Despite overall declines in HIV, tuberculosis and reproductive health-related deaths, women and youth in Tanzania bear a disproportionate burden of disease. FHI 360 set out to address these health disparities and shift social and gender norms by designing and implementing an integrated social and behavior change (SBC) strategy with the Government of Tanzania through the USAID Tulonge Afya project.
This was the first time integrated SBC programming was accomplished at scale and to this degree in Tanzania. The project used innovative and evidence-based approaches in a way that both stakeholders and communities found acceptable and that achieved positive results across a country that has diverse contextual, cultural and epidemiological needs.
USAID Tulonge Afya addresses behaviors that cut across the areas of HIV; sexual and reproductive health; maternal, newborn and child health; malaria; tuberculosis; and emerging health issues such as COVID-19. Given the large number of behavior change objectives being addressed by USAID Tulonge Afya, we realized that a project this complex required a strong adaptive management approach to enable ongoing revisions to its design, based on data and community insights. Through this approach, the project can employ effective strategies tailored to our diverse audiences, which include youth, pregnant women and their partners, parents of young children, people who are at high risk of HIV and people living with HIV.
During the initial design, we applied a framework used in our other integrated social and behavior change projects: a life-stage model to address the distinct health needs of individuals at various stages in their lives. Established theoretical frameworks and models, such as the socio-ecological model, put structure to the design. To better understand the factors that inhibit or facilitate behaviors, we applied a range of traditional research and human-centered design approaches to incorporate the perspectives of those we seek to serve.
We also incorporated several key approaches into the project’s design and implementation to generate data, insights and community perspectives, including:
- Codesign and codelivery of program activities: We use a range of participatory approaches to engage host-country government and communities in the design of activities and materials, as well as in their delivery. This includes use of peer educators, participatory small-group dialogues, interactive community radio and real-life stories as part of community theater and national mass media.
- Generate continuous insights with communities and integrate feedback loops: To strengthen future programming, we routinely analyze questions and answers and community feedback on community-level and mass media activities.
- Make use of ongoing evaluation and monitoring and evaluation data: We regularly collect, analyze and use a range of routine monitoring and evaluation, survey and service delivery data as part of our adaptive management approach. This helps us to identify what is working, where there are gaps and how we can apply learning to strengthen impacts.
- Update strategies annually, based on learning: We work closely with government and local and international implementers in the design and delivery of activities to ensure broader uptake and buy-in throughout the program cycle and to strengthen integrated SBC capacity at the local level. Our SBC strategy is updated annually to reflect learning.
Lessons from USAID Tulonge Afya demonstrate that programming with an inclusive and well-informed strategy and an adaptive management approach is effective in addressing social norms, transforming behaviors and bringing about social change. For example, HMIS data showed persistent lower uptake of family planning services in some of the project’s districts. Project staff ran a secondary analysis of the data to determine where there were lower rates of family planning and identified social norms that acted as barriers to its uptake. As part of its adaptive management approach, USAID Tulonge Afya adjusted its programming to strengthen SBC and service linkages in these identified areas. This resulted in an increased number of people accessing family planning services. In the district of Kaliua, the project implemented community theater activities to shift harmful social norms and strengthened SBC linkages in collaboration with a service delivery partner. This resulted in an increase in the number of people accessing family planning services from 2,384 to 2,948 within one month.
For additional information, view a case study and a webinar on the USAID Tulonge Afya project developed under the USAID Breakthrough RESEARCH project.
