A Research Spotlight From Breakthrough RESEARCH

USAID Tulonge Afya’s NAWEZA Platform

Building Evidence to Inform Practice for Integrated Social and Behavior Change Programming

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Advancing Social and Behavior Change Programming

Breakthrough RESEARCH, with input from the United States Agency for International Development (USAID) and cross-sectoral implementing partners, developed research and learning agendas (RLAs) to strengthen two important areas of social and behavior change (SBC) programming: integrated SBC programming and provider behavior change (PBC).

The RLAs identify and document:

  • Gaps in existing evidence on integrated SBC/PBC programming
  • Priority research and learning questions and the consensus-driven process used to derive them
  • Roles of key stakeholders for putting the research and learning agenda into action

What Do We Mean by Integrated SBC Programs?

Integrated social and behavior change (SBC) refers to programming that addresses behaviors concerning multiple health areas or development sectors in a coordinated and intentional way. Typically, integrated SBC programming involves developing a single, coherent SBC strategy, which may group behaviors that are:

  • Practiced by the same audience or people in the same life-stage
  • Influenced by the same social norms or individual level factors
  • Preceded by the same gateway behavior
  • Pertain to co-occurring health or development conditions
Health Communication Capacity Collaborative. 2017. Integrated SBCC Programs Implementation Kit.

Four Key Areas of Inquiry for Advancing Integrated SBC Programming

Implementing in an enabling environment
Intervention content and programmatic model
Effectiveness of integrated SBC programming (relative to vertical SBC programming)
Cost effectiveness
Breakthrough RESEARCH. 2019. “Advancing integrated SBC programming,” Research and Learning Agenda. Washington, DC: Population Council.
Breakthrough RESEARCH 2019

Applying the Research Questions to a Current SBC Project

In this A Research Spotlight From Breakthrough RESEARCH, we share key highlights from an integrated SBC project in Tanzania to:
  • Demonstrate how priority RLA questions are being answered to improve SBC programming
  • Share tools and resources for other program implementation and research partners
  • Raise the visibility of current innovative SBC work
The NAWEZA Platform

USAID Tulonge Afya Project’s NAWEZA Platform

What is NAWEZA?

NAWEZA is an integrated SBC strategy and platform for adults advanced by the FHI 360-managed, USAID-funded Tulonge Afya project in Tanzania that spans the health areas of family planning and reproductive health; malaria; maternal, newborn, and child health (MNCH); human immunodeficiency virus (HIV); and tuberculosis (TB).

NAWEZA works to address key individual, social, and structural determinants of priority behaviors through interpersonal communication, community-level dialogue and related activities, national-level above-the-line media, and community and mid-media.

Why use an integrated SBC strategy for these health areas and these target population groups in Tanzania?

NAWEZA’s core belief is that SBC integration may lead to stronger and more holistic programming and outcomes. It is designed to complement existing Government of Tanzania and USAID efforts toward the provision and strengthening of integrated health services.

Where is NAWEZA?

  • National: (media and technical support)
  • Essential SBC package in 19 USAID Boresha Afya regions
  • Enhanced SBC package in 29 districts, including eight in North/Central zone, eight in Southern zone, and 13 in Lake/Western zone
  • Zanzibar (technical assistance)

In addition to national and regional activities, enhanced districts receive increased SBC support through radio, district mobilization, joint planning, and grants.

Who does NAWEZA serve?

NAWEZA addresses pregnant women, their partners, and caregivers of under five children, with a focus on the first 1,000 days; and other key household, community, and health-provider influencers.

What approach was adopted for the integrated SBC strategy? Why?

NAWEZA employs a life-stage approach as a framework for integrated SBC. As individuals have different health needs and priorities based on their life stage, the life-stage appropriate SBC platforms will enable tailored messages, activities, and channels for each key life stage.

Enabling Conditions for Integrated SBC

Priority SBC Question

What Conditions Enable Appropriate and Feasible Design and Implementation of Integrated SBC Programming?

Why was this question important for USAID Tulonge Afya to answer?

To ensure the design and implementation of the project account for the specific social and environmental conditions of target populations within the identified geographic locations.

How did USAID Tulonge Afya identify answers to this question?

  • Literature review and stakeholder meetings
  • Behavior prioritization workshop

“Donors, governments, and implementers, while willing to take a chance, typically drive the performance of vertical health programs (malaria, HIV, FP/RH, etc.). That trickles down to how each aspect of an SBC intervention is delivered and assessed: not as part of a cohesive whole, but as contributing to gains for singular, detached health areas… Each stakeholder needs to buy into the ‘integration’ concept and what it means in practical terms, including what they will be contributing and benefitting from as a result of the integration endeavors. This takes time and resources but is an investment well spent as it will underpin a commitment to coordinated SBC efforts going forward.”

