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PUBLIC HEALTH EDUCATION
Year : 2011  |  Volume : 55  |  Issue : 4  |  Page : 276-285  

Evidence based communication for health promotion: Indian lessons of last decade


Public (Child) Health Consultant, New Delhi, India

Date of Web Publication30-Jan-2012

Correspondence Address:
K Suresh
Public (Child) Health Consultant, New Delhi - 110 070
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-557X.92405

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   Abstract 

Good health promotion programs which help achieve public health goals are derived from using a mix of epidemiological and social and behavioral science research information. Social data informed by behavioral theories provides a lens of understanding how recommended behaviors are adopted by different individuals within the population over a period of time. In addition to social and epidemiological data, evidence based and scientifically planned and monitored strategic communication interventions have to be linked to available service components of the program. Communication is increasingly understood as an enabler of individual and social level change to achieve established developmental goals including health. Democratization movements and the advent of the internet have changed the environment around any program communication from top-down, expert-to-consumer (vertical) communication towards non-hierarchical, dialogue-based (horizontal) communication, through which the public increasingly questions recommendations of experts and public institutions on the basis of their own, often web based, research. The amount of information available has increased greatly, including scientifically valid data and evidence-based recommendations alongside poor quality data, personal opinions, and misinformation. Evidence-based approaches include engagement with and listening to stakeholders, and being transparent about decision making, and honest and open about uncertainty and risks. Decision and policy makers cannot assume what the public wants without undertaking social science and decision science research. The Global Polio Eradication Initiative and Integrated Disease Surveillance Projects (IDSP) in India haves shown that monitoring of public concerns needs to be continuous and responsive, and hand in hand with the monitoring of technical strategies and appropriate Information Technology support for, not only data transmission but also for videoconferencing and community involvement through toll free 24×7 call service with universal access. This article elucidates the vital role of Health Promotion, a research based communication process, in achieving developmental, particularly health goals. It underscores that communication is as much a science as an art, as much process as it is about outcomes. It advocates for increased linkages between epidemiological research and social science research in planning effective health promotion interventions with quality service delivery.

Keywords: Strategic communication model, Behaviour change communication, Advocacy, Social mobilization


How to cite this article:
Suresh K. Evidence based communication for health promotion: Indian lessons of last decade. Indian J Public Health 2011;55:276-85

How to cite this URL:
Suresh K. Evidence based communication for health promotion: Indian lessons of last decade. Indian J Public Health [serial online] 2011 [cited 2017 Jun 25];55:276-85. Available from: http://www.ijph.in/text.asp?2011/55/4/276/92405


   Background Top


Health promotion in the new development paradigms {National Health (NRHM), Nutrition and Population, policies, MDGs, Child & Women Rights, Human Rights etc} is much more than merely writing press releases or producing audio/video clippings, posters or pamphlets. It is a concerted strategy derived from and intrinsically linked to larger health goals. This article elucidates the vital role of Health Promotion, a research based communication process, in achieving developmental, particularly health goals. It underscores that communication is as much a science as an art, as much process as it is about outcomes. The chapter advocates for increased linkages between epidemiological research and social science research in planning effective health promotion interventions with quality service delivery.

Traditionally health education, health promotion and communication efforts are limited to writing press releases or producing audio/video clippings, hoardings, posters or pamphlets. Recently that has expanded to advertorials in press, Radio and TV and social mobilization in the context of Pulse Polio Immunization for polio eradication. It was generally considered more as an art.

Communication in last decade is increasingly understood as an enabler of individual and social level change to achieve established developmental goals including health. The science of communication is a research driven consultative process involving planning, design and implementation of strategic interventions. It provides relevant information and adequate motivation to impact attitudes and behaviors in individuals or groups of people. It involves monitoring the changes in people's attitudes and behaviors as laid down by program objectives.

Democratization movements and the advent of the internet have changed the environment around any program communication from top-down, expert-to-consumer (vertical) communication towards non-hierarchical, dialogue-based (horizontal) communication, through which the public increasingly questions recommendations of experts and public institutions on the basis of their own, often web based, research. The amount of information available has increased greatly, including scientifically valid data and evidence-based recommendations alongside poor quality data, personal opinions, and misinformation.

