C-Change Picks - Focus on Family Planning
C-Change Picks #7 - Focus on Family Planning
Information about Social and Behaviour Change Communication, sponsored by C-Change
June 2 2009
From The Communication Initiative (The CI) and the United States Agency for International Development (USAID)'s C-Change programme.
C-Change Picks is an e-magazine supported by C-Change and implemented by The Communication Initiative that focuses on recent case studies, reports, analyses, and resources on social and behaviour change communication in the health sector - in particular HIV and AIDS, family planning and reproductive health, malaria, and maternal and antenatal health, as well as in the environmental sector. If you have received this newsletter from a friend or colleague and would like to subscribe, please contact cchange@comminit.com
C-Change Picks #7 focuses on social and behaviour change communication related to family planning. It highlights resources and case studies that illuminate strategic approaches to engaging within communities and with policymakers. It also provides a look at strategic thinking on the approaches to and impact of mass media campaigns and interpersonal communication for social and behaviour change.
C-Change is applying behaviour and social change communication to family planning programmes in Albania, Kenya, Madagascar, with a programme just beginning in the Democratic Republic of Congo. In Albania, a mass media programme which was launched in April 2009 with TV, radio, and print ads and outdoor displays is working to both promote the reliability and safety of modern contraceptives and counter current misconceptions about them. In Kenya, work is just beginning to build and strengthen the behaviour change communication (BCC) capacity of non-governmental and governmental organisations and align their strategies with the national strategy. For more information on current C-Change programmes, visit the website.
You will find the current edition of C-Change Picks online - click here.
For the archived issues of C-Change Picks, please click here.
C-Change Picks continues to seek new knowledge and experiences in social and behaviour change communication - your case studies, strategic thinking, support materials, and any other relevant documentation. Please contact cchange@comminit.com
Behaviour Change Communication and Engaging within Communities
1. Revitalising Underutilised Family Planning Methods
2. The Active Community Engagement Continuum
3. Lessons Learned in How to Improve Community Outreach
4. Vasectomy: Reaching Out to New Users
5. Approaches to Family Planning in Afghanistan
Social Change Communication and Engagement of Policymakers
6. Repositioning Family Planning: Mobilising Audiences
7. Assessing Integration of Services: A Handbook
8. Introducing and Mainstreaming Emergency Contraceptive Pills in Developing Countries
9. Understanding Operational Barriers to Family Planning Services in Conflict-Affected Countries
Social and Behaviour Change Using Mass Media
10. Mass Media Social Marketing of the Standard Days Method
11. Radio Campaign Suggests Lessons for Other Mass Media Campaigns
Social and Behaviour Change Using Interpersonal Communication/Counselling
12. Telephone Hotline Key for Family Planning Information in DRC
13. Client-friendly Balanced Counselling Strategy
BEHAVIOUR CHANGE COMMUNICATION AND ENGAGING WITHIN COMMUNITIES
1. Revitalising Underutilised Family Planning Methods
This series of seven 8-page briefs, all with the title "Revitalizing Underutilized FP Methods", looks at how the ACQUIRE Project (which stands for Access, Quality, and Use in Reproductive Health) integrated various communication strategies to stimulate authentic community demand for the intrauterine device (IUD) and vasectomy in seven countries – Bangladesh, Ethiopia, Ghana, Guinea, Honduras, Kenya, and Uganda.
The briefs outline a Supply-Demand-Advocacy (SDA) Program Model for reproductive health (RH)/family planning (FP) service delivery. In short, this model envisions ready supply (equipped facilities, proficient staff), demand for services (which includes communications and community engagement), and a supportive policy environment as prerequisites for a productive interaction between family planning client and provider. In this framework, skilled, motivated providers work with knowledgeable, empowered clients at the service site to address the clients' RH/FP needs; advocacy is also key to ensuring increased access to and use of quality services.
This model shapes the design and implementation of ACQUIRE's country-specific efforts to stimulate demand for underutilised FP methods. Each of the briefs explores the context in which the revitalisation programme was implemented, then outlines the specific steps taken with regard to the SDA process, shares results, and offers reflections on what ACQUIRE learned.
The briefs are focused on vasectomy demand in Bangladesh, Ghana, and Honduras and on IUD demand in Ethiopia, Guinea, Kenya, and Uganda.