- Prisca Rwezahura, USAID Tulonge Afya Director of SBC

What Was USAID Tulonge Afya’s Approach to Stakeholder Engagement?

For effective integrated SBC design and implementation, USAID Tulonge Afya systematically engaged stakeholders throughout the formative design process.

  • Behavior prioritization workshop with national-level stakeholders to select behaviors to be addressed under each package
  • Participatory strategy development workshop with national-level stakeholders
  • Shared strategy with stakeholders for review and input
  • Finalized strategy reflecting stakeholder input
  • Ongoing annual refinement of strategy based on project data and learning, and shifts in donor, Ministry of Health, and implementers’ needs and priorities


  • Map existing knowledge and current partner integrated SBC needs
  • Identify materials and tools that could be utilized or adapted to meet immediate SBC needs as part of USAID Tulonge Afya’s accelerated support strategy
  • Identify emerging formative research and SBC gaps
  • Support the establishment of a comprehensive SBC inventory within the MOHCDGEC’s database


  • Desk reviews of project and campaign reports, national guidelines, and published materials, including electronic and print content
  • Comprehensive SBC audit and landscape mapping analysis
  • Semi-structured key informant interviews
  • Stakeholder consultative meetings with USAID, government, and IPs

Behavioral Prioritization Workshop

October 2017
Best practice for SBC:

The behavioral prioritization workshop was held with key stakeholders, who engaged in a process of identifying and prioritizing behaviors for each target population.

FHI 360. 2018. USAID Tulonge Afya Quarterly Performance Report (FY18 Q3). 14.


Identify priority behaviors that are likely to effect morbidity and mortality for multiple health outcomes aligning with Government of Tanzania and USAID priorities.

Examples of Priority Behaviors Targeted Within NAWEZA:

  • Go early, attend, and complete more than four antenatal care (ANC) visits (eight contacts are desired)
  • Take intermittent preventative therapy-3 during ANC visits
  • Attend prevention of mother-to-child transmission services and take antiretroviral therapy as prescribed if living with HIV
  • Attend a health facility for delivery
  • Initiate breastfeeding within the first hour of birth
  • Talk with your health care provider about post-partum family planning options
  • Attend postnatal care visits and seek prompt and appropriate care at the health facility upon the first sight of post-partum danger signs
  • Bring your infant to the facility for an early visit at four to six weeks, and for HIV testing if the mother is positive or status unknown
  • Sleep under an insecticide-treated net every night, including children under age 5
  • After a live birth, use a modern contraceptive method to avoid pregnancy for at least 24 months
  • Exclusively breastfeed your infant for six months after birth
  • Seek and receive prompt and appropriate care at the first sign of newborn and childhood illness
  • For malaria, seek and receive prompt and appropriate care at a health facility for yourself or a child under age 5 with a high fever, including use of a rapid diagnostic test to confirm malaria
  • Seek and receive a full course of timely vaccinations for infants and children under age 2

Accelerated Support Strategy

October 2017 – July 2018
FHI 360. 2018. USAID Tulonge Afya Quarterly Performance Report (FY18 Q3).


To meet the urgent needs of service-delivery and other partners, USAID Tulonge Afya immediately launched an accelerated support strategy to address vertical health needs while the integrated SBC platform was developed. This accelerated strategy enabled USAID Tulonge Afya to meet implementing-partner needs and minimize gaps in programming and service delivery.


The strategy entailed material inventory, stakeholder technical reviews, and update or development of HIV, family planning, MNCH, and gender norms-specific SBC materials.


Radio spots and print materials (brochures, posters, and banners) that promoted priority behaviors across focal health areas, including HIV, family planning, malaria, and MNCH, as well as cross-cutting gender norms.

Underlying Determinants

Priority SBC Question

What Norms or Other Determinants Influence Multiple Behaviors?

Why was this question important for USAID Tulonge Afya to answer?

Identifying determinants that have ripple effects on multiple behaviors helps shape the design of the program. These underlying determinants can then be monitored over time to assess program success.

How did USAID Tulonge Afya identify answers to this question?

  • Audience consultations
  • Baseline survey


Determine emotional drivers of priority behaviors among target audiences for each of the focal health areas, which is essential to developing effective messaging and activities.


