essentials of IEC
education and communication (IEC) combines strategies, approaches
and methods that enable individuals, families, groups, organisations
and communities to play active roles in achieving, protecting
and sustaining their own health. Embodied in IEC is the process
of learning that empowers people to make decisions, modify behaviours
and change social conditions. Activities are developed based upon
needs assessments, sound educational principles, and periodic
evaluation using a clear set of goals and objectives. IEC activities
should never be developed or implemented independently from a
broader reproductive health programme that is being designed and
executed in the country. IEC activities not only need to have
an appropriate context in which they are shaped, but it is crucial
that health services providers be prepared to respond to any demand
that may be created as a result of effective IEC activities. The
influence of underlying social, cultural, economic and environmental
conditions on health are also taken into consideration in the
IEC processes. Identifying and promoting specific behaviours that
are desirable are usually the objectives of IEC efforts. Behaviours
are usually affected by many factors including the most urgent
needs of the target population and the risks people perceive in
continuing their current behaviours or in changing to different
Health information can be communicated through many channels to
increase awareness and assess the knowledge of different populations
about various issues, products and behaviours. Channels might
include interpersonal communication (such as individual discussions,
counselling sessions or group discussions and community meetings
and events) or mass media communication (such as radio, television
and other forms of one-way communication, such as brochures, leaflets
and posters, visual and audio visual presentations and some forms
of electronic communication).
Good communication between users and providers of any service
is essential; but it is especially important when providing RH
services, given the sensitive nature of some of the issues that
are addressed (such as sexual violence, female genital mutilation,
and providing contraceptives to adolescents). Accordingly, IEC
approaches must be carefully and appropriately designed and selected.
Although good "one-to-one" communication at the point of service
provision is essential for transmitting information and building
trust with the client, communication with other individuals and
groups within the community is also vital. It is through such
communication networks that service providers can obtain information
about users' needs, priorities and concerns. Such informal information
gathering is the first step in assessing needs (which can be supplemented
by other more formal means see section below). It also
helps providers better understand the specific setting and context
in which they are working, which will be useful in the later development
of IEC approaches, messages and materials.
These types of conversations, or passing on information by "word-of-mouth",
has been shown to be one of the most effective communication channels
for acquiring knowledge and promoting desired changes in behaviour.
Evidence of this is the speed with which rumours spread and the
force of their impact. Field staff should not ignore these informal
opportunities to educate the public through casual conversation
with people in the community.
Once a refugee situation stabilises, it becomes appropriate to
consider the development of more elaborate and formal IEC strategies.
This requires serious thought and significant allocation of time
and resources. The steps involved in the development of IEC are
outlined here, but this is not intended to be an exhaustive guide.
More in-depth information and details can be found in the items
listed in Further Reading. Whatever materials
and formal programmes are developed, it is important to ensure
that the different aspects are coordinated, and that the content
of any messages and the media used to convey those messages are
complementary. It is also vital to ensure that people are provided
with the necessary support and resources to act in the manner
can be both verbal and non-verbal.
In verbal communication, the tone of voice can communicate
feelings and emotions that are as significant as the words being
spoken. Accordingly, it is important to choose words that do not
offend in any way and that are easily understood. One should avoid
using trigger words, jargon, medical or other sophisticated terms.
The use of particular languages may be important in reaching all
sections of a community (women may speak fewer languages than
men, for example).
In non-verbal communication, body position, gestures and
facial expression, often referred to as "body language", can communicate
as much as words. It is often through such body language that
we express our attitudes towards an issue, a person or a person's
behaviour. Service providers must become skilled in interpreting
the body language of users as this may assist them in understanding
users' needs and concerns more fully. Service providers must also
be aware of their own body language and the signals they may be
unknowingly sending to users (e. g., movements or expressions
that indicate fatigue, boredom, fear, frustration, indecision).
It is important that the attitude conveyed by the service provider
be compassionate and non-judgmental.
communication skills are necessary to ensure that good-quality
services are provided and that service users are satisfied. It
is through communication that trust and rapport are established
between the provider and user of a service. Emotional support
and the communication of concern and understanding by health staff
are often as crucial in providing quality services as is clinical
care. If there is a strong provider-user relationship established
in this way, it becomes easier to move towards open dialogue on
more sensitive aspects of reproductive health.