2. The Active Community Engagement Continuum
This working paper presents a conceptual framework for analysing community engagement in reproductive health (RH)/family planning (FP), and the role the community plays in institutionalising lasting behaviour and social change. It is based on a review of documents, best practices, and the lessons learned from the ACQUIRE Project.
The Active Community Engagement (ACE) Continuum that is outlined here can be used by global RH/FP projects for strategic integration of community engagement into service delivery and to build a shared understanding of community engagement when designing, implementing, and documenting programmes. The framework provides a basis for discussion related to indicators, time frames, and definitions of terms and is a tool that global RH/FP projects can use to build a shared understanding of community engagement when designing, implementing, and documenting programmes.
Community engagement is one component of the SDA approach (described in item #1 above), and it is a critical aspect of a rights-based perspective on access to RH/FP information and services which acknowledges that political, economic, and cultural structures can be barriers to the public's ability to participate meaningfully in the solutions to their RH/FP health needs. The ACQUIRE project has found that, as communities and their members become more engaged, they can assume new and collective roles in decision making around allocating resources, planning programmes, defining policies, and ensuring their right to quality services.
The continuum itself consists of 3 levels of engagement - which move from consultative to cooperative to collaborative - spanning across 5 characteristics of engagement, which can be adapted as needed but which generally include:
- Community involvement in assessment
- Access to information
- Inclusion in decision making
- Local organisational capacity
- Accountability of institutions to the public
The paper lists a number of lessons learned from ACQUIRE's experience with community engagement. In essence, "[t]he ACQUIRE Project learned that communities can be engaged through a variety of interventions. The more engaged we were in building the capacity of the community to be equal partners, the more empowered communities became. Champions emerged who influenced both individual behavior and social change, resulting in mutual accountability between government and communities for RH/FP services and policies."
3. Lessons Learned in How to Improve Community Outreach
Published in February 2009, "Community Outreach: Lessons Learned in How to Improve Outreach" outlines an outreach strategy implemented by the Private Sector Project for Women's Health (PSP) in Jordan and designed to first contact women with the highest unmet needs for family planning services, and to then change their attitudes about family planning. PSP joined with 2 local non-governmental organisations: Circassian Charity Association (CCA) and General Union of Voluntary Societies (GUVS)) which both recruit and train women in the communities to become community health workers (CHWs) who provide health information to women aged 15-60 years old in towns and villages across Jordan, through home visits. The CHWs promote awareness and demand for birth spacing and use of modern contraceptives, self-breast exams and pap smears, antenatal care, postnatal care, and contraception options following delivery. Women willing to accept a modern family planning method or other services are referred to a nearby clinic. Interpersonal communication messages are reinforced by mass media communications on TV and radio and in print materials.
CCA and GUVS have found that women who are non-method users adopt modern methods at rates higher than women who use traditional methods (safe period, withdrawal). Furthermore, contrary to expectations, few women visited report that cultural or religious beliefs prevent them from adopting a family planning method. In the first visit, women who indicate that they do not use a family planning method because they wish to become pregnant are unlikely to adopt a family planning method. New visit protocol has been developed, and is illustrated in graphic form within the document.
4. Vasectomy: Reaching Out to New Users
This June 2008 article based on work by the INFO project discusses how family planning programmes can introduce or expand vasectomy services. The report identifies and addresses the barriers that discourage men from choosing vasectomy, describes the selection of communication channels and the design of persuasive messages, describes the development of provider training for both counsellors and those carrying out the procedure, and advises on planning and scaling up vasectomy services. The section "Vigorous Promotion Attracts Clients" is based on designing messages to change the views of vasectomy of both providers and clients through communication campaigns. Communication foci for moving forward are centred on promotion by mass media campaigns and interpersonal communication.
According to the report, a communication campaign needs to:
- Make people aware of vasectomy;
- Dispel myths and rumours;
- Disseminate accurate information about the procedure;
- Tell men where the method is offered;
- Prompt men to discuss vasectomy with family and friends;
- Encourage men to call and visit clinics; and
- Increase the number of vasectomies performed.