  • Small group and/or individual discussions by topic with each audience
  • Use of projective techniques to identify the underlying emotional drivers of behaviors (this was our main approach and most interesting)
  • After the interviews, moderators participated in an in-depth debrief with experienced team leaders to tease out key information and insights
  • Moderators also completed a written debrief form to document their impressions of the session and key findings that arose during the activities


HIV test and treat
  • Adults unaware of their HIV status
  • People living with HIV (PLHIV) (ages 18 to 35) who have not yet initiated antiretroviral therapy
  • PLHIV (ages 18 to 35) who have been adherent to their HIV regimen for at least six months
  • Facility-based health workers
  • Community health workers
  • Pregnant women
  • Parents and caregivers (of children under age 5 and children ages 6 to 12)
  • Facility-based health workers
Maternal, newborn, and child health (MNCH)
  • Currently pregnant women
  • Mothers and fathers of children under age 2
  • Health workers who provide MNCH services
Tuberculosis (TB)
  • General population adults
  • Adults currently undergoing treatment for TB including parents and primary caregivers of children under age 5
  • Health workers who interact with TB patients
Family planning (FP)
  • Unmarried youth ages 15 to 17 (male and female)
  • Married and unmarried young adults ages 18 to 24 (male and female)
  • Post-partum women (first child and three or more children)
  • Facility-based health workers


Guides for each target audience used projective techniques and questions with no obvious answers. These open-ended questions provided rare insights into participants' deepest desires, rather than superficial and often untrue data, and provided program and message developers with fresh and unique insights to inform message and campaign strategies.

Ethical Review

  • USAID Tulonge Afya developed discussion guides for each target audience segment, which were then reviewed and revised before being submitted to FHI 360’s Office of International Research Ethics for review
  • A non-research determination was provided for these audience consultations


Insight reports by focal health area provide a deeper understanding of primary and secondary emotional drivers that impact behavior.

Illustrative Output of Primary and Secondary Drivers With Select Key Audiences

Pregnant women and mothers of young children
Secondary Drivers
  • Independence
  • Control
  • Status
  • Security
Expectant fathers/fathers of young children
Secondary Drivers
  • Power
  • Achievement
  • Recognition
  • Security
Health care workers
Secondary Drivers
  • Status
  • Nurturing
  • Poverty of Time


  • Determine knowledge, attitudes, and health practices around priority health behaviors
  • Serve as the first part of a pre-/post-study; a second cross-sectional survey will be conducted in program implementation Year 5


  • Three survey questionnaires (household, individual, and caregiver) with questions related to the study’s five focal areas
Multistage sampling design:
  • 120 enumeration areas (EA) randomly selected across enhanced and nonenhanced districts using stratified probability proportional to size systematic sampling
  • 33 households sampled through systematic random sampling from each EA
  • A total of 3,960 households where several eligible household members were included in the data collection


  • Men ages 18 to 49
  • Women ages 18 to 49 who were not pregnant
  • Women ages 18 to 49 who were pregnant
  • Caregivers (ages 15 and older) of children up to 14 years (Note: Given the overlap with other subpopulations, this subpopulation was not explicitly targeted for sampling purposes but was identified through interviews)
  • Adolescents ages 15 to 17


Household questionnaire:
  • Demographic characteristics and relationships between all household members
  • Household access to water, sanitation, and hand-washing facilities
  • Asset ownership and household construction
  • Mosquito net ownership and usage and history of indoor residual spraying
Individual questionnaire:
  • Individual demographic characteristics
  • Exposure to health communication
  • Behavioral determinants
  • Initiation and uptake of healthy behaviors across the targeted health topics
Caregiver questionnaire:
  • Exposure to health communication among caregivers of children up to 14 years
  • Behavioral determinants
  • Initiation and uptake of healthy behaviors specific to children ages 0 to 14 across the targeted health topics

Ethical Review

  • Approved by FHI 360, the Protection of Human Subjects Committee, and the National Institute for Medical Research in Tanzania
  • All participants provided informed consent before the interview
  • The study team and staff received training on research ethics, confidentiality, and site entry procedures


  • Baseline survey yielded sector-specific insights on key factors associated with desired behaviors, indicating additional potential for behavior changes
Example: Sector-Specific Insights on Malaria
Example: Sector-Specific Insights on Malaria
  • The doer/non-doer analysis compared respondents who engaged in a specific behavior to those who did not, to identify factors that may be important for behavior change; for example, women with perceived partner support for contraceptive use were 7.6 times more likely to use a contraceptive method than women without perceived partner support (p=.0001)
Example: Perceived Partner Support for Contraceptive Use
Doers (n=1096)
Doers graph
Non-Doers (n=599)
Non-Doers graph
Consolidating a Strategy

How Did USAID Tulonge Afya Synthesize Learnings Into a Consolidated Strategy for the NAWEZA Platform?