Evidence-based approaches used in risk communication should be adopted as core principles by all health providers, experts, health authorities, policy makers, and politicians when communicating information about program interventions. These approaches include engagement with and listening to stakeholders, and being transparent about decision making, and honest and open about uncertainty and risks. Decision and policy makers cannot assume what the public wants without undertaking social science and decision science research. The Global Polio Eradication Initiative has shown that monitoring of public concerns needs to be continuous and responsive, and hand in hand with the monitoring of technical strategies

The following case studies describe examples of how different health promotions either helped or had reverse effects in the last decade in India:

Case Study 1: Collective behavior enforcement/ Role modeling:[1] Research on domestic violence indicates that women usually recoil to kitchen after an incidence of violence because it is seen as "safe place" for traditional women. In a village in Andhra Pradesh a respected teacher was beating his wife. The neighbors initially were reluctant to intervene in what they perceived as a private matter. Fed-up by the increasing periodicity of this routine nuisance one fine day the neighbors were galvanized into action. When the teacher was beating his wife, they collectively gathered pots and pans and banged them in protest outside the couple's home. Teacher was thus publicly shamed. Thus pots and Pans were symbolically turned into agents of liberation for the abused women. A private act of violence was transformed into a public action of protest and a new social behavior was modeled that exemplified collective efficacy of social learning.

Case Study 2: Social Mobilization for Polio Eradication[2],[3] (1996-till 2011): UNICEF India started post-PPI assessment of non-acceptors survey through NGOs and Medical college faculty in addition in 1996-97 -2000-2001. Based on the feedback, a need to involve community volunteers for raising awareness of the need and urgency of taking PPI drops every time, inter-personal communication of the reluctant/refusing families and involving various community leaders and empowering them to mobilize people in turn was initiated in Moradbad (UP) and neighboring districts. Over the years hundreds of such block and distinct level social mobilizers have become the key workforce for successful implementation of IPPI.

Case Study 3: Professional organization endorsement:[4] Mobilizing "Hand Washing for a Healthy Life" IPHA partnered with Hindustan Lever Ltd. and endorsed its Lifebuoy soap. One might feel it as an endorsement of a product for money but the social good done by this endorsement cannot be negated. We see frequent TV ads of this even today.

Case Study 4: Use of celebrities for health promotion: [5]

  1. Who does not know or has not seen Mr. Amitabh Bachan popularize "Do Boond" for polio eradication. Many Bollywood and other regional film artists have contributed to pulse polio campaign across India and neighboring countries.
  2. Ms Hema Malini popular Hindi Actress - member Rajyasabha endorses with her daughters a reverse osmosis water purifier for safe drinking water.
Case Study 5: Use of positive deviants for communicating peers:[6] The concept of positive deviance extensively used in ICDS in West Bengal and other states, demonstrates how a positive behavior by a few individuals or families in a community (positive deviants-mothers whose babies are well nourished) who do things differently that others in the community can eventually lead to far reaching results (reduction of child under nutrition).

Case study 6: Press and perverse consequences:

  1. Thiomersal and autism:[7] Thiomersal, a compound containing ethyl mercury, has been used to prevent bacterial contamination in biologics since the 1930s. In 1997, the FDA noted that, in view of the increasing number of vaccines given in early infancy, the total amount of ethyl mercury (as thiomersal) might exceed the level set and therefore asked vaccine makers to remove thiomersal from childhood vaccines as soon as practical in 1999. However since then many studies have failed to support any causal relationship between thiomersal and autism.
  2. Oral polio vaccine and sterilization:[2] In some parts of Uttar Pradesh boycotted the polio vaccine in 2001-2004, claiming that the oral polio vaccine could also cause sterilization in those vaccinated, fuelling widespread public distrust.
  3. Tetanus vaccine and sterilization: [8] In 1998-2000 Govt. of Rajasthan with a support from local UNICEF office launched tetanus toxoid injections (5 dose schedule) campaign for child bearing aged married women. The state Govt. itself doubted and was cautious of a possible misnomer (that it may be perceived as a ploy for sterilizing women at a young age) spreading and avoided unmarried women in childbearing aged women. Despite the precautions some families did refuse getting the toxoid injections their young women and adolescent girls giving the same reason as apprehended.


Case Study 7: International and national professional communities' feud: [9],[10] we all know how the international experts blamed Indian experts for not allowing the Govt. of India to introduce Hib vaccine across the country. While the global infection and case load may justify introduction of Hib in universal immunization program (UIP), there is not enough local evidence argued the pediatricians in India. Introduction many other vaccines with low cost effectiveness have to be introduced with caution say Indian experts.

