12 Timor Leste BCC Strategy For Child Health - Draft PDF

MINISTRIODASADE
Dirasaun Nacional Saude Comunitaria
BEHAVIOR CHANGE COMMUNICATION STRATEGY FOR CHILD

HEALTH
Long version
DILI, TIMOR-LESTE
February, 2008
Document prepared by:

Mario Mosquera
Rafael Obregon
Rocio Lopez
Table of Contents
DirasaunNacionalSaudeComunitaria ......................................................................................................... 1
Preface .......................................................................................................................................................... 4
Acknowledgments......................................................................................................................................... 5
ListofAcronyms............................................................................................................................................ 7
1.ExecutiveSummary................................................................................................................................... 9
1. 1 Key Components and Activities ........................................................................................................ 9
1.2CoreElementsoftheBehaviorChangeCommunicationStrategyforChildHealth ........................... 9
1.3MonitoringandEvaluation(M&E) .................................................................................................... 10
2.Backgroundandbriefsituationanalysis .............................................................................................. 11
2.1Socioeconomicandpublichealthcontext....................................................................................... 11
2.2ChildHealthinTimorLeste............................................................................................................... 13
2.3CommunicationContextinTimorLeste ........................................................................................... 13
3.FormativeAssessment ........................................................................................................................ 14
4.TheBCCStrategy ................................................................................................................................ 18
4.1CommunicationInterventions .......................................................................................................... 21
4.1.1InterpersonalCommunication(IPC) .......................................................................................... 21
4.1.2CommunityMobilization(CM)................................................................................................... 25
4.1.3Advocacy .................................................................................................................................... 26
4.1.4EntertainmentEducation(EE) ................................................................................................... 26
4.1.5MassMedia................................................................................................................................ 27
4.1.6CommunicationInterventionsbyChildHealthComponent...................................................... 28
5.MessagesandMaterialsDevelopment................................................................................................... 35
6.MonitoringandEvaluation(M&E)framework ..................................................................................... 36
6.1Impactevaluation ............................................................................................................................. 37
6.1.1ImpactIndicators ........................................................................................................................... 37
6.2OutcomeEvaluation.......................................................................................................................... 38
6.3ProcessMonitoring ........................................................................................................................... 39
6.4CHBCCBehavioralIndicatorsandM&EPlan.................................................................................... 40
7.Workplan................................................................................................................................................ 40
8.RecommendationsforImplementation(tobedeveloped).................................................................... 44
8.2JobdescriptionoftheBCCmanagerandteam(tobedeveloped) ................................................... 44
9.Appendixes.......................................................................................................................................... 44
Preface
Timor-Lestes National Development Plan (2008-2012) and strategy for health promotion and
reproductive health acknowledge the role of Behavior Change Communication (BCC) in
achieving national development. The BCC strategy for child health summarized in this document
is one of a series of such strategies that have been developed in the past two years. Its overall
goal is to promote and increase the practice of key behaviors that support the main components
of child health, including: EPI (Expanded Program on Immunization), nutrition, newborn health,
hygiene and Integrated Management of Childhood Illnesses (IMCI). The strategy is intended to
be consistent with and mutually supportive of the Reproductive Health (RH) BCC strategy and
the Infant and Young Child Feeding (IYCF) Communication Strategy. The strategy is intended
to be implemented by the MOH, in collaboration with NGOs on the ground and UN agencies
such as UNICEF, WHO and UNFPA, and with the support of communities.
Acknowledgments
The Behavior Change Communication (BCC) team would like to thank the many people and
organizations who provided technical and institutional support throughout the development of
the first draft of the child health BCC strategy. We greatly appreciate the opportunity given to us
by the Minister of Health of Timor-Leste Dr. Nelson Martins, Director General, Mr. Agapito da
Silva Soares, National Director of Community Health, Mr. Jos Magno dos Reis, and the Head
of Health Promotion Department, Mr. Carlitos Correia Freitas, to draft the BCC strategy.
We would also like to give special thanks and recognition to the BCC national facilitators, Mr.
Apolinario Guterres, Health Promotion Officer, Ms. Misliza Vital, National Technical Officer
for IMCI, Mrs. Rita M. Soares, Sanitation Program Officer, Mr. Elias Sarmento, Complementary
Feeding Program and Nutrition Officer, Mateus Cunha, National Technical Officer for EPI.
Grateful acknowledge is made to national MoH officers, DPHOs, national and international staff
of partner organizations, and community health volunteers whose valuable contributions were
important as the first step of the BCC strategy development (See Appendix G, with the list of
participants for BCC workshop for Child Health Strategy).
We greatly appreciate the funding, logistical support and technical backstopping of: TAIS
(Timor Leste Asitnsia Integradu Sade), a Technical Assistance project under USAID funding
through BASICS and IMMUNIZATIONbasics for the Ministry of Health of Timor. In particular
TAIS Director, Ms. Lauri Winter, Ms. Sarah Meyanathan, TAIS Community Mobilization
Coordinator, Ms. Santina da Cruz, Mr. Joao Fernandes, Mr. Mario Gusmo, Ms. Leopoldina
Magno, Mr. Cirilo Vicente, no Mr. Emilio Tilman.
The BCC team would also like to thank the following organizations:
UNICEF: Ms. Mary Ann Maglipon, Communication Specialist, Mr. Dominggus Monemnasi,
Senior Program Assistant, Dr. Carla Quintao, Health and Nutrition Officer, Ms. Faraja Chiwile,
Nutritionist Specialist, Ms. Nelia B. Soares, SPA for Health and Nutrition, Mr. Domingos
Monemnasi, Senior Program Communication Assistant. WHO: Dr. Telma Corte-Real, focal
point for IMCI, MCH and RH, Mr. Luis dos Reis, focal point for Nutrition and Environmental
Health and Communicable Diseases, Ms. Faviola Monteiro, Focal Point for Health Promotion,
Oxfam: Mr. Martinho Bere Bau, Health Program Officer, Mrs. Aguida Bendita da Silva,
Community Health Program Officer, & Ms. Louise Maher, Health Coordinator. Health Alliance
International (HAI): Ms. Nadine Hoekman, Ms. Anna Greer, BCC technical advisor; Ms.
Marianne Kearney, BCC technical advisor; Mr. Paulo Vaschoncelos, Coordinator for Health
Promotion and Community Outreach, Ms. Terezinha Sarmento, Officer for Maternal and Child
Health. Alola Foundation: Ms. Tanya Wells Brown, Maternal and Child Health Program
Manager, Ms. Karen Hobday, Health Promotion Coordinator and Ms. Beatriz X. Sequeira and
Ms. Aquelina Imaculada, Health Promotion Officers. Bibi Bulak: Ms. Madalena Pinto and
Mr.Francisco Pinto Amaral. Cruz Vermelha Timor Leste: Mr. Cornelio D. Gomes, Health
Coordinator, Ms. Joaninha X. Pereira Manager for Health, Ms. Rosemary Fenton, Health
Delegate. SHARE: Ms. Yoko Ito, SHAREs representative, Ms. Irene Babo, Project
Coordenator and Ms. Agustinha Gomes, Health Officer. UNFPA: Dr. Domingas Bernardo,
National Program Officer- Reproductive Health and Mr. Mariano Redondo, Communication
Officer. World Vision: Mr. Francisco da Costa, Project Coordinator for MCH and Antoninho
Pereira, Project Coordinator for Nutrition, CARE International: Mr. Herminio Lelan, Health
Coordinator and Ms. Joana Finchley, International BCC Consultant. AFMET: Mr. Yutaka
Kobayashi, Representative and Coordinator.
A special acknowledgment is given to the following individuals who provided expertise that
greatly enhanced this BCC strategy draft:
Mr. Michael Favin, BCC specialist, BASICS/IMMUNIZATIONbasics, Ms. Joan Schubert, BCC
specialist, BASICS, Mr. Paul Crystal, documenter, BASICS; Dr. Ingrid Bucens, Pediatrician,
TAIS and Ms. Cecily Dignan, Nutrition Adviser, Mr. Edi Setyo, Health Promotion Advisor, Ms.
Ruth Nicholls, Environmental Health and Mr. Rick Jacobson, Health Promotion Advisor.
List of Acronyms
BCC
Behavior Change Communication
BFH
Baby Friendly Hospital
CC
Community Consultation
CHC
Clinic Health Center
CH
Child Health
DHS
District Health Services
DPHO
District Public Health Officers
DTT
District Trainer of Trainers
EPI
Extended Program of Immunization
IEC
Information Education Communication
IMCI
Integrated Management of Childhood Illness
ITNs
Insecticide Treated Nets
IYCF
Infant and Young Child Feeding
HAI
Health Alliance International
LISIO
Livrinho Saude Inan no Oan
MCH
Maternal and Child Health
MoH
Ministry of Health
MSG
Mother Support Groups
MTT
Master Trainer of Trainers
OPV
Oral Polio Vaccine
ORS
Oral Rehydration Solution
RTTL
Radio Television Timor-Leste
SWOT
Strengths, Weaknesses, Opportunities, and Threats
TAIS
Timor-Leste Asistensia Integradu Saude
TBA
Traditional Birth Attendant
TIPs
Trials of Improved Practices
NGO
Non Governmental Organization
SHARE
Services for the Health in Asia and Africa Region
UNFPA
United Nations Population Fund
UNICEF
United Nations Childrens Fund
USAID
United States Agency for International Development
1. Executive Summary1. 1 Key Components and Activities