Activities for Strategy Development

  • Participatory workshop for strategy development
  • Analysis of research and audience insights
  • USAID and stakeholders agreement

Development of Materials and Media to Advance the Strategy

  • Pretesting
  • Platform development
  • Training
  • Ongoing consultants with Government of Tanzania, implementing partners, and other stakeholders

Development of Behavioral Profiles

Translating Research Insights into SBC Objectives

Illustrative Example From NAWEZA Platform

Illustrative Messages Developed to Support Communication Objectives to Achieve Prioritized Behaviors Related to Antenatal Care

  • You can be proud of protecting your baby by completing each essential pregnancy action.
  • You will be a strong and caring mother by going to ANC early and at least four times (ideally eight contacts) to ensure the health of your baby.
  • Modern contraceptive methods give you the freedom to take care of your newborn—they allow you ample time to raise your new child and participate in social and economic activities, so you can ensure the best for your family. Talk to your doctor about modern contraceptive method use after your baby is born.
  • If you take steps to prevent and treat malaria, you will be seen as a great mom/dad who loves and protects their child.
  • Going to the health facility for delivery improves your chances of having a safe delivery and a healthy baby.
  • Your health worker can provide you with the best care and information for you and your child—learn how to get the most from your health care system.
  • Support your pregnant wives/partners to get the best possible care for your unborn child.
FHI 360. NAWEZA: An Integrated Social and Behavior Change (SBC) Strategy to Engage and Support Adult Audiences to Take Action for their Health and Wellbeing. Internal report: unpublished.

NAWEZA Platform Components

  • Radio program/NAWEZA anchor show
  • Social media
  • SMS
  • Billboards
  • Community theater
  • Household and facility counseling
  • Small-group dialogues
  • Community/religious leader mobilization
  • Village health talks
  • Trainings for providers and implementing partners
  • Radio spots and community radio
  • New mother meet-ups
  • Tools and technical assistance for implementing partners and government
  • Link to facility-based services

Young adults participate in a round table discussion during a USAID Tulonge Afya-supported community radio show.

NAWEZA Brand Manifesto

I can’t always choose my circumstances. Or where I was born. But I CAN—“NAWEZA"—choose what I do to make my life better. And making my life better begins with recognizing that the most important choice I CAN make, is to keep myself and my family strong and healthy. Because when we are strong and healthy, we prosper more.  

There are those who say “I CAN” and those who say “I HOPE.” “I HOPE” is just a wish. But “I CAN” is a mindset. It says: I am the captain of my destiny. I am the master of my fate.

"I CAN” inspires me to be the best version of me, my best possible self.

I CAN be the best wife. I CAN be the best husband. I CAN be the best mama. I CAN be the best baba. I CAN do it!  

I CAN be healthy. I CAN keep my family malaria free. I CAN have kids when I choose to. I CAN live a full life even if I’m HIV positive. I CAN give my unborn baby the best chance. “I CAN” means I have the power, we have the power. I CAN take actions to make my family happier and healthier.  


Program Effects and Strategies

Priority SBC Question

What Are the Program Effects of the Integrated SBC Platform?

Why was this question important for USAID Tulonge Afya to answer?

  • Understand how underlying determinants are being addressed and what approaches improve the ability of individuals to practice healthy behaviors
  • Understand how systems have been influenced to support healthy behaviors
  • Capture insights on commitment and capacity for coordination and implementation of integrated SBC interventions

How is USAID Tulonge Afya identifying answers to this question?

Tulonge Afya is identifying answers through the use of an adaptive management framework and activities including:

  • Regular omnibus survey
  • Qualitative midterm evaluation led by Breakthrough RESEARCH, funded by USAID/Tanzania
  • Routine monitoring and evaluation by USAID Tulonge Afya

Adaptive Management Framework

USAID Tulonge Afya’s Adaptive Management Framework

adaptive framework

The SBC Adaptive Management Framework guides data collection and use at key points to enhance SBC programs. The framework has five phases that address data collection (including tools such as the household [HH] data collection tool), analysis, interpretation and decision-making, planning and documenting adaptations, and quality assurance (QA).

Using this framework, USAID Tulonge Afya is able to:
Address emerging priorities and achieve greater scale, saturation, and quality execution of activities
Contextualize and prioritize integrated SBC activities based on a better understanding of localized behavioral determinants and need, in collaboration with communities and local stakeholders
Continue strengthening integrated SBC systems at ward, district, regional, and national levels for sustainability


  • Assess a core set of program exposure and behavioral- and determinant-related indicators on a routine basis to track progress over time
  • Support an adaptive-management approach by allowing NAWEZA to identify successes to be scaled-up and gaps to be addressed, feeding into ongoing refinement of the project’s SBC strategy and theory of change


A quantitative survey administered through in-person interviews with a nationally representative sample of the project’s target audiences disaggregated by sex, age, and region.


NAWEZA target audiences


The survey gathers data on reach, recall, and exposure to project campaigns and messages, as well as indicators aligned with the project’s NAWEZA SBC strategy (e.g., HIV testing uptake, insecticide-treated net use, ANC attendance during most recent pregnancy, attitudes toward family planning).


