C-Change Picks - Focus on Family Planning
C-Change Picks #11 - Focus on Family Planning
Information about Social and Behaviour Change Communication, sponsored by C-Change
February 8 2010
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 (SBCC) 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 #11 focuses on SBCC strategies for promoting family planning (FP). This includes a concentration on integrating FP services with other health services, linking FP awareness activities with income generating activities, training reproductive health providers (particularly those at the village level), and identifying approaches that are appropriate for addressing youth. This issue closes with four resources that can be used to support the training of health service providers in family planning awareness and promotion.
To revitalise family planning programmes and garner high-level political and budgetary support for family planning, C-Change organised a conference in the Democratic Republic of Congo (DRC) in December 2009. DRC's Ministry of Health, other ministries, USAID, and the United Nations Population Fund (UNFPA), along with donor agencies and stakeholders, met for two days to address the situation related to FP services in the country, including the high unmet need for family planning methods (only 7% of women use a modern contraceptive method [DHS 2007]) and the high rates of maternal and child deaths. This conference led to recommendations and a plan of action for the DRC government and donors to address these critical needs. See the C-Change website for more information.
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
FAMILY PLANNING (FP) THROUGH HEALTHY FAMILY INITIATIVES
1.Fostering Linkages between Family Planning and Maternal/Child Health Services
2.Creating Healthy Families in Nepal
FP THROUGH LIVELIHOOD PROGRAMMES
3.Supporting Economic Independence and Family Planning In Mali
4.Integrating Reproductive Health Into Livelihood Programs In India
FP THROUGH HEALTH PROVIDER TRAINING
5.Forging Partnerships between Communities and Service Providers in Guatemala
6.Family Planning Promotion Training for Village Health Committees in Guinea
7.Creating Standard Delivery Practices to Increase Access to Family Planning in Guatemala
8.Reaching Out to Teen Mothers in Malawi
9.Preventing Student Pregnancy in Guinea's Forest Region
10.Reaching Youth Through Community Strategies
11.Postpartum Family Planning for Healthy Pregnancy Outcomes: A Training Manual
12.Constructive Men's Engagement in Reproductive Health: A Training-of-Trainers Manual
13.Basics of Community-Based Family Planning: Facilitator and Participant Guides
14.Programming for Training: A Resource Package
FP THROUGH HEALTHY FAMILY INITIATIVES
1.Fostering Linkages between Family Planning and Maternal/Child Health Services
"Helping Egyptian Women Achieve Optimal Birth Spacing Intervals through Fostering Linkages between Family Planning and Maternal/Child Health Services" explores a research intervention implemented by the USAID-funded FRONTIERS programme. The effort is designed to support Egyptian women in achieving healthier birth intervals through measurement of the acceptability and effectiveness of two birth spacing message models:
- Model I (health services model) - birth spacing messages were communicated through services by health workers to women during prenatal and postpartum periods.
- Model II (community awareness model) - Model I was supplemented by an awareness-raising component that reached out to men through training community "influentials" to communicate messages.
Providing birth spacing messages to low parity women during antenatal and postpartum care, and also to husbands through community awareness activities, was found to be feasible and acceptable. Both models proved effective in changing women's knowledge and attitudes towards birth spacing and in enhancing use of contraception at 10-11 months postpartum, by 48% among Model I mothers and 43% among Model II mothers, compared with 31% among control group mothers. Furthermore, over the postpartum period, women in the two intervention groups used contraception more consistently than women in the control group - median duration of protection against pregnancy was 6.8 months for Model I mothers, 4.5 months for Model II mothers, and 2.9 months for control group mothers. Finally, both intervention models were associated with an increased utilisation of services, especially FP services, by women who only had one child (36% increase in Model I clinics, 47% increase in Model II clinics, and 3.2% in control clinics).
"It is interesting to note that although contraceptive use reported among women in group II was not higher than in group I, service statistics showed a substantial increase in the proportion of FP clients with one child in Model II clinics. This could be attributed to a gradual gain in momentum of Model II interventions and awareness-raising activities, reaching a larger audience over time and impacting contraceptive use among other (and more) low parity women in the community."
This report concludes with a number of policy recommendations.