The design of this strategy was highly participatory, and included input from MOH staff from
Dili, DPHOs, national and international staff of partner organizations, and community health
volunteers. The foundation for this strategy comes from evidence-based public health
recommendations. Major steps included:
a review of existing documents on health communication and child health behaviors,

including a community consultation,
an analysis of factors favoring and blocking important behaviors related to child health
an analysis of various potential audiences and the best communication channels to reach
them
development and testing of messages and materials, and
two national BCC workshops to review and add to the process and recommendations.
Key features of this behavior-centered strategy include the following:
Promoting a core set of messages aimed to promote specific changes in practices related
to five key child health areas: EPI, newborn health, IMCI, nutrition and hygiene;
Using a variety of communication channels that reinforce one another: person-to-person,
print, community mobilization, entertainment-education, and mass media and advocacy;
Employing communication interventions that, working together, reach the largest
audience;
Linking communication with actions that make it easier for people to carry out the
various practices promoted in each area of child health;
Linking activities in the child health communication strategy with other child-healthrelated communication strategies (nutrition, reproductive health), to benefit all areas;
Actively monitoring the strategys impact on changes in behavior and in child health; and
Building local capacity to manage and implement the strategy under the leadership of the
MOH.
1.2 Core Elements of the Behavior Change Communication Strategy

for Child Health
Interpersonal
Communication(IPC)
Channel
Context
Multiple social
networks, including
church groups, clubs
and community
gatherings will promote
child health using IPC
Community
Advocacy
Entertainment
Education(EE)
MassMedia(MM)
A number of key
actions are needed to
influence high-level
decision makers to
provide commitment,
funding, policies, and
Street theater, radio

dramas, school plays,
songs, games, and
stories have been
widely used in TimorLeste to promote
Radio is quickly
becoming available
to many people and
communities, and the
availability of
television is also
Mobilization(CM)
Communities will be
invited to actively
participate in planning and
implementing BCC
activities to promote
improved child health. CM
Examples
ofKey
Activities
(inter-personal
communication -talking and discussing).
It will be crucial to
involve community
leaders, volunteers, and
health workers.
is essential for desired

practices to become
normal behavior in the
community.
organizational
support for the
MOHs child health
initiatives, including
the implementation of
this BCC strategy.
public health
messages. This
communication
approach presents
opportunities for
building on and
coordinating these
efforts.
growing. In this
strategy, MM are
closely linked with
EE, and reinforce
other communication
efforts.
Train health care

providers on the use of
counseling and
storytelling to promote
desirable child health
practices.
Implement a coordinated
process for participatory
planning with communities
to promote improved child
health
Seek endorsement
from the MOH and
partners at all levels
to incorporate the
BCC strategy into
their work plans.
Use theater,
storytelling, games
and radio dramas to
promote key behaviors
for child health
Broadcast a
weekly radio show
on child health with
the participation of
health workers and
community leaders.
Strengthen the skills

of community
volunteers to serve as
effective
communication and
change agents in their
communities, through
counseling and other
communication
activities
Produce a health
education tool box,
including child health
messages for nurses,
midwives and
volunteers
Train community
leaders and equip them
with a communications tool
box tailored to their needs
Give the same health
information at churches,
SISCa events and other
community forums,
including of local radio
Negotiate with
public and private
mass media to
identify mutually
beneficial
opportunities for
designing, producing
and broadcasting
creative health
programming.
Lobby for the
support of
government programs
outside the MOH to
promote desired child
health practices.
Produce a soap
opera for local
community radio
stations that addresses
key child health
behaviors and monthly
themes on child health.
Use a range of EE
products in small
group discussions and
in large public
gatherings, such as
SISCa, to keep things
lively and maintain
local enthusiasm and
interest.
Broadcast regular
public service
announcements on
radio and TV that
reinforce community
mobilization events
and monthly child
health themes.
1.3 Monitoring and Evaluation (M&E)

The proposed M&E framework for this strategy draws on the framework used for the Sexual and
Reproductive Health BCC strategy and is consistent with the SISCa monitoring and evaluation
framework. M&E is expected to take place during the various phases of the strategy, beginning
with a baseline assessment, continuing with ongoing monitoring activities, and ending with a
final impact assessment. It is anticipated that the M&E plan for this strategy will be designed to
both assess progress and impact and to be a way to build local capacity, enhance institutional
development, and create opportunities for sustainability.
10
2.
Background and brief situation analysis
2.1 Socio-economic and public health context

Timor-Leste faces multiple challenges in its path toward consolidating a democratic system.
They include internal conflicts, internally displaced population (IDPs) and political instability.
Against this backdrop, however, the country has continued its efforts toward improving the lives
conditions of its estimated 1.1 million inhabitants. This background on the socio-economic,
public health, and communication contexts provides critical elements for the design of the
countrys behavior change communication strategy for child health.
Despite some improvements, including the return to their places of origin of thousands of IDPs,
Timor- Leste remains one the poorest country in Asia. Indicators associated with the Millennium
Development Goals (MDGs) lag behind levels needed to reach targets. About 41% of the
population lives below the poverty line, and that nearly 55% of women and 45% of men are
illiterate (DHS, 2003). Lack of sanitation and access to safe water in many areas, particularly in
rural communities, is a major concern. By 2006 it was estimated that only 62% of the urban
population had access to sanitation services (WHO, 2008).
The countrys cultural, ethnic and linguistic diversity is central to BCC interventions. Although
the country has made Portuguese one of the official languages, the majority of the population
speaks Tetum, and other local languages such as Mumbai and Makasse. This reality demands a
combination of national-scale interventions with local targeted actions to reach specific
communities in their own languages and with activities and materials that are sensitive to local
cultural values and practices.
According to the World Health Organization (WHO), poor and unequal access to health services,
the absence of a regulatory framework, an inadequate referral system, and a lack of human
resources and technical capacity are amongst the main problems that negatively affect the public
health system of Timor-Leste. WHO also cites as critical challenges high prevalence of
communicable diseases (i.e., malaria, tuberculosis, and childhood respiratory infections), early
marriage and pregnancy, gender disparities, and high prevalence of malnutrition, iodine and
vitamin A deficiency), limited knowledge of HIV/AIDS, and lack of general awareness of health
problems and understanding of health benefits.
Efforts undertaken to improve the health conditions of the countrys population include the
formulation of policies and national strategies in areas such as sexual and reproductive health,
health promotion, and infectious diseases. Chief among them is the basic health care package
(BSP), which describes the main elements of the countrys response to its public health needs.
The BSP outlines the structure and functions of primary health care services, which serve as the
first point of contact with communities and families1.
The primary health care component (PHC) of the BSP emphasizes the important role of
community involvement and participation. The MoH is currently introducing the Sistema
Main elements of the BSP are clearly linked to behavior change issues, including a specific focus on health
promotion and behavior change communication activities.
11
Integrado de Saude Comunitaria (SISCa Integrated Community Health Service), which seeks
to create more opportunities for reaching local communities, particularly through the use of local
health volunteers. Under the SISCa model, the MoH expects development partners to provide
technical support to the districts and sub-districts districts that make up the public health system
of the country. SISCa is a mix of community-based health activities and a mobile health clinic
that aim to provide integrated health services to rural communities (hamlets). Under SISCa
health services should be from, with and for the community, meaning that communities
should own health activities and cover health promotion, prevention and treatment related to
communicable diseases, family planning, nutrition, maternal and child health and environmental
health (sanitation at home).
The main objectives of SISCa are to:
-Provide the integrated health services package for the community;
-Obtain and improve data collection about the population, children, and pregnant
women to implement appropriate interventions;
-Expand activities for health promotion and education for behavior change and
healthy life; and
-Increase the demand and participation of the community in health services.
SISCas target groups are community members, children under five, pregnant women, youth, and
elderly and disabled people. Implementation of SISCa requires that health staff, in partnership
with members of village councils, chiefs of villages, chiefs of hamlets, youth organizations,
women groups, and others leaders, work to mobilize resources and provide health care to the
community. Health volunteers are chosen directly from the community and are trained to provide
health assistance, together with health staff. SISCa creates an opportunity and a challenge for
planning and providing community-based BCC activities for child health.
The MoH, in collaboration with international cooperation agencies, international and local
NGOs, and other strategic partners has designed and implemented a number of health promotion
and health education interventions aimed at improving indicators in maternal and child health,
nutrition, family planning, and infectious diseases. Actions include behavior change
communication strategies for sexual and reproductive health (in collaboration with the United
Nations Population Fund), and nutrition (in collaboration with the nutrition technical working
group). This child health BCC will be designed to work with those strategies wherever possible
in order to maximize existing resources and enhance the impact of communication activities.
The design and implementation of BCC strategies is an important step in the MoHs efforts to
improve its health promotion and communication response. This represents a qualitative leap as
the design process has shifted from a focus on the development of communication products and
materials, which until now characterized health communication activities, to a more strategic
approach that draws upon behavior change theories, existing evidence, and data from formative
assessments.
12
2.2 Child Health in Timor-Leste

Respiratory and diarrhea infections, combined with poor nutrition, are the primary causes of
death among children under five. The following selected mortality, morbidity and health service
provision indicators, provide a useful summary of the challenges to improving the health of
young children23:
Almost 50% are underweight for their age;

Approximately 15% are wasted (thin) moderate acute malnutrition, and
3% are very wasted, severe acute malnutrition
Almost 50% of children are stunted (short for their age) chronic malnutrition
Almost 30% are severely stunted severe chronic malnutrition
Exclusive breastfeeding 31% ;
Vitamin A supplementation in 2007 was 35% (MOH Performance statistics,
2007);
Under-five mortality rate 83/1000 live births and infants mortality rate 60/1000
live birth.
Neonatal mortality is estimated at 33/1000 live births
Coverage for all immunizations are under 80 %
Cultural factors and individual and community practices play a central role in the health of
children. Inadequate disposal of feces, lack of routine and adequate hand washing, improper use
of insecticide treated nets (ITNs), and consumption of unhealthy foods are some of the most
common contributing factors to poor child health. Understanding these factors is crucial to an
effective communication response. These factors are discussed further in the formative
assessment section.
2.3 Communication Context in Timor-Leste
A study conducted under the auspices of the Hirondelle Foundation in 20074 found that informal
face-to-face communication and radio are the most reliable sources of information in the country.
Interpersonal communication remains the primary form of communication in the country, while
radio has increased its penetration and it is now estimated at 80%. Officials from RTTL have
indicated that the installation of new repeating antennas will soon allow for coverage above 90%.
A 2005 UNICEF study on communication habits provided details on interpersonal and
community-based communication dynamics in the country. Relevant findings included:
Information is mostly obtained through word of mouth, and people who have limited
opportunities to participate in community meetings tend to obtain less information.
Women, especially housewives, tend to be less exposed to information.
2The UNDPs National MDG Report 2004

