COMBI - a toolkit for social communication in fighting NCDs

COMBI: A TOOLKIT FOR SOCIAL
COMMUNICATION IN FIGHTING NCDs
DR AZIZAHAB MANAN
Public Health Physician
Senior PrincipalAssistant Director Of Health
(Non Communicable Disease Control)
Penang State Health Department
8th National Public Health Conference, 2- 4th August 2016 , Hotel Equatorial,Melaka

COMBI TRAINING IN PENANG, 23rd Sept– 2nd Oct 2015
Facilitator: Dr Everold Hosein (Ph.D), WHO Consultant

Outline
 Trend Of NCDs & its Challenges
 What is COMBI
 Why DoWe Need COMBI
 Is COMBI a Good investment ?
8th National Public Health Conference

Introduction
 Non Communicable diseases account for a growing number of health burdens
on families, communities and governments in Malaysia.
 NHMS(up to 2015) reported increasing in NCDs trend over the years
11.6
15.2
17.5
7.0
7.2
8.3
4.5
8.0
9.2
4.2
4.9 4.7
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
20.0
NHMS III (2006) NHMS 2011 NHMS 2015
Prevalence(%)
Prevalence of Diabetes, ≥18 years
(2006, 2011, 2015)
Total diabetes Known Undiagnosed IFG

Prevalence of obesity and overweight, ≥18 years
4.5
14
15.1
17.7
16.6
29.1 29.4 30
0
5
10
15
20
25
30
35
1996 2006 2011 2015
Prevalence(%)
obesity overweight

 NCDs burden responsible for up to 60% of all deaths,
80% are in low- and middle-income countries
 4 major noncommunicable diseases:
 Cardiovascular disease
 Cancer
 Chronic Respiratory disease
 Diabetes
 5 shared preventable risk factors:
 Tobacco use
 Obesity
 Unhealthy diet
 Physical inactivity
 Harmful use of alcohol
Chronic
Respiratory
Diseases
Cardiovascular
Disease
Diabetes Cancer
Harmful use
of alcohol
Obesity
Unhealthy
diets
Smoking
Physical
inactivity
Other NCDs
NCDs Burden

Prevention and Control of NCDs
 Many different approaches have been useful in the past, ranging from health
education to development support communication for social mobilization
 Numerous health campaigns over the years ( eg: healthy lifestyles campaign
including anti smoking, 10 thousand steps etc)
 While there have been some successes, there also been enormous frustration at
not being able to achieve more at a faster rate
 As a consequences, public health programmes struggle along -with minimal
behavioural impact

Life and ‘style’ of millions is pushed like
powerful flood waters
Our response is like a broken canoe with 3 people trying
to stop the Tsunami – the risk behaviours
Sporadic small initiatives

Challenges in Reducing NCDs burden
Are we in the right tract?
 NCD prevention and control depends on people carrying out very specific behaviours:
 putting less salt in the food one eats,
 exercising at least three times per week,
 eating a balanced diet, eating less,
 checking one’s blood pressure, checking one’s diabetes status, not smoking, and the list goes on.
 If we fail to get people adopting and carrying out these behaviours, we will fail to make a difference to
NCD.
 We cannot get people adopting and carrying out these behaviours unless we intimately and purposefully
engage them in considering the merits of recommended behaviours.
 Someone has to Do something; it is not enough to be aware, or motivated, or persuaded. Knowing what
to do and actually doing it are quite different things.
 We need to now not only focus on giving awareness and knowledge , need to do more!

 Was adopted byWHO since 2000,
 Has its roots in private sector consumer communication and Integrated Marketing Communication
 COMBI emphasises on :
 Sharp focus on achieving specific behavioural outcomes and not only informing and educating the
public. Go beyond increasing awareness and knowledge
 Offers a 10-Step process
 Begins with community-based behavioural research or known as situational market analysis for
communication keys (SMA-CK) and then applies a synchronised, integrated blend of
communication actions to the task of engaging people about the merits of recommended
behaviours.
 Social mobilization with a behavioural bite:
 Mobilization directed at the task of mobilizing all societal and personal influences with the aim
of prompting individual and family action with respect to specific healthy behaviours.
What is Communication
for Behavioural Impact- COMBI?

