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Jane T. Bertrand Jane T. Bertrand October 20, 2003 October 20, 2003

Health Competence Communication In Egypt

The Center for Communication Programs The Center for Communication Programs envisions a world in which communication envisions a world in which communication

• saves lives,

saves lives,

• improves health, and

improves health, and

• enhances well

enhances well-

• being.

being.

With our Staff of 450 in 30 countries, With our Staff of 450 in 30 countries, we partner with: we partner with:

• The U.S. Agency for

The U.S. Agency for International Development International Development

• Bilateral agencies

Bilateral agencies

• International and local

International and local NGOs NGOs

• Private foundations

Private foundations

• UN agencies

UN agencies

• Corporations

Corporations

• Small faith

Small faith-

• based groups

based groups

• Educational institutions

Educational institutions

CCP partners with organizations CCP partners with organizations worldwide to: worldwide to:

• Design and implement strategic

Design and implement strategic communication programs that influence communication programs that influence political dialogue, collective action, and political dialogue, collective action, and individual behavior individual behavior

• Enhance access to information and the

Enhance access to information and the exchange of knowledge that improve health exchange of knowledge that improve health and health care and health care

• Conduct research to guide program design,

Conduct research to guide program design, evaluate impact, test theories, and advance evaluate impact, test theories, and advance knowledge in health knowledge in health communication communication

Breakdown of Program Resources by Breakdown of Program Resources by Region, 2004 Region, 2004

Funding Agencies Funding Agencies

In addition to the U.S. Agency for International Development (US In addition to the U.S. Agency for International Development (USAID), AID), the following institutions and foundations have also provided su the following institutions and foundations have also provided support pport for CCP activities from 2000 to present. for CCP activities from 2000 to present.

African African-

• American Health Program of the

American Health Program of the People People’ ’s Baptist Church (AAHP) s Baptist Church (AAHP) APROPO APROPO-

• Peru

Peru Arab Resource Collective (ARC) Arab Resource Collective (ARC) Asian Development Bank Asian Development Bank Atlantic Philanthropies Atlantic Philanthropies Baltimore City Health Department Baltimore City Health Department BBC World Service Trust BBC World Service Trust Cable Positive Tony Cox Cable Positive Tony Cox CARE Kenya CARE Kenya Bill and Melinda Gates Foundation Bill and Melinda Gates Foundation Bogasari Bogasari Flour and Milling Company Flour and Milling Company Centers for Disease Control and Prevention (CDC) Centers for Disease Control and Prevention (CDC) Constella Constella Health Sciences Health Sciences Cowell Cowell Foundation Foundation David and Lucile Packard Foundation David and Lucile Packard Foundation Department for International Development (DFID), United Department for International Development (DFID), United Kingdom Kingdom Family health International Family health International Family Planning Association of Kenya Family Planning Association of Kenya Ford Foundation Ford Foundation Futures Group International Futures Group International Government of Burkina Faso Government of Burkina Faso Government of India Government of India Health Partners International Health Partners International Healthy Lifestyle Choices Healthy Lifestyle Choices International Center for Research on Women International Center for Research on Women International Trachoma Initiative International Trachoma Initiative Investcorp Investcorp Joint United Nations Programme on HIV/AIDS Joint United Nations Programme on HIV/AIDS (UNAIDS) (UNAIDS) Johns Hopkins University Johns Hopkins University Johnson & Johnson Foundation Johnson & Johnson Foundation Mary Mary Wohlford Wohlford Foundation Foundation Media for Development Trust Media for Development Trust National AIDS Prevention Center National AIDS Prevention Center Ohio University Ohio University Pan American Health Organization Pan American Health Organization Paul G. Allen Foundation Paul G. Allen Foundation Pfizer, Inc. Pfizer, Inc. Population Council Population Council Procter & Gamble Procter & Gamble Rockefeller Foundation Rockefeller Foundation Royal Netherlands Embassy Royal Netherlands Embassy San Gabriel Foundation San Gabriel Foundation Save the Children Save the Children State of Maryland, Governor State of Maryland, Governor’ ’s Office s Office for Children Youth and Families and for Children Youth and Families and AIDS Administration, Department of AIDS Administration, Department of Health & Mental Hygiene, University of Health & Mental Hygiene, University of Maryland Maryland United Nations Children United Nations Children’ ’s Fund s Fund (UNICEF) (UNICEF) United Nations Development United Nations Development Programme (UNDP) Programme (UNDP) United Nations Education, Scientific, United Nations Education, Scientific, and Cultural Organization (UNESCO) and Cultural Organization (UNESCO) United Nations Foundation United Nations Foundation United Nations Population Fund United Nations Population Fund (UNFPA) (UNFPA) Vietnam NCPFP Vietnam NCPFP William and Flora Hewlett Foundation William and Flora Hewlett Foundation World Bank World Bank World Health Organization World Health Organization World Wildlife Federation World Wildlife Federation Zanvyl Zanvyl & Isabelle Krieger Fund & Isabelle Krieger Fund

