Theoretical Framework Observing that change is a very difficult phenomenon to sell, Akinfeleye (2008) notes that communication is at the

center of the behaviour change process and identifies the major steps to include: Knowledge about the change; ability to recall major messages in the communication encounter; understanding the key issue in the message; personal network and/or peer influence and authority; recognition and appreciation of the benefits in the intended change; advocacy on other; and sustainability.

Other theories that found relevance in this study are the Individual Differences theory, the Health Promotion and Health Education theory, Freires Participatory theory and the Behaviour Change Communication theory (BCC).

Many communication models have informed the field of behaviour change. The early models like Lasswells communication theory of 1948 were linear in their understanding of communication, which was understood as a transfer of information, leading to foreseeable step-by-step change processes. These processes were usually identified with changes in behaviours much in line with the development thinking of the modernization paradigm.

The preceding behaviour change theories such as BCC, and Health Promotion Model used communication as a tool to persuade people to change their behaviours towards desired goals and although these theories had been rated as successful in the developed world, they failed in the developing countries because like the earlier communication theories, they are individual based and do not take into account the true contexts and challenges facing people in developing countries. They were for the most part fashioned after the linear, top- down communication process characterized by the transmission of knowledge of experts to the millions of uneducated using the mass media, in a persuasive advertising campaign style with the assumption that it will lead to behaviour change. Campaigns were characterized by oneway flow of communication and prevention messages, where the target audiences are not involved in the decision- making, sharing or ownership of ideas. This strategy like others
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before it was aimed at individual change in attitudes and behaviour with the assumption that the media is all powerful. Since the evolution of communication as an independent discipline, several scholars have conducted research into the effects of communication at the individual, group and societal levels and have postulated several theories to explain the various kinds of effects. The theory of mass communication effects propounded by Melvin De Fleur has undergone several paradigm shifts. The earlier theories were founded on the linear communication model of Lasswell which was an outgrowth of his work on the functions of the media as well as his work on propaganda which recorded success during the First and Second World Wars, using the media as its conveyor belts (Folarin, 2005). Lasswell had proposed a verbal model of the communication process through which communication functions are carried out. The model required answers to the questions of who, says what, in which channel, to whom and with what effect? In these early models of strategic communication, there were no participatory elements. The assumption was that the power of communication to enhance development was in the correct crafting of the content and in the adequate targeting of audiences. The goal was individual behaviour change. Communication For Social Change Theory Contemporary communication has been undergoing paradigm shifts from linear to transactional and cyclical processes that combine traditional and modern communication technologies to achieve effective health communication. Obono (2011) notes that the Linear models which traditionally dominated communication research are limited in certain respects, hence, the emergence of more holistic models that could capture the different sides of social reality. Moemeka, (1994) cited in Waisbord (2005), observes that in spite of the revision of the topdown, sender-receiver model of communication, the idea of communication as process has gained centrality in approaches informed by both behaviour change and participatory models.

More importantly, communication should be viewed as an integral part of development plans a part whose major objective is to create systems, modes, and strategies that could provide
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opportunities for the people to have access to relevant channels, and to make use of these channels and the ensuing communication environment in improving the quality of their lives (1994). The CFSC is a brilliant example of recent efforts to integrate different theories and approaches in development communication (Rockefeller Foundation 1999). Whereas traditional interventions were based on behaviour-change models, CFSC relies on participatory approaches in emphasizing the notion of dialogue as central to development. Development is conceived as involving work to improve the lives of the politically and economically marginalized (1998, 15). In contrast to the sender-receiver, information-based premises of the dominant paradigm, it stresses the importance of horizontal communication, the role of people as agents of change, and the need for negotiating skills and partnership. Another important contribution of CFSC is to call attention to the larger communication environment surrounding populations. In contrast to behaviour change and participatory theories that, for different reasons, pay little if any attention to the wide organization of information and media resources, CFSC calls attention to the relevance of ongoing policy and structural changes in providing new opportunities for communication interventions.

