Linda Lloyd
Publication Date
March 1, 2006

This 57-slide PowerPoint presentation explores COMBI - an approach to behaviour change that uses strategic social mobilisation and social communication in an effort to effect measurable changes in behaviour - through the lens of a specific health challenge in Malé, the Maldives: dengue. It shares preliminary results of the external evaluation of the Centers for Disease Control and Prevention (CDC)/World Health Organization (WHO)/Pan American Health Organization (PAHO) dengue COMBI initiative that has resulted in behaviourally-focused messages. Author Linda S. Lloyd has visited sites in Barbados (Island-wide), Brazil (4 sites), Guatemala (1 programme w/multiple sites), Laos (1 site), Malaysia (2 sites), and Nicaragua (1 site). This initiative is motivated by the conviction that, although there are good examples of IEC (information, education, and communication) programmes that have improved knowledge and attitudes, there are few good examples of communication programmes with measurable changes in behaviour.

Lloyd begins by tracing the history of COMBI, starting in 1994, when Dr. Everold Hosein first offered an "Integrated marketing communication for behavioural impact in health and social development" course at New York University. Additional slides list how COMBI has been put into action in different countries around the world to address challenges such as HIV/AIDS, leprosy, lymphatic filariasis, malaria, tuberculosis, and dengue.

As Lloyd explains, COMBI is a methodology for influencing and/or reinforcing a decision/behaviour/social norm, and/or mobilising various sectors of society to take action on a common issue and creating a sense of shared responsibility. COMBI is based on theory and practice, including behaviour change theories, communication theory, and marketing practice. For instance, COMBI shares with behaviour change theories the belief that the person or community should have: a positive intention toward the new behaviour; a minimum of barriers to achieve the behaviour; sufficient ability to carry out the behaviour; encounters with messages that serve as reminders; and belief that the actions will have positive results and benefits. However, according to Lloyd, COMBI is different because it is a methodology for planning sustained actions in communication and social mobilisation, and it focuses on measurable changes in behaviour, not just changes in knowledge or attitude.

To underscore this point, Lloyd introduces the acronym "HICDARM", which stands for Hear about the new behaviour; Inform yourself about it; and Convince yourself that it is worthwhile. Lloyd explains that IEC programmes focus on HIC. In contrast, COMBI programmes focus on: Decide to do something about it; Act on this decision; Reconfirm that your action has had a positive result; and Maintain the behaviour.

Subsequent slides detail the 15 steps for COMBI planning:

  1. Assemble a multidisciplinary planning team to: determine the behavioural objectives; review the formative research results; direct the pre-testing of the behaviour, the message(s), and the materials; design the communication and social mobilisation strategy; and evaluate implementation of the strategy.
  2. Establish preliminary behavioural objectives. Lloyd lists analytical methods for setting behavioural objectives, such as problem analysis, risk factor analysis, force-field analysis, the BEHAVE framework analysis, priority analysis, and the SMART objective analysis (Specific, Measurable, Appropriate, Reasonable, Time-limited). Images from Malé, in the Maldives - plastic containers and miscellany on roof tops, open water storage containers, and oil container storage in backyards illustrate a problem. The current message in this context is: Turn the container over or throw it away. The COMBI objective is to explore challenges (what is trash; what is useful? and people wish to use the roof for storage: "out of sight, out of mind"; who is responsible for checking the roof?) Similar challenges and objectives are outlined for the cases of water plants, abandoned open wells, and construction sites. To deepen these examples, Lloyd reviews the 4 Cs of Marketing: (i) Consumer: needs/desires/expectations; (ii) Cost: Is the cost of the behaviour worth the investment [time, effort, financial]? (iii); Convenience: service, location, hours of service, sensitivity of the provider, behavioural complications; and (iv) Communication: focus on integrated communications.
  3. Plan and conduct formative research/situation analysis.
  4. Present and disseminate the formative research results so they can be used by other groups in the integrated dengue programme (e.g., epidemiology, laboratory, entomology, communication, and training).
  5. Analyse, prioritise, and finalise the behavioural objectives: identify the most important breeding sites and identify the behaviours that can be "improved" or "changed" with greatest success.
  6. Segment groups by age, sex, educational level, place of residence (urban/rural) need (e.g., families who need to store water, families with tires in their patio).
  7. Develop the strategy: Think: message, source, channel, receiver, effect, feedback, and setting. (Slide 39 outlines the 5 integrated communication actions: advocacy/public relations/management; social mobilisation; publicity; interpersonal communication; and point-of-service promotion). Communication challenges here include selective attention, selective perception, and selective retention.
  8. Pre-test behaviours, messages, and materials.
  9. Establish a monitoring system. The challenge is that, according to Lloyd, there is a lack of indicators that more truly reflect the behaviour.
  10. Strengthen staff skills to plan, administer, implement, and monitor this process at all levels.
  11. Set up systems to manage and share information among the different dengue programme components.
  12. Structure your programme: Include personnel with experience in behaviour change, communication, and social mobilisation.
  13. Write a strategic plan (a COMBI plan) that describes the combination of communication actions that will be used in all the steps needed to implement the strategy.
  14. Determine a budget.
  15. Conduct a pilot test and revise the COMBI plan.

authorSTREAM website, August 23 2010.