Social & Behavior Change Interventions Landscaping ...

Social & Behavior Change Interventions Landscaping Study: A Global Review

Center for Communication Programs Johns Hopkins Bloomberg School of Public Health October 2011 Report prepared for the Family Health Division of The Bill & Melinda Gates Foundation

Social & Behavior Change Interventions Landscaping Study: A Global Review Summary report reviewing existing evidence and data on Social & Behavior Change interventions across the RMNCHN spectrum

Douglas Storey, PhD Center for Communication Programs Katherine Lee Caitlin Blake Peggy Lee Hsin-Yi Lee Nicole Depasquale Department of Health, Behavior & Society Johns Hopkins Bloomberg School of Public Health

October 2011

This report was commissioned by the Family Health Division of The Bill and Melinda Gates Foundation

SBC Landscaping Report

TABLE OF CONTENTS EXECUTIVE SUMMARY...............................................................................iv INTRODUCTION ..........................................................................................1 SEARCH PROCEDURES AND SOURCES OF EVIDENCE................................2 The scope of this review ...................................................................3 Databases searched ................................................................3 Geographical coverage—developing & developed countries ........................................................................4 Search terms ............................................................................4 RMNCHN search terms............................................................5 Intervention approach search terms ........................................8 Number of abstracts found and reviewed.............................11 SEARCH RESULTS ......................................................................................12 Distribution of articles by health area .............................................12 Distribution of articles by intervention type ....................................13 ANALYSIS OF MAJOR INTERVENTION APPROACHES.............................15 Community-Based Approaches.......................................................15 Community engagement .......................................................16 Community mobilization.......................................................18 Community outreach .............................................................19 Social mobilization................................................................20 Social movements and empowerment ..................................21 Positive deviance ..................................................................22 Interpersonal Approaches ...............................................................24 Client-provider (physician-patient) interaction......................25 Community/Frontline Health Workers/Midwives ..................27 Counseling ............................................................................29 Home visits/Household outreach ..........................................32 ii


Peer education.......................................................................34 Group-Based Approaches ...............................................................36 Social capital/social support .................................................36 Social networks .....................................................................39 Social norms/stigma/normative change ...............................40 Behavioral Economics Approaches .................................................42 Media & Social Marketing Approaches ...........................................45 Advocacy ..............................................................................45 Mass media ...........................................................................47 Strategic communication .......................................................49 Social marketing....................................................................51 Social media..........................................................................53 RECOMMENDATIONS FOR PROGRAMS ..................................................55 RECOMMENDATIONS FOR RESEARCH.....................................................59 Citations ....................................................................................................68

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EXECUTIVE SUMMARY This report summarizes programmatic and research implications from the past decade of research (2000-2010) on health-related social and behavior change interventions in developed and developing countries. We conducted a search for peerreviewed literature in three global databases, PubMed, Scopus and POPLINE, with a focus on interventions aimed at improving family health issues: reproductive health (RH), neonatal health, maternal and child health and nutrition (RMNCHN). From over 2000 items matching key intervention and health topic search terms, we selected a total of 625 unique articles for review that (a) described at least some elements of an intervention strategy, (b) identified social and/or behavioral determinants of health outcomes and (c) provided data about the impact of the approach on determinants and/or health outcomes. We conclude with programmatic and research recommendations. CATEGORIES OF INTERVENTIONS Articles meeting the inclusion criteria fell into five main categories (and subcategories): •

•

•

• •

Community-based approaches -‐ Community engagement, Community mobilization, Community outreach, Social mobilization, Social movements & empowerment, Positive deviance Interpersonal communication approaches -‐ Client-provider/physician-patient interaction, Community/frontline health workers/Midwives/Traditional birth attendants, Counseling, Home visits/household outreach, Peer educators Group-based approaches -‐ Social capital/social support, Social networks, Social norms/normative change Behavioral economics approaches Media and social marketing approaches -‐ Advocacy, Mass media, Social marketing/marketing of health services, Social media, Strategic/persuasive communication

Elements that define categories include emphasis on a particular location (e.g., community-based); emphasis on group processes, networks and social influences (e.g., social support, norms) but not necessarily on a geographically defined area; emphasis on face-to-face contact (e.g., counseling, frontline health workers, home visits); emphasis on

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economic or financial influences on decision-making; and emphasis on the use of one or more media, often for mass or social marketing of health-related products and behaviors. DISTRIBUTION OF APPROACHES Our review found the greatest volume of research in the area of RH, followed by nutrition (much more in developed than in developing countries), neonatal, maternal and child health. A substantial amount of the work on neonatal health was related to initiation and extending the duration of breastfeeding. Child health was a relatively neglected area of research in developed and developing countries alike. The largest intervention category by far was Interpersonal Communication (notably counseling, especially from developed countries), followed by Media & Social Marketing and Group-based, then Community-based and Behavioral Economics. There was relatively more Community-based research and less Group-based research from developing countries compared to developed countries, perhaps reflecting differences in access to electronic and interactive technologies. As a relatively new area of research, the number of publications on behavioral economics was low compared to other intervention approaches, but the greatest number was in the areas of nutrition and maternal health. KEY ATTRIBUTES OF SUCCESSFUL INTERVENTIONS Community-based approaches emphasize the engagement of civic structures that already exist, but may or may not be committed to or effective at ensuring public health. Although they may involve the use of face-to-face or media channels, they tend to focus on group processes (e.g., participation, consensus building, community dialogue) and the use of public events as ways of reaching and involving community members on a broad scale. The choice of a community-based intervention approach is often motivated by sustainability goals. One of the newer approaches in this category, Positive Deviance— referring to a positive but uncommon behavior—is community-based in the sense that deviance is defined against a community standard. The approach succeeds through intensive engagement with the community to both understand normative repression of healthy practices and mobilize support for normative change. With the exception of articles on positive deviance, very few of the communitybased studies we identified measured impact of the approach on health behavior v


outcomes, focusing instead on improvements in broader social conditions (e.g., access to quality services) and social processes (e.g., inclusive program planning or equitable service delivery) that should influence health outcomes. Interpersonal communication (IPC) approaches employ face-to-face interaction between health promoters/educators/communicators/service providers and clients in oneon-one or group settings in a health facility, the home or elsewhere in the community. By far the largest intervention category, counseling and variations on it is one of the oldest forms of medical intervention and is inextricably bound up with clinical practice. Its power comes from the opportunity to personalize information and advice and tailor them to the needs of patients/clients. IPC approaches require skilled communicators, something that should not be assumed. Successful providers have at least some training in counseling techniques and behavioral science, a commitment to client-focused practice, empathy and access to quality job aids, including print materials, electronic assessment tools and processes like motivational interviewing. Group-based approaches emphasize social structural factors that influence behavioral choices, including the network structure of a social group (and an individual’s position or role within that network), the nature of the interpersonal relationships (e.g., supportive, contentious, formal or informal) in a network, the role of norms and normative perceptions and the extent to which social and material resources (social capital) are available and equitably distributed. Social network and normative change approaches are more often linked to specific behavioral outcomes, while research on social capital interventions more often emphasizes change in the social environment rather than on behavior itself. Behavioral economics (BE) draws on social, cognitive and emotional factors to explain behavioral decisions that appear to be governed by economic considerations or the way behavioral options result in gain or loss. Gain or loss can be literally financial, as in receiving a subsidy or voucher for service utilization, or subjective as in a gain or loss of status or self-esteem. Relatively few studies examined non-financial incentives. As a relatively new approach to social and behavior change, there are fewer evaluations of BE effectiveness, and many of the studies we found were exploratory in nature, but they covered a diverse range of topics and employed a variety of channels or delivery modes from mass media to community-based to interpersonal.

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Mass media and social marketing approaches include the use of a broad range of media technologies from large (e.g., national television) to small (e.g., community radio) and from one-to-one technologies (e.g., texting) to one-to-many technologies (e.g., television, Facebook). Media are often used in an integrated way, with multiple delivery mechanisms deployed simultaneously to carry complementary and mutually reinforcing content. They also often cut across and complement other intervention approaches. One of the main strengths of these approaches is their ability to reach millions of people quickly with high quality information, although this can come at the expense of personalization of messages. Some newer mobile technologies and social media that give users more control over content may help overcome this challenge. SEVEN ACTIONABLE CONCLUSIONS For Programs (1) Choose the Right Tool for the Job We have a wealth of intervention options, but programs do not always employ the one that matches desired outcomes. Are the desired changes small scale and local or large scale and population-based? Are they relatively short-term (adoption of a behavior) or long-term (maintenance of a lifestyle)? Is the behavior private and personal or public and social? Are decisions made alone or together with family and friends? Each intervention approach has strengths and weaknesses that must be matched to program objectives. Few approaches are sufficient alone and most work better in combination with others. (2) Go Small—Personalize Interventions to Improve Impact In the end, which intervention approach is used may be less important than the content it delivers. Effective interventions personalize the attention and the information they deliver to clients. For example, counseling approaches, community outreach, and the deployment of frontline health workers are popular and widely used strategies because they allow personal contact with clients and patients, but many fail because providers lack the knowledge, skills or sensitivity to make their interventions client-centered. On the other hand, media and marketing approaches sometimes are too generic but can be personalized through careful message design that reflects local sensitivities and imagery, addresses local needs and touches the emotions.

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(3) Go Big—Maximize Reach and Scale If every aspect of every intervention had to be delivered door to door, the required time and human resources would be prohibitive. Fortunately, group-based and community-based approaches allow health professionals, outreach workers and peer motivators to reach groups of people simultaneously instead of one-by-one, while still allowing a relatively high degree of personalization. Activating social networks extends the reach of programs and brings social influences into play that often can reinforce and sustain behavior change. On an even greater scale, media of various kinds like television, radio, telephony and increasingly the internet further extend the ability of programs to reach geographically dispersed groups and individuals in great numbers with personalized messages; the more people reached, the greater the potential impact. For Research (4) Go Small in a BIG Way The growing interest in behavioral determinants reflects a need to identify the specific personal triggers that “close a sale”. However, to make a difference in health outcomes beyond the individual level, it is necessary to “close the sale” on a massive scale. How should we design interventions that allow personalization, but do it at scale? For example, how can we broaden and extend the impact of interpersonal approaches like the use of frontline workers in cost-effective ways? How can we replicate facility-based and community-based programs at thousands of sites while simultaneously reducing costs and human resources? What role can mass media and social media play in scaling up localized strategies that work? (5) Trace Pathways to Change Over Time Most worthwhile change in health outcomes is incremental and cumulative and normative change can be a generational phenomenon. Yet, the vast majority of the studies we found were cross-sectional or relatively short term (extending over a few months to a year). We found few rigorous evaluations of population-based programs over more than a year that attempted to understand the chronological and cumulative impact of program inputs (e.g., exposure to media messages or counseling) on the adoption and maintenance of behavioral decisions (e.g., risk reduction practices) and the subsequent impact of those changes on health outcomes (e.g., unintended pregnancy and STIs). Even more challenging viii


and rare is quantifying the link between program effects on social and structural changes (e.g., improvements in social capital, community engagement with health or policy change) and health behaviors and health outcomes. Documenting these indirect effects requires longer term monitoring and impact evaluation and more sophisticated multilevel longitudinal analysis than many programs are designed to provide. For the science of SBC intervention to advance, we need more multiyear field programs with research and evaluation systems designed to answer the question: How do short-term and intermediate changes in attitudes, norms, network structures, social capital and behavior affect longerterm changes in health outcomes at a level of social aggregation higher than the individual? (6) Achieve Innovation through Standardization The almost infinite variations on program settings, audiences and objectives make it clear that cookie cutter approaches to SBC are not likely to succeed, but this does not mean that we should reinvent the wheel with every intervention. Systematic, critical and reflective (rather than slavish) use of standardized tools and models can help to pinpoint inevitable shortcomings or gaps in knowledge and approaches, from which innovations spring. Critical use of and sharing of experience with common tools and approaches helps build a stronger platform for change at scale. In this spirit, we would do well to prioritize the development and testing of standardized program tools for planning, implementation, monitoring and evaluation that will make the personalization of initiatives faster, simpler, more systematic, more efficient and, therefore, more scalable. A wealth of such tools is available from a variety of sources, but these have never been compiled, tested systematically or standardized for the purposes of SBC interventions across the RMNCHN spectrum. What would a standardized package of tools look like? How well does this intervention support package work in different contexts and for different health outcomes? What training in the use of this package and its components would be necessary? (7) Nurture Promising Intervention Opportunities While older, widely validated intervention approaches should continue to be used and adapted for new applications through formative research, few of these need to be the focus of continued primary research because their effectiveness, when executed skillfully, is well known. Some of the newer approaches, however, deserve primary ix


research attention because they have not been tested for all uses where they might be impactful. (a) Determine How to Use Social Media for SOCIAL Change Social media, like cellular technologies and social networking websites have been examined thus far mostly for their ability to disseminate information (e.g., SMS texting to clinical patients or sending notices of events, posting program updates or providing links to useful health information on project Facebook pages). To a more limited extent, social networking media have been used to provide opportunities for social connection (e.g., chat rooms, online group counseling, online professional communities of practice). There is also evidence—albeit mostly anecdotal—that mobile technologies can be useful for social mobilization. But how any of these applications are related to health behavior change, especially in the long run is largely unknown. How can the networking capabilities of social media be used beyond short-term behavior change? Can mobile technologies and social networking media enhance social capital (e.g., social cohesion and access so social support) related to health behavior and health service use? How can commercial telecommunication service providers play a role in the wider use of social media for health? (b) Identify Non-Financial Incentives that Have Lasting Impact In part because Behavioral Economics is a relatively new intervention approach there are very few evaluations of full-scale BE projects. The most common strategies in this area involve subsidies of various kinds—essentially bribes—for healthy behavior. While this appears to work in the short term, effects tend to drop off quickly when subsidies end, so the sustainability of this approach has to be questioned: the more successful it is, the more it costs. On the other hand, non-financial motives for behavior that rely on perceptions of non-economic gain or loss (e.g., ones that trigger a positive or negative emotional state) can be powerful determinants of behavior and deserve more research attention. They are likely to be cheaper and may reflect the psychosocial mechanism underlying financial incentives anyway. Are there non-financial incentives that can become self-regulating and therefore habitual and sustainable? Can emotional rewards be associated with healthy behaviors such that continued practice becomes desirable? Can

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people learn to reward themselves emotionally for a healthy behavior or routinely avoid behaviors that produce unpleasant emotional reactions become? (c) Harness Positive Deviance on a Larger Scale Positive deviance can be a powerful community-based approach that engages families and households to examine their health practices and re-imagine how to achieve better health, but the approach takes time because it works best as a collective exercise. It has also seen little application in critically important health areas like newborn care, physical activity and birth spacing. Few examples of PD interventions describe efforts to scale up the innovations beyond the local community, yet social network research, in particular Kincaid’s (2004) work on bounded normative influence, suggests that PD could be linked to social network approaches. Key questions about this approach include: Are there ways to streamline and shorten the PD intervention process without jeopardizing the personal, community-based character of this approach? How can network approaches be incorporated into the PD process? Can PD be scaled up, perhaps by modeling the whole community response to family and community health, not just individual behavior? (d) Find the Key to Sustainable Counseling Although counseling is a heavily studied process, most of the work has focused on relatively short-term effects and technical skills. Counseling tends to be episodic and occasional, occurring at critical times in pregnancy, neonatal care, treatment regimens. Some counseling interventions provide intensive multiple encounters but during a short period of time (e.g.. for smoking cessation, breastfeeding or diet change) designed to get a client through a difficult transition period or establish a pattern of behavior that is hoped will persist. However, we have few studies that examine the longitudinal effects of counseling or the factors that sustain the effects of counseling encounters after they have stopped. How long do counseling effects persist? Are there counseling techniques that have more enduring impact? How can the impact of prenatal counseling (e.g., on birth preparedness, breastfeeding, immunization, child and maternal nutrition, intrapartum FP) be sustained throughout the first 5 years of a child’s life?

