the girls of this village get to high school? 50. In sending the girls in this village to high school. How much would it help if the school: Not at all A little A lot a. Was closer? 1 2 3 b. Was just for girls? 1 2 3 c. Had more female teachers? 1 2 3 d. Had flexible hours? 1 2 3 e. Had better transportation? 1 2 3 f. Had better toilets? 1 2 3 133 Household Characteristics 51. Is this household a single or a joint household? 52. How many members are there in your family? 53. Do you, your husband/wife, or any member of the household own any agricultural land? Yes [1] No [2] 54. IF YES: How much land? (INSTRUCTION: Write down the response using units that can be converted into decimals.) 55. Is this dwelling owned by you or your husband/wife? Or is it owned by a relative or family member? Or is it rented from a non-relative. Owned by self/husband/wife [1] Owned by relative [2] Rented from non-relative [3] Other [4] 56. RECORD CONSTRUCTION OF HOUSE. Roof: Concrete [1] Floor: Tin [2] Concrete [1] Kuchha [3] Kuchha/mud [2] Other (specify) [4] Other (specify) [3] Walls: Brick [1] Tin [2] Kuchha/mud [3] Other (specify) [4] 57. Does your household (or any members of your household) have any of the following? Yes No Number Almirah 1 2 Cot 1 2 Table/chair/bench 1 2 Watch/clock 1 2 Cycles 1 2 Chickens 1 2 Ducks 1 2 Goats 1 2 Cows 1 2 134 58. Was there any time in the last five years when your household had insufficient food to eat for several weeks running? Yes [1] No [2] Thank you for your time and cooperation. Interviewer: Date: 135 136 Module Seven Strategic Communication for Development Projects Guide Questions for Assessing Organizational Capacity 137 Module Seven: Strategic Communication for Development Projects: Guide Questions for Assessing Organizational Capacity Guide questions for assessing institutional capacity for communication work in the Borrower country is presented here in the form of a matrix. Typically, communication capacity within government institutions is fairly weak and information about private-sector groups engaged in communication work will help government staff identify ways of collaborating with outside institutions and individuals. This matrix may be adapted for use at the national level or at city and district levels. By analyzing institutional capacity for communication work at various levels, project planners will have a firm basis for deciding how national organizations and local groups can work together in designing and implementing communication activities. 138 Assessing Institutional Capacity for Communication Work at the State Level Instructions: Complete matrix by identifying resources for communication work at the City/Province level. The column labeled “Skills Inventory” identifies communication skills needed for the project. These resources may be available in the government or private sector. In each box, please provide name of agency, contact person, mailing address and telephone and (if available) fax numbers. GOVERNMENT SECTOR PRIVATE SECTOR Skills Inventory Government Academia NGO Commercial (a) Management of Note: communication programs Important to have this skill at the State and District/City level. Efforts to strengthen capacity may be needed. (b) Development of a Note: communication strategy Important to have this skill aimed at behavior at the State level. Efforts change to strengthen capacity may be needed. (c) Communication research-qualitative and quantitative techniques 139 Assessing Institutional Capacity for Communication Work at the State Level GOVERNMENT SECTOR PRIVATE SECTOR Skills Inventory Government Academia NGO Commercial (d) Material development and pretesting (e) Material dissemina- tion: - print, audiovisual for distribution through agencies, - mass media material for dissemination to mass audiences or households (f) Monitoring of Note: communication activities Important to have this skill at the State and District/City level. Efforts to strengthen capacity may be needed. 140 141 142 Module Eight Strategic Communication for Development Projects Implementation Plan 143 Module Eight: Strategic Communication for Development Projects: Implementation Plan : Female Education Awareness Program Bangladesh This module contains a sample implementation plan for project communication activities. It describes the research which guided decisions about the communication strategy and provides a budget summary and a timeline for activities. 144 Implementation Plan : Female Education Awareness Program Bangladesh Contents Background ... 146 CHAPTER 1 FEAP Communication Goals ... 147 CHAPTER 2 Communication Strategy ... 148 CHAPTER 3 Research Component ... 154 CHAPTER 4 Timeline ... 156 CHAPTER 5 Organizational Structure ... 158 CHAPTER 6 Budget ... 159 CHAPTER 7 Next Steps ... 159 145 Background The Female Secondary School Assistance Project (FSSAP) attended by key officials of the FSSAP, the Management is a major initiative of the Government of Bangladesh Technical Assistance team, and the World Bank, aimed at increasing secondary education of females in documents the decisions made about the behavior the country. Supported by the World Bank, this project change strategy for FSSAP. will provide an integrated development assistance package which addresses financial and sociocultural This volume is adapted from a report, Female Education barriers to female education. Awareness Program, by Cecilia Cabañero-Verzosa, Susan Middlestadt, and Beverly Schwartz, (1993). The The Female Education Awareness Program (FEAP) is a implementation plan was developed during a workshop major component, addressing the sociocultural barriers held in Dhaka in August 1993. For brevity, the tables to female education through a social marketing and from the Knowledge, Attitudes, Beliefs, and Practices communication strategy. This Implementation Plan, (KABP) study, the figures, the detailed budget, and the developed during a Communication Planning workshop appendix have been omitted. 146 CHAPTER 1 FEAP Communication Goals The FEAP has several communication program objectives, An information dissemination phase planned in early as noted in the Staff Appraisal Report dated February 16, 1992 involved the development of a set of informational 1993. These include the following: materials to be used in launching the FSSAP program in • To build awareness of the FSSAP and stipend August 1993 and in announcing the availability of stipends for girls in Grades 6 and 9 before the 1994 school year. availability; These materials included the following: leaflets for girls • To educate about the benefits of female education in Grades 5 and 8; posters on the value of female and encourage girls’ completion of secondary school; education for placement in schools and community • To motivate educated women to seek employment gathering places; and two radio ads which portrayed real- as school teachers; life situations that confront guardians as they make decisions about their girls’ education. A visual and word • To encourage girls to become school teachers; and identifier logo for the project was also developed. The • To motivate school authorities to offer teaching logo depicted the concept of "tapashi," which means a positions to females. person who works hard and is rigorous and devoted. The visual element portrayed a young girl reading a book. A detailed communication strategy for the main FEAP These various materials were pretested among a sample objectives of building awareness of the stipend availability of the intended audience to determine comprehension of and educating target groups about the benefits of girls' the messages. The materials are now being readied for completion of secondary school was developed during the distribution by the FEAP/FSSAP team. August 1993 Communication Planning workshop. 147 CHAPTER 2 Communication Strategy The FSSAP project goals serve as the anchor for the can enact certain policies and practices and promote strategy guiding the FEAP component. The strategy specific ideas to support and facilitate the adoption of described below refers to the plan of action for the new behavior, idea, or practice. communicating messages to target audiences through specific channels or means of disseminating information. To identify the target audiences for the FEAP, the team reviewed the FSSAP program goals and identified the groups whose behavior needed to be modified for these Four key decisions goals to be met. The FEAP/FSSAP team, composed of the participants to the Communication Planning workshop, made four To increase the number of girls in secondary education, decisions relevant to the formulation of the communication the FSSAP of the Government of Bangladesh has put in strategy. These decisions were based on the following place a mechanism for addressing the key constraints questions: that have prevented guardians and parents from keeping 1. Who is the target audience for our messages? girls in secondary school until they obtain their secondary school certificate. The major constraint for guardians has 2. What behavior should we promote among target been the lack of economic resources to allow them to audiences? enroll their girls in secondary school. (Please refer to 3. What message concepts will promote perceived Table 1: Most Important Disadvantages of Sending benefits of the new behavior? Daughters to Secondary School-Guardians.) Thus, the 4. What channels of communication will key element in the FSSAP is the provision of school reach our target audiences as often and stipends to help defray the full cost of the girls’ tuition affordably as possible? fees and a specified percentage of related schooling expenses such as uniforms and books. The following section documents these decisions and The communication strategy took the FSSAP program goal points out the research data that supported the decisions. as a starting point for designing the behavior change intervention. The Knowledge, Attitudes, Beliefs, and Identifying the target audience Practices (KABP) study made