CCP Worldwide CCP Worldwide

Africa Africa

Ethiopia Ethiopia Ghana Ghana Guinea Guinea Liberia Liberia Malawi Malawi Mali Mali Mozambique Mozambique Namibia Namibia Nigeria Nigeria South Africa South Africa Uganda Uganda Zambia Zambia Regional HIV/AIDS Regional HIV/AIDS Project Project

Asia Asia

India India Indonesia Indonesia Nepal Nepal

Europe & Eurasia Europe & Eurasia

Russia Russia Regional TB Project Regional TB Project

Latin America Latin America

Haiti Haiti Nicaragua Nicaragua Peru Peru

Near East Near East

Local Local established by established by former st former st Egypt Egypt Jordan Jordan CCPs CCPs aff aff Bangladesh Bangladesh Bolivia Bolivia Ecuador Ecuador Philippines Philippines Uganda Uganda Zambia Zambia

IR 3

Communication integrated into a broad range of programs that improve health.

IR 2

Effective health communication implemented at scale.

IR 1

Strengthened in-country capacity for strategic health communication.

IR 4

Research used to guide and advance health communication.

Strategic Objective Communication employed effectively to improve health, stabilize population and advance a health competent society

HCP Technical Meeting 6/17/03

Health Competence in The Health Communication Partnership

What is Health Competence?

• New approach to the design and

evaluation of integrated health communication programs

• Applies a systems perspective to health

improvement

• Cuts across areas of health behavior
• Emphasizes sustainability
• Predicts health outcomes and helps

identify strategic interventions

Origins of the Concept

WHO efforts to define health and well-being away from a narrow disease prevention perspective:

“A state of complete mental, physical, and social well-being and not merely the absence the disease” (WHO, 1958)

Evolution of the Concept

21st Century Field model (Evans and Stoddart, 1994)

• Interactions among multiple factors that

determine health

• Health, social, political, and environmental

policies

• Physical, family, and community

environments

• Characteristics and behaviors of

individuals and populations

Health literacy

• Variously defined as knowledge and comprehension

resulting from health education (e.g., Simonds, 1974) and as a broad set of factors that empower and facilitate achievement of health (e.g., Nutbeam, 2000; IOM, 2004) Social capital

• Refers to characteristics of social organizations that

“combine to facilitate cooperation among people for their mutual benefit (Kawachi et al., 1997)

• Social capital facilitates social mobilization for health

improvement.

