India in global stage is aspiring to be a powerful country with its potential powers in various field but the policy makers and governments ended acting a feeble role due to lack of providing the basic amenities to people. Average poor people struggle to get basic health facilities and proper sanitation. Most of them are unaware of various health hazards, for example, about the unsafe cause of open defecation. Population explosion, high maternal mortality and infant mortality rate were observed in India. Lower rate of health literacy and cultural taboos made worsen the situations. There were urgent needs felt to enhance the health literacy among marginalised people and empowering them. Thus, government health policies are made to harness BCC strategies to fight the superstitions and myths from society. In 1951, policy makers recognised health education as one of the major components of health care delivery system. “In 1946, the Health Survey and Development Committee, headed by Sir Joseph Bhore recommended the establishment of a well- structured and comprehensive health service with a sound primary health care infrastructure. It was in this context that the concept of health promotion and health education were introduced to achieve desired outcomes” (Public Health Resource Network, Book 05, 2007, p. 6). Empowerment of rural folks on health education was named as IEC (information, education, communication) which in course of time harnessed with BCC programmes (Behavior change communication). BCC strategies are mainly part of development support communication and involve participatory action research which came out as critique of dominant paradigm of development communication.
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“Criticism of earlier approaches to health communication has resulted in development of the term “behavior change communication” (BCC), but so rapidly is the term BCC becoming associated with persisting past practices that one would not be surprised if there is done- from its current approach to an approach which involves the active participation of the community in directing the design of a strategy appropriate to social and cultural contexts which promotes good health and reduces their risk for ill health” (Public Health Resource Network, Book 05, 2007, p. 7). The book, Public Health Resource Network (2007, p. 2-3) defines BCC as, “understanding people’s situation and influences, developing messages that respond to the concerns within those situations and using communication processes and media to persuade people to increase their knowledge and change the behaviors and practices that place them at risk……………………… In the BCC approach, there is more conscious focus on the receiver- rather than the sender- as the center of communication. Earlier IEC programmes tended to see their purpose as having to “sell” a particular message or idea. The BCC approach recognises individuals within the intended audiences as active, rather than as passive receivers of information and messages, who act on messages only if they are seen as advantageous or useful. In BCC approach there is greater appreciation that the audience may need new skills and social support to make and maintain behavior change.” One way process of communication of IEC compelled to introduce BCC process as a part of development process of communication. Neill Mckee (2002), defines BCC as, “research based consultative process of addressing knowledge, attitudes and practices through identifying, analysing, and segmenting audiences and participants in programmes and by providing them with relevant information and motivation through well-defined strategies, using an appropriate mix of interpersonal, group and mass media channels, including participatory methods” (cited in BCC strategy for NRHM in Uttar Pradesh, 2008, p. 9). BCC analyses the socio- demographic profiles of a particular target community and tries to remove the social and behavioral barriers with discussions, interpersonal communications. “It is about understanding the communities, context and environments in which behaviors occur. BCC is also about using persuasive techniques to demand health rights and to make public sector health services available and accessible to the neediest. BCC is about integrating new practices into long standing social, cultural and communication systems” (Nandita Kapadia-Kundu, 2008, as cited in BCC strategy for NRHM in Uttar Pradesh, p. 9).
BCC uses mass media, interpersonal communication, community mobilisation for change of behaviors of community for improvement of health status and development of future. Behavior Change Communication is used to generate knowledge, tries to bring changes in attitude, behavior, intentions of people. BCC along with other strategies advocates adopting a healthy behavior and overcoming barriers- whether it is mental block or physical block such as difficulty in accessibility of health facilities. Behavior Change Communication helps to bring a sustainable change in health behavior of community.
Conceptual framework of BCC:
Need of BCC:
BCC tools are used to increase the intervention of the promotive and preventive aspect of health among people. “BCC is a process that motivates people to adopt and sustain healthy behaviors and lifestyles” (INFO Reports, January 2008, Issue no. 16, p. 1). Needs of BCC (Public Health Resource Network, Book 05, 2007, p. 11) are:
“BCC alone can:
- Increase the intended participant’s knowledge and awareness of a health issue, problem, or solution
- Influence perceptions, beliefs, and attitudes that may change social norms
- Facilitate building of social/community norms that are facilitative and supportive to desired changes of behaviors/practices
- Motivate and provide the confidence and optimism needed for community action
- Demonstrate or illustrate healthy skills
- Reinforce knowledge, attitudes, or behaviors that are promotive of good health
- Show the benefit of behavior change
- Advocate a position on a health issue or policy
- Increase demand or support for health services
- Refute myths and misconceptions”
Goal of BCC strategies:
- “Empowering the family and individuals to take health related decisions based on information and analysis.