Case Study 8: Use of SMS and Toll free call number in IDSP: [11] Andhra Pradesh tried in one district during 2008-09 use of personal mobile phones of the workers to send SMS for weekly surveillance reports and SOS whenever there was outbreak or unusual event directly to a district level server, which collated and alerted the concerned PHC for action. Unfortunately what seemed a boon did not succeed? But there are a few such small attempts to capture periodical real time data. On the contrary the toll fee 24x7 call centers (1075) has become a boon to public in general and private doctors and health workers in particular to report on occurrence of any outbreak or unusual events, which hither to was difficult for them as they were scared of getting identified and taken to task by local health authorities.


   Strategic Communication in the Contemporary Development Paradigm Top


Good health promotion programs which help achieve public health goals are derived from using a mix of epidemiological and social and behavioral science research information. Epidemiology tells 'what' the problem is and 'where' the problems lie. On the other hand social and behavioral data tells the "Why?" of the problem, i.e. why people behave the way they despite knowing what cause the problem. Social data informed by behavioral theories (the diffusion of innovations) provides a lens of understanding how recommended behaviors are adopted by different individuals within the population over a period of time behavioral analysis also explains how attitudinal and behavioral challenges can be overcome. It facilitates both individual level and societal challenges. In addition to social and epidemiological data, evidence based and scientifically planned and monitored strategic communication interventions have to be linked to available service components of the program. For instance a communication initiative which creates demand for immunization program is not helpful if the vaccination services not easily accessible on the fixed days. Similarly emergency obstetric services communication will not be effective if the comprehensive emergency obstetric services are not available round the clock.

The [Box 1] shows clearly shift in thinking about strategic health promotion in the context of changing paradigm of health programming [12] and other developmental programs.



Concepts and some definitions of strategic communication

Strategic communication is uniquely situated to foster health and other development goals and help overcome challenges of meeting human rights (rights of children and women in particular) by finding creative avenues to address resistant attitudes and ensuring community participation. It consists of three key approaches: (1) Program communication-(also referred as Behavioral Change Communication- (BCC)), (2) Social mobilization and (3) Advocacy [13],[14]

[Figure 1] Strategic communication model [15] describes how the three distinct dimensions of communication are united through a planning and management continuum (represented by the arrow on the left) and the importance of linking the activities to service delivery.
Figure 1: Strategic Communication Model

Click here to view


Evidently, program communication addresses the knowledge, attitudes and practices of individuals, while advocacy and social mobilization contribute towards the creation of an enabling social and political environment that can support behavior change at the individual level. The arrow to the left suggests that strategic communication does not have a pre-determined starting point. Depending on the programming context, communication strategies can begin at different levels. Further, the line through the diagram reiterates the fact that behavior change and social change are inter-related and need to occur across all participants for a program to make a difference. Within the new development paradigm, the discourse of "behavior change" is linked to "social change". While behavior change implies individual level change; social change seeks to create a favorable environment for change.

Social change is most commonly understood as a process of transformation in the way society is organized within institutions and in the distribution of power within various social and political institutions.

Communication for social change is a process of public and private dialogue though which people define who they are, what they want and how they can get it [Box 2].



The role of communication in Behavior Change Communication: [16]

Agenda setting
: President, Prime minister or Health Minister's "statement" in communication terms refers to agenda setting. Media in all diversities is a primary source of information through which people learns about the world around them. What media chooses to report or not to report, often determines what people believe as being salient to their health world, (for example, Cancer may be killing more than any communicable disease but HIV/AIDS than TB or Dengue and Swine Flu are key health problems now that cancer). National leaders encouragement clarifies the importance of how policy makers, religious leaders should set the public, media and national agenda to tackle key health challenges like HIV/AIDS, Swine Flu, TB, Maternal and child mortality.

Communication for Role Modeling: Collective behavior enforcement through social mobilization to combat situations against those who are exploited because of their inherent limitations or weakness. Examples: domestic violence, child abuse, alcohol sale/consumption etc.

Culturally appropriate communication practices: The concept of positive deviance extensively used in ICDS in West Bengal and other states, demonstrate how a positive behavior by a few individuals or families in a community (positive deviants-mothers whose babies are well nourished) who do things differently that others in the community can eventually lead to far reaching results (reduction of child under nutrition).

