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GUIDELINES FOR
COMMUNICATION AND THE
DEVELOPMENT OF COMMUNICATION
AND BEHAVIOUR CHANGE
COMMUNICATION MATERIALS FOR PEOPLE WHO INJECT DRUGS
1
2
Acknowledgements
This publication was produced by Malaysian AIDS Council with the support of the International
HIV/AIDS Alliance as part of the Community Action for Harm Reduction (CAHR) project.
The publication was initiated by Malini Sivapragasam and Anushiya Karunanithy ( CAHR Malaysia of
Malaysian AIDS Council ). Chris Ng Cheong Soon was appointed as consultant to produce the first
draft and then edited by Anushiya Karunanithy.
The content of this guide has been discussed with representatives from the community and outreach
workers throughout Malaysia.
Maryna Braga ( International HIV/AIDS Alliance in Ukraine ) provided comments and suggestions.
Parimelazhagan Ellan ( Malaysian AIDS Council ) reviewed and edited the publication.
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Table of contents
Acknowledgements .................................................................. 3
Table of contents .................................................................... 4
Acronym ................................................................................. 5
Premise ................................................................................... 5
Purpose of the Guidelines ......................................................... 6
How to use this tool ................................................................ 6
Part 1: Communication, channels of communication and the
process of communication ........................................................ 7
Com m unication .............................................................................. 7
Principles of com m unication ............................................................ 7
How to adapt the w ay you com m unicate to different situations ........ 9
Part 1a: Effective Communication Skills ................................... 13
1.
2.
3.
4.
Active listening skills ...............................................................
Non-verbal cues .......................................................................
Giving constructive feedback ....................................................
Questioning Skills .....................................................................
13
15
16
17
Part 2: Developing IEC and BCC materials ................................ 18
Understanding IEC and BCC m aterials ............................................. 18
The 4–Step tool ........................................................................... 22
Appendix 1 ............................................................................ 26
Appendix 2 ............................................................................ 28
The 4 Step tool ........................................................................... 28
References ............................................................................ 34
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Acronym
HIV
Human Immunodeficiency Virus
PWID
People who inject drugs
CAHR
MOH
IEC
Community Action on Harm Reduction
Ministry of Health
Information, Education and Communication
BCC
Behaviour Change Communication
NSEP
Needle and Syringes Exchange Programme
MMT
Methadone Maintenance Therapy
SMS
Short Message Service
AIDS
Acquired Immunodeficiency Syndrome
VCT
IDU
Voluntary Counseling and Testing
Injecting Drug User
Premise
Human Immunodeficiency Virus (HIV) is highly transmissible through the sharing of needles and other
injection equipment, so it can spread very rapidly within the networks of people who inject drugs
(PWID) who share injecting equipment with each other. There is also a risk of HIV transmission from
PWID to their sexual partners.
Even though in Malaysia, the trends in HIV acquisition appear to be shifting progressively from PWID
predominant to more sexual transmission with PWID/sexual transmission ratio of 3.9 in 2000 to 0.3 in
2013. However, it is important to remember that HIV remains prevalent among PWID. In 2013, among
males, 21.5% acquired HIV infection via injecting drug use (Year-end CAHR Project Evaluation
Studies 2014). Currently, there are estimated 170,000 PWID in the country, based on the Global Fund
Response Progress Report MOH 2014.
Thus engagement with the community of PWID is important to reduce HIV transmission. Engagement
here involves communicating to them about HIV, its transmission, prevention, treatment and many
aspects of drug related harm. Effective Communication therefore is a crucial intervention to the
community.
This guideline was developed based on community input and the gaps.
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Purpose of the Guidelines
•
•
To introduce communication and to demonstrate the importance of effective communication
in outreach work.
To evaluate and discuss the characteristics of good communication and how to improve
communication skills.
This Guideline is developed for use by outreach workers and peer educators who work primarily with
PWID on HIV intervention.
This Guideline is a result of a three day consultation with outreach workers/peer educators and
clients. The focus is to provide some basic understanding of communication and the processes
involved. This includes defining the criteria for effective communication and exploring the channels for
communication.
How to use this tool
This Guideline provides a general introduction to Communication, Effective Communication and
specific communication skills that seek to increase the outreach worker’s/peer educator’s knowledge
of forms of communication, communication skills and social and interpersonal behaviour
The first part will discuss the key components of the communication process. This segment will also
focus on specific skills in communication.
The second part will provide steps in developing information, education and communication
(IEC)/behaviour change communication (BCC) materials.
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Part 1: Communication, channels of
communication and the process of
communication
In a work environment, success depends not only on one’s knowledge but also on one’s ability to
develop effective working relationships with clients in order to influence and motivate them, to handle
emotions of both self and the clients and to read interpersonal situations accurately. The ability to
communicate effectively is crucial and the skills to communicate are to be developed and mastered.
Communication
In a nutshell, communication can be described as a process of transferring information from one place
to another to one or more receivers. Information is conveyed as words, tone of voice, body language
or visuals. Communication includes speaking, reading, listening and reasoning. In outreach work with
PWID, communication would entail making contact, building rapport with clients and related agencies
and authorities and providing information on HIV, its transmission, prevention, treatment and many
aspects of drug related harm. This includes referrals to support assistance and organizations.
Principles of communication
Communication is complex especially when it involves a community that brings with it multiple needs
and issues, secrecy and fear and different levels of understanding information. It involves clients who
are active, mobile and not predictable, not to mention a working environment that can be challenging.
All these factors influence how information is sent and received and most of all understood. However,
there are key principles in communication that provides a framework and foundation.
Understand and apply the following principles in communication:
1. Know your audience
Your initial planning tools help you narrow down your audience. Spot analysis and contact mapping
provide the necessary information you need about your audience. Observing and understanding
injecting behaviour, drug sharing culture, and risk taking behaviours can be useful information when
you meet your target audience with the clear intent of providing the right intervention.