2.Creating Healthy Families in Nepal
Published by the CORE Group in March 2009, "Creating Healthy Families in Nepal: Sustaining Family Planning Practices Among Marginalized Groups" documents the sustainable activities and interventions of an initiative that aimed to help women and couples from disadvantaged groups in Nepal realise their reproductive intentions through: a) increased knowledge of and interest in family planning services through participatory learning and action/radio listening groups (PLA/RLG); b) improved quality of family planning (FP) services facilitated by community involvement in defining, implementing, and monitoring the quality improvement process; c) increased community access to FP services through voluntary surgical contraception (VSC) outreach; and d) improved social and policy environment for FP and reproductive health (RH) services and behaviour through capacity building and the Non-governmental Organisation (NGO) Institutional Capacity Tool.
This case study details a number of specific impacts of the project. A few key ones include:
- After completion of the project, some PLA members remained functional as members of mothers groups and some of them organised themselves into income generation groups called "saving/credit groups"; as part of these latter groups, some women share the RH/FP messages with the other women in the village.
- NGO partners catalysed community participation in all aspects of the project, encouraging family dialogue about family planning through radio listening groups, peer dialogue through literacy groups, and dialogue with health facility staff through Quality Improvement Teams.
- Use of health facilities has increased. The register from the Haripur Sub Health Post indicated that on an average, 30 patients come to the clinic every day for different services and treatment. In May-June 2008, a total of 800 patients were seen by the clinic. Out of 800 clients, 32 women received injectable FP (Depo) services and 31 pregnant women received antenatal care services from the health facility.
- VSC services provided in the Muslim communities increased in the year following the end of the project. Comprehensive FP and VSC services are well accepted and continue to be available year-round, not only in the winter months. There continue to be requests for expanded VSC services from District Public Health Offices to serve as a complement to their own services.
FP THROUGH LIVELIHOODS PROGRAMMES
3.Supporting Economic Independence and Family Planning In Mali
From the paper series Voices from the Village: Improving Lives through CARE's Sexual and Reproductive Health Programs, this May 2009 report, "Keneya Ciwara: Supporting Family Planning In Mali," describes an initiative to increase the availability and demand for quality health services at the community level while improving essential health practices in the household, including an element linking FP and income generation for women. The second phase of the Keneya Ciwara programme began in October 2008 and will last 3 years, eventually covering every health district in the country.
Keneya Ciwara revolves around a system of volunteer outreach workers ("relais") who seek to raise awareness about family planning and other health issues among community members who lack access to local health centres.
The other crucial component of the programme is Musow Ka Jigiya Ton (MJTs, or Women's Savings Clubs). Each MJT selects members who are trained by the programme to be community health agents. These agents then provide basic health information and peer counselling; for example, they talk with other women about how to better communicate with their husbands about family planning. Each health agent is given an initial stock of contraceptive products that she can sell to generate income, which she then contributes to a communal fund. This money can finance the purchase of more family planning products and also fund women's visits to the community health centre, where they can procure other contraceptives. Members can also borrow money from the fund to start their own small enterprises. As of May 2007, there were about 560 women participating in 20 MJTs across 7 villages in the Kendie health district. In the first phase of the programme, they were able to mobilise more than US$18,000 in credit and carry out 188 awareness-raising sessions on health and family planning, which involved nearly 4,000 local women.
According to this study, women's groups can help significantly increase rates of family planning. "The groups offer women economic independence from men, allowing them to support one another in the face of opposition from their husbands....An important next step in the program is thus to emphasize, particularly to men, that there are economic advantages to using family planning. Women's groups can help open up dialogue on this subject by giving women the support and negotiating skills to improve spousal communication."
4.Integrating Reproductive Health Into Livelihood Programs In India
This report details the implementation and evaluation of a project carried out in 2008 and 2009 to develop and test a sexual and reproductive health (SRH) curriculum for vocational students aged 15-24 from economically poor families in urban and rural areas of India. As part of the year long Samriddhi Project, a curriculum and teaching aids were developed and then used to build the skills of youth educators to teach SRH and family planning (FP) topics. The Samriddhi curriculum was integrated into existing vocational training programmes for youth. The goal was to equip low-income and at-risk youth in Andhra Pradesh and Delhi with accurate, age-appropriate information on how to maintain their reproductive health and prevent risky behaviours that lead to poor health outcomes including sexually transmitted infections (STIs), unplanned pregnancies, and unsafe abortions.
Key findings related to youth knowledge:
- In post-tests, 90% of male youth and 85% of female youth correctly discussed the changes that occur in their bodies during puberty.
- In the pre-test, only 39% of male youth correctly responded to the question, "How do girls get pregnant?" This percentage rose to 95% in the post-test.
- After the course, more than 90% of youth correctly identified pregnancy prevention methods.
