Behavior Change

Tools and Approaches

Trials of Improved Practices (TIPs)

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.

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.

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.

Other Applications of TIPs

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.

TIPs Results

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.

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.

Field Work

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. 

Negotiation

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.

Analysis

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.

Training, Costs, Expertise

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.