3
Ministry of Health of Timor-Leste and National Statistics Office of Timor-Leste. 2003. Timor-Leste 2003 Demographic Health
Survey (TL 2003 DHS).
4
Soares, E. & Mytton, G. 2007. Timore Leste National Media Survey. Final Report. Fondation Hirondelle, Dili, TL.
13
The value attached to information received by word of mouth is dependent on who

communicates it. There is a need to further explore who the most respected people are
and how they can be used as effective channels.
There are various types of extension officers in rural areas tasked to promote
development issues and programs. However, this study did not examine how effective
they were in spreading information, what obstacles they had; to what extent communities
used this information and how it changed their lives. Observations from MoH and TAIS
staff (2008) suggest that communications skills of the extension officers require
(intensive) on-the-job training on applications of BCC to improve their skills.5
Traditional media can be integrated with modern media. Songs and poetry were being
used to spread educational information. Social events have the potential for sharing
information among large numbers of people.
Recommendations emphasized that community-based communication strategies should be

encouraged, as well as the integration of traditional and mass media. Involving communities in
developing educational and health programs that use traditional channels to reach their target
audiences is essential because communities can best assess the appropriateness of such messages
to a particular audience, how the information should best be packaged, and how it should be
communicated.
The BCC team and its informants widely discussed opportunities to use media, particularly
radio, as a regular source of health information and to put family health issues on the public
agenda. In particular, Radio TLs unit on community and education could collaborate with the
MOH on public health education. However, no specific actions have been taken yet.
Collaboration between the MOH and RTTL should be strengthened as radio and TV continue to
expand their reach and penetration in communities. TV reach has increased from 19% in 2007 to
nearly 25% in 2008. However, TV use remains higher in Dili (79%) and very low in districts
such as Manufahi, Ainaro and Ermera. There is high out-of-home viewing (neighbors, communal
viewing). As TV increases its penetration in rural areas, communities have set up TV sets in
community centers to facilitate TV viewing.
The communication context of the country underscores the importance of interpersonal and
community-based communication interventions, combined with selected media interventions
such as use of radio, to reach target audiences at urban and rural levels. These aspects are
reflected across different components of this BCC strategy.
3.
Formative Assessment
Research has guided the design of this communication strategy. To that effect, a formative
assessment was conducted to assess behavioral, socio-cultural and communication variables
and/or factors related to child health in the country. This assessment included:
A desk review of past and ongoing child health communication interventions in the country.
Comment provided by Mr. Rick Jacobsen, Health Promotion Advisor, MoH Timor-Leste
14
Review of findings from a TAIS community consultation conducted in 2007 to

understand individual and community practices associated with child health. It built on a
situational assessment that included a review of research reports, secondary data, and
interviews with key informants.
Definition of key behaviors that this strategy seeks to promote.
A behavioral analysis that led to the identification of ideal, actual, and feasible behaviors,
and barriers and motivations and support for those behaviors.
A SWOT (strengths, weaknesses, opportunities, and threats) analysis of health promotion

at district level.
A communication and audience segmentation analysis (including a workshop focused on

IEC/BCC) to identify communication practices associated with child health.
Identification and selection of primary and secondary audiences.
This formative assessment was also based on various theoretical models and concepts that
included:
Barrier analysis to identify real and perceived barriers to performing a behavior.

Elements of the health belief model with a focus on perceived risks and benefits, and
perceived social norms.
Social learning theory concepts with a focus on self-efficacy of individuals perceived
degree of confidence to perform a particular behavior.
Principles of ecological models of behavior change with a focus on enabling factors to
perform a behavior.
Results from the assessment were used to inform the design of interventions, activities, and
messages. Thus, this behavior change communication strategy focuses on addressing barriers to
behavior change, promoting benefits of healthy/preventive behaviors, and enhancing enabling
factors to maintain or adopt healthy behaviors.
Due to space limitations, summaries of key findings from each formative assessment activity are
included as appendices. We encourage readers to carefully look at each of those appendices in
order to fully grasp our findings and make better sense of the strategy. This BCC strategy will
focus on five child health sub-programs: EPI, IMCI, Newborn health, Nutrition, and Hygiene.
Table 1 lists evidence-based behaviors for child health initially proposed for the BCC strategy,
which were later, refined through consultations with MOH and national and international
stakeholders.
Table 1. Key behaviors per child health component
Component
Key Behaviors for mothers and other caregivers
EPI
Bring children to immunization service delivery points at the ages (and with correct
intervals between doses) in the national schedule.
IMCI
Minimize the exposure of babies and young children to smoke
15
Newborn
Nutrition
Hygiene
Treat mild illness at home and look for danger signs

Take a child with one or more danger signs immediately to a trained health
provider (Complete list in the LISIO).
Ascertain understanding of providers treatment instructions and follow them
completely.
Sleeping under a bed net, during day and night time
Put the baby immediately to the breast at birth
Breastfeed exclusively for six months
Give adequate complementary feeding from about 6-24 months with continued
breastfeeding for at least two years.
Give appropriate nutritional care of sick and severely malnourish children.
Ensure adequate vitamin A intake for yourself and young children
Ensure adequate iron intake for yourself and young children
Purchase and use of iodized salt
Give adequate complementary feeding from about 6-24 months with continued
breastfeeding for at least two years.
Wash hands with soap and water after going to the bathroom or contacting
feces, and before eating, feeding or cooking.
Safely dispose of the feces of all family members
Treat water you are about to drink or use for cooking
Findings from the community consultation6 were used in a behavioral analysis that sought to
identify ideal, actual, and feasible behaviors, as well as barriers, motivations and supporting
factors that could hinder or facilitate peoples adoption of healthy behaviors. This analysis was
done at a national workshop that brought together participants from various health districts, staff
from the MOHs health promotion unit, and members of selected local and international NGOs.
Participants developed behavioral analysis matrices per each child health component and key
behaviors, based in great part on the community consultation report and findings from the desk
review. This behavioral analysis became the primary input to the BCC strategy and message
design development. Appendix A summarizes the results of the behavioral analysis for all child
health components. The reader can find the workshop participant contributions written in italics
within each the matrix.
A SWOT (strengths, weaknesses, opportunities, and threats) analysis of child health programs at
district level was conducted for each component with emphasis on health
communication/education and community participation. This analysis, part of one of the national
workshops held in the design process of the BCC strategy, identified issues that may facilitate or
hinder the implementation of the BCC strategy. Appendix B summarizes main elements of the
SWOT analysis and recommendations.
SeeTAISCommunityConsultationReport,2008.
16
The communication analysis and audience segmentation were conducted at a workshop that
convened national and local health promotion staff, and BCC specialists from national and
international NGOs. The workshop methodology followed participatory planning principles
using communication analysis matrices borrowed and adjusted from handbook Planning
Behaviour Change Communication (BCC) Interventions7. Participants broke into four (4) groups
that covered the five child health sub-programs: EPI, IMCI-newborn Health, Nutrition, and
Hygiene.
Building upon desk reviews, the community consultation report, and on summaries of the studies
on media use and communication habits, workshop participants identified critical
communication issues and practices and key audiences for each child health component.
Contributions of workshop participants were organized in the following categories: stakeholders,
audiences, channels, media and communication materials analysis. This information was later
used to identify and select the main elements of the BCC strategy for each child health
component and behavior.
Appendix C summarizes the main elements of the communication analysis and audience
segmentation (stakeholders, audiences, channels, media and communication materials analysis).
The BCC team identified commonalities among participants contributions and identified
crosscutting dimensions those relevant to all child health components to be addressed by the
BCC strategy. Appendix C focuses on the intended audiences, primary and secondary, their
affiliations, spaces where they spend time and communicate, who they consult about health
issues, who influences their health behaviors, and what media are accessible to them, and what
media they are likely to use.
We define audience segmentation as the identification of specific audiences that will be targeted
through research-based communication activities with the purpose of facilitating a change in
their behavior(s), or mobilizing them to influence audiences to perform the desired behaviors.
Audiences can be divided into two categories: primary and secondary:
Primary audience is the person or group of people whom we want to address directly
through specific messages with the intention to change or modify her/his, or their
behavior in order to improve their health status.
Secondary audience is the person or group of people who can influence the primary
audience to change her/his or their behavior(s).
Channel analysis examined issues such as types of communication channels available at different
levels (national, local), and what mass and community channels members of the primary and
secondary audiences prefer. Elements such as media formats (i.e., radio dramas, theater plays)
also were examined. Consistent with existing data, interpersonal communication, communitybased communication activities, and community radio emerged as the preferred and most
accessible communication channels in Timor-Leste.
Chen P. F (2006) Planning Behaviour Change Communication (BCC) Interventions: A Practical Handbook.
UNFPA Country Technical Services Team for East and South-East Asia Bangkok, Thailand.
17
4.
The- BCC Strategy
Building upon the findings and analysis of the formative assessment, main elements of the child
health BCC strategy were put forward by participants at a national workshop for the BCC
strategy development. This hands-on exercise included an intensive planning process with the
participation of 31 people, including health officers, health promoters, and members of local and
international organizations. Further refinement of the child health BCC strategy take into account
existing IEC experiences and materials already developed for child health in Timor-Leste. This
strategy should also guide actions to strengthen evidence-based interventions for health
promotion, disease prevention, and treatment through communication interventions, activities,
and messages that are culturally relevant and meaningful to local people.
Developed through a consultative and participatory process, the BCC strategy for child health is
intended to guide the execution of all communication efforts in child health in the country,
whether in community mobilization, community and government advocacy, interpersonal
communication, media advocacy, and skills building. Table 1 illustrates the BCC conceptual
framework for child health, which focuses on influencing different audiences through the use of
multiple interventions to facilitate community and individual health behavior change, with
capacity building as a cross-cutting component.
Table 1. Conceptual Framework, BCC Strategy for Child Health, Timor-Leste

Information Inputs
Participatory BCC Design
Communication
channels
Communication
approaches
Technical focus areas and key

messages
Communication
materials
Key Actions to Support Implementation
Information Inputs
Global BCC theory and experience (esp. COMBI), existing BCC strategies in Timor-Leste, community
consultation and other experience in Timor-Leste
Participatory BCC Design
18
Communication
approaches
Advocacy
Community
mobilization
Interpersonal
communication
Mass media
Technical focus
areas and key
messages
IMCI
Newborn
Immunization
Nutrition
Communication channels
Communication materials
Counseling at health
facilities, SISCa, home visits
Counseling cards for

community health volunteer,
outreach staff
Community group activities:

dramas, talks, games, mobile
units, dramas on tape and
video, mother support groups
Broadcast media: national
and local radio, TV
Hygiene
Edutainment
Advocacy meetings with

decision-makers
Reminder materials for health

staff
Video dramas
Radio spots
Tool kit of games
Small BCC manual for PSFs,
community leaders
Fact sheets, M&E reports,
PPTs for decision-makers
Key Actions to Support Implementation

Obtain partner commitment to actions and funding
Establish mechanisms for planning, coordination, M&E
Review and adjust existing IEC materials, prepare new communication materials if needed and arrange
channels
Prepare and carry out extensive training
Implement good management, coordination, M&E
19
IPC Tools and Training

Doctors/Nurses/Midwives
Community health volunteers, NGO CHWs,

Outreach Staff
Tools
Tools
Reminder materials for preventive consultations

*immunization,
Counseling cards for pregnant women and mothers

of newborns
Counseling cards for mothers of children 1-23
(59?) months old
*vitamin A
*weighing
Counseling cards for special groups (C-DOTS,