Key findings related to youth attitudes and perceptions:
- Most youth indicated they were comfortable attending the SRH sessions that were integrated into existing vocational training programmes.
- 65% of male youth indicated that, after this training, they would not be embarrassed to ask for condoms in a pharmacy.
- 70% of male youth reported feeling more aware of gender issues and bias.
For more information about the Samriddhi Project in India, click here.
FP THROUGH HEALTH PROVIDER TRAINING
5.Forging Partnerships between Communities and Service Providers in Guatemala
This December 2009 report explores the 4-year Maya Salud (Mayan Health) project, which sought to bridge the gap between those who wanted information, counselling, and services in sexual and reproductive health (SRH) in their communities and those charged with providing these services but who often lacked the knowledge, skills, and resources to do so effectively.
"Improving Family Planning by Creating Community-Service Provider Partnerships in Guatemala" details Maya Salud's use of the Partnership Defined Quality (PDQ) methodology, which engages community members in improving and monitoring the quality of their health services through partnerships with the health system. In the course of a 4-phase process, each of the 88 participating communities established its own Quality Improvement Team (QIT) composed of a subset of community members and health workers. Through dialogue and analysis, the QITs explored the root causes of inadequate quality of services and identified appropriate, feasible solutions for reaching the desired level of quality. The resulting Quality Improvement Plans delineated actions to fill gaps in knowledge, skills, or attitudes. One such action involved building demand by creating peer networks called Amigas/Amigos (friends) in participating communities. Amigas and Amigos learned the basics of FP, including modern methods, peer counselling, and referral (and sometimes accompaniment) to health facilities. In addition, steps were taken to ensure comfortable, confidential FP services, and to bring these services to particularly isolated areas through mobile health clinics.
Save the Children's final evaluation of Maya Salud (2009) measured a number of indicators and contrasted them to the project's baseline (2006), revealing that PDQ had improved access to and use of FP, and that users appreciated service quality. For example, the percentage of couples who discussed FP over a 3-year period rose from 44% to 46% in Nebaj, from 39% to 56% in Cotzal, and from 36% to 50% in Chajul. In 2009, 56% of women indicated that they had discussed birth spacing and desired family size with their partner in the previous year, whereas only 37% of women reporting having done so at baseline. Knowledge shifts were reported; for instance, 72% of women of reproductive age surveyed could name 3 or more FP methods in 2009, up from 52% in 2006. 21% of women of reproductive age received a home visit by a health care provider who spoke with them about FP in 2009, up from 5% in 2006. And 51% of such women received FP information during their last visit to their local health post in 2009, up from 13% in 2006. Practices also shifted: the number of new FP users rose from 2,087 (in 2006) to 5,638 (in 2008) - a 270% change; the percentage of married/united women using a modern FP method was 28.3% at baseline (2006), and 33.5% at endline (2009).
A number of strategic lessons learned are detailed in this report, including, in brief: invest first in trust; tailor your communications and schedules to your context; engage QITs in monitoring and evaluation (M&E); and promote learning and engagement among national stakeholders.
For more information about the Maya Salud (Mayan Health) project in Guatemala, click here.
6.Family Planning Promotion Training for Village Health Committees in Guinea
This March 2009 report, "Village Health Committees Drive Family Planning Uptake: Communities Play Lead Role in Increased Acceptability, Availability," describes the role of the Village Health Committees (VHCs) of rural Guinea and their partnership in increasing contraceptive availability and acceptance as a means to child survival through a project which included training community-based distributors (CBDs) in each participating village and adding family planning promotion to the job description of every VHC member.
The VHCs' primary purpose was threefold: (1) to forge a link of ownership and responsibility between the community and the health system; (2) to increase the community’s demand for and use of quality health services including family planning; and (3) to increase the health system’s ability to provide such services in a way acceptable and accessible to the local population. The VHCs were composed of seven to nine members, each a permanent resident of his or her village and respected by the community as a whole, typically district chiefs, Imams, village elders, representatives of traditional health workers, and a traditional communicator (griot).
Key findings from project evaluations show that the contraceptive prevalence rate increased substantially among women with children under 2 years. The use of modern family planning methods by mothers not wanting another child in the next 2 years rose. Almost three-quarters (73%) of women in Mandiana and Kouroussa spaced their last two pregnancies by at least 24 months. In all villages, Imams - many of whom were once opponents of family planning - talked about birth spacing via breastfeeding and oral/injectable contraceptives in their mosques. In some cases, the children or siblings of Imams became CBDs. CBDs - 225 women and 225 men - were trained in family planning policies and promotions, sales, referrals, sexually transmitted infections and HIV/AIDS, and improving relations with health facility workers. Villages without health facilities benefited from the family planning component as much as those with health facilities because of the presence of VHCs and their CBDs. Villages with access to family planning services almost doubled over 5 years. In addition, the VHC in Mandiana district successfully piloted a reintroduction of the intrauterine device (IUD).
