Behavior Change Communication and Practicing what you Preach

Saturday morning is a good time to catch up on our activities of the last two weeks. Rebecca is at a worship committee meeting and the kids are having their Saturday morning free (screen) time. A lot has happened since I wrote last, especially since I was away the week before last and Rebecca wrote about activities at home. June has a feeling of rushing. We are in the home stretch of finishing school, with exams coming up, and long reserved 'summer' vacation plans now in sight.

I say 'summer' in quotes because seasonally, Arusha in June feels a lot like early fall in the US. The weather has turned chilly. We regularly wear fleeces to work and school and have even turned on space heaters near our desks at work. Wet suits are de rigeur for our morning swim. The water temp has dropped to about 62F and will go down into the high fifties in the next few weeks. I have, in the past, compared our morning swim to a 'religious experience' or spiritual discipline as it were. But it does prepare one for any adversity for the rest of the day.

I need to back up one full week to catch up on our activities. I left Rebecca and the children for six days the past week, to go to Nairobi for a conference for MCC Health Sector workers in Africa. I left Sunday after church by bus, which only takes 5 hours (if the border is not too crowded). I arrived at Amani guest house at about 8pm.

It is very professionally satisfying to be in a gathering of colleagues from all over Africa who are doing similar kinds of projects in Africa. There were colleagues from South Africa (Lisutu), Mozambique, Zimbabwe, Kenya, Uganda, Ethiopia, NIgeria, Chad, and Burkina Faso. It was inspiring to hear about the work they are doing.

The week long workshop was focused on implementing and evaluating BCC (behavior change communication), projects into our health programs. Behavior change communication, for those who are not familiar, are strategies to get people to change, often long standing reinforced habits that are adverse to healthy living, and to adopt new practices. In the US you have certainly experienced this from everything to washing hands, wearing seat belts, not driving drunk, not smoking, using condoms, or getting vaccinated. The challenge BCC addresses is the reality that most people do not change behavior because they know better (Knowledge of risk does not usually change behavior). Strategies to change attitudes and practice need to go beyond just telling people about risk and what good behavior looks like.

Paul Fast, our facilitator made this point cleverly by pointing out that almost everyone in his country (USA) knows the importance of washing hands, but only about 3% do it correctly on a regular basis. He reinforced this point poigniantly at the end of the week by asking us to rub some 'simulated germ' lotion on our hands right before a break. The lotion is clear, but under a black light it glows. He then told us to have tea then wash our hands as we usually do. When we came back we looked at our hands and were surprised to see how badly we had done. The point was well taken as many there do teach hand washing as part of our WASH (water, sanitation, and hygiene) projects. It ran home the fact that getting people to adopt and continue to do a practice regularly takes knowledge as well as cues to action and other incentives or disincentives to reinforce it.

We had an interesting side discussion on the ethics of 'shaming' for a positive behavior change. It is not a practice in any MCC programs, but some West African colleagues talked about some govt. campaigns to end 'open defecation' involving a 'walk of shame'. This involves all the residents of a village, walking through the village and surrounding grounds together to find any open defecation, then identifying the person who likely did it and publicly 'outing'  and shaming them and making them clean it up. Is it justified if it saves lives?? While it may be effective, it was not something anyone in MCC could advocate for.

Although, even as most of us disavowed shaming as a BCC tool, I did point out that we do use it in our culture to change behavior, especially on social media. I gave the example of the #metoo campaign which used public shaming as a way to stop sexual harassment. It was interesting to debate situations where shaming might be appropriate and situations where it would not be. I think people finding out that they more tolerant of this practice in their own context then they expected was an interesting revelation.

Barrier analysis was another topic of discussion in the seminar. This is a tool or framework to analyze barriers that cause people to resist adopting a practice. It is done in an interview/focus group format to understand all the dynamics around a particular practice that one is trying to change. Often factors are quite complex-- a woman may not take her child to a clinic because of the opinion of her mother-in-law. A campaign to change behavior may need to involve the mother-in-law, and not just the mother. That is somewhat simplified, but understanding barriers is essential to changing behavior.

