FORMATIVE RESEARCH

BARRIER ANALYSIS AND SITUATION ANALYSIS VITAMIN A SUPPLEMENTATION

Lotta Adelstal (consultant) Helen Keller International Tanzania, 2011

TABLE OF CONTENTS 1. BACKGROUND AND RATIONALE FOR THE STUDY .................................................................... 2 2. TANZANIAN MUSLIM POPULATION........................................................................................ 3 3. PROBLEM AND BEHAVIORAL STATEMENT .............................................................................. 3 4. PURPOSE AND OBJECTIVES OF THE STUDY ............................................................................. 3 5. AUDIENCE ............................................................................................................................. 4 6. PROCESS OWNER AND CONTRIBUTORS.................................................................................. 4 7. THEORETICAL FRAMEWORK AND METHODOLOGICAL APPROACH........................................... 5 8. ETHICAL CONSIDERATIONS .................................................................................................... 9 9. LIMITATIONS OF THE STUDY .................................................................................................. 9 10. TIMELINE AND DELIVERABLES ............................................................................................ 10 ANNEX 1: TOOLS FOR MARKET SITUATION ANALYSIS .................................................................. 11

1. Background and rationale for the study

Efforts to fight vitamin A deficiency (VAD) started in 1987 using a disease-oriented approach for Vitamin A Supplementation (VAS). Under this strategy, VAS was targeted to high-risk children with measles, protein energy malnutrition, lower respiratory tract infection, xerophthalmia and diarrhea. This approach failed to reach a high proportion of VAD children who did not have the high-risk condition. Thus, beginning in 1997, VAS was integrated into the Expanded Program on Immunization (EPI) which targeted all children less than 2 years of age, as well as postpartum women. The program was further modified in pilot areas from 1999-2000 when VAS distribution was added to the subnational measles vaccine campaign that targeted all children between 6-59 months of age in selected mainland districts. Data from these pilot districts showed VAS coverage to reach 94 percent in 1999 and 99 percent in 2000.1 The high coverage achieved through using the measles campaign to distribute VAS led to the start of the national bi-annual VAS distribution rounds in 2001. The twice-yearly practice of VAS has attributed in part to the reduction in the under-five mortality rate (U5MR) from 137 to 81 per 1000 between 1996 and 20102. According to official estimates based on tally sheet administrative data, VAS coverage in Tanzania has remained 90 percent. However, the accuracy of VAS coverage estimates from administrative data are likely compromised both in the numerator (total number of children dosed) and the denominator (total number of targeted children). The numerator is collected from thousands of health posts and summarized at the district, regional and national levels involving many people and at most levels are hand calculations. The total number of children targeted is based on population projections from the last census in 2002 and is generally considered an underestimation of the true population. Consequently, many districts report coverage rates over 100 percent. Recent findings from a post event coverage survey (PEC) on mainland Tanzania indicate that coverage rates are closer to 65 percent. This means there are still roughly 2.5 million children in Tanzania who are not receiving VAS and can be considered hard to reach. Within this hard to reach population, the survey indicates that half of children not reached are missed because their caretakers did not know about the campaign.3 The survey further more narrates that a non-Muslim child is 3 to 4 times more likely to be supplemented than a Muslim child. Not knowing about the campaign was the reason for 68 percent of Muslims. Another interesting finding was about care-takers source of information. For example, only 1 percent of the Muslims who did take their children for VAS, learnt about the event from religious leaders whereas 10 percent of non-Catholic Christians and 17 percent of Roman Catholic Christians mentioned religious leaders as their source of information. Muslims mainly found out
1 2

EPI report 2001 MOHSW Tanzania. Tanzania Demographic and Health Survey report 2010. 3 TFNC / HKI Post Event Coverage report 2010.

about the campaign from roaming vehicles with loudspeakers (35 percent) whereas Christians mainly found out through their community leaders (36 percent). Lower coverage rates in urban areas, including Dar es Salaam, have been consistent for many rounds. Another significant difference found was that a child living in a household with an income mainly coming from the informal sector was 70 percent less likely to be supplemented than a child living in farming household4.