2. Know your purpose
When you approach your audience, be clear about what you intend to do. Prioritise. You may have a
specific outreach task and outcome to achieve. You may be just making initial contact. Your intention
may change in the process but be clear at each point of contact what you want to achieve.
3. Know your topic
As an outreach worker/peer educator, you are trained to provide specific interventions as per the
need of the clients. You may be providing a service or providing commodities at the point of contact.
At any point of contact, you may need to educate the client, provide advice or referral, so it is
important that you know your facts. Giving the wrong information can be detrimental to your clients.
Some of the topics that you need to cover:
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HIV prevention and
treatment
Harm Reduction and
Its Basic
Components
Safer Injecting
Drug Related Harm
Condom Negotiation
Safer Sex
Client Services –
testing, NSEP, MMT
& Sexual
Transmission
Disease
Counselling
Addiction
Relapse
Management
Legal AID
4. Achieve credibility with your audience
Your client probably has had some challenging life experiences and may have some trust issues. The
environment surrounding PWID may also present challenges to building trust. To make any progress
with the client, you need to find ways to build trust and achieve some level of credibility with him/her.
The clients need to perceive you as one who is reliable, responsible and accessible. You may have to
show more care and concern. You may need to accompany your client to relevant intervention.
5. Follow through on what you say
In your eagerness to work with your client, you may agree to certain conditions or promises. Once you
have made a commitment to your client, make sure you deliver.
6. Communicate in small pockets of information
While it is important for your clients to get certain information, be aware of the ability of your client to
take in information. It may be useful to breakdown information into smaller pockets of information that
can be delivered in stages at the appropriate time. Present the information in several ways to ensure
comprehension. Applying multiple communication techniques help get the message across better.
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How to adapt the way you communicate to
different situations
Communication happens within a context or situation. Each situation may give rise to many factors
that influence the effectiveness of your communication, both in how you engage your client and how
your client interprets your communication. Different clients react and respond to communication
differently. It is necessary to adjust your communication style to the client and the situation. Failure to
do so can lead to misunderstandings. Apply the following steps:
1. Know your audience
Regardless of whether you are dealing with your client, their families, the community, the authorities
or the network of support systems for the PWID community, you need to understand who you are
talking with. Consider the following points:
•
•
•
•
•
•
See things from their perspective and address their concerns and fears accordingly.
Recognize your relationship with the audience. Do you need to be formal or informal? Are you
more assertive or friendly?
Acknowledge differences in personality. Some are more confrontational; others are more
reflective. Some deal with facts better than abstract reasoning. Some interact better in a
group whilst others in a more personal one-on-one setting.
Use the audience analysis as a point of reference. Look at the age span, gender, education
level, values, cultures, family structures, and background experiences of those in your
audience. Tweak your language and information accordingly.
Keep in mind the needs of the client, not your needs
Be alert to the client’s stress level
2. Think about the situation
Every situation is different. The urgency of the situation may differ. The mood and mind-set of the
client may require a different kind of handling each time. Your work-related stress or personal issues
may affect the way you handle your client or react to the situation. Be aware how the different context
may influence the communication.
For example:
• What is the more urgent intervention, conducting counselling (individual and group) for
PWIDs or giving information on drug related harm?
• Are you motivating PWIDs for HIV testing, safer injecting needles as well as other referral
services?
• Is making home-visits to access the partners of PWIDs a new priority for change behaviour?
• Are you doing advocacy and interacting with the general community, obtaining feedback and
gaining insight into their thoughts and opinions in order to plan new interventions?
• Making appointments with clients can be a challenge, so is the agreed time and place
appropriate for the intended purpose?
• In your continuing efforts to do intervention with your clients, have you identified the issues
and the root problems accurately?
• For better impact, do a more personal touch or a more professional approach at that
particular point of contact?
Always assess and review the situation for intervention.
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3. Identify your role
As an outreach worker/peer educator, you take on multiple roles in executing your task. You provide
education and information, advice and advocacy, motivation and guidance, counselling and referrals,
demonstration of safer injection and condom use and links between client and other community
members. For each role, communication styles are adapted and adopted to facilitate communication.
Some common role types to explore:
advisor
observer
educator
negotiator
moderator
good listener
role model
friend
ally
agent of change
Each role requires a specific communication style. As an advisor, you may need to share lived
experience and hence take a more personal approach. An observer requires you to be a neutral but
keen observer of human behaviour in order to identify patterns of behaviour or root causes of
challenging behaviour that may help you frame an intervention. As a role model to a PWID, you need
to be the visible change they can see and believe and hence work towards. In each role, you carry
specific responsibility and communicate relevant information that help move the client closer to
change.
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4. Choose the appropriate method of your communication
The outreach worker/peer educator has at his/her disposal a wide array of communication tools. Each
of these communication tools has its limitations and its function.
The following shows the different categories of communication tools:
MEDIUM
verbal
Non-verbal
written
visualization
social media
METHODS
face-to-face, telephone, radio or television and
other media
body language, gestures, how we dress or act
letters, e-mails, books, brochures, pamphlets,
magazines, the Internet or via other media,
graphs, charts, maps, logos and other
visualizations can communicate messages
Facebook, websites, sms, whatsapp, twitter,
instagram, blogs,
Pick the method that is most effective for your audience and the situation. Keep in mind the
communication channel that is most accessible to your client.
The most common method is the Face to Face verbal method. For this face to face method to work
effectively, ensure the following points are factored in:
! Timing – choose a suitable time to make sure that there is sufficient time to cover all relevant
topics. Also ensure the timing does not interfere with the client’s need to inject drugs.
! Location – choose a location in which the client is comfortable. Also important is to bear in
mind that the location is quiet and private enough to minimize distraction.
! Personal biases – be aware of stereotyping and assumptions about the client that are
misconceptions.
! Competency – consider the client’s prior knowledge and language ability
! Consistency – use standard terminology and make sure when delivering the message to
more than one client, the message remains the same.