these theories had proved to be inadequate for health communication planning in Africa and other developing nations, which are community- driven and where decisions about preventing diseases are based on cultural norms that often override the individuals decision. They consequently came under criticisms for its inadequacy to respond to the challenges of the pandemic, thus setting the stage for the emergence of the Communication For Social Change theory (CFSC). Similarly, unlike the participatory theories, CFSC stresses the need to define precise indicators to measure the impact of interventions. It is particularly sensitive to the expectations of funding agencies to find results of interventions, and to the needs of communities to provide feedback and actively intervene in projects. Here accountability, a concept that is also fundamental in contemporary global democratic projects, is crucial to development efforts. Projects should be accountable to participants in order to improve and
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change interventions and involve those who are ultimately the intended protagonists and beneficiaries They also submit that development is not just introducing technology from the west, but encouraging a process of socio- political change in power structures that opens a space of freedom for peoples initiatives, knowledge and technical capacities. The CFSC theory is an integrated model which draws from the earlier behaviour change theories already discussed in this section as well as a broad literature on development communication developed in the early 1960s, particularly the work of Latin American theorists, communication activists, and the Convergence, Conflict and Network theories. The CFSC describes how communication processes might be used at a community level to bring about both individual and social change. It defines communication in this respect as the act of people coming together to decide who they are, what they want, and how they will obtain what they want. The rationale behind CFSC is that social change will be more sustainable if the affected community owns not just the physical inputs and outputs, but also owns the process and content of the communication involved. Behaviour change alone is not sustainable unless it also involves different kinds of social change.

The CFSC model says that if any external agents wish to contribute to the process of communication and social change, they should shift their approach away from persuasion and one-way transmission of information, and instead engage in dialogue and discussion with members of the community. Inspired by the academic rigor of Maria Elena Figueroa, Larry Kincaid and Jose Rimon of Johns Hopkins Centre for Communication Programs in 1999 The CFSC model describes an iterative process where community dialogue and collective action work together to produce social change in a community that improves the health and welfare of all of its members. Social scientists observe that beyond an individuals own social network, aggregates or categories, there are larger structural and environmental determinants that affect health behaviour such as living conditions related to ones employment and family life The model is thus based on the following assumptions:
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Individual behaviours and choices are often mediated and structured by social relationships, which are in turn are influenced by important differences of community, social status, educational levels, class, group affiliations and other structural differences such as gender and age. Thus, individual behaviour is always contextualized and socially embedded (i.e. social influence and peer pressure are major determinants of behaviour change).

There is social influence for individual behaviour changes where individuals who adopt new health behaviour publicly advocate its adoption to other individuals so that the rate of change (decline) in the prevalence of the disease increases.

Social change can be achieved through individual behaviour change such as the adoption of ITNs and visits to local health clinics that when aggregated leads to reduction in the prevalence of disease within communities which experience sufficient individual change

That communication is dialogue rather than monologue and is a cyclical process of information sharing as participants take turns creating information to share with one another and interpreting and reinterpreting its meaning until a sufficient degree of mutual understanding and agreement has been reached for collective action to take place. Turn taking in dialogue constitutes a minimal form of collective action as none are passive receivers of the information.

Dialogue represents a horizontal, symmetrical relationship among two or more participants that is created by sharing information. The outcomes of information processing by the participants are social mutual understanding, agreement and collective action as well as individual perceiving, interpreting, understanding and believing.

That when community dialogue and collective action take place, members of a community take action as a group to solve a common problem, and this leads not only to a reduction in the prevalence of disease within the community but also to social change that increases the collective capacity to solve new problems.

