BEHAVIOR CHANGE

The Key to Effective Relief and Development Programs

Save the children Federation, INC.

Training Manual

Ashley Aakesson, Behavior Change Specialist

Save the Children Federation, Inc.

Ethiopia Field Office

P.O. Box 387

Addis Ababa, Ethiopia

2005

Acknowledgements

This manual has attempted to incorporate approaches, methods, and tools for changing behaviors from a wide variety of sources. The author is especially indebted to the CHANGE and Linkages projects at AED, and the Manoff Group, Inc. for developing many of the concepts and tools utilized in the manual. Thanks also to various Save the Children US departments and projects, including the Food Security Unit and Saving Newborn Lives staff in Washington DC, the DAP staff in Ethiopia, Haiti, and Mozambique, and the Behavior Change Working Group in Ethiopia for supporting the development of this manual.

Special thanks to Elizabeth Bunde, Michigan State Population Fellow, who initially formatted the manual and developed the “Wall of Barriers” and “Continuum of Behaviors” Exercises.

Table of Contents

Page

Notes to Trainer: Introduction and Training Principles / 4
Unit 1. How and Why People Change Behaviors / 9
Unit 2. Putting Behavior Change at the Center of Our Programs / 25
Unit 3. Situational Assessment and Formative Research / 49
Unit 4. Field Exercise / 62
Unit 5. Developing Effective Strategies to Change Behaviors through Programs / 71
Unit 6. Monitoring and Evaluating the Impact of Behavior Change / 85
Unit 7. Planning the Behavior Centered Approach for Programs / 91
Annex 1. Examples of Behavior Change Strategies Resulting from the Behavior Centered Approach / 96

Notes to Trainer: Introduction and Training Principles

How to use this manual

This manual is intended to be used for training technical program planners and implementers. The authors have attempted to bring together proven tools and methods from many sources into one effective system for changing behaviors through programs. The approach to changing behaviors described in the manual can be used in every sector of emergency and development programs, including health, education, and food security. Each training unit includes content, learning objectives, key messages, exercises, instructions, and time and materials needed to complete the unit. The manual also includes case studies detailing the process as Save the Children/US has used it in actual programs. These case studies include challenges to implementation, strategies to overcome them, and the results achieved by this approach in changing behaviors on the ground.

A note on materials

This manual was designed so that it can be used for a training with a range of technologies available. In a low technology setting, the trainer can present the content on flipcharts, printing out just the Participant Handouts to distribute to participants at the appropriate times. If an overhead or LCD projector is available, the trainer may use power point presentations to present the content. In any case, the trainer may want to print all of the content as power point handout pages, in addition to the Participant Handouts.

Training methods and principles employed in this manual

One goal of this manual is to utilize adult learning methods when training staff about designing and implementing behavior change strategies. People tend to train others in the way they have been trained, so it is important to employ adult learning methods when using this manual to train staff. See Table 1 for a summary of adult learning principles, adapted from J. Vella, 1994, Learning to Listen, Learning to Teach.

Effective trainers respect and build on the knowledge and experience that training participants bring with them. They use a mixture of teaching methods for the concepts and skills they want trainees to retain and apply. These methods include presenting to a large group, small group work and discussion, demonstration, role plays, and practicing new skills with feedback and discussion after. Teaching new skills effectively requires giving the learners opportunity to practice the skills in the context of the training, so that they can gain confidence in their ability to use the skill when they have returned to their jobs.

Planning a training using this manual

Linkages, in their manual, Behaviour Change Communication for Improved Infant Feeding: Training of Trainers for Negotiating Sustainable Behavior Change, January 2003, has defined six areas that should be addressed when planning a training. They are as follows:

Who: / The learners (what are their skills, needs, and resources) and the trainer (s).
Why: / The overall purpose of the training and why it is needed.
What: / The skills, knowledge, and attitudes that learners are expected to learn. The content of the training (keep in mind the length of the training when deciding on the amount of content).
What for: / The achievement based objectives-what will participants be able to do after completing the training?
How: / The learning tasks or activities that will enable participants to accomplish the “what for”.
Where: / The location, including details of available resources and equipment, and how the venue will be arranged.

