Title of PresentationTitle of PresentationGoes HereGoes Here

Jane T. BertrandJane T. BertrandOctober 20, 2003October 20, 2003

Health Competence CommunicationIn 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, andimproves health, and•• enhances wellenhances 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 DevelopmentInternational Development

•• Bilateral agencies Bilateral agencies •• International and local International and local

NGOs NGOs •• Private foundations Private foundations •• UN agenciesUN agencies•• Corporations Corporations •• Small faithSmall faith--based groupsbased groups•• Educational institutionsEducational 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 behaviorindividual 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 careand 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 communicationcommunication

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

Funding AgenciesFunding AgenciesIn addition to the U.S. Agency for International Development (USIn addition to the U.S. Agency for International Development (USAID), AID), the following institutions and foundations have also provided suthe following institutions and foundations have also provided support pport for CCP activities from 2000 to present.for CCP activities from 2000 to present.AfricanAfrican--American Health Program of the American Health Program of the PeoplePeople’’s Baptist Church (AAHP) s Baptist Church (AAHP)

APROPOAPROPO--PeruPeruArab Resource Collective (ARC)Arab Resource Collective (ARC)Asian Development BankAsian Development BankAtlantic PhilanthropiesAtlantic PhilanthropiesBaltimore City Health DepartmentBaltimore City Health DepartmentBBC World Service TrustBBC World Service TrustCable Positive Tony CoxCable Positive Tony CoxCARE KenyaCARE KenyaBill and Melinda Gates FoundationBill and Melinda Gates FoundationBogasariBogasari Flour and Milling CompanyFlour and Milling CompanyCenters for Disease Control and Prevention (CDC)Centers for Disease Control and Prevention (CDC)ConstellaConstella Health SciencesHealth SciencesCowellCowell FoundationFoundationDavid and Lucile Packard FoundationDavid and Lucile Packard Foundation

Department for International Development (DFID), United Department for International Development (DFID), United KingdomKingdom

Family health InternationalFamily health InternationalFamily Planning Association of KenyaFamily Planning Association of KenyaFord FoundationFord FoundationFutures Group InternationalFutures Group International

Government of Burkina FasoGovernment of Burkina Faso

Government of IndiaGovernment of IndiaHealth Partners InternationalHealth Partners InternationalHealthy Lifestyle ChoicesHealthy Lifestyle Choices

International Center for Research on WomenInternational Center for Research on Women

International Trachoma InitiativeInternational Trachoma InitiativeInvestcorpInvestcorp

Joint United Nations Programme on HIV/AIDS Joint United Nations Programme on HIV/AIDS (UNAIDS)(UNAIDS)

Johns Hopkins UniversityJohns Hopkins UniversityJohnson & Johnson FoundationJohnson & Johnson FoundationMary Mary WohlfordWohlford FoundationFoundationMedia for Development TrustMedia for Development Trust

National AIDS Prevention CenterNational AIDS Prevention Center

Ohio UniversityOhio University

Pan American Health OrganizationPan American Health Organization

Paul G. Allen FoundationPaul G. Allen FoundationPfizer, Inc.Pfizer, Inc.Population CouncilPopulation CouncilProcter & GambleProcter & GambleRockefeller FoundationRockefeller Foundation

Royal Netherlands EmbassyRoyal Netherlands EmbassySan Gabriel FoundationSan Gabriel FoundationSave the ChildrenSave the Children

State of Maryland, GovernorState 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 MarylandMaryland

United Nations ChildrenUnited 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 FoundationUnited Nations Foundation

United Nations Population Fund United Nations Population Fund (UNFPA)(UNFPA)

Vietnam NCPFPVietnam NCPFPWilliam and Flora Hewlett FoundationWilliam and Flora Hewlett FoundationWorld BankWorld BankWorld Health OrganizationWorld Health OrganizationWorld Wildlife FederationWorld Wildlife FederationZanvylZanvyl & Isabelle Krieger Fund& Isabelle Krieger Fund

