An Adaptable Communication Strategy for Demand Generation: Female Condom

"Key messages should enable the target audience to self-select, emphasize key emotional and functional benefits of female condoms, and include a call to action. Messages should be based on formative research and tailored to..."

This is one of the guidance points included in a strategy document written to support communication on one of the "13 Lifesaving Commodities" - the female condom - as described in Demand Generation Implementation Kit for Underutilized Commodities in reproductive, maternal, newborn, and child health (RMNCH), the I-Kit. Materials associated with the I-Kit, like this commodity-specific strategy document for female condom use, were created to support the efforts of communication professionals working directly on social and behaviour change communication (SBCC) programmes, as well as other professionals working in the field of RMNCH.

It is intended to be a "quick-start foundation based on available evidence to provide guidance" for communication designed to help countries reach the goal of increased utilisation of the commodities such as the female condom (described here as "the only woman-initiated method of STI [sexually transmitted infection]/HIV prevention in existence...used correctly, female condoms are approximately 95% effective in preventing semen exposure that could lead to STI/HIV infection or unintended pregnancy") by: creating new users; convincing members of the intended audience to adopt new behaviours, products, or services; increasing demand among existing users; and taking market share from competing behaviours and products or services. Thus, the goal is to create informed and voluntary demand, help providers and clients interact effectively, shift social and cultural norms to support sustained commodity uptake, and encourage appropriate use of the commodity.

The strategy outlined in this document uses stages of change theory of behaviour change as a guiding framework - selected as a conceptual framework for long-term strategic thinking about demand generation for female condoms (as opposed to short-term campaign planning), particularly among intended audiences who are relatively homogenous in terms of their familiarity with the product, or lack thereof. A multi-stage behaviour change framework is "also appropriate to this commodity because new users must be motivated to acquire the skills required to try female condoms and use them successfully. The five stages are listed below, along with common barriers to use that a new female condom user is likely to experience at each stage:

• Pre-contemplation - She may lack personal risk perception, she may not have heard of female condoms, or she may be uninterested in them. She will need information that helps her to become aware of female condoms and how she could benefit from using them.
• Contemplation - She may believe in certain myths about female condoms and she is focused on barriers to use. Access, skills training, and support from influencers or role models may all help to interest her in trying the product.
• Preparation / Trial - The first 1-3 times she tries female condoms are critical points in her journey: discouragement or bad experiences may put her off or set her back. It is essential that she is supported (e.g. with skills training) through positive first experiences that give her confidence, and that she believes she can have reliable access to female condoms in [the] future.
• Action - By this stage she wants to use female condoms. However, barriers to continued use may include access and affordability. To become a regular user, she will need a reliable female condom outlet or outlets, as well as a source of support with any problems she encounters.
• Maintenance - She has now made female condom use a part of her life, but problems such as access and cost could still cause her to cease using the method.

As well as moving target users through the stages of change, interventions must actively prevent relapse..."

The strategy document offers key concept discussions on SBCC, social marketing, and channels and approaches, including advocacy, community mobilisation, entertainment-education, information and communication technologies (ICTs), and mass and traditional media. The conceptual framework for the strategy is structured as a multi-directional continuum of social and environmental contexts: the individual level, family and peer networks, community, and social and structural. The communication strategy includes 6 steps:

• Analyse the situation - for instance, ask questions such as: "What are the gender norms in country among couples, both married and unmarried, and how do these affect female condom use?"
• Define a vision - this should be agreed upon by the stakeholders involved in the strategy design process and will thus be "shared" by all.
• Choose the intended audiences: "Whose behavior must change in order to increase demand and appropriate use the commodity?"
• Select message strategy - "Communications objectives and product positioning should be derived from available evidence on the factors that drive or inhibit female condom adoption by both general and key population target uses, as well as common influencing audiences."
• Determine activities and interventions - "Activities should be carefully selected based upon type of messaging, ability to reach the intended audience through a variety of media/channels, timeline, cost, and available resources. It is helpful to refer to findings from the situation analysis to guide selection of activities and interventions."
• Plan for monitoring and evaluation (M&E) - "The M&E framework should include standard indicators to facilitate comparison between countries, and thus advocacy and resource mobilization for female condoms at the global level. For example, the table below [see page 26] includes two international standard behavioral indicators..."

The illustrative strategy for female condoms (beginning on page 29) details each step for this specific commodity used to support family planning and reproductive health. Various strategic points are included in terms of demand generation for female condoms, such as: "It is important that efforts to create demand among women are complemented by awareness-raising and distribution targeted to men, as well as by tailored sensitization and skills training for healthcare workers and health educators. The association of (male) condoms with disease prevention and promiscuity by target users creates attitudinal barriers to use in marital / co-habiting and other primary or long-term partnerships. The female condom's status as a newer, lesser-known product can represent an opportunity in such settings....Critically for programmers, studies show that women who receive coaching and counseling in how to talk about female condoms and negotiate their use are more likely to use female condoms than women who receive only information and written instructions..."

The resource notes that, "[i]n order to be most effective, demand generation efforts should be matched with efforts to improve logistics and expand services, increase access to commodities, and train and equip providers in order to meet increased demand for products and/or services. Without these links, the intended audience may become discouraged and demand could then decrease. Therefore, it is highly advised to coordinate and collaborate with appropriate partners when forming demand generation communication strategies and programs."

The Demand Generation for Reproductive, Maternal, Newborn, and Child Health Commodities activities are implemented by the Health Communication Capacity Collaborative (HC3) at Johns Hopkins Bloomberg School of Public Health Center for Communication Programs (JHU-CCP), with support from the RMNCH Trust Fund and the United States Agency for International Development (USAID), in partnership with Demand Generation sub-group of the UNCoLSC Demand, Access and Performance Technical Resource Team, including Population Services International (PSI), International Consortium on Emergency Contraception (ICEC), Jhpiego, and other partners.