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Bright Star, Bright Sindh WORKING TOGETHER FOR A BRIGHTER FUTURE for Sindh, PAkistan

To accommodate an expanding population, as well as a significant shift to a more youthful population, Pakistan has worked to increase access, awareness, availability, and utilization of key maternal and child health services. The United States Agency for International Development (USAID) Maternal and Child Health (MCH) Program was a reflection of Pakistan's effort. The large public health project included several components that set out to improve Maternal and Child Health in Pakistan's second largest province, Sindh.

From 2014- 2018, under USAID's MCH program, the Johns Hopkins Center for Communication Programs (CCP) led the Health Communication Component (HCC). HCC used strategic social and behavior change communication to improve maternal, newborn and child health and family planning in Sindh. CCP worked closely with several partners including Center for Communication Programs Pakistan, Rural Support Programme Network, and Mercy Corps.

Pakistan HAs the 6th largest population in the world

According to the Population Reference Bureau (2017), Pakistan's population has increased to over 260 million. More than one-third (36%) of Pakistanis are under the age of 15.

The current infant mortality rate is among the highest in the world. Maternal deaths are also cause for great concern. Across Pakistan, for every 100,000 live births, 178 mothers die due to a complicated pregnancy or challenges during delivery. These staggering statistics underline the urgent need to improve Pakistan's maternal and child health situation.

From the outset, HCC envisioned a Pakistan where individuals, families and communities would advocate for their own health, practice positive health behaviors and engage with a responsive health care system.

Working closely with the Sindh Population Welfare Department, Lady Health Worker Programme and other local partners, HCC implemented a comprehensive set of sustainable interventions anchored under an overarching campaign, Bright Star (Hum Roshan Tal Roshan).

Bright Star (Hum Roshan Tal Roshan) brought together all the communication activities undertaken by USAID’s Health Communication Component. The communication campaign was guided by a 360-degree media approach, whereby the various forms of media were used together in such a way so that media consumption gaps appearing in one form of media are addressed by another form of media. This approach maximized the penetration and retention of communication messages to the prioritized audiences in Sindh without the exclusion of any possible audience based on its media consumption habits.

Here is how we did it

SYSTEMS-LEVEL

HCC set out to strengthen the health system in Sindh by providing technical support to various key stakeholders, including the Department of Health and the Population Welfare Department, and also the overarching USAID Maternal and Child Health Program in Sindh.

Specifically, with the government institutions, HCC developed technical content and corresponding communication strategies. HCC also worked to build the capacity of the government human resources through direct technical assistance on health communication strategy development.

HCC recognized gaps in training opportunities for students and SBCC professionals and used that insight to develop dedicated capacity strengthening resources. Over the course of four years, HCC developed a pre-service training, conducted several workshops on Leadership in Strategic Communication and initiated a new Health Communication Course at a local college, SZABIST. These courses are now institutionalized at SZABIST and Health Service Academy.

Click below to listen to a SZABIST Representative reflect on the Health Communication Course:

HCC also expanded health communication professional networks in Pakistan through Springboard and 30 participants who were trained in Leadership in Strategic Communication Workshops.

SBCC practitioners were not the only group to benefit from training opportunities; religious leaders also received useful guidance on incorporating maternal and child health information into weekly sermons.

HCC prioritized the revision and adoption of an IPC Toolkit. Working closely with Department of Health and the Lady Health Worker Programme, HCC updated the content and refreshed the toolkit's overall approach. The revised IPC toolkit encouraged community health workers to take ownership of the toolkit's material in order to strengthen community-level interactions. The IPC toolkit quickly became popular and is now available in Sindhi and Urdu for use in Sindh, Punjab, and other provinces.

Mass-Level

The popular television serial Sammi incorporated an Entertainment-Education approach, relatable characters and robust storytelling to stimulate a discussion of stigmatized issues. Aired from January to June 2017, Sammi raised awareness of social issues and prejudices. In particular, Sammi explored the social practice of Vani.

Sammi reached more than 9 million viewers through both television, Facebook and other social media platforms. Sammi content also fed into blogs, music video, short films and television commercials to promote the series.

Interested in experiencing HCC mass media content? Click the following links for Television Commercials, Short Films, and our Bright Star Song.

HCC facilitated a series of discussions with SBCC practitioners and students on the popular film Bol, which was also produced under a USAID- funded, CCP-led health communication program (PAIMAN).

The series of discussions took place over a series of months and involved different groups.
Community-Level

Over the course of 5 years, HCC developed a suite of tools to support frontline health workers, led numerous training with community outreach and contributed thought leadership in the area of community health worked capacity strengthening. HCC provided capacity building and supportive supervision and interactive tools –including a smartphone application– for over 7,500 Lady Health Workers (LHWs) and Community Health Workers (CHWs).

