1. Designing for Behavior Change to Increase Access to Health Services in Madagascar Prepared by Mr. Elysée Ramamonjisoa and Ms. Linda Morales Presented by Sabrina Eagan Community-Based Integrated Health Program (CBIHP/MAHEFA) 4 November 2013

2. Context Community-Based Integrated Health Program, also known as MAHEFA, is a 5-year USAID- funded program in Madagascar Implemented by JSI Research & Training Institute, Inc and two international partners: The Manoff Group and Transaid and 19 Malagasy NGO partners North and west of the island (6 regions, 24 districts and 280 communes) MNCH/FP and water/sanitation Roughly 20-25% of the Malagasy population or about 3.5 million people 2

3. 3 Context

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5. What are the most powerful barriers and motivators to behavior change in each region? Who are the key influencing groups per behavior? What are the feasible actions for specific behaviors? What materials already exist and are they appropriate for our regions? What channels exist and which are most effective in reaching priority groups? Behavior-Centered Programming: Key Questions

6. Data collection method: face-to-face qualitative and quantitative surveys (3000 individual interviews conducted) The study universe: individuals named priority groups with specific characteristics relating to behavior 15 behaviors studied (MNCH, WASH) Two regions covered: Menabe and Sofia Results: Identification of major barriers and important motivators for each behavior Steps for Behavior-Centered Programming: Formative research

7. 7 Right/adequate formulation of the behavior to be promoted Priority group’s position on the BC scale (awareness, attempt) and identification of their groups of influence (e.g., spouse, MIL) Main barriers and key motivators Act on perceptions to minimize barriers and promote motivators Research results Decisions based on research results Behavior Description of priority group and groups of influence Determinants Key factors guiding activities Activities for target priority group Steps in Designing for Behavior Change: DBC Matrix

8. Address and offer solutions to problems/ difficulties experienced by the priority group in practicing the behavior Help maintain beneficial health behaviors already practiced by the priority group Are high visibility to mobilize the community Favor the promotion of community dialogue to find local solutions to local problems 8 Steps in Designing for Behavior Change: DBC Matrix Behavior Description of priority group and groups of influence Determinants Key factors guiding activities Activities for target priority group

9. 9 Behavior Description of priority group and groups of influence Determinant s Key factors guiding activities Activities for target priority group Research results Decisions based on research results Mothers of children under five treat their water every day, year round, and in all relevant locations  Mothers with children under five living in rural areas  Low literacy level  Poor families, needy  Participate in women’s group meetings  Want improved living conditions  Positive influence group is husbands Perceived self-efficacy barrier: lack of firewood Improve the perception of mothers of children under 5 that the lack of firewood can be solved by using other methods of treatment (SODIS, Sûr'Eau) CHW collaborates with the women’s group to organize a water treatment demonstration session where both SODIS and Sûr'Eau methods are shown DBC Matrix

10. 10 Lessons Learned: Locally tailored approaches Implementation steps for locally tailored approaches are in the Guide & Solutions manual for CHWs Examples: Care group: a family that has correctly adopted a healthy behavior then help other families in the community to practice the behavior Carnival: high visibility activity to mobilize the community for important health events (campaigns, international health days Demonstration: an approach to demystify unfamiliar practices for healthy behaviors, e.g., treating water with Sûr’Eau

11. 11 Lessons Learned: Channels of Communication: CHWs CHWs are trained on message transfer techniques and Behavior Change Empowerment approaches for interpersonal communication and group discussions

12. Lessons Learned: Tools to promote BC Maternal and child health flip charts developed by previous projects were updated and adapted according to research findings, and disseminated to community health workers.

13. Tool based on research results, with: - 17 approaches to reaching priority groups - Gender scenarios Approaches & scenarios are informed by: - Description of the main barriers to practicing certain behaviors - Description of the motivators perceived by those who practice the healthy behavior - How to direct the priority group on the choice of actions to take - Proposed solutions for the priority group to overcome barriers Lessons Learned: Tools to promote BC CHW Guide and Solutions

14. 14 Lessons Learned: Channels of Communication: Radio Mass communication through radio broadcasts and Village Listening Groups -Local radio stations broadcast messages on health, WASH and gender -Members of Listening Groups listen to the broadcasts and discuss issues raised, such as emergency transport or protection of water sources, to try to find solutions together

15. 15 This presentation is made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of JSI Research &Training Institute, Inc. and do not necessarily reflect the views of USAID or the United States Government. Thank you for your attention ! For more information, please contact eramamonjisoa@mahefa.mg eramamonjisoa@mahefa.mg lmorales@mahefa.mg seagan@jsi.com