Below is a sample schedule for a training using this manual:

Day 1
Introduction to the Behavior Centered Approach to Programming
9:00-9:45 / Participant Introductions
Review of Agenda
EXERCISE 1.1: Training Goals and Expectations
9:45-10:45 / PRESENTATION 1.1: Introduction to Theories of Behavior Change
EXERCISE 1.2: What Are Behaviors?
10:45-11:00 / Break
11:00-12:00 / EXERCISE 1.3: Internal and External Determinants of Behaviors
12:00-12:30 / EXERCISE 1.4: The Wall of Barriers
12:30-2:00 / Lunch
2:00-2:30 / EXERCISE 2.1: Participant Experiences with Behavior Change Interventions
2:30-3:15 / PRESENTATION 2.1: Approaches to Behavior Change
PRESENTATION2.2: Focusing programs on behaviors using The Behavior Centered Approach
3:15-3:30 / Break
3:30-4:15 / EXERCISE 2.2: The Continuum of Behaviors
4:15-5:00 / PRESENTATION 2.3 : The Behavior Centered Approach to Programming
5:00-5:15 / Review and Questions
Day 2
Designing and Implementing Strategies for Behavior Change
9:00-9:30 / Review of Day 1 and Agenda for Day 2
9:30-10:30 / Presentation 3.1: Situational Assessment
Exercise 3.1: Activities to Behaviors
10:30-10:45 / Break
10:45-11:30 / Presentation 3.2: Introduction to Formative Research and Methodologies
11:30-12:30 / Presentation 3.3: Formative Research Form
FIELD EXERCISE 4.1:Preparing for the Field Exercise
12:30-2:00 / Lunch
2:00-3:15 / Exercise 3.2: Planning Formative Research for Priority Behaviors
3:15-3:30 / Break
3:30-4:00 / Presentation 5.1: Developing a Behavior Change Strategy
4:00-4:30 / Exercise 5.1:The BEHAVE Framework
4:30-5:00 / Presentation 5.2: Developing a Communications Plan
5:00-5:15 / Review and Questions
Day 3
Field Exercise: Focus Group Discussions
8:30-9:00 / Assembly and Review of the Day
9:00-11:00 / FIELD EXERCISE 4.2:Focus Group Discussions
11:00-11:30 / Reassembly/Break
11:30-12:30 / FIELD EXERCISE 4.3:Research Groups Report Key Findings
12:30-2:00 / Lunch
2:00-3:00 / FIELD EXERCISE 4.4:Drafting Strategies Based on Key Findings
3:00-3:30 / PRESENTATION 6.1 : Monitoring and Evaluation
3:30-3:45 / Break
3:45-4:30 / EXERCISE 6.1: Incorporating Behavioral Indicators
4:30-5:00 / Review and Questions
Day 4
Planning the Behavior Centered Approach for Programs
9:00-10:00 / Review and Discussion of Behavior Centered Approach: Opportunities and Challenges
10:00-11:00 / EXERCISE 7.1: Situational Assessment for the Program: Prioritizing Behaviors
11:00-11:15 / Break
11:15-1:00 / EXERCISE 7.2:Assessing Gaps in Our Knowledge: Key Barriers, Motivating Factors, Feasible Practices for Priority Behaviors
1:00-2:00 / Lunch
2:00-3:00 / EXERCISE 7.2 (cont’d.): Planning Formative Research to Fill the Gaps
3:00-3:30 / EXERCISE 7.3: Planning the next steps after returning to the job
3:30-4:00 / Break
4:00-5:00 / Review and Questions
Training Evaluation

Notes on the Field Exercise

An important part of this training is the field exercise. Unit 4 describes the field exercise and subsequent training activities in detail. The exercise consists of splitting the group up into research teams, and giving each team the opportunity to conduct a focus group discussion, fill out the formative research form, and present results back to the main group. Participants can then use the results from the field exercise to practice designing a behavior change strategy.

