Designing for Behavior Change:
Using Barrier Analysis as a Tool to Catalyze Transformative Learning
Will Story, MPH
Child Survival and Health Technical Advisor, CRWRC-US
Co-Chair, Social and Behavioral Working Group, CORE Group
wstory@crcna.org
“What must underlie successful epidemics, in the end, is a bedrock belief that change is possible, that people can radically transform their behavior or beliefs in the face of the right kind of impetus.”
Malcolm Galdwell, The Tipping Point: How Little
Things Can Make a Big Difference
Why Do We Need to Design for Behavior Change?
A major key to successful and sustainable community health interventions is household-level behavior change. Availability of commodities, innovative delivery strategies, and increased knowledge about health behaviors are important to community health; however, these factors will not lead to a long-term impact on health outcomes if individual behavior change is not addressed using evidence-based, community-informed solutions. The Designing for Behavior Change (DBC) workshop responds to community health managers’ and planners’ need for a practical behavioral framework that helps them to strategically plan for behavior change by combining community input with evidence-based activities.
The DBC workshop is a six-day, field-tested training package that was developed in May 2008 by the Social and Behavioral Change Working Group of the CORE Group. It is built upon the BEHAVE Framework, developed by the Academy for Education Development in 2004. The DBC workshop is built upon Dialogue Education™ principles and has seen tremendous success in helping learners think about behavior change from “outside the box” (which is ironic considering that the workshop is designed around a framework that looks very much like a box).
All too often program managers use common behavior change methods that focus on raising awareness about a particular healthy behavior. These methods often disregard the behavioral determinants that are preventing a person from performing the healthy behavior in the first place. In the earlier versions of the DBC workshop, we found that learners had a difficult time understanding the concept of behavioral determinants, which made it unlikely that they would apply the concept after the workshop. In order to help learners move beyond the understanding of a concept towards transforming the way they think about and plan for behavior change, we added a new set of learning tasks to introduce a tool called Barrier Analysis. The goals of the new learning tasks were to 1) develop the competence and confidence of the learner to identify key behavioral determinants using Barrier Analysis, and 2) help the learner to use the results of Barrier Analysis to design their behavior change strategies.
What is Barrier Analysis?
Barrier Analysis “is a rapid assessment tool used in community health and other community development projects to identify behavioral determinants associated with a particular behavior1.”
A behavioral determinant is a reason why someone does or does not do something. In Barrier Analysis, community members are asked a series of questions to identify eight potential determinants (most of which are “barriers”) that can block people from taking action that will improve their own lives (e.g. exclusively breastfeeding their children up to six months). Those doing a behavior ("Doers") are compared with those who are not ("Non-Doers") in order to identify the most important behavioral determinants. Project staff members and communities then use the results to develop project activities and messages.
Has This Process Worked?
A clear demonstration of the process of transformative learning using Barrier Analysis took place in September 2008 where I co-facilitated a DBC workshop in Delhi, India with Nancy TenBreok, Asia Regional Health Advisor for CRWRC-Bangladesh. On the second day of the workshop, we introduced the concept of behavioral determinants and their role in developing a behavior change strategy. Since Nancy and I had taught this workshop twice before, we were not surprised by the feedback at the end of the day where learners expressed their confusion about the behavioral determinants. However, we knew that for the next two full days they would have a chance to practice and reflect on this new concept.
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Barrier Analysis follows seven simple steps (Box 1)2. The
learners made the connection between the first step in Barrier Analysis and
the first two days of the workshop. The goal was to ensure the health of
pregnant women and the safe delivery of their children; the behavior on
which we chose to focus was a minimum of three antenatal check-ups during
pregnancy; and the priority group was pregnant women living in the urban
slums of New Delhi. |
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Box 1. Seven Steps
of Barrier Analysis
1) Define
the Goal, Behavior and Priority Group 2) Develop
the Behavior Question
3) Develop
Questions about Determinants
4) Organize
the Analysis Sessions
5) Collect
Field Data for Barrier Analysis
6) Organize
and Analyze the Results
7) Use
the Results of Barrier Analysis
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The next two steps of Barrier Analysis required the
learners to apply their knowledge about behavioral determinants – however
limited it may have been – to the development of a questionnaire. Since we had
limited time in a workshop setting, we decided to create a questionnaire using
the three most influential behavioral determinants (as opposed to all eight
behavioral determinants discussed in Barrier Analysis). The first question, or
the behavior question, determined whether or not the pregnant woman had an
antenatal check-up at least three times during her last pregnancy. That is, was
she a “Doer” or a “Non-Doer”? The following questions asked about three
behavioral determinants – self-efficacy, perceived social norms, and perceived
consequences – as they related to the behavior. Once the questionnaire was
finished and translated into Hindi, the learners were organized into pairs – one
interviewer and one note taker – based on their experience with surveys. The
site for the survey had been selected prior to the workshop by HOPE Foundation,
an NGO that works in the Delhi slums and was participating in the workshop.
The next morning, 12 pairs of learners traveled to a Delhi slum with enough
questionnaires to interview six to eight mothers. Each pair was accompanied by a
HOPE Foundation staff person who knew the women in each household. After
approximately three hours, the learners traveled back to the workshop venue to
organize and analyze the results. The first step in analyzing the results was
separating the Doers from the Non-Doers by analyzing the behavior question. Once
the two were separated, we analyzed the behavioral determinant questions
together and then compared the responses of the Doers to the Non-Doers. Once the
results were analyzed, the learners immediately noticed the barriers to and
benefits of antenatal check-ups. By analyzing the responses that were mentioned
more often by Non-Doers compared to Doers they discovered that some of the barriers were fear of injections, lack of support from husbands and in-laws, and the cost. On the other hand, by analyzing the responses that were mentioned more often by the Doers compared to the Non-Doers they found out that some of the benefits were timely diagnosis of pregnancy complications and a healthy child. With this new information, they were able to design a behavior change strategy that addressed actual barriers that the community faced as well as emphasize the benefits that were important to the community.
What Does This Mean To Me?
Barrier Analysis was the catalyst to transformative learning during the DBC workshop. This tool gave learners the competence and confidence to identify behavioral determinants and use them to design their behavior change strategies after the workshop. In addition, Barrier Analysis has the potential to have a significant impact on the lives of the women and children in the communities in which we work.
1Davis Jr., Thomas P., (2004). Barrier Analysis Facilitator’s Guide: A Tool for Improving Behavior Change Communication in Child Survival and Community Development Programs, Washington, D.C.: Food for the Hungry.
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