C-Change Picks - Information about Behaviour and Social Change Communication - Family Planning
C-Change Picks #3 - Information about Behaviour and Social Change Communication - Family Planning
Sponsored by C-Change
October 16 2008
From The Communication Initiative (The CI) and the United States Agency for International Development (USAID)'s C-Change programme.
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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 communication for behaviour and social change to address health, environment, and civil society. If you have received this newsletter from a friend or colleague and would like to subscribe, please contact cchange@comminit.com
This issue of C-Change Picks focuses on social and behaviour change communication (BCC) in family planning and reproductive health, highlighting information and reports around issues that include: access to timely, updated, and culturally appropriate family planning information; research and resources for understanding/promoting long-acting and permanent methods (LAPMs); evidence from healthy timing and spacing of pregnancy (HTSP) programmes; and key communication challenges – and solutions – for successful family planning programmes, among others.
The C-Change programme is implementing programmes and undertaking research in Africa, Eastern Europe, and India that address behaviour and social change communication in family planning. Factors that influence contraceptive use and method choices are varied and include the cultural conventions and gender and social norms of a society, current and previous government policies and programmes, stockouts of contraceptives due to unreliable logistics systems, and the particular motivations and education of the woman and the couple. In Albania, traditional family planning methods (in particular, withdrawal) have been the norm and abortion has been used when such methods often fail. To address this situation, C-Change is developing an integrated communication programme that includes a national media campaign and community-based interventions to change social norms among young men and women and increase the use of modern contraceptives in Albania. In India, C-Change is evaluating using SCALE® - a systems approach that catalyses widespread social change in a short time - in the state of Uttar Pradesh to address reproductive health practices.
C-Change Picks continues to seek new knowledge and experiences in behaviour change and social change communication - your case studies, strategic thinking, support materials, and any other relevant documentation. Please contact cchange@comminit.com
For online access to the first two editions of C-Change Picks, please see:
- C-Change Picks 1 - Information about Behaviour and Social Change Communication
- C-Change Picks 2 - Information about Behaviour and Social Change Communication - HIV Prevention
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A Focus on Family Planning and Reproductive Health
1. Europe/Eurasia: Public and Private Sector Practices in Reproductive Health and Family Planning
2. Identifying Elements of Successful Family Planning Programmes
3. Trainer's Reference Guide for Healthy Timing and Spacing of Pregnancy
4. Long-Acting and Permanent Methods: Addressing Unmet Need for Family Planning in Africa
5. Training to Mobilise Muslim Religious Leaders for Reproductive Health and Family Planning
6. Engaging the Family in Health Timing, Spacing, and Pregnancy
7. Increasing the Accessibility, Acceptability and Use of the IUD in Gujarat, India
8. Promoting Healthy Timing and Spacing of Births in India through a Community-based Approach
9. Supporting Antenatal and Postnatal Care in Impoverished Contexts
10. Empowering Women Leads to Increased Family Planning and Reproductive Health
11. Community Awareness of Post Abortion Care: Bolivia, Kenya, Senegal
12. Interactive, Client-oriented Balanced Counselling Strategy Toolkit
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Family Planning/Reproductive Health
1. Europe/Eurasia: Public and Private Sector Practices in Reproductive Health and Family Planning
This USAID brief, developed through a collaborative effort by John Snow Inc. (JSI) and PSP-One, intends to synthesise some best practices in achieving reproductive health and family planning (RH/FP) goals for the Europe and Eurasia (E&E) region, and highlight the role of the private sector in meeting these goals. "Ten Best Public and Private Sector Practices in Reproductive Health and Family Planning in the Europe and Eurasia Region" is designed for policymakers, service providers, FP organisations, and other stakeholders with an interest in developing better public/private collaboration in achieving RH/FP goals. The criteria used to identify these best practices included effectiveness in improving RH/FP services and outcomes, potential for sustainability and replication, innovation, and ability to address local needs.
Though modern contraceptives are easily available in the urban centres in the E&E region, "significant barriers exist that limit access to information, services, and commodities for certain groups. In some cases, the barrier is financial, when free or subsidized commodities are unavailable to low-income users. Other obstacles include legal restrictions in the provision of FP services, unnecessary tests and medical examinations, and a lack of reliable information about modern methods."
The report states that private sector interest in FP varies substantially from one country to another and tends to focus on specific and saleable products, which results in limited method availability, impacting on the method mix in the region. "The private sector can help decrease the burden on the public health sector, allowing it to focus its limited resources on vulnerable population groups. The public sector, however, retains a fundamental role in setting the parameters of service provision and ensuring universal access to a broad method mix." According to this report, the private sector can address provider bias and identify special needs groups, which may foster a private sector increase in investment in the provision of mixed methods and improved quality of service.
