BEHAVIOR CHANGE COMMUNICATION AS

AN INTERVENTION TO IMPROVE FAMILY

HEALTH OUTCOMES
GARY L. DARMSTADT AND USHA KIRAN TARIGOPULA

Low coverage of life-saving preventive

health interventionsstemming from
unhealthful social norms, attitudes and
practices, and lack of knowledge among
key population groups and healthcare
providers in both the public and private
sector contribute to maternal, newborn
and child mortality and morbidity in
India. Specifically, lack of family planning
leading to suboptimal birth spacing and
to young maternal age at first pregnancy;
lack of routine antenatal care or skilled
attendance at delivery, including poor
hygiene practices; lack of early and
exclusive breastfeeding, newborn thermal
care and clean cord care; poor infant
and young child feeding practices; and
poor demand for preventive child health
measures, such as immunizations, all
result in avertable morbidity and death.
Although solutions to these problems are
available, the uptake of interventions to
improve family health outcomes remains

unacceptably low. Evidence suggests,

however, that social norms and practices
can be changed through the communication
of culturally contextualized messages
designed to support families in modifying
high risk practices and delivered through a
combination of mass media and mid media,
coupled with improved interpersonal
interactions involving reasoning and
negotiation between frontline healthcare
workers and target populations at the
family and community level.
While there have been many standalone initiatives to shape demand and
practices in rural settings in the past,
they have suffered from three major
limitations. First, they have not always
been scientifically developed so as to
systematically target risk factors and
address social and structural barriers to
behavior change, or have not focused on
a manageable list of proven interventions

Gary L. Darmstadt, Director, Family Health Division, Global Health Program, the Bill and Melinda Gates
Foundation, Seattle, USA, and Usha Kiran Tarigopula, Deputy Director, Global Health, India Country
Office, the Bill and Melinda Gates Foundation, New Delhi.

Vol. 56, Special Issue - 2010

and a key mix of stakeholders and

health providers involved in sanctioning
and supporting the uptake of the new
behaviors. Second, even interventions
that have adopted these approaches have
not integrated, aligned and synergized
communications using multiple channels,
particularly new and innovative
communication technology applications
and partnerships, especially with the
private sector. Finally, these elements
necessary for success have not been
c o m p r e h e n s i ve l y i m p l e m e n t e d a n d
demonstrated at scale. In short, the success
of these interventions ultimately requires
reaching a large number of stakeholders
and key behavioral targets, particularly
the poorest and most disadvantaged
groups, with a limited number of culturally
appropriate and aligned messages. In
this way, the capacity of families and
communities to take the risk of adopting
a modified or new behavior, and to be
producers of good health, is increased.
To a c h i e ve t h i s l o n g - t e r m g o a l ,
the Population Council was awarded a
landscaping grant to conduct an analysis
in rural Uttar Pradesh (UP) to inform
the development of a comprehensive
behavior change communication (BCC)
strategy to shape demand and practices
that could contribute to reduced maternal,
neonatal and under-5 mortality and
improved nutrition and reproductive health
outcomes, particularly in UP, Bihar and
throughout northern India.
This special issue of The Journal of
Family Welfare provides a synthesis of the
existing literature, as well as the results
of a number of comprehensive, original
formative studies and analysis of diverse
datasets carried out by the Population
Council and its six consortium members.a
This exercise has generated a vast amount

of useful information on family dynamics

that could be effectively used to develop a
comprehensive BCC strategy for shaping
demand and practices that would have a
direct bearing on family health.
Several key issues were addressed
in this study, including identification
of the barriers to the uptake of proven
preventive interventions; analysis of
successful approaches and strategies that
have worked, those that have not, and
reasons why or why not; identification of
the partners working in the area of family
health preventive care; and emerging
new and innovative opportunities and
approaches. Specific behaviors that were
studied in detail included care seeking
for essential maternal health services such
as antenatal care and skilled attendance
at delivery; clean delivery; early and
exclusive breastfeeding; newborn thermal
care including skin-to-skin care; clean cord
care; appropriate complementary feeding
(quantity, frequency, diversity of foods)
of young children aged 6 - 23 months;
routine immunization, in particular
measles immunization; and birth spacing
methods. These interventions were chosen
on the basis of their potential impact on
maternal, neonatal and child mortality
using projections for UP, modeled through
use of the Lives Saved (LiST) tool.1
T h e l a n d s c a p i n g a n d f o r m a t i ve
research exercise carried out by the
Population Council and its consortium
members is unique in many respects. For
the first time in India, the development
of a BCC strategy has been viewed
from a wider perspective that has not
only tried to identify and understand
the barriers and facilitating factors for
eight target behaviors in rural UP, but in
addition a systematic effort has been made
to identify possible partners who could