That information or message can be verbal or non verbal, intended or unintended and is shared or exchanged between two or more individuals rather that transmitted from one to the other. All participants act on the same information which can be created by the action of any participant or may originate from a third source such as media,

person or institution not directly participating such as church, school or non governmental agency among others. That community is a multilevel concept ranging from local, geographically defined entities, such as villages, cities and nations, to international entities widely dispersed in space and time. It is not a homogenous entity but is comprised of subgroups with social strata and divergent interests (individual differences) with disagreements and conflicts because those who do not see an issue the same way nor agree with other participants may drop out of the group. That emphasis should shift from audience members as individuals to audience members as social groups That there are external factors which hinder or facilitate community dialogue or collective action The CFSC describes a dynamic model that follows five stages, starting with a catalyst or stimulus which can be internal such as an increase in malaria morbidity and mortality, mass media including messages designed to promote individual healthy behaviour or collective action such as messages on the adoption of ITNs for malaria prevention, a change agent such as the ones used in most NGO interventions, an innovation such as ITNs, policies that prompt the community to act, and availability of technology. The catalyst represents the trigger that initiates the second stage- the community dialogue about a specific issue of concern to the community. The community dialogue and action is a series of steps some of which can take place simultaneously, leading to the solution of a common problem. Where a particular step is not successfully completed, the group may loop back to an earlier point in the process and consider earlier decisions. The 10 steps in community dialogue are: recognition of problem, identification and involvement of leaders and stakeholders, clarification of perceptions, expression of individual and shared needs, vision of the future, assessment of current status, setting objectives, options for action, consensus on action and action plan. The collective action which is the third stage refers to the process of effectively executing the action plan and the evaluation of its outcomes and this comprises implementation, among four other action steps.

Individual change- This is the fourth stage where the individual adopts and sustains the recommended behavior. Social change- At this stage, sufficient participation and individual change, when widespread and sustained, has societal impact. Stages four and five both feed into each other, since either can lead to change in the other. When a critical mass is achieved in a health campaign and majority of people in a social system adopt the recommended behaviour, that behaviour is often times considered the norm and non conformists are regarded as deviants. Because people do not want to be tagged deviants, they tend to embrace the mainstream behaviour. In the developing nations such as Nigeria, people care a lot about how their friends, family, colleagues, peers and opinion leaders perceive them and this of course influences their decisions to adopt or reject certain behaviours.

1. Catalyst
Internal Stimulus Change Agent Innovatio n Policies Technolog y Mass Media

2. Community Dialogue
Recognition of a problem Identification and involvement of Leaders and Stakeholders
Clarification

of perceptions

Expression of Individual and Shared Interests Conflict-Dissatisfaction

Vision of the Future

Action Plan

Disagreemen t Consens us Action

Options of Action

Setting Objective s

Status
Assessment

3. Collective Action
Assignment of Responsibilities
Y individuals Y Existing Community Groups

Mobilization of Organization
Y Media

Implementation

Outcome

Participatory Evaluation

Y Health Y Education Y Religious Y Other

Y Outcomes of Objectives

Y View Community Task Forces Y Others

4. Individual Change

5. Social Change

SOCIETAL IMPACT

Figure 2: Integrated Model of Communication for Social Change (Source: Figueroa and Kincaid, 2001)

