I. Initiation

a) Launch of the process

Behaviour-change interventions cost money and time, and add complexity to programmes and projects, so they need to be carefully considered. They should be used when necessary to address behaviours that are high priority for achieving the project objectives and that may be difficult to change without a specific focus. The list below shows some of the things that make behaviours difficult for people to change, and which might therefore justify a behaviour change intervention.

• Is ongoing or frequent (handwashing with soap).
• Requires complex skills (recognising and managing diarrhoea in the home).
• Does not produce immediate results (tree planting).
• Takes time and effort (collecting drinking-water from a safe water point rather than an unsafe surface source).
• Costs money (sleeping under an insecticide-treated bednet).
• Is socially unacceptable (men helping their wives with household tasks and childcare practices).
• Requires many people (keeping communal toilets clean).
• Involves multiple steps (doing three or more ante-natal clinics during pregnancy).
• Involves complex or new technology (doing household water treatment with unfamiliar equipment or products).

b) Behaviour change focus

It is important right at the start of the behaviour-change process to define clearly the behaviours to promote, so that:

• They can be understood by project staff, the people who are intended to practice them and the people around them;
• They can be measured and reported on objectively;
• The barriers, enablers and motivators to adopting them can be analysed and influenced.

In Action Against Hunger projects there are a number of standardised and internationally agreed behaviours to be promoted, based on evidence of their importance for health and nutrition. They are included in the organisation’s project management guidelines and should be systematically promoted by the different sectors of intervention. Here are some example behaviour indicators from the Action Against Hunger Multisectoral Monitoring and Evaluation Guidelines:

• WASH: Percent of households disposing children’s stools in protected latrines/toilets or otherwise using hygienic means of disposal.
• MHCP: Percentage of caregivers using appropriate weaning methods with their children.
• Nutrition and health: Proportion of children < 5 years who sleep under an insecticide-treated bed net (ITN).
• FSL: Percentage of households meeting minimum Household Dietary Diversity Score (HDDS).

These behaviours are well described and can be measured and reported using standard procedures. There are many other potential behaviours though that are important for achieving project objectives and that need to be defined in each context. For example, an intervention for community management of acute malnutrition may be affected by problems such as children who fail to respond to treatment and children who relapse after having been discharged as cured.

In both cases, there may be a number of caregivers’ behaviours that explain this, such as inadequate care practices in the home or inappropriate use of therapeutic foods. These behaviours need to be identified and then alternative behaviours clearly defined in each context so that they can be acted on through behaviour-change activities.

Defining the behaviours to promote may require some research, to ensure they are acceptable and feasible for the people who are intended to practice them. They may need to be adapted to take account of local conditions and preferences. The TIPs approach (Trials of Improved Practices) is one way to do this. Selected households or individuals are asked to trial a new behaviour and then give feedback on the experience, so the behaviour can be adjusted if needed, and so as to learn about barriers and enablers to its practice. This then becomes part of the Analysis stage.

It is also important to identify and describe the people who will be involved in practising the intended behaviours (the ‘priority group’), so as to target them appropriately and effectively in the behaviour-change intervention. Key aspects to describe include the following:

• Their socio-demographic characteristics;
• Their way of life and daily routine;
• Their current practices, knowledge and attitude regarding the behaviour;
• Their traditions or cultural beliefs linked to the behaviour(s) in question;
• Their stage of change related to the behaviour(s);
• Gender roles and dynamics.

Pages 17 to 23 of the ABC Formative research Guide provide tips for doing a literature review and a community assessment to find out about the priority group and community perceptions of the behaviour. See pages 72 and 73 of the Designing for Behavior Change Training Manual for a framework for summarising and presenting this information.