2. Identifying Elements of Successful Family Planning Programmes
The INFO Project, in collaboration with the World Health Organization (WHO) and partners of the Implementing Best Practices (IBP) Initiative, sponsored an online global discussion forum in order to share programme experiences, review research findings, highlight resources, and reach consensus on the core elements of successful family planning programmes. Before launching the forum, the INFO Project at the Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs conducted an online survey on what are considered the elements of successful family planning programmes. "Elements of Successful Family Planning Programs: Online Survey and Global Forum Discussion" reports the outcomes of both of these activities, undertaken in December 2007.
445 health care professionals from 98 countries responded by ranking the importance of a variety of factors involved in running family planning programmes. Results showed that effective communication strategies and outreach ranked second after staffing as one of the most important factors for success.
Communication challenges and solutions were summarised as:
a. Challenge: Lack of community interest in family planning messages due to socio-cultural factors, such as religious beliefs.
Solution: Convince local leaders before disseminating messages to the community and convince local leaders to help spread the messages.
b. Challenge: Radio spots have limited reach.
Solution: Repeat radio programmes and spots at different times throughout the day to reach a wider audience.
c. Challenge: Lack of qualified and committed health care providers and outreach staff.
Solution: Capacity-building activities for health care providers and outreach staff.
d. Challenge: Time-consuming for providers to counsel clients.
Solution: Decrease provider workload.
e. Challenge: Expensive to air mass media messages.
Solution: Negotiate with production studios to air mass media messages at a discounted rate.
f. Challenge: Messages reach only female clients.
Solution: Develop messages to address men by organising a community meeting.
3. Trainer's Reference Guide for Healthy Timing and Spacing of Pregnancy
Published by the Extending Service Delivery (ESD) Project in August 2008, this guide serves as a resource for trainers in developing in-service training for facility-based healthcare providers and community health workers, who already have some basic experience with and an understanding of reproductive health/family planning. It focuses only on the evidence of the health and social outcomes that are related to too early and too closely spaced pregnancies. It discusses all methods of family planning, including long acting and permanent methods (LAPMs), and provides information on assessing fertility intentions and desired family size with all clients, including older women and/or high parity women, who may be particularly interested in LAPMs. This is not a training manual, but a reference guide, which can be used and adapted by trainers based on whether the trainees are facility-based or community-based.
Also from the ESD Project, this guide provides an overview for health practitioners and programme managers about healthy timing and spacing of pregnancies (HTSP). It discusses key findings from global research on the link between pregnancy spacing and maternal and newborn health outcomes. It also highlights the benefits of timing and spacing pregnancies, shares HTSP messages for educating women, men, and communities, and identifies windows of opportunity for HTSP counselling.
4. Long-Acting and Permanent Methods: Addressing Unmet Need for Family Planning in Africa
This series brings together eight advocacy briefs on using long acting and permanent methods (LAPMs) of contraception to address unmet needs in Africa. LAPMs here include: the intrauterine device (IUD), contraceptive implants, vasectomy, and female sterilisation.
Brief 1: The Case for Long-Acting and Permanent Methods
Brief 2: The Benefits of Long-Acting and Permanent Methods for Individuals
Brief 3: The Role of Long-Acting and Permanent Methods in National Programmes
Brief 4: Strategies to Improve Availability, Access, and Acceptability
Brief 5: Contraceptive Implants: Safe, Effective, Long-Acting, Reversible
Brief 6: IUDs: A Resurging Method
Brief 7: Female Sterilisation: The Most Popular Method of Modern Contraception
Brief 8: Vasectomy: Safe, Convenient, Effective and Underutilised
5. Training to Mobilise Muslim Religious Leaders for Reproductive Health and Family Planning
"Mobilizing Muslim Religious Leaders for Reproductive Health and Family Planning at the Community Level: A Training Manual", created by USAID and the Extending Service Delivery Project (ESD), is a 5-day training curriculum designed to equip male and female Muslim religious leaders with the necessary information and skills to better understand, accept, and support the provision of maternal and child health, reproductive health, and family planning (MCH/RH/FP) information and services at the community level. The ultimate goal of the training is to build the capacity and leadership of Muslim religious leaders in MCH/RH/FP and gender to support couples and community members in making informed decisions on reproductive health issues such as safe motherhood, child spacing, sexually transmitted infections including HIV/AIDS, and to discourage harmful behaviours, especially gender-based violence. The manual presents concepts of MCH/RH/FP from a perspective that is consistent with and supported by the teachings of Islam. In addition, there are sections devoted to the needs of youth and building the leadership capacity of religious leaders.