  • Regionally disaggregated analysis of data is used to inform programming decisions, which then guides shifts in resource allocation and activity plans; for example, data indicating that message recall is low in certain areas or among target audience segments has been used to shift radio programming to better align with audience listenership preferences and needs
  • Routine data analysis is triangulated with the baseline survey data to produce a more robust evaluation of the project over time
  • Quarterly data review meetings provide an opportunity to examine trends in key indicators at both a national and regional level

Selected Results from Omnibus Survey

Health Area
Priority Behavior
Proportion of People Exposed to Health Messages
Estimated Number Exposed to Health Messages

Family planning

Priority Behavior

Healthy timing and spacing of pregnancy

Proportion of People Exposed to Health Messages


Estimated Number Exposed to Health Messages


Maternal, Newborn, and Child Health

Priority Behavior

Early ANC for pregnant women

Proportion of People Exposed to Health Messages


Estimated Number Exposed to Health Messages



Priority Behavior

Pregnant women take SP/Fansidar at least three times during pregnancy to prevent malaria

Proportion of People Exposed to Health Messages


Estimated Number Exposed to Health Messages


Tuberculosis (TB)

Priority Behavior

TB screening and treatment services for signs and symptoms

Proportion of People Exposed to Health Messages


Estimated Number Exposed to Health Messages



Priority Behavior

HIV testing if at risk and early initiation of ART if you test positive

Proportion of People Exposed to Health Messages


Estimated Number Exposed to Health Messages



Priority Behavior

Pregnant women test for HIV

Proportion of People Exposed to Health Messages


Estimated Number Exposed to Health Messages



Priority Behavior

Adherence to ART

Proportion of People Exposed to Health Messages


Estimated Number Exposed to Health Messages


Source: Omnibus survey conducted in September 2018 with a nationally representative sample. The estimated number of people exposed was computed using the average proportion of individuals who reported having heard each message per channel.

Midterm Evaluation

May 2019 – February 2020


Generate insights about implementation of USAID Tulonge Afya’s NAWEZA platform over the first two and a half years of the five-year project to identify successes and best/promising strategies and interventions that can be sustained throughout the project’s life and scaled up to other regions and districts.


  • Detailed desk review of project documents and data from sources provided by USAID Tulonge Afya prior to fieldwork
  • Utilized a cross-sectional research design to capture inputs from multiple perspectives using multiple qualitative methodologies to triangulate learnings, including:
    • Key informant interviews with national and regional staff from USAID Tulonge Afya and USAID Tulonge Afya implementing partners and collaborators
    • In-depth interviews with district implementing partners and civil society organization (CSO) staff responsible for implementing and supervising USAID Tulonge Afya SBC platforms at the community level
    • Focus group discussions among community volunteers and peer champions delivering the youth and adult platforms and beneficiaries of the platforms
    • Observations of NAWEZA platform and community theater activities


Purpose and content of each qualitative data collection method:

Qualitative Data Collection Method
Key informant interviews (n=27)
  • Capture perceptions of the transition from vertical to integrated SBC
  • Capture whether and how the integration has led to improved capacity, coordination, collaboration, and co-investment for SBC, and document associated challenges and opportunities
  • Perception of changes in capacity, coordination, collaboration, and co-investment for SBC
  • Challenges and facilitators of integrated SBC services (capacities, resources, reaching target populations)
  • Unanticipated outcomes or noticeable changes in providing integrated SBC services
  • Perceptions on integration verses vertical implementation of SBC programs
In-depth interviews (n=24)
  • Gain insight on barriers and facilitators for:
    • Engagement of CSO, implementing partners, and Government of Tanzania at the regional and district levels
    • Engagement of beneficiary audiences at the community level to support and facilitate delivery of quality SBC
  • Engagement of civil society structures by USAID Tulonge Afya
  • Challenges and facilitators (capacities, resources, reaching target populations)
  • Unanticipated outcomes or noticeable changes in providing integrated SBC services
  • Perception of resonance of USAID Tulonge Afya messages at the community level by beneficiaries
  • Perception of changes in community-level environments for USAID Tulonge Afya target behaviors
Focus group discussions with front-line implementers (n=24)
  • Understand front-line implementers’ perspectives of the program and perceptions of any individual- and community-level changes in knowledge, attitudes, and norms across the five priority health areas
  • Training and delivery of sessions
  • Perceived resonance of USAID Tulonge Afya project SBC messages among beneficiaries
  • Perceptions/observations of individual changes in knowledge, attitudes, behaviors
  • Perceptions/observations of community changes in norms
  • Challenges and facilitators in implementation of sessions
  • Unanticipated outcomes of providing integrated SBC services
Focus group discussions with program beneficiaries (n=36)
  • Understand beneficiary perspectives of the program and perceptions of any individual- and community-level changes in knowledge, attitudes, and norms across the five priority health areas
  • Resonance of USAID Tulonge Afya project SBC messages among beneficiaries
  • Perceived individual changes in knowledge, attitudes, behaviors
  • Perceived community changes in norms
  • Unanticipated outcomes of accessing integrated SBC services
Observations (n=29)
  • Assess the facilitators’ skills and ability during delivery of sessions
  • Duration of session
  • Materials used and topics covered during session
  • Perceptions/observations of individual changes in knowledge, attitudes, behaviors
  • Perceptions of facilitator’s delivery of session
  • Engagement of participants and interactive characteristics of session
  • Questions asked by participants on their concerns with messages
  • Post-session referrals