it clear that both male and Target audiences are groups of people that the FEAP female guardians were supportive of sending their girls to would like to reach with FSSAP program messages. school. The three key benefits perceived by guardians Audiences are categorized as primary, secondary, and were that the girl would be able to find a job; she would tertiary target audiences. The primary target audience is become self-sufficient and not be dependent on her those people whose behavior the communication strategy husband; and she would be able to marry an educated is intended to change. The secondary target audience man. (Please refer to Table 2: Most Important Advantage includes those people who influence the primary audience of Sending Daughter to Secondary School-Guardians.) to adopt the new behavior (also called “influencers”). The Other elements perceived by those guardians were that, tertiary audience is composed of people in authority who with secondary education, the girl would be able to help 148 educate her younger siblings; she could motivate others extra household chores and providing a supportive towards education; and she could give advice and counsel. environment so that the girl could continue to go to secondary school. To identify the target audience of the communication campaign, and to decide on which behavior to promote The secondary audience among this specific audience, the team considered the The KABP data also showed that male guardians often following questions: consult other men in the community with regard to the issue of girls’ education (and marriage). More male 1. Who makes the decision to send the girls to guardians consulted an uncle (16 percent) or a brother secondary school? (30 percent) than an aunt (4 percent) or a sister (2 2.Who influences this decisionmaker? percent). (Please refer to Table 4: Referents Concerning 3.What messages are most likely to influence this Marriage and Girls’ Enrollment.) decisionmaker to send the girl to secondary school? Thus, the team decided that the secondary audience 4.What channels of communication can be used to for the FEAP would be men aged 32 years and older. reach this decisionmaker? Who are the credible This number was obtained by taking the age of the girls sources of information for this decisionmaker? in Grade 7 (12 years old) and adding the average age of their male guardians. The influencers then would be men The primary target audience 32 years old or older. The KABP study showed that male and female guardians claimed that the decision to send their girl to secondary The tertiary audience school was made jointly. However, during discussions The school headmasters, headmistresses, and teachers with FEAP/FSSAP staff who have spent years in field work were in a position of authority in the school system and in the education sector, there was a consensus that, could promote the concept of secondary education of given the male-dominated decisionmaking process in girls within the community. The team decided that they the family and the community, the real decisionmaker constituted a powerful ally for the FSSAP and should be with regard to sending girls to secondary school is the provided with messages to obtain their support. male guardian. The KABP data show that male guardians were more active than female guardians when asked to Promoting a specific behavior identify specific steps taken to improve their girls’ The FEAP team was concerned with having people adopt education. Male guardians attended events at the new behaviors that would enable girls to go to secondary school (65 percent), worked with the school teacher (55 school and complete their secondary school certificate. percent), donated time at the school (59 percent), and The team agreed that behavior change would be donated money to the school (40 percent). (Please refer sustained if the parents and the girls have positive to Table 3: Steps Taken to Improve Female Education.) experiences with the schools and the stipend program. Rewarding and positive experiences with the school Thus, the FEAP/FSSAP team decided that the male system will encourage guardians to keep their girls in guardian was the main decisionmaker with regard to secondary school and delay marriage until the girls sending daughters to secondary school and that the complete their secondary school certificate. female guardian played a facilitating role, taking on the 149 Behavior change goals for male guardians responsibilities of the school officials in making the The team decided that male guardians should be stipend available to girls in secondary school; and influenced to undertake the following behaviors: • To know the benefits and value of female education; • To encourage male and female guardians to send their girls to secondary school. • To become aware of the government program that encourages secondary education among girls in The behavior change pyramid: Bangladesh through the FSSAP program; knowledge–enrollment–completion • To become aware of the availability of stipends that It would be useful to track behavior change throughout help defray secondary school expenses for girls; the project period. There are three levels of behavior change that may be monitored, which can be presented • To permit girls to enroll in secondary school; and schematically as an inverted pyramid. The base of the • To encourage girls to complete secondary school pyramid represents the smallest group: the girls who and take the secondary school certificate (SSC) complete their secondary school certificates. The mid- examinations. section would constitute the second largest group: those who enroll in secondary school. At the very top is the In keeping with the terms of the stipend, girls must stay largest group: the girls whose male guardians know unmarried during their schooling. Male guardians are about the stipend program, have positive attitudes thus responsible for postponing the girls’ marriage until about sending them to secondary school, and believe after they complete their SSC examinations. that doing this will bring benefits to the girls and their families. The concept behind this inverted pyramid is Behavior change goal for older men one of behavior change proceeding in phases—from in the community knowledge, attitudes, and beliefs, to initial trial of the The FEAP/FSSAP team decided that influencers should proposed behavior (in this instance, enrolling and be encouraged to do the following: obtaining a stipend), and finally to completion of • To know about the benefits and value of female secondary school and passing the secondary school education; certificate exams. What this implies for the FSSAP program is that, to obtain the target enrollment figures, • To serve as role models for the community by sending a larger group of male guardians need to be provided their own daughters to secondary school; and with knowledge about the stipends and need to be • To talk to male guardians with daughters in nurtured by the school system so that they will have primary school about sending their daughters positive attitudes and beliefs about sending their girls to secondary school. to secondary school. This inverted pyramid concept also recognizes that a percentage of girls will drop out of Behavior change goal for school headmasters/ school before completing secondary schooling. headmistresses and teachers The behavior change goals for school headmasters/ Tracking these three types of change provides headmistresses and teachers may include the following: information on problems that crop up over time which • To know the benefits and value of female education; communication activities may be able to address. For example, if by mid-project enrollment rates have • To have a positive attitude towards FSSAP; stabilized and are within project goals but completion • To sign the cooperation agreement which defines the rates are below targeted levels, the communication 150 program can be redirected to those segments of the Most Important Advantage of Sending Daughter to population that are likely to drop out. The communication Secondary School). strategy that will address a drop-out problem will be quite different from one meant to provide knowledge In formulating a key message concept, it is important about stipends and encourage positive attitudes and that the benefits mentioned by the communication beliefs about girls’ education. (Please refer to the campaign are within reach of the target audience. Thus, Appendix for a diagram of the inverted pyramid and of the three possible message concepts, it may be better Figure 1-6.) to highlight the benefit of the daughter becoming self- sufficient or that of her marrying an educated man. The The research plan that will enable the FEAP/FSSAP to benefit of the girl being able to find a job may not be track changes in knowledge, attitudes, and beliefs realistic, considering the poor employment opportunities among the target population is discussed in the next in Bangladesh at present. section. FEAP communication research will track knowledge, attitudes, and beliefs that affect enrollment However, there may be a way of using this message and drop-out rates, while program monitoring data will concept now, without promising that jobs are plentiful provide feedback on how well the educational system for girls with secondary education. The message can is able to provide the necessary stipends and other be presented in the form of testimonials from girls who services needed to maintain the new behavior of having did get jobs because they had a secondary education, girls complete secondary school. emphasizing that girls with secondary education are more likely to find a job than those without secondary Key message concepts for specific education. Another option may be to portray employers target audiences who state that they are searching for girls with secondary Possible message concepts for the primary, secondary, education for employment in their offices. The important and