HCC contributed towards the development of faith actors and journalist networks. HCC created communication influencers, who because of their social and normative roles within the province, were able to drive social and behavior change within local communities around mother and child health. USAID’s HCC mobilized and trained local journalists and local faith actors to become communication influencers. Supported by networks of peers, across their district and their province and aided by toolkits, these journalists and faith actors delivered health messages through the acts of ‘news-making’ and ‘sermon-making’ respectively to their local communities.

Overall, HCC has touched the lives of more than 2 million people residing in Sindh through existing community networks (LHWs, CHWs, Faith Actors, Journalist, etc).

Individual-Level

HCC implemented a family planning (FP) campaign across the 10 project districts which reached more than 95,000 people. The campaign included multiple components: a community fair, short film screenings, health stalls and local entertainment. The entire community was invited to participate in a family friendly community health event. Since being launched in May 2017, the FP campaign activities reached over 10 million people. The FP campaign spurred an increase in referrals for family planning from 8,230 to 11,686 per month.

Family planning services were available on site for interested attendees.

Changes in individual behaviors and subsequent actions as a result of community, mass media, and systems-level changes. The individuals are represented as Bright Stars: LHWs, CHWs, health provider, faith actor, journalist, community member(s) (male and female), and household (featuring elderly and children, around facility referral and its benefit). A “Bright Star” was seen as someone working to improve the health of his or her family, community or country. HCC used aspirational mass media pieces (i.e. television commercials) and thoughtful community- level approached to spark the movement. The result was an inclusive tide of change that encouraged individuals across Sindh to contribute towards meaningful behavior change and improve maternal and child health. In November 2017, HCC celebrated the achievements Bright Stars from across Sindh; the motivated individuals who brought improvements to their communities. During the Bright Star award ceremony, the award speeches highlighted key HCC efforts, such as Community Support Groups, that inspired Bright Stars to change their communities and improve maternal and child health.

Gender

HCC adapted an acclaimed gender approach, African Transformations, to develop a Community Dialogue Toolkit. The toolkit was designed to engage community members (segregated by sex) in deep discussions around the issues of gender, health and social norms.

Here is why it matters

Findings from HCC's Endline Study

HCC interviewed over 2,100 married women ranging from 16-47 years to evaluate the extent to which the HCC program achieved its program objectives among the target population. The women lived in rural and urban areas of our project districts: Umerkot, Jacobabad, Sukkur, Mirpurkhas, Larkana, Sanghar, Naushero Feroze, Matiari, Shikarpur, and Ghotki district.

Our study showed that exposure to HCC significantly contributed towards behavioral outcomes for women across Sindh.

Participants who were exposed to HCC FP messages had also a higher use of modern contraception at the time of the survey (33%) compared to (21%) with no exposure (p=0.000).
Overall, among participants who were exposed to HCC Bright Star Campaign, 86% approved of birth spacing compared to 67% with no exposure to the Bright Star Campaign (p=0.000).

In addition, a higher proportion of participants exposed to the Bright Star Campaign approved of limiting the number of births (81%) compared to those who were not exposed (66%). Among those exposed to the Bright Star campaign, 78% had discussed FP with their spouse in the last 12 months compared to 68% with no exposure to the campaign (p=0.000). Overall, a higher proportion (25%) of participants who were exposed to the Bright Star campaign had initiated discussions about FP with their spouse in the last 12 months, compared to those who were not exposed to the campaign (21%) (p=0.021).

Overall, more participants who were exposed to the HCC Bright Star campaign intended to deliver their next child at a health facility (91%) compared to those who were not exposed (80%) (p=0.000).

There was a statistically significant association between appropriate handwashing behaviors in the past 24 hours prior to the survey, and exposure to the HCC Bright Star campaign; 59% of participants with exposure to Bright Star practiced appropriate handwashing compared to 51% of those with no exposure (p=0.001).

HCC demonstrated that communication-focused individual- and community-level interventions have potential for promoting improved RMNCH outcomes through individual behavior change.

HERE IS WHY HCC is SUSTAINable

The Government of Sindh has committed to continue the work of USAID’s HCC, by initiating implementation of the FP campaign of the Bright Star movement in its future work, and by scaling up the use of the technical content, particularly through the LHW programme’s Roshan Mustaqbil Toolkit across the remaining districts of Sindh.

SZABIST and HSA will continue the health communication courses introduced by HCC, while over 10 universities across Pakistan have so far incorporated the entertainment-education into its curricula. In order for faith actors and journalists based in Sindh as well as Pakistan to continue to undertake social activities that USAID’s HCC supported – such as sermon-giving and news-making on maternal and child health – HCC consortium partner CCPP will continue to maintain its two existing networks of faith actors and health journalists. Crucially, it will seek to merge the provincially distinct networks of faith actors and health journalists developed under USAID’s HCC (in Sindh) and DFID’s EVA (in Punjab and Khyber Pakhtunkhwa) to better integrate these networks at the environmental level across Pakistan.

For more information on the Health Communication Component in Pakistan, contact: ccpinfo@jhu.edu

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