CCP WorldwideCCP Worldwide

AfricaAfricaEthiopiaEthiopiaGhanaGhanaGuineaGuineaLiberiaLiberiaMalawiMalawiMaliMaliMozambiqueMozambiqueNamibiaNamibiaNigeriaNigeriaSouth AfricaSouth AfricaUgandaUgandaZambiaZambiaRegional HIV/AIDS Regional HIV/AIDS ProjectProject

AsiaAsiaIndiaIndiaIndonesiaIndonesiaNepalNepal

Europe & EurasiaEurope & EurasiaRussiaRussiaRegional TB ProjectRegional TB Project

Latin AmericaLatin AmericaHaitiHaitiNicaraguaNicaraguaPeruPeru

Near EastNear East

Local Local established by established by former stformer st

EgyptEgyptJordanJordan

CCPsCCPs

affaffBangladeshBangladeshBoliviaBoliviaEcuadorEcuadorPhilippinesPhilippinesUgandaUgandaZambiaZambia

IR 3Communication

integrated into a broad range of programs that

improve health.

IR 2Effective health communication

implemented at scale.

IR 1Strengthened in-country

capacity for strategic health communication.

IR 4Research used to guide

and advance health communication.

Strategic ObjectiveCommunication employed effectively to improve health, stabilize

population and advance a health competent society

HCP Technical Meeting 6/17/03

Health Competence inThe 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 competenceinto 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 ofCommunication Initial Outcomes Behavioral

Outcomes Sustainable

Health Outcomes

Social PoliticalEnvironment

Service DeliverySystem

Community/Individual

SupportiveEnvironment

Service Performance

Client Behaviors:

Community

Individual

Environment

Service Systems

Community

Individual

UnderlyingConditions

Context

Resources

Reduction in:

Unintended/mistimed

pregnancies

Morbidity/mortalityfrom pregnancy/

childbirth

Infant/child morbidity/mortality

HIV transmission

Threat of infectious diseases

UnderlyingConditions

Domains ofCommunication

HealthCompetenceOutcomes

Envi

ronm

ent

Serv

ice

Syst

ems

Com

mun

ityIn

divi

dual

BehavioralOutcomes

SustainableHealth Outcomes

ContextDisease Burden

Social

Cultural

Economic

Communication

Technology

Political

Legal

Reduction in:

Unintended/mistimed

pregnancies

Morbidity/mortalityfrom pregnancy/

childbirth

Infant/child morbidity/mortality

HIV transmission

Threat of infectious diseases

ResourcesHuman and

Financial Resources

Strategic Plan/Health

Priorities

Other Development

Programs

Policies

SupportiveEnvironment

•Multi-sectoralpartnerships

•Public opinion•Institutionalperformance

•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 capacitybuilding

•National coalition•National commstrategy

•Availability•Technical competence•Information to client•Interpersonalcommunication

•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 socialsupport/stigma

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

Pathways to a Health Competent Society

Social PoliticalEnvironment

•Community action groups

•Media advocacy•Opinion leader advocacy

•Organizational development

•Coalition building

Service DeliverySystem

• 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 CompetentIndividuals & FamiliesKnowledge• Of health determinants (health literacy)• Of basic health concepts and practices (health literacy)• Of individual/family rights to good healthAttitudes• 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 healthSkills• Health information seeking & interpersonal discussion• Skills needed to practice appropriate health behaviorsResources• Access to health information• Access to social support• Access to health supplies

Outcome:Appropriate &

consistent behavior

Health Competent CommunitiesKnowledge• Community consensus on health prioritiesAttitudes• Perceived collective efficacy• Community norms, beliefs, attitudes favoring cooperation re: health• Perceived local ownership of/responsibility for health issuesSkills• Existence of functioning networks/groups addressing health issuesResources• 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 ServicesKnowledge• Providers meet minimum standards of clinical knowledge• Providers meet minimum standards of non-clinical knowledgeAttitudes• 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 skillsResources• 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 CompetentPolicy EnvironmentKnowledge• Health improvement and universal access to good health are

political priorities, expressed in policy documents• Existence of a national communication strategy for healthAttitudes• Policy maker/decision maker support for health priorities• Media support for health prioritiesSkills• Operational systems for institutional capacity building• Existence/enforcement of regulations and guidelinesResources• Existence of a national health coalition involving both private

and public sectors• Budget allocations for health programs reflect its

high priorityOutcome:

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 01 6

4 7 4 85 2 5 6 6 0

4 8

1 51 62 0

- 55

1 52 53 54 55 56 57 5

E D H S1 9 9 2

E D H S1 9 9 5

E D H S1 9 9 8

E D H S2 0 0 0

E ID H S2 0 0 3

M V H S2 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

MVHS2004

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.

VillageIndicators

Zohra Saft El Khamar

NazletHussein

Ali

MonshaatEl

Maghalka

Koloba ToukhEl 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 of 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 IndexIndividual 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-efficacyCommunity 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 overall 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 KolobaPercent 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

1925 25

34 3443

5561

010203040506070

0-4 5 6 7 8 9 10Health Competence Score

Perc

ent o

f wom

enin

itiat

ing

FP a

t Par

ity 1

Percent of women using FP at parity oneincreases 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<.0001HEALTH 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

1925 25

34 3443

5561

010203040506070

0-4 5 6 7 8 9 10

Health Competence Score

Perc

ent o

f wom

enin

itiat

ing

FP a

t Par

ity 1

Mean health competence level variesby community

11-14

Zohra MeansHC 9.0

CPR 51%Koloba MeansHC 6.9

CPR 25%

SOURCE: CHL Minya Village Health Survey 2003 (n=2,240 married women 15-49), Chi-square(7) = 159.45, p<.0001HEALTH 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 41 9 2 3

3 03 5

4 3

5 8

7 1

1 8 1 92 6

3 34 2

5 5

4 35 2

01 02 03 04 05 06 07 08 0

0 1 2 3 4 5 6 7H 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 it y 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 < .0001HEALTH 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.

Perc

ent o

f wom

enin

itiat

ing

FP u

se a

t par

ity 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 ofThe Communication for Healthy Living Project

• 140 couples, 9000guests in Minya Stadium

• Celebration (speeches, songs, contests)

The Event: A Traditional Pageant

• Traditional marriage processionalong the Corniche (65 horsecarriages, 4 tractor-drawn ‘tuf-tufs’)

The Event: A Traditional Pageant

•Traditional group ‘weddingreception’ taken to scale

- probably the largest everconducted 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 thefuture

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 - extensiveMedia Reach TV/Radio:

est. 20% = 15 million people

“Entertainment Educates” forMaximum Reach

Regional CoverageAl-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

UnderlyingConditions

Domains ofCommunication

HealthCompetenceOutcomes

Envi

ronm

ent

Serv

ice

Syst

ems

Com

mun

ityIn

divi

dual

BehavioralOutcomes

SustainableHealth Outcomes

ContextDisease Burden

Social

Cultural

Economic

Communication

Technology

Political

Legal

Reduction in:

Unintended/mistimed

pregnancies

Morbidity/mortalityfrom pregnancy/

childbirth

Infant/child morbidity/mortality

HIV transmission

Threat of infectious diseases

ResourcesHuman and

Financial Resources

Strategic Plan/Health

Priorities

Other Development

Programs

Policies

SupportiveEnvironment

•Multi-sectoralpartnerships

•Public opinion•Institutionalperformance

•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 capacitybuilding

•National coalition•National commstrategy

•Availability•Technical competence•Information to client•Interpersonalcommunication

•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 socialsupport/stigma

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

Pathways to a Health Competent Society

Social PoliticalEnvironment

•Community action groups

•Media advocacy•Opinion leader advocacy

•Organizational development

•Coalition building

Service DeliverySystem

• 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