There are seven possible outcomes of social change, with many of the individual and social outcomes being related and affecting one another. For example, individual knowledge about a health problem is aggregated at the community level to determine the average level or distribution of that type of knowledge in the community. The relationship between individual and social change is exemplified by the case of malaria prevention by sleeping under ITNs by pregnant women or removing stagnant water sources in the individuals surroundings. If pregnant women are given ITN education during antenatal visits, and a consensus is reached through dialogue and a critical mass of people take joint action at the same time, and then the strategy can lead to an effective long term solution to the problem of mosquito- borne disease. When community dialogue and collective action are implemented in the stipulated ways, then in addition to an improvement in the health status of the communitys members, there will be an increase in the communitys sense of collective self efficacy (the confidence that together they will succeed in other projects), sense of ownership (the degree to which they perceive themselves as being responsible for the success), social cohesion (their degree of interconnectedness and cooperation), social norms (accepted rules of participation and sharing of benefits) and collective capacity (their overall ability to engage in effective dialogue and collective action often made possible by social capital). Thus the dialogue and collective action process is a learning process whereby individual members through their participation in community projects, sharing of information and experiences, increase their capacity for cooperative action and form social structures such as networks, teams, leaderfollower relationships, which increase the community overall capacity for future collective action. Figueroa et al argue that individual and social change is both necessary for attaining sustained health improvement. They explain that individual change is often limited to a short duration in time while in a situation where only social change occurs, if it is not accompanied by the required changes in individual behaviour for health and indeed other areas of development, the capacity or potential for improvement in health or other areas of development may increase but with little impact (2002). Figueroa et al (2002), identify the catalyst in the CFSC model as the missing piece in most of the literature about development communication which implies that the community spontaneously initiates dialogue and action or that an external change agent visits the
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community to mobilize the community. They argue that communities rarely initiate a dialogue about a problem spontaneously or that some do take action on their own without being visited by external change agents. What the model implies is that some type of catalyst is usually necessary to stimulate a community to consider and discuss a problem. Thus, according to Social Scientist Kippax (2007), the contextual, rather than the individual factor which forms a key part of the CFSC theory where the focus is on seeing people and communities as agents of their own change appear to be more relevant in planning communication strategies in community driven societies such as Nigeria and is consequently appropriate in explaining health behaviour among pregnant women in Nigeria. In fact, several Development organizations such as UNESCO (2001: 20) and UNICEF have echoed this view and appear to be using this theory in planning health behaviour change communication programs in Nigeria. For example during a UNICEF Workshop held in Kaduna from 20- 26 March, 2011, in which this researcher was a participant, part of the program of activities was a visit to Kabala Community, a suburb Kaduna State. At the Leaders palace, participants were treated to one of the community dance and drama pieces used by the community to influence its members to adopt safe health behaviors such as sleeping under ITNs and hand washing. The CFSC Model therefore finds relevance in explaining how communities use culture based edutainment programs, through participatory approach to bring about social change in communities. The communities in turn bring about individual development and behaviour change through interactions between people, culture and environment. Figueroa and Kincaid (2002) describe the CFSC as both a descriptive and prescriptive model as it could be used to describe and explain why previous community projects were successful or unsuccessful. It can also be used by local leaders and external change agents to increase the likelihood that community action will be successful. They argue that CFSC cannot be adequately understood using traditional gauges that only isolate and analyze quantitative results but rather demands a more qualitative assessment. Modified CFSC Integrated Model Figueroa et al have identified three levels at which the CFSC Model can be assessed or evaluated (Kincaid et al, 2002: IV) and these include:

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Members of the community who want to know how well their effort has achieved the objectives they set for themselves and would like to share the results with the rest of the community

External change agents involved in the process who need to document how well a community has performed, to inform governments, funding agencies and the community

Researchers who want to conduct systematic analysis of the relationship between the process and its outcomes across a sample of communities to share with practitioners as well as other scholars.

Figure 3: Modified CFSC Integrated Model, 2011 Source: Field work

The Modified CFSC Integrated Model (figure 3) is an adaptation of Figueroa and Kincaids CFSC Integrated Model, with the only differences being the specifity given to some of the

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elements in the change processes and the addition of a few other elements such as interpersonal or social networks and learning as some of the factors leading to individual and social change. These additions were informed by researchers field experiences and indepth literature search. The catalyst In the first step of the change process, which Figueroa and Kincaid identify as the catalyst, the researcher, in a bid to relate the model to the study at hand includes specific elements and indicators as attributes of the variables in the CFSC Integrated Model. These include the following: The addition of Messages as an attribute deriving from the Mass Media, ITNs as an attribute of Innovations Health facilities and Antenatal Clinics workers as attributes of Change Agents and Free Distribution of ITNs, as examples of Government Policies.