COMBI
COM= Communication, B –Behavioural, I=Impact
(Not Behavioural Change –but Behavioural Maintenance as ultimate result)
COMBI QUERY
HOW COME PEOPLE KNOW BUT DON’T ACT?
HOW COME WE BUILD SERVICES BUT
PEOPLE DON’T COME?
THE REALISATION:
KNOWING WHAT TO DO IS DIFFERENT FROM DOING IT (yet we persist with communication
for awareness and education.)
WAYS OF BRIDGING THIS KNOWELDGE/ACTION GAP

10 STEPS : COMBI
10 step process for developing an integrated and synchronized communication
plan aiming to achieve significant behavior impact
Implementation, Monitoring And Evaluation, Budgeting
Step 6: Management
And Implementation
Of COMBI
Step 7: Monitoring
Implementation
Step 8: Assessment Of
Behavioural Impact
Step 9:
Implementation Plan
Schedule
Step 10 :The Budget
The Communication Strategy and COMBI Plan of Action
Step 4:The Overall Strategy For
AchievingThe Stated Behavioural
Result (Restate the SBO)
Step 5:The COMBI INTEGRATED PLAN
IdentifyingThe Behavioural Objectives ( Critical Steps )
Step 1:The Overall Goal
Step 2:The Behavioural
Objectives
Step 3: Conduct Situational
Market Analysis for
CK(SMACK)

3 IMPORTANT PRINCIPLES IN COMBI
(Three life episodes and lessons learned by the COMBI founder )
3 COMBI
foundational
principles
CONNECT
MINDFUL OF
THE
COMPETITOR
LISTEN

Connect
Connect to the
individual’s need, want,
or desire and not focus
just on the technical
merits of recommended
behaviours
Our recommended behaviours
may be technically fantastic but
unless individuals see these
behaviours as connected to
what is of value to them, they
will remain understood but not
adopted.

The public is thinking:
What's in it for me?
One of the most
important aspects
of marketing is to
give your customers
a reason to buy your
products / services

 Deep understanding of why the competitor is preferable
 More sensitive engagement with people as we offer the value of recommended behaviours
 What are your products and services?
 What are their benefits?
 How do they differ from competitors’ product and services ?
Mindful of the Competitor
Who are the Competitor??
The alternative behaviour or non-behaviour
(no action)
more appeal to the individual than what we
are recommending!

LISTEN :
Listening to individuals, families
and the community
Tells us whether our behavioural
recommendations are realistic
and appropriate.
It is in listening to people
that we Learn !
-how they wish to be engaged
-how to connect the action to
their life
-how to offer in a more realistic
way what at first seems
unrealistic
Listen

Do nothing…. make no posters/phamplets , no t-shirts, no
videos, etc… do nothing,
until one has set out sharp, specific, precise behavioural
goals or objectives
Prevents the rush into the production of “IEC” (information-education-communication) materials such
as T-shirts and posters and pamphlets, without first thinking through the relevance of these materials
to the behavioural outcome desired.
These materials may or may not be needed; but this decision turns on how these items serve the
behavioural objective(s). And that calls for a clear statement of expected behavioural results at the
very start.
To make it precise and sharp , apply:
• The 4 + 1 Ws
Who will do What, Where, When,
….and, by the way, Why?
• SMART
S = Specific
M= Measurable
A= Appropriate
R= Realistic
T= Time-bound
Planning Principle 1: COMBI Mantra #1:

Penang COMBI KOSPEN:
Step 1: Overall Goal
To decrease morbidity and mortality due to chronic non-
communicable diseases (primarily cardiovascular
diseases, hypertension, diabetes), linked to obesity, poor
nutrition, and inadequate physical activity in Penang