tertiary audiences are described below. These do aspect of message design is to give messages that not constitute the final messages, but are descriptions audiences can find relevant and persuasive. Promising of key concepts that need to be tested among the target unachievable benefits weakens the message because audience before they are disseminated via print or target audiences quickly find out the truth and ultimately broadcast media. Pretesting of message concepts with the source of the message loses credibility. the target audience allows communicators to identify what aspects of the message are understood and are Although messages are to be primarily directed to male found credible by the target audience. guardians, it may be worthwhile to provide subliminal messages about the female guardian's role as a joint Message concepts for male guardians decisionmaker and as a source of support and Messages for male guardians need to communicate the encouragement for girls to complete their secondary idea that sending girls to school would benefit guardians, education. This can be done through illustrations their families, and especially the girls themselves. The showing the male and female guardians talking about KABP data show that male guardians see the following their girl's education or showing the female guardian benefits in sending a girl to secondary school: she will taking on extra household chores so her daughter can find a job (29 percent); she will be self-sufficient (10 go to school. By portraying the female guardian's role in percent); and she will marry an educated man (6 sending the girl to secondary school, it is hoped that in percent). The female guardians’ perception of benefits the long run there will is consistent with that of the male guardians (Table 2: 151 be social acceptance of the need to consult the female regular source of income from tuition fees may mean the guardian about family decisions such as sending girls school can afford to increase the number of teachers; to school. and girls who get stipends are more likely to continue their schooling, thus contributing to the school’s income. Message concepts for older men in the community Influencers in the community were supportive of the idea The message concepts should also include a “call to of sending girls to secondary school; 99 percent of male action” so that headmasters/headmistresses and influencers said they would encourage guardians to teachers are reminded to undertake a specific action send their daughters to secondary school (see Table 5: which will encourage male guardians to send their Intention, Attitudes, and Subjective Norms). daughters to secondary school. The "call to action" might ask teachers to talk to male guardians about the The key messages to be tested may include the concept stipend or to organize a parent/teacher meeting during that educated girls will contribute to the good of the which they can announce the availability of the stipend. community because they will be able to take care of the health and informal education of their siblings and A message for school officials will include encouragement contribute to their parents’ economic well-being when they to sign the cooperation agreement before the beginning become self-sufficient. Influencers would be portrayed of the 1994 school year. as wise people who help their community by promoting ideas that improve the quality of people’s lives. Channels of communication The next decision dealt with how messages will be The message may include asking influencers to talk to disseminated to their specific target audiences. The male guardians of daughters in Grade 5 and to encourage choice of channels of communication is guided by the them to send their daughter to secondary school. It may following principles: also ask the influencers to announce the availability of 1. The channel of communication should be the stipend to male guardians with eligible daughters. accessible to the target audience. If radio is to be used, working radio sets should be available to the Message concepts for school headmasters/ people the program wants to reach. headmistresses and teachers The KABP study noted that 85 percent of male guardians 2.A mix of channels of communication and 35 percent of female guardians obtained their including mass media, interpersonal and information about education from meetings with group communication is an effective way to teachers (Tables 6 and 7: Source of Information on reach target audiences. Decisions concerning Education, Male Guardians and Female Guardians). choice of channels should be based on reach, Message concepts can be developed based on frequency, managerial feasibility, and interviews that FEAP staff and thana project officers may effectiveness per contact. conduct in the near future. The working group at the 3.In cases where the target audience is Communication Planning workshop considered that semiliterate, special effort should be made to headmasters/headmistresses and teachers would think produce print materials that are highly pictorial girls’ education beneficial for their schools for the and easy to understand. following reasons: schools whose girl students can get 4.Whether the channel is mass media or stipends will have a regular income from the girls' tuition interpersonal communication, credible message- fees, which are paid fully by the stipend program; a bearers should be used. 152 In Bangladesh, ownership of working radios and televisions school managing committees (SMCs), and teachers’ was low. Only 37 percent of male guardians said that they associations. At the community level, a number of local had a working radio at home, and only 14 percent mentioned groups, non-governmental associations, religious groups, having a working television set at home. However, 75 percent and social development groups could be tapped to of guardians had access to a radio either in their own house promote the concept of female education. or that of a neighbor. Forty-eight percent had access to a TV nearby or in their home. In the interviews with guardians, 22 The following World Bank Mission Papers extensively percent of the males mentioned having listened to the radio review various communication channels available in daily for the last seven days, while only 10 percent had Bangladesh for development programs: A Study of Cost- watched television daily for the last week. Only 3 percent of Effectiveness of a Public Awareness Program for the the male guardians read a newspaper daily. The figures Proposed Female Secondary School Assistance Project reported for female guardians are about the same for radio in Bangladesh, by Atiur Rahman, Reaz Uddin and Kamal and television, but almost no female guardians read the Uddin Ahmed, January, 1992; State of the Art of Media newspaper in the week preceding the interviews (Table 8: Campaigns: A Comprehensive Review of Literature, by Working Radio/TV in the Home-Guardians and Table 9: Achintya das Gupta and Anish Barua, February, 1992; and Access to Different Forms of Communication in the Last Seven Inventory of Organizations in Information Dissemination, Days-Guardians). by Tahmina Rahman, July, 1992. On the other hand, influencers reported higher figures for ownership of a working radio or TV in the home (Table 11: Other audience segments Working Radio/TV in the Home-Guardians). Compared to Other target audiences to which the FEAP would like to the guardians, more influencers listened to the radio, watched provide messages about female education include TV, and read newspapers (Table 12: Access to Different Forms educated women, who need to be motivated to become of Communication in the Last Seven Days-Influencers). teachers; girls in secondary school, who may be steered in the direction of choosing teaching as their profession; When asked whether they could read and write Bangla, and school headmasters/headmistresses, who can be a higher percentage of male guardians than female enjoined to hire more female teachers in their schools. guardians said they could (Table 10: Can Read or Write Bangla-Guardians). The Appendix contains suggestions made by the team regarding messages and channels of communication to It was evident that, for the FEAP to launch a successful be used for these target audiences. communication program, it must rely heavily on interpersonal channels of communication and community networks to relay the message about female education. Mass media might be used to increase people’s awareness of the value of female education, but the persuasion and instruction would need to come from face- to-face communications occurring at the community level. Interpersonal communication channels that could be tapped included a wide variety of interpersonal networks that link community members to each other and to the school. These include parent-teacher associations (PTAs), 153 CHAPTER 3 Research Component The purposes of FEAP monitoring and evaluation In addition to the current sample of forty-eight secondary plan were: schools and ninety-six primary schools, the subsequent 1. To assess the impact of the Female Education surveys should include samples of schools, girls, and guardians from eight control thanas where there is no Awareness Project on knowledge, attitudes, beliefs, and practices of rural Bangladesh men and women FSSAP. The thanas should be selected to match the toward female secondary school education. Phase I and Phase II thanas in the sample regarding level of impoverishment, number of secondary school 2.To monitor how well the FEAP is working and to certificate passes, number of schools in the thana, refine communication activities as needed. distance from schools, and religion. In addition, control thanas should not be adjacent to either Phase I or Phase Major quantitative KABP tracking studies for II thanas in the sample. The selection of secondary assessing impact of FEAP schools, primary schools, and Grade 5 girls should be A baseline KABP survey was conducted in May and June made following the listing and random number of 1993 with 864 rural men and women from sixteen procedures outlined in the Appendix. thanas (eight Phase I thanas and eight Phase II thanas). The survey specifications, including copies of the The proposed timeline for the major quantitative tracking questionnaires and details of the sampling, are in the KABP studies is as follows: Appendix. The survey used a multistage school-based • Baseline KABP survey in Phase I and Phase II thanas. sampling plan to select a representative sample of male and female guardians and community leaders from rural • FEAP information dissemination. communities. Specifically, three secondary schools were • Stipends become available in Phase I thanas. selected from each thana, two primary schools were • Repeat of KABP survey in Phase I, Phase II, selected from each secondary school, and three Grade and control thanas. 