STIs, etc.)
*de-worming
Reminder materials for curative consultations
*diagnosis
Simple health promotion manual that includes how

to:
*Assist in SISCa
*feedback to client
*instructions to client (how to take medicine, danger
signs, how to prevent)
*give reminders
*Facilitate good group discussions (e.g. following a

radio or video drama)
*Organize community health education activities
(demonstrations, exploration walks, community
monitoring)
*confirm understanding
invite questions
Training
Training
Sensitization on empathetic treatment
Counseling skills
IPC skills
Group work skills
Effective use of reminder materials (job aids)
Planning skills
Effective use of health promotion tools
BCC strategy elements are systematically reinforced in the child health components addressed by
the strategy. We grouped communication activities that are crosscutting throughout the five child
health components. As mentioned above, the CH BCC strategy has been designed to be
consistent with and mutually supportive of the Infant and Young Child Feeding (IYCF)
Communication Strategy recently planned with the MoH and the nutrition working group, and
the sexual and reproductive health behavior change communication strategy designed in
collaboration with the United Nations Population Fund (UNFPA).
20
In the following sections, we introduce the goals and behavioral objectives of the strategy and
summarize the communication interventions per child health component.
4.1 Communication Interventions
Workshop participants put forward counseling, demonstrations, health education and group
discussion interventions as the primary strategy elements, while the mass media and other
communication activities were perceived to play a supporting role. Mass media will promote
healthy behaviors that are feasible for certain groups of listeners or viewers, while individualized
counseling8 will increase likelihood of behavior change through support, motivation and
encouragement. Mass media can be also used to promote the credibility of community volunteers
as sources of important health information.
For each child health component (EPI, IMCI, newborn health, hygiene, and nutrition) and
selected key behaviors, communication activities were identified and selected on the basis of
their cultural relevance. These activities are intended to target primary and secondary audiences
in order to enhance reach and reinforcement of key messages. For example, the use of film on
benefits of breastfeeding, followed by counseling and education on how breastfeed correctly and
encourage women to breastfeed, is one of the specific activities under the nutrition component.
Cross-cutting activities were identified in an effort to maximize resources, and create synergies
among components and with other interventions developed by local and international partners.
For instance, radio dramas and theater plays/Community drama can be used to promote all or
most of the key messages related to all components of the child health BCC strategy. The
development and production of a radio soap opera facilitate the integration of all components and
behaviors into the story. In addition, messages included in this soap opera will reinforce
messages in the radio soap opera developed for sexual and reproductive health, particularly on
common child health-related components such as the preparation of a birth plan. Similar
synergies will be sought with the nutrition communication strategy and other activities
undertaken by local and international partners.
Next we discuss each of the communication interventions selected for this strategy, followed by
a table that summarizes main communication activities per child health component.
4.1.1 Interpersonal Communication (IPC)
Background research and formative assesment data suggest that interpersonal communication is
the main source of information in Timor-Leste and that community meetings, celebration parties,
and family gatherings tend to bring people together wherein information sharing usually occurs.
Workshop participants viewed counseling as interchangeable with health education. However,
often in Timor-Leste health education is typically a health worker giving and telling people what
they should do and why (one-way communication), whereas counseling implies a two-way
communication process (client - provider interactions) in which both parties contribute essential
Favin M. 2004. Promoting Hygiene Behavior Change within C-IMCI: The Peru and Nicaragua Experience. Prepared under
EHP Project 26568/CESH.CIMCI.PAHO.Y5. Washington, DC 20523
21
information and ideas. This will require intensive on-the-job training, besides the (minimal) input
on IPC during the MTT (and more so in DTT) sessions.
We suggest a perspective that draws upon both concepts -- counseling and health education -and is defined as a two-way communication process that may lead to behavioral change through
dialogue and negotiation. Good interpersonal interaction between community members/families
and health workers is, by definition, a two-way communication process where both speak and are
listened to, both ask questions, express opinions and exchange information and both are able to
fully understand what the other is trying to say9. This is to understand behavior change as a
process focused on negotiation of small but important behavioral changes and a progression of
such changes over time. It is a chance to talk over issues that are important to people through
current situations and help communities and families to identify feasible changes in the existing
behaviors for harm reduction or gradual adoption of preventive practices.
Interpersonal communication interventions can be interconnected along different child health
components. Training health staff and community leaders to communicate effectively on
immunization, for instance, can increase knowledge and understanding among caregivers and
mothers on the role of vaccination in the prevention of childhood illnesses, when and where to
take their child for his/her next vaccination and help thinking through how to overcome barriers
to bringing the child. IPC about vaccination can be part of birth preparation as well as serve as
the motivation for a postpartum visit. Counseling mothers on feeding practices is also an
opportunity to referring mothers whose children are due for immunization.
Interpersonal communication should make effective use of existing social networks or
interpersonal relationships (family, friends, acquaintances, neighbors and colleagues) that bind
people together to enhance the communication process. For example, in Timor-Leste young
mothers mothers or mothers-in-law are often key decision-makers for fertility decisions.
Therefore, counseling the young woman about the benefits and methods of birth spacing may be
ineffective if her mother or mother-in-law is uninformed or opposed to this practice.
IPC can be used in different settings. Each setting is shaped by the socio-demographic
characteristics of the target audiences and health providers (nurses/midwives, SISCa volunteers,
community leaders), as well as by the environment in which the communication takes place:
health facilities, schools settings, street meetings, churches, households, SISCa posts. Age, sex,
language, and educational background of providers and people affect how they communicate
with each other. Factors such as the degree of privacy, time selected for encounters, comfort, and
waiting time can also inhibit or enhance individual/group-provider interaction.
In the context of the child health BCC strategy, interpersonal communication either face-to-face
or in small groups can take place in different settings and be facilitated by SISCa volunteers,
community leaders and health personnel. It can support change at individual and community
levels:
At the individual level:
DiPrete Brown, Lori, et al. Training in Interpersonal Communication: An Evaluation of Provider Perspectives and Impact on
Performance in Honduras; March 1995; Quality Assurance Project, Bethesda, MD.
22
It can take the form of household visits, small group discussions or health facility talks
intended to increase individual and family knowledge and understanding about health
risks, health benefits, health-seeking behaviors, adoption of healthy behaviors,
management of acute conditions at home, and compliance with medical treatments.
At the community level:

It can motivate the broader community to develop interest in and talk about health issues,
social norms, problems and misconceptions related to CH.
Several organizations in Timor-Leste have developed IPC tools and materials, such as
counseling cards -Health Alliance International (HAI)-, flip charts -Alola Foundation, UNICEF,
HAI, Cruz Vermelha, SHARE, CARE International, Oxfam and World Vision-, and other
audiovisual materials available to facilitate learning and behavior change. The MoH started to
include IPC skills in their master trainings for trainers for the SISCa program. An interesting IPC
methodology is CARE Internationals training of health volunteers on how to use storytelling
techniques. According to Joana Finchley10, storytelling can be used to illustrate familiar practices
and hopefully through these personalized scenarios people recognize their own behaviors.
Stories can be used in workshops, training courses, meetings, etc. It is the humanness of the
storytelling that joins people together and moves them beyond their story to take action and
hopefully moves them to change. A story need not be long. It can take the form of a memory, a
joke, or an anecdote. They all work -- everyone has a story to tell!. This also requires changes
in current HP/MoH products, such as flipcharts, flash cards, which should encourage health staff
and volunteers to ask questions and negotiate (using TIPs e.g.) when delivering key messages.
Thus staff and volunteers need training in how to use these new products.11
We suggest the use of the counseling and negotiation approach used in Trials of Improved
Practices (TIPs) as a method for interpersonal communication. TIPs is a formative research
technique that seeks to understand current behaviors, test more beneficial behaviors with
families, and assess their acceptability and feasibility, the barriers to these practice (excluding
certain external barriers such as government policies), and meaningful motivations and benefits.
The counseling and negotiation approach used in TIPs can also be very effective for promoting
behavior change on an ongoing basis.
This method involves a series of encounters (home or clinic visits or discussions at the health
education table during SISCa) in which the caregiver and health worker or volunteer:
Asks about and discusses the childs health or nutritional status and about the caregivers
current perceptions and practices;
Gives feedback on positive practices and ones that could be improved to benefit the child;
Asks for suggestions of small changes in practices and, as needed, offers some
suggestions for consideration;
Discusses possible changes and reaches an agreement with the caregiver on one or a few
specific actions that the caregiver feels she can take;
Asks the caregiver to verbalize precisely how (what steps) she will try to take;
10
11
Joana Finchley is an International Health Consultant.

23
Asks the caregiver to repeat what she has agreed to try and agrees on when they will meet
again to review progress. (The counselor may record the agreements and give a simple
reminder slip to the caregiver.)
This method requires IPC skills to guide the assessment of current perceptions and practices,
adjust advice to individual situations, motivate individual/household action, and provide followup support to sustain the new behaviors. This approach focuses on behaviors rather than
knowledge only, and can be an effective counseling and negotiation process for health workers
or volunteers to use to promote healthy behaviors12.
The effectiveness of this approach will depend upon training and continued support of
volunteers. The Health Promotion Department is currently leading a Training of Trainers
Workshops to coach SISCa volunteers in community surveillance and health education using
adult learning approaches1314: learning by doing, active participation, demonstration, practice and
reinforcement, as an alternative to lecturing people on what they must do. In an adult learning
approach, the trainer has to acknowledge the trainees experiences and build upon their
knowledge and expectations, developing problem-solving skills and working with others in
teams or as part of communities. However, this section in the so-called MTT training has
demonstrated not to be sufficient to enhance change from lecture style teaching to IPC practices
by the trainers. The DTT sessions often lack the IPC curriculum, due to the sense that content
(on nutrition e.g.) is more important than the process (how the message gets across). This may
be an inefficient way of training trainers (and eventually volunteers), as lecture style training
sessions are more likely to be forgotten (up to 80% of the content!) than participatory methods
(through role play e.g.) to 20%). Health staff and volunteers may also save time once they
target their health promotional efforts, if they first try to find out what clients already know and
what they would like to learn.15
We suggest including negotiation counseling skills in those Training of Trainers Workshops to
train health workers and volunteers in community trials of negotiation counseling to enable them
to replicate these skills throughout the country as appropriate (but not by adding only 1 hour in
the MTT curriculum). This will also integrate problem solving, counseling, education and
information-giving skills along with communication of basic public health knowledge on health
issues. National staff of TAIS (Timor-Leste Asistnsia Integradu Sade) has been trained to use
negotiation counseling for the community consultation on child health practices in Timor-Leste
and have training and facilitation skills to work with national and district counterparts.
Equally, positive deviance could identify ideal practitioners in communities who could be used
to assist TIPs processe. Using a model practioners approach for family planning by
encouraging volunteers to mentor for other families.
12
See for more information: Dickin K and Griffiths M., Piwoz E., 1997. Designing by Dialogue. A Program Planners Guide to
Consultative Research for Improving Young Child Feeding. Support for Analysis and Research in Africa. Prepared for the Health
and Human Resources Analysis (HHRAA) Project By Manoff Group and SARA/AED.
13
Kirchmann K and Inh B L, 2004. General guide for facilitation and training material for ToT participants. ToT Book. GTZ
Vietnam
14
See: Guidelines for Training Community Surveillance Volunteers in Timor-Leste
15
24
4.1.2 Community Mobilization (CM)