STEP 2: STATE TENTATIVE SPECIFIC BEHAVIOURAL OBJECTIVE(SBOS)
The entire COMBI Plan turns on
this specification of expected
behavioural outcomes
It would be best to limit our
focus and restrict oneself to
one fundamental behavioural
objective at a time.
At most, no more than three
related behavioural goals .
The more precise and specific the
behavioural objective, the better
the impact
In tackling too many desired behavioural outcomes, we may very well end up, like butterflies, flitting
from one flower to the next, but not accomplishing very much by the end of a year . We would
have worked hard and have been well intentioned but in attempting to do too much, we achieve little.
Research over the years have shown that people have enormous difficulty in recalling more than
three themes or messages from a communication presentation

Do nothing….
make no posters, no t-shirts, no videos, etc…do
nothing …until one has carried out a Situational
“market” analysis (SMA) in relation to preliminary
behavioural goals/objectives.
Why the Situational Market Analysis (SMA)?
To discover the Communication Keys (CK) which would enable
engaged communication with the “consumer” to facilitate consideration
of the suggested behaviour.
SMA = LISTEN TO THE CUSTOMER
Planning Principle 2: COMBI Mantra #2:

The Situational “Market” Analysis for
Communication Keys (SMACK)
SMACK is essential to understand the desired behaviour from the
perspectives of the “consumer”.
SMACK will prompt one to examine those reasons why people do or
do not accept a recommended health behaviour
Critical step in acquiring an understanding of the desired behavioural
result from the perspective of the “consumer

First, we Hear about the new behavior
then, we become Informed about it
and later Convinced that it is worthwhile.
__________________________________________________________________________________________________________
In time, we make the Decision to do something about our conviction
and later we take A ction on the new behavior
We await next Re-confirmation that our action was a good one
and if all is well, we M aintain the behavior
HIC-DARM Analysis: GETTING THE BEHAVIORAL RESULT
TO ASSESS THE CURRENT SITUATION : knowledge levels, attitudes, current behaviours, behavioural trends.
HOW COME PEOPLE KNOW BUT DON’T ACT?
HOW COME WE BUILD SERVICES BUT PEOPLE DON’T COME?
KNOWING
DOING

 Anthropological-type Research
 DILO (Day in the Life Of) Analysis
 MILO (Moment in the Life Of) Analysis
 TOMA (Top of the Mind) Analysis
 Armchair—sit and think
 Research by walking around, then sit and think
 In-depth interviews
 Focus Group Research: Homogeneous, small groups,
 questionnaire guide, open-ended questions.Usually one issue – in private sector: shape of bottle;
screw top. Bias in interviewers if health staff. Note non-verbal cues. Caution with focus groups
 Force Field Analysis ,SWOT Analysis:Strengths,Weaknesses,Opportunities,Threats
 Primary sources (Survey/ Quantitative/Qualitative Research)
 Secondary sources/Secondary Analysis
SMA involves listening to people and learning about their perceptions on
recommended behaviour(s) through tools such as :
Tools for the Situational Marketing Analysis-
Market research

DILO (Day in the Life Of)
Learn the behaviour of the day. To examine the daily activities of those we wish to engage
to identify the communication contact points
MILO (Moment in the Life Of)
Is the behaviour feasible, realistic, trial .To examine the difficulties/steps involved in
carrying out the recommended behaviour
TOMA (Top of the Mind Analysis)
What is the first thing they think / top of their mind that relate to the behavior.
To explore people’s perception and immediate association with the behaviour
Tools for the Situational Marketing Analysis

