Behavior change communication (BCC) can help to mobilize individuals, families, and communities to reduce the risk of mosquito bites and embrace the dengue vaccine
The anti-dengue arsenal is growing. New insecticides and diagnostics, GM mosquitoes, better surveillance systems and the first dengue vaccine, along with smart mosquito control practices, have the potential to dramatically reduce the burden of the disease. But these tools are only useful if they are used.
Modern behavior Change Communication (BCC) techniques could help to turn the tide against dengue fever in Asia, according to Muhammad Shafique, Malaria Consortium Regional Behaviour Change & Communications Specialist.
In an interview with Break Dengue (see full transcript below), Muhammad questions the effectiveness of some information, education and communication materials designed to improve community health. Instead, he calls for more evidence-based strategies that mobilize communities to play an active role in adopting healthy behaviors.
“We should discourage the ad hoc allocation of money for the development of information, education and communication (IEC) materials and some volunteer training which is then labeled as BCC,” he says. “This practice has limited effectiveness and always brings into question the BCC approach. When there are setbacks, it further erodes the trust of donors on the approach.”
Outmoded information and communication materials should be swapped for up-to-date strategies that try not only to inform but to change behavior, he says.
“There is a huge knowledge-practice gap regarding malaria and dengue in these communities,” says Muhammad. “Many surveys have revealed that most people know the causes of dengue but they do not practice the required behaviors to prevent mosquito breeding. That means something is missing in our existing BCC strategies, which focus more on knowledge than actual practices.”
Establishing village health committees, training local volunteers and highlighting local examples of healthy behaviors are among the approaches that the Malaria Consortium has found to be effective in the past. The organization is already turning its attention to how this way of thinking can be applied to dengue fever, building on its experience and a growing body of research in the field of BCC.
BCC is gaining momentum and will be one of many topics tackled at this week’s Aid and International Development Forum (AIDF) Asia Summit in Bangkok (21 & 22 June).
Interview: Muhammad Shafique, Malaria Consortium Regional Behaviour Change & Communications Specialist
What can behavioral change communication bring to the fight against dengue?
Behaviour change communication (BCC) can play a very important role in fighting dengue. Firstly, it helps us get a grasp on a community’s existing knowledge, beliefs, perceptions and behaviors with respect to dengue prevention and control. This, in turn helps us to develop tailored and culturally appropriate BCC strategies to improve their health.
Do you think this field has gained momentum recently? Have books like ‘Nudge’ and ‘Thinking, fast and slow’ helped governments and funding agencies to take it more seriously?
I believe BCC is gaining momentum. National programs and donors have started to understand the importance of BCC in health programs. However, these initiatives still need to be well planned and incorporated into projects at the proposal/design stage, with clearly chalked out BCC activities and processes. BCC activities should include all the usual steps, including formative assessments to ensure the development of context-specific strategies and tools. We should discourage the ad hoc allocation of money for the development of information, education and communication (IEC) materials and some volunteer training which is then labeled as BCC. This practice has limited effectiveness and always brings into question the BCC approach. When there are setbacks, it further erodes the trust of donors on the approach.
Do some campaigns still rely too heavily on the ‘deficit model’ of communication: giving people information and presuming – or hoping – they will take action instead of taking a closer look at motivations and barriers to action?
Unfortunately, most campaigns are expert-driven and focused on developing messages and IEC materials. In many cases, BCC strategies are developed without any formative assessment which means they lack a basic understanding of context, perceptions, social, cultural and economic barriers and behaviors of the community members. As a result, the desired objectives are difficult to achieve. Another main reason for failure is the lack of community participation and engagement in the change process. The communities are considered to be passive recipients and are not involved in the planning or implementation process, which further alienates them from the interventions.
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The communities – volunteers and community-based organizations – should be given a key role in project implementation so that they own the project. When they are actively involved, they are partners rather than recipients and feel accountable for the success or failure of the project, which ensures their ownership and fosters sustainability. To succeed, the strategies and campaigns should be context-specific, well-informed and based on the actual needs of the communities. They should be supported by the appropriate theoretical models in order to influence sustained behavioral changes in the target communities.
Are there any examples of campaigns that led to behavioral shifts that have had an impact on dengue fever?
