On Safari in Tanzania: Spotting the big 5 (or big 40!) Behaviour Change Techniques

Change Exchange Behaviour Change Consultant, Eleanor Bull, writes about her recent experiences in Tanzania with the SAFE project

‘So if you give oxygen to the mother before starting her caesarian section, it really can save her life’, summarises the anaesthetist trainer. ‘Are we together?’ she adds. ‘Yes’ chorus the nurse anaesthetist delegates in unison. Behind them, Nim and I begin tapping away at our ipads. The trainer just used the behavior change technique ‘information about health consequences’ to encourage the nurse delegates to give oxygen to mothers pre-surgery, a health practice the trainers are teaching in this maternity emergency medicine course.

In September we spent a week in Mwanza, northern Tanzania. Many people come to this beautiful part of the world for a safari, to spot lions, elephants or leopards sleeping in trees, but Nim and I were observing the three day emergency medicine training course Safer Anaesthesia From Education (SAFE) Obstetrics. We are behaviour change consultants volunteering on the latest Change Exchange project, helping the World Federation of Socieities of Anaesthesiologists (WFSA) explore the impact of its SAFE Obstetrics course. ‘Safari’ in Swahili actually means journey and it was clear from the welcome we received and warm atmosphere that the course would be a journey of discovery for all involved.

Part of the Change Exchange’s work was to understand which behaviour change techniques (BCTs) trainers use to help delegates to make changes in their practice when they go back to their health facilities across Tanzania. We live coded the course using an e-version of the Michie et al. (2013) BCT Taxonomy v1 on our tablets, which Manchester Implementation Science Collaboration has adapted for use in coding training courses.

Some of the BCTs we hoped to spot were ‘demonstration of behaviour’, ‘practice and behavioural rehearsal’, ‘action planning’ and ‘problem solving’, because of their evidence base in changing behaviour. In fact the faculty of 14 anaesthetist doctor trainers used nearly 40 techniques across the three days. Interestingly, this included a big focus on those used to build motivation for change which are rarely used in similar courses we’ve observed in the UK. For example, in a fantastic instance of the BCT ‘identification of self as a role model’ to encourage use of the World Health Organisation’s pre-surgery checklist, a trainer emphasised to delegates ‘you know the value the checklist can add to people’s lives… if you use it, you will be an example for others in your team and they will have no choice but to follow you…they will follow you’. One of the very entertaining local trainers even livened up a session by unexpectedly handing a delegate a 10,000 shilling note (£3.50) as she had given a great answer to a question. Unfortunately we couldn’t code this as the BCT ‘material reward’ because the reward was directed at the nurse’s knowledge not her actual behaviour…but still very amusing!

Aside from the BCT content, we loved noticing the different styles of the trainers (the ‘how’ of behaviour change) who hailed from six different countries. The international faculty from outside of East Africa tended to make more use of diagrams and check understanding by asking knowledge questions; the trainers from East Africa tended to engage learners by saying most of a sentence with a gap for delegates to reply in unison (‘in emergencies we must always be’…. ‘Prepared’) and asked the lovely question ‘are we together?’ to check understanding. Overall then, there were plenty of sights to be seen on our behaviour change technique safari and no one was sleeping!


SAFE Obstetrics and The Change Exchange

In an exciting new project for The Change Exchange, we are working with the World Federation of Societies of Anaesthesiologists (WFSA) to understand and explore the impact of their Safer Anaesthesia from Education (SAFE) course.  SAFE is 10 years old and has been training healthcare professionals in safe obstetric and paediatric anaesthesia in many countries, most recently in Tanzania, Nepal, Zimbabwe and Bangladesh, with support from the Laerdal Foundation.  We are working with the SAFE project team to explore the data they have collected on previous courses, taking a behavioural perspective on the impact of the courses on practice.  We are collecting quantitative data on behavioural determinants of key practices across Tanzania, Nepal, Zimbabwe and Zambia.  Excitingly, two of our behavioural science consultant volunteers, Eleanor Bull and Nimarta Dharni, are travelling to Tanzania to interview previous SAFE participants, exploring the barriers and facilitators to implementing the learning from SAFE in routine practice.

Wendy and Nim in Uganda with Royal College of Midwives

Our time in Kampala working with midwives on the momentum project is nearing its end.  The momentum project is a health partnership which seeks to facilitate a mentoring programme of student midwives by skilled Ugandan midwifery practitioners. It does this through twinning of Ugandan midwives with midwives from the uk and through training in mentoring skills.  In a short week we have contributed to sessions on behavioural change and communication skills in the training programme, conducted interviews with midwives, twins, students and representatives from the Ugandan private midwives association and the nursing and midwifery council and have had many conversations late into the night about research and evaluation processes and measures. On our final day we were able to visit two very different hospital settings. We are tired but also inspired and exhilarated. The midwives here in Uganda and those we have met on the momentum project from the UK are passionate, knowledgeable and positive.