Individuals and Community Groups
communication with service users, it is necessary to open a dialogue
with influential individuals and groups within the community.
Such individuals and groups will need to be identified as early
as possible. The nature and intention of services should be explained
to them and their concerns and priorities discovered and understood.
This will not only help make the services more appropriate to
the clientele being served, but it will help garner family and
community support for the client in the reproductive health behaviour
being promoted. The following are some pointers for identifying
such individuals and groups:
Familiarise yourself with the community with the help of someone
who lives in the environment of the refugees and who provides
them with some service, advice or protection.
Identify individuals who are most important in the social structure
of the community with which you are working. They can be existing
formal leaders (elected or appointed), but, more often than
not, they are informal leaders. This can be done by asking many
people in the community. As certain individuals are named repeatedly,
it will become clear that they are the true leaders.
Identify individuals who have some influence within the community,
people whose opinions are respected. They will make suggestions
about how to approach people and work with them effectively.
They can also serve as role models for desired behaviours and
Provide these individuals with very clear information about
what your intentions are, what you plan to do, and how they
can contribute as partners. Be specific about what they will
gain from working with you and allowing you access to the community.
Provide them with input about your plans before you proceed,
and secure their willingness to participate and to support
is a key component of an IEC programme. In the best of circumstances,
a good counsellor is compassionate and non-judgmental, is aware of verbal
and non-verbal communication skills, is knowledgeable concerning RH
issues, and is respectful of the needs and rights of the users. In a
refugee situation, there is often a poor counsellor-to-client ratio,
emergencies are common and the local environment is not conducive to
counselling. However, at a minimum, counsellors should strive to ensure
that every service user has the right to the following:
to learn about the benefits and availability of the services.
to obtain services regardless of gender, creed, colour, marital status
to understand and be able to apply all pertinent information to be able
to make an informed choice, ask questions freely, and be answered in
an honest, clear and comprehensive manner.
a safe and effective service.
to have a private environment during counselling or services.
to be assured that any personal information will remain confidential.
to be treated with courtesy, consideration and attentiveness.
to feel comfortable when receiving services.
to receive services and supplies for as long as needed.
to express views on the services offered.
of the Counsellor
role is to provide accurate and complete information to help the user
make her/ his own decision about which, if any, part of the services
(s) he will use. The role of the counsellor is not to offer advice or
decide on the service to be used. For example, the counsellor will explain
the available family planning methods, their side effects and for whom
they are considered most suitable. The user then makes a decision, based
on the information given, about which method she/ he wishes to use.
counselling requires understanding one's own values and not unduly influencing
the user's by imposing, promoting or displaying them, particularly in
cases where the provider's and the user's values are different.
a Needs Assessment
never to assume that you know what refugees need or want in their lives
or from your projects.
effective interventions, you must find out what refugees think and know
about various issues, including their ideas about: what causes sickness
and disease and what maintains health, health care, traditional medicine,
and reproductive health. It is important to build a relationship of
trust and mutual respect in order to get accurate and complete information
about sensitive issues such as sexual and reproductive matters.
usually necessary to use multiple methods in undertaking a thorough
needs assessment. Focus groups, individual interviews or Knowledge,
Attitude, Behaviour and Practice (KABP) surveys can be valuable ways
to gather information and help develop systems, activities, materials
or messages to support RH interventions. Only after there is an accurate
picture of the refugee community's knowledge, attitudes, behaviours,
expectations and aspirations surrounding reproductive health can you
determine what programme and messages might be best suited to its needs.
and IEC activities and materials should be based on relevant research
conducted through the use of quantitative (how many) and qualitative
(what, why and how) methods. Research and discussions should be seen
as an integral and ongoing part of planning and implementation.
available incidence or prevalence rates of targeted problems.
Attitude, Behaviour and Practice (KABP) Surveys use a series of closed-and
open-ended questions to determine what people in a community know,
think, believe or do in relation to their reproductive health. Findings
are presented in the form of percentages of people who think or do
a certain thing. These surveys require many respondents that are randomly
selected from the community. Interviewers are needed to implement
the survey and they must be trained. This is generally considered
an expensive and time-consuming method. Also, this kind of survey
does not usually gather information about what inhibits or promotes
certain behaviours, since those factors may arise from the context
in which people live and not from their knowledge and attitudes.
interviews allow the researcher to get deeper insights into a person's
thoughts and feelings. Using an interview guide, interviewer and respondent
talk at length about the respondent's feelings about a specific service
or issue. If trust is established and confidentiality ensured, the
interviewer can often get very valuable information about the interviewee
and the community, information that might not otherwise be revealed.