- Motivating the community to play a proactive role in improving their health status.
- Effecting greater utilisation of health services through an improved public understanding of health care.
- Creating competencies and enabling environment to assist with the above objectives” (Public Health Resource Network, Book 05, 2007, p. 14).
Tools of BCC:
Tools of BCC are intended to delineate planning, implementation, development of BCC strategies of any programme. Major BCC tools for strategic plan are:
- Situation analysis: This stage involes identification of social determinants, mental blocks or areas which need to adopt a healthy behaviour or change of habits or attitudes of people. The reasons behind the particular health issue are identified in this stage. Research should done on audience analysis- demographic and attitudal profile of the audience; idenitification of the knowledge, attitude, behaviour, beliefs and values of people; identification of primary and secondary audience; availability of health services in the locality; available media or peer groups in the area.
- Strategic design: Strategic design should contain a ‘SMART’ objective-
The strategic design contains the objectives of the BCC plan- the desired change in the behaviours, knowledge, attitude and practice of the target audience and also develops a conceptual framework of BCC plan to work out the objectives. Implementation plan is sketched in this stage. Drawing out a BCC plan involves these six steps-
- “Identifying key behaviors that need to be changed and analysisng their determinants.
- Stating the mix of audience- message- media and communicators.
- Deciding the monitoring and evaluation startegy- especially the indicators that help us assess whether communication occurred and whether it was effective in securing behavior change.
- Deciding the plans needed to build capacity to implement this plan.
- Deciding the budgetary requirements.” (Public Health Resource Network, Book 05, 2007, p. 16).
- Message development: Appropriate message should be developed for target group. ‘Type of appeal’ applicable for a particular group should be decided in this stage.
- Pretest: Pretesting the messages is required for modification of messages based on the reactions of the target groups.
- Implementation of the programme: According to Public Health Resource Network, Book 05, 2007, p. 15, key components of implementation framework are:
- “Message, media and communicators
- Monitoring, evaluation and feedback
- Institutional structure and functions
- Capacity building
- Budgetary aspect”
- Monitoring and Evaluation: Programme implementers should keep eye on the proper implementation of the programme and if needed, they may modify a change in the mid term of the programme after evaluation of the programme based on reactions and feedback from the target groups.
BCC along with IEC helps to eradicate many killer diseases. The example of such success stories are given here:
Success story Part-1:
The Polio eradication in India (along with several other countries) is considered as one of the most successful campaigns in the field of public health, globally. In the year 1988 global leaders and countries decided to end polio and started initiatives to reach to every child in every country for immunization (although India introduced the oral polio vaccine in 1985 in an Immunisation Programme in the backdrop of over 200,000 cases of polio annually (as per estimates of the Indian Academy of Pediatrics). India committed itself fully into this mission which was globally led by UNICEF and WHO partnering with various international bodies and countries. It was no doubt a massive challenge for a country like India to achieve a zero-polio status as India has been contributor of almost half of Polio cases globally at some point of time. For a country as populated, as diverse, as difficult to reach out to rural areas there was a need for dedicated efforts on the part of the health workers, vaccinators & the whole public health machinery supported by a communication strategy through which the message of polio vaccination and its importance needs to reach every Indian- from the Metro cities to remotest villages of country. Each year twice national level immunization campaign are held with an intent to cover all children under the age of five (http://www.unicef.org/india/health_3729.htm). In every campaign around 2.3 million lakh vaccinators are involved directly in the process led by 155,000 supervisors. To make all this fruitful in achieving the Zero-polio status an effective awareness campaign including inter personal communication component is vital.
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For each campaign awareness is done by IEC materials viz. banners, posters, leaflets, hoardings also through television, radio and newspapers along with extensive loudspeaker announcements. The vaccinators along with other health personnels were also trained to enhance their interpersonal skills, so they could mobilise communities better. There were in initiatives to make resistant communities, individuals understand accept the vaccination for the children. Mention of two different incidents during such campaign gives an idea of how both awareness initiatives and service delivery efforts complement each other.