2. Tanzanian Muslim population

The lack of religious data in government census reports implies that there is no information on the size or geographical location of the Muslim community in Tanzania.5 Some estimate that the Muslim and Christian communities are more or less equal in size, each accounting for 30 to 40 percent of the population, whereas others estimate that Muslims account for 35 percent and Christians 60 percent. The remainder consists of practitioners of other faiths, indigenous religions, and people of no religion. Most Tanzanian Muslims are Sunni (80-90 percent), though there are also Ibadi, Shia, Ahamadiya, Bohora, and Sufi Muslims. Muslim majorities are found in the coastal area of Dar es Salaam, the regions Tanga, Mtwara and Lindi and in some pockets in mainland areas.6

3. Problem and behavioral statement

Problem statement: The VAS campaign only reached 65 percent of targeted children which implies that 2.5 million Tanzanian children are excluded. According to the PEC survey, half of these children are not provided with VAS due to caretakers lack of awareness and knowledge of the service. Muslim children face a higher risk of not receiving supplement than non-Muslim children. The barriers and motivators to participate in VAS among the Muslim community need to be explored and findings used to shape the behavioral change strategy for the twice-annual VAS events. Behavioral statement (goal): All caretakers with child(ren) between 6-59 months take their children to the local health facility or mobile service posts, receive and in the presence of the service provider consume vitamin A supplementation during the VAS campaigns in June and December.

4. Purpose and objectives of the study

The purpose of the study is to contribute to increased coverage of the twice-yearly vitamin A supplement campaigns, especially among the Muslim population. The formative research will inform the behavioral change communication strategy targeting caretakers, the primary target audience, and possible other target audience(s). It will help formulate sharp messages and select effective communication channels for both interpersonal- as well as mass communication.

4 5 6

TFNC / HKI Post Event Coverage report 2010. Religious surveys were eliminated from government census reports after 1967. Bureau of Democracy, Human Rights and Labor, International Religious Freedom Report, 2006 and 2010.

The main objectives are to Determine the factors that hinder the Muslim community to bring their children between 6 to 59 months to the twice-yearly vitamin A supplement event (the barriers). Determine the factors that prompt the Muslim community to bring their children between 6 to 59 months to the twice-yearly vitamin A supplement event (the motivators). Generate in-depth understanding and knowledge about the care-takers (primary audience) of the vitamin A campaign and other important and influential groups (secondary audiences), including the Muslim community and its leadership. Other objectives are to Collect and analyze data on the feelings, thoughts, beliefs and perceptions that may affect vitamin A supplementation of children aged 6 to 59 months during supplementation campaigns. Provide useful information on other factors influencing vitamin A supplementation for children 6 to 59 months during the campaigns of vitamin A.

5. Audience
Helen Keller International (HKI) together with its partner, the Tanzanian Food and Nutrition Centre (TFNC), are committed to fight vitamin A deficiency. The TFNC is the national institute responsible for nutrition, including research, policy formulation, advocacy, monitoring and evaluation, and facilitating education and training activities. The TFNC conducts the national VAS campaign while each district is in charge of its own local campaign managed by the district VAS focal point. This study is meant to contribute to HKIs and TFNCs effort to improve the quality and effectiveness of interventions at both levels.

6. Process owner and contributors

The study has been commissioned by HKI in Tanzania. A consultant is recruited to design, plan and implement the formative research. This includes developing the research protocol and tools, training of field researchers, implementing the field research, compilation and analysis of data, and writing the research report. Although the consultant has the overall responsibility, all work is done in close collaboration with the HKI VAS coordinator, Ms Temina Mkumbwa, and in consultation with HKI regional advisor. Apart from supporting the overall work and participate in the field research, the coordinator brings invaluable experience about the local context and key stakeholders. She will liaise with key stakeholders such as the TFNC and the Ministry of Health (MoH) and supervise the field research. The coordinator also has an important role to peer-review the approach, tools and analysis. The current study is also a learning opportunity for HKI staff such as the VAS coordinator and communication specialist. One could consider involving HKI colleagues from other offices in a peerreview process, including experts within the CORE Social and Behavior Change Working Group. Such 4

joint analysis would contribute both to organization-wide learning as well as improved quality in the current work. The data collection for the Barrier Analysis will be done by a team consisting of four data collectors and a supervisor (HKI VAS coordinator). The data collectors will be recruited by HKI and trained for two days in the survey methodology, the tool (questionnaire), how to write down the answers and basic communication skills, amongst others. Apart from collecting data, the data collectors will translate the interviews, and contribute to organizing and analyzing the data. Each field visit will begin with a visit at the district hospital to liaise with medical officer and the VAS coordinator. The selected districts will first be contacted by a letter, introducing the study, its purpose and value, and requesting permission to conduct the study within their district. The selection of communities will be done together with the district. A district representative, preferably the VAS coordinator, will accompany the team to act as gate-opener in the communities. A community leader will introduce the study and the data collector to each household.7