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INTRODUCTION Families around the world face a daunting array of challenges to their health. These include a broad spectrum of issues related to reproductive health (from contraception and birth spacing to the prevention of sexually transmitted diseases), maternal health (from conception through gestation to safe delivery, postpartum recovery, mental health and intrapartum health management), neonatal health (beginning with fetal development through safe birth to breastfeeding and the prevention of neonatal mortality and morbidity), child health (including early childhood nutrition and disease prevention) and nutrition (including diet and physical activity across the lifespan). Overcoming these challenges requires reliable access to a complex and interrelated set of resources that include biomedical, social and behavioral components. Many interventions featuring combinations of these resources have been proposed, tried and evaluated with varying success. Two studies of note, Darmstadt et al. (2005) and Oona et al. (2006) provide indepth reviews of intervention strategies to prevent neonatal and maternal mortality, respectively. Although both of these reviews focus substantially on biomedical interventions, both also point to important intervention delivery modalities that include facility-based efforts, various kinds of outreach and home care, community engagement and the deployment of communication media to educate, create demand and improve care seeking and service utilization. Both also sound a theme that we take up in our own review: the importance of bundling intervention strategies into packages that mobilize complementary resources according to the needs of specific prenatal, perinatal, postnatal and childhood periods, clients and settings. The current report picks up where reviews like Darmstadt and Oona leave off. We focus on social and behavior change (SBC) intervention approaches that help deliver and support biomedical interventions and which are necessary to achieve sustainable, population-based improvements in reproductive health, maternal, neonatal and child health and nutrition (RMNCHN). Our mandate from the Bill & Melinda Gates Foundation was to review published literature on SBC intervention approaches and answer a series of questions: • • •

What do we know about the impact of different approaches on health practices and health outcomes? What are the characteristics of effective interventions? Which approaches are most likely to result in short and long-term change? 1


• •

What are some promising opportunities for innovation? What key research questions, if answered, have the potential to advance the field and strengthen practice?

SEARCH PROCEDURES AND SOURCES OF EVIDENCE The literature on social and behavioral determinants of disease and wellness is vast and includes a staggering range of primary research from biomedical, public health, social science and behavioral science perspectives. Much of this research has implications for social and behavioral interventions, but only a relatively small subset assesses interventions or intervention approaches themselves, the degree to which they are successful and why. Even narrowing our focus to family health topics—the RMNCHN spectrum—we are still left with a substantial volume of evidence. The technical complexity and volume of research within even this relatively bounded set of health sub-disciplines and the specialization that is characteristic of contemporary scientific research results in a body of scholarship that is scattered across a huge variety of outlets. Scholars specializing and publishing in one area of health—say, nutrition or health communication—may be unaware of similar, related or even redundant scholarship in other journals or by other communities of scholars. An advantage of this is the opportunity it provides to extrapolate across a wide range of replications with variation. However, many of the hundreds of pilot studies and trials that exist are narrowly focused on specific local conditions or client groups. Even the most rigorous of these are sometimes so situation-specific that it is difficult to generalize from the results. Therefore, in this review, we have opted for an aerial view of the intervention approaches that have been most commonly used in an effort to derive general conclusions about what has worked across a variety of settings. Another complication we faced in conducting this review is that different subdisciplines within the social and behavioral sciences sometimes use different vocabulary for similar concepts (e.g., physician-patient interaction versus provider-client communication or community mobilization versus community engagement), making the comparison of approaches and perspectives challenging. For example, scholars working from more humanistic or ethnographic vantage points may use terms such as “empowerment” or “agency” to describe how some individuals, groups or communities overcome health and social inequities or marginalization to develop a stronger and more assertive identity relative to other forces in society. Social psychological scholars may use terms such as 2


“self-efficacy” or “collective efficacy” to describe similar ideas, albeit with somewhat less emphasis on power relationships in society. Both sets of vocabulary are nuanced enough to encompass the dimensions of social and behavioral change envisioned by scholars in either camp, yet scholars in these two traditions typically read and publish in very different scholarly venues. The scope of this review In order to bring this review to a manageable scale, we decided to focus our attention on articles published in peer-reviewed journals during the last ten years (20002010) and, within that period, on publications that explicitly aimed to test or derive implications for social/behavioral interventions to improve health. Obviously, much research on public health interventions (including 60+ years of behavior change communication research) predates this period, but we decided that the most recent decade of scholarship was likely to reference and build upon the foundations of earlier work to the extent that historically sound principles of effective SBC interventions still would be represented. A recent review of mass media campaigns (Wakefield, Loken & Hornik, 2010) used a similar strategy with excellent results. Databases searched The databases and search engines we employed were PubMed, SCOPUS and POPLINE. •

PubMed (http://www.ncbi.nlm.nih.gov/pubmed) is a service of the U.S. National Library of Medicine at the National Institutes of Health. It comprises more than 20 million citations for biomedical literature from MEDLINE, life science journals and online books. Many of the citations include links to full-text content from PubMed Central and from publisher web sites. Available search term dictionaries allowed us to hone in on key words in the abstracts and full text of citations that reflect the topics of interest to this project.

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Scopus (http://www.info.sciverse.com/scopus) is a subscription service of Elsevier BV, a global publisher of science and health information based in the Netherlands. It comprises citations from 18,000 peer-reviewed journals, including over 1,200 open-access titles and approximately 38 million records dating as far back as 1823, of which 19 million are reference enhanced with abstracts and links to full text. Compared to PubMed, Scopus provides somewhat better coverage of social science literature.

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POPLINE (http://www.popline.org/aboutpl.html) is maintained by the K4Health Project (https://www.k4health.org/k4h) at the Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs with funding from the United States Agency for International Development. (USAID). It contains citations with abstracts of scientific articles, reports, books, and unpublished reports in the field of population, family planning, and related health issues and comprises 370,000 records dating back 1973. It adds approximately 8,000 records annually. In addition to free text searching, the database can be searched by keywords from a controlled vocabulary of 2,400+ terms and includes links to free, full text documents and the ability to limit searches to peer-reviewed journal articles. Compared to Scopus and PubMed, POPLINE provides somewhat better coverage of reproductive health and of health communication publications.

Geographical coverage—developing and developed countries We initially restricted the search to studies focused on RHMNCHN in lower-income (developing) countries where Foundation investments were most likely to go: Asia and the Pacific (excluding Japan), Africa, The Caribbean, Latin America, Eastern Europe and the Middle East (except Israel). However, following consultation with the Foundation after a preliminary progress report, we were asked to expand the search to include higherincome (developed) countries, as well, on the assumption that newer intervention approaches may be appearing first in more technologically advanced settings and that an exclusive focus on developing countries might miss emerging evidence on newer, promising approaches. Consequently, we repeated the searches focusing on studies conducted in North America, Australia and New Zealand, Western Europe, Russia, Japan and Israel. Search terms Available search terms differ somewhat across the three databases, so we started by developing an optimum set of terms based on the lists below, first a set of terms that helped us zero in on intervention-related research, then lists of terms identifying health topics and intervention approaches (see descriptions of these lists, below). We then used the lists to search the titles and abstracts of holdings in each database. As the search progressed, we refined the lists, adding and subtracting terms to generate the most complete set of relevant intervention studies as possible. All publications selected for initial examination included the following terms in their title or abstract: 4


•

Behavior change and/or social change,

Each article selected also contained at least one term indicating assessment of an intervention, approach or health challenge, such as • • • • • • • • •

Ameliorate Change/changing Effectiveness Evaluate/evaluation Evidence Gain Impact Improve/improved/improving Modify/modified

RMNCHN search terms For health-related search terms, we began by developing an initial list of health topics that spanned the mandate of the Foundation’s Family Health Division: reproductive health, maternal health, neonatal health, child health and nutrition. As we developed our search strategy, we explored variations on these terms and phrases that were known to the study team and that appeared in trial searches that we conducted. This resulted in the final list of search terms shown in Table 1. Table 1: Health topics included in review Abstinence Adolescent health Adolescent pregnancy Adolescent sexuality Anemia Birth intervals Birth outcomes Birth rate Breast feeding Child abuse Child health Child health services Child mortality Child nutrition Child nutrition sciences Child nutrition disorders Child/birth spacing Child survival Child welfare Condom use

Fetal nutrition disorders Food High risk women Immunization Infant mortality Infant nutrition Infant nutrition disorders Infant welfare Infectious disease transmission/prevention or control Integrated management IMCI (Integrated Management of Childhood Illness) Malaria Male circumcision Maternal health Maternal health services Maternal nutrition

Nutrition Obstetrics Oral rehydration Perinatal mortality PMTCT (Preventing Mother to Child Transmission) Population dynamics Post abortion Pregnancy Reproductive behavior Reproductive health Reproductive health services Safe delivery Safe motherhood Safe (or unsafe) sex Sex education Sexual health Sexually transmitted diseases (STD, STI) Teen pregnancy 5


Contraception/ contraceptives Diet Family planning Family planning services Fertility

Maternal mortality Maternal welfare Maternal/Child Health (MCH) Midwifery Neonatal health

Tract infection Sexual behavior Reproductive medicine Reproductive health Women in development

Some health topics are relevant to more than one part of the RMNCHN spectrum. For ease of analysis, we then grouped health intervention areas into clusters based on the spectrum of reproductive, maternal, neonatal, child health and nutrition, shown in Table 2. For example, most of the articles addressing adolescent health issues were concerned with some aspect of reproductive health, while child/birth spacing articles typically addressed some aspect of reproductive health, maternal health and neonatal health, but less so child health or nutrition. Thus, in discussing the evidence of intervention effectiveness, we considered some articles in more than one category. Table 2: Health topics by category Health topics (alphabetically) Abstinence Adolescent health Adolescent pregnancy Adolescent sexuality Anemia Birth intervals Birth outcomes Birth rate Breastfeeding Child abuse Child health Child health services Child mortality Child nutrition Child nutrition sciences Child nutrition disorders Child/birth spacing Child survival Child welfare Condom use Contraception/contraceptives Diet Family planning

Reproductive health R R R R R

Maternal health

Neonatal health

M M M

N N

R R

R

M

Child health

Nutrition

NU

N N N N N N N N N N N

C C C C C C C C

NU

NU NU NU

C C

R R NU R 6


Health topics (alphabetically) Family planning services Fertility Fetal nutrition disorders Food High risk women (re: pregnancy) HIV/AIDS Immunization Infant mortality Infant nutrition Infant nutrition disorders Infant welfare Infectious disease transmission/ prevention or control Integrated management IMCI (Integrated management of childhood illness) Malaria Male circumcision Maternal health Maternal health services Maternal nutrition Maternal mortality Maternal welfare MCH (maternal & child health) Midwifery Neonatal health Nutrition Obstetrics Oral rehydration Perinatal mortality PMTCT Population dynamics Post abortion Pregnancy Reproductive behavior Reproductive health Reproductive health services Reproductive medicine Safe delivery Safe motherhood Safe (or unsafe) sex Sex education Sexual health Sexual behavior

Reproductive health R R

Maternal health

Neonatal health

Child health

Nutrition

M N

NU NU

M R

N M

NU C

N N N N R

M

NU NU NU C

N N M

C C

NU NU

C

R M M M M M M M

NU C N N NU

R

M C

R R R R R R R R

N N

C

M M

M M

N N

R R R R 7


Health topics (alphabetically) Sexually transmitted diseases Teen pregnancy Tract infection (reproductive, urinary) Women in development

Reproductive health R R

Maternal health

Neonatal health

Child health

Nutrition

M R

M

Some of these terms generated a large number of hits (e.g., HIV/AIDS and reproductive health) while others generated relatively few hits (e.g., abstinence, tract infection), reflecting the relative emphasis of research on the respective topics. Intervention approach search terms The Foundation identified an initial list of promising intervention approaches they were interested in that included community engagement, client-provider interactions, front line worker performance/outreach, mass media, social marketing, provision of financial incentives, social movements (large-scale or community-based), social networks, use of social media, and addressing social norms. As we developed our search strategy, we explored variations on these terms and phrases that were known to the study team and that appeared in trial searches. This resulted in a final list of intervention search terms listed below. All selected articles had to reference at least one of the terms shown in Table 3. Some of the intervention terms generated a large number of hits (e.g., counseling and health promotion) while others generated relatively few hits (e.g., marketing of health services and social franchising), reflecting the relative emphasis of research on the respective topics. Table 3: Intervention approaches included in search Behavioral economics Client-provider interaction Community engagement Community health services Community health worker Community intervention Community mobilization Community outreach Counseling

Mass media Maximizing access Midwives Normative change Peer education Persuasive communication Physician-patient interaction Positive deviance Social franchising 8


Financial incentives Front line workers Health communication Health education Health marketing Health promotion Home visits Household outreach Interpersonal communication Marketing of health services

Social marketing Social media Social mobilization Social movement Social networks Social norms Social support Strategic communication Traditional birth attendants

Over the past 40 years, behavior change strategies most commonly have been defined within the overarching public health strategy of health education or health promotion (Glanz, Rimer & Viswanath, 2008). For example, health education is “any combination of learning experiences designed to facilitate voluntary adaptations of behavior conducive to health” (Green et al., 1980). It covers a full spectrum of health processes and outcomes from disease prevention to detection, care and treatment, rehabilitation and health maintenance and can be delivered through almost any means imaginable. Health promotion is even broader than health education and more ecological in scope: “the process of enabling people to increase control over and to improve their health…to create environments conducive to health, in which people are better able to take care of themselves” (Epp, 1986). Health communication is another extremely broad term, defined as “a multifaceted and multidisciplinary approach to reach different audiences and share health-related information with the goal of influencing, engaging and supporting individuals, communities, health professionals, special groups, policy makers and the public to champion, introduce, adopt, or sustain a behavior, practice or policy that will ultimately improve health outcomes” (Schiavo, 2007). All three of these terms have been applied so broadly that the labels themselves do not indicate the characteristics of the intervention. For the purposes of this review, we reclassified interventions that were labeled as health education, health promotion or health communication according to primary characteristics of the strategy (e.g., a community focus, use of counseling or of a particular delivery channel). Across the remaining set of intervention approaches, we tried to group the main descriptor terms in meaningful ways to reflect shared characteristics (Table 4).

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Table 4: Grouped intervention categories and sub-categories Intervention Categories 1. Community-based approaches

2. Interpersonal communication approaches

Sub-categories • • • • • • • •

3. Group-based approaches 4. Behavioral economics 5. Media and social marketing

• • • • • • • • • • • •

Community engagement & interventions Community mobilization Community outreach Social mobilization Social movements & empowerment Positive deviance Client-provider/physician-patient interaction Community/frontline health workers/Midwives/Traditional birth attendants Counseling Home visits/household outreach Peer educators Social capital/social support Social networks Social norms/normative change Financial incentives/vouchers Advocacy Mass media Social marketing/marketing health services Social media Strategic/persuasive communication

Proponents of particular approaches may use labels to differentiate themselves, sometimes for academic reasons related to preference for a particular paradigm or research agenda and sometimes to emphasize a particular new or unique feature of an otherwise familiar approach. The purpose of our classification scheme is to highlight common features of similar approaches, not favor some labels or approaches over others. Elements that define categories include emphasis on a particular location (e.g., community-based); emphasis on group processes, networks and social influences (e.g., social support, norms) but not necessarily on a geographically defined area; emphasis on face-toface contact (e.g., counseling, frontline health workers, home visits); emphasis on economic or financial influences on decision-making; and emphasis on the use of one or more media, often for mass or social marketing of health-related products and behaviors. This analysis resulted

in the five super-categories and their sub-categories, shown above. These groupings are not always mutually exclusive. For example, many communitybased interventions also involved face-to-face contact with health workers or health 10


promoters; interpersonal communication can happen in community and small group settings as well as in one-on-one interactions; and many interventions employ communication technologies in some way, but do not necessarily highlight that as a formal feature. Many interventions—in fact, most of the best interventions—employ multiple approaches. Number of abstracts found and reviewed Searches of the PubMed, Scopus and POPLINE databases using the terms above, returned a total of 536 peer-reviewed articles from developing countries and 1546 from developed countries in over 230 different journals. The identified journals reflected a diverse range of biomedical, clinical, humanistic, social scientific, and policy-related research domains. Dealing with the large number of studies required some triage. First, we focused on articles that had implications for family health. For example, most articles on men who have sex with men (MSMs), intravenous drug users, incarcerated populations, military populations and commercial sex workers were excluded from the review because— although they are important in the larger realm of public health—they had little relevance to the primary audiences targeted by the Foundation: families, women and children. A limited number of such articles were reviewed if they revealed something new about SBC that potentially could be relevant to family health audiences. We also rejected some articles that dealt with health topics of limited relevance to RMNCHN objectives, such as adult dental health or deafness. Second, we focused our attention on articles that held clear implications for intervention development. We excluded a number of studies that merely tested or validated research methods, as well as some laboratory-based trials that were primarily biomedical rather than behavioral in nature. Third, we focused on articles (including program evaluations, randomized trials, and reviews) that provided some description of an intervention or suggested how results of the study could be applied to an intervention. We rejected some, mostly short, articles that did not identify any social or behavioral determinants of health outcomes. Using the original set of hits, we visually inspected and assessed the lists of titles and abstracts for relevance and redundancy. Redundant articles were deleted. In summary, an article was excluded from review if it met any of the following criteria:

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• • • • •

It focused on a target audience of limited importance to family health objectives, It focused on health outcomes of limited relevance to RMNCHN objectives, It focused exclusively on the refinement of a research methodology, It provided no description of an intervention or failed to indicate how results of the study could be used to design or improve SBC interventions for health; It reported only the magnitude of impact due to an intervention, but not any determinants of response or outcomes;

Through this process, we selected a total of 625 unique articles for review, 203 from developing countries and 422 from developed countries.