Studies on which sources of information are convincing men to seek vasectomies show that both mass media and interpersonal communication can be effective. Mass media can increase general awareness and willingness to inquire about vasectomies. The incorporation of telephone hotlines with mass media campaigns has shown itself to provide confidentiality and the ability to direct men to service locations and health counselling. Recruiting satisfied clients as promoters and finding venues for their messages can change community attitudes. If men are reluctant to talk about their vasectomies because of perceived community disapproval, communication campaigns, including mass media, can address this barrier.
The document conclusions include adopting a gender perspective: "What works for women clients does not necessarily work for men. To reach men, family planning programs must understand men's point of view, address men's concerns and questions, and tailor services - including the setting, staff, and services offered - to men's needs.”
5. Approaches to Family Planning in Afghanistan
This paper presents a culturally-sensitive approach to family planning in Afghanistan that is reported to yield results through the Accelerating Contraceptive Use project. According to this paper, "Challenges and Successes in Family Planning in Afghanistan," the project achieved increases of 24-27 percentage points in the contraceptive prevalence rate in three rural areas of Afghanistan from 2004 to 2006. Although cultural factors and misconceptions about family planning presented obstacles, it was found that religion in Afghanistan, which is 99% Muslim, is not a barrier to expanding family planning services. Strategies found to support rapid scale-up of contraceptive use include: emphasising the use of birth spacing to protect the health of mothers and children, engaging clinicians and communities in culturally sensitive ways, increasing the number of female community health workers, and providing activities to empower women, including a health-oriented literacy programme.
Recommendations from the document include:
- Provide family planning services to help reduce maternal deaths where there are gaps in maternal health services.
- Emphasise the health of mothers and children in family planning and birth spacing messages.
- Do not assume that local NGOs understand or support community-based health care.
- Question unproven assumptions that narrow the potential for success. Get to know the community and find out what the actual context is.
SOCIAL CHANGE COMMUNICATION AND ENGAGEMENT OF POLICYMAKERS
6. Repositioning Family Planning: Mobilising Audiences
Published at the end of 2008 by the Population Reference Bureau and Africa's Health in 2010, this toolkit is designed to help those working in family planning across Africa to advocate for the visibility, availability, and quality of family planning services and counselling, including contraceptive use and healthy timing and spacing of births. The toolkit, "Repositioning Family Planning: Guidelines for Advocacy Action", was developed in response to requests from several countries to assist them in accelerating their family planning advocacy efforts.
The toolkit supports family planning advocates in convincing key programme managers, opinion leaders, and policy-makers that family planning confers important health and development benefits to individuals, families, communities, and the nation, so that they will 1) act directly or use their influence to expand and improve family planning services, and 2) disseminate accurate information on the benefits of family planning. The toolkit is intended to suggest a range of audiences that can be mobilised, ways to engage those audiences, and what each can do for family planning. It provides the advocates with the latest family planning data and trends, ready-to-use messages, and suggested activities for reaching out and involving specific audiences.
The kit contains eight briefs:
- one update on population and family planning in sub-Saharan Africa, including regional and country data;
- four briefs devoted to communication with influential audiences
- two briefs on how to develop an advocacy strategy and work with the media; and
- a list of materials, advocacy manuals, and other resources available on the internet.
The kit also contains a CD-ROM with copies of the briefs, internet links, PowerPoint slides, and additional advocacy materials.
7. Assessing Integration of Services: A Handbook
Published by Population Council, "Assessing Integration Methodology (AIM): A Handbook for Measuring and Assessing the Integration of Family Planning and Other Reproductive Health Services" provides a roadmap for the Assessing Integration Methodology (AIM), which is a tool for describing and measuring attempts to integrate the provision of family planning information and services with other relevant services.
Many rationales underlie the move toward integrating family planning with other services. Benefits include: (1) meeting multiple reproductive health needs of a client simultaneously, (2) reducing the stigma associated with providing a service independently, (3) combining several services needed for a multifaceted health condition, and (4) achieving cost efficiencies through sharing staff skills, infrastructure, and equipment. The Population Council's experience indicates, however, that creating service configurations for integrated services is usually not straightforward and can place a strain on the underlying logistics, training, supervisory, and management systems.