7. Theoretical framework and methodological approach

Promoting healthy behaviors takes more than knowledge and providing instructions. Evidence show that behavior change projects are far more powerful if theoretical frameworks guide formative research on the barriers and motivating factors to change, and incorporate findings from such research into project strategies, messages and activities.8 The main methodology used for this formative research is Barrier Analyses, which builts on the Health Belief Model and the Theory of Reasoned Action, the two most commonly applied behavioral change theories. The formative research will then inform the design of the behavioral change communication strategy, using the Design for Behavior Change (DBC) Framework, recently updated by the Social and Behavior Change Working Group within the CORE Group.9 The study will both review secondary data and collect primary data to gain the knowledge needed to shape effective behavior change communication targeting the Muslim population. Through triangulation, the study aspires to get as close to the whole picture as possible and gain a rich understanding of what is in the minds of the vitamin A campaign primary target audience in relation to VAS. It will include diverse sources of information and knowledge. In the first step of the field study, focus is on caretakers (primary audience) whereas the second phase will focus on caretakers and influential persons (secondary audience), for example religious leaders. The design and data collection includes both quantitative and qualitative methods. The main tool for the first field study (Barrier Analysis) is a questionnaire with closed and open-ended questions for use in individual interviews, and uses both qualitative as quantitative techniques. The second field study will be purely qualitative and apply a combination of key informant interviews and focus group discussions.
7 8

The community leader will introduce the study but not be present at the time of the interveiw to avoid response bias. CORE Group, Social and Behavior Change Working Group: Finding and Recommendation from a review of CORE Group members efforts to improve exclusive breastfeeding coverage, 2010 9 The Design for Behavioral Change Framework builds on the BEHAVE Framework developed by the Academy for Educational Development (AED).

However, the focus and the tools for this part of the study will be guided by the outcome of the earlier phase. The research is divided into three components: Pre-study: Field study 1: Field study 2: Secondary data and key informant interviews to gain a basic understanding of the Muslim population and its leadership, select the sampling sites and prepare tools. Barrier Analysis to gain an understanding of key behaviour determinants among primary target audience (care-takers). Situation analysis using qualitative methods to acquire in-depth knowledge on target audiences (care-takers and other influential people).

Pre-study The work starts with an initial fact-finding and context-learning step to gain an understanding of the Muslim community and its leadership. It will inform how to proceed with the study both in terms of site selection, sample size and how to best approach the Muslim community. Since statistics on religion are unavailable there is limited data and information available on the various religious groups. 10 The pre-study will identify and interview key informants, for example the Muslim Council BAKWATA and the Islamic Foundation in Morogoro. The questionnaire will be developed and pre-tested during the training for the data collectors. The revised questionnaire will be translated into Kiswahili. The results from the pre-testing will generate an idea of the potential responses to the questions and a draft coding guide will be developed. Field study 1 Barrier Analysis Definition: The Barrier Analysis helps understand why a promoted behavior has low coverage or is not adopted at all. It does so by (1) comparing perceptions among those that are doing the behavior (doers) and those that are not doing (non-doers) the behavior, and (2) identifying the key determinants of behavior. These determinants can both block - act as a barrier people to make decisions beneficial to their health or the health of their children or motivate to take action (positive determinants of behavior). The Barrier Analysis is a rapid assessment to identify key determinants of behaviour providing qualitative and quantitative knowledge. A series of questions help to explore and describe how the two groups, doers and non-doers, think and feel in relation to VAS (qualitative), but also provide quantitative elements, for example statistical comparison of non-doers and doers, which indicates the most important differences between the two groups. It will uncover the respondent's perceptions of the problem (e.g. child is frequently ill due to vitamin A deficiency) and the behaviour promoted (e.g. vitamin A supplementation), and reasons and thought process behind behaving in a

desirable way or non-desirable way. The key behaviour determinants identified will then be targeted in the BCC strategy.11 The determinants and questions to explore are: Determinant Perceived susceptibility Perceived severity Perceived action effectiveness Perceived social acceptability Perceived self-efficacy Cues for action Action signals and recalls Perception of the Divine will Positive or negative attributes Questions Could it (the problem) happen to me? Is this a serious problem? Does the preventive action work? Is the action is socially acceptable? Is it easy to do? Can I remember to do it? Is it Gods will that I should (not) have the problem, or that I overcome the problem? What are the advantages or disadvantages of behaviour?