Other frequently used methods are:
! Telephone
! Social media
In addition to the points listed for face-to-face verbal method, the additional points must be considered
when communicating via telephone and social media:
! Reception – poor reception can add to messages being misinterpreted
! Access – not all clients have access to social media
Also telephone and social media as mediums of communication require extra effort as voice quality
and text are vulnerable to misinterpretations. Be prepared to do the following:
!
!
!
!
Repeat, as necessary, to ensure that information is accurately received
Request and provide clarification when asked
Ensure all statements are direct and clear.
When receiving a message, demonstrate verbal acknowledgment that the message has been
received
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5. Use appropriate words
Ensure that your choice of words is words that your audience uses and understands. Remember you
are trained to use technical terms and jargons in outreach work but your clients and related audience
are not familiar with them. Explain them in local terms.
6. Use appropriate body language
Very often, you use body language during communication. Be aware of your non-verbal
communication at work and use them to support your communication. Apply:
! Eye contact – eye contact must be purposeful but comfortable.
! Personal space – maintain appropriate distance between you and your client
! Posture and gesture – reinforce your ideas with appropriate gestures and postures.
Non-verbal communication is guided by the level of your relationship with your audience. The closer
you are and the stronger your rapport is with your client, your non-verbal communication can be less
formal.
7. Pay attention to the other person's feedback
Just as you respond in various ways to someone communicating with you, your client too may
respond accordingly to you. This response is called feedback. Feedback indicates how effectively you
are getting your client’s attention and how much adjustment you need to make to maintain your
client’s interest in what you have to say. Look out for:
! Questions that seek clarification and offer challenge
! Nonverbal communication such as crossing arms, looking away, yawning, and nodding that
may indicate negative responses
! Anxiety such fidgety movements, nervousness, restlessness that will counter efforts to
educate the clients on more factual matters
! Confusion such wrong responses and distressed facial expressions that indicate that the
information is too much or too complicated for the client to absorb or simply that you are not
clear in your delivery
The quicker you are able to identify and respond to your client’s feedback, the more positive impact
you will have on him/her.
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Part 1a: Effective Communication
Skills
It takes skills to communicate effectively. Content is the ‘what to say” component of communication.
Skills provide you with the “how to say” component of communication. Both are equally important and
must go hand in hand.
1. Active listening skills
Listen! Listen! Listen! Effective listening is crucial for your clients to be heard and felt that they are
heard. You are also able to respond accurately and appropriately. This, in turn, makes you a more
credible outreach worker/peer educator and hence increases the rapport between your clients and
you.
A. Barriers to listening
Identifying barriers to listening is the first step in improving communication. Check and see if you have
the characteristics listed below.
I.
Judgmental attitude
When you think of a PWID, you think of all the stereotyped negative images one
associates with the community. Stories that one constantly hear about the community
– the lying, the stealing, the dysfunction within the family, the lack of responsibility
and reliability, the resistance to help and services, and the lack of self-care and
personal hygiene, often influence how you think of the community and that can
develop a personal bias and a negative and judgemental perception about the client.
You come across as having a lack of empathy for the client.
II.
Jumping to conclusions
In the heat of the moment, you think that you understand the flow of your client’s
thoughts and thus interrupt with your own response without hearing him/her out
completely. You have already evaluated and concluded what he/she wanted to say
before he/she has had the chance to complete her thoughts or arguments.
Having a closed mind
You only want to hear what you want to hear and you are not willing to accept when
your client offers a point of view that differs from yours. You sometimes take a
position of superiority to your clients and that you are always right.
III.
Being inattentive
While communicating with your client, you are thinking of something else totally
unrelated. You may be thinking of an urgent personal matter or a work related matter.
You have an internal conversation going on. Sometimes, you are busy formulating
and rehearsing what you want to say to your client in your mind.
Being inconsistent
You show high levels of inconsistency in terms of information, commitment as well as
delivery of services. You come across as having misplaced priorities
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IV.
Cultural issues
You are not aware of the cultural differences and practices of your client perhaps out
of ignorance or insensitivity on your part. Similarly assuming that because you share
the culture of your client, you understand him/her and you overlook subtle
differences.
All the above characteristics can interfere with effective communication. The sooner you are
able to be aware of your shortcomings, the sooner you can make the change to help you
communicate better.
B. Steps in active listening
One thing you can do is practice active listening skills. Below are some steps that you can take
towards active listening.
I.
II.
III.
IV.
V.
VI.
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Stop talking and interrupting your client and listen to what your client is saying. That
way you can fully understand your client’s view or perspective and respond
accordingly
Focus your thoughts. Remove distractions either in the surrounding or in your mind.
Demonstrate to your client that he/she has your complete attention.
Try not to be defensive. Accept that your client can and does disagree with you and
your points of view. If stay with the facts, you can always stand your ground.
Summarize, paraphrase or repeat what you have heard to make sure you have heard
correctly. Allow your client to clarify as and when necessary.
Take time to understand the cultural influences that shape your client and his/her
challenging behaviour.
One of the key principles of outreach work is respecting the client and his/her
challenges in life. As the key person bringing services to the PWID, you should not
have preconceived negative notions about the clients.
2. Non-verbal cues
Often a person says one thing but communicates something totally different through his/her vocal
intonation, facial expression and body language. These are the non-verbal cues in communication.
This mix signal can often confuse the receiver. Often, the sender is not aware that he is sending out
mixed signals via his/her non-verbal cues.
A. Non-verbal cues will include the following:
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.
X.
Facial expression and eye contact
Facial expressions give away a lot of information about how we feel during
communication – for example the frown, the blank look, the frozen smile. Eye contact
of forced can be intimidating or unnerving.
Posture and gesture
The way you sit or stand can convey your attitude or feelings about what you are
doing or thinking. For example, slumped indicating boredom, shifting indicating
uneasiness or discomfort, and relax indicating calm.
Voice
Speech rate, pitch, articulation, pauses, emphasis, volume, and verbal “vocalizations”
communicate a lot of information. They can reflect anxiety, impatience, or a lack of
confidence.