SEARCH RESULTS Distribution of articles by health area Globally, the health area represented most heavily in the literature was reproductive health (RH), followed by nutrition, neonatal, maternal and child health, in that order (see Figure 1). Roughly two-thirds of the reproductive health-related articles were focused on HIV/AIDS and sexually transmitted diseases (STDs), while the rest were divided between contraception, birth spacing, teenage pregnancy prevention, sexuality and fertility. Breastfeeding was considered an RH issue if it concerned lactational amenorrhea as a contraceptive method; otherwise it was considered a neonatal health issue and as such made up the bulk of the neonatal references in developed countries. Child health is a relatively neglected area of research in developed and developing countries alike. Nutrition was the second most heavily represented health area in developed countries, while it was the smallest category in developing countries.

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Distribution of articles by intervention type Globally, the intervention approaches represented most heavily in the literature were in the Interpersonal category, followed by Media & Social Marketing and Groupbased, then Community-based and Behavioral Economics, in that order (see Figure 2).

There was relatively more community-based research and less group-based research from developing countries compared to developed countries and much greater research attention to interpersonal and group-based approaches in developed countries (Figure 3). The absolute number of research articles from developed countries was greater than from developing countries across all categories of interventions, with one exception: community-based approaches. There were more publications on community-based approaches from developing countries across all health areas except nutrition. Research on interpersonal intervention approaches was heavily skewed toward developed countries, with much of that work focused on reproductive, neonatal and maternal health. In developed countries, research on group-based approaches has focused on RH and nutrition, while in developing countries research on group-based approaches is distributed fairly evenly across health areas. Although the amount of research on nutrition in developing countries was relatively limited, the greatest number of nutrition-related research studies described group-based approaches.

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Figure 3: Number of articles by intervention approach, health area and type of country

The number of publications on behavioral economics was low compared to other intervention approaches, but the greatest number was in the areas of nutrition and

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maternal health. In developing countries, the largest number of publications on behavioral economic approaches focused on RH, especially HIV/AIDS prevention and treatment. In developing countries, the only intervention category that had received attention on a par with developed countries was media and social marketing. There were nearly 40 articles on media and social marketing approaches to RH in both developed and developing countries. However, there has been relatively little attention globally to the use of media and social marketing for maternal, neonatal and child health. In contrast, there has been a lot of attention to the use of these strategies for nutrition promotion in developed countries.

ANALYSIS OF MAJOR INTERVENTION APPROACHES In this section of the report, we summarize key features of each intervention approach, provide a few illustrative examples of each subcategory and identify a few key ideas about the strengths and, in some cases, weaknesses of the approaches.

COMMUNITY-BASED APPROACHES (71 articles) Community-based approaches emphasize the engagement of civic structures that already exist, but may or may not be committed to or effective at ensuring public health. These approaches emphasize the community, rather than the individual, as the point of engagement. Although they may involve the use of face-to-face or media channels, they tend to focus on group processes (e.g., participation, consensus building, community dialogue) and the use of public events as ways of reaching and involving community members on a broad scale. These approaches also acknowledge the importance of the local cultural context in shaping response to public health issues. In this regard, they overlap to some extent with the interventions we have characterized as Group-based approaches. By engaging existing civic and social structures at the community level, these approaches attempt to catalyze and facilitate collective action, especially participation, in as many aspects of program design and implementation as possible. They also aim to enhance coordination and mutual support among the levels and sectors of civil society in order to break down power differentials and create new patterns of public health improvement.

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The choice of a community-based intervention approach is often motivated by sustainability goals. An underlying goal of many community-based programs is to enhance and broaden local ownership of health improvement and its subsequent sustainability. Outcomes of community-based interventions usually include some kind of collective action, rather than individual action, although the health benefits of the intervention may be realized at the individual as well as the community level. That is, individual health behaviors may change as result of collective action and community support for behavior change, but the community as a whole may also benefit from collective action that changes overall health conditions or processes. However, with the exception of articles on positive deviance, very few of the community-based studies we identified measured impact of the approach on health behavior outcomes, focusing instead on improvements in broader social conditions (e.g., access to quality services) and social processes (e.g., inclusive program planning or equitable service delivery) that should influence health outcomes. Empirical evidence of the link to health behavior is sometimes missing, but many of these programs succeed in demonstrating that aspects of program quality and accessibility can be improved, at least temporarily. None of the studies reviewed attempted to determine if such changes persisted over time.

Community Engagement (19 articles) Community Engagement refers to any approach that aims to (1) address a challenge or overcome a problem faced by a community as a whole, or (2) whose primary audience is community members as a whole, or (3) whose intervention site is defined geographically as a community. Such interventions typically involve participatory activities, usually in order to create ongoing relationships between community members and health service deliver, or processes such as community dialogue and collective planning that benefit the community in the longer term. Participatory formative research or interactive public events conducted during the planning phase of a program sometimes serve to engage or draw community participants into the process of change. For example, Baptiste et al. (2006) describes a youth-focused HIV/AIDS prevention program in South Africa and Trinidad called CHAMP. The intervention consisted of health education and skill-building activities to strengthen parental monitoring of youth behavior and to improve parent-child communication. In addition, community advisory boards were assembled in both countries to oversee culturally appropriate adaptation. The participatory framework had four core aspects: (a) linking collaborators outside and 16


inside the community to design a program; (b) creating a stakeholder advisory group; (c) designing programs that integrated scholarly and indigenous knowledge and perspectives to shape prevention messages and activities; and (d) using credible messengers. The intervention parents showed significantly greater pre- to post-test gains in knowledge of youth RH issues than the comparison group, increased discussions on sex, and more positive attitudes toward people with AIDS. No differences were found in social network support or parental monitoring. Two malaria interventions used community engagement to develop communitybased and culturally compelling materials for promoting bed net repair (Panter-Bricka, 2006) and health education combined with free distribution of prophylactic therapy for malaria provided by community volunteers (Nsungwa-Sabitia, 2007). Both measured improved preventive behaviors in the targeted audiences. Community engagement is often paired with efforts to strengthen existing health services, train or motivate front line workers or community health workers, increase the availability of health supplies and disseminate educational messages through interpersonal or mass communications channels. Community engagement also may facilitate normative change by involving multiple community segments (primary and secondary audiences) within the community. For example, several studies targeted mothers, as well as other decision-makers in the household, the husbands and mother in laws (Byaruhanga et al., 2010; Syed et al., 2008; Darmstadt et al., 2006). Key Ideas • •

• • •

Community engagement interventions have focused more on RH issues, but have also been successfully used for maternal, neonatal and child health programs. Very few have addressed nutrition. Outcomes of community-based interventions usually include some kind of collective action, rather than individual action, although the health benefits of the intervention may be realized at the individual as well as the community level. The choice of a community-based intervention approach is often motivated by sustainability goals. Local participation in design and implementation helps adapt programs to local needs and creates local ownership. Community approaches allow—perhaps even require—a strong interpersonal communication component.

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Community Mobilization (11 articles) Community mobilization approaches are designed to encourage action or participation on a broad scale (rather than by a relatively limited number of individuals) within a particular community. This approach differs from community engagement in that it has a stronger emphasis on social and structural change, not just behavior change. Actions are typically planned, carried out and evaluated by community members, groups and organizations on a participatory and sustained basis usually with the goal of achieving sustainable change in standards of living. Such interventions tend to be strategically integrated, employing health service providers, community leaders, outreach activities, community events and media in an attempt to cover the entire community while simultaneously engaging the social structures that deliver and support services. For example, female genital cutting (FGC) was the focus of a women’s and girl’s health program in Nigeria (Babalola, 2006) that combined community mobilization activities with media advocacy and mass media programming. Discussions were facilitated with key opinion leaders and women’s groups at the local level, as well as at larger-scale community events. Workshops were designed to increase parent’s understanding of the health threat associated with FGC, to increase their self-efficacy to refuse pressure to perform FGC, and to increase perceived social support for FGC discontinuation. A social systems approach to individual and social change involved the following steps: preparing to mobilize; organizing the community for action; exploring the health issue and setting priorities with the community; then planning, acting, and evaluating together. Discussion points and materials were also developed for newspapers, radio call-in shows and other public forums with the goal of changing social norms. Evaluation was conducted in two states of Nigeria. In one state, ideation factors and intentions to refuse female genital cutting either remained stagnant or worsened. In the second state, improvements were found. However, program exposure in both areas was found to increase intentions to refuse FGC more than five-fold. In an example from the United States, Klausner et al (2005) described the systematic response of the San Francisco Department of Public Health to a syphilis outbreak. Among the coordinated response elements were increased surveillance, testing and treatment programs, provider and community mobilization for sexual health education, improved risk factor identification, increased public health advocacy and collaboration with community organizations and with the business community. 18


Key Ideas • • •

Community mobilization interventions have been examined mostly in the context of reproductive health, primarily for HIV and STD prevention. Community mobilization programs tend to be strategically integrated across levels of social ecology: households, communities, service delivery systems and the political environment. The combination of community mobilization and advocacy can elevate interventions to a level that may be needed for broad social change.

Community Outreach (11 articles) Community Outreach involves the dissemination of information or resources by agents of a particular organization or agency to communities and community members. Many interventions in this category are linked to schools in some way. Compared to Community Mobilization, Community Outreach approaches seem to place somewhat more emphasis on the extension of existing service operations into the community and improved coordination, than on collective mobilization or social change. Outreach often involves interpersonal communication and face-to-face contact and in this sense overlaps with some of the Interpersonal intervention approaches, but it differs in that the target is the whole community rather than individual stakeholders in the community. Outreach efforts may be primarily one-way (dissemination) or two-way (dialogic) in nature. For example, in a multi-component community outreach intervention trial among adolescents in rural Tanzania, Ross et al. (2007) randomized twenty communities to receive standard adolescent RH services or an intervention package aimed at increasing knowledge and skills to delay sexual debut, reduce sexual risk-taking, and increase the appropriate use of sexual health services. The intervention consisted of 12 forty-minute, participatory, teacher-led, peer-assisted, in-school sessions during school hours for primary school students in years 5-7 of their education; training and supervision of 2 to 4 health workers who provided adolescent-friendly sexual and reproductive health services; peerelection of 4-5 adolescents to be trained in the social marketing, promotion and distribution of condoms; and community-wide activities consisting of community events, annual adolescent health weeks in interschool competitions, performances by local adolescent groups, bi-annual adolescent health days, and quarterly video shows to facilitate community-wide discussion. Government workers from existing agencies were trained and supervised to administer this program. 19


Key Ideas • • •

Community outreach studies focused almost exclusively on reproductive health, mostly for HIV prevention but to some extent for adolescent RH. Health outreach activities work best when accompanied by service delivery improvement. Appropriately trained teachers and even students can serve as effective local motivators, particularly if schools and the educational system back them up.

Social Mobilization (9 articles)

Social Mobilization is defined by UNICEF (2011) as a broad effort to engage people's participation in achieving development goals through self-reliant efforts and multilevel dialogue. Like Community Mobilization, Social Mobilization efforts typically look beyond behavior change to social change and attempt to address marginalization and inequity by involving all relevant segments of society: decision-makers and policy makers, opinion leaders, bureaucrats and technocrats, professional groups, religious associations, commerce and industry, communities and individuals. Unlike Community Mobilization interventions, these tend to be implemented across multiple sectors or over a larger geographic area than a physical community (e.g., via online delivery such as social media or through advocacy). Only one article from a developing country described itself as a social mobilization effort. Agarwal (2008) reviewed a social mobilization program in India that aimed to build links between health providers and slum communities for improved health outcomes of mothers and young children. Through an extensive situational analysis and subsequent coordination of identified stakeholders, the program was able to organize community-based organizations (CBOs) in slums and mobilize community action to establish outreach camps and clinical services in hitherto unreached and vulnerable urban areas. Unlike many social mobilization efforts, this one was able to document improvements in exclusive breastfeeding, institutional deliveries and immunizations in the intervention areas. In an example from the United States, King et al (2008) described CDC efforts to scale up and diffuse the Real AIDS Prevention Project (RAPP), an approach featuring street outreach, one-on-one encounters, role model stories, community networks and small group activities to increase risk reduction and condom use behavior among AfricanAmerican and Latina women. Factors in the successful dissemination approach included 20


collaboration between program and research specialists, needs assessment among partner agencies, training of CBOs on the intervention package, national training for health departments and CBOs and ongoing support and technical assistance to programs on the ground. Key Ideas • • •

Social mobilization has been studied mostly in the context of reproductive health. Compared to community mobilization, social mobilization generally involves broader social development goals, including reduced inequity. Social mobilization and advocacy for the marginalized go hand in hand.

Social Movements and Empowerment (12 articles) Social Movements and Empowerment refer to broad, far-reaching political and social change efforts. Unlike other community-based, collective intervention approaches, social movements tend to have a more explicit political agenda, like the empowerment of women or the validation of sex work as valid employment. Such interventions often seek to redress wrongs or correct inequities that, in the present context, are associated with poor health. With a few exceptions, interventions in this category tend to measure structural and process changes rather than behavior change. The majority of interventions that claimed to use a social movements or empowerment approach tended to focus on gender norms, gender relations or on improving women’s ability to communicate their needs more effectively. Few addressed in a concrete way the broad sociopolitical shifts that the term “movement” usually implies. Although they claim to empower women and change gender norms, few studies go beyond improving communication and negotiation skills to address broader structural issues like equity and sustainability. Shrestha (2002) described an intervention in which female community health volunteers and currently married women of reproductive age received empowerment training to enhance contraceptive use. At the conclusion of the six-month intervention, there was a statistically significant increase in modern contraceptive use, from none at the start to 52 percent. Similarly, Rios et al (2007) aimed to increase health service utilization by empowering women, strengthening local organizations, and increasing the demand for health services. Participatory activities were used to empower women in decision-making 21


and capacity building, to strengthen leadership and to ensure program sustainability. Only preliminary analyses were reported, yet, in both quantitative and qualitative evaluations, there was an overall improvement in health knowledge and utilization of health services. In the Indian state of Orissa, Everingham (2002) described the role of Mahila Sanghas (feminist groups) in promoting women’s empowerment. A local educational team created opportunities for community learning through workshops, training about community organization and leadership, cultural teams of artists employing songs, street theater and puppet shows to motivate villager’s action, and development activities that encouraged advocacy and promoted the redefinition of and sensitization about female roles in civil society. Overall empowerment was demonstrated through the growth of women’s leadership in grassroots organizations. Key Ideas • • •

Social movements have been studied mostly in the context of reproductive health, focused somewhat more on RH/FP than on HIV/AIDS, as well as in the context of maternal and child health. Social movements aim for fundamental structural change in power relationships. The broad sociocultural objectives of social movements can make it difficult for programs using this approach to focus on specific health behaviors and health outcomes, so these may be subsumed under other longer term, albeit important goals.

