Healthcom II (communication for child survival) : final evaluation, project number 936-5984

The contractor achieved and in some cases surpassed all contract objectives (some of which were reduced due to lack of funding) and, overall, received high praise for its efforts. Short-term TA activities were conducted in over 20 countries (none required) in addition to long-term work in 9 countries (as required). An important 5-step communication methodology -- Assess, Plan, Pretest, Deliver, and Monitor-- was developed and used in 13 different child survival and health areas. Applied research included 10 evaluations of Healthcom I, several intercountry comparisons of particular behavioral issues, and research on applying, adapting, and institutionalizing communication methods and on promoting the sustainability of behavior changes. In terms of dissemination, the project completed more than 15 issue reports; published 20 major scientific articles; held 10 seminars, 43 country-level workshops, and 6 training sessions; and published several manuals and books, including "Notes from the Field: Communication for Child Survival"; "Communication for Health and Behavioral Change: A Developing Country Perspective", "A Tool Box for Building Health Communication Capacity", "A Learner's Kit for Focus Group Research", and "A Behavioral Video and Guide". Key shortfalls were in the areas of institutionalization and evaluation. The issue of institutionalization, for example, was never clearly and summarily assessed, nor was there any analysis of why Healthcom interventions had an impact in some countries and not in others. Further, the evaluations of Healthcom programs seemed selective, with undue emphasis on positive findings. Also, most evaluations and reports failed to document the number of people reached by Healthcom interventions. Finally, while cost-effectiveness analysis was included in the contract, little was done in this area -- a major gap in the evaluation process. Despite these problems, health communication for behavior change is now accepted as a critical component of any public health intervention, including (an unexpected project spin-off) AIDS control programs. This is the legacy of almost 20 years of USAID effort in this area, an effort of which Healthcom II was a part. Lessons were learned in several areas. (1) Health workers perform better when they feel appreciated by the community; are given culturally appropriate, interactive, and pretested tools, with target audiences; and helped in overcoming their reluctance to engage mothers in two-way communication. (2) As programs become more decentralized (as in Senegal), it is essential to improve management ability as well as the skills of local workers. (3) The SOMAVITA project in Indonesia showed the importance of using channels such as village administrators and Fatayat volunteers in reaching otherwise "hard-to-reach" groups. (4) Preventive behaviors, since they lack immediate results, are more difficult to affect than treatment behaviors. Interpersonal communication, especially the use of community volunteers, is recommended. (5) A mix of communication strategies (mass media, direct mail, and face-to-face interaction) is needed to contact all segments of society. However, while face-to-face interventions are often more effective than mass media such as radio, their overall impact is less because they reach fewer people. It is also important that communication programs address health workers and not just mothers; program effectiveness can be severely limited if health workers give out messages contrary to those of the program. Applied research findings with particular relevance to future programs include the following. (1) Health communications increase immunization coverage, oral rehydration therapy (ORT) use, the percentage of women breastfeeding within 6 hours after birth, and Vitamin A capsule distribution. (2) Health communication is more effective when combined with changes in health worker activities. (3) Health communication can increase not only the demand for services, but also the timely use of services (e.g., immunizations). (4) Interventions such as promoting immunizations are easier to affect with health communication techniques than interventions requiring more difficult tasks, such as home mixing of oral rehydration solutions. (5) In order to sustain behavior change, some level of communication must be sustained.