BEHAVIOR CHANGE

COMMUNICATION
TOPIC 8
 INTRODUCTION
Definition of BCC
• Behavior change communication (BCC) is an
interactive process with communities to
develop tailored messages and approaches
using a variety of communication channels;
1. To develop positive behaviors.
2. Promote and sustain individual, community
and societal behavior change.
3. Maintain appropriate behaviors.
 INTRODUCTION Cont….
• In the context of the AIDS epidemic, BCC is an essential part
of a comprehensive program that includes both services
(medical, social, psychological and spiritual) and
commodities (e.g., condoms, needles and syringes).
• Before individuals and communities can reduce their level of
risk or change their behaviors, they must first;
 Understand basic facts about HIV and AIDS,
 Adopt key attitudes,
 Learn a set of skills and be given access to appropriate
products and services.
• They must also perceive their environment as supporting
behavior change and the maintenance of safe behaviors, as
well as supportive of seeking appropriate treatment for
prevention, care and support.
 INTRODUCTION cont….
• In most parts of the world, HIV is primarily a
sexually transmitted infection (STI).
• Development of a supportive environment
requires national and community-wide discussion
of relationships, sex and sexuality, risk, risk
settings, risk behaviors and cultural practices that
may increase the likelihood of HIV transmission.
• A supportive environment is also one that deals,
at the national and community levels, with stigma,
fear and discrimination, as well as with policy and
law.
 INTRODUCTION Cont….
• The AIDS epidemic forces societies to confront
cultural ideals and practices that can
contribute to HIV transmission.
• Effective BCC is vital to setting the tone for
compassionate and responsible interventions.
• It can also produce insight into the broader
socioeconomic impacts of the epidemic and
mobilize the political, social and economic
responses needed to mount an effective
program.
 THE ROLE OF BEHAVIOR CHANGE
COMMUNICATION
• BCC is an integral component of a comprehensive HIV & AIDS
prevention, care and support program.
• It has a number of different but interrelated roles. Effective BCC can:
1. Increase knowledge. BCC can ensure that people are given the
basic facts about HIV and AIDS in a language or visual medium (or
any other medium that they can understand and relate to).
2. Stimulate community dialogue. BCC can encourage community
and national discussions on the basic facts of HIV&AIDS and the
underlying factors that contribute to the epidemic, such as risk
behaviors and risk settings, environments and cultural practices
related to sex and sexuality, and marginalized practices (such as
drug use) that create these conditions.
 It can also stimulate discussion of healthcare- seeking behaviors
for prevention, care and support.
 THE ROLE OF BEHAVIOR CHANGE
COMMUNICATION Cont….
3. Promote essential attitude change.
BCC can lead to appropriate attitudinal changes
about, for example, perceived personal risk of HIV
infection, belief in the right to and responsibility for
safe practices and health supporting services,
compassionate and non-judgmental provision of
services, greater open-mindedness concerning
gender roles and increasing the basic rights of those
vulnerable to and affected by HIV and AIDS.
4 Advocate. BCC can lead policymakers and opinion
leaders toward effective approaches to the epidemic.
THE ROLE OF BEHAVIOR CHANGE COMMUNICATION
Cont….

5. Reduce stigma and discrimination. Communication

about HIV prevention and AIDS mitigation should
address stigma and discrimination and attempt to
influence social responses to them.
6. Create a demand for information and services.
BCC can spur individuals and communities to
demand information on HIV & AIDS and appropriate
services.
 It can contribute to development of a sense of
confidence in making and acting on decisions.
THE ROLE OF BEHAVIOR CHANGE COMMUNICATION
Cont….