- At the end of the training, participants should be able to:
define RH/FP and describe its components: safe motherhood including child survival and management of complications of unsafe abortion/miscarriage; birth or child spacing (family planning); prevention and management of reproductive tract infections, including sexually transmitted infections and HIV/AIDS; and the prevention of gender-based violence, including the discouragement of harmful traditional practices; - dispel myths and misconceptions about RH/FP;
- identify gender constraints to RH/FP including MCH;
- describe the Islamic perspectives on RH/FP information and services;
- identify ways in which religious leaders can help mobilise the community around MCH/RH/FP; and
- develop action plans in support of MCH/RH/FP information and services in their communities.
All of the Qur'anic messages and Islamic information presented in the manual is referenced so that the trainer can research the information him/herself and share the sources with the participants.
6. Engaging the Family in Health Timing, Spacing, and Pregnancy
This case study examines the rationale, strategy, and impact of World Vision's child survival project, Pragati, carried out in 3 districts of Uttar Pradesh, in north-central India. Pragati (which is Hindi for "acceleration" or "momentum") strove to improve health outcomes and change behaviours related to women's and children's health, and to ensure that pregnant women and new mothers had ready access to information about and methods of birth spacing and family planning. Pragati was supported by United States Agency for International Development (USAID) resources.
As detailed within "The Right Messages - to the Right People - at the Right Time", the innovation in this project was a timed and targeted approach to BCC for all project components. That is, BCC on health, nutrition, and family planning was timed to a woman's stage of pregnancy, the age of her infant, and/or the fertility intentions of the couple. It sought to engage all decision-makers in the family, including but not solely limited to the individual who might accept a contraceptive method. World Vision developed, tested, and launched a package of training, tracking tools, job aids, and supervision protocols in this effort to ensure consistent content and quality of BCC across time and place. This case study stresses that pivotal to Pragati's effort to share information with the right people at the right time in their lives was the project's ability to tap into India's existing community volunteer structure.
The Pragati project undertook a baseline survey in 2003 and a final evaluation in 2007 to measure the effect of its work. Each study used a 2-stage, 30-cluster sampling method and a sample size of 300 mothers in each of the 3 districts. Over 4 years, the contraceptive prevalence rate more than doubled in the project zone. In addition, women's knowledge of at least one source of family planning increased from 27% to 99% of mothers of children less than 2 years of age in Ballia, from 21% to 91% of such women in Lalitpur, and from 31% to 75% in Moradabad.
7. Increasing the Accessibility, Acceptability and Use of the IUD in Gujarat, India
This May 2008 report details an operations research study carried out to explore the strategy of using behaviour change communication (BCC) to increase use of the Intra Uterine Device (IUD) in rural and urban areas in Vadodara District in the state of Gujuarat, India. The specific hypothesis being tested was that, by improving the demand for the IUD and simultaneously strengthening the technical competencies and counselling skills of the providers, IUD use would increase. The study was carried out by the USAID-funded FRONTIERS Program of the Population Council, in collaboration with the Department of Health and Family Welfare, Government of Gujarat, and the Center for Operations Research and Training, Vadodara. These collaborators were motivated by the observation that, although the IUD is a highly effective (and relatively inexpensive) contraceptive method, it is unpopular worldwide; India is no exception, with less than 2% of women adopting this family planning method.
In order to test their hypothesis, researchers first engaged in a diagnostic and preparatory phase that involved formative research designed to understand the users' perspectives about the IUD and its use, as well as prevailing myths and misperceptions about the contraceptive. Similarly, informal discussions and focus group discussions (FGDs) with providers helped in understanding providers' perspectives and their problems in promoting the IUD and personal biases against the IUD, if any. The findings were used for preparing BCC materials and counselling aids, which were then field-tested for language, clarity, and acceptability of the messages and then modified, if required.
The impact of the intervention was evaluated 9 months after introduction of the interventions. The methodology involved a pre- and post-intervention design with no control group. Researchers found that demand generation activities and provision of good-quality IUD services, together with a supportive programmatic environment - when carried out simultaneously - showed increased acceptance of the IUD. The IEC and counselling aids developed for the study were well accepted by health care providers, clients, and national and state government officials. A revised version of these IEC materials has been accepted by the IEC Division of the Ministry of Health and Family Welfare (MOHFW) and is expected to be produced for the entire country.
