Social and Behavior Change Communication to Address Family Planning Uptake in an Integrated Program in Zambia

This 64-page report summarises the final evaluation findings of the effectiveness of an action research study by Care Zambia that explored the effects of two complementary sets of interventions to increase family planning (FP) use and address the underlying social norms that influence uptake, particularly among people living with HIV. First, in order to improve access to family planning at a large rural health center, the team established a family planning screening and referral system. Second, the project team also implemented a series of social and behaviour change (SBCC) communication strategies at the community level to increase demand for FP and reduce barriers to FP use.

Between November 2009 and June 2011, CARE Zambia worked as a partner on a United States Agency for International development (USAID) funded Communication for Change (C-Change) Project in the Mwase Zonal Rural Health Center (Mwase RHC) catchment area in Lundazi District, Eastern Province, Zambia. Under the family planning referral system, clinic workers in three units of the Mwase RHC - the outpatient department (OPD), antiretroviral therapy (ART) clinic, and the laboratory - were trained to ask clients about their interest in family planning. Interested patients were then referred to the family planning section and provided with a referral slip. The first phase of SBCC activities included participatory dialogues facilitated by volunteers from neighbourhood health committees (NHC), who were trained using the CARE Social Analysis and Action (SAA) approach. Using tools and participatory learning activities from SAA, these volunteers facilitated recurring community dialogues within neighbourhood health committee meetings. During the second phase of SBCC activities, this cadre of facilitators integrated a field-tested SBCC tool into their community dialogues.

The findings of the research are as follows:

• Fertility Intentions and Ideal Family Size: At endline, a smaller proportion of female respondents were unsure of their fertility desires than at baseline, and more women reported that they wanted no more children. Respondents continued to report perceptions that community ideals relating to family size were higher than their personal ideals. If community perceptions of norms influence childbearing more than personal preferences, these norms could inhibit use of FP services to limit family size. Qualitative data indicated that women more than men are sensitive to perceptions of community pressures and expectations about childbearing. However, inter-survey analyses indicated that perceived norms of ideal family size have shifted downward, for male as well as female respondents. Whereas 67% of female respondents at baseline believed that the community’s ideal family size included six or more children, 47.7% of the endline female sample cited this figure. Among male respondents, these proportions decreased from 66.2% to 54.6% from baseline to endline.
• Knowledge and Use of Family Planning: Over the life of the project, female use of modern methods of FP increased. By endline, over half of women in the survey sample were using a modern family planning method, increasing from 43% at baseline to 54% at endline. Current use of contraceptives fell slightly among all men (52.1% at baseline vs. 44.7% at endline). However, current use of contraceptives did increase among HIV-positive men, from 63% at baseline to 70.4% at endline. It is notable that, at endine, more than twice as many HIV positive men were currently using contraception, than were HIV-negative men (70.4% vs. 34.3%), a difference that probably reflects higher condom use among HIV-positive respondents. At endline, women reported greater knowledge of FP sources and methods than at baseline.
• Approval of Family Planning: Approval for FP was high among all groups and not significantly different based on sex or HIV status. Inter-survey comparisons indicated that female approval for FP increased significantly during the study period. Male approval for FP was fairly constant. Larger proportions of women in the endline sample reported that their husbands or partners approved of FP, compared to baseline female respondents. Approval of FP use by recently married couples, however, remained low, a finding that complements qualitative data on the strength of community norms related to fertility. These include the belief that couples who do not want children are not normal, that the primary purpose of marriage is to bear children. Although communities continue to expect couples to bear children early in a marriage and believe that children give a marriage meaning, some shifting in attitudes may be occurring that allows some space for birth delay. Compared to baseline, higher proportions of both male and female endline respondents rejected the idea that a woman who uses FP will be unfaithful, possibly suggesting a change in the prevailing perception that contraceptives promote promiscuity. However, young, unmarried women’s use of FP seems to be contentious.
• Gender Attitudes and Norms: Endline data from both survey and focus groups suggested a shift in some attitudes and beliefs related to gender. Women reported more equitable attitudes and beliefs about gender at endline than at baseline, as measured using a scale adapted from the Gender Equitable Men (GEM) scale. However, this change was not statistically significant. Strongly held norms around shared decision-making in couples were confirmed through FGDs, where both men and women of different ages indicated they engaged in joint decision-making around family planning and childbirth. Importantly, however, qualitative data-supported by survey data on gender relations, also suggested that men had final decision-making authority in the household, including making final decisions about family planning. Interestingly, at endline significantly more women indicated that it is woman's responsibility to avoid getting pregnant. At baseline, 22.5% of women disagreed with the statement "that it is a woman’s responsibility to avoid getting pregnant", whereas only 7.4% disagreed at endline.

The report concludes that the important changes, although not all statistically significant, in key outcome variables were in increased current use of FP, increased approval of FP use, and improved attitudes related to a few gender norms. These changes occurred primarily among female respondents. When significance was analysed by HIV status, most changes were significant only for the HIV-negative female subsample. Analysis of programme-reach variables also indicated greater effects of interventions among female respondents than among male respondents.

HIV–positive female respondents exclusively reported two key improvements not observed among HIV–negative female respondents: increased access to contraceptives from CHWs, and increased interaction with clinic workers on the subject of FP. Together, these suggest a degree of success for efforts to improve FP service provision to HIV–positive individuals at the clinic and community level. Male respondents reported increases in two important variables related to C-Change activities: increased attendance at meetings where FP was discussed and increased access to contraceptives from the Mwase Lundazi RHC. For the first variable, meeting attendance, the increase was significant for the male sample overall and for HIV–positive male respondents.