PRODUCT
C1 : Consumer’s
Need/Want/Desire
We do not sell a
service/behaviour
We offer a solution to
your Need/Want/Desire
We do not create
Needs/Wants/Desires;
We respond to what is
there; if latent, we bring
to the top-of-the mind.
Explore TOMA
PRICE
C 2 : Cost
in relation to benefit @
value and in relation to
the Competitors
Not just price; but time,
effort, etc.
–Reducing cost by
incentives affects
cost/value ratio
–Increasing value by
branding affects
cost/value
Explore MILO
PLACEMENT
C 3 : Convenience
to get product or service
or to carry out behaviour.
what alternative
behaviours serve as
competitors to the
recommended behaviour
Explore The DILO
PROMOTION
C4: Communication
Integrated, Engaged
Communication Using the
Five-Point Star Blend of
Communication
Interventions
Integrated Marketing Communication
The 4 C’s – Consumer Need analysis to get the DARM

 HICDARM confronts a major challenge in behaviour adoption: How come we
know what to do but we don’t do?
 The Four Cs offer some answers to that query:
 We fail to connect to the first C, the Consumer’s Need/Want/Desire
 We fail, with the second C, Cost, to engage the consumer in a fresh review of the
Costs vs. value calculation
 We fail, with the third C, Convenience, to show how feasible it is to carry out the
behaviour.
 We fail, with the fourth C, Communication, to engage via an integrated, synchronised,
blend of communication actions with regard to the first three Cs.
HICDARM AND THE FOUR Cs
“We have a great product/service/behaviour in response to your
need/want/desire (C1) at a wonderful cost/value ratio (C2) and easily
available (C3).”

Head
Knowing
HIC
Heart
Doing
DARM
Behaviour
Change
HICDARM – NEEDS & GOALS
Hear
Informed
Convinced
Decision
Action
Re-confirmation
Maintenance

6%
9%
12%
13%
20%
16%
24%
Hear Informed Convinced Decision Action Re-confirm Maintain
Have heard but now
needs to be informed
Now needs to be
convinced
-that is worthwhile
Need to be triggered/
encouraged to Decide
to do something
about the behaviour
Need to be
prompted to Act
Have acted and now
need to have action
Re-confirmed
Need to be encouraged
to maintain the
behaviour
Psychographic market segmentation:
NOSA analysis: target groups, priority market segments.
Have yet to hear about the
behavior eg: 10000 steps

SMACKing – Situational Market Analysis for
Communication Keys(CK)

To have within a period of 12 months from the start of this COMBI
programme, 25% of individuals age 18 and older (approximately 330,000 of
1.3 million in this age group) who are not now engaged in “High Physical
Activity” (HPA) to carry out Brisk Meditative Walking” (BMW) every other
day for one session of 30 minutes (BMW 30) which is about 3000 steps
or an accumulated 30 minutes (meaning two 15-minute sessions
(approximately 1500 steps per session) or three 10- minute sessions,
approximately 1000 steps per session) for three separate periods of 21
days within the first year of this COMBI Plan, OR carrying out some
other kind of equivalent Vigorous Physical Activity of their choosing in
the same time period,
Step 4: Restate Specific Behavioural
Objective (SBOs)

Example : SBO
 To have 50% (800,000 women) of all women giving birth
inVietnam during the 12 month period of December
2010 and November 2011 (projected to be 1.6 million
women giving birth) “exclusively breast feed” their baby
for a period of six months from within one hour of
birth to the end of the first six months, meaning that they
feed the baby nothing else but breast milk, not even water,
no other liquids, no infant formula, and no other food but
breast milk.This behaviour, for the moment, will be
referred to as EB6 Behaviour. It will be later re-branded.


Behavioural Theme
Branding
 ✔ BMW 30
 Brisk Meditative Walking
 Just 30 minutes.
 All at once. Or 3 x 10-minutes, Or 2 x 15 minutes
 Every other day – 21 days – Just 5 weeks
 And then add two more 21 day sessions
 Be Healthy, Look Good, Feel Good

Branding
 ✔ BMW 30
 Rebranding: Cabaran AKTIF21 hari
 Hanya 30 minit
 Sekali gus atau 3 x 10-minit, atau 2 x 15 minit
 Minima selang sehari selama – 21 hari – hanya 5 minggu
 Ulangi sekurang kurangnya 2 lagi pusingan selama 21 hari
 Cergas tubuh dan minda , lebih tenaga untuk segalanya….