Ethical Review

  • Approved by the National Institute for Medical Research in Tanzania and the Institutional Review Board of the Population Council in New York, United States
  • All participants provided informed consent before engagement; all attendees of an observed session or event were notified by the session leader of the data collectors’ purpose in observing the event


Dissemination meeting with USAID Tulonge Afya and key stakeholders, final report, and slide deck highlighting key findings and programmatic recommendations (forthcoming May 2020).

Strategic Engagement of Key Stakeholders Throughout the Research Process

Research Process graph
Adapted from Project SOAR. 2016. Project SOAR Approach to Research Utilization. Washington, DC: Population Council.

Illustrative Learnings From the Midterm Evaluation

Importance of engaging community leaders when addressing culturally sensitive issues

...It used to be a challenge before because people thought it was a waste of time to come and listen to you.... So, we were helped by village and hamlet leaders, village and ward executive officers and they know about the TA [USAID Tulonge Afya] project.
—CSO, Newala District

Shifts in attitudes among program beneficiaries

I came to realize that if a couple that doesn’t practice FP [family planning], it makes a woman miserable. It also decreases family production. The woman becomes miserable because she is constantly caring for pregnancy and babies, such that she cannot get involved in production activities. Therefore, I learned that the family that practices FP makes a woman feel happy and production increases at the family level.”
—NAWEZA male beneficiary

Confusion around roles and responsibilities of SBC coordinators of various health areas within an integrated approach

“For instance, for a person dealing with HIV in vertical programs, they are usually involved in everything, so I go for supervision and I create guidelines, and my work here is to support all HIV interventions in SBCC, whether it be HIV testing, or STIs, or VMMC [voluntary medical male circumcision] or care and treatment. It is everything. So, I must know everything. If you tell me now to start doing SBCC for malaria I would have to start to learn so that I can know all I need about malaria.”
—Government of Tanzania, national-level representative

Processes to ensure commitment and capacity for integrated SBC

“...we are engaged in every step of this (SBC materials) development, in the past I think we were more just served with the materials like ‘here they are please use them’. I think that’s the difference.”
—USAID Boresha Afya, implementing partner
  1. What did the evaluation highlight as key findings among beneficiaries regarding the influence of current programming on behaviors and social norms?
  2. How can the project shift focus to ensure stakeholders at all levels are empowered and provided with the capacity to deliver quality integrated SBC programming?
  3. What are the recommendations related to capacity building, coordination, collaboration, and systems strengthening for integrated SBC activities and follow-on investments to USAID Tulonge Afya?


  • Collect and analyze a core set of program indicators on a routine basis—called monitoring and evaluation, or M&E—to track achievement against targets and pinpoint areas of success (such as high-performing districts) and areas of concern (like stagnant indicators) to explore through more focused information gathering
  • Enable adaptive management and enhance program responsiveness to changes in context and new learning, including identifying successes to be scaled-up, gaps to address, and new and emerging priorities to be incorporated into the NAWEZA SBC strategy and implementation plan


  • Data gathered as part of routine monitoring and adaptive management are drawn from a variety of sources and captured in the project’s online M&E system. Within this system, users can run standard or custom reports and access a set of data visualization dashboards that display priority project indicators
  • Quantitative data is gathered from various sources, including:
    • Media monitoring reports
    • Social media metrics
    • CSO activity reports
    • Project-developed service invitation application that tracks referrals to facility-based health services
    • Surveys (for example, omnibus surveys)
  • Qualitative data is gathered through:
    • Supportive supervision activities
    • Routine review and update meetings
    • Reports on audience questions and feedback from community activities and radio programming
    • Intensive analyses through interviews and discussions with target audiences, implementing partners, and project stakeholders to better understand promising approaches that contribute to high performance or underlying causes of performance gaps
  • Program data is triangulated with survey and service delivery data drawn from the District Health Information Software 2 (DHIS2), where appropriate, to understand connections between program implementation, shifts in behavioral determinants, and service uptake, and identify priority areas for intensified support
  • Routine data reviews are conducted on a quarterly basis; these reviews are guided by the data dashboards and allow the project to assess progress against targets, identify high-performing areas, and pinpoint challenges that require additional attention


  • Routine monitoring and adaptive management activities engage a broad cross-section of project staff and stakeholders, including national- and zonal-level project teams, service-delivery implementing partners, government counterparts and local government authorities, CSOs, health care providers, and project participants
  • The project’s M&E team maintains and manages the M&E system in accordance with program data management and quality assurance guidelines; community-level data is fed into the system by CSO staff; data collected electronically are automatically imported into the system