1 2 3 4 5 6 7 8

Site selection: The Barrier Analysis will include two selected sites, both with a dominant Muslim population. One site will be in coastal area of Tanga. And the other will be located in an in-land district with a pocket of a large Muslim population, probably in Morogoro with high representation of the fundamentalist Muslim branch Ansarisu. The selected sites will be low performing areas, i.e. with poor VAS coverage history. Target population and sample: The Barrier Analysis will use the same target population as that of the vitamin A supplementation campaigns, care-takers of children aged 6 to 59 months, but only including Muslim care-takers. 45 doers and 45 non-doers from each of the two sites will be interviewed, with a total sample size of 180. Organisation: The starting point for the field work will be chosen randomly and the direction for collecting the data will be decided by using spinning the bottle method. Each household will be approached by the community leader who will introduce the study. The supervisor will accompany the data collector until the subject is identified as a doer or a non-doer after which the supervisor and the community leader move on to the next household for the same procedure. The next household will be the neighbour and included in the sample only if it is the other (doer or non-doer) as opposed to its neighbour. This will create a chain of doers, non-doers, doers, non-doers, making sure that the living environment gradually changes in the same way for the two groups to be compared. If the 45 doers and 45 non-doers are not found in the same community, the team will move on to the neighbouring community. Non-doers and doers will be identified with the following behavior question: Non-doer: Will respond "no" to the question: "Did (NAME) received and consume Vitamin A supplementation during the June 2011 campaign of vitamin A supplementation?

11

One of the key factors for successful behavior change strategies is to target several (approximately 4) and greater variety of key determinants, according to CORE Group, Social and Behavior Change Working Group: Finding and Recommendation from a review of CORE Group members efforts to improve exclusive breastfeeding coverage, 2010

Doer: Will respond "yes" to the question above and can also correctly identify the color of the capsule of vitamin A. If the caretaker of a child is interviewed but was not present during supplementation, the interviewer will ask the verification question to the person who took the child to the June 2011 event.

The draft coding guides based on the results from the pre-testing will be finalised and responses compiled in tally sheets. The consultant and nutrition coordinator are responsible for tabulating the survey results in the tally sheet and the special Barrier Analysis Excel sheet while still in the field. Field study 2 Situation analysis - qualitative research The Barrier Analysis will provide a thorough understanding of the key determinants for VAS among the Muslim population. To deepen our understanding of both the primary and the secondary target audiences, the formative research continues with a situation analysis. We will, among other things, explore religious and other leaders position in relation to the desired behavior. The combined findings of the two studies will help develop a sharp audience profile, which will shape the behavior change communication strategy, including the messages, and channels and activities to convey these messages. The situation analysis will most probably involve both in-depth interviews with target audiences and key informants, and focus group discussions, and include various tools. Decentralization has required each district (over 133) to find its own way for social mobilization and behavior change communication of the target audiences. Recently revised national guidelines support these events but provide limited guidance on social mobilization and behavioral change communication.12 Currently, HKI is supporting the development of a social mobilization toolkit for districts that will be developed in tandem with the current research. Mainland districts past experiences of vitamin A campaign work will be collected, and lessons from the Zanzibar will also be considered (78 percent post event coverage rate). Definitions: The Focus Groups (FG) are in-depth facilitated discussions, usually lasting one to two hours. The results of the FGs are expressed in qualitative terms. The interactive nature of FGs makes them effective at collecting personal ideas, allowing participants to hear the thoughts of others, often triggering their own memories or ideas which enriches the debate. Key informant interviews can be structured or unstructured, intended to elicit the opinions and knowledge of persons of special importance or status, or those who have access to observations difficult to access. Key informants capacity to make an analytical interpretation of an event or action may vary, and sometimes only provide a description of things without providing their thoughts on its meaning or significance.