Personal space and distance
There is an invisible space around you that you maintain depending on the closeness
of your relationship with others. The distance that you put between yourself and your
clients or relevant audience or maintain can reflect attitudes, create feelings, and
indicate the balance of power.
Personal appearance
The way you present yourself physically conveys either a positive or negative image
about you. This plays a significant role in determining credibility and professionally
you are perceived as well as how a message that you send will be received,
interpreted and understood.
B. Applying non-verbal cues
I.
II.
III.
IV.
V.
Be conscious of your own habits and non-verbal cues that may be interfere with your
message and pay attention to your client’s non-verbal cues. Always clarify if you
notice a difference between what you hear and what you are witnessing.
Be aware that non-verbal cues can differ from one culture to the next. Make sure you
understand what it means to make eye contact, touch, and to use hand gestures in
the community you work in.
Display confidence and authority.
Speak in the appropriate tone of voice and be aware of your own anxiety and stress
creeping into your voice when communicating with a particularly challenging client or
community person.
Dress for the job – appropriately. In whatever role that you may adopt with your client,
you are, first and foremost, acting in your capacity as an outreach worker/peer
educator and represent your organization. While you may or may not wear uniforms
at work, ensure that your personal appearance reflect professionalism.
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3. Giving constructive feedback
Your task as an outreach worker/peer educator is to engage your clients into making informed
decisions for a safer behaviour. In the process of engagement, your communication may require you
to share with them your observation or opinion with regards to their progress. Your clients may not
perceive your constructive feedback as positive or necessary. They may not be ready for negative or
critical feedback. They may not want the information that you need to share with them. They may
become defensive or emotional. The situation could be tense. Hence communication becomes a
challenge.
Hence it becomes more and more important for outreach workers/peer educators to equip themselves
with feedback skills as they work with clients who may have challenging issues.
A. Good feedback skills are as follows:
I.
II.
III.
IV.
V.
Give clear, honest and concise feedback. Be specific. Give examples. It is not about
right or wrong but what happened and what could be done better.
Be supportive and encouraging, reinforcing and motivating. Offer solutions and
options for improving.
Deliver feedback face to face. Remember, giving feedback is not an excuse to attack
the client or is it a channel for you to rant and vent your frustration. So be as positive
as you can.
Focus on the issues and behaviour, not the person.
Be aware of your client’s capacity to understand what you are saying. Do not
overload the client with feedback over matters that he/she has trouble keeping track.
B. Steps for giving feedback
I.
II.
III.
IV.
V.
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Schedule feedback as and when necessary or on a regular basis depending on the
arrangement you have with your client. Decide on a location at a time and place
where there is minimal interruption.
Identify and focus on content. Prioritise the issues to be discussed
Focus on process – review what happened, what went wrong and what was done
right. Make recommendation and offer options to move forward.
Involve the client in making a plan for improvement.
Close the discussion. Summarize what was discussed and agreed upon.
4. Questioning Skills
Some people are very good at gathering information from others. They can ask the same question in
many different ways to elicit different responses. However, this process does not come naturally to
everyone. The communication process can be impeded by asking the wrong questions.
There are two basic reasons why we ask questions:
I.
II.
To probe for more information
To clarify on the information that was given.
Hence there are essentially two key formats that are used:
I.
II.
Open questions
This involves asking questions in such a way that allows the person to answer in
whatever way he/she chooses. These questions encourage people to talk, open up or
to expand on an idea or view point. This is useful when you are probing and wants
the client to freely offer information that you can use to plan an intervention.
Closed questions
The closed questions are used when specific answers are required. These questions
encourage short answers like yes or no. They help establish facts and check on
details. Hence to clarify on the information that you have gathered, you use the
closed questions.
In order to be better at communication, improve on your questioning skills by practising and using the
different types of questions you can ask. Also decide on your needs – do you need more elaboration
or just clarification and get to the point.
Misunderstanding can occur at any stage of the communication process. Hence it is important to pay
attention to possible barriers that may block, distort or alter communication.
In the event that despite the best efforts and intentions, miscommunication happens or there is a
breakdown in communication. At such a time, follow the steps outlined below:
I.
II.
III.
IV.
V.
VI.
Stay calm and assess objectively what went wrong. This is not the time for blame.
Speak more slowly, quietly and confidently. Be assertive when you troubleshoot the
problem.
Acknowledge the client’s feelings. You want to avoid speculation and putting your
client on the defensive. Reassure the client that you are op top of things.
Set ground rules for future contact.
Accept criticism positively and acknowledge mistakes, if any.
Be honest about what happened
In conclusion, effective communication involves minimising potential misunderstanding, addressing
and overcoming any barriers to communication at each stage in the communication process.
In addition, effective communication requires good active listening skills, awareness and a good
understanding of non-verbal cues in communication, feedback skills and questioning skills. Couple
effective communication skills with accurate content, you can overcome the barriers to
communication.
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Part 2: Developing IEC and BCC
materials
Understanding IEC and BCC materials
A. IEC materials
In times where disease and risks to health pose a threat to a community, health promotion and health
education information is needed to create awareness about and draw attention to the issue. The aim
is to enable the community to use the information and take action. Hence any materials – be it print
materials, electronic media, or mass media that performs such an action are called “information,
education and communication” (IEC) materials.
IEC materials
CATEGORY
Print
Electronic Media
Broadcast Media
EXAMPLES
Posters, brochures, leaflets, flyers, banners,
billboards, training modules, signs, display
boards, flipcharts
Slide presentation, CD-roms, audio recordings,
video recordings, internet and social media
Public service announcements, radio, television,
video programmes, film, recorded music
It is important to remember that IEC materials are designed to deal with a specific health concern and
aimed at a specific audience. Developing the IEC material should be based on knowledge of the
target population.