I am not aware of any examples yet. This is an area of innovation for Malaria Consortium.
Despite knowing how to reduce the risk of dengue, many people do not practice good household mosquito control. What do you think are the barriers to overcoming inertia in this area?
There is a huge knowledge-practice gap regarding malaria and dengue in these communities. Many surveys have revealed that most people know the causes of dengue but they do not practice the required behaviors to prevent mosquito breeding. That means something is missing in our existing BCC strategies, which focus more on knowledge than actual practices. Another issue is the use and repetition of similar knowledge-related messages and materials, which were developed long ago and do not correspond to the actual needs and ‘stages of change’ of the communities. Therefore, we need to review and revise our BCC messages/materials and strategies on a regular basis and develop motivational messages to further encourage communities to take action.
Communities also need some support mechanisms at the household (family) and community levels, and access to diagnosis and treatment health facilities in order to perform or continue the recommended behaviors. Community volunteers and community-based organizations/structures, if revitalized and mobilized, can also play a positive role in encouraging community members to modify their behaviors to prevent dengue more effectively. If the community is provided with health education through culturally appropriate channels and receives proper support from other local or national institutions/sectors, there is a better chance that they will follow positive dengue control behaviors to stop mosquito breeding in their communities.
What is positive deviance and can you give an example?
Positive deviance (PD) is an innovative, asset-based behavior change approach that looks at and builds on the assets or strengths of the community, on what is already working in the community. A one-week interactive process with communities helps us understand the context and existing behaviours around the health issue (a component which is missing in most BCC approaches) and identifies ‘positive deviant’ individuals who, despite living in the same environment and sharing similar risks, occupations, and socio-economic resources as others in the community, manage to have better health outcomes than their neighbours and peers.
The PD approach focuses on existing behaviors or practices and shares these simple, local and easily replicable behaviors with other community members via the actual PD role models or volunteers. The PD role models serve as evidence of the effectiveness of the behaviors, which encourages their peers to more readily accept their easy-to-adopt local behaviors. In contrast to other deficit-based BCC approaches, which find faults and problems in a community and aims to fix them, positive deviance puts emphasis on existing positive behaviors of communities and encourages others to follow.
A new vaccine is available for dengue fever. What are the barriers to increasing vaccine uptake?
First of all, we need to create demand for the vaccine through focused BCC campaigns using culturally appropriate channels of communication. The major barriers to vaccine uptake will be a lack of knowledge, accessibility, affordability and availability. Therefore, we need to improve community knowledge about the vaccine – its effectiveness, importance, benefits, affordability and availability.
In the ASEAN region, do you think vaccine hesitancy (or even anti-vaccine sentiment) is a problem? Or it is more to do with access, affordability and so on?
As far as I know, there is no hesitancy towards vaccines in these communities. The important thing is that we need to create demand for the vaccines and ensure a regular supply is maintained and that the community has access. The community will only pay for a vaccine when they understand that its benefits will outweigh the costs – for example, if they can work extra days to earn more money, instead of being sick with dengue. Overall, a strong public-private partnership is required for the social marketing of vaccines at affordable prices in these communities.
This week’s Aid and International Development Forum (AIDF) Asia Summit in Bangkok (21 & 22 June) includes sessions that address community health, mobilizing communities for development projects and vaccine adoption.
|Example of a positive deviant from the Malaria Consortium PD dengue project:
Ma Su Lei Yee is a 25-year-old farmer who lives in Sein Pan Kone village, Hinthada, in southwest Myanmar. She and her family have never had dengue despite living in a community that has a high risk of transmission. She understands that dengue is caused by mosquitoes that bite during the day.
To prevent mosquito bites, she always wears long-sleeved clothes and sleeps under mosquito nets during the day time as well. She always covers the big water containers, changes water in small containers every 2-3 days and changes her Buddha flower vase regularly to prevent mosquito larvae from forming. She cleans the household surroundings and fills in the ditches with sand, especially in the rainy season, to avoid larvae breeding. She removes empty cans, coconut shells and turns extra containers upside down to avoid larvae growth. She recognizes the signs and symptoms of dengue and goes for early diagnosis if she has a fever. “If a patient does not get an early diagnosis from a health facility, he or she can die with dengue fever,” she said.
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