Abt Associates Inc., RKSWAMY BBDO, Confederation of Indian Industry (CII), Ideosync Media
Combine, International Institute of Population Studies (IIPS), Indian Clinical Epidemiology Network
(INDIACLEN).
a

The Journal of Family Welfare

collaborate, complement and leverage

the implementation of the BCC strategy.
Potential partners were explored from the
communication sector as well as other
sectors including advertising and media
agencies, entertainment, new and emerging
information communication technologies
(ICT), public and private health sector
providers including frontline health
workers, and medical professionals bodies
such as the Federation of Obstetric and
Gynecological Societies of India (FOGSI),
the Indian Academy of Pediatrics (IAP) and
the National Neonatology Forum (NNF).
The study also explored the possibility
of leveraging the implementation of the
BCC strategy under corporate social
responsibility (CSR). Importantly, the
study took the view that families and
communities themselves are key producers
of good health, and must be supported and
equipped by a variety of actors to do this
more effectively.
Prior to planning and initiating
the landscaping exercise, staff from the
Population Council (M.E Khan, John
Townsend and Katherine Williams), the
Bill and Melinda Gates Foundation (Gary
L. Darmstadt and Usha Kiran Tarigopula),
and the Johns Hopkins University Center
for Communication Programs (JHUCCP)
(Douglas Storey) and a well-known medical
anthropologist with vast experience in India
and South Asia (Bert Pelto) held several
meetings to select the target behaviors
that could have the greatest impact on
family health and to develop a pathways
model that could provide the framework
for research, data collection and ultimately
the development of a comprehensive BCC
strategy. The pathways model, originally
developed by JHUCCP, was adapted
and designed to help guide research to
understand the barriers and facilitating
factors in adopting healthy behaviors,
and during the course of the research was
continuously reviewed, modified and
found to be highly useful for informing the

Vol. 56, Special Issue - 2010

study design, and data collection, analysis

and synthesis (Figure 1).2
The articles included in this issue of
The Journal of Family Welfare provide crucial
leads regarding the barriers and facilitating
factors that have a significant bearing on
the various target behaviors. Key findings
and observations of these studies have
been presented in articles 2-8 included in
this volume, while detailed information is
presented elsewhere.3,4 Detailed findings
from the analysis of potential partnerships
are also included in a forthcoming volume.5
The study found that three or more
antenatal check-ups seem to be a catalyst
for several targeted behaviors, including
institutional delivery, early breastfeeding,
postnatal care within 7 days of delivery,
full immunization of children aged 12-23
months and postpartum contraception
for birth spacing. 6 Similarly, the article
o n i m m u n i z a t i o n i d e n t i f i e s s e ve r a l
programmatic factors that facilitate the
adoption of full childhood immunization,
such as providing families information
about the next immunization date, the
consistent presence of the ANM to provide
services on the scheduled immunization
day and advice by frontline health workers
or a medical doctor to all stakeholders in
the family particularly mothers- in-law,
about the risks children face if not fully
vaccinated against preventable diseases.7
It is also important to note that pervasive
lack of knowledge that breast milk is
comprised mostly of water, that exclusive
breastfeeding means not feeding anything,
even water, until the child is 6 months of
age, and improper breastfeeding skills are
major reasons for the inappropriate early
initiation of supplementary feeds such as
animal and/or formula milk to the child.8
Moreover, women, husbands and
mothers-in-law are not aware of the
importance of postnatal check-ups for
the mother and newborn within 7 days
of delivery and have poor knowledge

The Journal of Family Welfare

Source: Modified and adopted from Health Communication Partnership. 2003. Conceptual Framework: Pathways towards social and behavioral change in HIV/
AIDS. Health Communication Partnership, based at Johns Hopkins Bloomberg School of Public Health. Center for Communication Programs.