1. Public Relation/Advocacy/Administrative Mobilization:
Highlighting the particular behaviour on the public and administrative/programme
management agenda via various key channels such as mass media, news coverage, official
memoranda, community leaders agenda, capacity building etc…
2. Community Mobilization:
group meeting, partnership, traditional media, road shows, leaflets, posters, home visits,
community research etc
3. Sustained appropriate advertising:
M-RIP-Massive, Repetitive, Intense, Persistent via mass media, engaging with people. Six Hits:
To truly engage the consumer, strive for “six hits” per day for five days per week for three
weeks. Six flights per year (minimum 3 x /year) – Key media channel
4. Personal Selling/Interpersonal communication/Counselling:
At community level at service points, door to door. Use SHAPE to communicate
( sincere/sensitive, humorous/ honest , attentive/articulate, proficient, empathetic, enthusiatic)
and other personal counselling principles.
5. Point of service promotion : Accessible and readily available solutions to health problems
Step5: The COMBI INTEGRATED PLAN
(Using the Communication Keys – arising from the smacking activity and outline the communication
strategy

COMBI’s Five Integrated Communication Actions
A COMMUNICATION MODEL: MS.CREFS
M ESSAGE
S. OURCE
C HANNEL
R ECEIVER
E FFECT
FEEDBACK
SETTING
what media/channels are most popular and most influential;
what traditional media are used;
who would be credible sources of information;
what media would provide useful triggers and prompts to action;
how does information and influence flow in communities and families;
are there local marketing, advertising, public relations agencies, etc. Relating to MS.CREFS

 Syncronised, Strategic, Integrated—everything
with a behavioural hook.
 M-RIP: Massive, Repetitive, Intense, Persistent
 Six Hits: To truly engage the consumer, strive
for “six hits” per day for five days per week for
three weeks.
 Six flights per year : minimum 3 x /year
 Not Cheap
COMBI’s Five Integrated
Communication Actions

Where is COMBI being Applied ( Ref: WHO,2004)
Health
Programme
Countries Where COMBI
Planning and Implementation are taking Place
Dengue Belize (planning), Brazil (planning), Cambodia (pre-implementation), Costa Rica (pre-implementation),
Cuba (planning), Dominican Republic (pre-implementation), El Salvador (planning), Guatemala (implementing),
Honduras (planning), Indonesia (pre-implementation), Lao People’s Democratic Republic (implementing), Malaysia
(implemented 2001), Myanmar (pre-implementation), Nicaragua (implementing), Panama (planning), Philippines
(planning),Thailand (planning)
HIV/AIDS Moldova (planning), Sudan (planning), Ukraine (planning)
Leprosy India (implemented 2002), Mozambique (implementing)
Lymphatic
Filariasis
India (implemented 2002,2003), Kenya (implemented 2002, 2003) Myanmar (planning), Nepal(implemented 2003),
Philippines (implemented 2003), Sri Lanka (implemented 2002, 2003), Tanzania (planning), Uganda (planning),
Zanzibar (implemented 2001, 2002, 2003)
Malaria Afghanistan (pre-implementation), Ghana (pre-planning), Sudan (pre-implementation), Uganda (planning)
TB Bangladesh (planning), India (implementation), Kenya (implementation)