7. Promote services for prevention, care and support.

BCC can promote services for STIs, intravenous drug
users (IDUs), orphans and vulnerable children (OVCs);
voluntary counseling and testing (VCT) for mother-to-
child transmission (MTCT); support groups for PLHA;
clinical care for opportunistic infections; and social and
economic support. BCC is also an integral component
of these services.
8. Improve skills and sense of self-efficacy. BCC programs
can focus on teaching or reinforcing new skills and
behaviors, such as condom use, negotiating safer sex
and safe injecting practices
 KEY ROLE OF STIGMA IN BCC
• Failure to address stigma jeopardizes BCC programs in
critical ways:
• Prevention. BCC programs that fail to address stigma
allow some people to ignore the messages of HIV
prevention. Stigma can cause people to perceive
individuals with or at risk for HIV as the other (“them”),
reinforcing their feeling that HIV “couldn’t happen to me.”
 Failure to address stigma can also deter individuals from
seeking out VCT and proper medical care, including MTCT
prevention services.
 Stigma is also sometimes attached to carrying condoms.
Stigma can work against prevention programs.
 KEY ROLE OF STIGMA IN BCC
• Quality of care. Stigma can perpetuate harmful
practices, such as discrimination against or poor
treatment of PLHA, IDUs, MSM, or SWs.
 A BCC campaign to increase demand at a health
facility would be hurt if poor quality of care were
encountered there by PLHA.
• Policy. Programs that fail to address stigma help
perpetuate discriminatory laws and practices and, in
some cases, result in failure to enforce laws against
them.
 Such programs also miss an opportunity to influence
policy direction.
 THE PROCESS OF BEHAVIOR CHANGE
Stage 1- Stages of behavior change continuum
 Unaware
 Aware
 Concerned
 Knowledgeable
 Motivated to change
 Practicing trial behavior change
 Practicing sustained behavior change
THE PROCESS OF BEHAVIOR CHANGE cont…

Stage 2- Enabling factors

 Providing effective communication.
 Creating an enabling environment- policies,
community values, human rights.
 Providing user- friendly, accessible services and
commodities.
THE PROCESS OF BEHAVIOR CHANGE cont….

• Stage 3- Channels
 Mass media
 Community networks and traditional Media.
 Interpersonal communication.
 Group communication.
Conclusion
• When changing behavior, the individual, community, or
institution goes through a series of steps— sometimes
moving forward, sometimes moving backward and
sometimes skipping steps.
 BCC GOALS
• Behavior change communication goals need to be
developed in the context of overall program goals and
specific behavior change goals.
The following highlights the place of BCC goals within an
overall program.
• Program goal: Reduce HIV prevalence among young people
in urban settings in X country. Behavior change goals:
Increase condom use.
Increase appropriate STI care-seeking behavior.
Delay sexual debut.
 Reduce number of partners.
 BCC GOALS cont….
• BCC goals:

 Increase perception of risk or change attitudes toward use of condoms.

 Increase demand for services.
 Create demand for information on HIV and AIDS.
 Create demand for appropriate STI services.
 Interest policymakers in investing in youth-friendly VCT services (services
must be in place)
 Promote acceptance among communities of youth sexuality and the value of
reproductive health services for youth (services must be in place)

Conclusion
• BCC goals are related to specific issues identified when assessing the
situation, knowledge, attitudes and skills that may need to be changed
to work toward behavior change and program goals.
 GUIDING PRINCIPLES FOR BCC
1. BCC should be integrated with program goals from the
start. BCC is an essential element of HIV prevention, care and
support programs, providing critical linkages to other
program components, including policy initiatives.
2. Formative BCC assessments must be conducted to improve
understanding of the needs of target populations, as well as
of the barriers to and supports for behavior change that their
members face (along with other populations, such as
stakeholders, service providers and community).
3. The target population should participate in all phases of BCC
development and in much of implementation.
4. Stakeholders need to be involved from the design stage.
 GUIDING PRINCIPLES FOR BCC cont….
5. Having a variety of linked communication channels
is more effective than relying on one specific one.
6. Pre-testing is essential for developing effective BCC
materials.
7. Planning for monitoring and evaluation should be
part of the design of any BCC program.
8. BCC strategies should be positive and action-
oriented.
9. PLHA should be involved in BCC planning and
implementation.
 Steps in developing a behavior change communication strategy

