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.

A reflective blog from Nisha & Fiona

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

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

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.