A View From SiB – Behaviour Change Communication

Behaviour Change Communication

What is Behaviour Change Communication?

As several of you who have met me on a project visit already know, Behaviour Change Communication (BCC) is a topic I’m passionate about. Each word on its own seems to have a clear and unambiguous meaning. We know what we mean by the words: ‘Communication’; ‘Behaviour’; ‘Change’. But put them all together and exactly what is BCC? And where do you start in the health sector?

One short way to define BCC is:

“BCC is the comprehensive process in which one passes through the stages: Unaware > Aware > Concerned > Knowledgeable > Motivated to change > Practicing trial behaviour change > Sustained behaviour change”


We know, in even long standing and well-resourced projects (such as a cataract project) that many people and especially many women, do not come for eye care and especially not for surgery, or delay for years, for a whole range of issues in the continuum mentioned from the wiki site above. But what are the key barriers for the target audience in the local communities where you work?

So for your BCC strategy to be effective, it needs to be clear how the various communications options and activities will help to change people’s behaviour. But a key issue for eye care is exactly what knowledge and attitudes do you need to change to create the behaviour required – attendance at your eye care services, or adherence to a treatment regime etc.

Patient blockages – supply side

Also you need to separate the supply and the demand side issues.

So consider the “blockages” or “obstacles” that prevent people accessing your services from the supply side. These obstacles are due to service delivery factors:

  • The distance
  • Pricing
  • Space at the hospital
  • Staff training and recruitment
  • Transport
  • Clinic days or hours
  • Staff attitudes etc

And to address these issues you will need to conduct advocacy with policy makers, local officials, managers and staff at the clinic etc. And it is important to influence these people. These activities are under a specific range of targeted information sharing and lobbying that falls under a banner of “advocacy”,  as well as staff training.

The materials developed and meetings that are held with policy makers and ministry of health officials and staff will be different from any BCC approaches and materials that need to be developed for the local community and their key opinion leaders.

Patient blockages – demand side

The “blockages” (also sometimes called vulnerabilities or risk factors) BCC aims to work with on the demand side, are targeting the local community. BCC will aim to address local issues where your project is active.

These could be:

  • Belief’s about effectiveness of your services
  • Fear in general or pain in particular
  • Lack of access to family resources
  • Previous stories in the community about your services
  • Traditional and local practitioners not referring
  • Fatalism
  • Lack of self-worth
  • Incorrect information
  • Low priority in the family
  • Feeling of exclusion
  • Incomplete information about treatment or services
  • Confusion about any fees or costs
  • Lack of information on clinic days

The list goes on and on. The key issues will be different in different communities. And so effective strategies to unblock the issues will also vary.

Importance of KAP surveys

As the list of possible blockages above demonstrates, it is not just knowledge about eyes and eye care services that is important, it is also people’s attitudes, beliefs and behaviours, some of which are ingrained in a community. That is why to plan a good BCC strategy you need first to conduct a survey that includes people’s attitudes and behaviours. The best known of these are KAPs – Knowledge, Attitude and Practices – surveys. These have a long history within health service planning and in all countries there are experienced individuals and organisations who can quickly and efficiently work with eye care teams to plan such surveys and feedback results in an accessible format.

This information is necessary to feed into your BCC strategy planning. And will guide you where to put your efforts to achieve specific behaviour change. In planning for a KAP you target key segments of the population – from your clinic data you will know that key target groups are not accessing your services in the numbers or proportion expected. A key weakness still in many eye care projects is that women and especially elderly women are not presenting for services at the levels expected.

In this newsletter, Sightsavers Sierra Leone report on their KAP study and how they will use it to inform their new BCC strategy.  click here.

BCC Strategy – Key Points

From the “Health Communication Capacity Collaborative” website I found this useful way to start to consider the many issues that need to be considered when planning your BCC strategy and where to focus your efforts:

Social and behavioural change communication uses science and data as well as creative ideas to focus on:

  • Changing or positively influencing social norms in support of long term, sustainable behaviour change at the population level
  • Fostering long-term normative shifts in behaviour in support of increasing the practice of healthy behaviours
  • Improving health services provider-client interactions
  • Strengthening community response to issues
  • Influencing decision makers and family and peer networks
  • Increasing demand for health services and products
  • Increasing correct use of health services and products
  • Influencing policy
  • Encouraging an increased capacity for local planning and implementation of health improvement efforts.


As the “Health Communication Capacity Collaborative” then suggests on their website, there are many steps that need to be considered for any one of these approaches listed in the box above. These steps help guide in developing a clear BCC strategy that will take a whole group of people from being “unaware” (or wherever they are on the continuum presently) through to a “positive and sustained new behaviour”.

Specific blockages for women

To refer to an issue that I know many of you still encounter: Women with cataract do not come for cataract surgery – sometimes even after you have seen them, diagnosed the problem and invited them to come for surgery. Still they do not attend.

To unpack the blockages / vulnerabilities / risk factors / obstacles (whatever words you use to you consider the issue) you can look at the continuum and consider where key “blockages” are in your community.  Unaware > Aware > Concerned > Knowledgeable > Motivated to change > Practicing trial behaviour change > Sustained behaviour change

I cannot generalise and hence whisk you through the steps you might need to go through in your location to start to understand any specific knowledge gaps, fears, financial and distance barriers, fatalism, use of ineffective traditional healers, need for family permission…..whatever will need to be addressed to enable access to and uptake of eye care surgery / services to improve… but I can suggest that communication does need to consider all the local barriers and then devise strategies to help people overcome them.