Behavior adoption curve: Diffusion as a social process through which a new idea or product is communicated through certain channels over a period of time to "individuals, community and society" [Figure 2]. Five key characteristics of a new product, idea or behavior that contribute towards its adoption are: (1) relative advantage of adopting the new behavior (for example, adopting a vaccine prevents illness), (2) compatibility of the new behavior in relation to the individual's existing social norms (for example, sending a girl child to school may not be compatible with social norms), (3) complexity of adopting the behavior (for example one needs trained person to administer an iron injection but iron pills can be taken by the individual). (4) observability of the adopted behavior (for example are the results of adopting and innovation visible to others such as using helmets or going to school) and (5) trialability which is the opportunity to experiment the behavior before adopting it on a sustainable basis (for example trying out using condoms/ cigarettes before making it a habit). Within the public health context, many innovations that are promoted tend to be preventive innovations such as getting vaccinated to prevent a serious illness. Thus, they tend to have a slow rate of adoption because potential adopters may not easily perceive its relative advantage, the adoption may be complex, the outcome is not necessarily observable and trialability is limited.
Figure 2: Behavior adoption curve

Click here to view


Diffusion of innovations: A behavior change theory: [17]

Applying the theory of the diffusion of innovations, communicators can identify among participants (better word than beneficiaries or target groups) "early adopter," i.e. people / who are either already practicing or have adopted a new behavior or idea that a program is trying to promote within a community, and use these early adopters to further promote the behavior so that it diffuses through the entire community. Early adopters may include opinion leaders in the community and enjoy a certain social status. Using both qualitative and quantitative research, communicators tend to use different strategies and communication channels to stimulate the early or late adopters than the "laggards" or "resistors".

Communication for advocacy: [14] Advocacy= Influencing heart and minds of decision makers

Successful advocacy strategies aim to influence decision makers at various levels; at international, regional, national or district levels. Approaches to advocacy begin with data and reasons for addressing development problems that appeal both to the mind and the heart of people in leadership positions. These reasons should also appeal to the interests of all concerned. For effective advocacy evidence should be used in support of making arguments. For instance, advocacy that uses health economics data looks beyond the impacts of health conditions alone (burden of diseases data) to the impacts on educational development, economic output, national development and even human rights. Through multiple regression analysis-among other tools-it is possible to identify causal links between a problem and its social impact. The data on economic and social impact due to a disease could be used to develop a basic document such as a comprehensive situational analysis report that addresses the above mentioned questions related to the issue. From this report, depending on the audience for the advocacy strategy (community members, local leader, regional leaders, and national policy makers) the information that directly related to the situation should be used. Also, the document is useful to produce informational material such as pamphlets, press releases, TV or radio spots or even documentaries.

In general, advocacy can be differentiated based on participants and approaches into:

  1. Policy advocacy: Uses data and approaches to advocate to senior politicians and administrators about the impact of the issue at the national level, and the need for action. For example, the Safety Injection Global Network (SIGNS) advocacy campaign began with a survey of 198 decision makers in 33 countries on their perceptions of the status of safe injections in their countries. Based on the date, it was possible to frame arguments which addressed their knowledge of the situation and their concerns. The results fed into the framing of future advocacy strategies.
  2. Program advocacy: Used at the local, community level to convince opinion leaders about the need for local action. For instance, in the case of mobilizing religious leaders in communities for immunization, or in the case of religious leaders interpreting faith-based texts in the light of children and women's rights.
Communication of Social Mobilization [14]

Social Mobilization can help to create a climate in which change can occur. It sets out to garner support from local people so that the programs and interventions are accepted and well suited to the felt need. Well-planned social mobilization efforts also seek to empower communities to take control of their own situations, including accepting or rejecting interventions. Social mobilization, integrated with other communication approaches, has been a key feature in numerous communication efforts worldwide and in India too. Some prominent examples include: (a) Polio, (b) Malaria control (environmental control) (c) RNTCP [Box 3].



National vector borne diseases control program (NVBDCP) [18] has many successful examples of mobilizing communities for vector control like using Gambusia fish in tanks, emptying weekly coolers and water storage tanks for minimizing vector breeding places. My own personal experience in a village in Koppal district, Karnataka during Chikungunia epidemics in 2006 and 2007 is good and successful experience. A young lady entomologist showed the indoor breeding places of mosquitoes in the disease affected AWW's house to the village leaders. In the next 2 days the entire village household cleaned their water storage tanks and kept doing the exercise until the entire epidemic was brought under control.

Indian Pharmaceutical Association (IPA) in 2005-06 ran a project creating awareness among consumers and TB patients using fact card, counseling and treatment monitoring. A total of 60 retail Pharmacists trained worked hard for one year to monitor 133 patients. Apart from this Individual community members like private practitioner, chemists, social worker, restaurant owner and a brave women (with HIV) were involved as DOTS providers.


