A Guide for the Design of Behavior Change Strategies and Interventions for Public Health in Sudan

By: Anab Mohamed

Email: anab.mohamed87j9@gmail.com

        Covid19 has come and it is here to stay. It is going to be a while before effective vaccines are developed and cures are found. For Sudan, access to essential medicines and interventions for communicable, non-communicable, and neglected diseases has been challenging, which is also likely to contribute to the longer time it would take to access the Covid19 vaccines once they are developed. Sudan’s current transitional state involves challenges within the health and pharmaceutical sectors, a hallmark of which is the reduced capacity of the pharmaceutical sector to access the global pipeline of drugs and vaccines. Until those challenges are overcome, it is important to maintain vigilance over the spread of Covid19 in communities. With future plans to slowly begin lifting the lockdown measures, the conflation of " going back to normal" and lowering the guard against covid19 poses a serious risk. For that reason, it is important to ensure that the spread of Covid19 is sustained, and not miss the glaring link between individual behavior and health outcomes. One of the ways to do this is through sustaining healthy practices and behaviors, to effectively reduce the risk of transmitting covid19. A SWOT analysis¹ of Sudan’s healthcare system has revealed that one of its key strengths is the abundance of policies, plans, and strategies². With the appropriate guiding knowledge and toolkits, this asset can be harnessed to achieve sustainable health outcomes if they effectively incorporate and implement behavior change work as a linchpin of public health programs for sustaining healthy communities.

     The intersectionality, complexity, and multilayeredness of behavior determinants can challenge behavior change interventionists. However, with the right tools and frameworks, behavior change interventionists can navigate these complexities, so they can effectively utilize them to map and design behavior change activities that can lead to sustained healthy practices. When behavior determinants are properly understood, effective behavior change programming can take place when coupled with the health system's strengths. Considering the social and economic behavior determinants highlighted during the Covid19 Pandemic in Sudan, I have developed a matrix that links a given behavior determinant to one or more change objectives³, in order to navigate the complex intersectionalities of behavior determinants with the goal of supporting behavior change interventionists to understand the complex drivers of behavior determinants across multiple behavioral levels. My theories are that a given cluster of behavior determinants is more powerful and complex as influencers of the intended change and that a behavior change is driven by interacting factors that can reinforce each other across multiple levels of behavior.  By providing a way for better understanding the intersectionality of determinants, this suggested tool, adapted from the taxonomy of behavior change methods⁴, is intended for the purpose of supporting the design of behavior change interventions in a manner that is tailored to the particular socio-cultural context of interest, and for helping behavior change workers in selecting the appropriate tools.

Approach to developing the tool 

 Analysis of socio-cultural context

    Analysis of the social and economic context reveals that the adoption of social distancing measures to be one of the most challenging behavior changes. This is due to the following set of cultural beliefs, practices, and norms which constitute the determinants of social distancing:

• Beliefs, which can be religious-based, or unsubstantiated beliefs about immunity against disease 
• Cultural practices, including handshaking, and hugging
• Fear of perception as rude or snobby if hands are not shaken, or are hugs avoided. This relates to the understanding of self in relation to other members of society, whereby fears of ostracism as a result of adopting these health practices prevail 
• Nature of the social fabric and dynamics in which people value gatherings and see closeness as forms of endearment, intimacy, and genuine relationships 
• Social networks thriving on gatherings, and social events 
• Individual’s or family’s own sense of self-worth as perceived in relation to their ability to uphold the social standards of togetherness, attending gatherings and events 
• Traditions, such as religious celebrations, and gatherings during wedding ceremonies 
• Peer pressure through which people feel pressured to comply with the social structures and may often compromise the values of health in order to satisfy the socio-cultural norms
•  Poverty, food and livelihood insecurity, most people are part of the informal sector, such as tea ladies, street vendors, and sellers
• Distrust of the government, conspiracy theories, beliefs that the coronavirus is a hoax perpetrated by the government to find excuses for their shortcomings 
• Misinformation about the coronavirus, with a diminished understanding of transmission pathways, or awareness of how the virus spreads in the community 
• Disbelief, non-acceptance of facts presented 
• Denial and dismissal of preventative measures as invasive, and extraneous 
• Fear of stigma of disease( if tested positive), tendency to hide any indication or arise any suspicions that the person may be sick

Identification and coding of determinant and change objective categories 

    The behavior change methods taxonomy was adapted to identify change objectives that should be targeted in behavioral change interventions in order to promote the adoption of social distancing. The socio-cultural analysis helps in identifying change objectives, or targets for behavior change, where each of these determinants can be grouped in the following categories, each of which represents a behavioral level: 

1.  Individual-level Barriers 
2.  Barriers due to knowledge gaps 
3. Awareness and Risk Perception 
4. Attitudes, Beliefs and Outcome Expectations
5.  Social Influence 
6. Public Stigma Reduction 
7. Social Norms 
8. Social Support and Social Networks 
9. Communities 

    For example, let us consider “fear of perception as rude or snobby if hands are not shaken, or are hugs avoided, fears of ostracism as a result of adopting these health practices prevail”. These determinants can be grouped under Individual-level Barriers, social influence, and social norms. Let us then consider another determinant “nature of social fabric”, which falls under the change objectives of Social Norms and Social Support/Social Networks. It becomes clear then that those two determinants intersect under “Social Norms” Through this process of coding behavior change determinants to change objectives categories allow behavior change interventionists to discover intersectionalities of change objectives and highlights clusters of determinants that interact with each other to impact behavior change. In this manner, behavior change interventionists can prioritize behavior change targets, and to mobilize their resources efficiently and effectively. The identification of converging and also diverging determinants is helpful for optimizing the design and implementation of behavior change interventions and programs, that could result in impactful behavior change results and potentially favorable sustainable health outcomes.