Orbis Zambia has undertaken a specific study looking at the “blockages” for women in their community, and how this will now inform their project design. This research article can be accessed  here.

Strategies to address blockages

And then deciding “how” to address the relevant issues is the next step to be considered….

For example:

  • helping people in a community to talk about an issue, helping them to find words to bring up the subject within their family; providing information about the procedures, the time, the location of effective services
  • helping families know costs and of any subsidies or financing mechanisms available to help meet those costs
  • introducing people to the nurses or even surgeon
  • introducing people to a previous patient (a satisfied customer)
  • improving counselling services to address specific fears and apprehensions
  • improving information available in various formats
  • using specific elder groups to get older people to jointly talk about their feelings of being entitled to health services
  • involving traditional healers to get them to refer patients to you
  • asking local medical practitioners, refractionists or optometrists to promote your services

These are all possible issues that need to be considered for your communication strategy. But without doing the research to know what are the key issues in your location you will not unblock the reasons.

Sightsavers India’s article explains how they worked with various community groups to inform and  encourage people to access local eye health services. Access here.

BCC strategy Aims & Targets

BCC is different from ordinary instructional method of communication and is target specific. A society consists of many sub-groups. The strategy for BCC will vary depending on your key audience.

A successful BCC requires lots of research and meticulous planning about knowledge levels around eye problems and eye care and behaviour/attitude pattern of the target group. But at a minimum what BCC aims to achieve is:

  • Increase knowledge
  • Stimulate community dialogue
  • Promote essential attitude change
  • Advocate for policy changes
  • Create a demand for information and services
  • Reduce stigma and discrimination
  • Promote services for prevention and care

Measuring BCC strategies

A leaflet explaining cataracts, or a new billboard explaining your hospital’s new pricing structures, is not a communication strategy. These two examples are simply giving information or messages, in one or other medium. This ‘giving of information’ may be necessary, but is not sufficient on its own to form a BCC strategy or campaign. BCC is more than a one-off activity – what is needed is a reasoned and costed BCC strategy.

Plan for clear expected outcomes that you can measure (at the population level). You will then also be able to evaluate whether you got value from your BCC activities.

One quick way to measure impact of BCC strategies are patient exit interviews, where staff ask patients (a limited number) of questions: eg how or where they heard about the services, how long had they known about their eye problem, what was the key deciding factor that made them attend now, what was their experience here, would they recommend the eye unit to a family or community member etc.  This is very useful information, as if you have recently developed new BCC approaches, to learn what strategies are working in your community, to inform future planning.

Good regular data collection will also help. Eg  where community health workers are referring patients up to the district hospital, to then track the numbers of patients who attended. Or, of those patients who were identified with cataract, who actually had surgery. So you can monitor which people with eye problems are still ‘slipping through the net’.

Fred Hollows Foundation Vietnam 2013 paper ‘Attitudes of parents, students and teachers towards glasses use in Hanoi and Ho Chi Minh City’ reviewed attitudes in more depth barriers to children not only accessing services, but also, are they wearing the spectacles they have been provided with? and if not, why?  Giving useful information for future planning. Access here.

How to get your messages to the public

BCC should be creative. It should involve all the mediums that your key audience can access or use:

  • Radio
  • TV
  • The web
  • phone and SMS messages
  • Leaflets
  • Dramas
  • Newspaper articles
  • Events such as WSD
  • Billboards
  • Phone-ins

…. and also delivered at various locations:

  • The local market place
  • The bus stop
  • The elder clubs or old people’s homes
  • At the clinic
  • At the optometrist
  • In schools or libraries
  • Adverts on the buses or trains
  • The wider hospital setting.

Cross referencing and reinforcement of your key messages across various mediums will help “get your message across”.

Fred Hollows Foundation Vietnam helped promote two writing contests. One was an online writing contest for students in Tien Giang province, where 10,299 students studied and then wrote articles about Refractive Error.  Both contests involved many groups and organisations, and publicised eye care issues to an even wider audience, helping promote new eye care services.  Access here.

Example of effective BCC

And BCC should, when appropriate, be fun.

The best BCC campaign I have been involved with kicked off in cinemas in a capital city. Our target audience was a captive audience – they had even paid to come in! We were one of the adverts prior to the main film. So we had shot our own mini-advert, but we also had informal and fun discussions (carefully pre-scripted and delivered both by health and communications staff) with the audience on the contents of our mini-advert – complete with spot lights, pop-up surprises within the audience, free handouts; even prizes. We had factual leaflets and posters in the foyer alongside the sweets and popcorn – we had even branded the popcorn holders. We asked everyone to sign up to our text alerts (before switching their phones off!).  We recruited ambassadors to our cause there and then.  But we aimed to be a sensation, and we were memorable!  And we had a fun week being the “new infotainment” in the cinema advert offer. Next we took our key messages and branding out into our more mainstream BCC campaign. We had learnt a lot about our key audience (and the advertising world!) during our KAP, planning and pilots, but during the interaction with them in the cinemas their enthusiasm and engagement influenced the wider roll-out of the whole campaign. They energised the whole campaign (camel races anyone?).

And we could, finally, measure a positive change in people’s health seeking behaviour – which is what it is all about.

Sally Crook

SiB Programme Manager



June 2016