In this context, AIM has been designed to fill the information gaps embedded in questions such as the following: Which service combinations are feasible? Which services are acceptable to clients and providers? Which services can effectively increase access to one or both services without compromising the quality or safety of their delivery? Does their joint provision lead to a synergistic impact on both the individual client's health status and that of the population served? In short, the rationale behind AIM is that offering services in a combined fashion requires appropriate methodologies for determining the feasibility of various combinations, assessing and monitoring the quality of service received, and evaluating their effect on utilisation.
To that end, the handbook:
- explains the basic principles of conducting studies using AIM,
- provides tips for the data collection, and
- makes available data collection instruments that have been validated in projects
- throughout the developing world for the integration of:
- family planning and antenatal care (ANC) services,
- family planning and postnatal care (PNC),
- family planning in post abortion care services, and
- family planning and HIV and sexually transmitted infection (STI) prevention and detection.
8. Introducing and Mainstreaming Emergency Contraceptive Pills in Developing Countries
Published in March 2009 by the Population Council, "The ECP Handbook: Introducing and Mainstreaming the Provision of Emergency Contraceptive Pills in Developing Countries" provides comprehensive guidance to help managers of integrated reproductive health programmes, health care directors, and policymakers introduce emergency contraceptive pills (ECPs) within local and national family planning programmes. Operations research has demonstrated the feasibility and acceptability of ECPs as a way of preventing unintended pregnancy following unprotected sex or failure of an existing contraceptive method. The handbook presents a step-by-step process for introducing ECPs that can be adapted to each country’s needs and resources. The process, based on research conducted in several developing countries, covers the full continuum of ECP programming, including the following:
- Needs assessments and operations research
- Drug registration
- Training and logistics
- Introduction of ECP scale-up
Additionally, the handbook discusses ways to address the needs of specific segments of the population, including special groups, such as adolescents and rape survivors. The handbook contains four sections:
- Introduction and Background' describes the existing situation of ECP programming around the globe.
- Addressing the Needs of Specific Populations' describes programming approaches designed for specific populations.
- Introducing and Mainstreaming ECPs' describes five chronological steps for making ECP programming an integral component of a national reproductive health programme.
- The 'Bibliography' lists resources for ECP programming.
A CD-ROM of the handbook is also available.
9. Understanding Operational Barriers to Family Planning Services in Conflict-Affected Countries
Published in August 2008 by the USAID-funded Health Policy Initiative, this February-May 2007 study highlights issues affecting provision of family planning in conflict-affected settings, using experiences in Sierra Leone as the focus from which to derive lessons on refugee/internally displaced persons (IDP) family planning needs; barriers to quality, accessible services; policy actions to overcome barriers; and capacity building of local groups to recognise and analyse barriers. According to the study, entitled "Understanding Operational Barriers to Family Planning Services in Conflict-Affected Countries: Experiences from Sierra Leone", the adoption and implementation of appropriate "operational policies" can alleviate barriers to healthcare until international community guidelines and protocols on refugee/IDP health needs are met through national policy and guideline development.
The document notes that the range of complementary reproductive health services (e.g., safe motherhood, prevention of gender-based violence, HIV/sexually transmitted infection prevention) are essential and have been identified as part of the Minimum Initial Services Package (MISP) for reproductive health in crisis situations.
The report details women's and men's responses on family planning at the three stages of study. Responses show increased availability of condoms with the presence of non-governmental organisations both during and after the conflict, and increased family planning services after the conflict, though clinics were reportedly hampered by stockouts of medicines of up to one month. Reports varied on barriers such as price, and some women reported going to local markets for lower priced family planning products such as injectable contraceptives. Barriers to family planning included lack of availability in the immediate post conflict stage, limited knowledge of contraceptive use, particularly among IDP women, inability to travel to hospitals, and restrictions on family planning access for single women, adolescents, and women with low parity. Some refugee women reported learning from programmes on sensitisation to the need for family planning, provided by national and international organisations.
Recommendations for stakeholders include a suggestion that Ministry of Health and non-governmental organisations should collaborate to develop strategies for encouraging male involvement, addressing sexual violence, and increasing knowledge on the availability of emergency contraception; and an identified need to provide in-service training for all health facility personnel on reproductive health.
Recommendations for the international community include an identified need to systematically examine and strengthen the reproductive health knowledge of camp providers.