Related concepts

Translating health competence into a program framework

“A health competent society is one in which individuals, communities, and institutions have the knowledge, attitudes, skills, and resources needed to improve and maintain health.” Health competence: a set of factors or conditions that facilitate and predict the achievement and sustainability of desired health outcomes

Pathways to a Health Competent Society Conceptual Framework -- At a glance

Domains of Communication Initial Outcomes Behavioral Outcomes Sustainable Health Outcomes

Social Political Environment Service Delivery System Community/ Individual Supportive Environment Service Performance Client Behaviors: Community Individual Environment Service Systems Community Individual

Underlying Conditions

Context Resources

Reduction in: Unintended/ mistimed pregnancies Morbidity/mortality from pregnancy/ childbirth Infant/child morbidity/mortality HIV transmission Threat of infectious diseases

Underlying Conditions Domains of Communication Health Competence Outcomes

Environment Service Systems Community Individual

Behavioral Outcomes Sustainable Health Outcomes Context

Disease Burden Social Cultural Economic Communication Technology Political Legal Reduction in: Unintended/ mistimed pregnancies Morbidity/mortality from pregnancy/ childbirth Infant/child morbidity/mortality HIV transmission Threat of infectious diseases

Resources

Human and Financial Resources Strategic Plan/Health Priorities Other Development Programs Policies Supportive Environment

• Multi-sectoral

partnerships

• Public opinion
• Institutional

performance

• Resource access
• Media support
• Activity level

Service Performance

• Access
• Quality
• Client volume
• Client satisfaction

Client Behaviors Community

• Sanitation
• Hospice/PLWA
• Other actions

Individual

• Timely service use
• Contraception
• Abstinence/partner

reduction

• Condom use
• Safe delivery
• BF/nutrition
• Child care/immuniz.
• Bednet use
• Political will
• Resource allocation
• Policy changes
• Institutional capacity

building

• National coalition
• National comm

strategy

• Availability
• Technical competence
• Information to client
• Interpersonal

communication

• Follow-up of clients
• Integration of services
• Leadership
• Participation equity
• Information equity
• Priority consensus
• Network cohesion
• Ownership
• Social norms
• Collective efficacy
• Social capital
• Message recall
• Perceived social

support/stigma

• Emotion and values
• Beliefs and attitudes
• Perceived risk
• Self-efficacy
• Health literacy

Pathways to a Health Competent Society

Social Political Environment

• Community action

groups

• Media advocacy
• Opinion leader

advocacy

• Organizational

development

• Coalition building

Service Delivery System

• Norms & standards
• Rewards & incentives
• Job/peer feedback
• Job aides
• Training in CPI
• Supportive settings
• Community outreach
• Internet portals
• Distance learning

Community & Individual

• Participation in social

change efforts

• Strengthening social

networks

• Peer support groups
• Multimedia programs
• Enter-education
• Social marketing
• Household care
• Interactive media &

internet

Health Competent Individuals & Families

Knowledge

• Of health determinants (health literacy)
• Of basic health concepts and practices (health literacy)
• Of individual/family rights to good health

Attitudes

• Perceived social support for efforts to improve health
• Positive beliefs/attitudes about the benefits of preventive health
• Appropriate levels of perceived health risk
• Perceived self-efficacy to manage individual/family health

Skills

• Health information seeking & interpersonal discussion
• Skills needed to practice appropriate health behaviors

Resources

• Access to health information
• Access to social support
• Access to health supplies

Outcome: Appropriate & consistent behavior

Health Competent Communities

Knowledge

• Community consensus on health priorities

Attitudes

• Perceived collective efficacy
• Community norms, beliefs, attitudes favoring cooperation re: health
• Perceived local ownership of/responsibility for health issues

Skills

• Existence of functioning networks/groups addressing health issues

Resources

• Opportunities to participate in community affairs regarding health
• Access to services
• Access to transportation
• Access to health information sources
• Active local leadership on health issues

Outcome: Community responsiveness to health problems

Health Competent Services

Knowledge

• Providers meet minimum standards of clinical knowledge
• Providers meet minimum standards of non-clinical knowledge

Attitudes

• Providers are client-oriented (treat clients as individuals, not cases)

Skills

• Providers meet minimum standards for clinical skills
• Providers meet minimum standards for non-clinical skills

Resources

• Operational referral and follow-up systems
• Adequate staffing at health facilities
• Facility physical plant meets minimum standards
• Commodities & supplies consistently available

Outcome: Quality service delivery

Health Competent Policy Environment

Knowledge

• Health improvement and universal access to good health are

political priorities, expressed in policy documents

• Existence of a national communication strategy for health

Attitudes

• Policy maker/decision maker support for health priorities
• Media support for health priorities

Skills

• Operational systems for institutional capacity building
• Existence/enforcement of regulations and guidelines

Resources

• Existence of a national health coalition involving both private

and public sectors

• Budget allocations for health programs reflect its

high priority

Outcome: Health is high on public agenda

Minya Village Health Survey 2004

HCP Summative Evaluation Unit (Tulane) HCP Program Research Unit (Johns Hopkins) Al-Zanaty & Associates

Communication for Healthy Living Project

Why Minya?