   Communication for Behavior Development/Change Top


Entertainment education : Entertainment Education Strategy [19] is a research based communication process or strategy of deliberately designing and implementing a program to entertain even while it educates in order to increase audience members knowledge about a social issue, create favorable attitudes shift social norms, and change behavior.

Taru project-Bihar- case study: This was a radio soap opera, named after the protagonist, revolved around the life of a little girl in a village in Bihar. It was aired twice a week in MP, Bihar and Jharkhand between February 2002 to February 2004. The objectives of the project were to promote gender equality sand reproductive health. It was multitude partnerships (population communication International New York, Ohio University, Athens, All India radio and Centre for Media studies in Delhi). The on ground partnership with Janani an NGO, Janani's rural health providers (30,000 couples with 3 days training in as many villages). Weeks before Taru went on air intensive publicity was created usng folk performances and through posters and wall paintings. During the road shows radios were gifted to form listeners clubs. This effort resulted in 10% listenership among the villages amounting to over 20 million listeners.

Interpersonal and Participatory Development Communication[20],[21] [Box 4]

  1. Interpersonal communication refers to one on one or on small group (e.g. doctor, health worker or counselor who dialogues with an individual or family or a small group of people with common interest or change of behavior), IPC helps to move from knowledge to trial and continued practice of a new behavior. The objectives of IPC are to i) to share information ii) respond to questions or doubts iii) convince or motivate the listener to adopt/adapt certain behavioral practices or use certain health services. IPC involves listening skills, the ability to empathize and be supportive. Individual IPC works better in sharing confidential issues needing confidentiality like HIV/AIDs, sexually transmitted diseases, family planning methods; postnatal counseling etc. the group IPC is useful in sharing some common issues with a family, small groups of pregnant women, diabetic patients, participants of temporary family planning method users etc.
  2. Participatory development communication (PDC) approach on the other hand moves away from a focus on individual level to promoting social change involving community driven initiatives and empowerment. It facilitates information exchange between various stakeholders to address a common problem, implement a joint development initiative and identify the required partnerships, knowledge and material conditions at the community level. Growth monitoring at the anganwadi (Village) level involving parents is a good example of PDC. Apart from showing differences between the children, it encourages community action for complimentary feeding, hygiene /feeding practices, home practices of managing young and sick children etc. Thus communication in a PDC is seen as facilitation. PDC sees the communicators as a facilitator, an enabler of change. Effective behavior and social change process depend significantly on attitudes and interpersonal communication (IPC) of the facilitators.
  3. Focus group discussions (FGD): is a type of PDC with specific subject of objective for discussion. IN FGD the facilitator encourages dialogue between the participants, to share different opinions, activities to meet similar end. The facilitator consolidates the positive behaviors at the end of the discussions.



   Private sector approaches to Behavioral /Social Change Top


Connecting with youth [21] Pepsi way: the Pepsi story is about the process of feeding research work back into the advertising and marketing strategies not just to increase the sale but also to shape how young people feel and behave and create brand loyalty towards consumer product. Entering Indian market in 1990 at the beginning of the economic liberalization. The campaigns of "are you ready for the Magic", Yehi Hai Right Choice Baby", Nothing official about it", Azad Zindgi ki" and recent …… With changing times Pepsi engages new faces of celebrities like Kapil Dev, Sachin to Dhoni and Riana and film stars from Aamir Khan to latest craze Ranbir Kapoor. Over all Pepsi tries to address young people's dreams and notably constant messages on how to maximize and get more out of life.

Toll Free (1075) [11] Surveillance number in IDSP: [11] IDSP encourages any person in the community in general and private practitioners and health workers in particular to report any suspected outbreak or occurrence of unusual events in the community not only in human population but also in animals to identify outbreaks of bird flu (H5N1) to take up public health actions like culling etc

COMBI- in TB program. COMBI [22] is a process that strategically blends a variety of societal and personal influences and communication interventions to encourage individual and families to adopt and maintain recommended healthy behaviors. It believes in the fact that there is no single magical communication intervention and instead relies on a strategic combination of the following five inter-related strategies:

  1. Public relations/advocacy/administrative mobilization for putting the particular health behavior on the public and administrative agenda via mass media.
  2. Community mobilization: including participatory research, community group meetings, partnership meetings, traditional media, posters, videos and home visits.
  3. Advertising: Multi-media channels, engaging people in reviewing the benefits, effective repetitive, intense persistent (M-RIP). It identified that it takes six exposures (known as six hits) for a person to register a message.
  4. IPC/Counseling/Personal selling: At the community level, in homes and particularly at service points with appropriate literature.
  5. Point service promotion: Emphasizing easily accessible anti-Tb treatment through AWWs and health workers.