5 girls were selected from each primary school. The male and female guardians and the community leaders • Stipends become available in Phase II thanas. influential for each of these girls were then interviewed. • First impact analysis ready for mid-project review. This baseline survey was to provide an assessment of • Repeat of KABP survey in Phase I, Phase II, and initial levels of knowledge, attitudes, beliefs, and control thanas. practices in these rural communities. • Final KABP survey in Phase I, Phase II, and control This survey should be repeated at least every two years thanas. in May and June according to the timeline below, with The impact analysis should focus on changes and the same ninety-six primary schools identified during the differences in exposure to the FEAP messages, awareness baseline survey. However, each time a different sample of the FSSAP, beliefs, attitudes, normative beliefs about of girls, guardians, and community leaders will be sending girls to secondary schools, general attitudes surveyed. Thus, the design is essentially cross-sectional towards education, participation in education activities, rather than a true panel design. school attendance, and school enrollment. It is likely that 154 there will be trends in these characteristics in the society These surveys should be conducted annually, especially at large. Thus, it is necessary to examine the level of the in the early years of the FEAP, using the following plan: characteristics separately for people living in Phase I thanas (for whom the stipends become available in • Fall, 1994 Study of Grade 5 and Grade 8, Cohort 1. 1994), for people in Phase II thana s (for whom the • Winter, 1995 Follow-up of Cohort 1 . stipends will become available in 1995), and for people • Fall, 1995 Study of Grade 5 and Grade 8, Cohort 2. in the control thanas (for whom the stipends will not be • Winter, 1996 Follow-up of Cohort 2. available through the FSSAP). The impact of the FEAP/ • Fall, 1996 Study of Grade 5 and Grade 8, Cohort 3. FSSAP will be demonstrated if the changes (e.g., in • Winter, 1997 Follow-up of Cohort 3. attitudes towards secondary education for girls) are greater and faster among communities in Phase I than • Fall, 1997 Study of Grade 5 and Grade 8, Cohort 4. in Phase II than in the control thanas. • Winter, 1998 Follow-up of Cohort 4 Rapid annual qualitative monitoring studies for Formative research on the transition from adjustment of FEAP Grade 8 to Grade 9 To monitor how well the FEAP is working, it will be advisable The initial formative research for the FEAP of the FSSAP to conduct rapid monitoring studies. These studies should focused on transition from Grade 5 to Grade 6. Additional be conducted with small school-based samples, e.g. girls formative research is recommended to study the transition in Grades 5 and 8 and their headmasters/headmistresses, from Grade 8 to Grade 9. This research plan should be teachers, guardians, and influencers in fewer than ten similar to the initial formative research scheme. The secondary schools. The sample should include schools Appendix contains preliminary specifications for the that did and did not elect to participate and girls who did knowledge, attitudes, beliefs, and practices survey. Briefly, and did not continue in school. the purpose of the survey is to determine the advantages and disadvantages of sending girls to Grade 9, as perceived The studies of girls, guardians, and influencers should by male and female guardians, the girls themselves, and be conducted in the fall of the year. Then a short follow- those who influence them. The study should begin with a up study of the cohort of girls can be conducted the qualitative study with open-ended questions among about following year to determine the percentage of girls who 160 respondents (forty male guardians, forty female successfully made the transition from Grade 5 to Grade guardians, forty Grade 8 girls, and forty influencers), 6 and from Grade 8 to Grade 9. followed by a quantitative study with closed-ended questions with samples of about 800 to 1,000. The rapid assessment instrument should be qualitative rather than quantitative in nature. Qualitative questions should be designed to assess reactions and perceptions of the FEAP and the FSSAP. To provide rapid feedback about the transition, girls and guardians should be asked in the fall if they intend to progress to the next class, or to send their girl to the next class. In the following year, each household should be revisited and asked if the girl did in fact enroll. Those who did should be asked why; those who did not should be asked why not. 155 CHAPTER 4 Timeline The timeline shows the sequence in which major project Training of fieldworkers activities take place. Major activities are described below. Persons who will be responsible for field implementation of project activities need to understand the goals of the Formative research (qualitative and Female Education Awareness Program so that they can quantitative studies) participate in and contribute to the attainment of these The formative research will provide the project team with goals. Fieldworkers include the thana project officers and data on the knowledge, attitudes, beliefs, and practices the local network of cooperating partners in of the audiences being targeted by the FEAP. Both implementation, such as school managing committees, qualitative and quantitative research techniques can be parent-teacher associations, NGOs, community-based used during the formative research phase. These groups, etc. research techniques are used for different though There are two parts to this training activity. The first part complementary purposes. consists of training in the technical content of the campaign. This means field teams will be informed Qualitative research provides depth of understanding of about the FSSAP objectives, as well as the organizational a particular idea or practice. It asks the question "Why?" means through which these objectives will be attained. and explores motivations, perceptions, and behavior. The second part provides the motivational push for field It provides interpretative data which can then be used teams to be partners in pursuit of a vision for improving to formulate message concepts and behavior change female education. intervention strategies. The training should not only aim to provide them with On the other hand, quantitative research techniques the information necessary for them to carry out their measure the level of occurrence of a particular specific tasks but should motivate them by providing knowledge item, perception, or behavior. It asks the them an understanding of the benefits they and their questions "How many?" and "How often?" It provides communities will gain from becoming active participants objective data and is definitive and descriptive. in this undertaking. Quantitative data are useful for providing information on baseline measures of knowledge, attitudes, beliefs, and A concept borrowed from commercial marketing has practices, which are then compared to postintervention been shown to be effective in getting field teams measures to determine if there was a significant change committed to a specific goal. This is the concept of within the target population. conducting “sales conferences,” where the field implementors are given a motivational seminar/ Communication planning orientation session to galvanize support for a given A formal planning exercise involving the key officers of campaign. During these “sales conferences,” materials the FSSAP and the FEAP was employed to define the to be used in the campaign are shown; the role of the communication strategy. This planning exercise should field team and their contribution to the campaign's be replicated at the thana project officer level to ensure success are described; and a system of rewards for their participation and support during implementation. achieving campaign goals is presented. 156 Material development and pretesting At this stage, materials are developed, pretested and produced. During the motivational seminars/orientation sessions, the materials are presented to the field teams so they can learn how to use these informational materials in their face-to-face communications. It will also help them understand the overall communication strategy guiding the messages that they will hear on the radio, watch on TV, or read in the newspapers. Launching the intervention This phase refers to the official announcement to the public about the availability of the stipends and the package of assistance that the Government of Bangladesh is making available to females of secondary school age in the project sites. This phase is usually of short duration. Activities are focused on providing the press with information kits and informing mass media personnel about the official announcement and activities related to the project launch. After the launch activities, the campaign proceeds with all field activities. Materials are disseminated, fieldworkers visit schools and households. Community networks are mobilized. Routine monitoring While field activities are in progress, it is useful to track performance of the FSSAP tasks, especially at the point of contact with the client groups (the girls and their guardians) to identify possible areas of misunderstanding or dissatisfaction. Corrective action needs to be taken immediately to solve problems encountered in the field. Postintervention evaluation The impact of the FEAP on selected indicators such as knowledge, attitudes, beliefs, and practices should be assessed every two years. 