8. Promoting Healthy Timing and Spacing of Births in India through a Community-based Approach
This 2008 report details an operations research study carried out in India to assess the feasibility and effectiveness of using behaviour change communication as a strategy for promoting the lactational amenorrhoea method (LAM) and postpartum contraception among pregnant women with a parity of zero or one. Funded by USAID, the study is a collaborative undertaking by the Population Council's Frontiers in Reproductive Health Program (FRONTIERS), the Lala Lajpat Rai Medical College, Meerut, and the District Directorates of the Health and Family Welfare and Department of Women and Child Development. These partners were motivated by the observation that the Indian Family Welfare Program has failed to educate people about the importance of using contraceptive methods for spacing births rather than adopting sterilisation after having children in quick succession.
In this context, researchers began in July and August 2006 by carrying out baseline data collection as well as a formative study that included focus group discussions held with newly married and first-time-parent men and women, mothers-in-law, community leaders, and family planning providers. In addition, 30 in-depth interviews of newly married and first-time-parent men and women were conducted. Based on the findings of the formative study, simple, unambiguous messages on the risks of early- and short-spaced pregnancies and the benefits of maintaining at least a 3-year interval between births were developed. These messages were then incorporated into a series of communications products. The educational campaign was implemented by 267 community workers (CWs). CWs visited each eligible woman individually to explain postpartum care, including LAM and postpartum contraception. As part of these visits, the CWs gave each woman a printed, pocket-sized HTSP booklet, instructing her to share it with her husband and mother-in-law. Group meetings both for pregnant women and older women and for husbands, community elders, and village leaders were also held to raise community awareness.
Researchers claim that the study showed the following:
- The BCC model developed to promote HTSP was effective in promoting LAM and postpartum contraception and could be rolled out easily.
- Misconceptions about the return of fertility and its links to the biological marker of the menstrual cycle are the main barriers in a timely beginning of postpartum contraception.
- Acceptance of CWs in a family increases if counselling focuses on HTSP and its benefits to mother, child, and family.
- The complementing effort by CWs of two Ministries to achieve similar objectives is feasible and provides a synergistic effect.
- The BCC materials, counselling aids, and messages developed for the projects are ready to use in scaling up the programme.
9. Supporting Antenatal and Postnatal Care in Impoverished Contexts
"Maternal and Newborn Care Practices Among the Urban Poor in Indore, India: Gaps, Reasons and Potential Program Options," published at the end of August 2008, describes maternal-newborn care practices and care of infants aged 2-4 months (feeding practices, morbidity status, immunisation status, and nutritional status) in urban slum dwellings of Indore city, Madya Pradesh (India). The findings presented in this report are from a study carried out by UHRC between December 2004 and February 2006 in 11 out of 79 slums where its Indore Urban Health Program has been operational since April 2003. Also discussed in this report are reasons for following these practices, what facilitates and what hinders following optimal practices, and potential programme options for their improvement.
Strategies for supporting mothers and newborns through antenatal care include:
- Enable families (pregnant women, their husbands, and in-laws) to perceive the benefits of appropriate antenatal care practices through persuasive reinforcement of optimal practices by trained slum-based CBOs and involving early adopters as change aides in group meetings/home visits. Early adopters include: a progressive early adopter/relative/neighbour/an elder lady of the community.
- Encourage families and/or pregnant women to join a health savings fund group from which they can draw money if needed for health care.
- Train 'Basti' Community Based Organisations (BCBOs) through pictorial and group discussion, accommodating literacy issues, to monitor behaviours of mothers and assess their progress.
- Establish telephone links of slum-based birthing huts with public or private medical facilities that can offer support.
- Establish "outreach camps" for individual appointments, particularly in the evenings, and group discussions. Attempt to partner with private medical providers when possible to increase confidence in outreach camps.
- Enabling community members to analyse the benefit of and harm of not practising optimal behaviours through discussions using case narratives and/or use of pictorial material by CBOs.
- Refresher training for BCBOs and TBAs, related to resuscitation; cutting and tying the cord tie and thermal protection.
- Engaging in collective dialogue with mothers-in-law (MILs), elder ladies of the community and TBAs to: a) assert the positive role they can play in promoting optimal delivery practices; and b) discuss ways of avoiding harmful traditions.