   Monitoring and Evaluation of communication efforts Top


  1. Result Based Monitoring and Evaluation of Communication interventions: [23] A result based monitoring and evaluation system addresses issues such as: Are the goals of communication program being achieved? How is the achievement of program outputs causally linked to changes in the lives of people? This is in addition to design and implementation monitoring and evaluation, which answer compliance with design and implementation strategy. The monitoring and evaluation will have to be on-going at critical stages of communication campaign to feed into the decision making process needed to make management changes to improve communication design and implementation to stimulate the desired behavior changes. It should provide information that is critical by showing a) Direction of change b) pace of change c) magnitude of change d) Unanticipated changes if any.
  2. Indicators for Behavioral and Social change: An indicator refers to information on a particular circumstance that is measurable in some form. We always use a numerator and denominator and work out either percentage or per 1000. The numerator is generally the achievement up to certain time; the denominator is the expected or planned achievement. When compared the serial rates will indicate the progress and the pace at which progress is being achieved. It can measure tangible (service delivery, training, product etc), the intangible (community empowerment) and the unanticipated or results that were not planned. Indicators give an indication of the magnitude and direction of change over a period of time, rather than informing us about every aspect [Box 5].

Commonly used indicators are:

  1. Input indicators: To measure the quantity and quality and timeliness of resources provided for a project for example funding, human resource, equipment, communication materials or organizational capacity.
    • E.g. proportion of staff sanctioned / on board or trained for the tasks assigned.
    • Proportion of funds made available and /or spent during a given year or specific period
    • Proportion of equipments bought and being used
    • Number of posters or TV/radio spots produced and put to use
  2. Output indicators: Measure the quantity : quality and timeliness of products or services created/ provided:
    • E.g. proportion of people trained out of the total or targeted.
    • Proportion of communication activities reports being received monthly
    • Number of AWW/ASHA who can give polio drops
  3. Outcome indicators: Measure short term effects of the communication activities:
    • Number or proportion of people who took their child for immunization after seeing a TV spot
    • Number of people who washed their hands after defecation following participating in an FGD
    • Proportion of teachers who can teach and integrate life skill education in the school curriculum after two exposure for training
  4. Impact indicators: Measure long term effects on people and their surroundings.
    • E.g. Reduction in vaccine preventable diseases or proportion of full vaccination coverage after 3 years.


Planning measurement of strategic communication in program:

  • Outcome mapping: Focuses on changes in behavior of people, groups or organizations with whom the program had worked. It focuses on eventual changes (e.g. number achieving desired post training competencies for PLA, or FGD) rather than number of trainings conducted.
  • Most significant change: It enables the selection of stories that capture changes in lives of stakeholders, their colleagues and the character of their participation in collective action Proportion of ANMs counseled pregnant women regularly (in all contacts for afternoon nap to improve the quality of ANC) following skill development training
  • Strategic communication capacity indicators: These indicators measure the capacity of the supervisory staff to conduct social mobilization and communication based on behavioral objectives.
  • Social change indicators: Theses assess the capacity of local health care providers (ASHA, AWW) to deliver education and mobilization services for ANC, HIV/AIDS testing or institutional delivery.
  • Stigma and discrimination indicators: These indicators measure denial of health services such as examination, treatment or conducting a delivery for an HIV/AIDs, [24] leprosy or TB patient. They may also measure the number of children sent out of school after knowing either they or their parent suffering from HV/AIDs or leprosy. Even family discrimination of isolation or even rejection may be measured.
  • Community capacity domains: Proportion of population knowing immunization day, site, number of times to return etc may be measured using this indicator. Community support in organizing immunization session, or ensuring injection safety or cold chain can also be measured.
  • Social change communication and mobilization: The number of Panchayat / Mahila mandals/youth clubs members participating in immunization session, or mobilizing resistant families are some examples.
  • Monitoring and Evaluation Advocacy . Indicators for advocacy are difficult to develop. Indicators on policy changes, strengthening civil societies, people centered policy making and tracking results at individual level, the organization and the wider community by Village/Taluka/District development committees are some examples for this.


 
   References Top

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