The MoH is currently implementing the SISCa model in an attempt to improve access to health
services, community involvement, and intersectorial collaboration. This approach provides a
great opportunity to develop a synergistic combination of community mobilization, interpersonal
communication, and use of local and national media. CM helps improve community participation
through interaction between health providers, community stakeholders and community members.
CM is the process through which action is stimulated by a community itself, or by others: it is
planned, carried out, and evaluated by a communitys individuals, groups, and organizations.
Mobilizing communities is in tune with the Timor-Leste Health Promotion strategy, which is
focused not only on individual behavior change but also on strategies that address the
determinants of health and empower people to participate in improving the health of their
communities. Similarly, SISCa is a primary health care model that requires a lot of social
support. Its success depends on the interaction of key players at the aldeia and suco levels -- such
as health providers, suco council members, suco chiefs, aldeia chiefs, youth organizations,
womens networks, Katuas (cultural leaders) and other community leaders, NGOs, UN agencies
and other development sectors -- who can play a role in mobilizing people to build and support
collaboration/coordination and service integration. CM will stimulate community action by
involving different groups and community stakeholders to work together in child health. The
relevance of CM for child health can be summarized in six points. CM:
1. increases community dialogue and collective action in which members of a community
take action as a group to solve a common problem, such as high rates of diarrhea, lack of
potable water and so forth, which leads not only to a reduction in the prevalence of
disease within the community but also to social change that increases the collective
capacity to solve new problems.
2. increases program sustainability if the individuals and communities most affected feel
ownership of the process and content of the programs.
3. emphasizes the shift from transmission of information from outside technical experts to
dialogue, debate and negotiation on issues that resonate with members of the community.
4. emphasizes that outcomes should go beyond individual behavior to social norms,
policies, culture and the supporting environment.
5. allows people to identify all the available resources in the community.
6. can overcome and complement limitations of interpersonal communication, by working
together with local mass media in BCC interventions.
An extensive community mobilization program motivates sustained attention to the essential
actions by families, individuals and health providers and other influential groups.
An interesting example of CM in Timor-Leste is the church messages initiative. Research
conducted in Timor-Leste shows that the church is one of the most trusted sources of information
and an important influencers on family affairs. Engaging priests and catechists to give health
messages is an attempt to raise awareness and understanding of different child health issues
among churchgoers and a way to disseminate information to the whole community.
25
These messages were developed based on the results of the community consultation (formative
research). After church officials and the MoH stated their interest and commitment to the
dissemination of child health messages through the church, the messages (initially drafted by
TAIS) were revised several times based on input received on technical content and language
from relevant departments at MoH and partners (see booklet for dissemination of church
messages for child health developed by TAIS).
4.1.3 Advocacy
Advocacy for health is define as a combination of individual and social actions designed to gain
political commitment, policy support, social acceptance and systems support for a particular
health goal or program16. To facilitate CM, mobilizers (health providers, community leaders,
NGOs staff) should carry out advocacy activities at different levels in order to gain stakeholders
support of our initiatives or programs.
Table 2. Advocacy for Community Mobilization
Administrative/government
advocacy
To inform authorities and decision-makers of your program and enlist their

cooperation.
Community advocacy
To elicit a commitment from community leaders and program beneficiaries
Media advocacy
To place a specific issue on the public agenda,

To provide legitimacy to community interventions
To generate sufficient public pressure to ensure the adoption of decisions or public
policies that benefits the community.
4.1.4 Entertainment-Education (EE)

Community-based and mass media entertainment-education (EE) activities have been widely
used in Timor-Leste over the past five years. UNICEF, HAI, and UNFPA have all used street
theater, radio dramas, school plays, songs, games and written stories to promote public health
messages. There seems to be consensus that entertainment-based interventions are likely to
increase audience reach and attention to messages. The nature of EE interventions will facilitate
bringing together messages from all child health components included in this strategy.
Some important elements of entertainment-education include:
EE interventions use narratives to emotionally engage the audience in the lives of

believable characters in an entertaining way, rather than using didactic rational appeals
for behavior change.
16 WHO,1995. Report of the Inter-Agency Meeting on Advocacy Strategies for Health and Development: Development Communication in Action. WHO, Geneva, 1995
26
EE uses elements of communication and behavioral theories to reinforce and promote

specific values, attitudes, and behaviors17.
EE uses self-efficacy and modeling to promote particular behaviors. Self-efficacy refers

to a feeling of personal empowerment to perform a particular behavior. Modeling takes
place when people observe others performing a behavior either in real life or in a drama.
Characters are created to perform as role models demonstrating the feasibility of
performing the new behaviors and the real benefits obtained from those behaviors.
EE assumes that education does not have to be boring and that entertainment can be
educational.
EE projects acknowledge the structural barriers to behavior change and in addition to

individual behavior, address society as a unit of change.
New EE projects have introduced participatory approaches, seeking to empower

individuals and communities to create social change.
In contrast to commercial entertainment products, in EE for health promotion the creative team,
health providers and personnel, and the behavior change communication team must engage in an
ongoing dialogue to ensure an adequate balance between creativity and research as stories,
dramas, and other EE products are developed. In the case of the CH BCC strategy, emphasis has
been made on ensuring that stories address barriers to the desired behaviors, promote the
benefits of those behaviors, and enhance enabling factors to performing those behaviors.
4.1.5 Mass Media
We define mass media to include radio, TV, and print media, as well as community media,
particularly radio, and other forms of traditional media that may reach large numbers of the
target audience. Although mass media are still in a growing phase in Timor-Leste, and thus far
particularly TV still has limited penetration, data suggest rapid progress towards increased radio
coverage and penetration, and gradual penetration in the case of TV. Also, while interpersonal
communication and community mobilization will remain as the two central interventions of the
child health BCC strategies, current data suggest that radio already provides good national
coverage and targeted coverage at local levels community radio. Print media, on the other hand,
has limited reach and circulate primarily in urban areas.
In this strategy mass media are expected to provide the type of support that has been extensively
documented in public health. They can:
Support community mobilization and interpersonal communication efforts.
Help raise awareness of health issues and behaviors and facilitate advocacy for decision
and policy making for an improved environment to promote healthy behaviors.
Promote specific behaviors through multiple activities and products such as radio and TV
public service announcements, radio and TV magazines, and radio and TV shows.
17 Barker,, Kriss. 2008. Radio Serial to Change Social Behavior. Population Media Center. http://www.comminit.com/en/node/269267
27
Enhance the credibility of non-professionals such as community volunteers as reliable

sources of information and services.
Convey important logistical information easily, e.g. about times and places for health
campaigns or SISCas.
Local and international organizations in Timor-Leste have used public service announcements to
raise public awareness and advocate on various issues, ranging from HIV/AIDS to gender issues
to conflict resolution to childrens rights. RTTL produces a weekly health radio program in
which health issues are discussed and some health professionals are invited to provide guidance.
This BCC strategy will use mass media interventions primarily to raise awareness on key
behaviors and support advocacy efforts on health policy and decision making. Mass media in
this strategy is a complementary intervention that will set the stage for subsequent interpersonal
and community mobilization activities, or reinforcement of messages provided via counseling
and education sessions. A similar approach has been used in the design of the sexual and
reproductive health BCC strategy, in which mass media are used to raise awareness and advocate
for important decision making among key stakeholders, political leaders, and health providers,
especially on quality of health services and care.
4.1.6 Communication Interventions by Child Health Component

As stated earlier, this strategy draws on cross-cutting and component-specific activities. Below
we provide summaries of communication activities for each child health component. While some
activities are similar for two or more components, it is important to understand that each will
focus on specific messages on EPI, IMCI, or nutrition. Also, it is important to keep in
perspective that these activities may be modified and or adjusted at the time of the preparation of
the workplan. However, the summary below should serve as the basis for the implementation of
communication activities as it is derived from the intensive research activities undertaken
throughout the design of the strategy.
Summaries of Communication Activities by Child Health Component
I.
EXPANDED PROGRAM ON IMMUNIZATION (EPI)
Key Behavior: Bring children to immunization service delivery points at the ages (and with
correct intervals between doses) in the national schedule.
AUDIENCES
Mothers/caregivers with
children under
5/important
relatives
INTERVENTIONS
Interpersonal
communication:
Community
Mobilization:
COMMUNICATION ACTIVITIES
To conduct face-to-face and small group counseling sessions to
negotiate and discuss:
Traditional beliefs and practices that might prevent mothers
from bringing their children for immunization
Side effects of vaccines
Need to follow the immunization schedule
Need to pin the LISIOs high on the wall;
To activate social networks (community leaders, volunteers,
catechists, women groups) and encourage peer communication
(mother to mother) to reach remote areas in order to disseminate
information about the benefits of immunization indicating when and
where to get vaccinated.
28
Mass media:
To promote childhood immunizations on national and

community radios and national television using radio drama,
TV-Radio PAS and radio magazines that include information
about age for immunization, and places and time of vaccinations.
To provide reminder materials for immunization including a pouch

Community
Advocacy
Community
Mobilization:
Mass media:
Edutainment:
Capacity building
MOH/health
workers
Capacity building
for the LISIO and other important documents related to the child.
With religious, political leaders, media, health services and
community leaders:
To increase and maintain acceptance and support for
immunization,
To promote and sustain community involvement with
service delivery and child tracking, and media partnerships
at various levels
To promote and hold community discussions and meetings with
leaders and community at large in public settings such as SISCa to
address concerns about immunization and plan immunization
activities.
To organize community tracking systems to remind and motivate
families when a vaccination is due.
To strengthen the alliance between MoH and the church in order to
extend the experience of church messages to other districts
To generate and maintain support for immunization programs, and
maintain public confidence in vaccine safety through radio-TV
PSA, press release and media interview, media coverage of
immunization campaigns.
To promote the value of vaccines, model key behaviors, and
maintain public trust in immunization through theater,
storytelling, games, radio drama broadcasting through national
and local broadcasting, and use in small group discussions with tape
recorder/CD player, loud speakers in public gatherings such as
SISCa.
To train community volunteers in health education skills on
immunization and basic participatory planning and mobilization
skills.
To train community leaders (the example of training catechist to
convey health messages at the end of the mass) in specific
knowledge related to EPI and skills in connection to the nature and
scope of his/her involvement in support to immunization.
To train health workers in counseling skills in immunization
(training session should include issues about respect for traditional
practices, client-oriented services and understanding of lack
immunization compliance).
To train health workers in community mobilization and
participatory planning skills.
Advocacy
II.
To encourage MOH to clarify policies about which facilities people

can use based on their residence & disseminate correct information
to health staff and the public.
To encourage MOH to increase and sustain the amount and
reliability of outreach sessions such as SISCA
INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (IMCI):
29
Key behaviors:
Minimize the exposure of babies and young children to smoke