of postnatal danger signs that signal the

need for medical care among mothers and
newborns. 9 Notably, less than 1 percent
of women in rural UP are aware of the
lactational amenorrhea method (LAM), and
73 percent of women with a child less than
6 months and 53 percent of women with
a child more than 6 months were exposed
to the risk of unwanted pregnancy.10 The
formative study repeatedly underscores
equity issues; that the poor, scheduled
castes, scheduled tribes and non-literate
segments of the population receive neither
adequate information nor health services.
The article on the reach of different
media clearly indicates that interpersonal
communication channels must take the
lead role in behavior change while mass
media could provide a supportive role in
disseminating knowledge and bringing
about the desired behavioral and social
change.11 The majority of rural women in
UP (58 percent) have no exposure to any
media and the percentage with access to
any media varies from a mere 9 percent
to 87 percent depending on the womans
background characteristics like caste, class,
education and village size. Similarly, the
perspectives of senior program managers
from the media (press, radio, and TV)
and advertising agencies on the proposed
BCC strategy highlight the challenges
in partnering with them in this effort. 12
The article on emerging information and
communications technologies (ICTs)
and their possible role provides leads
on how mobile technology could be
leveraged to communicate with families
and improve the functioning of frontline
health workers.13 These cues need careful
analysis for future action and research.
Similarly, the study of the corporate sector
provides a clear indication that under
CSR, a substantial amount of funds are
available, which is likely to further increase
as the new directives of the government on
CSR are implemented.14 The willingness
of the corporate sector to partner in the

Vol. 56, Special Issue - 2010

BCC strategy and their articulated need

for assistance in capacity building for staff
who plan and manage their CSR activities
provides an important opportunity to
further leverage the impact of the corporate
sector. The information provided in the
present issue of the journal and the BCC
plan developed by the Population Council15
and its partners, listing key barriers to
uptake of proven behaviors, possible
messages and the optimal media mix to
promote behavior change, and measurable
indicators to assess the impact could be
immediately used to develop the BCC
strategy. However, there is scope for further
data analysis and to undertake rapid
assessments to generate complementary
information to answer key related questions
that will enhance the utilization of findings
and facilitate the acceleration of desired
behavior change. Some questions that need
further attention include:

What are the points of engagement

from which key behaviors are
addressed? Antenatal care involves
several contacts and seems to be a
p o we r f u l m e c h a n i s m t o i m p a r t
knowledge and motivate desired
behavior change. How many such
contacts are required to increase
knowledge and change behavior? How
can one be strategic about contacts
and how much content can be packed
into a contact? How can programs be
best designed to achieve the desired
number and quality of contacts?

What do we know about how

behaviors are linked or clustered
together? Are there key behaviors
from which other behaviors flow? For
example, women who undergo three or
more antenatal check-ups often adopt
other targeted behaviors as well.

H o w d o t h e Vi l l a g e H e a l t h a n d
Sanitation Committees at the village
level, and the Rogi Kalyan Samiti
( Pa t i e n t We l f a r e C o m m i t t e e ) a t

the Primary Health Center and/or

Community Health Center level within
a district, fit into the program?b,c

What are the learnings from the pulse

polio campaign that could be utilized
in designing the BCC strategy for
family health?

What are the characteristics of villages

that are not reached and covered by
an Accredited Social Health Activist
( A S H A ) o r A n g a n wa d i Wo r k e r s
(AWW) in terms of population size,
accessibility and caste structure? If BCC
is dependent on these frontline health
workers, how can programs reach out
to them?

How can ASHAs and other frontline

health workers, including the AWW
and ANM, be motivated to promote
desired behavior change? While
providing financial incentives is one
method, what are other possible
approaches? How should financial
incentives be rationalized? Should each
behavior or a package of behaviors be
incentivized? How do two frontline
health workersASHAs from the health
department and AWWs from the ICDS
programcollaborate and complement
each other? Will task sharing among
these workers make the program at the
community level more comprehensive
and sustainable?
What do we know about the business

plan for CSR? Individual companies

are spending on CSR programs:
how do we collectively organize and
optimize these funds?

What have we learned about how

to engage with the corporate sector?
What can we learn from their business
practices that could be utilized to
increase the effectiveness of public
health programs?