How can one tell if COMBI works?
 COMBI’s impact is defined by the behavioural results specified from the very outset. Once these
have been established, the social science research methods of tracking surveys, sample surveys, field
observation and in-depth interviewing allow for measuring the achievement of specific behavioural
results
 The essential pre-requisite, however, for measuring impact is having clear behavioural outcomes as
programme goals
 In Johor Bahru, Malaysia, a three-month COMBI Programme resulted in 85% of
households in sampled areas carrying out the desired behavioural task over a 12-week
period.Three months later, 70% were still maintaining the checks
 COMBI has also supported over 40 million people to participate in Mass Drug Administrations,
motivating over 75% of entire populations to prevent lymphatic filariasis in 6 COMBI-supported
countries. Sri Lanka and Kenya both attained over 80% of the total populations, meaning that over
90% of those eligible for treatment had complied
 In the state of Bihar, India, COMBI contributed to early case detection of leprosy through improving
the number of people selfreporting at clinics.The proportion of skin cases attending clinics rose by
69% with the number of female skin cases rising by 73%

Leprosy: skin cases attending clinics increased by 69%
Skin cases (women) attending clinics increased by 73%
Leprosy control, Bihar State, India
 Over 6,000,000 people targeted
 Key behaviours:“Check your skin for early signs of
leprosy” and “Seek early diagnosis”
Campaign was M-RIP:
 200,000 posters, 84 radio spots, 41
newspaper advertisements (in concentrated
flights)
 68 vehicles used for community mobilisation over
3 days
 400,000 school children took home worksheets
 3,000 banners and dangler flags at service centres,
22,000 badges worn by staff

Moldova COMBI : To promote positive mother and child health @
antenatal/Child care behaviours as part of a United Nations Children's
Fund (UNICEF)/Ministry of Health and Social Protection campaign
69%
32%
62%
59%
81%
76%
88%
91%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Seeing a doctor in the first
12 weeks of pregnancy
Taking folic acid in the first
12 weeks of pregnancy
Taking iron tablets for at
least 2 months during
pregnancy
Knowledge of danger signs
Before
After

Is COMBI a good investment?
COMBI’s investment value
lies in the following:
• Social mobilization will be
strategically targeted
• Existing resources will be
better utilized
• The true constraints and
problems affecting
behavioural outcomes will
be in greater understanding
• Encouraging public-private
sectors partnerships
• Give more value for money ,
should be able to sustained
if done in a proper way …..

Conclusion
 COMBI incorporates the many lessons of the past 50 years of health education
and communication in behaviourally-focused, people–centered strategy
 Its methodology effectively integrates health education, community
mobilization, consumer communication techniques and market research,All
directed sharply and smartly to specific, precise behavioural outcomes in
health
 It can be used as an effective communication tools to reduce NCDs and its
risk factors
 So remember …….
Connect, listen, be mindful of the competitor and DO NOTHING

ACKNOWLEDGEMENT & References
Dr. Everold N. Hosein (Ph.D), Senior Communication Advisor-Consultant, World
Health Organization (WHO) and Communication Consultant to UNICEF, UNFPA,
and UNDP
Mobilizing For Action – COMBI , WHO Mediterranean Centre for Vulnerability
Reduction(WMC), Tunis
National Health Morbidity Survey 2015 report , Institute for Public Health (IKU)
Training on Strategic Health Communication Planning: Applying WHO’s
Communication for Behavioural Impact(COMBI) Planning Methodology for
Behavioural Results in Health ( Focus on NCD), Penang 28th Sept – 2nd October
2015
COMBI – Sharing Countries initiative (internet link)
For more information on how COMBI may be applied to behavioural goals in promoting healthy
behaviours, please contact email: socmob@who.int

COMBI - a toolkit for social communication in fighting NCDs

Recommandé

Recommandé

Contenu connexe

Tendances

Tendances (20)

En vedette

En vedette (20)

Similaire à COMBI - a toolkit for social communication in fighting NCDs

Similaire à COMBI - a toolkit for social communication in fighting NCDs (20)

Plus de PPPKAM

Plus de PPPKAM (8)

Dernier

Dernier (20)

COMBI - a toolkit for social communication in fighting NCDs