HC3 in Action: Enhancing Family Planning Service Delivery through SBC

"When family planning SBC and service delivery partners align, programs are more effective and lead to better population and reproductive health outcomes."

In 34 countries around the world and at the global level, the Health Communication Capacity Collaborative (HC3) has worked to align social and behaviour change (SBC) and service delivery partners by developing resources for understanding and using strategic communication along the service delivery continuum. HC3 is also integrating SBC and service delivery in an attempt to improve family planning (FP) outcomes for youth, women of advanced maternal age (AMA), women of high parity (HP), and couples. This brief, which is part of the "HC3 in Action" series, describes key examples, challenges, and insights from FP service delivery initiatives across the HC3 project.

HC3's work around the integration of SBC and service delivery has revolved around the Circle of Care Model, a conceptual framework for improving service-related outcomes. HC3 also developed the Service Communication Implementation Kit (I-Kit), a resource that is designed to help service delivery project managers increase demand for and uptake of services and improve consistent long-term maintenance of healthy behaviours. As part of this effort, HC3 convened periodic meetings of SBC and service delivery partners working in FP and reproductive health as a forum for discussion, debate, and collaboration.

Meetings of a different kind were part of HC3 Nepal's Smart Jeewan ("Smart Life") campaign, which focused on married young families with the aim of maximising contacts and referrals among eligible couples using a systematic district intervention model. HC3 Nepal facilitated tripartite meetings among communities, health facility management, and clinic personnel to increase community ownership of local health services. In an effort to improve counseling, the district intervention model also included health worker training designed to orient workers to interpersonal communication, the Smart Paramarsha ("Smart Counseling") mobile application (app), and linkages with child immunisation clinics. As part of the latter, HC3 peer facilitators systematically attended Expanded Programme on Immunization (EPI) clinics, where they counseled young couples on postpartum FP options and ways to avoid early, unplanned pregnancies. The FP-EPI linkages led to 99,920 contacts and 20,317 referrals from January 2016 to May 2017. "This comprehensive district intervention model spotlights the impact of working with facilities, governance, communities and service delivery partners to generate FP demand and raise the quality of health services."

Based on formative research findings that showed the key role that health providers play in youth uptake of long-acting reversible contraceptive methods (LARCs), HC3 created a suite of SBC materials that programme managers could use to improve providers' attitudes towards youth use of LARCs and their counseling abilities. The suite includes: a provider training video, a video discussion guide, a brochure, and series of posters. Since its launch in April 2016, this LARCs for Youth collection has been adapted 29 times for audiences in over 20 countries.

In order to increase the number of FP clients who are informed, empowered, and confident, HC3 developed a set of digital health tools: Smart Client (for women) and Smart Couple (for both men and women). These tools reach FP clients directly via their mobile phone with information and skills in an entertaining and engaging format. They use interactive voice response (IVR) to deliver a fictional drama, personal stories, examples of "smart client" dialogues, and quizzes over a series of 17 calls, along with supporting short message service (SMS) reminders or challenges. A quasi-experimental pre-post design trial was conducted in Kaduna City, Nigeria, to assess the effects of Smart Couple among 670 women and 652 men. Nearly all the ideational and behavioural indicators assessed increased significantly with higher exposure to the tool (e.g., odds of discussing FP with one's spouse by ten-fold for women and more than 12-fold for men, and support for women who use contraceptives by 94% for women and by 188% for men).

Noting that little to no work has focused on pregnancies among women aged 35 and older (AMA) and women who have had five or more births (HP), and that providers rarely counsel women about these risk factors, HC3 developed the healthy timing and spacing of pregnancies (HTSP): AMA and HP I-Kit. It includes a set of adaptable communication tools for audiences from all socio-ecological levels: individual, family, peer, community, and structural. Two organisations piloted the completed I-Kit: Marie Stopes International (MSI) in Niger and the Association Togolaise pour le Bien-Être Familial (ATBEF) in Togo. Each organisation used relevant elements of the I-Kit to incorporate the risks of AMA and HP pregnancies into provider training and outreach. According to HC3, both pilot projects successfully mainstreamed AMA and HP topics in routine service provision, community group discussions, and mass media.

HC3 also developed the Provider Behavior Change I-Kit for programmes designed to improve quality of health care. This I-Kit can be used to understand and prioritise provider barriers and develop an SBC intervention to influence factors that undermine providers' willingness and ability to perform their jobs well. Once the I-Kit was available, HC3 and the Maternal and Child Survival Program (MCSP) applied it through a two-day workshop held in July 2017 in Madagascar.

In conclusion, "the examples included in this brief illustrate work in action that increased FP referrals in Nepal, increased LARC access for youth worldwide, empowered FP clients with digital health tools, reached AMA and HP audiences in Togo and Niger and addressed provider behavior challenges in Madagascar."