Positive Deviance (9 articles) Positive Deviance (PD) refers to a “strength-based” intervention approach that identifies people who practice uncommon but successful behaviors (positive deviants) and then publicizes the benefits of the practice experienced by the positive deviants and the means by which those benefits were achieved. This approach is community-based in the sense that deviance is defined against a community standard; that is, deviant households and individuals are different from their neighbors and peers in a positive way. The approach succeeds by promoting successful alternatives to current normative practices at the community level. Positive deviance emerged from nutrition research in developing countries but is beginning to appear in the literature on birth outcomes and infant mortality. Often, the PD approach is paired with community and social mobilization activities, since part of the PD 22


approach is to transform deviant behaviors into normative behavior (Marsh et al., 2002; Ahrari et al., 2006). Applying the approach typically requires a preliminary stage of consultation with local health workers, followed by community-based assessments in which households or individuals (children, parents) are identified who successfully maintain health under constrained conditions to an extent that distinguishes them from their peers. In-depth interviews and observations are then used to identify specific behaviors that account for the deviance of those individuals or households from the community health norms. Results of this research are then used to develop recommendations and promotional activities for the rest of the community, usually delivered through communitybased or home-based education sessions, although they could be delivered through mass media, as well. Use of these intensive techniques has been associated (mostly in literature that predates the span of the current landscaping effort) with reported improvements in food choice and food preparation, in child care practices, reductions in female genital cutting, risk reduction among commercial sex workers, breastfeeding, hygiene practices, care during pregnancy, early childhood cognitive stimulation and parenting interactions. Some evidence was reported of mothers applying PD practices they had learned with one child to the care of subsequent children, suggesting some value of PD for sustaining health behavior change. Pachon et al. (2002) identified families of positive deviant children in rural Vietnam and interviewed these families on feeding and care practices to inform the design of a two-week nutrition education intervention to improve children’s food intake, as well as the feeding practices of the parents. At the community level, the intervention measured an increase in consumption of the foods suggested by the positive deviant households. However, process evaluation indicated that program protocol often was not followed consistently. In Egypt, an intervention that was based on the results of PD inquiries mainly focused on facilitating weekly meetings of pregnant women who were identified as at-risk for delivering low birth weight infants. The target women reported eating more food and avoiding second hand smoke, which in turn translated into a significant reduction of low birth weight in the area compared to control areas and the country baseline (Ahrari et al., 2006). A program in Pakistan (Marsh et al., 2002) also used PD research to identify uncommon practices from the community and to plan community mobilization activities to

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disseminate them. In intervention areas, communities formed neighborhood support groups to promote and practice newborn care behaviors. Key Ideas • •

•

•

PD approaches, more than any other community-based approach, have been studied in relation to nutrition, neonatal and child health. Properly used, the positive deviance approach involves more than just research on normative behavior. It requires intensive community engagement to both understand normative repression of healthy practices and mobilize support for normative change. Virtually all intervention studies using the PD approach come from developing countries. In developed countries, the technique is more often used as a research technique to uncover uncommon but healthy practices, however few studies of this kind are translated into practice. In more individualistic cultures, the PD approach may have less utility (Vossenaar et al., 2010).

INTERPERSONAL APPROACHES (245 articles) This was by far the largest intervention approach category. Counseling and variations on it is one of the oldest forms of medical intervention and is inextricably bound up with clinical practice. Many health and medical professionals recognize it as essential to effective practice, even while arguing that biomedical interventions, not information, improve health. Direct client-provider contact is also widely used because it offers the opportunity to personalize interventions and tailor them to the needs of patients/clients. Even interventions that do not involve direct contact with clients often attempt to simulate aspects of a face-to-face encounter. For example, media campaigns often model positive interpersonal communication between a husband and wife or between clients and providers. Interpersonal communication (IPC) interventions typically employ face-to-face interaction between health promoters/educators/communicators/service providers and clients. IPC may occur in one-on-one as well as group settings as long as the group is small enough to allow dyadic interactions between members of the group and the promoter/facilitator. These interactions can occur in a health facility, the home or elsewhere in the community. Although other intervention approaches (e.g., communitybased or group-based) may include some element of interpersonal communication, IPC interventions focus on the advantages of personal contact, namely, the ability to tailor 24


information to a client’s needs and the power of persuasion and social influence in a faceto-face encounter. Counseling is a specialized form of IPC that involves some degree of formal training in the techniques of effective interaction. Frontline service delivery interventions by community health workers, midwives or traditional birth attendants also tend to involve interpersonal or face-to-face communication, but differ from counseling in the extent to which they emphasize the role of the health workers themselves in reaching clients at the end of the service supply chain with quality services, rather than on the interpersonal communication that happens during those contacts. A fairly large number of IPC interventions addressed breastfeeding, a practice that can be difficult to learn and maintain over a period of six months or more with interpersonal coaching and support. Health education and counseling, home visits and peer education approaches seem to be particularly successful in improving knowledge, initiation and duration of exclusive breastfeeding not just because they are able to hand-deliver information, but because of the social support they provide. Interpersonal approaches that combine the use of front line workers and home visiting were also successful for programs designed to improve newborn care. One notable technique used in a number of successful interpersonal interventions is motivational interviewing. Motivational interviewing (Miller, 1983) involves collecting data about a client before an interpersonal intervention occurs, then using that information to zero in on and discuss client gaps in knowledge or risk perception or on barriers to or inconsistencies in behavior that prevent healthier outcomes. This makes the interaction more focused on the specific needs and conditions of the client and more oriented toward problem solving and the achievement of concrete goals. Client-Provider (physician-patient) Interaction (11 articles) Traditionally, Client-Provider Interaction (CPI) referred to efforts by physicians to educate and influence their patients about behavior change and/or acceptance of and compliance with prescribed treatment. In recent years, the concept has expanded to describe a broad range of patient-centered skills on the part of physicians and of health literacy on the part of patients that enhance the process and outcomes of (usually clinicbased) interactions. Client-provider interaction is similar to physician-patient interaction, but applied to a broader range of medical and public health professionals responsible 25


for the delivery of services. Providers include primary care professionals such as doctors, midwives and nurses, as well as secondary care providers such as vaccination teams and outreach workers. Abdel-Tawab & Roter (2002) found that most family planning consultations are physician-centered, with patients passively following a physician’s agenda, but that there are particular interaction skills (e.g., questioning skills, rapport building skills, social talk, expressing concerns, expressing support) that can be learned and used on the part of both providers and clients that make interactions more effective. The way these skills are manifested in interactions may be culturally determined to some extent or influenced by the nature of the issues that need to be discussed. For example, Ceylan et al.’s (2009) study focused on CPI with post-abortion women and found special challenges dealing with the emotional trauma associated with the procedure, as well as with provider preconceptions about the needs of these women, indicating that formative research in the design phase of interventions should assess preferences for interaction style matched to health topics. Fortunately, the approach tested by Abdel-Tawab and Kim et al. (2001), based on Roter’s pioneering work on interaction analysis, has been widely validated. Successful CPI depends on the client-provider relationship, not just on the use or non-use of particular communication techniques. Petersen et al (2009) evaluated the effectiveness of smoking cessation communication by midwives, and found that low quitting self-efficacy of the mothers was partly attributed to feelings of low social support from the midwives. Everett and Steyn (2005) assessed physicians’ attitudes toward smoking cessation among pregnant women in South Africa and found that doctors regarded HIV, poor nutrition, alcohol abuse and psychosocial stress as equal or higher risks to pregnant women than smoking, and tended to underestimate the magnitude of the risk of smoking during pregnancy. Moreover, physicians believed that they were ill equipped with the necessary training, time, and resources to effectively deliver a counseling intervention, and doubted that such an intervention would be convincing to patients. This lack of self-efficacy and skills to counsel women on smoking cessation is clearly a barrier to effective interaction. Key Ideas •

Client-provider interactions have been studied mostly in the context of RH/FP and maternal health. 26


• • •

Didactic educational counseling by providers is less participatory, less engaging and less effective. Rapport building and personalization are the keys to successful CPI. Roter’s pioneering work on interaction analysis has been widely validated and should be used to assess culture-specific or topic-specific preferences for CPI style during the design phase of programs.

Community/Frontline Health Workers/Midwives (34 articles)

Community Health Workers (CHW) are typically paraprofessional members of a community who are chosen by community members or organizations to provide basic health and medical care to their community. They may also be referred to as village health workers, community health aides, community health promoters and lay health advisors. Typically, CHWs are trained to deliver health services and social support, but do not necessarily have formal public health or medical training. The term Frontline Health Worker usually describes non-professional health personnel who carry out front-line curative, protective and promotion tasks within health care delivery systems. Unlike other kinds of frontline workers, midwives are professionally trained to care for childbearing women during pregnancy, labor and birth, and during the postpartum period. They also care for the newborn and assist the mother with breastfeeding. They may also provide primary care to women, well woman care related to reproductive health, annual gynecological exams, family planning and menopausal care. Midwives are often autonomous practitioners, but may refer women to general practitioners or obstetricians when a pregnant woman requires care beyond the midwives' training and experience. Midwives, CHWs and traditional birth attendants may all be front-line workers, through home visits or outreach. At the “front-line”, these individuals go the extra mile to reach the hard-to-reach, and interventions may thereby seek to enhance competence and training of these workers. Any contact with the mother and child (for wellchild care, immunizations or treatment for childhood diseases) can be an opportunity for pre-emptive diagnosis, counseling and treatment. Community health workers are often the providers at the right place and time to provide that service. For example, Hodgins et al. (2010) conducted a pre-post study to determine the feasibility of improved maternal and neonatal care seeking and household practices. Local female community health volunteers (FCHVs) who were respected members of the community conducted antenatal counseling and early postnatal home visits. The 27


intervention included an antenatal health education package for birth preparedness/complication readiness, self-care in pregnancy, essential newborn care and micronutrient supplementation. The FCHVs also engaged other family members, especially husbands and mothers-in-laws. Over the course of the intervention, service utilization and neonatal care indicators improved. A community-based behavior change program aimed at reducing neonatal mortality in India (Kumar et al., 2008) used community health workers to deliver essential newborn care packages including birth preparedness, clean delivery and cord care, thermal care, and information on breastfeeding and danger sign recognition. The intervention arm not only showed improvements in birth preparedness and good practices for newborn delivery and care, it also reduced neonatal mortality by more than half compared to the control arm. In the United States, Roman et al. (2007) found the nurse/CHW teams were more successful at reaching women with prenatal mental health risks than a state Medicaid prenatal health program delivered by visiting nurses. The combination of medical mental health expertise with paraprofessional social support expertise in a singe team accounted for this success. Midwives can play a key role in many aspects of maternity care. They function as an intermediary between medical professionals and pregnant women, help interpret prenatal results and client records and help reduce anxiety about dealing with medical procedures during prenatal, labor and postpartum phases. Midwives with training in patient communication and theories of behavior change do this more effectively. Beyond perinatal health, evidence of midwife success on other health issues produced mixed results. Tobacco cessation and nutrition interventions had generally positive results, but breastfeeding interventions less so. Overcoming persistent cultural biases and disinterest in breastfeeding

requires more than just information delivery and awareness building. Midwives can play an instrumental role in breastfeeding, but only if they themselves are culturally attuned, are able to provide social support and mobilize the support of a woman’s family and peers. In the area of postnatal care, Ellberg et al. (2010) found that fathers are sometime treated with condescension as outsiders and left out of decision-making by midwives who are overly focused on the mother alone during the immediate postpartum period, underscoring the need for midwives to work with both members of the couple.

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Key Ideas • • • •

Community/frontline health worker interventions have mostly been applied to maternal and neonatal health issues, including breastfeeding. The effectiveness of frontline health workers is enhanced if they are provided with and trained in packages of services (e.g., essential birth kits, newborn care kits). Frontline health workers should be skilled communicators. A perennial challenge in work with community health workers is the need for constant training and re-training. New health workers come on line as former workers retire or transfer to other areas, so systems are needed to make this process as seamless and efficient as possible

Counseling (112 articles) Counseling is a popular intervention approach that has been used across a wide range of family health topics, including diet and nutrition (particularly in developed countries), HIV prevention and risk reduction, smoking cessation (mostly during the prenatal period), breastfeeding, contraception and RH and mental health. It is popular for a number of reasons. First, it can take place in clinical settings, and thus can enhance the degree of control that health and medical professionals have in their interactions with clients and patients, who are often perceived to be resistant to behavior change suggestions. Second, almost by definition, counseling involves personal contact and an opportunity to understand and influence the unique individual factors that affect health outcomes of particular clients to an extent that less personal approaches do not. But the personal attention that counseling allows also requires a greater investment of time in each patient, something not all providers and patients are willing or able to make. Not all providers have the interpersonal skills or understanding of psychosocial processes that make counseling successful. Thus, much of the research on counseling focuses on improving the efficiency of counseling interactions by identifying essential provider skills, zeroing in on essential psychosocial factors that affect client decision-making, and packaging these in ways that can be implemented in the most time-efficient and effective form. There are many variations on counseling practices ranging from single brief, ad hoc or standardized, one-on-one encounters to multiple, intensive, individualized sessions, to group counseling sessions that can generate ongoing social support. The most effective applications of counseling strive to make the interaction personal and tailor it to the needs of the specific client. The number of counseling sessions needed to achieve health 29


improvement objectives varies, depending on the complexity of the behavior, and whether addiction or extreme social pressure are involved. Counselors who understand psychosocial theory and can draw on it to guide their interactions with clients tend to be more successful. In the area of reproductive health, counseling can decrease discontinuation rates if users are educated about what to expect in terms of side effects. Prevalent local norms and preferences are also crucial social determinants of contraceptive use. The personal attention that can accompany counseling helps bring those factors into focus so they can be addressed. Yet a single, simple counseling session may not suffice (Campo De Cetina et al., 2001; Ortayli et al., 2001). Instead, women need ongoing help using family planning methods and dealing with side effects. Counseling was a common intervention approach in the area of neonatal breastfeeding, although this was often combined with other community-based, facilitybased or social support approaches. For example, Yanikkerem et al, 2009) found a significant increase in mother’s knowledge about breastfeeding and infant nutrition after a one-hour postpartum education session carried out in the clinic several hours after delivery. In the Philippines, a counseling intervention trained peer counselors to visit mothers who had breastfeeding problems or suboptimal feeding practices (Salud et al, 2009) and successfully converted 70% of mothers using formula-feeding or mixed-feeding to exclusive breastfeeding. Dealing with the complicated issues around HIV and PMTCT may call for the use of counseling. Holmes (2001) analyzed PMTCT policies in the Asia-Pacific region and found limited attention to counseling on such topics as infant feeding or Caesarian delivery and the effects they have on HIV transmission rates. Programs that emphasize testing over other interventions tend to miss women who become infected late in pregnancy or after initiation of breastfeeding, indicating a need for counseling earlier in the prenatal period, including counseling that reaches spouses and other family members. Similarly, in IMCI (integrated management of childhood illness) programs, it can be difficult to explain to mothers the complex inter-relationships between multiple child health issues, a challenge that counseling may help overcome through personalization of information. IMCI communication strategies often use a combination of pictorials (such as photonovelas), flip charts, and pocket-sized cue cards or reminder cards that encourage and facilitate client-provider interaction about these complex, integrated issues, although 30


even this is not an automatic guarantee of success. For example, in Benin clinicians trained in IMCI counseling achieved only short-term improvements in caregiver knowledge of health messages (Kelly, 2007), while in India the intervention did not show any change in care-seeking behavior by caregivers over time (Mohan, 2004). But the skills of providers to deliver IMCI counseling can atrophy if not reinforced: initial improvements in counseling among doctors trained in IMCI in the India study largely disappeared six months after training. These findings suggest the need for more continuous training for clinicians and further longitudinal study of IMCI counseling efficacy. The face-to-face nature of most counseling approaches presents opportunities for personalizing information to the needs of specific clients, but the success of personalization is not a foregone conclusion. Counselors need client-specific information in order to tailor information and advice properly. A number of techniques and tools have been developed to facilitate this process including computer-assisted or paper and pencil tests administered and the use of directed questioning and elicitation before a counseling session begins. Garfinkel and Blumenthal (2001) argue for the adaptation of “co-active coaching”, a technique derived from executive management training, for use in counseling HIV patients. This approach is built around goal-setting counseling through which clients envision desirable future conditions and identify strategies for reaching them. Another approach that is more widely used in health care is motivational interviewing, a technique that combines the use of risk or harm diagnosis tools with counseling that builds on the results of the diagnosis. Callahan et al. (2007) described its use in one large urban HIV clinic and two small rural primary health care clinics in California. Clinicians administer a standardized risk diagnostic questionnaire to clients that generate a personalized risk behavior profile for each client. The clinician then reviews the diagnosis and uses the results, as well as the Stages of Change theoretical framework, to guide the counseling session toward identification of ways to reduce risk. The article described an ongoing randomized study to test the effectiveness of this approach, but did not provide impact data. Group counseling also seems to confer benefits. Lapinski et al. (2009) reported increased partner communication, increased status disclosure with one’s partner and decreased sex while consuming alcohol among HIV positive MSMs who received a combination of individualized and group counseling compared to those receiving 31


individual counseling only. Bertens et al. (2009) found increased awareness of risk behaviors, increased intention to negotiate safe sex and increased communication with partners about safe sex among immigrant women in the Netherlands who had received interactive, multiple small group counseling sessions. Finally, Kotz et al. (2009) used a technique they refer to as “confrontation counseling” in smoking cessation programs for pregnant women. The confrontational aspect of the counseling involved the use of spirometry to measure breathing function among smoking medical patients with newly diagnosed airflow limitations, then to confront the patients with their test data and use it as an opportunity to discuss risk perceptions, self-efficacy and risk denial. Compared to a control group, the intervention group had higher levels of COPD risk perception, higher levels of quitting self-efficacy and lower risk denial. No actual quitting data were reported. Key Ideas • • • • •

Counseling interventions have been widely and successfully used across all areas of the RMNCHN spectrum. In developing countries the use of counseling has been particularly common in RH and nutrition interventions. Barriers to behavior change often include a gap between local explanatory models of wellness and biomedical models, pointing to a need for locally tailored information that builds on existing local wisdom and practices. Motivational interviewing is a promising technique that can enhance counseling effectiveness. Hospital or clinic-based counseling interventions can be powerful because they reach women at critical moments in service delivery. Extending counseling into the community through home visits can help build neonatal and child care skills and solve postpartum problems where they occur.