157 CHAPTER 5 Organizational Structure The Project Implementation Unit (PIU) has established two The FEAP team’s major role is that of management of the key positions for the FEAP, an Asst. Director and a Project communication program. It should use outside talent to Officer. The main task for the FEAP team will be the develop and produce communication materials and management of the communication program. Key undertake communication research. By the third year of responsibilities will be the development of a communication the project, FEAP must begin to study ways of building the strategy in consultation with the FSSAP senior officers (this capacity for communication work within the Department was accomplished during the August 1993 Communication for Secondary and Higher Education (DSHE). Consultants Planning workshop); the training of thana project officers in organizational development may be brought in at this on communication program objectives and related field stage to provide various options for building staff capacity activities; negotiations with local partner groups for for communication work within the DSHE. community-level communication activities; quality control of the messages being disseminated by the FEAP at both the central and local levels; and the development of a dissemination strategy for the materials (print, audio, and audiovisual) used in the communication program. Community-level negotiations, such as those with local partner agencies and groups, will be done in coordination with the thana project officers. 158 CHAPTER 6 CHAPTER 7 Budget Next Steps The proposed budget for the FEAP component This implementation plan lays out the overall strategy amounts to US$ 4.724 million to cover the period 1994- guiding the FEAP communication program activities. The 99. This provides for the following budget line items: following administrative steps can be taken in the next communication research (13 percent); mass production few months to activate the various components: and distribution (38 percent); training for PIU staff (5 1. Disseminate the print materials for the percent); interpersonal communication (22 percent); information dissemination phase to the and technical assistance (22 percent). communities and schools. 2. Negotiate with local partner agencies who can The budget is presented according to an annual assist in community-based communication disbursement schedule. The 1994 schedule of activities to reach various target audiences. disbursements showed a large amount of funds for 3. Complete staffing of the FEAP office. The Project mass production and distribution which may need to Officer position still remains unfilled. It is important be reallocated to the next year, considering that the to have adequate staff resources available to materials developed for the information dissemination manage the range of FEAP communication program phase will just have been distributed in late 1993. The activities. An option that the FSSAP may wish to FEAP team should review this budget by mid-1994 to consider is to contract an outside consultant to determine current expenditure levels and the pace of supplement the management capacity of the two project activities, and adjust the budgets accordingly. persons currently assigned to the FEAP. This consultant may be from within Bangladesh, a neighboring country, or an international organization with extensive experience in Bangladesh. 4. Conduct briefings and training sessions for the local groups, including the thana project officers on the FEAP component of the FSSAP. 159 160 Module Nine Strategic Communication for Development Projects Timeline 161 Module Nine: Strategic Communication for Development Projects: Timeline This module consists of a sample timeline of communication activities for each stage of the project cycle. It outlines a sequence of communication activities and an estimated duration for each activity that may serve as a guide to planning, recognizing that the allocation of responsibility between the Bank and Borrower and the timing of tasks over the project cycle will vary somewhat depending on resource availability, institutional capacity, and exigencies of the local situation. The timeline is presented in two formats, a Word 6.0 file and a Microsoft Project file. The Microsoft Project file contains seven columns, including an estimated duration for each activity, a start date and a finish date. It also includes a description of the relationship between activities, showing which activity precedes another, in the “Predecessor” column. For example, the relationship between task 4 and task 5 is that both tasks can start at the same time (they have a “start-to-start” relationship) but task 5 can be extended one more week after task 4 has been completed. In a “finish-to-start” (FS) relationship, one task has to be completed before another task can begin. The main advantage in using Microsoft Project software to generate the timeline is the ease with which one can adjust the dates. In the Word 6.0 file, any change in dates will mean manually keying in the changes in succeeding activities. In Microsoft Project, the software will automatically recalculate new dates for all succeeding activities. 162 Sample Timeline for Project Preparation and First Year of Implementation (Microsoft Project format) ID Task Estimated duration Resources/Responsibilities Additional notes 1 Country X: Population, health, and nutrition communication activities 2 Identification 3 Determine if communication component is needed 4 Select borrower organization unit responsible for activities 5 Select project site 6 Hire communication specialist for project preparation 7 Preparation 8 Review criteria/process: selection of consultant for implementation 9 Review client profile—secondary data on knowledge, attitudes, beliefs, and practices (KABP) 10 Prepare the communication research plan 11 Hire consultant for planning research 12 Conduct planning research as part of social assessment 13 Assess organizational capacity for communication work 14 Assess government’s capacity-building proposal 15 Prepare a communication strategy 16 Initiate work on implementation plan 17 Pre-appraisal/appraisal 18 Agree on purpose, content, and methodology 19 Agree on process of selecting Implementors 20 Finalize Implementation plan 21 Hire consultants for Implementation 22 Prepare documents; negotiate loan approval 23 Develop and pretest material 24 Orient health workers 25 Prepare for project launch 26 Supervision 27 Launch communication activities 28 Monitor communication activities and modify as needed 29 Submit annual work plan 30 Completion 163 Sample Timeline for Project Preparation and First Year of Implementation (Microsoft Project format) ID Task Duration( Week) Start Finish Predecessor Resource 1 Country X: Population, health, and nutrition 115 1/16/95 3/28/97 ------------- ------------- communication activities 2 Identification 10 1/16/95 3/24/95 ------------- ------------- Borrower, 3 Determine if communication component is needed 6 1/16/95 2/24/95 ------------- World Bank 4 Select borrower organization unit responsible for activities 4 2/13/95 3/10/95 3SS+4w Borrower 5 Select project site 4 2/20/95 3/17/95 4SS+1W Borrower 6 Hire communication specialist for project preparation 4 2/27/95 3/24/95 4SS+2w, 5SS Borrower 7 Preparation 26 4/3/95 9/29/95 ------------- ------------- 8 Review criteria/process: selection of consultant for 4 4/3/95 4/28/95 6FS+1w World Bank implementation 9 Review client profile—secondary data on knowledge, 4 4/3/95 4/28/95 6FS+1w Borrower attitudes, beliefs, and practices (KABP) 5/1/95 9 Borrower 10 Prepare the communication research plan 4 5/26/95 11 Hire consultant for planning research 4 5/15/95 6/9/95 10SS+2w, 8 Borrower 12 Conduct planning research as part of social assessment 8 6/12/95 8/4/95 11 Borrower 13 Assess organizational capacity for communication work 8 5/15/95 7/7/95 11SS Borrower 14 Assess government’s capacity-building proposal 4 7/10/95 8/4/95 13 World Bank 8 8/7/95 9/29/95 14, 12 Borrower 15 Prepare a communication strategy 4 9/4/95 15SS+4w Borrower 16 Initiate work on implementation plan 9/29/95 17 Pre-appraisal/appraisal 22 10/2/95 3/1/96 ------------- ----------- 18 Agree on purpose, content, and methodology 4 10/2/95 10/27/95 16 Borrower, World Bank 19 Agree on process of selecting Implementors 4 10/2/95 10/27/95 18SS Borrower, World Bank 20 Finalize Implementation plan 8 10/16/95 12/8/95 19SS+2w Borrower 21 Hire consultants for Implementation 4 12/11/95 1/5/96 20, 8 ----------- 22 Prepare documents; negotiate loan approval 8 12/11/95 2/2/96 20 World Bank 23 Develop and pretest material 8 1/8/96 3/1/96 20, 21 Borrower 8 1/8/96 23SS 24 Orient health workers 3/1/96 Borrower 8 1/8/96 23SS, 24SS 25 Prepare for project launch 3/1/96 Borrower 26 Supervision 56 3/4/96 3/28/97 -------------- ----------- 27 Launch communication activities 4 3/4/96 3/29/96 25, 22 Borrower 28 Monitor communication activities and modify as needed 52 3/4/96 2/28/97 27FS+4w World Bank, Borrower 4 3/397 28 29 Submit annual work plan 3/28/97 Borrower 0 3/28/97 3/28/97 29 ----------- 30 Completion 164 Notes (Microsoft Project format) 6. Hire communication specialist for project preparation Borrower needs a communication specialist to prepare the proposal for the project’s communication activities 16. Initiate work on Implementation plan includes strategy, research plan, budget, timeline, and capacity-building component. 