This timely publication of key findings

from the formative studies will not only
help in disseminating knowledge on
behavior change in India, but is also aimed
to generate further discussion and research
on questions that remain unanswered
and thus impede progress in this area
globally. Most importantly, the information
contained in this volume provides critically
needed evidence on how to work with
families, communities, the health system
and the private sector to save the lives of
women and children now.

References
1.

Johns Hopkins Bloomberg School. n.d. LiST:

The Lives Saved Tool An evidence-based tool
for estimating intervention impact<http:// www.
jhsph.edu/dept/ih/IIP/list/index.html>.

2.

Health Communication Partnership. 2003.

Conceptual Framework: Pathways towards
social and behavioural change in HIV/AIDS.
Health Communication Partnership, based at
Johns Hopkins Bloomberg School of Public
Health. Center for Communication Programs.

Village Health and Sanitation Committee is a village level accountability structure created under the
National Rural Health Mission for planning and monitoring health activities including the development of
village health plans. Committee members include panchayat representatives, ANMs, AWWs, teachers,
community health volunteers and ASHAs. This committee has about `10,000 or $ 225 as untied funds
for local problem solving.
b

Rogi Kalyan Samiti (Patient Welfare Committee) is an accountability structure created under the
National Rural Health Mission at the level of a Community Health Center and at a district government
hospital. This committee is an innovative mechanism to involve peoples representatives in the
management of public hospitals with a view to improve their functioning by levying user charges.
This committee has annual flexible funding up to `100,000 or $2,250 for any services and equipment
required locally.
c

The Journal of Family Welfare

3.

Khan, M.E., Darmstadt, G.L., T. Usha Kiran and

Ganju, D. (eds.). 2010. Shaping demand and
practices to improve family health outcomes:
A formative study in rural Uttar Pradesh. New
Delhi. Population Council (forthcoming).

4.

Khan, M.E., Darmstadt, G.L., T. Usha Kiran and

Ganju, D. (eds.). 2010. Shaping demand and
practices to improve family health outcomes in
India: Synthesis of findings from the literature.
New Delhi: Population Council (forthcoming).

5.

Khan, M.E., Darmstadt, G.L., T. Usha Kiran and

Ganju, D. (eds.). 2010. Shaping demand and
practices to improve family health outcomes
in northern India: Exploring partnerships. New
Delhi: Population Council (forthcoming).

6.

Khan, M.E., Hazra, A. and Bhatnagar, I. 2010.

Impact of Janani Suraksha Yojana (JSY) on
selected family health behaviors in rural Uttar
Pradesh. Journal of family welfare, 56.

7.

Ahmad, J., Khan, M.E. and Hazra, A. 2010.

Increasing complete immunization in rural Uttar
Pradesh. Journal of family welfare, 56.

8.

Aruldas, K., Khan, M.E. and Hazra, A.2010.

Increasing early and exclusive breastfeeding in
rural Uttar Pradesh. Journal of family welfare,
56.

9.

Varma, D.S., Khan, M.E. and Hazra, A. 2010.

Increasing postnatal care of mothers and
newborns including follow-up cord care and
thermal care in rural Uttar Pradesh. Journal of
family welfare, 56.

14. Ahuja, R., Bhattacharya, D., Bhargava, R. and

Ganju, D. 2010. Role of the corporate sector
in promoting family health in Uttar Pradesh.
Journal of family welfare, 56.
15. Population Council. 2010. Shaping demand and
practices to improve family health outcomes
in northern India: A framework for behavior
change communication. New Delhi: Population
Council (forthcoming).

10. Goel, S.,Bhatnagar, I., Khan, M.E. and Hazra,

A. 2010. Increasing postpartum contraception
in rural Uttar Pradesh. Journal of family welfare,
56.
11. Ganju, D., Bhatnagar, I., Hazra, A., Jain, S.
and Khan, M.E. 2010. Reach if media and
interpersonal communication in rural Uttar
Pradesh. Journal of family welfare, 56.
12. Ramakrishnan, N. and Arora, V. 2010. Media
perspectives on partnerships to address family
health in northern India. Journal of family
welfare, 56.
13. Garai, A. and Ganesan, R. 2010. Role of
information and communication technologies in
accelerating the adoption of healthy behaviors.
Journal of family welfare, 56.

Vol. 56, Special Issue - 2010

The Journal of Family Welfare