Assumptions 

    In order for this tool to be valid and useful for the design of effective behavior change methods to target a change objective, it must identify determinants that actually predict the behavior of interest. Identification of behavior predictors should be based on a careful and informed analysis of the socio-cultural and economic contexts that is participatory and thus incorporate the target community’s values and input. Determinations of relevant determinants of the target behavior should not be based on the interventionist's assumptions or biases. The critical assumptions for the design of behavioral change interventions are that the behavior change interventions are rooted in a deep understanding of socio-cultural dynamics, that they are culturally informed, involve participation and input of intended users, and that the desired behaviors are internalized and projected. Additionally, change objectives must be clearly defined and operationalized in a manner that establishes a consensus as to what they constitute relative to the context in question. 

 Using  and applying the tool 

     The matrix below maps determinants of a given behavior to one or more behavioral levels or change objectives. The columns list determinants of the behavior of interest and rows list the behavioral levels. Each behavioral level or change objective is color-coded for better visualization. The highlighted cells indicate that the given behavior determinant and falls under that particular behavioral level. For example, beliefs and cultural practices can fall under barriers due to knowledge gaps. Rows and columns totals are used as a scoring system that helps in understanding which changes objectives can influence determinants more than others. Row totals indicate the total number of determinants for given change objectives. This translates into how many determinants can be influenced by addressing a given behavioral level. Column totals are also included and they refer to the number of behavioral levels that drive a given behavior determinant. This number is valuable because it is indicative of the extent to which a given behavior determinant can be influenced by addressing the given behavioral levels.

    Looking at the table, it is easy to identify overlapping clusters or groupings of determinants ( highlighted in red) that operate at one or more behavioral levels. This allows behavior change interventionists to design innovative behavior change approaches that are tailored for targeting more than one determinant across multiple behavioral levels. It can also aid behavior change interventionists to understand how determinants operate and intersect across the different behavioral levels.

    Within the context of international development in public health, behavior change intervention designers would find this tool as a valuable asset in their design of behavior change programs and activities for the following reasons: 

•  A given set of change objectives can be influenced by one or more determinants. Identifying clusters of determinants that influence change behaviors can lead to a better understanding of behavioral determinant “clusters” of health. In this context, clusters refer to groups of determinants that interact across the same change objectives 
• Supports the design of behavior change interventions that incorporate determinants that are derived from the community that is intended to be the end-users of the intervention 
• Supports optimal utilization of time and resources by facilitating the design of behavior change interventions in a way that is tailored to a given context 
• Aids in decision making and prioritization of interventions 
• Allows mobilization of resources, especially when programming budget constraints are faced 
• Guides and informs policies and strategies that integrate behavior change work in public health programming 
• Aids in the navigation of cultural terrains where a given socio-cultural context is directly linked to health outcomes. Thus organizations and behavior change interventionists can use this tool to tailor behavior change interventions 
• Utilizes a scoring and color-coding system to see which determinant has the most influence, which also provides insight into the change objective and has the most priority when it comes to planning behavior change interventions 
• Relies on analysis of a given context and thus supports linking behavior change interventions to the actual needs of target communities 
•  Can be expanded on for utilization in other public health scenarios to assist in the design of behavior change components of programs and activities 
• Encourages engagement of appropriate and relevant stakeholders and actors for effective collaboration and cooperation when it comes to designing and implementing behavior change activities

• Promotes community participation in the design of behavior change interventions, which makes this tool a great way for engaging local systems 

1SWOT which stands for Strengths, Weaknesses, Opportunities, and Threats, is a tool that is used to identify and/or assess those four components of a given organization^↩

2Ebrahim, E. M. A., Ghebrehiwot, L., Abdalgfar, T., & Juni, M. H. (2017). Health Care System in Sudan: Review and Analysis of Strength, Weakness, Opportunity, and Threats (SWOT Analysis). Sudan Journal of Medical Sciences (SJMS), 12(3), 133-150. https://doi.org/10.18502/sjms.v12i3.924^↩

3A change objective is a belief or practice that has been selected for a targeted behavior change. Adapted from: Gerjo Kok, Nell H. Gottlieb, Gjalt-Jorn Y. Peters, Patricia Dolan Mullen, Guy S. Parcel, Robert A.C. Ruiter, María E. Fernández, Christine Markham & L. Kay Bartholomew (2015): A taxonomy of behaviour change methods: an Intervention Mapping approach, Health Psychology Review, DOI: 10.1080/17437199.2015.1077155^↩

4Gerjo Kok, Nell H. Gottlieb, Gjalt-Jorn Y. Peters, Patricia Dolan Mullen, Guy S. Parcel, Robert A.C. Ruiter, María E. Fernández, Christine Markham & L. Kay Bartholomew (2015): A taxonomy of behaviour change methods: an Intervention Mapping approach, Health Psychology Review, DOI: 10.1080/17437199.2015.1077155^↩