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| Behavior Change - Tools
and Approaches |
| Trials of Improved
Practices (TIPS) |
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| TIPs is a formative research tool developed
by the Manoff Group
to help program planners select and "pretest"
the actual practices that the program will promote. Mothers
and other family members actually try out and sometimes
modify a menu of possible improved practices prepared
on the basis of previous community research. |
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| TIPS: Probably the
first use of TIPs (at the time called concept or intervention
testing) was by Manoff International in the Nutrition
Communication/ Behavior Change project in Indonesia
in the late 1970s. Derived from the commercial marketing
concept of "doing a test market," this first
use of trials proved to be extremely helpful in program
design. Planners learned that it was feasible to promote
breastfeeding equally from both breasts (rather than the
customary one); how to improve instructions for preparing
homemade oral rehydration solution; and of the need to
modify weaning food suggestions in different regions.
Mothers themselves came up with suggestions on ingredients
and cooking technique that were incorporated into program
messages. |
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| Since this first experience, TIPs have
been effectively used in formative research related to
infant, child, and maternal nutrition in many countries.
Sometimes the research was carried out by research companies
(breastfeeding and child feeding in Nigeria), sometimes
by ministry of health staff, and sometimes by NGO field
workers. In Pakistan, eight NGOs carried out TIPs on maternal
and child health and nutrition in the countries' four
provinces. WHO recommends using a simplified version of
TIPs to adapt the generic "mothers card" that
is part of IMCI counseling to reflect specific foods and
other behaviors appropriate for each country or region
of a country. This has been done in over a dozen countries.
Much TIPs experience has been summarized in the guide
Designing
by Dialogue, available from the SARA Project. Other
manuals cover the use of TIPs on breastfeeding and dietary
approaches to micronutrient malnutrition. |
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| Other Application
of TIPs |
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| TIPs have also been used in other areas
of public health. Certain behaviors that are impossible
to predict precisely (such as childbirth) or which take
a long time (child immunization series) are impossible
to test in TIPs. However, TIPs have been used in formative
research on compliance with taking iron tablets, ARI standard
case management in the Philippines, community IMCI in
Guatemala, purchase and use of insecticide-treated bednets
in Zambia, and interspousal communication regarding family
planning in Pakistan. |
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| TIPs Results |
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| TIPs indicate both what behaviors should
be included and not included in the program but also how
to promote them (the best motivation, helpful information
and strategies that will facilitate behavior change, etc.)
For example, in Nigeria, almost all mothers rejected the
advice to make weaning food "thicker," but almost
all accepted the idea of adding a little palm oil, ground
nuts, and other calorie- and nutrient-dense foods to the
weaning food. TIPs also indicate to what extent families
can solve nutritional problems without the need for additional
income or food. Again in Nigeria, none of 28 children
aged 6-23 months had an adequate caloric intake in the
initial food recall but 21 did on the final TIPs visit.
In Nicaragua, however, TIPs indicated that most families
did not have access to sufficient vitamin A- and iron-rich
foods, so messages to plant easily-grown foods (a recommendation
that was well accepted in the trials) become an important
component of the project. TIPs also help focus planning
on behavior (rather than knowledge alone) and orient field
workers and give them practice in counseling and negotiation,
skills that they can transfer into their regular work
ethic. |
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| Steps in Applying TIPs:
Based on a literature search and exploratory research
(most commonly in-depth interviews but sometimes focus
group discussions or recipe trials), the research team
designs the TIPs (the population segments, sampling frame,
and counseling and motivation guides for the expected
problem practices in health and nutrition). Usually the
sample is relatively small, somewhere in the range of
20 to 80 families, although the more diverse the population
and extensive the behavioral issues, the larger the sample
needs to be. |
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| Field Work |
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| Field work usually consists of two or
three visits/interviews. In the first (assessment) visit,
the families' situation is analyzed through interview
questions and sometimes through a food frequency assessment
or dietary recall. Experienced field workers, who can
independently assess the feeding (or other) problems can
move right into negotiating improved behaviors. The alternative
is to bring back the interview information and have the
research team analyze the findings and assess the problems
and best menu of behavioral solutions. |
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| Negotiation |
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| In the negotiation visit, the field
worker gives feedback to the mother (or other family members)
on their practices (both on what they are doing well and
areas they might improve) and gives several relevant suggestions
of actions the mother might try for a trial period. (This
period is often 5-7 days but may be as long as a few months).
These are discussed thoroughly and in the end the mother
accepts one to three of these ideas for trial. In the
final (evaluation) visit, the worker learns what the mother
did and why, how she and others felt about it, etc. If
it was part of the initial visit, a food frequency assessment
or dietary recall is repeated. |
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| Analysis |
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Analysis of TIPs findings is relatively
straightforward and generally easier than analyzing
in-depth interviews or focus group discussions. Some
of the analysis is quantitative: in each segment, how
many mothers (etc.) had each particular problem or situation,
how many accepted which improved behaviors, what were
the most effective motivations, what was their experience
and success during the trial, what modifications in
the suggestions did they make and why, who in the family
and community influenced their behavior, what were the
main barriers they had to overcome and how did they
do this; what were their perceived benefits; and what
is their intention to continue the new practice(s).
There are essentially two types of TIPs. For nutrition
problems, there are usually a number of alternative
actions that a mother might take (e.g., re: number or
quality of snacks, amounts fed per meal, food consistency,
adding nutrient-rich foods to staples, feeding bowl
or utensils, order of eating, giving the child his own
plate, etc.). Such situations call for negotiation TIPs.
Other behaviors that are treated in TIPs, such as compliance
with taking daily iron tablets, are not really negotiable
(although a series of behaviors to reduce side effects
may be tested), so directed at such a behavior, the
TIPs are really designed to learn about the most effective
ways of facilitating a series of behaviors (obtaining,
remembering, taking, etc.) that are already determined
by the program. |
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| Training, Costs,
Expertise |
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| TIPs requires careful planning, including
elaboration of the counseling guides, and good training,
including field practice, particularly for the assessment
visit (if it includes food frequency and/or dietary recall
questions) and for the negotiation visit, which requires
skills that not even experienced field workers experienced
in qualitative research may have. However, with good training,
even barely literate indigenous NGO health workers in
Guatemala were able to effectively carry out TIPs. Depending
on the availability of experienced researchers in-country,
outside expertise may be needed for planning, training,
field supervision, analysis, and drawing out program implications.
The cost of TIPs vary greatly. Major categories may include
salaries, per diems, transportation, and contracts with
a research company. |
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