12

Ministry of Health and Social Welfare, Implementation guidelines for vitamin A supplementation and deworming, September 2011

Tools such as force-field analysis, TOMA (top of the Mind Analysis), DILO (Day in the Life of) analysis and MILO (Moment in a Life of) analysis will also, if deemed fruitful, be applied (see Annex 2 for a description of tools). Target Population: Interviews and focus groups will most probably include caretakers, Muslim leaders, health service providers, local authorities and nutrition stakeholders.

8. Ethical considerations
The study does not present a risk to the participants. Participants will be briefed on the merits of the study and consent will be required in advance. No participant will be forced to participate if (s)he refuses. In addition, information collected from participants will be kept confidential and no names of individuals will be used in reports.

9. Limitations of the study

One of the most common biases is the interviewer bias. The interviewer may subconsciously give subtle clues with body language, or tone of voice, influencing the subject into giving answers skewed towards the interviewers own opinions, prejudices and values. Response and self-reporting bias are the type of biases where the subject consciously, or subconsciously, gives a response that they think the interviewer wants to hear or give answers that put them in a good light. Surveys like a Barrier Analysis which captures perceptions will always have to be aware of self-reporting bias. Data collectors will be trained during two days and the importance of being aware of biases will be discussed. The data collectors are accompanied by the HKI nutrition coordinator with vast experience in field research and interview techniques. Maybe the most important bias is the recall bias. The last campaign was in December 2011 and was a combination of VAS and the measles vaccination. Apart from being a much louder campaign than the twice-yearly VAS events, vaccinations are perceived as important among caretakers and, thus, certainly remembered. However, the current study relates to the VAS campaign in June 2011, thus a doer is defined as a caretaker that took his or her child(ren) between 6 and 59 months to the June 2011 supplementation. Finally, some ambiguities in data collectors translation of responses can lead to information bias.

10. Timeline and deliverables

FEB 3 4 MARCH 2 3 4
13

Activity Step1: Capture existing knowledge and establish relationships Step 2: Decide on the geographical area and sample size, and develop protocol and tools Step 3: Select and train field staff. Pre-test tool. Step 4: Formative research, phase 1 (prepare, implement and organize data) Step 5: Analyze data from phase 1 and prepare for phase 2 and pilot communication activities Step 6: Formative research, phase 2 Step 7: Analyze and draft report Step 8: Develop BCC strategy Step 9: Prepare and conduct workshop with key national stakeholders (1-2 days) Step 10: Implement BCC strategy

1
14

APRIL 2 3

MAY 2 3

JUNE 1 2

13 14

In the second week of March (12-16 March) activities related to the development of the social mobilization toolkit is taking place and the consultant occupied. Easter week.

10

ANNEX 1: TOOLS FOR MARKET SITUATION ANALYSIS

Force field analysis A force-field analysis simply refers to analyzing those forces in the field, in the environment, which prevents people from acting in appropriate ways and those forces which support them in new behaviors. An understanding of these forces enables one to shape appropriate messages to encourage new behaviors. Top of the mind analysis (TOMA) TOMA gives an idea of peoples perceptions and immediate associations with a particular issue. It works by asking what three things come to mind when someone says a particular word. For example one Top of the Mind analysis on the words vitamin A may show that there is no local term for them. A day in the life of analysis (DILO) The most difficult and most rewarding tool, DILO, puts the target audience right at the center of its analysis by looking at a day in the life of the people you are trying to reach. It lists their daily activities from the time they get up to the time they go to sleep. DILO helps to empathize, identify contact points and barriers to the behavior being adopted. For example, a DILO in one community may reveal that most children, especially those under five years, usually fall asleep outside the house (before bedtime) without any protection from mosquitos and therefore render them vulnerable to malaria. Women may not tell you this in an interview because it is a normal everyday habit. However, observing this behavior has a huge implication for communication interventions. Another example is that most women are engaged in subsistence farming and spend most of their time farming. This limits their chances of taking their bed-nets for treatment since time is constraint. DILO would therefore help identify times and places where treatment could be done or signal that alternative ways need to be explored. Moment in the life of analysis (MILO) MILO takes you into the situation of the target group at the exact point they are carrying out the behavior you want to influence. It asks what exactly they are thinking, what is motivating them to do this rather than what you want. MILO asks in what ways their choice at that point could have been influenced.

11