SOCIAL AND BEHAVIOUR CHANGE USING MASS MEDIA
10. Mass Media Social Marketing of the Standard Days Method
This report by the Institute for Reproductive Health is based on a study conducted to research the potential of socially-marketing the Standard Days Method (SDM) in three countries - Benin, the Democratic Republic of the Congo (DRC), and Ecuador. SDM is a relatively new method of natural family planning that helps couples to recognise when they are most fertile. Most women who use this method use special colour-coded beads called CycleBeads to help keep track of where they are in their cycles. This study, "Social Marketing Final Report: Three Country Overview", sought to assess the feasibility of providing the SDM through social marketing programmes in different contexts, and evaluate the impact of mass media campaigns on knowledge, sales and distribution, and quality of information provided by pharmacists. In each country a social marketing campaign was conducted to raise awareness of the SDM and the benefits of CycleBeads. The study found that the social marketing campaign succeeded in raising awareness of the SDM in all three countries, but was most successful in countries in which television augmented information provided by clinics and other sources.
According to the study, the mass media campaign increased knowledge of the SDM in all three countries, with substantial increases observed in the endline survey compared to the baseline in Ecuador (from 5% to 30%) and Benin (35% to 64%). Television was the major source of information about the SDM in Ecuador, while in Benin it was both television and clinic personnel. In DRC, where television was not used, the clinic was the major source of information. In both Benin and Ecuador, more than a quarter of the SDM clients were new family planning users. Very few were using family planning in the months preceding SDM use.
11. Radio Campaign Suggests Lessons for Other Mass Media Campaigns
This report presents the findings of a qualitative assessment of the radio serial drama "Rock Point 256" which is produced and broadcast in Uganda under the auspices of the Uganda AIDS Commission. The study explored the impact of the radio programme on the intended youth audience and on others who are considered significant in the lives of young people - such as local community members, teachers, and youth leaders. "Qualitative Assessment of Radio Serial Drama Rock Point 256 in Uganda" shares findings related to programming, composition and delivery of messages, comic books and other supplementary materials, and findings related to behavioural change after exposure to "Rock Point 256". The evaluation found that while the drama resonated with the intended audience in terms of themes and production, the programming, messaging, and the relevance of the storyline to communities could be strengthened.
The evaluation found that most people had heard the radio promotions and some had seen the billboard advertisements and T-shirts of both the "Rock Point 256" and the related "Be a Man" radio series. The radio spots had far reaching impact in terms of public perception and listenership. However, many only heard the radio promotions and never proceeded to listen to the actual radio drama. Few people had seen a copy of the comic books; however, participants who had only been exposed to the comic books were able to narrate the "Rock Point 256" stories with clarity.
According to the report, the research team observed a level of assertiveness and clarity of thought displayed by youth respondents exposed to "Rock Point 256" in their discussion of issues surrounding transactional relationships. Researchers found that parents optimised the drama as a point to initiate discussion with children. This optimisation was expressed not only by the parents, but also by some young people who, as a result, mobilised their siblings and friends to listen to the radio programme. The report suggests that this is indicative of social change since it was novel that parents were rallied around a common goal of ensuring the survival of their children. Schools have also appropriated the "Rock Point 256" drama as a guiding communication tool for the classroom.
Based on the findings, the evaluation makes the following recommendations that could be useful for other mass media campaigns:
- There is a need to assess the appropriateness of radio stations chosen for broadcasting programmes.
- There is a need to focus on the technical direction of radio drama in ways that will help the actors to act with a radio audience in mind, with more emphasis on making their characters' voices distinctive. Alternatively, calling a character by name would help late entrants to know who is saying what and to whom.
- There is a need to find good distribution mechanisms for the comic books and other print materials and to possibly consider schools as a distribution point.
- To determine behaviour change after exposure, there is a need to follow-up with the audience through audience activation and analysis.
For more information on the campaign itself, please see this summary of "Rock Point 256".
SOCIAL AND BEHAVIOUR CHANGE USING INTERPERSONAL COMMUNICATION/COUNSELLING
12. Telephone Hotline Key for Family Planning Information in DRC
This case study, entitled "Phone Hotline spreads Family Planning Information in DR Congo", describes how Population Services International (PSI), under their Family Planning Project, set up and managed la Ligne Verte (which means "hotline" in French) in the Democratic Republic of Congo (DRC). It also explores the lessons learned that may point to the use of cell phone technology as a powerful new tool for health education, especially in countries like the DRC that have little communications infrastructure, such as standard telephone networks and roads.