I was invited to share some researh in our maternal child health project that we have been doing and is almost complete. We are trying to understand why women in our Maasai community go regularly to antenatal care, then refuse to go to a health facility to deliver their babies. After extensive interviews and discussion we are beginning to get a picture, and have found that traditional birth attendants TBAs play a very significant role in deciding where she will give birth. And many have a deep mistrust of clinics because of a negative experience where someone was turned away---that may have happened only once. The lesson is, no amount of educating women about the risk of home delivery will change her practice if her TBA is against it.

The second to last day, we made a visit to a maternal and child health project that one of MCC Kenya's partners runs in Kibera slum. I had the opportunity to see this in November and it was quite unforgetable then. The program, which runs care groups (peer education) to promote antenatal care, breast feeding, and skilled delivery is highly effective. This seems amazing when one enters this place which can appear like total squalor at a glance. Filty water runs down small alleys between rusted tin shacks, like row houses, only smaller than a backyard tool shed.

We visited several women at their home to ask what they had learned. It was amazing and sobering to see them making a life in a tiny home, and here how they sanitize water, vegetables, and care for their infants. I think what is most stunning is seeing people making what is a 'normal' life there. People making repairs, selling things, doing work, going to care group meetings etc. This is not a refugee camp. The only true sign of hopelessness I saw was the number of men who were staggering around drunk at 9 in the morning. They came to the city with their wives to find work and a better life, and ended up here. It seems like it would have to be worse than the village, but people come and come and come.

We wrapped up on Friday and I returned to Arusha in the afternoon, and was picked up by Rebecca and the kids at around 9pm from the shuttle stop. I was lucky that they were out in town until then. They had gone to our church for a choir concert with a number of guest choirs celebrating Pentecost. Sadly our choir was not a part as many of us (including me) were out of town. But apparently it was quite beautiful and they all enjoyed it. It was also serenipitous that they were finished when I arrived in town.

There was no day of rest over the weekend as we had some big events scheduled for Sunday. As coordinator of Sunday School, we had planned a field trip for the Sunday School kids to visit an orphanage in town. This is connected with their offerings. We collect Sunday School offerings over the school year, then they are given away at the end to a charity we select. We arrange a field trip for the kids to visit the place we are making the donation. Samaritan Village orphanage had about 50 childen in it and seemed a good place to take our offerings. Logisitics for this is fairly elaborate including scheduling a bus, getting permission slips, buying refreshments, cutting a check for the donation, etc. I spent a good part of Saturday morning getting ready for this.

Rebecca was helping Oren at the same time getting ready for a bake sale at church hosted by the confirmation class as a service project in preparation for their graduation. Oren will complete his confirmation class this coming Sunday, it was a year long process. Oren made chocolate chip cookies to sell for the fund raiser which also took much of Saturday morning to prepare.

We went out Saturday evening to the kids school (St. Constantine's) to a sort of music concert. A bit more like a Kareoke night with many kids performing. It was an opportunity to build community with other parents since we do not always get opportunities to see them.

Sunday was the big day and I am glad to say that despite the complex preparations, the field trip went off without a hitch. We left reasonably on time, about 50 kids and 10 adults and arrived at the orphanage. Our kids were great and sang several songs (Rebecca played guitar) and taught them hand gestures. I did a participatory message on Pentecost then we shared refreshments and gave them our gifts. They were very well received and the kids from the orphanage really seemed to appreciate the visit. We got back shortly after our church service ended and in time for the bake sale and a church buffet luncheon featuring some international dishes. Rebecca and I were exhausted by the time it was all over, but thankful that all went well. After a week of travel and a busy weekend I collapsed and slept through most of the evening while Rebecca and the kids went and saw the new release of 'Aladdin'.

After the weekend it was good to be back to a week of more normal routines. As Rebecca wrote last week, the kids were home from school for two days during Eid, so having a full week of school of work actually felt like a bit of a break. We braved cold swims with our wetsuits every morning before going to work. We have needed to focus on getting work permits and residence visas for ourselves and a SALT volunteer this week as ours are expiring at the end of August and the process has become complex. Not all the expats we know have been successful at renewing their visas, so we are praying. One of our staff went down to Dodoma (the new capital this week) to deposit our paperwork and ran into a number of obstacles and had to come back unsuccessful. We are regrouping for another try this coming week. More updates as things progress.

Lunch after church.