  • All collected data links back to the project’s activity monitoring and evaluation plan (AMEP) and theory of change, with indicators aligned to project outputs, immediate and intermediate outcomes, and priority behavioral objectives
  • Data dashboards feature key indicators for programmatic decision-making and reporting, such as reach among target audiences and proportion of participants completing a full series of sessions within multi-session interventions


  • Data dashboards provide at-a-glance visualizations to identify areas of project success and areas in need of strengthening, and summarize progress toward project targets
  • Detailed reports and visualizations draw from multiple data sources to illustrate trends over time and associations between project activities, service uptake, and changes in behavioral determinants and promoted behaviors
  • The project’s adaptive management tool tracks data and decisions made based on supportive supervision visits, data review meetings, and other adaptive management activities

Illustrative Outputs Inform Adaptive Management

Figure 1 shows a dashboard visualization from project monitoring data illustrating progress against NAWEZA reach targets for the first half of Fiscal Year 2021 (Quarters 1 and 2).

FIGURE 1. NAWEZA Platform Project Targets Speedometer

adaptive framework

Figure 2 uses project monitoring data to show participant retention in multi-session interpersonal communication activities from January through March 2021. Multi-session activities are designed to reach and engage participants throughout the course of several complementary sessions. Data on the proportion of participants retained across each session provides a more nuanced understanding of priority population reach and exposure. It can also indicate participants’ perception of how engaging and beneficial they find the sessions.

FIGURE 2. Participants Reached and Retained in Multi-Session NAWEZA IPC Activities Within USAID Tulonge Afya Enhanced Districts

Multi-Session NAWEZA IPC

Note: IPC is an acronym for interpersonal communication.

Figure 3 shows omnibus survey data thats tracks USAID Tulonge Afya’s progress in shifting priority behavioral determinants over time and enables comparisons between those who are and are not exposed to SBC activities. These data are used to inform an understanding of how the project contributes to its behavior change objectives.

FIGURE 3. Confidence to Seek and Receive Prompt and Appropriate Care at the Health Facility (for Self or Under Age 5 Child With Fever)

Prompt and Appropriate

Notes: FY represents fiscal year, which may not be the same as calendar year. No data were collected in Quarter 1 of FY2021.

Figure 4 presents data accessed via the national DHIS2 system. It allows the project to visualize trends in HIV testing over time and assess positivity yields, contributing to the project’s understanding of whether it is effectively driving demand for HIV testing among higher-risk audiences.

FIGURE 4. HIV Testing and Positivity Yields Within 29 USAID Tulonge Afya Enhanced Districts, by Quarter

Testing and Positivity

Note: FY represents fiscal year, which may not be the same as calendar year.
Source: Tanzania HMIS, National Health Data Warehouse, District Health Information Software 2. https://dhis.moh.go.tz

The service delivery data illustrated in Figure 4 was used to help advocate with government counterparts. USAID Tulonge Afya was initially requested to support the Government of Tanzania to design and implement a mass SBC campaign focused on HIV testing and the new availability of ART after a positive diagnosis (“Test and Treat”). USAID Tulonge Afya responded to these needs with an SBC campaign that utilized mass media, among other channels, to introduce the new service delivery modality and reduce HIV-related stigma. During this time, testing rates increased and positivity yields decreased.

Though the campaign was influential in its initial goals, PEPFAR desired a more targeted approach that focused on promoting testing among only higher-risk audiences. The data in Figure 4 were used to gain consensus around changes in the implementation of the Government’s SBC strategy. USAID Tulonge Afya shifted its approach to place greater emphasis on the use of very targeted interpersonal communication. The right half of the figure shows the results of this shift in the campaign—testing rates went down and positivity yields increased (as desired), with positivity yields higher than before the start of the SBC activity.

Consolidating Learnings for Continuous Program Refinement

Selected Examples

USAID Tulonge Afya uses its adaptive management tool to support purposeful and routine collection, review, and application of data and learning to refine the NAWEZA SBC strategy and plans. The tool supports decision-making and documentation of the project’s change process, through capturing:

  • Data gathered through routine activity monitoring that indicates the need for project adaptation
  • Mutually agreed upon and required adaptations
  • Action steps necessary to implement the adaptation

  • Target Audience

    Service Visibility


Insights for Integrated SBC Programs
Holistic Programming to Address Multi-Level Determinants and Needs

USAID Tulonge Afya designed and implemented an integrated SBC program to address the needs of priority populations more holistically and engage those populations with the information, motivation, and skills they need to adopt healthy behaviors relevant to their stage in life. Because of the integrated program, USAID Tulonge Afya could effectively target social norms and other factors that impede or facilitate the adoption and sustainability of multiple behaviors. These practices and factors include, for example, couples communication, joint decision-making, and norms around men seeking health care, which may receive less emphasis in sector-specific programs but are critical for transformative change.