The programme is based on the idea that if knowledge of two or more methods of family planning is strongly correlated with the uptake of contraception, having a discussion about family planning is even stronger: A woman is 3 times more likely to adopt a modern method if she has a conversation with a knowledgeable person. To increase the number of such discussions, the FPP launched la Ligne Verte in early 2005. By dialling a toll-free number, callers can speak to a trained educator and get accurate information about birth spacing in general, the correct use of family planning methods and how to avoid unwanted pregnancy, and the nearest Association de Santé Familiale (ASF) partner clinic. Important features of la Ligne Verte are both the assurance of caller anonymity and the fact that each call is free (for the caller). The FPP offers the hotline as one element of an integrated package of services.
The organisers have found that men make up the vast majority of callers to la Ligne Verte. All calls made to the hotline are free, so lack of money to pay for a call is not a factor (although it is likely that men have better access to cell phones in the first place). Likewise, it is unlikely that men are more exposed to information about the hotline than are women, since most of the FPP's family planning messages are primarily designed for women. The organisers have also found that project activities correlate with hotline calls, and the largest number of calls originated from where the organisation has activities.
Based on experience with the hotline, the organisers make the following conclusions:
- Men in the DRC have a higher unmet need for family planning information than anticipated.
- Two minutes per call is not adequate.
- Call data could be mined to further evaluate and guide programming.
According to the report, the FPP’s experience in the DRC indicates that a hotline is a valuable asset in a programme that aims to increase knowledge, acceptance, and use of family planning methods; it is perhaps especially important where other forms of communication are not readily available.
13. Client-friendly Balanced Counselling Strategy
The toolkit "The Balanced Counseling Strategy Plus: A Toolkit for Family Planning Service Providers Working in High HIV/STI Prevalence Settings", developed and tested by the Population Council in Kenya and South Africa, provides the information and materials needed for health care facility directors, supervisors, and service providers to implement the "Balanced Counseling Strategy Plus" (BCS+) approach in their family planning services. BCS+ is described here as an interactive, client-friendly approach for improving counselling on family planning and prevention, detection, and treatment of sexually transmitted infections including HIV.
This toolkit includes the following:
- BCS+ Trainer’s Guide that supervisors and others can use to train health care facility directors and service providers on how to use the BCS+ for counselling family planning clients.
- BCS+ User’s Guide on how to implement the BCS+. It can be distributed during training or used on its own with the BCS+ job aids.
- BCS+ job aids comprising: BCS+ algorithm that summarises the 19 steps needed to implement the BCS+ during a family planning counselling session; BCS+ counselling cards that the provider uses during a counselling session; and BCS+ method brochures.
Communication for Change (C-Change), implemented by AED, is USAID's flagship programme to improve the effectiveness and sustainability of social and behaviour change communication programmes, activities, and tools. C-Change works with global, regional, and local partners to incorporate knowledge about the social determinants and underlying causes of individual behaviours and takes into account research and lessons learned from implementing and evaluating activities. Employing innovative and tested methods, C-Change works to meet the continuing challenges posed by evolving health issues that require a behaviour change communication approach. C-Change also works to strengthen the capacity of local organisations to plan, implement, and manage programmes, thus ensuring sustained local knowledge and skills. Please visit the C-Change website. To contact C-Change, please email cchange@aed.org
The Communication Initiative (The CI) network is an online space for sharing the experiences of, and building bridges between, the people and organisations engaged in or supporting communication as a fundamental strategy for economic and social development and change. It does this through a process of initiating dialogue and debate and giving the network a stronger, more representative and informed voice with which to advance the use and improve the impact of communication for development. This process is supported by web-based resources of summarised information and several electronic publications, as well as online research, review, and discussion platforms providing insight into communication for development experiences. Please see The CI website.
This publication is made possible by the support of the American people through the United States Agency for International Development (USAID) under the terms of Agreement No. GPO-A-00-07-00004-00. The contents are the responsibility of the Communicative Initiative and the C-Change project, managed by AED, and do not necessarily reflect the views of USAID or the United States Government.
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