The nature of the field exercise will depend on the purpose and context of the training. The trainer should work out the details of the exercise before hand, particularly as transportation and other logistics might be involved. Also, the trainer will need to notify the groups that the “research teams” will be talking to in advance. The trainer should draft some simple question guides in advance, which the research teams can help to modify as appropriate as part of Presentation 3. 3.

One example of a field exercise is breaking the group into two health teams (one to talk with women and one with men), and two agriculture teams (one to talk with women and one with men). The teams go into nearby communities for brief (one hour) focus group discussions on any topic related to their project. For example, “Using bed nets” for the health team, and “Soil conservation techniques” for the agriculture team.

If it is not feasible to go into the community to do the focus groups, research teams can talk to colleagues not participating in the training, or they can practice with the other participants, taking turns being the research team. These options will be less realistic as an exercise. In such a case the topic could be, “Starting a company exercise program”, or “Increasing savings in the provident fund”. If participants conduct focus group discussions with other participants or colleagues, it is important to note that they should not do “role plays”, responding as they think community members might respond, but that they participate as themselves, speaking from their own beliefs and experiences.

1

Draft March 2005

Unit

1

Why and How People Change Behaviors

Introduction

I

N order to understand how to develop and integrate behavior change strategies into your program, it is important to first develop a basic understanding of the theories behind behavior change, the nature of behaviors, and the factors that influence behaviors. This unit is designed to provide a basic background in these issues.

Learning Objectives

The learning objectives of Unit 1 are:

To reach agreement on the goals of the training.

To understand theories about behavior change and what they have in common.

To understand the characteristics of behaviors.

To understand some factors (determinants) that influence behaviors at the individual and group level.

Materials

The materials needed for this unit are:

Flipcharts

Overhead Projector

Markers

Masking Tape

Note cards or ½ sheets of paper

Unit Content

Exercise 1.1: Training Goals and Expectations

Presentation 1.1: Introduction to Theories of Behavior Change

Exercise 1.2: What Are Behaviors?

Exercise 1.3: Personal Experiences With Behavior Change/Determinants of Individual Behavior

Exercise 1.4: The Wall of Barriers

EXERCISE 1.1: Training Goals and Expectations

Key Messages: Understanding the goals of the training and sharing participant expectations.

Materials:

Overhead Projector or Flip Chart

Markers

Time: 15 minutes

FACILITATOR STEPS

Go around in a circle, asking each participant to say what she or he hopes or expects to gain from participating in this training. Give plenty of time for each person to answer. Ask if anyone would like to add anything.

Uncover a pre-written flip chart or transparency stating the goals of the training:

By the end of the training participants will:

  • Understand theories about how and why people change behaviors
  • Share personal and professional experiences with behavior change
  • Know about “best practices” in programs to change behavior
  • Know a process for developing, implementing, and monitoring effective Behavior Change strategies
  • Be familiar with some of the tools and methodologies in this process
  • Plan how to use this approach to Behavior Change in their program

Reflect on how the trainer’s and participants’ goals and expectations overlap or differ. Keep both lists of expectations/goals displayed throughout the training.

PRESENTATION 1.1: Introduction to Theories of Behavior Change

Key Messages: Theories of behavior change help programmers understand how and why people change their behaviors. There are several models of behavior change. They share common elements. We can use these common elements to think about how programs can enable change in beneficiary communities.

Materials:

Overhead Projector or Flip Chart and Markers

Handouts:

Participant’s Handout 1.1: Common Theoretical Factors

Participant’s Handout 1.2: Stages of Change Model

Time:30 minutes

FACILITATOR STEPS

I. Behavior Change Theories

Theories developed by social and behavioral sciences about how and why people change behaviors include :

  1. Health Belief Theory,
  2. Theory of Reasoned Action
  3. Trans-theoretical Model (also called the Stages of Change Model).

We are going to examine the common elements among all of these theories as well as exploring one model a bit further in order to better understand the processes that happen in behavior change.

II. Common Theoretical Elements

Place a copy of Handout 1.1 on an overhead projector or a piece of flip chart paper at the front of the room. Different theoretical models of how and why people change behaviors have many factors in common. Interventions in relief and development programs which are intended to bring about behavior change are more effective if they draw on these factors.