Structural Constraints and Solutions

While donors and governments have strong interest in integrated SBC programming, their structures are still largely organized by individual programmatic sectors. This organization creates an initial challenge for budgeting, M&E reporting, and coordination, as well ensuring the appropriate emphasis on each priority health area. USAID Tulonge Afya was successful in generating buy-in for an integrated SBC strategy and approach in Tanzania, including the Government of Tanzania’s ownership of integrated SBC platforms and strong leadership and engagement from national, regional, and district-level stakeholders in the development, implementation, and oversight of integrated campaigns. To build on these successes, continued investment and advocacy are needed to ensure systems and structures facilitate integrated SBC programming.

Simplifying Complex Data

Given the number of indicators across multiple health areas that must be tracked over time, the M&E of integrated SBC programs is complex and requires a robust system that captures data from across data sources and, most importantly, presents it in a way that supports effective decision-making. Easily digestible data visualizations that track priority indicators, including changes in determinants and behaviors, and quickly call attention to areas of high and low performance are more useful than large arrays of granular data.

Coordination, Collaboration, and Co-Investment

Partner collaboration and technical support are key to ensuring that supply- and demand-side interventions are aligned and programming facilitates government oversight of quality SBC.

"EGPAF’s [Elizabeth Glaser Pediatric AIDS Foundation] Boresha Afya has been working in Tabora for 5 years. Despite efforts, there was still low uptake of family planning and high unmet family planning needs. We worked with USAID Tulonge Afya to find the root cause… One thing that came repeatedly during our analysis is the fact that our service provision was not well aligned with demand creation …there were also prevailing social norms holding us back. We co-designed activities that provided an opportunity for community members to talk about prevailing social norms and how some [norms] negatively affect health while also identifying that which uplift health and … family planning uptake. The positive social norms were then modeled through community events linked with service provision. Since we started this collaboration … we have witnessed huge increase of FP service uptake … For example, in last quarter of 2019 before the intervention, modern contraceptive methods uptake was only 64,000. However, in January - March 2021 period, a total of 130,786 clients received at least one of the modern contraceptive method[s]. This is remarkable achievement.”

—Dr. Saidi Mgeleka, USAID Boresha Afya Zonal Manager, Tabora Region, Tanzania

“This [USAID Tulonge Afya supportive supervision tool] is the best innovation I have ever come across in the course of coordinating health promotion activities in my career. The tool is very simple and user friendly, and after finishing observing IPC [interpersonal communication] sessions the tool automatically generates a summary report on volunteer’s performance. This enables the project to make quick corrective measures and real time feedback to other project staff who may not be part of the supervision.”

—Mr. Thomas Metusela, District Health Promotion Coordinator, Mwanza Region, Tanzania

For More Information

For more information about USAID Tulonge Afya or the NAWEZA platform, please contact Kara Tureski, ktureski@fhi360.org, or Waziri Nyoni, wnyoni@fhi360.org, or visit USAID Tulonge Afya.

For more information about Breakthrough RESEARCH visit the Breakthrough RESEARCH project.


This USAID Tulonge Afya case study was developed by Sanyukta Mathur and Krista Granger, Population Council, with input from Kamden Hoffmann, Population Council; Rachel Yavinsky, PRB; and Marissa Pine Yeakey, consultant. It was designed by ProGraphics in consultation with Nancy Andrews, former Creative Director at PRB, and edited by Nancy Matuszak, Editoral Director at PRB.

The case study was developed with the assistance of FHI 360 and the USAID Tulonge Afya project. Thank you to Kara Tureski, Director of Social and Behavior Change, FHI 360; Claire Gillum, Technical Advisor, FHI 360; Waziri Nyoni, Country Lead, Chief of Party, USAID Tulonge Afya; and Joseph Msofe, Director, M&ERL and Knowledge Management (MERL/KM), USAID Tulonge Afya, for their guidance and critical input.

This website is made possible by the support of the American people through the United States Agency for International Development (USAID). The Breakthrough awards are supported by USAID’s Office of Population and Reproductive Health, Bureau for Global Health, under Cooperative Agreements: #AID-OAA-A-17-00017 and #AID-OAA-A-17-00018. Breakthrough ACTION is based at the Johns Hopkins Bloomberg School of Public Health’s Center for Communication Programs. Breakthrough RESEARCH is based at Population Council. The contents of this website are the sole responsibility of Breakthrough ACTION and Breakthrough RESEARCH. The information provided on this website is not official U.S. Government information and does not necessarily represent the views or positions of USAID, the United States Government, Johns Hopkins University, or Population Council. All rights reserved.

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