When you plan to develop your own IEC materials, use the points below as a framework:
1. Suitability of the format for the target audience
Whether it is a poster, a brochure or a pamphlet, will the target audience peruse it? Is the
format convenient to use and will draw the necessary attention and impact it seeks?
2. Location where the print materials will be used
Will it be used indoors or outdoors? Is it put in one specific location or is it meant to be taken
by the client as a personal reference?
3. Use of words
Would there be words used and if yes, how much of the content will be words. Is there too
few words that the message is lost or too many words that takes too long to understand?
4. Use of graphics and images
Are the graphics eye-catching and appropriate? Do the graphics and images used distract
from the messages intended?
5. Choice of information
Is the information given relevant to the intended intervention? Is there an overload of
information?
6. Language used
Is the language used formal or informal? Is the language familiar to the target audience?
Would the clients used the language in their everyday communication and would most likely
share the message to their peers?
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If the IEC material is suitable to the target audience, the target audience will be able to:
1. Get the key message
2. Understand the meaning of the pictures used
3. Know what to do next
B. BCC Materials
Behaviour Change Communication (BCC) is a process that motivates people to adopt and sustain
healthy behaviour and lifestyles. Since HIV is mainly a behavioural disease, BCC is an integral
component of a comprehensive HIV/AIDS prevention, care and support programme.
As an effective intervention for PWID, BCC can:
1. Increase knowledge
In order to adopt change, the PWID must first get knowledge about their situation and the
risks they are taking as well as understand the options available to them. Thus, BCC sets out
to inform and educate the PWIDS on facts relating to HIV and AIDS in a language or visual
medium that they can understand and to which they can relate.
2. Stimulate community dialogue
It is important too that the community supports the process and progress of the PWID.
Discussions therefore focus on the underlying factors that contribute to injecting drug
behaviour, risk settings, environment and cultural practices relating to sex and sexual
behaviour as well as healthcare-seeking behaviours.
3. Promote essential attitude change
PWIDS often take a self-defeatist attitude towards self, self-worth and self-care. There needs
to be a change of attitude about personal risks to infection, responsibility for safe practices,
and trust in health supporting services.
4. Reduce stigma and discrimination
Stigma and discrimination persists among PWIDs. It promotes a sense of shame and
isolation, avoidance of VCT and proper medical care, and the perpetuation of discriminatory
laws and policies.
5. Improve skills and sense of self efficacy
Improved knowledge is good but improved skills can sustain behaviour change. Teaching and
reinforcing new skills and behaviours such as condom use, negotiating safer sex and safe
injecting practices can influence better decision making.
B-1. BCC strategies include
1.
2.
3.
4.
5.
adopt interactive and interpersonal approaches to engaging target audience
incorporate education and life planning skills to enable behaviour change
repeat key messages via multiple channels
connect target audience with families, role models, communities and spiritual groups
link closely with policy and advocacy activities at the local, community and national levels
If the BCC is well designed and executed, the target audience will be able to:
1. Develop the skills and capabilities to manage their own health and personal development
2. Foster positive change in behaviour, knowledge and attitudes.
3. Get support from families, health services, government and social agencies that provides the
sustaining environment for change
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B-2. Theories of Change
It is important to note that The Behaviour Change Communication approach is modelled on behaviour
change theories. These theories help in understanding what motivates change and maintains
sustaining change in behaviour. Among them are:
1. The Health Belief Model
The Health Belief Model stipulates that a person’s health-related behaviour depends on the
person’s perception of 4 critical areas:
a. The severity of a potential illness
b. The person’s susceptibility to that illness
c. The benefits of taking preventive action
d. The barriers to taking that action
2. Theory of Reasoned Action
Theory of Reasoned Action states that an individual’s behaviour is primarily determined by
the person’s intention to perform that behaviour. This intention is determined by two important
factors:
a. The person’s attitude towards that behaviour
b. The influence of the person’s social environment
3. Stages of Change Theory
Stages of Change Theory see behaviour change as a 5-stage process. According to this
theory, tailoring interventions to match a person’s stage of change brings about efficient selfchange.
The 5 stages are:
Stage
1. Pre-contemplation
BCC approach
Encourage awareness and value change
2. Contemplation
a. Early contemplation
Promote benefits of the new behaviour
b. Late contemplation
Reduce the costs involved in adopting new
behaviour, foster social support, and teach relevant
skills necessary for change behaviour
3. Preparation for Action
Personalise risks and benefits, deliberate decision
making, increase self-efficacy and self- esteem and
perception of positive change among peer group.
4. Action
Reward and support change
5. Maintenance
Continue support of the behaviour change
Note: People progress through these stages at their own pace, often relapsing and recovering before
reaching the goal of maintenance
20
B-3. Planning and Developing BCC strategies
A general step-by-step guide for planning and developing BCC strategies is outlined below:
1. State Programme Goals
The first step is to identifying programme goals. Program goals should be in line with the
National Strategic Plan for PWIDs.
Eg. Reduce HIV prevalence via sex among PWIDs in urban settings
2. Involve stakeholders
Decide who the stakeholders are in this particular intervention and invite their participation to
contribute ideas in the planning process.
3. Identify target population
Target population can be PWIDs who are at risk, service providers, policy makers, community
leaders and people and family members.
4. Assessing BCC intervention
Before a plan can be made, information about PWID situation and behaviour must be
collected, influences on and barriers to decision making by and behaviour change in PWIDs
must be explored, attitudes towards services and perceptions of risks must also be
understood.
5. Segment target population
Focus on the group to benefit from the BCC intervention. This helps narrow the scope of
intervention to specific setting, behaviour, language use, knowledge, attitudes, and practices.
6. Define behaviour change objectives.
This targets the specific behaviour shift that the intervention will influence.
Eg. If the programme goal is reduce HIV prevalence via sex among PWIDs in urban settings,
then the behaviour change objective is increase condom use.
7. Define BCC goals
This sets the tone for the BCC intervention and help form the strategy.