Treat mild illness at home and look for danger signs
Take a child with one or more danger signs immediately to a trained health provider
(Complete list in the LISIO).
Ascertain understanding of providers treatment instructions and follow them completely.
Sleeping under a bed net, during day and night time
AUDIENCES
Mothers/caregi
vers with
children under
5/important
relatives
INTERVENTIONS
Interpersonal
communication:
To conduct face-to-face and small group counseling sessions at
home, health centers, community settings and SISCa to negotiate
and discuss about:
The dangers of exposing children to smoke.
Traditional treatments that are helpful and those that are
harmful to health.
Specific danger signs and the importance of immediate
care-seeking when a danger sign appears.
The causes of malaria, the need to sleeping under treated
bednets and proper use of bednets
Treatment of a child with diarrhea with no signs of
dehydration
Community
Mobilization:

catechists, women groups) and encourage peer communication
(mother to mother) to reach remote areas in order to disseminate
information about :
The dangers of exposing newborns to excessive smoke.
Traditional treatments that are helpful, while reminding
families of the need for immediate care-seeking when a
danger sign appears.
Specific danger signs and on the importance of acting
immediately.
Traditional health practice that can be potentially harmful
for the health of the child and the mother.
To increase awareness of child danger signs, when a
child should be taken to a health facility immediately.
To provide reminder materials to mothers/caregivers to
identify dangerous signs for diarrhea, malaria,
pneumonia and home treatment of early or mild
dehydration
With religious, political, media, health leaders, UN agencies and
NGOs and community leaders to encourage the development/
strengthening of a community-based IMCI that involves the
participation of families, community leaders, health providers, UN
agencies and NGOs with the goal to reduce infant and early
childhood mortality.
Mass media:
(TV-Radio PAS, radio
magazines and community
radios)
Community
Advocacy
MoH and
Health workers
Capacity building
To train health workers in counseling skills in IMCI

(training session should include issues about respect for
traditional practices, client-oriented services and
understanding of danger signs and on the importance of
appropriate care-seeking / acting immediately and
30
Advocacy
III.
following health worker instructions).

To link health education with clinical training on IMCI,
so that health workers trained in IMCI are familiar with
child health messages.
To encourage doctors, nurses, midwives to promote IMCI
messages and providing services following IMCI
protocols
To improve, sustain /expand outreach health service
delivery and health promotion activities to remote,
populated areas.
To encourage the enacting of rules regarding which
facilities people can use and disseminate this information
to target audiences.
HYGIENE:
Key behaviors:
Wash hands with soap and water after going to the bathroom or contacting feces, and before eating,
feeding or cooking.
Safely dispose of the feces of all family members
Treat water you are about to drink or use for cooking
AUDIENCES
Mothers/caregi
vers with
children under
5/important
relatives
INTERVENTIONS
Interpersonal
communication:
Community
Mobilization:
Mass media:
(TV-Radio PAS, radio
magazines and
community radios)
To conduct face-to-face and small group counseling sessions at home,
health centers, community settings and SISCA to negotiate and discuss
about:
Hand washing with soap (ashes or sand) after critical times
The correct and consistent use of latrines among adults and
children over 5
The potties for night use by children
Disposing the babys and familys feces in a latrine or toilet
Safely store and retrieve treated water for family consumption
Treating drinking water and use it for cooking
catechists, women groups) and encourage peer communication (mother
to mother) to reach remote areas in order to disseminate information
about :
Hand washing with soap (ashes or sand) after critical times
The correct and consistent use of latrines among adults and
children over 5
The potties for night use by children
Disposing the babys and familys feces in a latrine or toilet
Safely store and retrieve treated water for family consumption
Treating drinking water and use it for cooking.
To promote handwashing with soap, the removal of stools
from the household environment, the home treatment and safe
storage and retrieval of drinking water, safe disposal of
children's stools in connection to safe handling of weaning
food.
To provide reminder materials to mothers/caregivers with
regard to hand washing, safely dispose of the feces of all
31
School
Teachers/
School children
Interpersonal
communication
Community
Advocacy
MoH and
Health workers
Capacity building
Advocacy
family members and water treatment and storage.

To train teachers to teach school children and parents about
good sanitation and hygiene practices for the children and
families.
To encourage children to educate/share information with their
parents in hygiene and sanitation.
To encourage parents to listen to their children and support
them as they try to implement proper hygiene and sanitation
practices at home.
With schools, religious, political leaders, the media, health leaders, UN
agencies and NGOs and community leaders:
To encourage the development/strengthening of communitybased water systems, wells, and hand pumps and the
creation/training of community water/sanitation committees.
To increase household access to soap and water
To support the development of a range of household toilet
(HHT) technologies options and promote HHT construction,
through micro-credit or other alternative financing schemes.
To make schools institutions of learning, practicing and
diffusion of good sanitation and hygiene practices for the
children, their teachers and parents, and their communities at
large.
To train health workers in counseling skills on hygiene
(training session should include issues about respect for
traditional
practices,
client-oriented
services
and
understanding of factors that influence peoples current
hygiene practices).
To encourage doctors, nurses, midwives to delivery hygiene
messages
IV.
NUTRITION18
Key Behaviors:

Give adequate complementary feeding from about 6-24 months with continued breastfeeding for at least two
years.

AUDIENCES
INTERVENTIONS
18
This matrix is adapted from the Behavior Change Communication Strategy for Improved Infant and Young Child
Feeding Practices in Timor-Leste. In this strategy, there are only four behaviors promoted out of seven listed above:
Regular growth monitoring, immediate breastfeeding (and colostrums feeding), exclusive breastfeeding for six
months, nutritious complementary feeding, and continued breastfeeding for two years. For more information and
details, we encourage the reader to go through the main strategy document cited above.
32
Mothers,
Fathers of
children under 5
Interpersonal
communication:
Caregivers of
children under 5
Community
Mobilization:
Mass media:
Community
Community
Mobilization:
Mass media:
Edutainment:
Capacity building
Bring their children to health facilities for weighing

Initiate breastfeeding within one hour of birth
Practice frequent, on-demand breastfeeding, day and night.
Increase breastfeeding frequency during and after
Infants illness
Continue to feed children during illness and to increase
amounts of quality foods and liquids given to a sick child
Continue to breastfeed children up to 2 years
The Introduction of appropriate foods, in addition to breast
milk, at 6 months
That every meal given to a child is nutrient dense
That porridge is not too thin (should be too thick to drink
and should stay easy on a spoon).
Adequate vitamin A intake for yourself and young children
Iron intake for the mother and young children
Community activities (games, cooking demonstrations, etc.)
Mother Support Groups
Church UNICEF
Nutrition events
Radio and TV appearances of Breastfeeding champion (prominent
Timorese) Alola
Stickers for immunization cards (the first vaccine!)
Jornal Labarik UNICEF
To animate the communities and generate actions for IYCF through
small and large group activities and monthly suco level nutrition day.
There will be contests (quiz, cooking, games) performances
(breastfeeding songs, community theatre, films, folk media) and
service delivery (counselling, supplements, growth monitoring, etc),
as well as celebration of successes (nutrition certificates for
optimally fed babies) and other creative ways to fuel enthusiasm in
the communities.
Mass media (radio and print) will reinforce messages promoted by
health workers and other community members and extend the reach
of the campaigns messages to areas outside of program sites where
partners are working: Radio (UNICEF with TAIS, CONCERN and
SHARE).
Song competition UNICEF
Drama DVD Alola
Lafaek CARE
To equip community volunteers with the facilitation and negotiation
skills necessary for convincing mothers (and the communities) to
adopt improved IYCF practices.
The NWG will be the venue for bringing together nutrition
stakeholders to harmonize messages and field approaches and to
maximize materials and other resources. Partners will be involved in
reviewing and interpreting formative research, developing key
messages, pre-testing materials, facilitating training sessions, and
monitoring and evaluating activities. NGOs and MoH staff, along
with community-based partners, will initiate and carry out
community activities. The partnerships (local, district, national) will
also be the venue for learning and dissemination of lessons.
Support:
Grandmothers,
Stakeholders
To conduct face-to-face and small group counseling sessions

(health worker to mother, mother to mother, house to house
visits, etc) to negotiate and discuss:
Building
Partnerships.
33
MOH/health
workers
Capacity building
Policy Advocacy
This includes training, demonstration, coaching, and tactic sessions,

field visits and cross visits. Practice rather than theory will
characterize training activities. The goal is to equip field workers and
service providers with the facilitation and negotiation skills
necessary for convincing mothers (and the communities) to adopt
improved IYCF practices.
Center-staging child survival and IYCF through lobbying for: (1)
The passage of the milk substitute code and fortification; (2)
Resources for improving health service delivery; and, (3) Policies
that promote child survival and IYCF (example, make breastfeeding
counseling a requirement similar to immunization).
V.
NEW BORN19
Key behaviors:
Make a birth plan

Deliver with a skilled attendant
Identify danger signs for newborns (see whole page in LISIO)
Reduce prevalence of harmful traditional practices for mothers / newborns
Increase prevalence of recommended preventive health behaviors (infection prevention, preventing
hypothermia, exclusive breastfeeding, routine postpartum visits)
AUDIENCES
Wives/husbands
/close
families/in-laws
INTERVENTIONS
Interpersonal
communication:
Mass media:
Community
- Local Leaders:
-Traditional
Leaders
- Teachers
Interpersonal
communication
To conduct face-to-face and small group counseling sessions at home,
health centers, community settings and SISCA to negotiate and discuss
about:
Birth planning process, teach families to recognize, and
motivate them to act on, maternal danger signs.
Delivering with a skilled attendant, preferably in a facility, but
at home if family refuses a facility birth.
The issue of transportation costs for midwives.
Replay of radio soap opera episodes related to SM in health centers,
community settings and SISCA through rotakassettes, followed by
group discussions
Production and dissemination of radio and TV PSAs
encouraging health seeking behaviors and use of health
services
To place the issue of traditional practices affecting the health
of (women and) children in the public agenda, managing the
topic with respect and encouraging discussion between
audiences and MoH technical staff.
Supporting activities
Training workshops with journalists on SM issues
To consult and learn from traditional leaders/grandmothers if
there are acceptable alternative ways to keep the mother and
newborn safe and warm (regarding harmful practices such as
sitting fire and/or staying at home postpartum)
19
This matrix is adapted from the Timor-Leste National BCC Strategy for ReproductiveHealth20072011and
Community Consultation report, 2007. For more information and details, we encourage the reader to go through the
main strategy document and the report cited above.
34
- Community
Organizations
Advocacy
Community
Mobilization:
Mass media:
MoH and
Health workers
Capacity building
Advocacy
To discuss with main influencers in the community about

barriers to care-seeking and explanations for causes of illness
Encourage leaders and existing groups in communities to
develop a general plan for emergency transportation, contact
points for obstetrical and other emergencies and /or pooled
emergency funds
Dissemination of communication and education materials to
suco chiefs and other local leaders for use in murals, wall
papers, etc.
Creation of mobile communication unit (MCU) to mobilize
communities to discuss and learn about RH/FP/SM issues.
MCU includes basic equipment to implement educational
activities in local communities.
Implementation of participatory planning process led by local
health districts to involve local actors in supporting key SM
interventions.
Design and implementation of an advertising campaign to
create brand recognition for FP/RH/SM strategy (slogan;
logo) through PSAs, posters, caps, t-shirts.
Promotion of communication strategy activities and products
in local communities and schools
Production of weekly radio magazine dealing with health
issues, including SM. This magazine will include the
participation of health authorities and professionals as well as
political and community leaders.
Design and dissemination of radio and TV PSAs involving
celebrities to place SM issues on political and public agenda
Training sessions with health providers to improve
interpersonal communication between providers and clients
using TIPs.
Design and production of IEC tool box for health providers
(i.e. will include brochures on selected SM topics; games for
activities with mothers during wait time at health services;
miniflip chart for use during home visits). These also will
include counseling materials (counseling cards or a flip chart
that guides a promoter or health worker to talk to a mother or
couple about RH issues).
Taking steps to improve the attitudes and interpersonal skills
and treatment by nurses and midwives.
To encourage doctors, nurses, midwives to develop a birth
plan format and test it in their communities to learn if people
are willing and able to make and follow specific plans.
To create and promote incentives for local health districts and
health providers (i.e., national award to most improved health
district).
5. Messages and Materials Development