Home Visits/Household Outreach (32 articles) The primary tactic of household outreach—home visits—bring services, information and counseling directly to the home via a health professional of some kind. Home visitors may include physicians, nurses, midwives, paraprofessionals, traditional providers, cadres, trained peer-educators, other health workers and volunteers. Home visits and household outreach are most often provided by community health workers or front line workers trained by an agency or organization to reach audience segments or families that otherwise would have limited access to services. Besides “going the extra mile” to reach the hard-to-reach, home visiting—like counseling and other

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interpersonal communication strategies—can help personalize and reinforce information and interactions in ways that make them more compelling and impactful. Studies describing household outreach/home visiting as a strategy were concentrated in the areas of reproductive health and STI prevention. One reason for this may be the need to involve sexual partners and family members in reproductive health decision-making. Norms and gender inequity often pose obstacles to women’s effective prevention or attaining of proper care; therefore the inclusion of male partners or household members (e.g. mothers-in-law) in interventions can be a crucial element in fostering attitude and behavior change. Another common element in household outreach is the involvement of parents to reinforce or support youth education for sexual and reproductive health. Overall, while studies largely recognize the need for household support, particularly from male partners, to improve maternal outcomes concerning reproductive or sexual health, interventions targeting men remain few in number. Similarly, the benefits of parental involvement in adolescent reproductive health would seem to be critical, but we found limited recent attention to this issue. One illustration of this is a Syrian neonatal and maternal health intervention that trained registered midwives to conduct home visits where they provided health education and social support for post-partum women (Bashour, 2008). A significantly higher proportion of mothers reported exclusive breastfeeding in the intervention arm (30%) than in the control arm (20%). The study determined that midwives made an impact with just one visit to the household and that more visits did not generate a higher adherence rate. In contrast, Wen et al. (2009) provided five home visits by community-based early childhood nurses to 56 first-time Australian mothers during the first year of their child’s life, during which they delivered stage-appropriate one-to-one consultation on sustained breastfeeding, introduction of solids, avoiding food rewards, drinking water and using a cup. Compared to state averages, children of intervention mothers were breastfed longer, were less likely to receive solid foods before 4 months and were more likely to use a drinking cup. More visits do not necessarily mean more impact. Scheiwe et al. (2010) found improved maternal knowledge of nutrition among low-income mothers, but limited effects on changes in child diet or dental health as a result of monthly home visits over a fouryear period by trained volunteers. Also using an RCT design, Watt et al. (2009) found no effect of monthly home visits during the first year of life on nutrient intake, but did find 33


lower use of breast milk substitutes and bottle feeding and increased consumption of fruit and vegetables. Key Ideas • •

• •

Applications of home visiting and outreach have been studied more extensively in the areas of maternal and neonatal health and to a lesser extent in RH and nutrition. Evidence indicates that home visiting per se is not a panacea. Programs that provided repeated, intensive home contact over time by health care providers with specialized training in the health issue of interest tended to be more successful, but not universally so. Home visiting seems to work best when health workers are themselves from the community because they are better equipped than outsiders to address local social/cultural issues. Household outreach is often needed in RH/STI work because sexual partners and household members alike share decision-making responsibility.

Peer education (58 articles) Peer education is an approach in which community peers, drawn from a population targeted for the education, provide guidance and support for behavior change. Because of their socio-cultural similarity to a program’s intended audience, peers are thought to be empathetic and credible and better able to draw on local knowledge, to tailor information to audience needs, to build rapport, to interact more effectively, and to serve as role models for behavior change. Two examples illustrate the benefits and challenges of using this approach. Ajuwon & Brieger (2007) assessed the relative efficacy of a teacher instruction group, a peer education group and a combination of the two on adolescent reproductive health knowledge, attitudes, perceived self-efficacy and sexual behaviors among a group of secondary school students in Southwestern Nigeria. Students were randomly assigned to one of the three intervention arms. Students receiving peer education had higher knowledge of reproductive health and attitudes toward contraception, but this did not necessarily translate into behavior. The intervention, did however, facilitate more open discussion in the school environment among students and teachers, a typically taboo subject within this developing country. A second study focusing on the West African Youth Initiative (WAYI) in Nigeria and Ghana by Brieger et al. (2001), found improved knowledge, attitudinal and

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behavior change related to reproductive health among school-aged adolescents as a result of peer education. Not only were adolescents in the intervention arm more knowledgeable about reproductive health, they reported greater use of contraceptives in the previous 3 months, higher willingness to buy contraceptives and higher self-efficacy in using the contraceptives. A notable aspect of WAYI was its flexibility and multi-channel approach. Different project sites were allowed to develop their intervention with a mix of educational strategies, but all based on the foundation of peer educators. Also, the peer educators were allowed to use different strategies for reaching members of the target audience depending on local conditions, such as one-on-one sessions, group talk sessions, distribution of educational materials and community drama performances. This study did identify some limitations to using a peer education approach. Adolescents that receive training to become a peer educator may not be able to stay in that role for an extended period of time. Peer educators eventually “age out” of the target audience, so in order for the program to be sustainable, peer educators must be constantly recruited and trained. Another health area in which peer education may be useful is neonatal health and breastfeeding. In general, studies showed that the use of peer counselors was an effective way to promote breastfeeding initiation and duration, and tended to be more effective than standard doctor care. However, randomized control trials produced mixed results. Dennis (2002) found no change in breastfeeding initiation associated with peer education, but the mothers and volunteers perceived the intervention experience positively. Scheiwe et al (2010) found no effect of breastfeeding peer education on children’s BMI after four years, while Hoddinott et al (2007) found that peer education was more effective where peers and midwives worked together. Three randomized control trial intervention articles did find behavior change, with women in the intervention groups having more initiation and effectively maintaining breast feeding (Dennis et al., 2002; Merewood et al., 2007; Pugh et al., 2002). Pugh et al. also found that infants in the intervention group had fewer sick visits and reported use of fewer medications, which was estimated to off-set the costs of the intervention by $301 per mother.

Key Ideas •

Peer education has been used and studied most extensively in the areas of reproductive and neonatal health (primarily breastfeeding). The approach is more common in developed than in developing countries.

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• • • •

Peer education is flexible and can be delivered in a variety of settings, including schools, communities and the workplace. Peer educators are members of the intended audience and are able to “speak in the language” the target understands. Some topics may be handled well by older peer educators who are more experienced, knowledgeable, and trustworthy than peers of the target audience. Sustainability of peer education approaches is an issue. Age cohorts change and peer educators must be continuously recruited and trained.

GROUP-BASED APPROACHES (132 articles) Group-based interventions emphasize and take advantage of social structural factors that influence behavioral choices. Such factors include the network structure of a social group (and an individual’s position or role within that network) and the nature of the interpersonal relationships (e.g., supportive, contentious, formal or informal) in a network. Other factors are the extent to which social and material resources (social capital) are available and equitably distributed. In this category we also include interventions that focus on normative pressures (both positive and negative) that influence attitudes and behavioral choices among members of the group. Normative change efforts take advantage of the social dynamics of groups to reinforce positive norms or undercut negative norms. Social capital/social support (50 articles) Social capital refers to relationships within and between social networks and to the social cohesion and personal investment in the community that individuals can draw on to satisfy a variety of personal and social needs. It has been a popular and heavily researched concept since the early 1900s, especially since Robert Putnam’s widely read 2000 book, Bowling Alone. Many overlapping definitions of the term are available, but most are based on the notion that social networks have value. Besides providing a coping resource for individuals, social capital enhances cooperation and confidence in collective action. Social capital typically refers to a relatively durable, self-sustaining ecological pattern of psychosocial support (sometimes called cognitive social capital) and access to social-structural resources (sometimes called structural social capital). Both can be 36


individual in nature (having people you trust and can turn to in need) or institutional in nature (having access to social networks and organizations that provide support and resources). For example, Payet et al. (2005) described the presence of a thriving farmer’s market in a community as a form of social capital that creates a healthy social space where people can interact and that encourages social and civic participation in ensuring a supply of healthy food. Few if any of the articles we reviewed described a truly systemic or durable type of social capital, although most saw their efforts to create or increase social support and access to resources as a way of building social capital and strengthening the social fabric over the longer term. Social capital is a multidimensional concept with many of its own determinants. For this reason, interventions that aim to improve social capital as a route to behavior change must address multiple aspects of social structure and social resources, many of which are difficult to change in the short term. Quite a few of the studies that claim to take a social capital approach actually tackle only a subset of the underlying factors. Two of the more comprehensive interventions illustrate this approach. Agarwal et al. (2008) focused on weak linkages between health providers and slum communities in Madhya Pradesh, India. Two SBC approaches were used: (a) a demand-supply approach to build social capital that encouraged collective action in order to strengthen norms and networks around health service utilization by the urban poor; and (b) a ward coordination approach that focused on encouraging local stakeholders like CBOs (community-based organizations) to improve health services by coordinating with each other to negotiate better health service coverage in underserved slum areas. Findings suggested a substantial increase in institutional deliveries, exclusive breastfeeding and immunization rates for both pregnant women and children through the implementation of the demandsupply/linkage approach. Valadez et al., 2005, focused on social networks and fostering social capital in Nicaragua through 3 strategies—strengthening physical capital, human capital, and social capital—in order to improve community level safe motherhood and child survival. The program involved (a) Investment in physical capital such as building community health huts, equipping health workers with scales for use in growth monitoring, and supporting traditional birth attendants with clean birth kits; (b) investment in human capital such as training paramedical personnel to give health education talks to women during pregnancy and after birth, and/or carrying out house visits and/or community visits and (c) investment 37


in social capital such as forming mothers’ clubs, women’s groups, adolescent groups, men’s groups, and/or community health committees. The evaluation found that physical capital (density of health huts), human capital (density and variety of paramedical personnel) and social capital (density of health committees) were associated with pregnant women attending antenatal care (ANC) 3+ times, and/or retaining ANC cards. Organizational learning on the part of community groups was related to changes in maternal and child health behaviors of the women (including changes in the proportion using post-partum care), but not an increase in delivery of babies by a clinician. In developed countries, interventions of this type focused more on human and social capital, in particular social support, than on physical capital and structural change. Schools and faith-based communities may be good places to develop social capital and social support. For example, Sirikulchayanonta et al. (2010) assigned some schools to receive a combination of 11 activities including games, gardening, art, the use of cartoons, education about plants and their health benefits, and instruction in the cleaning and cooking of fruits and vegetables. Besides providing group activities with other students, the program was designed to mobilize social support from teachers and parents, as well. After eight weeks, children from the treatment schools had higher levels of fruit and vegetable consumption and were eating a greater variety of foods. Another fruit and vegetable intervention aimed at schools and the home environment consisted of 12 twohour after-school sessions over 12 weeks, including instruction on media literacy (teaching children how to understand food-related advertising), role playing talking to parents about food choices, and designing a “media campaign” to convince parents to change household eating patterns. At the end of 12 weeks, parents reported an increase in fruit and vegetable availability in the home and increased parental support to children for healthy eating. Children reported increased motivation to consume fruit and vegetables. Working with churches, Anderson et al. (2010) tested an intervention consisting of 12 web-based instruction modules, each taking 5-10 minutes to complete, that church members could access on their own. Eight of the sessions focused on social support for dietary change, self-efficacy and self-regulation, outcome expectations related to dietary change and the benefits of taking walks with someone and of families eating together. Four additional modules emphasized self-regulation and diet maintenance. In addition, the church provided support for a period of 16 weeks with pulpit reminders, bulletin notices, posters, newsletters and a church wide “step drive” aimed at increasing the collective 38


amount of physical activity. At the end of 16 weeks, the study measured an increase in self-efficacy, self-regulation and level of social support and found that changes in those factors mediated a positive effect on both fruit and vegetable intake and exercise. Key Ideas • • • •

Social capital/social support interventions have been used most commonly to address reproductive health and nutrition. Social capital is a powerful concept that should facilitate and sustain a wide variety of health behaviors and health outcomes, but it requires long term effort to change. Not all social capital is protective or promotes good health; sometimes it reinforces unhealthy behavior. There is some justification, but limited empirical data, that social support can facilitate difficult behavior changes, especially those that require consistent behavior over time in order to realize health benefits.

Social networks (33 articles) A social network is a structured pattern of interpersonal relationships connected by communication ties and shared interests. Social networks operate on multiple levels, from families and peer groups to global virtual networks, such as Facebook groups. Members of a social network tend to be more homogeneous and to communicate more often with each other than with individuals outside the network, making networks a powerful way to reach people and to bring social pressure to bear on behavioral decisions. Communication ties within a network range from close face-to-face interactions to interactions over a great distance using various electronic and newer social media. The relationships between individuals and the people around them are important determinants of behavior. For example, Boulay & Valente (2005) used survey data from a program evaluation to examine how individuals construct their own social networks, which, in turn, can determine the extent of the network’s influence. This study focused on women (ages 15-49) in the Mid-Western Region of Nepal and the criteria they used to select family planning discussion partners, as well as individual-level factors that increase the likelihood that a contraceptive user will be added to such a discussion network. Not surprisingly, women prefer to have other women belonging to the same ethnic group in their network, but were also likely to base network selections on contraceptive use and attitudes toward family planning. They concluded that women might add contraceptive users to their discussion network as a means of confirming their own existing beliefs and 39


practices and suggest that program research should examine the dynamics of social network formation and how this might affect the behavioral influence of peer discussion networks. Social networks can play a positive role in promoting physical activity, weight loss and nutrition. A qualitative study in Australia interviewed obese individuals about their attempts to lose weight and opinions of what would be most helpful for them in their weight loss struggles (Thomas et al., 2008). Family and friends were the most common source from which individuals learn about weight loss techniques. Individuals also felt more accepted and supported if they had participated in intervention programs with another member from their social networks. Networks can be problematic, too. For example, Lavender et al. (2006) studied breastfeeding barriers and influences of social networks, not only from the woman’s perspective, but also from the views of their family and found that there were often discrepancies regarding support. Women expected family members to be the main source of support by being present and offering encouragement. Family and friends on the other hand felt that the best support they could provide was by leaving the woman alone while she was breastfeeding. Family members were also a bit embarrassed about breastfeeding even though the women themselves had not expressed embarrassment. Thus, interventions should encourage active communication within close family networks to help women express their individual requirements. Key Ideas • • •

Most of the evidence for the use of social network approaches comes from work on reproductive health and the vast majority of studies are based in developed countries. Social network approaches may be particularly useful for reaching members of marginalized groups, if an entry point to the network can be found. Behaviors change as the social network contacts changed. By introducing new sets of network contacts and increasing the number of pro-social individuals in a network it is possible to create social and environmental influences that foster behavior change.