Eg. If the programme goal is reduce HIV prevalence via sex among PWIDs in urban settings,
then the behaviour change objective is increase condom use. To influence an increase in
condom use, the BCC goal is change attitudes toward condom use.
8. Develop action plan
a. This provides the framework or the vehicle in which the BCC objectives and goals
can be rolled out via specific communication activities. The action plan includes:
b. Developing a theme and key message
c. Identifying the channels of dissemination
d. Identifying the partners for implementation
9. Monitoring and evaluation
a. Monitoring and evaluation focusses on the process of implementation of the BCC.
Reporting tools and information gathering systems must be put in place to enable one
to track the outcome of the intervention i.e. the change in behaviour as a result of the
BCC intervention.
As part of the processes involved in communication strategies, IEC and BCC needs to be assessed,
reviewed and monitored for efficacy and impact. Ideally BCC interventions will be pre tested and
reworked before implementation. Any outcome must be measured against original objectives within a
specific time frame.
21
The 4–Step tool
The 4-step tool is a step by step guide that examines the processes that help define the IEC/BCC
materials that outreach workers and peer educators use in the course of their work. This guide
focusses on specifics:
1.
2.
3.
4.
The community known as the target audience
The desired behaviour change outcome
The key message for the specific channel of communication
Implementation and monitoring.
Getting started
Programme objective
Before proceeding to develop IEC/BCC materials, briefly describe the programme objective/s that
warrant the development of IEC/BCC materials
What do you want to do?
Why do you want to develop new IEC/BCC materials?
Is the development of IEC/BCC materials to support a new area of work, supplementing
existing materials or work in progress or improving upon existing materials?
How does the development of IEC/BCC materials going to add value to the current situation?
What outcomes are expected from this intervention?
Remember, Programme objectives must be in line with the National Strategic Plan. So you can start
by revisiting the National Strategic Plan
For example:
NATIONAL STRATEGIC PLAN 2011-2015
Goal
To prevent and reduce the risk and spread of HIV infection
Specific objectives
To further reduce by 50% the number of new HIV infections (i.e notification rate of
HIV) by scaling up, improving upon and initiating new and current targeted and
evidence based comprehensive prevention interventions
For PWIDS, refer to strategy 1.1
Prevention of HIV transmission through the sharing of needles and syringes –
sustaining and scaling up of existing comprehensive prevention interventions which
includes the harm reduction (needle syringe exchange and methadone maintenance
therapy) programme continues to be needed and their coverage increased to include
other identified populations
Key activity
Implement targeted behaviour change approaches for male and female IDUs which
emphasize risk reduction and promote safer sexual and risk reduction behaviour.
Your programme goal
Prevention of HIV transmission through the sharing of needles and syringes.
Specific goal
Emphasize risk reduction and risk reduction behaviour to sustain and scale up of
existing herm reduction via the needle exchange programmes.
22
Step 1: Community profile
The purpose of this section is to define the target audience. It examines the WHO, WHAT, WHERE,
WHEN and HOW aspects of the community of PWID.
You are already working with the community of PWIDS.
Who makes up the majority of the population? Are they the same people that populate your
port? Are they locals or from out of town? What is the gender mix – predominantly male,
female or TS?
What is their background – single, married, educated, or uneducated? What is their income
level? Do they have family support?
Are they living alone or with family? Are they of the same religion and ethnicity?
What is the dominant language used? What are their injecting habits?
Are they sexually active? Above all, is there a particular group of PWIDs that concerns you?
Eg. Your community profile
The average age was 35 years. The majority of PWIDs were male, of Malay ethnicity. 30% are
married with children, 50% are divorced and the rest are single.. Most of them earned less than
RM800 per month. 80% of them had been in jail at least once. Most (70%) had injected in the prior
month. The median age at first injection was 25 years; the most common drug injected was heroin
(80%) followed by buprenorphine. There were some who injected heroin with crack together. A small
number were injecting other drugs such as amphetamines. High risk behaviours were common and
included needle-sharing, unsafe disposal, and inappropriate cleaning of needles as well as limited
condom use.
Step 2: Behaviour and behaviour change
The purpose of this section is to define the desired behaviour change outcome from the intervention
with the primary audience. It examines behaviour and the circumstances that influence behaviour as
well as obstruct behaviour change.
Based on your observation and past experience with the community,
What is the main issue that troubles you?
What remains a challenge for you and that is preventing you from achieving success with your
ongoing intervention?
Of the many issues and challenges that you deal with, what do you see as the most important
issue to address?
For example:
1. Voluntary counselling and testing (VCT).
The community that you work with is resistant to testing. The pamphlets that you have given
them are too wordy and the majority of them are illiterate or does not want to read. Your
behaviour change objective is to increase the percentage of clients getting tested.
2. Unsafe disposal of needles
It is a constant challenge to manage the client’s disposal of used needles. They have been
given the necessary presentation on needle disposal and yet there has been very insignificant
change. Your behaviour change objective is to increase awareness of the dangers of unsafe
disposal of needles and therefore increase the safe practice of disposing used needles safely.
23
Step 3: Identifying key messages and key communication
channels
The purpose of this section is to develop key messages for the development of IEC/BCC materials
and to match it with the appropriate channels of communication.
What messages do you think would impact the desired behaviour change?
Would the messages be promoting services, products or well-being of the clients?
What is the intended purpose of the message – to inform, to educate, or to persuade?
What are some of the benefits from the desired change of behaviour?
How do you frame the benefits in a statement?
How would you get this message across to your clients?
What would be the best channel that has the most impact on behaviour change and most
relevant to the client?
Eg. You have witnessed the dangers of injecting drugs of an unknown source. You want to warn your
clients about the risks of buying drugs that may be contaminated with other harmful ingredients – like
rat poison, bleach, etc.
You want to client to be aware of the risks each time they inject drugs and to stop their habit. Your key
message is injecting contaminated drugs can kill you. The benefit from the desired change of habit is
stopping this habit can reduce your risk drastically and prolong your life.