28. Monitor communication activities and modify as needed includes the following. Evaluate whether: • communication activities are taking place • communication materials are reaching target audiences • communication activities are associated with changes in KABP. Conduct communication planning sessions every two years to update strategy. Review results of monitoring research and modify activities as needed. 165 166 Module Ten Strategic Communication for Development Projects Budget 167 Module Ten: Strategic Communication for Development Projects: Budget Following is a sample communication budget from the Chad Health and Safe Motherhood project. Budget line items for communication activities are divided between investment and recurrent costs. 168 Developing and Implementing a Nationwide IEC Program Scope and Objective. The objective of this component possibility of integrating the traditional sector in primary is to strengthen the capacity of the Ministry of Public care delivery. Project activities to strengthen IEC Health (MOPH) and its Information, Education and activities are determined on the basis of this plan Communication (IEC) Division to develop and implement described in the implementation manual. During IEC programs with respect to improving health and negotiations, the Government gave assurances that the contraceptive behaviors of the Chadian population and Division of IEC would operate with the terms of reference to support district, health, nutrition and FP services. To agreed upon with IDA during appraisal. this end, the project would: (a) reinforce the MOPH capacity to plan, coordinate, and control the quality of Project Support. The project would finance: (a) training IEC activities; (b) conduct training programs in IEC, of personnel at the central level for the national IEC staff, interpersonal communication, and social mobilization; in order to develop the IEC unit’s capability to develop (c) conduct quantitative and qualitative studies on the and implement IEC activities and to train regional staff. basis of which the IEC strategies and messages would This includes: a two-year training external in IEC for one be developed. person from the IEC unit; and short-term training outside Chad, preferably in Africa (13 person-moths); (b) KAP Background. Although IEC techniques have been and qualitative studies that would be used for IEC recognized by Government as important tools to strategy and message development. In addition, the empower the population to take charge of its own health, KAP survey would provide baseline data for the efforts in this regard have been limited to uncoordinated evaluation of the IEC subcomponent; (c) the production actions in donor-financed vertical health programs (par and dissemination of IEC materials to target 2.27). The National Health, Information and Education communities; (d) a minimum of audiovisual equipment (NHIE) Strategy developed in 1987 needs to be updated to be used to inform/educate decision- and policy- to reflect realities and health priorities as established in makers as well as for training activities; (e) vehicles (two the context of the new National Health Plan. With the cars and seven small motorcycles) to make it possible help of an international consultant (IEC), the Government for the IEC specialist of the Central IEC Unit to supervise has reorganized the Health, Information, and Education IEC activities and carry out training; (f) some IEC activities Unit (HIEU) into a Division of IEC and the National IEC for priority areas that are not financed by other donors; Task Force had prepared an action plan on which the IEC (g) two years of a resident specialist services (UNDP subcomponent of this project is based. According to financing of a UN Volunteer): past experience shows the plan, the Division of IEC would be strengthened and that the success of IEC activities depends on the support staffed to carry out a well-defined role of coordination, of well-trained IEC specialists. At present there are no conceptualization, and supervision/control of quality. Its IEC specialists in Chad. Therefore, this position would activities would focus on key messages developed on initially be filled at the international level while a Chadian the basis of the research results and focusing on nutrition, is being trained under the project to assume these FP, maternal and child health problems, genital responsibilities, and (h) short-term technical assistance mutilation, AIDS/STD prevention, and other for specific tasks for which no Chadian expertise exists. communicable diseases. It would also look at the 169 CHAD Health and Safe Motherhood IEC Programme Budget (US$’ 000) Quantities Base Cost I. Investment Costs Unit 1995 1996 1997 1998 1999 Total Unit Cost 1995 1996 1997 1998 1999 Total A. Equipment Aud/Vis. Equipment lot 1 - - - - 1 6 6 - - - - 6 Aud/Vis. Equipment lot - - 1 - - 1 3 - - 3 - - 3 Light vehicle unit 1 - - - - 1 18 18 - - - - 18 Vehicle 4x4 unit 1 - - 1 - 2 36 36 - - 36 - 73 Motorbike unit 7 - - - - 7 1 9 - - - - 9 Office Equipment lot 1 - - - - 1 35 35 - - - - 35 Subtotal Equipment 105 - 3 36 - 144 B. Studies KAP Study unit 1 - - - - 1 202 202 - - - - 202 Qualitative research unit 2 2 1 1 1 7 35 71 71 35 35 35 247 Subtotal Studies 273 71 35 35 35 449 C. Specialist Services UN Volunteers/a per year 1 1 - - - 2 30 30 30 - - - 61 Short-term experts person months 3 3 2 2 2 12 15 45 45 30 30 30 182 Subtotal Specialist Services 76 76 30 30 30 242 D. Training Training on IEC & management person months 3 3 2 2 2 12 12 36 36 24 24 24 145 Long-term IEC training per year 1 1 - - - 2 29 29 29 - - - 59 IEC reg'l staff training/b person months 2 - - - - 2 8 16 - - - - 16 Training of trainers/c unit - 2 - 2 4 10 - 20 - 20 - 40 Subtotal Training 82 86 24 44 24 260 Total Investment Costs 535 232 93 146 90 1,096 II. Recurrent Costs Supervision of training per visit 1 1 1 1 1 5 23 23 23 23 23 23 113 Office Equipment per year 1 1 1 1 1 5 8 8 8 8 8 8 41 Aud/Vis. Equipment per year 1 1 1 1 1 5 4 4 4 4 4 4 20 Production of IEC material per year 1 1 1 1 1 5 9 9 9 9 9 9 45 Supervision of IEC in 2 regions per trip 2 2 2 2 2 10 9 18 18 18 18 18 91 Regional seminar/d persons - 40 - 40 - 80 - 3 - 3 - 5 Total Recurrent Costs 62 65 62 65 62 316 TOTAL 597 297 155 211 152 1,412 170 \a UN volunteers financed by UNDP/UNICEF. \b IEC staff person assigned per region. \c 3 weeks x 20 persons/region (includes per diem, organizational and travel allowance). \d 20, 000 FCFA/day 171 172 Module Eleven Strategic Communication for Development Projects Best Practices 173 Module Eleven: Strategic Communication for Development Projects: Best Practices This module contains illustrative examples of “best practices” in population, health, and nutrition communication. The examples describe the projects’ communication goals, the methods used to promote changes in knowledge, attitudes, or behavior, and a brief summary of the outcome of communication activities. Project examples were provided by various agencies, including the Academy for Educational Development (immunization and breastfeeding), the Johns Hopkins University Center for Communication Programs (sexual responsibility), Manoff Group, Inc. (iodized salt and malnutrition), and Population Services International (HIV/AIDS and family planning). 174 Best Practices Contents CHAPTER 1 Bangladesh: Promoting Family Planning ... 176 CHAPTER 2 Ecuador: Increasing Immunization Coverage ... 177 CHAPTER 3 Ecuador: Marketing Iodized Salt ... 178 CHAPTER 4 Indonesia: Improving Nutritional Status ... 179 CHAPTER 5 Jordan: Initiating Breastfeeding ... 180 CHAPTER 6 The Philippines: Promoting Sexual Responsibility Among Teens ... 181 CHAPTER 7 Zaire: Reducing the Spread of HIV/AIDS ... 182 175 CHAPTER 1 Promoting Family Planning in Bangladesh From 1983 to 1985 an intensive communication program The campaign used multiple media, including radio was carried out in Bangladesh in tandem with a social spots, a radio serial drama (soap opera), and films shown marketing program that increased the availability of pills on television, in cinema halls, and on mobile film vans. and condoms. The broad goals of the family planning motivational campaign were to (a) actualize latent demand Results for contraception; (b) help create a demand for family The communication campaign increased positive planning among couples reaching reproductive age; and attitudes about modern contraceptive methods from 61 (c) motivate those who, for one reason or another, still percent in 1983 to 74 percent in 1985. The number of resisted the concept of family planning. Contraceptives respondents who had actively sought information about were made available to low-income, unreached, and family planning in the past six months rose from 11 percent underserved populations to help couples who were ready in 1983 to 19 percent in 1985. There was an increase in to accept modern contraception, to gain access to it. the proportion of respondents who discussed family planning with their spouse (from 34 percent to 38 percent), Methods with a distinct shift in the content of discussions from the The motivational campaign identified rural men as the general topic of the advantages of a small family to more primary target audience, with rural women and urban men specific topics such as the use of specific contraceptive as secondary target audiences and opinion leaders and methods. Over the two-year period, awareness and use other influentials as the tertiary target audience. of most modern contraceptive methods increased Qualitative research identified “resistance points” that substantially among survey respondents, paralleling mitigated against the adoption of family planning even results found in the 1983 and 1985 Bangladesh among those not desiring any more children. Research Contraceptive Prevalence Surveys. Awareness of findings confirmed that earlier IEC efforts had been nonclinical contraceptive methods increased from 78 successful in generating almost universal awareness of percent to 84 percent for oral pills and from 52 percent to the concept of family planning. However, the benefits of 65 percent for condoms. Current use of pills increased family planning had not yet been internalized by target from 4 percent to 5 percent and condom use increased audiences. Couples cited religious reasons, the lack of from 4 percent to 6 percent. Current use of any modern communication between spouses, a fear of detrimental method (including pills, condoms, vaginal methods, health effects, and ignorance about contraceptive options tubectomy, vasectomy, and intrauterine devices) as explanations for not using contraceptive methods. increased from 14 percent to 25 percent. For these reasons, messages positioned modern contraceptives as safe to use and encouraged husbands to discuss the subject of family planning with their wives and to choose the method most suitable to them both. Messages also stressed the personal, economic, and health benefits of family planning. Because contraceptives were made more accessible through social marketing outlets, couples had the opportunity to take action in response to messages about contraceptive choice. 