Social norms/stigma/normative change (49 articles) Social norms interventions refer to initiatives that attempt to shift perceptions of the attitudes and behaviors that are commonly approved and practiced, or to shift the actual prevalence of typical behaviors. The social nature of social norms means that normative 40


change interventions are almost always group-based, either through the use of communityoriented strategies or the use of media to shift public perceptions on a large scale about which behaviors are perceived to be common or publicly supported. Local social boundaries play an important role in social networks and their influence on the creation of new social norms. According to bounded normative influence (Kincaid, 2004), if a minority individual can maintain a majority status within his/her own, locally bounded segment of a larger social network, then this person can maintain their attitudes and behaviors, recruit converts in the surrounding areas of the network, and establish their behavior as a new norm for the entire social network. To accelerate this process, the minority subgroup can centrally locate itself in the social network as well as engage in more frequent and persuasive communication relative to the majority. Most social systems have some level of diversity in beliefs and norms, so programs should look for the opportunities to reinforce positive norms and counter negative ones. For example, Darmstadt et al. (2006) conducted a systematic review of the Saving Newborn Lives Initiative on antenatal, intrapartum, and postpartum care practices for mothers and newborns in Bangladesh communities and homes. Findings revealed that nutritional restrictions are often placed on pregnant women by their local culture. Most women lack decision-making power within the family and so are helpless to counter these pressures. Attitudes that stigmatize persons with particular health or other characteristics (e.g., being HIV positive, teen pregnancy, depression, TB) may also be normative. Social norms interventions attempt to shift such perceptions to reduce the negative consequences of attitudes that discriminate and make it difficult for those stigmatized to seek and obtain care. For example, Qiu et al. (2009) conducted a longitudinal cohort study among 1520 mothers in rural areas of China, in which four interviews were conducted over a 6-month period to determine important factors that enable the initiation of breastfeeding. The most important factors concerned stigma and social norms surrounding breastfeeding, and suggested that favorable paternal attitudes was the biggest predictor of breastfeeding initiation. In order to bring about normative change, it was suggested that health professionals target women and men prior to conception in order to give prospective parents enough opportunity to change their social norms around infant feeding practices. From developed countries, Barker et al. (2010) reviewed 58 reproductive health interventions with men and adolescent males in which normative perceptions related to 41


father’s involvement, gender-based violence, maternal, newborn and child health and gender socialization were the focus. The majority of the interventions were either pilots or short term studies, but there was evidence that these interventions produced positive behavior and attitude changes relevant to sexual and reproductive health; maternal, newborn and child health; interactions with children, violence against women and healthseeking behavior, suggesting that changing gender norms and promoting genderequitable relationships among men and women can contribute to a broad range of behavior changes. Key Ideas • • • • •

Much of the evidence for the use of social normative intervention strategies comes from studies of reproductive health and nutrition in developed countries and from work on neonatal and maternal health in developing countries. Generally speaking, interventions focused on changing social norms or reducing stigma produced positive effects on attitudes and perceptions, but these changes were not always linked to changes in health outcomes. School-based interventions can take advantage of group influences on students, the role of schools as a socializing force, and involvement of parents in their children’s health and wellbeing. When new practices align with traditional beliefs and values, messaging should highlight those associations. A change in norms related to gender equity can have repercussions on a wide range of behaviors and on the sustainability of change.

BEHAVIORAL ECONOMICS APPROACHES (32 articles) Behavioral economics (BE) draws on social, cognitive and emotional factors to explain behavioral decisions that appear to be governed by economic considerations or the way behavioral options are assigned value, but which may or may not conform to rational economic choice. Financial incentive refers to monetized inputs, subsidies or vouchers that motivate action or provide a reason for preferring one option to others. Microfinance initiatives provide financial services to low-income clients or lending groups who traditionally lack access to banking and sources of credit. Having access to more capital can relieve economic stress that limits family options and may allow investment in beneficial health products or practices. We found only 32 articles that referred to some aspect of economic influences on health behavior, most often cost as a barrier to accessing services, healthy foods or health 42


care products. Of those 32, only 12 described the evaluation of an intervention and of those, 4 merely provided free or subsidized food or exercise classes, one paid participants for completing a training course, and two provided vouchers to reward behavior. This class of intervention approaches employs a variety of channels or delivery modes from mass media to community-based to interpersonal, but are distinct in their focus on economic factors in decision-making, under the assumption that people attach value to behaviors and associate choices with gain or loss. Gain or loss can be literally financial, as in receiving a subsidy or voucher for service utilization, or subjective as in a gain or loss of status or self-esteem. As a relatively new approach to social and behavior change, there are fewer evaluations of BE effectiveness. Many of the studies we found on this approach were exploratory in nature, but they covered a diverse range of topics including drug prescription compliance, postpartum mental health (after a pregnancy loss), patient retention in experimental studies, HIV risk reduction or prevention, breastfeeding and complementary feeding, adolescent women’s use of RH services, family food choices and food preparation, unintended pregnancy prevention, dietary choices for cardiovascular health, and malaria prevention. These studies all identified cost or lack of financial support as barriers to behavior change or highlighted the need for counselors and other health care providers to explore and deal with cost-related or financial issues when working with clients. Economic interventions bearing implications for health have risen in low and middle-income countries over the past 10-15 years, and financial incentive programs such as conditional cash transfers for food choice and weight loss are also increasing in developed countries. These interventions, however, mostly achieved short-term effectiveness, that is, during availability of financial incentives. Nevertheless, our review indicates that financial incentive programs are encouraging and are potentially useful in a number of health areas, including maternal and neonatal health. Bond et al (2009) reviewed three weight management programs for parents and children under 5 years of age that included pre-school or home-based parental skills education and physical activity programs for Black, Latino and Native Americans. Of the three studies, the one in which African-American parents were paid for completing learning exercises and homework was the only one that resulted in slower rates of BMI increase over a two year period. 43


But sustainability is a critical issue. Owen et al. (2010) reported on a successful application of the Stanford Model of Chronic Disease Self-Management, which involved a complex year-long intervention consisting of 16 weeks of hour-long sessions on nutrition, cooking, shopping, diet and exercise management delivered in different combinations and modalities chosen by the participants themselves using the “Stated Preference Method”. After 16 weeks, one of the trial groups received additional group support sessions to help them maintain their preferred program. Results showed that weight loss occurred in groups that had chosen programs with subsidized food choices and exercise classes. However, this group expressed the strongest negative reactions when the subsidized programs stopped, with fewer complaints from participants who had lost more weight. Addressing immediate financial needs can sometimes create economic stability and allow sustained contact with health promotion programs. For example, Pronyk et al. (2008) conducted a 2-year, two component cluster RCT consisting of group-based microfinance, in which groups of women received small business loans and could access additional funding when everyone in the group had repaid their original loans. Additional intervention components included gender and HIV risk reduction training. Intervention groups had higher levels of HIV-related communication, were more likely to have accessed VCT, and less likely to have had unprotected sex at last intercourse with a nonspousal partner. While these examples are promising, care must be taken to ensure equal access to financial incentives. Lim et al. (2010) evaluated India's Janani Suraksha Yojanaj, a largescale conditional cash transfer program that paid community-level health workers and pregnant women to access facility-based delivery services. But uptake of this offer was highly variable with from 5% to 44% of village women taking advantage of the payments. Although the program produced improvements in antenatal care and in-facility births and in perinatal and neonatal deaths, the poorest and least educated women were least likely to receive payments. Key Ideas • •

The majority of evidence supporting the use of behavioral economics approaches comes from work on nutrition, maternal and reproductive health. Providing subsidies, vouchers and cash payments can motivate change in behavior, but sustaining that change may be dependent on the continuation of the subsidy. 44


• •

More attention may be needed to identify non-financial incentives, particularly for use in programs for children. Microfinance initiatives fare better when parallel services such as skills training, technological support, education and health education are offered simultaneously.

MEDIA & SOCIAL MARKETING APPROACHES (134 articles) These terms refer to the use of a broad range of media technologies from large (e.g., national television) to small (e.g., community radio), including one-to-one technologies (e.g., texting) and one-to-many technologies (e.g., television, Facebook). Media are often used in an integrated way, with multiple delivery mechanisms deployed simultaneously to carry complementary and mutually reinforcing content. Media and social marketing approaches are somewhat less common in the areas of neonatal and child health, but when used, they are able to reach large and geographically dispersed target audiences, something most interpersonal and group-based approaches cannot do. Intervention approaches in this category include Advocacy, Mass Media, Social Marketing, Strategic Communication and the use of Social Media. Social and behavioral drivers must be addressed on a population level and not merely at the clinical or household level if an intervention seeks to achieve society-wide change. Mass media and strategic communication approaches have the ability to reach millions of people quickly with high quality information. However, this ability to reach millions creates another challenge that community-based, interpersonal and group-based approaches address more naturally: personalization of information. Audience segmentation and “micro casting” (using specific channels matched carefully to intended audience sub-groups) offer potential solutions. Some newer mobile technologies and social media that give users more control over content also help achieve personalization. Strategic communication explicitly creates opportunities to blend media, community-based and interpersonal components into integrated packages that can reach all audiences with precisely the right information and services. Advocacy (17 articles) Advocacy in a public health context refers to a broad set of activities, including efforts of individuals or groups to influence public policy and resource allocation within a 45


political, economic or social system. Top-down advocacy can be designed to influence community leaders, organizations and health care systems to support health programs or health improvement goals. From the other direction, bottom-up advocacy by community activists or health professionals can be designed to influence or build partnerships with media to support health programs and influence the public health agenda. At a personal level, satisfied adopters of a new health behavior can be encouraged to advocate similar behavior change to friends and neighbors. Advocacy interventions often overlap with community mobilization approaches and involve the engagement of civil organizations and leaders, but they are often mounted in conjunction with national media-based campaigns as a way to generate public discussion or about policy or normative change and help to create an enabling environment that facilitates health improvement. Advocacy efforts are most often indicated when barriers to social and behavior change exist at the structural, policy or organizational level. As a result, they generally require a longer term vision rather than a focus on relatively shortterm changes in knowledge, attitudes or behavior. Perhaps for this reason, we found no studies that made an explicit link between advocacy and behavior change. Most publications on this topic were historical reviews or prospective advocacy papers themselves. For example, Chandeying et al. (2005) described the Thai government’s health system reform in 2000, leading to strategies and actions to address sexual and reproductive health problems. The Thai government approach drew on three aspects of health reform theory: political involvement, creation of relevant knowledge and social movement or social learning. Components of the program included a “100% condom” program, prevention programs and media campaigns for at-risk group, a comprehensive STI case management system for vulnerable populations, re-training of professionals in sexual and reproductive health, enhanced screening for asymptomatic cases and the incorporation of sex education into primary school curriculums. The program required advocacy efforts with each of the involved agencies and institutions and with the private sector to enlist their support and commitment to the effort. One study that did describe an intervention was an evaluation of the African Youth Alliance (AYA) adolescent sexual and reproductive health program in Uganda (Mehryar et al, 2009). AYA used a combination of behavior change communication to teach adolescent life skills, advocacy for adolescent-friendly clinical services, and institutional 46


capacity building at the national and local levels. The program claimed an increase in the use of condoms and other contraceptives and a reduction in the number of reported sexual partners among adolescent females. In the area of breastfeeding advocacy, Bhandari et al. (2008) described the development of evidence-based policies, implementation strategies and legal frameworks to support exclusive breastfeeding. They claimed to improve coordination among researchers, clinicians and program managers through the development of tools for research dissemination, the design of interactive data utilization workshops and the formation of coordinating committees to integrate breastfeeding program efforts. Key Ideas • • •

Most of the evidence for use of this approach comes from work on reproductive health in developing countries and from work on neonatal, child health (youth) and nutrition in developed countries. Advocacy can be important for creating a supportive policy, regulatory and funding environment that makes other types of interventions possible. Advocacy requires longer term thinking and is less geared toward direct behavior changes compared to other intervention approaches.

Mass media (39 articles) This intervention category refers to the use of a diverse set of technologies including the Internet, television, newspapers, film and radio, that are capable of simultaneously—almost instantaneously—reaching audiences on a large scale, often over considerable distance. Such media may or may not have interactive capabilities. Mass media are often used to deliver entertainment-education programs, i.e., programs or materials that provide educational, motivational or persuasive information delivered through an entertaining format, such as a radio health drama or health messages inserted into the storyline of a popular television program. Programs using mass media rarely rely on a single medium to achieve their objectives. Typical media programs are theory-based and disseminate messages through multiple channels to trigger specific sequential determinants of behavior. They often intentionally try to catalyze interpersonal discussion in order to extend and reinforce the impact of media messages through social networks. The use of broadcast media for behavior change is a complicated by the varieties of broadcasting systems that operate nationally, regionally and globally. In developed countries, media are usually owned and 47


operated by commercial entities, creating barriers to access by health promoters. Centralized, national broadcasting systems still exist in some developing countries, but these are steadily giving way to diversified broadcasting systems with an active private sector. As a result health issues often compete with commercial entertainment, sports and news for public attention. Several studies show clear effects of mass media campaigns on RH/FP outcomes, but the precise mechanism of these effects varies. Do & Kincaid (2006) found an effect of campaign exposure on contraceptive ideation (perceived attributes of FP methods), which mediated contraceptive adoption in the Philippines. Boulay et al. (2002) found an effect of a national radio drama in Nepal on FP discussion in village level networks. Women who discussed the program with listeners but did not listen themselves were at least as likely to adopt contraception as those who had been directly exposed to the radio program. In the area of maternal health, Shefner-Rogers & Sood (2004) evaluated a multimedia campaign in Indonesia to encourage husband’s involvement in and spousal communication about birth preparedness. Exposure to television and radio spots fostered household and community dialogue about the important role of the “alert husband” and attempted to guide viewers through stages of behavior change to promote safe motherhood. The combination of direct exposure to campaign messages and interpersonal communication about the messages was the strongest predictor of knowledge gain and birth preparedness behavior. Most effective mass media campaigns are designed from an explicit theoretical base such as the Transtheoretical Model, Stages of Change, Reasoned Action or Social Cognitive theory. Such theories specify the determinants of behavioral decision-making and make it easier to create interventions that are tailored to the factors that influence the decisions of one intended audience or another. For example, using survey data, DeVet et al. (2008) found different effects of media on people at different stages in the Transtheoretical Model: messages aimed at awareness building and self-reflection related to diet were more important for people in early stages of change (precomtemplation or contemplation) while self-management messages were more important for people in the later stages of change (action or maintenance).

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Key Ideas •

• • • • • •

Most of the research on mass media interventions turned up in this review comes from work on reproductive health and nutrition, but successful mediabased health campaigns have been documented across the full RMNCHN spectrum (Wakefield et al., 2010). One medium is not inherently better than any other, but a channel that works well for one audience may be inappropriate for another. Success is more likely in programs that use multiple media, particularly when the desired outcome is habitual or ongoing (e.g., diet, exercise) as opposed to episodic (e.g., immunization). The careful integration of research into programs, especially during the design phase, helps ensure that the right pathways to and determinants of behavior are identified and incorporated into message strategies. The combination of direct exposure to campaign messages and interpersonal communication about the messages is often the strongest predictor of knowledge gain and behavior. Effective mass media programs are theory-based, relatively well-funded, target a large population and are implemented over a period of months or years. The complexity of the media environment means that audiences are fractured, thus no one medium is likely to serve all audience segments. For this reason, the need for personalization of media content and delivery mechanisms becomes more important than ever.

