Behavior change does not result from increasing knowledge alone. Many contextual factors, including the behaviors of family and the community, influence individual behavior change. Therefore, the range of behavior change activities often extends beyond conventional communication, to link and coordinate communication activities with training, health systems support, product and service improvements, social norm change and even new or improved policies.

The strategic selection and implementation of an appropriate set of behavior change interventions can help to directly improve skilled careseeking practices during and after childbirth and help to create a supportive, enabling environment at household, community, health facility and policy levels.

One of the fundamental principles of the behavior change approach is promoting behavior change in the context of social change. Community engagement, ownership and empowerment are key to sustained behavior change. At the community level, a behavior change approach focuses on activities that create and sustain an enabling environment for behavior change and social change, building partnerships with communities and developing interventions considering the community's own assessment of their needs and priorities. Community-centered behavior change interventions promote the empowerment of community partners and encourage collaborative design and implementation of local programs. A community-oriented behavior change approach identifies people and communities as agents for their own change, placing information within the community for dialogue, debate and collective action and using available resources to overcome barriers. An assets-based approach helps communities identify, strengthen and utilize resources and knowledge that exist within the community itself to support behavior change and improve health outcomes.

Several concepts underlie the CHANGE approach to developing behavior change interventions to improve maternal and newborn survival:

• Behavior-based programming;
• Standardized format for strategic application of research results to behavior change strategy development;
• Consultative research that includes "concept testing" and negotiated behavior change;
• Localization; and
• Use of community interviewers

CHANGE's qualitative research tools explore factors influencing use of skilled care. The behavior-based tools were designed to document current behaviors, barriers, motivators, amenability to change, conditions of acceptability and "user characteristics." Each element is essential to the design of behavior change interventions.

These guides emphasize skilled care for all births:

• The need to reposition TBAs as "links" to skilled care for all women, instead of their current role as care providers;
• The critical, lifesaving importance of use of skilled care during the early postpartum period; and
• The need to enable skilled maternity care providers to actively participate in provision of higher quality, more "caring" services for women.
  

The left side of the behavior change strategy worksheet helps program planners to analyze current and feasible behaviors. The right half of the worksheet suggests the interventions that may be needed to promote behaviors.

Negotiating behavior change involves talking with women, families and communities to develop recommendations that come as close to the "ideal" behaviors as local conditions permit. This helps program planners to understand participants' "conditions of acceptability," in other words, what would make the new idea acceptable to them. Testing and negotiating new behaviors before strategies are designed can help use resources efficiently by increasing the likelihood of success and sustained change.

Documenting the precise words, phrases and concepts that communities use allows them to be woven into behavior change materials and messages to increase local comprehension. Too often, "messages" are not developed locally and may not retain the intended meaning once they reach families and communities. Defining local cultural context and linguistic subtleties can make a message meaningful and actionable. This localization process has been called the "house-to home" metaphor by UNAIDS.

Interviewers are recruited from the local community and selected for appropriateness of age and gender per category of respondent. When community interviewers keep personal journals of their interview experiences, their journal entries, along with notes kept by the trainers and community research coordinators, provide a unique perspective. Community interviewers can work in pairs so that one person can interview and one person can record. A supervisory "coach" can help increase interviewer confidence to work with the instruments and improve the quality of interviews and record keeping.

Community interviewers facilitate transfer of research results when they participate in community discussions and strategy workshops. These discussions help to maximize the participation of key stakeholders in design of locally appropriate strategies to increase use of skilled care.