The channel to communicate this message is the needle and syringe exchange programme NSEP
box kits. A sticker label with two columns will be pasted on the top side of the box.. On one end is the
column with the key message “If injecting drugs, always use your own clean syringe”. On the other
column are words referring to the drug “I am … rat poison, mosquito spray, battery liquid, bleach…”
Every client who gets the NSEP box kit containing the new needles and syringe will be reminded each
time they see the box.
Step 4: Implementation, Monitoring and Evaluation
The purpose of this segment is to ensure the IEC/BCC material is monitored and evaluated for
impact.
How can you know that your BCC material has achieved the objectives that you intended?
What systems are in place to help quantify the use of the material? What qualitative measures
can indicate that your BCC material is working?
What significant or subtle change in behaviour have you noticed among your clients?
Always go back to your objectives. You may not have a formal research plan to collect data and to
measure the impact of your intervention but there are certain indicators that will let you know that a
shift has happened in the mind-set of the client. There are visible actions signalling a change in
behaviour has happened. Part of your monitoring must track this process.
Eg. If your objective is to push for an increase in VCT testing, feedback from your clients and
monitoring the clients will let you know that there is a shift in knowledge and readiness to consider
testing. There is an increase in the number of clients who got tested as a result of your intervention.
Over a period of 6 months since the video on VCT was shown to the clients, 10% of the clients got
tested. 40% of the clients are asking questions about VCT.
This information can help you re-evaluate your intervention to reach out to the remaining 50% that did
not benefit from the intervention.
24
The five components on monitoring to ascertain that dissemination reached the relevant audiences:
1. Reach : Are adequate number of audiences reached over time?
2. Coordination : Are the message adequately coordinated with service and supply delivery? Are
communication activity taking place on planned duration?
3. Scope : Effectively intergrating with audiences, issues and services?
4. Quality : Quality of communication ( message, media and channels )
5. Feedback : Are changing needs of target populations are captured?
The template on the 4 step tool
The template collates the information that came out of the process in developing IEC/BCC materials.
WHO: target audience
What:
1. key behaviour
2. key desirable behaviour
Key message
Benefit statement
Channel of communication
Monitoring and evaluation
Example:
WHO: target audience
What:
1. key behaviour
2. key desirable behaviour
Key message
Benefit statement
Channel of communication
Monitoring and evaluation
Young women injecting drug user aged 15-24
1. Not addressing the risks involved in
sexual behaviour
2. Use condom correctly each time one has
sexual intercourse
“ wearing a condom protects you from infections”
so you stay safe and live longer”
Interpersonal (one on one, peer influence, small
groups)
IEC materials on condom use,
condom demonstration ,
sexual health talks
Outcome indicators – number of individuals
reported using condoms every time they had sex
within a period of time.
Impact indicators – Decrease in incidence of
sexually transmitted infections among targets.
25
Appendix 1
Word used by the community (Bahasa pengguna dadah)
Abuk
Adik/jambu
Anak burung
keluar
Anjing
Anto/kaki petik/barua/spy/sos
informer polis
Babi/beruk/bond
Badi
Bagi air
Bahagi air
Balaci
Bangkai
Barang/kubah/peh hoon/tepung/stok
Barel
Belon/supik
Ber-be-gher
Beras/pok tih
Bidas/pistol/spare[part/pen
Bom/roket/peti ais/kapal
Buah/kuda
Bukak kedai
Cair
Cari makan
Chi (blanket)
Cik husin/kurap/belen/ cita
Cirit/petik
Dedar/dedor/sanggap
Doctor
Gantong/sandor/pajak
GD/Otek/barua
Hantu
Helai/baju
Jaga air
Jalan kapal
Jam rolex/rantai anjing
Jaring/pukat
Jarum/syringe/cooker
Kacip/kakers/chawtut/kick
Kambang
Kantoi/berusung
Kapal
Karaoke/nyanyi
Kencing/opai/lebon/gebang/lipat
Keping
Kereta
26
tembakau
lelaki comel, cantik, handsome
orang gantian kuda semasa
polis (GD)
pemberi matlumat,
polis
takut
kongsi dadah
kongsi/share barang dalam tiub (suntikan)
orang suruhan
D8 narkotik
dadah
alat sedutan
isap gam
baru nak gian
morfin/heroin
syringe
seludup, sesuatu benda yg nak diseludup
dlm lokap/penjara
pil kuda
masa menjual dadah di
port
lembut hati
kerja
kertas balut tembakau
marijuana/ganja
pembuka rahsia
gian/ketagihan
tukang cucuk
hutang barang dgn tokan
polis, penguatkuasa
pemberi matlumat pd
pihak berkuasa
plastic packing
pengawal keselamatan port
penguatkuasa yg membekalkan barang
salah dlm lokap/penjara
gari
operasi polis
alat suntikan
layan stim tahap tinggi
menyimpan tanpa izin
ditangkap
orang suruhan
oral seks/blowjob/isap
tipu member
duit
handset di penjara
Kuda
Lambong/berkuak
Lentok
Lemau
Line clear
Line x clear
Lot/pocai
Mat/awe/bro/joe/macai/ balachi/minah
Mati air
Menyambar
Nasi tambah
On
Orga/dapur/tukir/kokgoh
Pacak
Pai’e/spark
Panching
Parkos
Patah kaki
Payung /paying kembang
Pau
Panas
Pentau/eling
Piaw/kaw/bantal/kembong
Pistol/dapur/ceper/mata/tabung/pump
Port
Projek
Roket
Runner/kuda/ terjun/nyambar
Sanggap
Sejuk
Slippa/lima/ 5 chai/ happy 5/ pak min
Spare part
Spelit/tek
Stoking
Suwek/pewai
Tak correct
Tergantung/tak cukup haul
Terjun/runner
Tokan/pusher/towkay/boy/Costello/
escobar/runner/contact/juragan
penyeludup dadah dlm pusat
Serenti/ runner barang
lari pusat
khayal, mengguna dos yang lebih
kurang dos
selamat
ada operasi
boto asam
nama pangillan rakan
tutup cerita
beli dadah
batu api
hisap dadah
alat utk hisap/bon
suntik dadah
mancis/lighter
umpan/ambik supply
ubat batuk
takde transport
minta belanja
dadah/support
samun
heroin/ubat
pil ecstacy/ATS
dapat barang kuantiti banyak
alat alat suntikan
lokasi, kawasan IDU berkumpul
mencuri dsb
menyimpan barang salah di
dalam bontot/vagina
ambil barang/bahan,
pergi beli dadah
gian
ais, syabu, batu, meth
eramin 5
alat-alat hisap dadah/jarum
seleweng
kondom
overdose
tak cukup
tak cukup dos
tukang beli
Top up
Ubat/tiang/batang/ekor butir/tudung/paipbarel
Ubat chuit
Up-sye-rey
pengedar/ tokey jual dadah
kongsi beli dadah/share duit
ambil barang
tambah duit
dadah/barang dalam straw
ubat potong gian (Thailand)
semua boleh
Ushi/ciput/cipurit/kemut/ngujung
dapat barang kuantiti sik
Tong-tong /donate/torekt
27
Appendix 2
The 4 Step tool
Getting started
Programme objectivec
Before proceeding to develop IEC/BCC materials, briefly describe the programme objective/s that
warrant the development of IEC/BCC materials
What do you want to do? Why do you want to develop new IEC/BCC materials? Is the
development of IEC/BCC materials to support a new area of work, supplementing existing
materials or work in progress or improving upon existing materials? How does the
development of IEC/BCC materials going to add value to the current situation? What outcomes
are expected from this intervention?