Ask participants to volunteer to read one row of the Common Theoretical Factors table out loud, and to try to explain in their own words what it might mean. Make sure to praise each attempt, then give additional explanation if needed.

III. Trans-theoretical or Stages of Change Model

Place a copy of the Trans-theoretical or Stages of Change Model in the front of the room (using an overhead projector or on a flipchart). Review the Theory as follows.

The Stages of Change Model represents:

  1. A process that an individual goes through when changing a behavior
  2. Individuals may progress through some stages faster than others
  3. Individuals may move back and forth between stages rather than moving in the same direction along the scale

Different types of behavior change interventions or messages are more effective than others depending on where the majority of the audience (those groups whose behavior they aim to change) is along the scale.

There are 6 phases in the scale:

  1. Pre-contemplation: People in this stage have no intention to change behavior in the foreseeable future, are unaware of the risk, or deny the consequences of risk behavior.
  1. Contemplation: People are aware that a problem exists, are seriously thinking about overcoming it, but have not yet made a commitment to take action.
  2. Intention: People intend to take action in the near future.
  3. Trial: People are taking inconsistent action to modify behaviors or environment.
  4. Action: People modify their behavior or environment to overcome their problems; the behavior change is relatively recent.
  5. Maintenance: People work to prevent relapse and maintain the behavior change over a long period of time.

Source: Adapted from Prochaska and DiClemente, 1986.

Ask for questions from participants. Participants will look at the stages of change model again related to specific behaviors.

EXERCISE 1.2: WHAT ARE BEHAVIORS?

Key Message: Understanding of the characteristics of behaviors creates a common language to discuss what changes are desirable and how program activities affect behaviors.

Materials:

Overhead Projector

Note Cards

Markers

Flipchart Paper

Masking Tape

Handouts:

Participant’s Handout 1.3: What Are Behaviors?

Time:30 minutes

Facilitator Steps

Ask participants to tell you what the characteristics of behaviors are; list responses on a large piece of flipchart paper. After participants have provided responses, distribute Handout 1.3: What are Behaviors?, and read it out loud. Draw comparisons between the participant list and the Handout.

Pass out a note card to each participant and markers. Ask participants to think of a time in their life when they or a loved one have successfully changed a behavior and write the behavior on the card. Examples could include starting an exercise program, changing a work habit, or saving a certain amount of money each week. Be sure to tell participants that these behaviors will be discussed among the group, so they may not want to use a very private example.

Collect the cards, mix them up and read each one out loud. Post each one as it is read in the front of the room (grouping any that may be the same or similar). Choose some behaviors and review the list behavior characteristics with participants: How is this behavior an action? Is it an observable or hidden action? How is it specific, measurable and feasible?

Exercise 1.3: Internal and External Determinants of Behaviors

Key Message: The ability of individuals and groups to adopt new behaviors is influenced by internal factors (personal beliefs, attitudes) and external factors (access to resources, social norms). These factors are called determinants and can either support or discourage change. Behavior change interventions must build on positive determinants and reduce negative ones in order to be effective.

Materials:

Cards from previous exercise with examples of personal BC

Flip Chart

Markers

Masking Tape

Handouts and Tools:

Participant’s Handout 1.4: Some Determinants that Influence Behaviors

Time:60 minutes

Facilitator Steps

Refer back to the personal examples of behavior change from the last exercise. Ask for volunteers to discuss their or their loved one’s experience with changing a behavior. To get the discussion going it may be helpful if the facilitator has an example ready. The answers to the following questions can lead into a discussion of internal and external determinants of behaviors.

  1. Why did you or your loved one want to change?
  2. What things helped you or your loved one to change? (Facilitator may probe for internal or external determinants.)
  3. What things made it difficult for you or your loved one to change? (Facilitator may probe for internal or external determinants.)
  4. Did the change happen all at once? How long did it take? Did you or your loved one go through different “stages” on the way to change?
  5. How would you advise or help others to make a similar change?

Facilitator should discuss each question separately and summarize responses to each question on separate flip chart pages taped at the front of the room.