Challenges to changing health behaviours in developing countries: A critical overview

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Abstract

This overview of recent research on health behaviour change in developing countries shows progress as well as pitfalls. In order to provide guidance to health and social scientists seeking to change common practices that contribute to illness and death, there needs to be a common approach to developing interventions and evaluating their outcomes. Strategies forming the basis of interventions and programs to change behaviour need to focus on three sources: theories of behaviour change, evidence for the success and failure of past attempts, and an in-depth understanding of one’s audience. Common pitfalls are a lack of attention to the wisdom of theories that address strategies of change at the individual, interpersonal, and community levels. Instead, programs are often developed solely from a logic model, formative qualitative research, or a case-control study of determinants. These are relevant, but limited in scope. Also limited is the focus solely on one’s specific behaviour; regardless of whether the practice concerns feeding children or seeking skilled birth attendants or using a latrine, commonalities among behaviours allow generalizability. What we aim for is a set of guidelines for best practices in interventions and programs, as well as a metric to assess whether the program includes these practices. Some fields have approached closer to this goal than others. This special issue of behaviour change interventions in developing countries adds to our understanding of where we are now and what we need to do to realize more gains in the future.

Introduction

Many of the Millennium Development Goals (MDGs) require behaviour change. Whether or not behaviour is the source of poor health, malnutrition and mortality, it is now acknowledged to be a critical part of the solution. The many Lancet series on child mortality, maternal mortality, malnutrition, child development, and mental health (e.g., Black et al., 2008, Campbell and Graham, 2006, Engle et al., 2007, Jones et al., 2003) have drawn attention to the behavioural solutions to these problems and the difficulty in implementing them. Breast feeding, diet, condom use, and hygiene are some behavioural solutions that require low technology and little expense. They are now known to have a significant and long term impact on reducing disease, disability and death.

The health field looks to behavioural and social scientists to provide guidance on how to change these and other simple behaviours. Firm answers are not often found. Instead, the literature reports as many failures as successes, making it difficult to extract the important messages. Moreover, findings tend not to build on each other. More needs to be done to bring this literature together so that, irrespective of the specific behaviour and country, researchers and program developers can learn from each other and contribute to a foundation of theory and evidence. In this introduction, we discuss a number of current and past interventions in order to outline how program developers have identified strategies to change behaviour, along with their implementation and outcomes. Consensus on strategies related to safer sex practices and psychotherapy has progressed to the point where they have clear guidelines on best practices for the field and a metric for assessing a program’s use of them. Before creating guidelines for other areas, we need behaviour change evaluations of interventions built around three sources, namely theory, evidence and an in-depth understanding of the audience.

In many ways, behaviour change research in developing countries fits a similar pattern regardless of the specific health problem. Typically, multidisciplinary teams of biomedical and social scientists collaborate with local organizations to implement and evaluate small- or large-scale programs. Second, they address behaviours to be performed at the individual or household level, that are currently at a low level and so not normative, such as safe water, latrine use, hand-washing, safe delivery, newborn care, child responsive feeding, HIV prevention, health care seeking, and providing social support. Third, the behaviour change activities often include components of behaviour change communication, or social marketing, aimed at informing, mobilizing, and selling a practice or product. Fourth, they usually target an audience whose behaviour is guided by more than cognitions – perhaps by habit, resources or social forces. Finally, and unfortunately, they encounter common problems that often lead to little change. It should be recognized that the behaviours may be difficult to change because they are habitual, normative and preventive. Habitual behaviours are difficult to change because they are performed automatically without much thought; normative behaviours bear the weight of tradition and approval; and preventive behaviours often lack a salient immediate outcome.

Section snippets

How much change can we expect?

This raises the question of how much change we can expect from interventions in the short term and the longer term. Naively, we often think it sufficient to advise people to dig and use a latrine in order to save their lives and those of their children. But if one has stayed alive for 30 years without a latrine, one may doubt the credibility and urgency of the message. Others with a broader view of the community, a strong motivation to keep one’s family healthy, and an abstract understanding of

Limitations to identifying change strategies

Programs rarely rely on a combination of theory, evidence and insights about their audience to identify what and how to change behaviour. Programs are generally planned using a logical or empirical frame. Using the logical strategy, one builds a program by connecting desired outcomes to current resources within a logic model. According to the Logic Model used for program planning (e.g., Innovation Network Inc., 2007) and adopted by donors, one considers the problem in relation to the desired

An overview of behaviour change interventions

An overview of articles on health behaviour change highlights how researchers have selected change strategies based on theories, evidence, and an in-depth knowledge of their audience. We focus here on topics covered by the eleven articles in this Special Issue, namely hand-washing, use of safe water, diet, and safer sex. We placed them in the context of other interventions addressing similar problems. The empirical articles in this Special Issue are located in countries such as Bangladesh,

Conclusion

Interventions to change health behaviours related to the Millennium Development Goals provide accumulating evidence about effective solutions. Considering the successes and failures of these interventions may help to create a better blueprint for how to identify change strategies. Several approaches were noted, including a logic model, formative qualitative research, and case-control designs. However, the examples of HIV prevention and psychotherapy demonstrate how two groups of researchers

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