Still at 1995 national levels of CPR and unmet need

1 1 1 0 1 6 4 7 4 8 5 2 5 6 6 0 4 8 1 5 1 6 2 0

• 5

5 1 5 2 5 3 5 4 5 5 5 6 5 7 5 E D H S 1 9 9 2 E D H S 1 9 9 5 E D H S 1 9 9 8 E D H S 2 0 0 0 E ID H S 2 0 0 3 M V H S 2 0 0 4 T o t a l U n m e t N e e d C P R

Source: EDHS 1992-2003, MVHS 2004

MVHS 2004

Minya villages vary on key health indicators

SOURCE: CHL Minya Village Health Survey 2003 (n=2,240 married women 15-49). Blue = highest score on indicator, Red = lowest score on indicator.

Village Indicators

Zohra

Saft El Khamar Nazlet Hussein Ali Monshaat El Maghalka

Koloba

Toukh El Khail Ebshedat Current use (modern)

56 42 41 46 28 47 38

Use at parity one

51 35 36 48 25 39 28

Appropriate to use FP before 1st birth

9 3 14 11 11 9 4

4+ antenatal visits for pregnancy

60 37 43 35 39 24 19

First postnatal checkup for mother within 2 days

• f birth

21 13 31 26 31 23 10

Ever heard about HIV/AIDS

95 79 70 75 69 90 70

Aware that passive smoking increases heart disease

42 30 32 33 18 34 45

FGC should be discontinued

9 25 12 26 7 61 26

Ever heard about Hepatitis C

80 41 45 35 46 54 45

Health Competence Index One thing that may explain part of the variation in health status across villages is differences in health competence. The Minya Village Survey includes variables that correspond to health competence indicators at the Individual and Community levels.

Health Competence Index

Individual level factors

• Positive attitudes toward spacing
• Number of FP methods known
• Ever discussed spacing with anyone
• Discussed FP with spouse in past 6 months
• Discussed FP with health worker in past 6 months
• Exposed to FP messages in past 6 months
• Self-efficacy

Community level factors

• Comfortable discussing FP in public
• Contact with health worker in past 6 months
• Have access to additional health information if needed
• Have sufficient health information
• Have a local health CDA
• Have had local meeting on health in past 6 months
• Have access to a Gold Star facility

14 items were used to create an additive index of health competence with values ranging from 0-14 for each respondent (Ι = .68)

Selected health competence indicators and

• verall score: Zohra vs Koloba

SOURCE: CHL Minya Village Health Survey 2003 (n=2,240 married women 15-49) * One-way analysis of variance, F=123.96, p<.0001

Health Competence Indicator Zohra Koloba

Percent with positive spacing attitudes

88 78

Percent with high number of FP methods known

18 11

Percent knowing a local group active in health improvement

8 1

Percent discussed FP with spouse in past 6 months

18 15

Percent discussed FP with health worker in past 6 months

20 9

Percent comfortable discussing FP in public

18 16

Percent with high collective efficacy

12 9

Mean health competence score* 9.0 6.9

Percent with high self-efficacy

18 11

19 25 25 34 34 43 55 61

10 20 30 40 50 60 70 0-4 5 6 7 8 9 10

Health Competence Score

Percent of women initiating FP at Parity 1

Percent of women using FP at parity one increases with level of health competence

SOURCE: CHL Minya Village Health Survey 2003 (n=2,240 married women 15-49), Chi-square(7) = 159.45, p<.0001 HEALTH COMPETENCE INDEX (14 items, all dichotomous, a=.68): Positive attitudes toward spacing, n of FP methods known, ever discussed spacing with anyone, discussed FP with spouse past 6 months, discussed FP with HW past 6 months, exposed to FP messages past 6 months, have sufficient health information, contact with HW past 6 months, above average health self-efficacy, comfortable discussing FP with others, have access to health information, have local health CDA, have had local meeting on health past 6 months, have access to Gold Star facility.

