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COMBI founder and WHO Communication Advisor-Consultant Dr. Everold Hosein to the Yemen Times: - "The COMBI approach,C*helps take people from knowledge into the area of action." (Business).

Dr. Everold Hosein, Communication for Behavioral Impact (COMBI) founder and World Health Organization (WHO) Communication Advisor-Consultant was in Yemen last week conducting a training workshop organized by the Ministry of Public Health and Population in collaboration with WHO.

The workshop, which was financed by the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), aimed to educate participants on how to use the COMBI approach to address health concerns, such as the elimination of malaria.

The COMBI approach was created to get the behavioral results desired for social development. COMBI interprets social mobilization as a process which strategically blends a variety of communication interventions intended to mobilize societal and personal influences. This can in turn prompt an individual to adopt and maintain a particular behavior.

With a PhD in Communication and Business Administration focused on marketing administration, Hosein has worked with the International Planned Parenthood Federation as well as with a major public relations company in New York City. He has also been involved in extensive consulting work for UN agencies including the United Nations Population Fund (UNPF), United Nations Children's Fund (UNICEF), United Nations Development Program (UNDP), UN AIDS and the World Bank.

Ali Saeed of the Yemen Times met Hosein and spoke to him about the COMBI approach and how the public sector can make use of it.

Can you explain in more detail what the COMBI approach is?

The focus of COMBI is to achieve behavioral results desired in social development work of UN agencies and the WHO. The reason we put the emphasis on behavioral impact is that for the past 50 years in public health education and in what we call development communication the focus has been on making people aware and knowledgeable about behavior that will make a difference in their lives.

Behaviors such as breastfeeding, washing hands after using the toilet and sleeping under mosquito nets are ultimately the goal of our public health education. The problem we have had so far is that we have been very good at getting people to be aware and knowledgeable about what to do, but we have been less successful at getting people to actually anything about it.

We are trying to bridge this gap between knowing what to do and doing it, and COMBI is an approach to help close this gap, to help take people from knowledge into the area of action.

We put the focus on action and we use a lot of techniques we have learned from the public sector in the past 50 years and the private sector in the past 150 years.

In essence, we are trying to marry what people in the private sector do in terms of marketing communication and what we in public health have done in terms of health education and health communication. That is the marriage we hope will make the difference between people knowing what to do and then taking the next step and carrying out the actions.

How did you come up with the COMBI approach?

The COMBI approach came about as a result of failure. It came about as a result of not being able to understand how committed people knew what to do but did not do it.

In looking at that, and looking also at what the private sector was doing, we realized that there was a missing engine so to speak. This realization came to me when I was working with the public relations company in New York and also with UNICEF at the same time.

We realized that so far in our communication work, we put the emphasis on teaching people be aware and be knowledgeable. However, when you look at what the private sector was doing in what they call integrated marketing communication, we realized that they put the emphasis on getting people to act, to walk into a shop and buy a particular product.

I then started working in New York on this new approach during the mid 1990s. We first offered a training program at New York University in 1994 which was entitled "Integrated Marketing Communication for Behavioral Impact in Health and Social Development."

The focus was to get people to plan marketing communication with other aspects of health education. When we realized the gap between people knowing what to do but not doing it, we started working on something different. It is not enough to just give people the information in order to have them act on it. Something extra must be done.

Looking at the history of health education, people are knowledgeable but do not act.

Look at the private sector; it has a better way of focusing on getting people to act, for example, getting them to walk into the shop and buy a particular product. This is why at New York University, we started offering this training which was called integrated marketing communication. This was the same approach the business sector was using. We decided to offer this course regularly.

At that time I was asked to join the WHO. My first meeting there ended with a presentation on integrated marketing communication for behavioral impact in health.

At that meeting I realized that many of my colleagues in the WHO and the UN were slightly uncomfortable with marketing language. They did not think that in the health sector we market anything, and they could not see the link between marketing and getting people to use mosquito nets for example.

As a technical measure, we decided to drop the integrated marketing term and just have a description of what we are doing, which is communication for behavioral impact, and that became the acronym COMBI. However, the foundation of COMBI is in fact integrated marketing communication.

The reason we changed the language was to accommodate people's feelings. The terminology was perhaps not appropriate for what we were doing in health and social development.

But I have been a firm believer that the techniques used by the private sector to get people to drink Coca-Cola and to buy Pizza Hut and so on can be modified and used to get people to use mosquito nets, family planning, and to get families to breastfeed their children.

Such behaviors can be handled very effectively with the same marketing communication principles that the business sector uses.

How did you get the idea of applying the COMBI approach in malaria elimination?

Well, the idea came to us not only with malaria elimination, but it came to us to bring about any behavior you want to achieve in health.

The COMBI approach started working in relationship to leprosy and how to get people with skin lesions to go in for a skin check to see if they have leprosy.

We use COMBI with dengue, we use COMBI with tuberculosis, and we use COMBI with HIV/AIDS. We also use the approach with malaria elimination in several African countries, including here in Yemen. Now Yemen is making progress and is even getting close to the possibility of becoming a country in which malaria would be eliminated.