28
Step 1: Community profile
The purpose of this section is to define the target audience. It examines the WHO, WHAT, WHERE,
WHEN and HOW aspects of the community of PWID.
You are already working with the community of PWIDs. Who makes up the majority of the
population? Are they the same people that populate your port? Are they locals or from out of
town? What is the gender mix – predominantly male, female or transgender? What is their
background – single, married, educated, or uneducated? What is their income level? Do they
have family support? Are they living alone or with family? Are they of the same religion and
ethnicity? What is the dominant language used? What are their injecting habits? Are they
sexually active? Above all, is there a particular group of PWIDs that concerns you?
29
Step 2: Behaviour and behaviour change
The purpose of this section is to define the desired behaviour change outcome from the intervention
with the primary audience. It examines behaviour and the circumstances that influence behaviour as
well as obstruct behaviour change.
Based on your observation and past experience with the community, What is the main issue
that troubles you? What remains a challenge for you and that is preventing you from
achieving success with your ongoing intervention? Of the many issues and challenges that
you deal with, what do you see as the most important issue to address?
30
Step 3: Identifying key messages and key communication channels
The purpose of this section is to develop key messages for the development of IEC/BCC materials
and to match it with the appropriate channels of communication.
What messages do you think would impact the desired behaviour change? Would the
messages be promoting services, products or well-being of the clients? What is the intended
purpose of the message – to inform, to educate, or to persuade? What are some of the
benefits from the desired change of behaviour? How do you frame the benefits in a statement?
How would you get this message across to your clients? What would be the best channel that
has the most impact on behaviour change and most relevant to the client?
31
Step 4: Implementation, Monitoring and Evaluation
The purpose of this segment is to ensure the IEC/BCC material is monitored and evaluated for
impact.
How can you know that your BCC material has achieved the objectives that you intended?
What systems are in place to help quantify the use of the material? What qualitative measures
can indicate that your BCC material is working? What significant or subtle change in
behaviour have you noticed among your clients?
32
The template on the 4 step tool
The template collates the information that came out of the process in developing IEC/BCC materials.
WHO: target audience
WHAT:
1. key behaviour
2. key desirable behaviour
Key message
Benefit statement
Channel of communication
Monitoring and evaluation
33
References
1. Malaysia National Strategy Plans on HIV/AIDS 2011-2015
2. Baseline Report for Community Action on Harm Reduction Project (CAHR) – international
HIV/AIDS Alliance, Regional technical support Hub for Eastern Europe and Central Asia
3. Global AIDS Response Progress Report 2014 Malaysia
http://www.aidsdatahub.org/sites/default/files/publication/Malaysia_narrative_report_2014_%2
82%29.pdf
4. The rapid assessment and response guide on injecting drug use (IDU-RAR)
http://www.unodc.org/documents/hivaids/IDU%20rapid%20ass.%20and%20resp.%20guide.pdf
5. Behaviour change communication (BCC) for HIV/AIDS – a strategic framework
http://www.hivpolicy.org/Library/HPP000533.pdf
6. National strategy for behaviour change interventions and communications for HIV/AIDS
http://www.gov.bw/Global/NACA%20Ministry/BCIC_Strategy_Sept06.pdf
7. Targeted interventions for high risk groups (HRGs) – operational guidelines
http://www.ilo.org/wcmsp5/groups/public/@ed_protect/@protrav/@ilo_aids/documents/legald
ocument/wcms_117312.pdf
8. Outreach Competencies – minimum standards for conducting street outreach for hard to
reach populations
http://www.attcnetwork.org/regcenters/productDocs/2/2009%20updated%20Outreach%20Co
mpentencies.pdf
9. Tools for behaviour change communication
https://www.k4health.org/sites/default/files/BCCTools.pdf
10. Staying safe –a manual to train peer educators in IDU interventions
http://www.unodc.org/documents/southasia/publications/training-modules/staying-safe---amanual-to-train-peer-educators-in-idu-interventions.pdf
34
35
Malaysian AIDS Council
No 12, Jalan 13/48A, The Boulevard Shop Office, Off Jalan Sentul, 51000 Kuala Lumpur, Malaysia.
+603 4047 4222
+603 4047 4210
contactus@mac.org.my
www.mac.org.my
36
Malaysian.AIDS.Council
myAIDScouncil