The main feature of the message and materials development phase of the child health BCC
strategy is the development of core or base stories that build upon findings from the
formative assessment and key messages that can be used to design and develop materials for the
five components of the BCC strategy. These stories bring together messages and situations
35
focused on the key behaviors for child health and seek to promote benefits, address barriers and
enhance enabling factors. The materials selected for the child health BCC strategy are meant to
work in synergy with existing IEC materials in Timor-Leste in order to support and complement
community mobilization and interpersonal communication activities for child health. Appendix
D describes a model used to develop messages and materials for this strategy, which is expected
to be used in subsequent phases of the process.
6. Monitoring and Evaluation (M & E) framework

The proposed monitoring and evaluation (M&E) framework for child health BCC strategy draws
on the framework used for the Sexual and Reproductive Health BCC strategy20 and is consistent
with SISCa monitoring and evaluation framework21. In order to avoid duplication of efforts, the
BCC team suggests the use of a similar framework to facilitate synergies between both strategies
and SISCa M&E efforts.
M&E took place throughout the various stages of the interventions, starting in the project-design
phase with a baseline assessment and consideration of historical trends, and ending with an
assessment of ultimate outcomes. As BCC interventions require specific data to establish their
impact, the BCC team suggested the following steps:
Engaging MoH and partner organizations in defining M&E indicators and reviewing
available sources of information to define reliable baseline data.
Use child health data collected through different research studies including the DHS
survey scheduled for 2009,
Use data from the Ministry of Healths information management system which collates
tri-monthly data at community health clinic level through district health facility level.
The BCC team is aware that the quality of data provided by the national public health
information system may be uncertain, but they could give a helpful indication of the current
stage of some selected behaviors. The team is also aware of research currently being undertaken
in public health in Timor-Leste which will provide meaningful data for a baseline on child health
BCC interventions such as the University of New South Waless health seeking behavior study
that includes maternal and child health issues, and the current Health Alliance Internationals
Child Spacing Study.
The BCC team has worked with the assumption that a behavior-centered approach must
recognize that communication alone cannot overcome such structural barriers as inaccessible and
unfriendly health services, deeply-seated cultural practices that limit womens decision-making
power, lack of education, availability of food, unemployment, and lack of resources. Therefore
BCC intervention should be articulated to social, health and development policies. M&E is
understood here as a dynamic tool and process for keeping programs on track and stakeholders
20
Ministry of Health Republic Democratic of Timor Leste, 2007. National Behaviour Change Communication Strategy 20082012. For Reproductive Health, Family Planning and Safe Motherhood.
21
Ministry of Health Republic Democratic of Timor Leste, 2008. Monitoring and Evaluation of SISCa Program
36
(at all levels) motivated. It is aimed at improving our understanding of results while also
strengthening local capacity, institutional development, and sustainability of efforts22.
Monitoring and evaluation is critical not only to help assess the BCC outcomes and successes of
the child health interventions, but also to provide feedback to the community, assess how
community groups may have changed as a result of communication activities, and identify future
directions. M&E should be community-based and focused on decision making and action, in
which families and community groups have a key role in the planning, design, implementation
and evaluation of BCC programs under the leadership of the MoH (see community-based Health
Information System for SISCa).
6.1 Impact evaluation
Impact evaluation assesses how changes in key behaviors promoted by the BCC interventions
are contributing to the impact indicators stated in the Basic Service Package (BSP). The actual
impact of BCC interventions in child health status is, however, difficult to assess because the
impact on morbidity and mortality depends on various efforts aimed at contributing to child
health improvements and development in general, in addition to the BCC activities.
The goals for impact in child health, therefore, should be literally taken from the Basic Service
Package, which in turn will demand analysis of comparative effects. Timor-Leste is committed
to improving child health as stated in its National Development Plan. This means reducing
U5MR from 165 to 55, and the infant mortality rate (IMR) from 126 to 42 deaths per 1,000 live
births by 2015 to meet the MDG goals. As stated in the BSP, significant action and active
district-level management is required in order to achieve this aim.
Impact evaluation requires preliminary information collected at the beginning of the health sector
interventions (MCH, HP, EPI, nutrition, hygiene, IMCI, etc.), a public health management
information system, as well as an evaluation design that allows establishing associations among
environmental factors (physical, psycho-social-cultural-economical) and factors related to health
sector interventions contributing to changes in the reproductive health status of the population,
including BCC interventions.
6.1.1 Impact Indicators
Impact indicators should address questions such as the following:
Does the BCC intervention contribute to the CH BSP intended goals, and to what extent?
Does the BCC intervention impact vary across different groups of intended audiences,
geographic areas, and over time?
Are there any unintended effects of the BCC intervention, either positive or negative?
How effective are the BCC interventions in comparison with other interventions?
37
The essential pre-requisite, however, for measuring impact is to have clear behavioral outcomes
that contribute to child health goals.
6.2 Outcome Evaluation
Outcome evaluation is used to assess the effectiveness of a BCC program in meeting its stated
behavioral objectives for each component of child health. While process evaluation considers
how well the process is carried out (see below), outcome evaluation considers the consequences
(intended and unintended) of the program. In this M&E framework it is suggested that outcome
indicators should be broken down into outcome indicators and intermediate outcome
indicators.
6.2.1 Outcome Indicators
Outcome indicators measure the effects expected from BCC strategy implementation. Generally,
these changes in selected key behaviors are achieved in the last stages of the implementation
plan (summative evaluation of the child health BCC strategy) or halfway through the
implementation of the program. In summary, outcome indicators are defined by the behavioral
results specified from the very outset; for example:
Key behavior: Handwashing after critical times
By the end of the BCC strategy action plan in December 2012, to increase the number of
mothers/fathers/ caretakers who always wash their hands with soap (ashes or sand) after going to
toilet/bathroom or after having contact with feces, before eating or cooking, or when cleaning the
bottom of the baby, starting from X to X.
6.2.2 Intermediate Outcome Indicators
Intermediate outcome indicators should focus on short-term outcome indicators, referring to
early results of the BCC interventions, while the assessment of long-term indicators may be
thought of as outcome evaluation of the BCC strategy. The intermediate outcome indicators are
based on the provisional communication objectives built from the sub-behaviors23 or combine
with predictors of behavior change: knowledge, perceived risk, perceived severity, perceived
benefits and barriers, attitudes, behavioral and normative beliefs, behavioral control, and
enabling factors. The example of handwashing can be operationalized in the following way to
determine intermediate outcome indicators:
Sub-behaviors for washing hands with soap or substitutes can be24:

-
Get/buy a soap or an acceptable substitute
23
Sub-behaviors are essential actions undertaken by an individual and/or a group of people, in order to increase the
probability to perform the main behavioral objective.
24
The example was adapted from Favin M., Naimoli G. and Sherburne L. 2004. Improving Health through Behavior
Change. A Process Guide on Hygiene Promotion. Prepared under Environmental Health Project, Project
26568/CESH.CIMCI.PAHO.Y5. Washington, DC 20523.
38
Rinse hands with clean water after defecation

Rub with soap or an acceptable soap or substitute
Rub at least 3 times
Rinse with water
Dry on a clean cloth or in the air (i.e., avoid drying on potentially contaminated cloth or
clothes)
Tentative predictors of behavior change

% of primary audiences that stated perceive benefits of washing their hands
% of primary audiences that stated perceive risk of not washing the hands after critical
times
- % of primary audiences that stated positive attitude towards handwashing
This particular behavior is, however, very difficult to measure because not always people will
tell the truth and perhaps the best alternative is to measure it by observation.
-
6.3 Process Monitoring

Process monitoring is used here to refer a type of evaluation focus on assessing how well a BCC
program has been implemented and to adjust communication activities and tasks to meet the
program behavioral objectives. It examines the operation of the program, including which
activities are taking place, and assesses the performance of the people involved in the
implementation and who is reached through the activities. Process monitoring assesses whether
inputs and resources have been allocated or mobilized and whether activities are being
implemented as planned.
It involves on-going monitoring of the implementation process, identifying program strengths,
weaknesses and areas that need improvement. It includes assessment of whether messages are
being delivered appropriately, whether IEC materials are being distributed to the right people and
in the right places, and whether planned BCC activities are actually taking place, along with
other measures assessing how well the program is working. Data from process evaluation can be
used in at least three ways:
Making decisions about refining the strategys objectives, activities, behaviors, products,
services, and so on.
Documenting and justifying how resources have been spent.
Making a compelling case for continued or additional funding (especially if combined with
behavioral impact data).
6.3.1 Process Monitoring/Output Indicators
These indicators describe the outputs to be generated throughout the BCC program
implementation. They should specify the quantity, the quality and the time period expected for
the production of IEC materials, distribution, training of trainers, workshops, presentations,
broadcasting, delivery of commodities and other resources, messages, trainings, infrastructure,
and activities-tasks described in the action plan. Sometimes they are considered as the Terms of
Reference (TOR) of the project.
39
The number of people exposed to the BCC activities