Strategic communication (17 articles) Strategic communication is a broad term that can refer to almost any intervention that uses theory and research to design optimum communication and messages strategies. Typically, however, it refers to multimedia communication programs, usually implemented over time, that—like social marketing—use techniques adapted from the commercial sector, such as audience segmentation, staged behavior change and branding. Many of the interventions described in the mass media section of this report may be jointly classified as strategic communication. Strategic communication interventions “are designed on the basis of scientifically collected data to achieve measurable objectives that reach and involve specific audiences and that position health practices persuasively as a benefit in the minds of the intended audience” (Piotrow et al., 1997). They are theory-based; emphasize a close, even participatory relationship with the audience throughout the planning, implementation and evaluation of a program; approach behavior as a societal phenomenon, not just an act of individual decision-making; use multiple, closely coordinated channels often operating at multiple levels of society in a complementary way to inform, motivate, and engage 49


people and groups; demand high quality production values and creativity to optimize audience attention and involvement; and consider sustainability of behavior change to be one of the most important program objectives. Persuasive communication, a subset of strategic communication, is strongly theorybased and focuses on attitudes and other psychosocial drivers of behavior change such as risk perception. While focused mainly on decision-making at the individual level, persuasive communication interventions may also invoke social influences, such as normative pressures, group identity or concern for others, to influence individual choices. Some persuasive interventions seek direct impact on members of a primary audience, while others seek to indirectly influence a primary audience by enlisting the aid of secondary audiences that exert influence on the primary audience (e.g., significant others, role models, opinion leaders). Two examples will suffice to illustrate strategic and persuasive communication approaches. Quinn et al. (2005) evaluated a neonatal health program (LINKAGES) in Bolivia, Ghana and Madagascar and provided evidence for the effectiveness of strategic communication to improve breastfeeding practices on a national scale. The project worked on three levels: building the capacity of government workers, NGO staff and community members to deliver key messages; disseminating behavior change messages through mass media, interpersonal communication networks and community mobilization; and communitybased activities that included home counseling. The ten-year program reached 1 million to 6.5 million people in the various countries and had significant impact on the rate of immediate postpartum initiation of breastfeeding (as high as 78% in Madagascar) and the rate of exclusive breastfeeding for 6 months (79% in Ghana). Rimal et al. (2009) tested the use of the risk perception attitude (RPA) framework using data from the BRIDGE project, a USAID-funded behavior change HIV/AIDS prevention campaign in Malawi. The radio-based intervention featured HIV+ patients talking about HIV risk, HIV testing and how they are able to live positive lives an avoid infecting others. Cross-sectional data from 860 women showed that only 19 percent perceived that they were at risk of HIV infection, but it was efficacy beliefs not risk perception that drove condom use intentions. Moreover, efficacy beliefs were found to moderate the relationship between risk perception and intentions to remain monogamous. The authors concluded that risk perceptions serve as critical cues for action, but once

50


individuals have been made aware of their risks, health campaigns can more constructively focus on enhancing and sustaining efficacy beliefs. Key Ideas • • •

•

Most of the evidence for the use of strategic communication comes from work on reproductive health/HIV prevention and to some extent from neonatal health/breastfeeding. Strategic communication (science-based application of behavior change theory and project management principles) can be incorporated into and used to strengthen most other types of interventions. Strategic communication programs often tap multiple levels of communication, for example, by encouraging interpersonal communication to reinforce the media messages, engaging the community through the use of small media (flyers, brochures, pamphlets), activating social networks and creating links to service delivery. Programs should use theoretical frameworks more regularly and more explicitly both for design and evaluation.

Social marketing (36 articles) Social marketing is another form of strategic communication that adapts traditional marketing theories and principles to the promotion of a “product”—usually a behavior—in order to improve personal and social wellbeing (Storey, Saffitz & Rimon, 2009). Unlike commercial marketing, the “product” in this case is usually a behavior. In practice, social marketing involves coordinating as many communication forms and approaches as possible (e.g. advertising, public relations, internet communication, community mobilization, counseling) to reinforce and complement each other, while ensuring that all points of consumer contact communicate the same fundamental value associated with the “product” and behavioral outcomes. Social marketing sometimes refers to the promotion of specific health services (e.g., pharmacies) or service providers (e.g. VCT clinics, vasectomy clinics) in order to increase service uptake, utilization or delivery. This may overlap with the marketing of specific health products (e.g., a new brand of pills or condoms) that can be obtained at service delivery sites. A few examples include Meekers et al.’s (2005) evaluation of the "100% Jeune" social marketing program in the two largest cities in Cameroon, which used mass media, interpersonal communications, widespread distribution of subsidized condoms, peer education, distribution of a monthly magazine, an 18-episode “Let’s Talk about Sex” radio

51


drama, weekly radio call-in shows, integrated television, radio, and billboard advertising and a network of branded youth-friendly condom outlets. Cross sectional survey data of young adults (N=3536) showed changes in perceived social support, condom use selfefficacy and use of condoms at last sex with a regular partner for both male and female youth. In developed countries, several studies focused on dietary change. Pollard et al. (2008) used a combination of TV, radio, press, point of sale ads, PR events, website presence, school-based activities and theory-based messaging focused on values, beliefs and knowledge related to fruit and vegetable consumption. Large population-based surveys before and 12 months after the intervention found improvements in knowledge of dietary recommendations and increased fruit and vegetable intake. Audience segmentation and tailoring messages to specific audience characteristics and needs is a time-honored commercial marketing technique. For example, Della et al. (2009) used a VALS (Values, Attitudes & Lifestyles) segmentation technique to tailor messaging on fruit and vegetable intake. Segmentation is based on analysis of attitudes, norms, behavioral controls and intentions that cluster differently for different audience subgroups, making it easier to personalize messages according to different decisionmaking processes. Similar cluster analysis was used by Reedy et al. (2005) to design marketing materials on cancer prevention diets and by Griffiths (2003) to segment audiences for the promotion of micronutrient fortified foods. Key Ideas • •

•

•

Evidence for the use of social marketing most often comes from work on RH/HIV prevention (typically condom use) and, in developed countries on diet and nutrition. Repeated (high dose) program exposure is often needed to achieve behavior change. Programs can accomplish this through the use of a mix of mass media and interpersonal communications to repeatedly expose youth to key campaign messages. Program characteristics that are associated with success include audience segmentation, a focus on behavior change rather than just knowledge change, theory-based messaging and rigorous outcome evaluations with measures of behavioral determinants as well as outcomes to strengthen learning from experience. Social marketing programs, particularly if they focus on the purchase of a product, may sometimes miss the most at-need audiences.

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Social media (24 articles) The term social media refers to a variety of web-based and mobile technologies and software applications that permit users to engage in dialogue with each other, often over great distances, share information, interact and collaborate with each other and create and exchange user-generated content. At the time of this writing, social media commonly refers to the kinds of networked dialogue made possible by Facebook, Twitter and other platforms that run on computers and smart phones. Twenty-four articles (almost all from developed countries) described some application of social and interactive media. Our review did not turn up any examples of health interventions that specifically used Facebook or Twitter, but did uncover a variety of applications of cell phones for personalized counseling and texting, as well as numerous examples of web-based message delivery and interactive communication that give power to the user to seek and exchange information and engage with others. What can social media do that is unique from the capabilities of other communication options? Like other media, they can be used to spread awareness of an issue or behavior, facilitate timely information sharing within a targeted audience, expand the reach of other program messages through interpersonal communication, encourage interpersonal influence, and disseminate and shift perceptions of public opinion. Unlike many other forms of communication, social media can be highly targeted to deliver the right message to precisely the right audience (e.g., sending a text message to specific cell phone user with a reminder to take a medication). They allow interactivity, both between health promoters and clients as well as among clients, to an unusual degree. This interactivity can be empowering to clients, increasing their level of involvement with the issue and with each other around the issue. Because users of social media are networked with each other, the dynamics of networks apply: the power of nodal opinion leaders to influence behavioral decisions; within group and between group normative influence; the issues of homophily and trust that predict information exchange, disclosure and conformity; and dissemination as a function of density and closeness of network links. Tools for measuring many of these dimensions of networks are available, but so far have not been widely used in studies of social media and health behavior. Programs using social media need to integrate such measures into their design and evaluation systems.

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Examples of two studies that reported modest behavioral impact were Woodall et al. (2007), which found that emailed messages about changes to a nutrition education website increased repeat visits to the website and was associated with higher selfreported fruit and vegetable intake among users. In the area of HIV prevention, Kang et al. (2010) reviewed 42 studies of risk reduction among sexually active Australian teenagers and found some evidence that texting messages on condom use and STD testing had an impact on those behaviors. Most of the studies we reviewed did not report behavioral impact, but nevertheless suggested a number of opportunities and design implications for the use of social media for health behavior change. These suggestions include: that internet applications can be theory-based and provide an anonymous, affordable, private experience (Barak & Fisher, 2009); that web-based applications have the potential to involve whole communities in the design and management of HIV prevention programs (Langanke & Ross, 2009); that a combination of mass media, texting and web-based messaging have the potential to influence condom use and STD testing (Kang et al., 2010; Ybarra & Bull, 2007; Wilkins & Mak, 2007); that web-based nutrition and diet programs can actively engage users in goal setting, information seeking, and tailoring of information to personal needs (Rolnick et al., 2009); and that websites can provide a broad range of functions including banner ads, outreach, coupons for services, and group chat opportunities, among others (McFarlane et al., 2005). Several articles offer cautionary notes about social media. For example, McConnon et al. (2009) note that although websites can be useful for the delivery of weight management programs, it can be hard to maintain levels of use as users continuously seek newer, more current information and may not always want to use the social networking and social support functions of websites. Key Ideas • • • •

Most of the evidence for the use of social media comes from developed countries and the health areas of RH and nutrition. Social media are by definition networked and permit interactivity on a scale and to a degree that other intervention approaches do not. Access to social media is growing dramatically, even in the poorest areas of the world. The use of social media leaves electronic traces that create important opportunities for monitoring and evaluation. Tools for measuring the use and content of social media are becoming more and more widely available. 54


•

Programs using social media may need to integrate such measures into their design and evaluation systems.

RECOMMENDATIONS FOR PROGRAMS (1) Choose the Right Tool for the Job In a sense, there is no such thing as an unsuccessful intervention approach. Virtually every variation on community-based, interpersonal, group-based, economics-based and media-based approaches produces successful outcomes if it is matched to the desired outcomes, designed with clients in mind and is implemented skillfully. Like a carpenter selecting tools for a building project, SBC programs must choose the right tools for the job at hand. It must match the scale of the change that is sought, how long it will take to achieve that change, how long the change must be sustained and who the audience is. Although most intervention approaches can be adapted and combined to match particular program needs, Table 5 suggests some potential complementarities between approaches and objectives. Table 5: Potential matches between intervention approaches and program objectives Intervention approaches Communitybased Community engagement Community mobilization Community outreach Social mobilization Social movements Positive deviance Interpersonal CPI CHW/ Frontline Counseling Home visits/ home outreach Peer

Scale of change Larger/ Smaller/ population localized based

✓ ✓

If scaled up

Long term/ sustained

✓

✓

✓

Target audience Individuals / families

Community

✓

✓

✓

✓

Society

✓

✓

✓

✓

✓

✓

✓

✓

If scaled up

If scaled up

✓ ✓

Short term/ temporary

✓

✓

✓

Change time frame

✓ If scaled up

✓

✓ ✓

✓

If scaled up

✓

✓

If scaled up

✓

✓

✓

If scaled up

✓

If scaled up

✓

✓

If scaled up

✓

✓

✓ If contact sustained With scaled up training If contact sustained If contact

✓ ✓

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Intervention approaches educators Group-based Social capital Social networks Social norms Behavioral Economics Behavioral economics Media/ Social marketing Advocacy Mass media Social marketing Social media Strategic communication

Scale of change Larger/ Smaller/ population localized based

Change time frame Short term/ temporary

✓ ✓

Long term/ sustained sustained

Target audience Individuals / families

✓ ✓ ✓

✓

✓

Maybeunproven

✓

Maybeunproven

✓

✓

✓

✓

✓

✓

✓ ✓

✓

✓

✓

✓

✓

✓ ✓

✓

✓

Society

✓

✓

✓ ✓

Community

Microfinance If scaled up groups

✓

✓ ✓

✓ ✓

✓

✓

✓

✓

✓

Maybeunproven

✓

✓

✓

For example, some community-based approaches (community mobilization, social mobilization and social movements) are more amenable to long-term societal changes by virtue of their emphasis on sociopolitical and structural change and capacity building. Positive deviance and community mobilization may be suited to population level change if they are scaled up, perhaps through mass media campaigns that publicize models of personal of community protective behaviors on a mass scale. Most Interpersonal approaches are limited to relatively short-term individual or small group-oriented programs unless contact with clients and households can be maintained over time. This may be more likely with frontline workers, home visitors and peer educators who live in the community and have closer personal ties to clients. The quality of interpersonal interactions can be strengthened on a large, even national scale if, for example, counseling skills are taught online or via distance learning in the media. Population-based change through social network interventions is mostly untested, but potentially possible if media are used to catalyze network connections on a large scale. Sustaining long-term change through social network and normative change approaches should be an ideal match, but we are unaware of any empirical tests of this hypothesis. Social capital interventions are almost by definition oriented toward longer term structural change at the community and societal levels, while social norms approaches 56


range in focus from short term change in individual level perceptions of norms that can influence behavioral decisions like routine immunization, to long term change in societal level prevalence of behaviors like family planning. Behavioral economics approaches so far have been mostly focused on individual behavioral decisions. Their impact on larger scale and longer-term change has been largely untested. Some BE programs operate at the community or small group level (e.g., lending groups) and could potentially have population-based and longer-term effects on poverty and health if they are scaled up and sustained over time, but there is limited evidence so far. The various media and social marketing approaches are somewhat less suited to purely local, small-scale change because they are less cost-effective at that scale. They can be highly cost-effective for individual level change at the population level. Social media may have the potential to create individual and perhaps societal change by virtue of their reach and adaptability, but this potential is largely untested as is their ability to sustain change over time. Mass media and social media may be effective for long-term change if they are used to shift norms (e.g., related to diet and exercise) and sustain public opinion favorable to health (e.g., related to child protection). There is more evidence of such long-term impacts in the political science literature but less in the health domain. As with any longer term, macro-level change, it is challenging to link those changes to specific behaviors and health outcomes—a challenge our field should take on in a serious way. For the most part, in the area of reproductive health, the most common and strongest intervention approaches were mass media, interpersonal communication (especially peer education) and community engagement. Microfinance approaches to building social capital and addressing gender equity also show some promise. The need for household outreach in the area of maternal reproductive health is clear; however, interventions have yet to demonstrate consistently effective means of incorporating partner, parental and community support into maternal health programs. Community outreach to school or work-based settings for reproductive health have been effective, especially when they include a peer education component. The best interventions for addressing child health are not obvious. This review found relatively few studies focused on children and youth and few of those focused on early childhood (1-5 years). It is likely that strategies similar to those used for neonatal 57


health are applicable: social support from one’s family and community is important as are norms related to child rearing. Improved social capital that creates better child protection may help, as well. Positive deviance approaches might help identify and encourage locally effective but uncommon practices that produce healthy children, while media approaches can help popularize those practices and create new child care norms. (2) Go Small—Personalize Interventions to Improve Impact In the end, which intervention approach is used may be less important than the content it delivers. There are many examples of health promotion programs that reached the right people but used low quality messages that addressed the wrong behavioral drivers or were delivered by poorly skilled promoters. Effective interventions personalize the attention and the information they deliver to clients. For example, counseling approaches, community outreach, and the deployment of frontline health workers are popular and widely used strategies because they emphasize personal contact with clients and patients in order to deliver services directly to them in ways that are appropriate to their needs. Social marketing strategies, particularly those that use mass media and other electronic forms for the delivery of program messages, are often considered to be more distant and less personal because they typically reach people with technologies, not face-to-face. But not all face-to-face interventions are successful. Many fail because health care providers lack the knowledge, skills or sensitivity to make their interventions clientcentered. Training of health workers can improve their skills, but not all training curricula are equal. The best appear to be theory-based and designed to help health workers at the client-provider interface to understand client behavioral decision-making and translate that understanding into information, advice, and support that are practical and tailored to individual client needs. These principles lie at the heart of “motivational interviewing”, a technique used by some of the more successful interpersonal and group-based interventions we reviewed. By the same token, the best mass media interventions are those that take care to match language and content to the preferences of the audience, feature people who are homophilous with the intended audience, and frame messages in personal, attractive and emotionally engaging ways in order to make the messages relevant and useful to the individual receiver. One need only think about the best television news anchors to 58


recognize the truth of this principle. Eyes looking directly into the camera, body inclined slightly forward, an easy smile and the use of colloquial language all convey the attitude, “I care about you; here is what you need to know”. The same principle can be seen in a study by Finfgeld-Connett (2005) who analyzed transcripts of social support sessions delivered by nurses either face-to-face or via telephone and found that the physical distance inherent in the use of telephone technologies can be overcome if the counselor can maintain “psychological presence” and full attention to the patient throughout the call, if there is interpersonal reciprocity (i.e., the client has an equal opportunity to speak and ask questions), and if quality practices (i.e., according to standards) are maintained even though the contact is at a distance. (3) Go Big—Maximize Reach and Scale Another thing most successful interventions do, which sometimes creates tension with personalization, is to generalize the approach in order to implement at scale. If every aspect of every intervention had to be delivered door to door, the required time and human resources would be prohibitive. Fortunately, group-based and community-based approaches allow health professionals, outreach workers and peer motivators to reach groups of people simultaneously instead of one-by-one, while still allowing a relatively high degree of personalization. Activating social networks extends the reach of programs and brings social influences into play that often can reinforce and sustain behavior change. Media of various kinds like television, radio, telephony and, increasingly, the internet further extend the ability of programs to reach geographically dispersed groups and individuals in great numbers with personalized messages; the more people reached, the greater the potential impact. But with the ability to reach millions, comes the need to design intervention activities and materials that can appeal to many people simultaneously. This means creating generic programs that nevertheless have personal appeal.