Focus Groups are in-depth discussions, usually of one to two hours
in length, with a small group of people. Members of the Focus Group
should have something in common with each other (age, sex, and experience)
in the expectation that this will make it easier for them to talk
together. They are representatives of the target group in that they
are deliberately chosen. The intention is to make sure different
groups within the community are represented within the Focus Group,
or that several Focus Groups are held with members drawn from various
sectors within the community. Discussions are lead by a facilitator
who follows a prepared guide that allows for probing into the thoughts
and feelings of group members. This method is often considered cost-effective,
as many people are gathered together at one time to express their
opinions. Findings are presented in the form of comments or extracts
from interviews, which illustrate what people are thinking about
certain topics, or why they engage in a particular activity.
Tools for Conducting RH Needs Assessments
Health for Refugees Consortium (1) has field-tested
and finalised five RH needs assessment tools. These are
Refugee Leader Questions
Group Discussion Questions
Survey for Analysis by Computer
Survey for Analysis by Hand
Health Facility Questionnaire and Checklist
of these tools is to assist relief workers in refugee/ displaced person
settings in gathering information to assess attitudes toward RH practices
and local medical practices/ policies, the extent of needed services and
the degree to which current services provide what is needed.
It is important
to note that not all tools will be appropriate for all refugee situations.
The order in which the tools are used may also vary. In general, refugee
leaders are consulted before any information is gathered from the larger
population. This is often followed by group discussions, key informant
interviews and facilities review. In some situations, a survey may be
conducted but this is often dependent upon resources, time, skills of
available staff and whether or not the level of effort required by a quantitative
survey is warranted. A clear needs assessment objective will help field
workers decide which tools are appropriate for their particular situation.
provided by the tools must be reviewed in the context of the broader
objective of the needs assessment. Any tool used should be adapted to
the local situation and resources available. Judgement is required by
those applying the tools. In many cases, other resources may exist to
support the needs assessment and these should be used. Examples of additional
strategies for collecting information include: camp registration records
(information on women's ages, marital status, and sometimes pregnancy);
clinic, health centre and/ or traditional birth attendant records; in-depth
interviews with representatives from UNHCR, UNFPA, Ministry of Health
and NGO staff; camp health coordinating committees and NGO logistics
officers; and structured observation at different times of the day and
night in the refugee community.
The RHR Consortium comprises American Refugee Committee, CARE, Center
for Population and Family Health, Columbia University's Mailman School
of Public Health, The International Rescue Committee, JSI Research
and Training Institute, Marie Stopes International and the Women's
Commission for Refugee Women and Children.
the GATHER method of counselling may appear simplistic, it is
complete and thorough:
users about themselves
users about the service(s) available
users choose the service(s) they wish to use
how to use the service(s)
in Developing IEC Activities
gathered through the needs assessment provides the framework for the
development of suitable IEC activities. Any activities and materials
must always be culturally sensitive and appropriate. These are the major
steps you should follow when designing an IEC activity:
Conduct a needs assessment.
Set the goal. This is a broad statement of what you would like to
see accomplished with the target audience in the end.
Establish behavioural objectives that will contribute to achieving
Develop the IEC activities and involve as many other partners as
possible. After their successful implementation, you should be able
to have a significant impact on achieving the behavioural objectives.
Identify potential barriers and ways of overcoming them.
Identify potential partners, resources, and other forms of support
for your activities and gain their sustained commitment.
Establish an evaluation plan.
should determine the level of achievement of the behavioural objectives.