Despite often difficult circumstances, the humour is universal and crosses any potential cultural or language challenges.

We look forward to returning to continue to look at the evaluation of change and its impact not only on the student midwives learning but also on the learning environments.

A reflective blog from Nisha & Fiona


Our aim this week is to go out and see for ourselves what the Ugandan health care workers are up against when safely delivering pregnant women throughout the region. So for this blog post we thought we’d bring you along with us to give you a flavour of what we found…… We left Masaka heading southwest towards Rakai district on unusually smooth, paved roads, gently weaving around the motorbikes (boda bodas) laden with people and bananas. Shacks and small one-room buildings line the roads in town, selling metal doors, plastic buckets and bowls, and all the phone credit you can use.

Occasionally, joints of meat hang for sale in the sun, and small thatched shacks offer pyramids of tomatoes, watermelons, potatoes and the occasional avocado.

After some time we leave the main road and are unceremoniously catapulted onto ‘real’ Ugandan roads made of compacted dusty, red and rutted earth. We slow to almost a crawl at points, picking our way through banana fields, past students being taught beneath the shade of a tree outside their school, until the buildings thin out to just one or two scattered across the rolling hills. The 20 or so kilometres takes us over an hour, and are uncomfortable enough for us in our sturdy van let alone how it must feel for a woman in the throes of a difficult labour heading for help on the back of a boda. Nisha’s pedometer registers 6000 steps – confirming our feelings of being thrown around inside the car. Progress is slow, but we finally reach the village and turn into the health centre.

Outside, we see queues of young men and boys listening to a lecture under a tarpaulin advertising safe male circumcision. We’re told they’ve been collected in government cars as part of an outreach HIV prevention project, and later today will each make the call of whether or not to go ahead with a circumcision, right here and now, before the ride back….. We walk on towards the scattering of delapidated buildings that make up the health centre, which a member of staff later tells me he is worried will all soon fall in on their heads. We share his fears.

We find the course graduate that we’re visiting in the labour ward – the ward is empty, and strikingly filthy. This is a level three health centre – in theory two steps down from a hospital, yet there are no drugs, no syringes, no gloves and often no water available here. Patients’ families are sent to the village drug store to buy their own, but the midwives themselves agree that the cost of the gloves alone (officially a requirement) can be prohibitive. A Ugandan colleague gamely volunteers to be our ‘mystery shopper’ and try out the drug store and it’s a sobering experience. Although she does come away with a sealed strip of paracetamol, albeit with no date stamp.

Against this backdrop we now understand more than ever the importance that the RCOG faculty place on urging trainees to become advocates, lobbying for the resources that should be provided, rather than only teaching new clinical skills. We have huge sympathy with the health care workers struggling to function in these conditions, but perhaps stronger sympathy still for the mothers for whom this represents the best and only source of help. It’s a grounding lesson in what our behaviour change theories and techniques are up against in this part of the world – but also a challenge calling behavioural scientists to action: The reality facing this midwife in this health centre on her return to work seems to have drained her initial post-course enthusiasm pretty fast – how can behavioural science help to sustain her motivation and sense of empowerment long enough to overcome some of the barriers, and keep going long enough to make a difference?

Is it science or just communication?

This week, I attended a national meeting about patient centredness and was inspired by the work across the NHS to transform care: empowering patients to control their own health and wellbeing; engaging them by increasing their motivation for healthy behaviours and enabling them by providing opportunities and planning to make positive changes.
I reflected on what our Change Exchange volunteers were doing in Uganda and Mozambique and how much of the work was similar to the work on patient centredness across NHSE. Our volunteers are taking cutting edge behavioural science and translating it, at the front line of health education, to increase understanding of what drives people to do health threatening or health protective behaviours. At the same time, they are studying their activities to add to the body of behavioural science knowledge.

I thought about what was at the heart of learning to be more patient centred and learning to empower, engage and enable people in self care and it is, of course, communication. I don’t mean “skills” but I mean genuine communication: people coming together to understand each other.

As our volunteers reflect on what has been successful in their translation of behavioural science I feel sure that it will be about the deeper understanding of people that the deeper understanding of behaviour facilitates.