RECOMMENDATIONS FOR RESEARCH (4) Go Small in a BIG Way

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A fundamental tension in all SBC interventions is between Going Big and Going Small. Going Small means being able to personalize information and deal with people at the intimate level where they make behavioral choices. The growing interest in behavioral determinants reflects a need to identify the specific personal triggers that “close a sale”. Counseling attempts to do this face-to-face and the desire to reach people directly underlies most community-based approaches. Behavioral economics approaches attempt to do this by unpacking seemingly irrational personal behaviors and by tipping the balance of the marketing exchange relationship in a more “profitable” direction. Going Small is often very effective, but it is hard to do well. Providers do not always have the skills, interest or time to give clients the personal attention they need and unless a provider understands why the person sitting in front of her behaves as she does, it is very difficult to personalize the interaction. It is hard to know what people are thinking and empathy is a difficult skill to teach. Going Big, on the other hand, means reaching lots of people. It means going to scale in order to have national, not just local impact. It most often does this by identifying the statistically most common factors that influence the greatest number of individuals in a particular audience, then creating messages and strategies that address those factors. Going to scale often also involves creating or activating networks (especially those that transcend geography) in order to expand the reach and influence of a program through social connections. While Going Big is often very effective it, too, is hard to do well. Mass media messages geared to the lowest common denominator can be over-generalized to the point that they don't hit anyone's hot buttons. In addition, a common denominator strategy excludes people on the margins who have legitimate needs but are out of the mainstream. Furthermore, once a mass media message is sent, the sender loses control over it. Audiences do with it what they will and—unlike with face-to-face communication—the opportunity to give and receive feedback on the meaning of the message is more limited. This is changing somewhat with newer interactive technologies like smart cell phones and social media, but the degree to which these can be considered mass media in the traditional sense of that word is a matter of debate. Finally, some programs are enamored of the delivery technologies themselves to the point that the content of the messages becomes a secondary concern. 60


In short, Going Small tends to work very well, but has relatively small impact at the population level, while Going Big tends to work very well, but misses a lot of people on the margins. Key research questions that could be addressed include: •

• •

How can we design interventions that combine the best of both worlds? What approaches allow personalization, but do it at scale? Are there approaches that can empower more people to tackle health issues consistently and on their own in a cost-effective way? What are the best, most efficient ways to scale up localized efforts so they can operate at the population level? How can we replicate facility-based and community-based programs at thousands of sites while simultaneously reducing costs and human resources?

(5) Trace Pathways to Change Over Time A critical challenge facing many behavior change programs that attempt to achieve population-level impact on health is documenting the indirect link between program inputs (e.g., exposure to media messages or counseling), behavioral decisions (e.g., risk reduction practices) and health outcomes (e.g., unintended pregnancy and STIs). Programs that are asked to change behaviors often are held accountable for health outcomes also. For example, even when it is known that breastfeeding improves neonatal nutritional status and disease resistance and that a particular behavior change program increased breastfeeding initiation or duration, the program is also expected to quantify its indirect contribution to nutritional outcomes. Even more challenging is documenting the link between program effects on social and structural changes (e.g., improvements in social capital, community engagement with health or policy change) and health behaviors and health outcomes. Documenting these indirect effects requires longer term monitoring and impact evaluations and more sophisticated multilevel longitudinal analysis than many programs are designed to provide. For the science of SBC intervention to advance, we need to systematically trace those direct and indirect pathways over time. Our research found a great number of pilot studies and small scale randomized trials, as well as many qualitative, programmatic descriptions of programs, but many of these lacked data linking inputs to outcomes. We found relatively few rigorous evaluations of population-based programs, a complaint that many reviews of the literature echo. The relative paucity of research on population-based programs over time has made it difficult to understand the impact of cumulative ecological and structural changes on health outcomes through changes in behavior over time. This suggests a need for more 61


program research on extended field programs—research integrated into full-scale programs from formative research during the design phase through monitoring and process evaluation during implementation to theory-based impact evaluation. There are so many variations on program context, with different configurations of audiences, objectives, social and infrastructural settings, personal and household experiences, intervention resources, baseline knowledge and motivation, that the likelihood of having a single formula for intervention success is close to nil. However, the science behind behavior change is fairly well understood. We understand the main drivers of behavior: knowledge, skills, ideation, risk perceptions, outcome expectancies, normative perceptions, motivation, social support and access to resources, to name a few. However, we don’t always know which of those drivers are relevant in a particular place at a particular time for a particular audience and a particular objective. The interactions among these factors also vary from one setting to another. Model fitting can help us map the science onto specific situations but this requires rigorous program research that is fully integrated into program practice. Short-term trials and pilot studies use theory and research, of course, but have relatively low external validity. What the SBC field needs more multiyear field programs with rigorous built-in research and evaluation systems designed to measure and causally link short-term and intermediate changes in attitudes, norms, network structures, social capital and behavior with long-term changes in health outcomes. Key research questions that could be addressed include: •

• • •

How can we trace the cumulative effect of behavior change at one point in time to subsequent behaviors? For example, how does learning to breastfeed one’s first child affect motivations to immunize and nourish that child, space the next pregnancy, and take care of one’s own health in the meantime? Can health competence be learned early in family life to the extent that all subsequent family health decisions are improved? How do short-term and intermediate changes in attitudes, norms, network structures, social capital and behavior affect longer-term changes in health outcomes at a level of social aggregation higher than the individual? Randomized trials are unlikely to answer these questions? Which multilevel, multivariate, longitudinal research designs are most suited to this challenge?

(6) Achieve Innovation through Standardization The almost infinite variations on program settings, audiences and objectives make it clear that cookie cutter approaches to SBC interventions are not likely to succeed. Every

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intervention is unique in its own ways and needs to be tailored or personalized in order to improve the likelihood of success, but this does not mean that we should reinvent the wheel with every intervention. Different for the sake of difference is not innovation; haphazard does not equal creative. Creativity often results from highly disciplined decision-making processes and adherence to exacting standards of quality and performance, consistent with one’s vision for an outcome. Working from standards and guidelines does not necessarily prevent SBC interventions from being innovative, flexible and responsive to the unique needs of a particular program. To the contrary, systematic, critical and reflective (rather than slavish) use of standardized tools and models helps to pinpoint inevitable shortcomings or gaps in knowledge and approaches, from which innovations spring. Critical use of and sharing of experience with common tools and approaches helps build a stronger platform for change at scale. In this spirit, we would do well to prioritize the development and testing of standardized program tools that will make the personalization of initiatives faster, simpler, more systematic, more efficient and, therefore, more scalable. Is it possible to design a suite of tools for formative research, program design, implementation, monitoring and evaluation that can be adapted to the specific health priorities and objectives of programs? A wealth of such tools is available from a variety of sources, but these have never been compiled, systematically tested, or standardized for the purposes of SBC interventions across the RMNCHN spectrum. A short list of illustrative examples includes (Table 6): Table 6: Some available program, implementation and research tools Purpose Program design tools

Implementation tools

Tool/source The Message Development Tool A guide to the application of conceptual frameworks for message design across the program lifecycle. (Matson, M. & Basu, A., 2010). COMBI An integrated marketing approach to health and social development (WHO, 2002) Meta-Theory of Health Communication An ecological model for program design and research that specifies relationships between communication inputs, skills and knowledge, ideation, environmental supports & constraints, health behaviors and health outcomes. (Kincaid et al., in press) “All-In-A-Day” Take Home Tool 63


Purpose

Tool/source An interactive package of activities designed to facilitate conversation between parent, child and provider about physical activity and dietary practices (Kubik et al., 2008)

Counseling tools

Diet, Physical Activity & Health Implementation Toolkit A WHO guide to program design and implementation (Candeias et al. 2010) WICHEALTH.ORG A web-based modular instructional tool for women’s and children’s health (https://www.wichealth.org/) (Bensley et al, 2006) Self-administered risk reduction tool A 20-minute normative feedback and goal setting session for HIV risk reduction. (Chernoff et al., 2005) Motivational Interviewing A technique that involves the combined use of risk or harm diagnosis tools with counseling that builds on the results of the diagnosis.

Evaluation tools

(Callahan et al., 2007) Computer-assisted counseling tool An automated risk assessment and profiling tool for HIV/STD clinics (Mackenzie et al., 2007) Retail outlet exit survey Mass marketing exit survey tool to assess female condom use Agha (2001) Cost-effectiveness analysis Approach to multivariate causal attribution and cost-effectiveness assessment for media campaigns (Kincaid & Do, 2006) World Bank social capital assessment tool Framework and tools for measuring social capital (Pronyk et al., 2008)

Key research questions that could be addressed include: • •

• •

What would a standardized package of tools look like? From the many tools that are available, which subset could be compiled into an intervention support package that covers all intervention approaches and major steps in intervention design, implementation, management and evaluation? How well does this intervention support package work in different contexts and for different health outcomes? What training in the use of this package and its components is necessary?

(7) Nurture Promising Intervention Opportunities While older, widely validated intervention approaches should continue to be used and adapted for new applications through formative research, few of these need to be

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the focus of continued primary research because their effectiveness, when executed skillfully, is well known. Some of the newer approaches, however, deserve primary research attention because they have not been tested for all uses where they might be impactful. (a) Determine How to Use Social Media for SOCIAL Change Social media, such as cellular technologies and social networking websites have been examined thus far mostly for their ability to disseminate information (e.g., SMS texting to clinical patients or sending notices of events, posting program updates or providing links to useful health information on project Facebook pages). To a more limited extent, social networking media have been used to provide opportunities for social connection (e.g., chat rooms, online group counseling, online professional communities of practice). There is also evidence—albeit mostly anecdotal—that mobile technologies can be useful for social mobilization, but how any of these applications are related to health behavior change, especially in the long run is largely unknown. What can social media do that is unique from the capabilities of other communication options? Like other media, they can be used to spread awareness of an issue or behavior, facilitate timely information sharing within a targeted audience, expand the reach of other program messages through interpersonal communication, encourage interpersonal influence, and disseminate and shift perceptions of public opinion. Unlike many other forms of communication, social media can be highly targeted to deliver the right message to precisely the right audience. They allow interactivity, both between health promoters and clients as well as among clients, to an unusual degree. This interactivity can be empowering to clients, increasing their level of involvement with the issue and with each other around the issue. Because users of social media are networked with each other, the dynamics of networks apply: the power of nodal opinion leaders, within group and between group (bounded normative influence), the issues of homophily and trust, dissemination as a function of density and closeness of network links. Key research questions that could be addressed include: • • •

How can the networking capabilities of social media be used beyond shortterm behavior change? Can mobile technologies and social networking media enhance social capital (e.g., social cohesion and access so social support) related to health behavior and health service use? Can social media create and sustain social change, not just behavior change? 65


•

How can commercial telecommunication service providers play a role in the wider use of social media for health?

(b) Identify Non-Financial Incentives that Last In part because BE is a relatively new intervention approach there are very few evaluations of full-scale BE projects. The most common strategies in this area involve subsidies of various kinds—essentially bribes—for healthy behavior. While this appears to work in the short term, effects tend to drop off quickly when subsidies end. Therefore, the sustainability of this approach has to be questioned: the more successful it is, the more it costs. On the other hand, non-financial motives for behavior that rely on perceptions of non-economic gain or loss (e.g., ones that trigger a positive or negative emotional state) can be powerful determinants of behavior. These deserve more research attention. They are likely to be cheaper and may reflect the psychosocial mechanism underlying financial incentives anyway. Also, BE interventions to date have produced mostly short-term changes in behavior that correspond to the period of availability of financial incentives. Are there non-financial incentives that can become self-regulating and therefore habitual and sustainable? Can emotional rewards be associated with healthy behaviors such that continued practice becomes desirable? Can people learn to reward themselves emotionally for a healthy behavior or routinely avoid behaviors that produce unpleasant emotional reactions become? Key research questions that could be addressed include: • •

How can we design economically sustainable BE interventions? How can we expand the use of non-financial incentives that trigger gain frame thinking?

(c) Harness Positive Deviance on a Larger Scale Our review found evidence that positive deviance can be a powerful communitybased approach that engages families and households to examine their health practices and re-imagine how to achieve better health. This approach is intensive and takes time because it works best as a collective exercise. Once positive but uncommon practices are identified, PD interventions attempt to popularize them, mostly within the community where the innovations are found. Few examples of PD interventions describe efforts to scale up the innovation beyond the local community. Yet social network research, in particular 66


Kincaid’s (2004) work on bounded normative influence, suggests that PD behaviors could be disseminated on a broader scale through social network approaches. These two perspectives have not been studied together. Marsh et al. (2002) note that little PD work has been done outside of infant nutrition and that other family health areas like newborn care may be more complicated. Additional research may be needed to test the feasibility of PD approaches in new health areas, particularly those that involve longer term behavior change that must be sustained over time in order to be effective, such as diet and exercise, hygiene, and birth spacing. Key research questions that could be addressed include: •

• •

Are there ways to streamline and shorten the PD process without jeopardizing the personal, community-based character of this approach, perhaps through the wider use of standardized tools or online training in PD methodology for community-based organizations? How can network approaches be incorporated into the PD process? Can PD be scaled up, perhaps catalyzed at a national scale, by modeling whole community response, not just individual response, to family health issues?

(d) Find the Key to Sustainable Counseling Although counseling is a heavily studied process, most of the work has focused on relatively short-term effects and techniques. Counseling tends to be episodic and occasional, occurring at critical times in pregnancy, neonatal care, treatment regimens. Some counseling interventions provide intensive multiple encounters but during a short period of time (e.g.. for smoking cessation, breastfeeding or diet change) in order to get a client through a difficult transition period or establish a pattern of behavior that—it is hoped—will persist. However, we found few studies that examine the longitudinal effects of counseling beyond a few months to a year or the factors that sustain the effects of counseling encounters after they have stopped. Key research questions that could be addressed include: • • •

How long do counseling effects persist? Are there counseling techniques that have more enduring impact? How can the impact of prenatal counseling (e.g., on birth preparedness, breastfeeding, immunization, child and maternal nutrition, intrapartum FP use) be sustained throughout the first 5 years of a child’s life?

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