Having such specific indicators makes evaluating and monitoring the
progress and impact of the activities much easier. Additionally, process
indicators could be established to track to what extent and how well
the planned activities have been carried out.
objective must be SMART:
(what and who)
(something you can see, hear or touch usually expressed
with an action verb)
IEC messages. A good message is short, accurate and relevant. It will
make, at the most, 3 points. It should be disseminated in the language
of the target audience and should use vocabulary appropriate for that
audience. The message tone may be humorous, didactic, authoritative,
rational or emotionally appealing. It may be intended as a one-time
appeal or as repetitive reinforcement. It is often necessary to develop
several versions of a message depending on the audience to whom it
is directed. For example, differing information about contraceptive
services will be relevant to women who already have three or four
children already, from that which would be appropriate for adolescents
who are just beginning to be sexually active. Their needs and priorities
are different, so the IEC materials used with each group must also
differ. Find out if materials already exist in the host country or
country of origin, and if appropriate, use these instead of developing
by trying out the materials with small groups from your larger target
audience, is an essential part of developing messages and educational
materials. It is through pre-testing that you will ensure that people
understand the message as intended. Pre-testing may need to be repeated
frequently until you are sure your information is being conveyed as
Determine suitable methods and channels of action and communication.
Once the target audience is identified and researched and the key
messages have been chosen, it is time to decide which media and
combinations of information channels will reach the target group.
Both formal and informal groups can be targeted. Different channels
do different jobs. Each has its own strengths and weaknesses, depending
the role it will take in the communication programme. The choice
of messages and media will be influenced by many factors: cost;
literacy levels; artistic style within the community; familiarity
with, and extent of penetration of a particular medium for both
service providers and users; and availability of the medium in the
target population's community.
and refinement of messages and the choice of the communication channel
or medium are inseparable. Very different messages will be developed
for different media, for example radio, stories, poems, songs, posters
or flip charts, for the nature of the medium affects what messages can
be successfully used. The skills of those using the materials must also
be considered. It may be necessary to provide training to those staff
expected to use the materials. For example, it is important to recognise
that placing a picture or poster on a clinic wall at which people may
or may not look is quite different from using a series of pictures in
the form of a flip chart as an educational tool in a group setting.
are some suggestions for key messages on technical topics that may be
shared. These are presented as examples only and are shown out of context.
The choice of any message will, in reality, be context-specific; often
a group of messages will be decided upon, rather than just one.
importance for women to seek medical care as soon as possible
Where to go for counselling if it is available
How to prevent it, particularly in collaboration with others in
The reasons why it is important for women to seek prenatal care
The need to and how to identify obstetric complications and refer
The reasons it is important to breastfeed exclusively and the importance
of maternal nutrition
Sexually Transmitted Diseases (STDs)/ HIV/ AIDS:
to use condoms and how to dispose of them safely
How HIV is and is not transmitted
Means of prevention
Common signs and symptoms
Where to receive counselling
Where to receive treatment
Where to go for support services
Why it is important to inform and involve all sexual partners
How and where to obtain reproductive health services, including
Where to get information or counselling
How adequate birth spacing contributes to healthy families
Health of Young People:
How young people can protect themselves through safe sex
Delay and patience is a positive value and that there are other
ways to have fun
Young people need to take responsibility for their own health
High-risk behaviours may result in long term, unwanted consequences
to Providing Services, Support and Follow-up
of any kind to be effective it must be linked with the availability
of support and resources so target audiences can act in the manner which
is being recommended. It is therefore essential that the content of
any IEC programme accurately reflect the nature and quality of the services
provided. Logistical support must be adequate to ensure the necessary
supplies (material and human) are consistently available and adequate
training should be provided to health workers to support inter-personal
communication and community follow-up. People must be able to act on
the advice contained in the IEC messages and materials.
Box for Building Health Communication Capacity", Healthcom, Academy
for Educational Development, Washington, DC, 1995.
M. Methodological Review: A Handbook for Excellence in Focus Group
Research, Washington, DC, Academy for Educational Development, 1988.
Health and Family Planning Print Materials for Low-Literate Audiences:
A Guide", Program for Appropriate Technology in Health, Seattle, PATH,
Health Promotion and Education Initiatives in Reproductive Health: A
Framework for Action Planning", WHO, RHR, Geneva, 1998.
for Life", UNESCO/ UNICEF/ WHO. "Guide to Planning Health Promotion
for AIDS Prevention and Control", WHO AIDS Series 5, Geneva, WHO, 1989.
Reproductive Health Needs Assessment Field Tools", RHR Consortium, 1997.
for Project Evaluation: A Guide for Evaluating AIDS Prevention Interventions",
Family Health International , AIDSTECH/ Family Health International,
Durham, NC, 1992.