176 CHAPTER 2 Ecuador: Increasing Immunization Coverage From 1985 to 1988, under the leadership of charismatic immunized. Immediately prior to each jornada, mass First Lady Doña Eugenia Cordovez de Febres Cordero, the media promotions were conducted to make parents Government of Ecuador implemented the Plan to Reduce aware of the times and places where immunizations Childhood Disease and Mortality (Plan de Reduccion de could be obtained. At the local level, the Ministry of Enfermedad y Muerte Infantil–PREMI). The key goal of the Health, in cooperation with other governmental and project was to decrease the national rates of morbidity and nongovernmental organizations, mobilized parents to mortality from four principal causes: vaccine-preventable take their children to be immunized at the designated childhood diseases, diarrheal disease, malnutrition, and times. To make immunization services more accessible, acute respiratory infections. The immunization program special immunization sites were set up in addition to aimed to increase coverage of children under one year of the regular health facilities. age from 48 percent to 80 percent. Results Methods The project used the mass media to emphasize the The project used the mass media to emphasize the importance of child survival and of PREMI as the importance of child survival and of PREMI as the appropriate means to improve child survival rates. The appropriate means to improve child survival rates. PREMI PREMI program acronym was widely recognized by developed a communication campaign promoting Ecuadoreans. Immediately after the first jornada of immunizations, oral rehydration therapy, growth October 1985, about 30 percent of the population knew monitoring, and breastfeeding. Its main focus was on the acronym PREMI without prompting. By August 1986, child immunizations. Awareness-generating activities after two more rounds of jornadas, recognition levels utilized a wide array of communication channels, increased to 65 percent. Respondents of split surveys including creative TV spots broadcast frequently and a (urban and rural) conducted in the first six months of large number of print materials disseminated to the PREMI consistently reported radio followed by TV as their general population as well as to mothers, social security main source of information about PREMI. About 80 health workers, primary school teachers, students, percent of the respondents claim radio ownership and doctors, and political leaders. By the conclusion of the close to 60 percent claim to own televisions. PREMI project in June 1988, the Communication Unit of the National Institute of the Child and Family (INNFFA) A survey conducted in April 1987, eighteen months into had produced a total of thirty-nine print materials that the campaign, found that 40 percent of the general included a nutrition poster, four research booklets population and 62 percent of radio owners recalled (containing thirteen studies), two social marketing books, immunization as the subject of radio health messages. a training methodology textbook, twenty-six health PREMI was associated with significant change in teaching posters with corresponding teacher’s guides, knowledge about when to start immunizations. Data a comic format textbook and its guide, and two technical from four surveys showed an increasing proportion of reference books for doctors. respondents with the correct knowledge: 65 percent in November 1985; 72 percent in April 1986; 90 percent in In addition to disseminating mass media messages, July 1986; and 91 percent in April 1987. Measles PREMI conducted a series of seven special events immunization coverage among 12 month-olds increased (jornadas) in which thousands of children were from 15 percent in 1985 to 35 percent in 1987. 177 CHAPTER 3 Ecuador: Marketing Iodized Salt The Mass Media Nutrition Education Project experimented majority of the households. The greatest increase in with the use of radio to promote the use of iodized salt in awareness about the nutritional value of iodized salt the Imbabura Province in the Sierra. But before the project occurred among the mestizo population. Prior to the could promote a specific product, such as the iodized salt campaign, only 5 percent of mestizo households were that ECUSAL (a Morton Salt subsidiary) was about to aware that iodized salt was better than noniodized salt. market in Ecuador, it needed to educate household Results of the final survey showed that 95 percent of those members about the nutritional value of iodine. The aware of the campaign message stated that iodized salt popular conception was that coto (Quechua for goiter) was was best. As a result of the campaign, mestizos were a normal condition. Therefore, increasing people’s able to discriminate between ordinary refined salt and awareness that goiter is a serious illness was the first task. iodized salt. Recall of specific messages about iodized salt was higher among mestizo households (41 percent) Methods than among the indigenous population (19 percent). Radio was the primary channel used in this campaign complemented with print materials, such as posters and leaflets. For six months beginning in April 1974, messages were broadcast up to 200 times daily. The frequency of broadcasting decreased in September 1974, but some spots continued to be broadcast sporadically through April 1975. A radio mini-drama in the local language, Quechua, was the key material in this campaign. It featured a mother learning about goiter from her doctor as they discuss her child’s illness. Prior to this nutrition communication campaign, iodized salt was not available in the Imbabura Province. The only manufacturer of iodized salt, ECUSAL, agreed to make iodized salt available in exchange for free promotion of iodized salt. The company also provided 5,000 one-ounce sample packages to be given to both mestizo and indigenous populations. Results Three waves of interviews were conducted to determine the level of knowledge about iodized salt. A baseline measure was taken in February 1974; a mid-project measure was obtained midway through the campaign; and a final measure at the end of the campaign. Message awareness tests indicated that the messages reached a 178 CHAPTER 4 Indonesia: Improving Nutritional Status From 1977 to 1983, the World Bank supported a Nutrition households had been visited by a nutrition kader, in Development Project that included a Nutrition comparison villages 44 percent. Mothers in project villages Communication and Behavior Change component aimed averaged 47 percent correct recall of nutrition messages at improving nutrition-related behavior in sixty villages in as compared to 28 percent in comparison villages. five subdistricts. One of these areas was part of the Nutrition Intervention Pilot Project (NIPP), which field-tested a range Evaluation data on households confirmed the changes in of community nutrition interventions including growth knowledge, attitudes, nutrient intake, and nutrition status monitoring, oral rehydration, nutrition education with of mothers and children in the project sites. Breastfeeding emphasis on breastfeeding and weaning foods, home and mothers and children in project areas ate a much greater village gardens to increase production of fruits and variety and quantity of the food promoted compared to vegetables, and small-scale food processing and food mothers in comparison villages. storage, as well as immunization, and in selected areas, family planning counseling by traditional birth attendants. Nutritional status of children in each of the five subdistricts of the project were significantly better than that of children Methods in the comparison group. Mean weights of children in the A combination of face-to-face communication and mass project were from one-half to one kilogram higher than the media was utilized in helping the community to improve mean weights of children in the comparison group, the diets of malnourished children and of pregnant and representing a highly significant difference of at least half a lactating mothers. A qualitative research phase identified standard deviation between mean weights. Children in the the beliefs, attitudes, and practices of mothers of project group showed more favorable growth patterns with malnourished children and of pregnant and lactating growth curves that flattened out at seven months of age, mothers. Dietary modifications needed to improve the compared to the five months for the comparison group. nutritional status of malnourished children and of pregnant Their average weight never fell below the normal zone, and lactating mothers were discussed by project staff and whereas those of the children in the comparison group these families. Agreements on dietary modifications were dropped below normal starting at thirteen months of age. made based on what the families are able to do with Overall, about 40 percent of those in the project are better available resources. Messages were then geared to nourished than those in the comparison group. respond to the needs of the families. Multiple regression analysis indicates that the difference Results in nutritional status can be attributed to the nutrition One year after the communication activities began, 2,000 education efforts rather than to other factors such as kaders (village-level health volunteers) had learned the occupation, food expenditure, mother’s age, or education. program messages and offered more specific advice than Mothers’ knowledge about appropriate feeding led to the kaders on other nutrition education programs in adoption of these practices. In project areas, 87 percent of comparisons areas. They were devoting more time to the children consumed more than half of the recommended nutrition work, averaging fourteen hours each month calorie intake and 82 percent consumed more than half compared to seven hours spent by volunteers in the recommended protein intake. In the comparison group, comparison areas. In project villages 67 percent of the figures were 62 percent and 60 percent respectively. 