Introducing FOAM:Focus, Opportunity, Ability, Motivation

A draft behavior change model for

HW programs

Dakar, May 29, 2007

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Overview of Presentation

Background

Behavior change models

The Hanoi Workshop

Next steps

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Background

Many tools available (eg. Handwashing Handbook)

All stress audience-centered programming

Lack of holistic model to explain all factors influencing HW

Global Scaling Up HW Project presents an opportunity Learning objective Common framework

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What is a BC Model

Diagram that represents the various “determinants” of behavior change “Determinants” are internal or external factors that

influence an individual to perform a behavior

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Advantages of a BC Model

Provides a common language Identifies critical linkages Informs M&E Enables evidence-based and comprehensive

programming Can be adapted across populations

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Foundations of BC Models

Draw on disciplines such as public health, marketing, communication, advertising, business, social psychology and consumer behavior

Foundations include Health Belief Model, Theory of Reasoned Action and The Stages of Change which have been studied extensively

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Two Examples of BC Models

WB’s BC continuum PSI’s PERForM

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World Bank BC Continuum

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PSI’s PERFORM

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USE RISK -REDUCING BEHAVIOR

HEALTH STATUS QUALITY OF LIFE

OPPORTUNITY ABILITY MOTIVATION

POPULATION CHARACTERISTICS

SOCIAL MARKETING INTERVENTION

PRODUCT PLACE PRICE PROMOTION

AT RISK

Attitudes Belief

Subjective Norm

KnowledgeAvailability Brand Appeal

Quality of Care

Threat

Outcome Expectation

Intention Locus of Control

Willingness to Pay

Self Efficacy

Social Support

Social Norm

Brand Attributes

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Examples of PERForM Applications in Cambodia

Data: 2003 sero-surveillance: 42% new HIV/AIDS cases from

husband to wife Formative research: low condom use with trusted

partner due to 1) low perceived risk and 2) low social support – confirmed later through TRaC survey

Number One: widely available (over 95% of brothels) and affordable but associated with commercial sex

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Examples of PERForM Applications in Cambodia (2)

Program responses: launch of OK Condom “Klahan” (Be brave) BCC campaign

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OK Condom

Marketing strategy: Different product launched with family planning positioning in

2004 Differentiated distribution channels from Number One condom Advertising and promotion includes mass media and

sponsorships

Key results: Total condom sales in Cambodia grew from 20 million in 2004

to over 25 million in 2006 OK Condom’s share at 10% of total sales

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Klahan BCC Campaign

Aimed at building social support and improving personal risk perception among trusting couples

Integrates mass media (8 TV and radio spots), mobile video units, website and outreach through NGO peer-educator networks

Key determinants and exposure tracked through TRaC annual surveys

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Spots

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Generic Vs Branded

Generic (BCC) campaigns aim to change knowledge, attitudes and beliefs related to intended behavior and/or build “primary” demand for product category

Branded build “secondary” demand for product

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Generic Vs Branded (2)

PSI generally does not put product brand on “generic” or BCC campaigns: Enhances credibility Facilitates stakeholder buy-in Facilitates use by partners

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PERForM and M&E

TRaC = annual targeted KAP-type surveys Compares those who perform the desired

behavior to those who do not Identifies key determinants correlated to desired

behavior Establishes dashboards, allows for monitoring

and campaign impact evaluation

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The Hanoi Workshop

Held April 24-27, 2007 Participants included HW Coordinators,

GoV/MoH and Global team Facilitated by a communication consultant Key objective: develop a global behavior change

model for the “Scaling up HW Behavior Change” project

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Process

1. Agreement on expectations and parameters

2. Review of existing frameworks

3. Overview of research and theories on change

4. Country/regional presentations

5. Identification of relevant determinants for HW

6. Decision to group determinants under opportunity, ability and motivation

7. Development of draft BC model FOAM

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F in FOAM

Focus: desired behavior (consistent

HW at critical times)target populations

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O A M

Opportunity: institutional or structural factors that influence an individual’s chance to perform a behavior

Ability: individual’s skills and proficiency to perform a behavior

Motivation: drives, wishes, urges, or desires that influence an individual to perform a behavior

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Access/availability

Product attributes

Social norms

Knowledge

Social Support

Attitudes & beliefs

Intention

Expectations

Threat

Focus Opportunity Ability Motivation

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Opportunity

Availability/access: ease of obtaining the cluster of goods and services needed for the behavior

Can I get water/soap when I need it?How far to go to get it?Is there water and soap when I wash hands? What is the price?Can I buy it when I need it?Am I able to make the decision to buy soap?Who makes the decision to buy soap?

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Opportunity (2)

Product attributes: perceived or actual characteristics of goods and services

Does soap smell good?Does water look clean?Is the color (soap or water) nice?Is it anti-bacterial? Is the soap agent I have at home

appropriate for all critical times?

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Opportunity (3)

Social norms: behavioral standards which exist in the community for an individual to follow

Are people around me washing their hands with soap?

Who around me is washing hands?

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Ability

Knowledge: true facts accumulated through learning about objects, actions, and eventsDo I know why HW is important? Do I know that washing with water is not good

enough?Do I know when to do it? Do I know that germs that are invisible can make

me or my child sick?Do I know that HW can prevent my child from

getting diarrheal disease and ARIs?

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Ability (2)

Social support: Physical, emotional, or informational assistance an individual or community gives or receives for a behavior

Has anyone talked to me about HW?Has anyone helped me to HW?Has anyone made me feel good about

HW or rewarded me?

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Motivation

Attitudes and beliefs: perceptions or mental positions about a product or behavior. Evaluations or assessment of a product or behavior which may or may not be true.

Do I believe that HW is necessary? Do I believe that HW improve my child’s health?Do I think that all soaps the same and equally

effective?

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Motivation (2)

Expectations: what an individual thinks will happen as a result of performing the behavior.

Will washing my hands reduce my child’s immunity?What will others think of me if I HW? How much do I

care what they think (subjective norms)?What do I think could happen if I HW? What if I do

not HW? Does God/fate decide whether my child will suffer

from diarrhea or ARI (locus of control)?

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Motivation (3)

Threat: perceived danger or harm associated with performing or not performing the behavior

How likely is my child to get diarrhea or ARI (susceptibility)?

How dangerous is diarrhea or ARI for my child (severity)?

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Motivation (4)

Intention: individual’s plan to perform or facilitate the behavior

Am I planning to install a HW station?Next time I go to the toilet/feed my baby

am I going to washing your hands with soap?

How much am I willing pay?

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From Model to Practice

FOAM can be integrated into existing tools and frameworks

Enables full marketing mix vision Informs monitoring/MIS Informs the formulation of communication

objectives in the advertising brief FOAM Operational Matrix (FOM) can be used for

planning purposes

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Enabling Environment

Population Characteristics and HWWS Behavior

Research

Focus

Opportunity Ability Motivation

Key determinants

Marketing mix

Program Objectives

Product

Monitoring and evaluation

Price Place Promotion

Implementation

1

2

3

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Concept & Message development

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Channel Choice

Advocacy development

Communication Strategy

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FOAM Operational Matrix (FOM) from VN

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Next Steps

Feedback from PPPHW BCC sub-working group and SC Country-level validation/training workshops

Vietnam workshop tentatively planned early July Tanzania FOAM workshop planned for mid July

Identification of key determinants to be tracked in household surveys based on formative research

Inclusion of FOAM communication objectives in advertising agency briefs and spot formative research

Training or TA on application of FOAM for HWTM