1. State program goals

 Clearly identifying overall program goals is the first step in developing a
BCC strategy.
 Program goals are established after reviewing existing data,
epidemiological information and in-depth program situation assessments.
2. Involve stakeholders
 Key stakeholders need to be involved early on in every step of the process
of developing HIV &AIDS programs and their BCC components.
 Stakeholders include policymakers, opinion leaders, community leaders,
religious leaders and members of target populations, including PLHA.
 Their active participation at appropriate stages of BCC strategy
development is essential.
 A stakeholders’ meeting should be held at the planning stage to obtain
guidance and commitments to the process and to develop coordination
mechanisms
 Steps in developing a behavior change
communication strategy cont….
3. Identify target populations
 To develop communication, it is important to identify the target populations as clearly as
possible.
 Target populations are defined as primary or secondary.
 Primary populations are the main groups whose HIV & AIDS-related behavior the program is
intended to influence.
 Secondary populations are those groups that influence the ability of the primary population to
adopt or maintain appropriate behaviors.
 For example, an HIV program may seek to increase condom use among sex workers and clients
(primary populations). But to achieve this objective, it may be necessary to change the behavior
or gain the support of brothel owners and police (secondary populations).

Target populations include:

1. Individuals at high risk or vulnerability, such as sex workers, their clients, youth, migrant
workers, IDUs, or uniformed services personnel
2. People providing services, such as health workers, private practitioners, pharmacists,
counselors and social service workers
3. Policymakers, such as politicians
4. Leaders and authorities, formal and informal, including law-enforcement, social and
religious leaders
 Steps in developing a behavior change
communication strategy cont….
4. Segment target populations
 Based on the formative BCC
assessment, target populations can
then be segmented.
 For example, sex workers can be
grouped more specifically according to
work location (street, home, brothel),
income level, ethnicity, or language.
 Steps in developing a behavior change
communication strategy cont….
5. Conduct formative BCC assessments
• The formative BCC assessment should collect information on:
 Risk situations, showing in detail how decisions are made in different situations,
including what influences the decisions and settings for risk
 Why individuals and groups practice the behaviors they do, and why they might be
motivated to change
 (or unable to change) to the desired behaviors
 Perceptions of risk and risk behaviors
 Influences on behavior, such as barriers or benefits
 Insights of opinion leaders
 Patterns of service use and opinions about these services
 Perceptions of stigma and discrimination
 Future hopes, fears and goals
 Media and entertainment habits
 Health care-seeking behaviors
 Positive deviants, or those most willing to model change
 Media resources
 Steps in developing a behavior change communication
strategy cont….
6. Define behavior change objectives
• Whether the target population is a particular group or
the general public, it is important first to refer to the HIV
& AIDS program behavior change objectives.
• Following are some common behavior change
objectives:
1) Increased safer sexual practices (more frequent condom
use, fewer partners)
2) Increased incidence of healthcare-seeking behavior for
STIs, TB and VCT (for example, calls or visits to facilities)
3) Increased use of universal precautions to improve blood
safety
 Steps in developing a behavior change
communication strategy cont….
7. Design BCC strategy and Monitoring and Evaluation (M&E)
Plan
• A BCC strategy is best designed in a participatory fashion,
including members of target populations, organizations
planning to work with them and stakeholders.
• A well-designed BCC strategy should include:
1) Clearly defined BCC objectives
2) An overall concept or theme and key messages
3) Identification of channels of dissemination
4) Identification of partners for implementation (including
capacity-building plan)
5) A monitoring and evaluation plan
 Steps in developing a behavior change
communication strategy cont….
8. Develop communication products
• Observable changes in behavior, as specified in the behavior change objectives,
are a final program outcome. Such changes are generally preceded by
intermediate changes.
• Such changes include:
1) Knowledge change: an increase in knowledge among targeted youth of modes
of transmission
2) Attitude change: an increase in perception of personal risk or a change in
authorities’ attitudes toward promoting condoms to youth
3) Environmental change: a decrease in harassment of sex workers by police or
an increase in acceptance of messages about condom use on television.
• An effective BCC strategy needs to be developed to guide achievement of
intermediate and longer-term outcomes. Examples of BCC objectives are:
 Increased demand for information about HIV and AIDS. (Youth will ask for
information about HIV and AIDS.)
 Increased knowledge about HIV and AIDS. (Youth will have correct knowledge
of modes of transmission of HIV and AIDS.)
 Steps in developing a behavior change
communication strategy cont….
9. Conduct pre-testing
• Pre-testing is key to ensuring that themes,
messages and activities reach the intended target
populations.
• It is important to pre-test at every stage with all
audiences for whom the communication is
intended, both primary and secondary.
• Pre-testing should be done of themes, messages,
prototype materials, training packages, support
tools and BCC formative assessment instruments.
 Steps in developing a behavior change
communication strategy cont….
10. Implement and monitor
• In the implementation phase, all elements of the strategy go into
operation.
• An especially important element is management.
• All partners, programmers and channels of the BCC strategy must be
closely coordinated.
• There must be links among critical program elements, such as supply
and demand.
• It is important that monitoring be carried out as planned.
• Often monitoring receives inadequate attention, both in terms of
collecting information and, still more often, in making sure it gets fed
back in usable form to people who need it for decision-making and field
implementation.
• Specific personnel must be designated to make sure that the monitoring
plan is developed with input from the people who will use it.
 Steps in developing a behavior change
communication strategy cont….
11. Evaluate
• Evaluation refers to the assessment of a project’s
implementation and its success in achieving
predetermined objectives of behavior change.
• BCC interventions should be evaluated against their stated
objectives and in reference to a baseline that may be
qualitative or quantitative (or both).
12. Elicit feedback and modify the program
• As programs evolve, target populations acquire new
knowledge and behaviors, and communication needs may
change.
• Day-to-day monitoring will provide information for making
adjustments in short-term work planning
 CHALLENGES
• It is important to keep in mind that the process does not occur in a vacuum.
Challenges to BCC programmers include:

1. BCC vs. IEC. In practice, IEC has often resulted in the production of discrete
communication material’s. The use of the term BCC is part of an effort to
establish communication as strategic and integrated into entire programs.

2. Integrating BCC into all programs. BCC is a component of all successful

interventions and must be included in their original design. However, in
reality this doesn’t always happen. It is essential to identify opportunities
for improving the quality of communication components.

3. Limited training resources. Limited capacity and availability of trained, in-

country resource people, including advertising agencies and media outlets,
can hamper the effective implementation of BCC programs.
4. Political and physical environments. In some countries, geography and
population diversity can complicate the development of BCC programs.
This is especially the case where vast distances must be covered, or
multiple languages and cultural traditions included, in a single country
program.
 CHALLENGES cont….
5. Sustainability. To be effective, BCC strategies and components must evolve
constantly to meet the changing needs of target populations. This requires
the continuous input of human and financial resources.
6. Expanding the response. To have a real impact on the epidemic, responses
must be expanded in quality, scope of activities and geographic coverage.
Expanding comprehensive BCC strategies is a continuing challenge.
7. Budgets. The steps necessary to develop a comprehensive BCC strategy
are often not adequately budgeted. For example, a budget will be
prepared for the production of materials but not for the process necessary
to develop the appropriate content. Capacity-building needs are ongoing
and resource-intensive and this must be taken into consideration. Donors
and managers need to understand the costs and benefits associated with
BCC activities.
8. Linkages and coordination. For BCC to be effective, their messages and
information should be coordinated. Building and maintaining linkages and
coordination is an ongoing challenge.
THANK YOU