The Christian Science Monitor shared the story of Setarah Khatoon of Bihar, India (Taghavi, 2013, http://www.csmonitor.com/World/Asia-South-Central/2013/0504/Could-India-s-polio-eradication-success-story-be-a-model-for-its-other-health-issues). She got married at the age of 16 and by the age of 20 she had 3 miscarriages. She had one baby girl and one day she saw Bollywood star Amitabh Bachchan’s TV advertisement telling parents advocating ”do boond zindagi ki” (two drops of life) – actually during the polio campaign celebrities are engaged to spread the message that two drops of polio vaccine can save the life of a child. After watching the advertisement in her small Mumbai house she went to a pharmacy for getting her child vaccinated, the pharmacist directed her to a nearby clinic run by an NGO ‘Doctors for you’ where her child got vaccinated (free of cost of-course). Her baby girl became the first in her family to get vaccinations and apart from that she got access to regular medical check-ups, advice on nutrition and about birth control options too.
In another incident shared by UNICEF (http://www.unicef.org/india/reallives_7444.htm) in another part of the country millions of people were on their way to the annual Urs in Ajmer Rajasthan at a time of the year 2011. Before proceeding to Ajmer via Delhi the devotees need to make a stop over at Bareily, UP to pay homage to a local dargah. The local administration, along with gearing up to host over 200,000 devotees from West Bengal, Bihar, Jharkhand, Madhya Pradesh, Uttar Pradesh and Nepal, decided to administer oral polio vaccine to children upto 5 years of age travelling amongst the devotees. The administration with the health department and other NGOs were able to immunize 10,414 children as a result of this effort.
The above two incidents show how the awareness IEC component go hand in hand with the service delivery component in achieving the desired output.
Success story Part 2:
Challenges of BCC:
Gap between health education and BCC:
In India especially in North East due to inaccessible geographical areas, cultural diversity and other reasons, access to health care services especially secondary and tartiary is limited to the large group of rural population. To make up for that gap the promotion of preventive aspect (PPA) of health plays a vital role. When it comes to saving life it becomes the ultimate life saver. But all the facilities in health system have to be lined up equally along with BCC efforts to provide health education to the masses. Service providers have to ensure the quality services to the people in the hospitals when people visit to them. It is more important to fruitful utilisation of services along with demand generated through IEC and BCC. Otherwise, the effort of health education would go haywire definitely. BCC successfully helps to create a demand of health seeking behavior among individuals and communities.
- Behavior Change Communication (BCC) strategy for NRHM in Uttar Pradesh. (2008). Available at https://www.google.co.in/webhp?sourceid=chrome-instant&rlz=1C1AVSX_enIN408IN438&ion=1&espv=2&ie=UTF-8# accessed on 18/ 06/2014 at 9.58 PM.
- David, Rohit. (2014, May 26). India’s Success In Polio Eradication Is A Model To The World: Dr. Nata Minabde. The Times of India. Available at http://timesofindia.indiatimes.com/home/opinion/interviews/Indias-success-in-polio-eradication-is-a-model-to-the-world-Dr-Nata-Menabde/articleshow/32680701.cms, accessed on 19/06/2014 at 08:15 PM.
- Measure Evaluation and Polpulation Health’s Behavior Change Communication. (n. d.). Available at http://www.cpc.unc.edu/measure/prh/rh_indicators/crosscutting/bcc on 18/06/2014 at 10. 45 PM.
- Public Health Resource Network’s Behavior Change Communication and Training for Health (Book 05). (2007). Raipur: Surya Offset Printers (I) Pvt. Ltd.
- Taghavi, Roshanak. (2013, May 4). Could India’s Polio Eradication Success Be A Model For It’s Other Health Issues? The Christian Science Monitor. Available at http://www.csmonitor.com/World/Asia-South-Central/2013/0504/Could-India-s-polio-eradication-success-story-be-a-model-for-its-other-health-issues, accessed on 19/06/2014 at 08:18 PM.
- Tools For Behavior Change Communication. (2008, January). INFO Reports, John Hopkins Bloomberg School of Public Health, Issue no. 16. Available at http://www.k4health.org/sites/default/files/INFO Reports_Tools for BCC_0.pdf#sthash.2xvFcwSi.dpuf accessed on 18/ 06/2014 at 10.03 PM.
- UNICEF India’s Polio Eradication. India Celebrates Victory over Polio.(n.d.). Available at http://www.unicef.org/india/health_3729.htm accessed on 19/06/2014 at 08:19 PM.
- UNICEF India’s Time To Take Stock, Time To Discuss RTE. (n.d.). Available at http://www.unicef.org/india/reallives_7444.htm accessed on 19/06/2014 at 08:20 PM.
- UNICEF’s The Story of The End of Polio. (n.d.). Available at http://www.unicef.org/immunization/files/The_Story_of_the_End_of_Polio.pdf accessed on 19/06/2014 at 10:04 PM.
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