10. Empowering Women Leads to Increased Family Planning and Reproductive Health
This paper, entitled "Women's Empowerment in Ethiopia: New Solutions to Ancient Problems," documents the challenges and successes of two Pathfinder International projects in 4 regions in Ethiopia that aimed to combine increased access to reproductive health care and family planning with comprehensive social change. In collaboration with partners, community and religious leaders, and medical providers, these programmes have, according to the authors, advanced changes in law enforcement and community values to overcome harmful traditional practices.
The first project, Empowerment of Ethiopian Women, ran from April 2003 to June 2006 and focused on removing obstacles to women's basic rights, both social and economic. The project was designed to promote access to reproductive health/ family planning (RH/FP) services and freedom from sexual exploitation, violence, forced marriage, and other harmful traditional practices (HTPs). The second project, the Women and Girls Empowerment Project, was designed to continue the work, but also expand the focus to adolescent girls in recognition of a need for early intervention. This second project works to increase awareness and education among girls and women about RH/FP and personal rights, as well as to emphasise education, life skills, and leadership development. It also provides educational support to economically poor girls and promotes female education through role models and mentoring.
According to the report, by integrating women's reproductive health needs with economic, educational, social, and legal concerns, people are adopting gender sensitivity across society. The authors propose that by sensitising all levels of society, from national, to regional, to local leaders and throughout local communities, in conjunction with the different interventions, the transformation of beliefs and behaviour takes on a momentum of its own.
The report concludes that gender responsive programmes should recognise that practices such as female genital cutting (FGC), early marriage, abduction, rape, lack of access to and control over resources, and the absence of decision-making and negotiation power all negatively affect women's reproductive health and rights. Because many women have limited control over their sexual lives and contraceptive use, integrating gender issues into reproductive health and HIV/AIDS programme interventions becomes critical. Active male involvement in reproductive and family care-giving enhances responsible parenthood and reduces gender-based violence that affects women’s reproductive health and rights.
11. Community Awareness of Post Abortion Care: Bolivia, Kenya, Senegal
This presentation for the Post Abortion Care (PAC) Technical Meeting, Washington, DC, United States, March 2008, illustrates the post-abortion care model of the United States Agency for International Development (USAID), which consists of three components: community empowerment through community awareness and mobilisation; emergency treatment; and family planning (FP) counselling, including provision of selected reproductive health care, sexually transmitted infection, and HIV testing and treatment. "Community Empowerment Through Community Awareness and Mobilization: Hearing the Voice of the Community" presents a contextual comparison of the problems and resolutions of PAC model programmes within three countries: Bolivia, with 48 community groups involved; Kenya, with 16 groups; and Senegal, with 16 groups.
The needs specific to each country situation are presented. Results of pre- and post-knowledge, attitudes, and practices (KAP) surveys are included. The programmes emphasise the theme of the three delays: delay in recognising the problem; delay in seeking care; and delay in receiving appropriate care.
The sections on "recognising the problem" identify the following communication-specific challenges: ignorance of FP and lack of FP information; lack of understanding of contraception (particularly among youth and adolescents); and prevalence of rumours and myths preventing contraception use. Communication strategies used in these cases were: workshops, health fairs, public awareness activities, workshops with psychology students, and work with health care directors.
12. Interactive, Client-oriented Balanced Counselling Strategy Toolkit
The Balanced Counseling Strategy (BCS) is an interactive, client-oriented counselling strategy. It uses three key job aids (visual memory aids) for counselling clients about family planning. "The Balanced Counseling Strategy: A Toolkit for Family Planning Service Provider", as well as the job aids, are published by the Population Council with support from the United States Agency for International Development (USAID). The process - tested and refined in Guatemala, Peru, and Mexico - involves a set of steps to determine the method that best suits the client according to her preferences and reproductive health intentions.
The BCS toolkit includes:
- User's Guide
- Trainer's Guide
- Three job aids or memory tools for use by the provider and client:
i. An algorithm that summarises the 11 steps needed to implement the strategy.
ii. Counselling cards with basic information about 15 family planning methods, plus a card with the checklist to be reasonably sure a woman is not pregnant.
iii. Brochures on each of the methods for the client to take once a method is chosen.
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Communication for Change (C-Change) implemented by AED, is USAID's flagship programme to improve the effectiveness and sustainability of communication for behaviour and social change as an integral part of development efforts in health, the environment, and civil society. C-Change works with global, regional, and local partners to use communication to change behaviours and social norms, supported by evidence-based strategies, state-of-the-art training and capacity building, and cutting-edge research. The ultimate goal is the improved health and well-being of people in the developing world. Please see 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.
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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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