The characteristics of the people exposed to the BCC activities
The type and amount of resources spent
Media response
Intended audience participation, inquiries, and other responses
Meeting of deadlines
Production of deliverables
Print material distribution and estimated number of viewers
Number of community meetings and number of community organizations and stakeholder
mobilization
Number and frequency of radio and television PSAs broadcast
These proposed indicators should match with a detailed workplan broken down into strategy
components and into activities, tasks, timeframe, responsible implementers and budget.
6.4 CH BCC Behavioral Indicators and M&E Plan
The behavioral indicators proposed in appendix I are still provisional and open to discussion,
modification and adjustment. Achievement of these objectives will be a critical step in achieving
the stated child health goals. The proposed date to conclude the BCC strategy action plan is
intended to coincide with the end of the HEALTH SECTOR STRATEGIC PLAN 2008
2012.
Methods and actions for M&E should be refined by MoH and partner organizations considering
among other things, the following questions:
Time periods (when and how frequently monitoring should be conducted and for how
long).
What modes of data collection should be used?
Who the clients for the information should be?
How the findings should be used?
What decisions are needed?
The resources available and needed to carry out monitoring and evaluation activities.
7. Workplan
A detailed workplan for communication activities and tasks were jointly developed through a
working session with MoH and partner organizations in December 2008. The working sessions
were facilitated by a BCC consultant, facilitators from the MoH and partner organizations. The
enclose workplan includes descriptions of activities, task and plans for IEC material production,
suggestions for procurement and distribution of IEC materials as well as identify which staff
and/or partner agency to be involved, define responsibilities, trainings and supervision activities
required (for whom, what, when, where, why, facilitated by whom), see appendix J.
40
While the workplan (see appendix J) is still tentative and subject to revisions, Table 2
summarizes the main elements and phases of the child health BCC strategy. It is organized by
communication interventions (i.e., interpersonal communication, edutainment, mass media,
advocacy), communication activities (i.e. home visits, group sessions, radio soap opera), phases
(i.e., strategic planning, capacity building, implementation), and tentative dates. This table
provides an overview of the strategy. Specific activities per each child health component are
described in sections 3.3 and 3.4. It is important to note that while Table 2 refers to advocacy and
mass media as separate interventions in order to more clearly show specific activities in each
case.
Table 3
BCC STRATEGY
INTERVENTIONS, ACTIVITIES AND PHASES
COMMUNICATION
INTERVENTIONS
PHASES
Meetings to reach consensus on the strategic

approach
Consensus
Building and
Strategic
Planning
Develop CH BCC Strategy Workplan

Harmonize materials, messages and BCC
interventions among partners (synergies)
Draft the Monitoring and Evaluation framework
41
TENTATIVE
TIMELINE
December
2008

Interpersonal
Communication
HP/DHS: train health providers to improve

interpersonal communication skills, in
particular in counseling/negotiation and
storytelling25.
HP/DHS/NGOs: strengthen interpersonal
communication skills among community
volunteers so they can give information and
counsel effectively at SISCa and home visits
HP/DHS: produce a health education tool box
for nurses, midwives and CV
Community volunteer conduct home visits,
small group educational meetings, SISCA
interpersonal communication activities.
Community Mobilization
Edutainment
Advocacy
HP/DHS/community
volunteers:
support
implementation of health information given at
masses (church messages), in accordance with
the health topics scheduled on a monthly basis.
DPHO/HP: train community leaders in
facilitating public educational talks and
dialogues in their communities about CH
issues.
HP: produce a tool box for community leaders,
including a How-To-Do Guide for local
leaders.
MOH: promote and implement participatory
planning processes led by district health
services to involve local stakeholders in
supporting key CH interventions
HP/DHS/community
volunteers:
support
HP/DHS: create mobile communication unit
(MCU) to mobilize communities on CH issues.
MCU includes basic equipment to implement
educational activities in SISCa settings.
HP/DHS: combine SISCAs with film showing
and quizzes in the evening (before or after the
SISCa).
UNICEF/TAIS/, other donors and PVOs:
advocate with the MoH to gain political
commitment with the CH BCC strategy, which
may include technical support from UN and
Capacity Building
Participatory
Planning and
Implementation at
District and Aldea
Level
Capacity Building
First Semester
2009 (and onthe-job
support for
the full year.
First Semester
2009
First Semester
2009
2009-2012
First Semester
2009
2009-2010
First Semester
2009
Participatory
Planning and
Implementation at
District and Aldea
Level
2009-2012
2009-2012
Build and Sustain

BCC Strategy
Platform
2009-2012
25
This is already part of the MTT and DTT training for SISCa trainers, but needs much more attention. Currently
there is much focus on didactic lecturing and handing over the content. Process is undervalued. This also required
on-the-job support, when DHPOs start training others (volunteers, community leaders e.g.)
42
Mass Media
PVOs to train DTTs in their annual work

plans, considering 1-2 focal point partners for
each district
HP: advocate with public (RTTL) and private
mass media (Media Development Center,
community radios), to forge sustainable
collaboration for co-production, postproduction and broadcasting of CH IEC media
products
HP/MOH: advocate Specific actions on school
health education with the MoE. Plans for 2009
for SHE includes Loron Eskola Saudavel
LES)
HP/MOH: advocate with other relevant
government sectors and civil society
organizations at different administrative levels
HP/MOH: advocate with relevant stakeholders
at district and village level to support
HP/partners/ Media Development Center/
RRTL: produce a radio drama dealing with key
behaviors on CH issues to be broadcast in
Tetum on RRTL and replayed over local and
community radio stations and SISCa
gatherings
HP/partners: produce a weekly radio magazine
dealing with CH. It will include participation
of health providers, political and community
leaders
HP/partners/ RRTL: produce and broadcast
radio soap opera, and radio and TV PSAs
promoting key behaviors and services
HP/partners/RRTL: broadcast radio soap
opera, and radio and TV PSAs promoting key
behaviors and services linked to health
information given at masses (church
messages), in accordance with the health topics
scheduled on a monthly basis.
Develop/review indicators and train CHC/DHS
health staff who are responsible for reporting
for the HIS
HP/partners: collect baseline data by
identifying potential sources of national and
district information with relevant behavioral
data at the beginning of BCC intervention,
addressing different CH issues.
HP/partners: plan and conduct a communitybased evaluation at selected sites in year 2,
looking at outcome intermediate indicators and
output indicators
HP/partners: set up a BCC community-based
information system for the collection of
routine data (input-activities) to monitor the
43
2008-2012
2008-2012
Implementation
First Semester
2009
First Semester
2009
2009-2012
Participatory
Monitoring and
Evaluation
Participatory
Monitoring and
Evaluation
November
2009
First Semester
2010
First Semester
2008
BCC intervention progress (output indicators).

HP/ partners: Conduct a national end-line
study in year 4, looking at outcome indicators
in different CH components targeted by the
BCC intervention.
2012
8. Recommendations for Implementation (to be developed)

This tentative workplan and timeline for BCC activities and phases are linked to the Health
Sector Strategic Plan 2008 2012, Ministry of Health, Timor-Leste. The agenda and suggested
activities should be subjected to ongoing review and discussion among MoH and partner
organizations and, it will require continuing BCC technical support to the health promotion
department to implement the strategy, as well as maintaining an active BCC working group that
meets regularly. It might also require modifying HPs work plan to accommodate these
activities.
It is suggested that the BCC strategy for child health will be implemented by the MoH and
DHSs as well as by NGOs/UN agencies working in child health. The Health Promotion
Department , supported by the BCC Working Group in Child Health, will coordinate activities
and service as an information clearinghouse. One proposal for the partners to consider is to
implement the strategy intensively for one year in two or three districts, and then to use that
experience to modify the strategy, if needed and to use those districts to inspire and teach other
districts to also implement the strategy intensively.
The Ministerio, supported by the BCC Working Group in Child Health, will coordinate M&E
activities at the national level and will assist DHSs, if requested, in simpler monitoring at the
district level.
8.2 Job description of the BCC manager and team (to be developed)9.
Appendixes
Appendix A summarizes the results of the behavioral analysis for all child health components.
Appendix B summarizes main elements of the SWOT analysis and recommendations.
Appendix C summarizes the main elements of the communication analysis and audience
segmentation
Appendix D describes a model used to develop messages and materials for this strategy
Appendix E contains the draft matrix of proposed IEC materials - child health BCC strategy
Appendix F drafts Core Stories addressing five priority child health areas
Appendix G includes drafts of Public Health messages for CH BCC Strategy
44
Appendix H, contains the list of participants for BCC workshop for Child Health Strategy
Appendix I includes the outcome and intermediate outcome indicators and potential data sources
Appendix J contains the BCC workplan, which includes descriptions of activities, task and plans
for IEC material production, suggestions for procurement and distribution of IEC materials as
well as identify which staff and/or partner agency to be involved, define responsibilities,
trainings and supervision activities required.
45

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12 Timor Leste BCC Strategy For Child Health - Draft PDF

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MINISTRIODASADE

Dirasaun Nacional Saude Comunitaria

BEHAVIOR CHANGE COMMUNICATION STRATEGY FOR CHILD

Document prepared by:

Behavior Change Communication

Baby Friendly Hospital

Clinic Health Center

District Health Services

District Public Health Officers

District Trainer of Trainers

Extended Program of Immunization

Information Education Communication

Integrated Management of Childhood Illness

Insecticide Treated Nets

Infant and Young Child Feeding

Health Alliance International

Livrinho Saude Inan no Oan

Maternal and Child Health

Mother Support Groups

Master Trainer of Trainers

Oral Polio Vaccine

Oral Rehydration Solution

Radio Television Timor-Leste

Strengths, Weaknesses, Opportunities, and Threats

Timor-Leste Asistensia Integradu Saude

Traditional Birth Attendant

Trials of Improved Practices

Non Governmental Organization

Services for the Health in Asia and Africa Region

United Nations Population Fund

United Nations Childrens Fund

United States Agency for International Development

1. Executive Summary1. 1 Key Components and Activities

a review of existing documents on health communication and child health behaviors,

Key features of this behavior-centered strategy include the following:

1.2 Core Elements of the Behavior Change Communication Strategy

Street theater, radio

is essential for desired

Train health care

Strengthen the skills

1.3 Monitoring and Evaluation (M&E)

Background and brief situation analysis

2.1 Socio-economic and public health context

2.2 Child Health in Timor-Leste

Almost 50% are underweight for their age;

2The UNDPs National MDG Report 2004

The value attached to information received by word of mouth is dependent on who

Recommendations emphasized that community-based communication strategies should be

Review of findings from a TAIS community consultation conducted in 2007 to

Definition of key behaviors that this strategy seeks to promote.

A SWOT (strengths, weaknesses, opportunities, and threats) analysis of health promotion

A communication and audience segmentation analysis (including a workshop focused on

Identification and selection of primary and secondary audiences.

Barrier analysis to identify real and perceived barriers to performing a behavior.

Key Behaviors for mothers and other caregivers

Minimize the exposure of babies and young children to smoke

Treat mild illness at home and look for danger signs

The- BCC Strategy

Table 1. Conceptual Framework, BCC Strategy for Child Health, Timor-Leste

Participatory BCC Design

Technical focus areas and key

Key Actions to Support Implementation