The rationale behind this was to give the model practical application and life. It demonstrates the invaluable place of the mass media in the daily lives of the people and how media messages constitute catalysts, through creating awareness about an innovation such as ITN. Similarly, the creation and emergence of a new product can stimulate dialogue. In the same vein, health care facilities such as Antenatal care units can through health education talks during antenatal visits also create awareness about ITN to pregnant women who hitherto were not exposed to media messages about the innovation. These health talks may also have been stimulated by a new government policy such as the free distribution of ITNs using hospitals as conduits or government mouthpiece. Community dialogue In the second stage of the behavior change process, Social Networks have also been added to Interpersonal networks. These are considered important; particularly in our environment which is community driven and people depend on social networks such as grapevine, neighbours, colleagues, healthcare practitioners, opinion leaders, friends and family for information about innovations and decisions on whether or not to accept these innovations. This became necessary in the face of researchers empirical testing of social context factors as influencers of pregnant womens responses to the communication messages on the adoption of ITN.
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Collective action No additions were made to the variables in stage three because they were found to be adequate in explaining the process of behavior change among pregnant women in Lagos State. This stage describes the implementation step as the outcome of dialogue. This means that all stakeholders recognize that malaria is a major problem in society and consciously or unconsciously get involved in actions to sensitize and create awareness about ITNs as a major solution to the identified problem. For example, government may enact a policy of distributing free ITNs to pregnant women using health care facilities as conduits. Hospitals, in turn may develop health education programmes to create awareness and inform pregnant women about the benefits and efficacy of ITNs in preventing malaria. An example of this is the recent ITN sensitization campaign carried out by the NAF Hospital, Shasha, in the Oguntade community of Alimosho LGA, during which the doctors, nurses and other healthcare workers gave health talks to the community members and ITNs were distributed free to all pregnant women. Another example of collective action is the decision making and implementation after informal discussions between neighbours, colleagues in the work place, online and offline friends and family members. The mass media also play a key role in collective action through their agenda setting and social responsibility functions. The frequency and prominence accorded ITN messages determine the importance the public attaches to it. Individual change Learning was added to the elements in stage four of the change process and this decision was premised on the assumption that knowledge, which is an important element in behaviour change, is a learned process. The goal of the communication campaign messages on the adoption of ITNs for malaria prevention is to teach new information about health risks and the behaviour that minimizes those risks. This agrees with the assumption of the Health Belief Model, which posits that knowledge is brought to target audiences through an educational approach that primarily focuses on messages, channels and spokespeople (Andreason, 1995 as cited in Schiavo, 2007: 38). It argues that in order to engage in healthy behaviours, intended audiences need to be aware of their risk for severe or life threatening diseases and perceive that the benefits of behavior change outweigh potential barriers or other negative aspects of the recommended actions. Learning can also be achieved through an observational approach, with the person observing an action, understanding its consequences
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and as a result of personal and interpersonal influences, becomes motivated to repeat and adopt it (Schiavo, 2007: 38). For example the process of acquiring the knowledge and skill of putting up an ITN is a learned process and understanding its benefits will motivate pregnant women to not only sleep under ITNs occasionally but daily. Schiavos assertions are drawn from Banduras Social Learning theory (1977, 1986 & 1999) the National Cancer Institute and National Institute of Health Reports (2002) as well as the Health Communication Partnership (2005c), which identify attention, retention, reproduction, performance and self efficacy as the key components in the learning process and the factors that influence them and which include a combination of personal and outside factors and events. The argument here is that learning plays a vital role in the decision of pregnant women to use ITNs, their knowledge about how to use and their decision to repeat and adopt it by sleeping under ITN daily. The individual change stage also identifies environmental constraints as some of the barriers hindering their decision to use ITNs, repeat usage and sustain the behaviour. Social change The process of behaviour change in the CFSC model is cyclical and transactional in nature, while the stages are in some instances simultaneous with their attributes in some instances overlapping and at other times complementing one another. Although there may be differences in the timing of individual change among pregnant women, if the change widespread and sustained, it may lead to the desired social change. Each of the two levels of change however feeds into the other as social change will in turn lead to more individual change.

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