I went to some African countries and they are far away from even being considered to be countries which have achieved certain stages in malaria elimination. So Yemen has made a lot of progress.

Right now we are in the last stages of the process and we suspect that we probably will take another ten years at least get to the point of saying "we have eliminated malaria here."

What is new in the COMBI approach in comparison with other approaches?

I think the new components are all related to achieving behavioral results. We have to move beyond just informing and educating people.

For example, I think most people in Yemen understand how you get malaria and how you can get treated for malaria. But there is a certain segment of the population that even though understands the concepts we promote in health care still has difficulties in carrying out the recommendations we are making.

Our recommendation is that if you are pregnant, sleep under a mosquito net for the entire course of pregnancy. If you have children under the age of five, bring them mosquito nets and get them to sleep under the nets.

Our focus is going to be that if you know you should be doing it, why not do it now?

The COMBI approach preserves the process of what we call market research. By this, we mean going to the community and listening to people to find out what the difficulty is that they face in carrying out a particular behavior.

I would say the program that we have been working on in Yemen focuses on the production of communication materials, making posters, making pamphlets and so on, referencing why people do not carry out the appropriate behavior.

I do not think we have done enough. We have not done enough listening to the community - conducting the market research, in other words.

That is why people are still reluctant here to follow our recommendations of sleeping under mosquito nets, or if you have a fever and you are in an endemic area, immediately think that it could be malaria and get quick treatment.

The longer you wait, the more problematic the disease is and the more likely you can die. The earlier the treatment the better, and that's a particular behavior that we have to focus on.

I would recommend to the Ministry of Health in Yemen to conduct market research to figure out what are the behaviors people already know about, why those behaviors are not being carried out and then to plan a communication program. After that, decisions can be made about the need for posters or pamphlets to get people to jump this hurdle of 'I know what to do, but I'm not doing it yet.'

So I think our program, the COMBI approach, is different in the way it focuses on market research and in the way it focuses on listening to people in the community. It is also different in the way it focuses on helping people to make that leap from knowing what to do to actually doing it.

Our program puts emphasis on personal communication between professionals who know the answers to these questions and to the questions that people are going to ask rather than putting too much emphasis on posters and pamphlets.

Do you think that the COMBI approach can be useful for non-health sectors?

Definitely. I would say wherever there is a behavioral patter that can make a difference in the lives of people, you can use the COMBI approach. It doesn't have to be in the health sector only.

For example, it can be used to prevent violence against children. I was working in Jordan where violence against children is a big problem. Teachers hit and slap children, and parents beat children thinking that this is the proper way to discipline them. It is not the proper way to discipline children.

We can educate people about behavior related to preventing violence against children using the COMBI approach.

For instance, a certain behavioral patter can be taught as to how children can be intellectually stimulated when they are very young, under the age of two. UNICEF has a program for child stimulation and COMBI can be used to teach specific behaviors to parents and caregivers.

I would say that [for] any behavior anyone wishes to accomplish in the social development of Yemen, the COMBI approach can be used to achieve this particular behavior.

What are the humanitarian advantages of the approach?

The humanitarian advantages are that if you succeed in getting people to carry out the right behaviors that will improve their lives, it is one of the most beautiful humanitarian things you can do.

If we can get a family to protect children from dying from malaria, that to me is the essence of fulfilling a humanitarian need. We need to protect our children as well as our adults from diseases which might kill them.

What do you expect the outcomes of the COMBI workshop in Yemen will be?

At the end of the workshop, we will have three to four working groups who will create a presentation using what we called the ten steps of planning a COMBI program. Participants learn about the COMBI approach and will then be able to use the COMBI plan in getting the behavioral results that they want to be accomplished.

There is also another outcome where a few of the colleagues in the workshop will be working with me to come up with an actual strategic communication plan related to malaria elimination. The follow up to the workshop in that sense is going to be important, because I'm going to depend on them for advice on what kind of communication plan will enable us to reach the goal of eliminating malaria in Yemen.

What do you recommend to Yemenis who work in the health sector?

My recommendation to them is that I'm focusing on health communication when it comes to malaria, but I'm sure that there are other diseases which affect the health of people in Yemen. I would encourage the Ministry of Health together with WHO colleagues to see how we can use the COMBI approach in other aspects of health.

One of the health problems that I think will eventually emerge in Yemen is the problems related to obesity and diabetes. I'm not saying this as an expert on the subject, but when I talked to colleagues in Yemen I realized that people here do not exercise very much. People do a lot of sitting around while chatting, chewing qat and not being physically active while eating a lot of sweets.

Some of my colleagues told me that in qat sessions, people also mix qat chewing with sugar, and after the long session they do not do any exercise. That is going to contribute to obesity and diabetes.

This is something that people should be worried about in the future. Here, COMBI can be used to promote the behavior of exercise, for example, if we want to prevent ourselves from obesity....

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Publication:Yemen Times (Sana'a, Yemen)
Date:Sep 13, 2009
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