11-14

19 25 25 34 34 43 55 61

10 20 30 40 50 60 70 0-4 5 6 7 8 9 10 Health Competence Score Percent of women initiating FP at Parity 1

Mean health competence level varies by community

11-14

Zohra Means HC 9.0 CPR 51% Koloba Means HC 6.9 CPR 25%

SOURCE: CHL Minya Village Health Survey 2003 (n=2,240 married women 15-49), Chi-square(7) = 159.45, p<.0001 HEALTH COMPETENCE INDEX (14 items, all dichotomous, a=.68): Positive attitudes toward spacing, n of FP methods known, ever discussed spacing with anyone, discussed FP with spouse past 6 months, discussed FP with HW past 6 months, exposed to FP messages past 6 months, have sufficient health information, contact with HW past 6 months, above average health self-efficacy, comfortable discussing FP with others, have access to health information, have local health CDA, have had local meeting on health past 6 months, have access to Gold Star facility.

1 4 1 9 2 3 3 0 3 5 4 3 5 8 7 1 1 8 1 9 2 6 3 3 4 2 5 5 4 3 5 2 1 0 2 0 3 0 4 0 5 0 6 0 7 0 8 0

1 2 3 4 5 6 7

H e a lt h C o m p e t e n c e S c o r e

In d iv id u a l s c a le C o m m u n ity s c a le

SOURCE: CHL Minya Village Health Survey 2003 (n=2,240 married women 15-49), Individual scale Chi-square(7) = 171.35, p<.0001, Community scale Chi-square (7) = 101.90, p < .0001 HEALTH COMPETENCE INDEX (14 items, all dichotomous, a=.68). Individual level scale

Individual vs Community Health Competence:

Community factors may be more important at lower levels of health competence, individual factors may be more important at upper levels

(7 items, a=.82): Positive attitudes toward spacing, n of FP methods known, ever discussed spacing with anyone, discussed FP with spouse past 6 months, discussed FP with HW past 6 months, exposed to FP messages past 6 months, above average health self-efficacy; Community level scale (7 items, a=.72): comfortable discussing FP with others, have access to health information, have sufficient health information, contact with HW past 6 months, have local health CDA, have had local meeting on health past 6 months, have access to Gold Star facility.

Percent of women initiating FP use at parity 1

Next Steps

Addition of more community level variables

• Level of community inputs:

– NGO activity – Project expenditures

• Community infrastructure:

– Access to health & social services – Leadership – Access to communication resources

Images of The Communication for Healthy Living Project

• 140 couples, 9000

guests in Minya Stadium

• Celebration (speeches,

songs, contests)

The Event: A Traditional Pageant

• Traditional marriage procession

along the Corniche (65 horse carriages, 4 tractor-drawn ‘tuf-tufs’)

The Event: A Traditional Pageant

• Traditional group ‘wedding

reception’ taken to scale

• probably the largest ever

conducted in Egypt

• Chance to celebrate the promise of marriage, health and

family

• Marriage is the foundation of family life - the entry point

for family health messages

• ~575,000 marriages per year
• Hopes, dreams and practices of

this generation will shape the future

Why Newlyweds?

To demonstrate:

• political support for family

health

• public - private

partnerships for health

• power of ‘entertainment-

education’ to reach maximum number of people

Why a big event?

• Under the auspices of the Governor of Minya and

the Minster of Health and Population, with the support of SIS, & USAID

The Event - Political Support for Family Health

• Governor General Hassan Hemeida, “We thank the

Ministry of Health and Population as well as USAID for their support.”