179 CHAPTER 5 Jordan: Initiating Breastfeeding From 1989 to 1990, the Noor al Hussein Foundation, a hospitals, initiation within the first six hours increased only nongovernmental organization linked to the Queen of slightly (from 17 percent to 25 percent). Jordan, conducted a communication campaign to promote breastfeeding. Specifically, the goal of the campaign was Supplementation behavior was measured in two ways, to increase the practice of breastfeeding initiation within showing different results. The first approach was to the first six hours after birth and breastfeeding determine the percentage of women who were exclusively supplementation when children reached four months of breastfeeding children of different ages. When measured age. Women aged 35 and younger with children less than this way, supplementation behavior remained essentially two years of age were the target audience. unchanged from 1988 to 1990. However, when mothers who were supplementing in 1990 were asked at what age they started doing so, 60 percent said they had started at Methods four months or later, compared to just 47 percent in 1988. The campaign broadcast radio and TV spots from March to May 1989, and again in March and April 1990. Messages focused on five behaviors that mothers did not adequately understand and that health care providers seemed not to support: initiate breastfeeding in the first hours after birth; avoid all liquids other than breastmilk in the period immediately after birth; increase milk supply by breastfeeding on demand; delay all milk supplements including juices during the first four months of life; wean gradually. Ten TV spots and a radio mini-drama series were the primary channels used to disseminate these messages to mothers. Results Initiation of breastfeeding within six hours after birth increased significantly during the campaign, but only among mothers who gave birth in public hospitals (from 43 percent to 69 percent) or at home (from 42 percent to 67 percent). Among mothers giving birth in private 180 CHAPTER 6 The Philippines: Promoting Sexual Responsibility Among Teens In the early 1980s, the Population Center Foundation were advertised in TV spots linked to this song and (PCF) in the Philippines established information and video. PCF established a referral network of counseling counseling centers for young people in major cities. and service agencies and individual professionals such Towards the end of the decade, PCF decided to as clinical psychologists. address the issue of teenage pregnancy in a more dynamic manner. A 1982 study showed evidence of a Results trend toward premarital sex and teenage pregnancy. A baseline, mid-project, and final survey tracked More than 5,000 15–24-year-olds were interviewed in levels of awareness and audience reaction to mes- 1985 for the Young Adult Fertility Survey. Results sages. The second survey conducted in August 1988 showed that 37 percent of married women reported reported that almost all youth interviewed recalled the having had premarital sex; only 12 percent had used song “I Still Believe” (92 percent) and liked it (92 contraceptives. percent). Seventy percent of those interviewed could interpret the message correctly. Forty-four percent Methods said they talked about the song with friends and In 1988, PCF launched the Multimedia Campaign for parents, and 25 percent said they sought information Young People to promote sexual responsibility among about contraceptives. The telephone hotline “Dial-a- youth. They chose popular music as the channel for Friend” received 8,000 calls in the first seven months messages. Lea Salonga, a local singer, teamed up of operation. This was considered a low figure since with Menudo, a Puerto Rican group with a local many attempted to call but could not get through. following of 400,000 members in the Te Quiero Mucho According to an estimate based on the survey, about Menudo Club. 150,000 callers tried to call “Dial-a-Friend.” The campaign targeted a broad audience com- posed of young people between 12 and 24, especially 15-19-year-olds, with messages aimed at increasing awareness of the problems of early pregnancy and pregnancy before marriage. Two songs were chosen as the vehicle for these messages: “That Situation” (a fast tune) and “I Still Believe” (a love song). A telephone hotline, “Dial-a-Friend,” was estab- lished in June 1988, a month after the release of the song “I Still Believe.” Four telephone hotline numbers 1 81 CHAPTER 7 Zaire: Reducing the Spread of HIV/AIDS Human immunodeficiency virus (HIV) seroprevalence is The campaign’s goal was to promote safe sex practices high in Zaire, ranging from 6 to 8 percent in Kinshasa and among urban youth. At first, the target audience was other major urban areas and 3 to 4 percent in rural areas. comprised of boys and girls aged 12 to 19. Later it was Heterosexual contact accounts for more than 80 percent expanded to include “young and prospective parents” of AIDS cases in Zaire, and the ratio of AIDS infection aged 10 to 30. This second, older audience was targeted between men and women is 1:1. to address the problems of mother-to-child transmission and AIDS orphans. Young women are particularly vulnerable to HIV infection because of their economic and social status. Young girls Television and radio spots, songs about AIDS, drama on who are unable to finance their education often resort to a radio and television, and notebooks for schoolchildren “beau marriage,” usually to an older man, to ensure were all used to disseminate a single message about financial security, or they accept an older man’s offer of safe sex practices. This message debunked the myth financial support in exchange for sexual favors. In addition, of casual transmission and suggested sympathetic the traditional practice of polygamy, which is common in treatment of persons with AIDS. Zaire, keeps women economically disadvantaged, thus providing an incentive for prostitution. Results By the end of 1990, Zaire’s 13 million urban residents Methods were receiving an average of ten minutes a day of An estimated 13 million urban Zaire residents have access televised AIDS messages, in the form of music videos, to television, as the country’s eleven regional capitals are interview programs, dramas, or spots. Post-tests of linked by television satellite. The combination of high specific media interventions showed high viewer/listener seroprevalence and the viability of television as a channel rates and excellent recall of key messages. Results from of communication led to the decision to launch a social an August 1990 program impact study in Kinshasa communication campaign in 1988 using mass media in showed the following: urban areas. The media campaign was part of an • Increased awareness regarding asymptomatic aggressive social marketing program promoting carriers. The number of people who agreed with PRUDENCE, a condom brand marketed by Population the statement “You can avoid getting infected with Services International, a nonprofit organization. the AIDS virus simply by avoiding sexual contact PRUDENCE was sold at a subsidized price so that it would with people who look sick,” decreased by 14 be affordable to low-income groups. percentage points (56 to 42 percent). 182 • Increased abstinence and mutual fidelity for AIDS prevention. When asked “How have you changed your behavior in the face of AIDS?”, the proportion of individuals who responded “By becoming mutually faithful,” increased 16 percentage points, from 28.9 to 45.7 percent. When asked “How have your friends changed their behavior in the face of AIDS?”, the proportion of respondents indicating that their friends were practicing abstinence was 19 percent higher than in the baseline study. • Increased knowledge and acceptance of condoms for AIDS prevention. The number of people naming condoms as their first mode of AIDS prevention grew from 5 to 13 percent, a 150 percent increase. The number of people who had ever heard of condoms increased by 11 percent. • Increased condom use for AIDS prevention. When asked how they had changed their behavior in the face of AIDS, the proportion of people who responded by “By using condoms,” increased from 3.6 to 18.8 percent. As a result of the social marketing efforts, the sales of PRUDENCE condoms increased from less than 1 million in 1988 to 8 million in 1990. PRUDENCE condoms account for an estimated 90 percent of all condoms distributed through the commercial sector in Kinshasa. Consumer intercept studies conducted in 1990 showed that condoms are purchased and used primarily as a means of avoiding exposure to HIV and other sexually transmitted diseases. 183 The World Bank A partner in strengthening economies and expanding markets to improve the quality of life for people everywhere, especially the poorest