An update from Kitovu

We’re coming to the end of our 2nd week out in Kitovu – we are caked in red dust, exhausted but also buzzing with ideas of what our next steps could be…. We’ve been very lucky in having really a very receptive, dynamic group of RCOG and Ugandan facilitators to work with, and have already seen many of our suggestions for incorporating behaviour change techniques put into action. The focus groups we have run with Ugandan facilitators and delegates have been particularly insightful, and helped us to gain a more culturally informed perspective. We will be sorry to say goodbye to the majority of the UK team at the end of the week once the training course finishes – after which the real work starts for us. Over our final 10 days out here, we’ll be accompanying the Marcus Filshie fellow Felicity Illingsworth on visits to local health centres to see how previous graduates have got on since completing their training, and reflecting on opportunities for supporting them to make and maintain long term changes. And just to make sure we don’t have an idle moment, we’ll also be developing the behavioural science input into the new Masters’ Training Programme to be delivered in September.
Fiona and Nisha

An update from Beira….

Corina and Eleanor reflect on their first week in Mozambique:

It has been a fantastic week working with our Ipswich colleagues and partners in Beira Central Hospital. This amazing partnership aims to help improve patient safety through projects related to two key strands: equipment maintenance and medication safety. We have been predominantly involved in the complex strand of medication safety, through conducting interviews, focus groups and questionnaires with staff involved in implementing new medication safety procedures. We have also attended drug calculation training and coded the training for behaviour change techniques; presented information to Beira healthcare staff on the role of Health Psychology and the importance of behaviour in healthcare; and worked with our Ipswich partners to deliver training on antibiotic resistance.

All of this work would not have occurred without the invaluable translation help from Luana and Ermerlinda, as unfortunately our Portuguese does not stretch far beyond Obrigado!

A return to Kitovu with RCOG

The June Excellence in Obstetrics Skills course at Kitovu finally gets underway today, run by a new team from the Royal College of Obstetrics and Gynaecology. It is great to see the course incorporating recommendations from Nisha and Amy’s visit in April, in particular the revised action planning guidance: adding implementation intentions and coping planning.  We hope to develop other recommendations into workable formats in collaboration with the RCOG team, as the course progresses.

Nisha and Fiona’s other key aims for this week are to explore what types of social support may be acceptable and practical for Ugandan practitioners, in the absence of support from the UK team further down the line, and to collect video stories from previous graduates of the Excellence in Obstetrics Course to illustrate the positive outcomes delegates might expect from adopting the recommended practice changes.  In behavioural science terms, this provides a more convincing rationale to foster autonomous motivation for change based on local experiences.  Following a day of preparation and rehearsals yesterday with the returning Ugandan course graduates who will form part of the training faculty, we have our behaviour change technique checklists and audio recording equipment at the ready to see what difference behavioural science input could make this time around.  More to follow…..
Nisha and Fiona

After 5 months….

Amy and Nisha had a busy and exciting trip with the Royal College of Obstetrics and Gynaecology in Uganda in April.  We were so impressed by how much they managed to achieve in a relatively short time.  In a 2-week period, they packed in a lot of data collection methods!  They made field notes, carried out focus groups, collected behavioural expectation data and coded the education for behaviour change techniques using the Behaviour Change Technique Taxonomy.
On their return, they wrote a report for RCOG, constructed in terms of capability, opportunity and motivation, provided suggestions about enhancing learning and developed some considerations for RCOG to think about on the basis of their findings.

For example, they found that there was an increase, pre to post course, in delegates’ expectations about using an ABCD approach to acutely ill patients.  They coded 20 behaviour change techniques that the faculty were using, including demonstration of the behaviour, graded tasks and using a credible source.
We have received some early feedback from RCOG – they found the report interesting and helpful and are planning to implement some changes.  We look forward to Nisha and Fiona’s findings.


Eleanor and Corina have landed in Beira, Mozambique, with the team from Ipswich Hospital.  Eleanor and Diane have already visited the partners when the Beira partners were in Ipswich last month.  With a focus on medication safety, we are looking forward to an update from them about what behavioural science can offer this partnership.


Wendy and Nimarta are about to depart for Kampala with colleagues from the Royal College of Midwives working on the MOMENTUM project with the Ugandan Private Midwives Association.  The MOMENTUM project is about mentoring of student midwives and takes a mentoring approach throughout, with the UK midwifery consultants twinning with their Ugandan counterpart to bring about postive changes in mentoring in midwifery training.  Taking a collaborative and action research approach, Wendy and Nim are, on a short trip, developing ideas about how behavioural science can assist these partners in meeting their aims.  We look forward to their update.

University of Plymouth-Masanga Hospital, Sierra Leone

Discussions are underway with this partnership about how behavioural science evaluations can assist them in understanding the impact of their elearning on healthcare workers and community members when they suspect someone is infected with a highly infectious disease.  So far, we have designed a behavioural science-based questionnaire to assess capability, opportunity and motivation for key behaviours such as hand washing, using a buddy when putting on or taking off personal protective equipment and providing oral hydration even if someone is not thirsty.  An update is expected in July.