• Karima Mukhtar –

Soap opera star “Doctora Karima” & a national icon for family health

• Tarek Allam –

Popular performer & variety show host with a social message The Event - Celebrity Endorsement of Family Health

• Public-private partnerships for health
• Procter & Gamble (Ariel)
• Toshiba
• Sila Cooking Oil
• Vodaphone
• Enjoy juices

The Event – Private sector alliances

• Leveraged health program by covering almost

1/3 of event costs, plus value of giveaways

• Long-term private sector investments in health

Service Promotion

• by MOHP during couples’ preparatory meeting
• by Governor / MOHP during event
• by CSI (USAID project) in prep meeting,

in-stadium and gift-pack for couples

The Event - Health Information & Services

The “Mabrouk”

(Congratulations) Family Health Booklet

• Content presented to

couples in August 31st prep meeting

• Contest questions from

“Mabrouk” asked during event (winners won a Toshiba washing machine)

• Given to each couple

with wedding picture

The Event - Health Information & Services

• Extensive media coverage
• TV/Radio - National & Regional
• Ch 1. Good Morning Egypt, Good Evening Egypt,

If We Stop Dreaming (TV)

• Ch 7. Sept 9th promotion and 1.5 hr coverage;

Sept 16th 1.5 hr coverage

• Radio - Shabab w Reada
• National Press - extensive

Media Reach TV/Radio:

• est. 20% = 15 million people

“Entertainment Educates” for Maximum Reach

Regional Coverage Al-Jazeera praise for the event

Minya Newlywed Celebration is only one part of a multi-level national “Family Health” program

• Mass Media
• TV/Radio spots, “Enter-educate” formats, talk show

guest appearances (for couples as health advocates)

• Press inserts, contests, etc.
• Outreach programs (links to school health

programs)

• Participatory village health programs
• “Health” as an entry point to civil society
• Marketing of Health Services

Future Directions -- CHL “Family Health” Program

Underlying Conditions Domains of Communication Health Competence Outcomes

Environment Service Systems Community Individual

Behavioral Outcomes Sustainable Health Outcomes Context

Disease Burden Social Cultural Economic Communication Technology Political Legal Reduction in: Unintended/ mistimed pregnancies Morbidity/mortality from pregnancy/ childbirth Infant/child morbidity/mortality HIV transmission Threat of infectious diseases

Resources

Human and Financial Resources Strategic Plan/Health Priorities Other Development Programs Policies Supportive Environment

• Multi-sectoral

partnerships

• Public opinion
• Institutional

performance

• Resource access
• Media support
• Activity level

Service Performance

• Access
• Quality
• Client volume
• Client satisfaction

Client Behaviors Community

• Sanitation
• Hospice/PLWA
• Other actions

Individual

• Timely service use
• Contraception
• Abstinence/partner

reduction

• Condom use
• Safe delivery
• BF/nutrition
• Child care/immuniz.
• Bednet use
• Political will
• Resource allocation
• Policy changes
• Institutional capacity

building

• National coalition
• National comm

strategy

• Availability
• Technical competence
• Information to client
• Interpersonal

communication

• Follow-up of clients
• Integration of services
• Leadership
• Participation equity
• Information equity
• Priority consensus
• Network cohesion
• Ownership
• Social norms
• Collective efficacy
• Social capital
• Message recall
• Perceived social

support/stigma

• Emotion and values
• Beliefs and attitudes
• Perceived risk
• Self-efficacy
• Health literacy

Pathways to a Health Competent Society

Social Political Environment

• Community action

groups

• Media advocacy
• Opinion leader

advocacy

• Organizational

development

• Coalition building

Service Delivery System

• Norms & standards
• Rewards & incentives
• Job/peer feedback
• Job aides
• Training in CPI
• Supportive settings
• Community outreach
• Internet portals
• Distance learning

Community & Individual

• Participation in social

change efforts

• Strengthening social

networks

• Peer support groups
• Multimedia programs
• Enter-education
• Social marketing
• Household care
• Interactive media &

internet