7.Creating Standard Delivery Practices to Increase Access to Family Planning in Guatemala
"Increasing Access to Family Planning Among Indigenous Groups in Guatemala" describes an initiative to promote equitable access to family planning and reproductive health services among indigenous women in Guatemala through development of a set of locally appropriate service delivery practices.
From April 2006 to April 2008, USAID’s Health Policy Initiative undertook a participatory research endeavour with the aim of reducing barriers to access and use of FP/RH services among disadvantaged groups. The project reviewed existing research and policies to identify the factors affecting access to FP/RH services, and then conducted interviews with service providers, indigenous women, and community educators and traditional midwives in 3 departments of Guatemala. During stakeholder workshops at the national and community levels, project staff developed a set of service delivery practices that could improve access to services. These practices were then incorporated into operational guidelines that were pilot-tested in 5 districts in Quiché. Next, the Health Policy Initiative helped the Departmental Office of Health in Quiché develop a list of 10 locally appropriate service delivery practices. Following the collection of baseline information on the status of the 10 priority service delivery practices, the Quiché team trained service providers in the new guidelines through a series of one-day workshops. The team then monitored implementation of the guidelines in the 5 pilot districts.
The project interviewed programme implementers to capture lessons learned and best practices. They found that, in developing a targeted programme, local health programme managers should consider the following practices:
- When identifying barriers: Involve the intended population in identifying barriers to service access; interview users and non-users of health services and providers, using local language when appropriate, to understand why the intended population is not using services; and incorporate all major service providers in the study.
- When planning interventions: Involve the intended population in the design, development, and implementation of programmes; include all stakeholders, including local leaders, in programme implementation; strengthen the relationship between the area, district, and basic health units through the development of technical guidelines for FP services to ensure quality and uniformity of services throughout the system; work with community members to disseminate information that clarifies misconceptions about FP; train all health centre personnel, including non-medical staff, on FP issues; and strengthen the commitment of district health officials to FP.
- When engaging in advocacy: Involve representative NGOs in advocacy efforts at the local level to build support and consensus from the community and to promote early involvement of the intended population; advocate at all levels - central, district, and community - to build political will and momentum for interventions; promote a continuous process of advocacy, policy dialogue, data sharing, and information gathering and dissemination; and involve the right stakeholders - representative NGOs, major service providers, Ministry of Health officials, and district- and community-level health officials - to strengthen commitment to equitable access to FP/RH services.
8.Reaching Out to Teen Mothers in Malawi
This August 2009 case study examines a communication initiative implemented by Save the Children to improve the health of Malawian women aged 10 to 24 and their children in the southern Mangochi district through increased voluntary use of family planning services. In 2006, Save the Children launched the 27-month project "Reaching Out to Teen Mothers in Malawi". Save the Children built upon several interventions from a previous project, "Nchanda ni Nchanda," and reached out to 35,000 youth, promoting delayed marriage, delayed sexual debut, and use of modern contraceptives, specifically reaching out to teen mothers.
Teen Mothers Clubs (TMCs) provided a total of 2,035 young women with a venue in which to discuss their common concerns - openly and without stigma - and to get support from fellow teen mothers and friends. In in-depth interviews with teen mothers at the end of the project, many reported improved knowledge about FP and greater ability to successfully negotiate contraceptive use with their partners. They also said that the male motivators helped their husbands become more supportive of FP.
Save the Children’s situation analysis had revealed that parents, community leaders, teachers, and chiefs believed that access to and knowledge of FP would increase youth promiscuity. So, the project continuously involved these individuals - whom it calls "gatekeepers" to mark their important role in youths' lives - in its activities. In one such activity, a team of 4 gatekeepers, plus 2 in-school teen mothers and one teacher, raised awareness among community members and schoolgirls about the benefits of FP, the dangers of teen pregnancies, etc.
The project also invited initiation counsellors - the women and men who guide children's initiation into adulthood - to participate in the project. Overall, 150 such counsellors attended a workshop where FP messages were developed and incorporated, along with HIV prevention practices, into messages passed on to initiates. The counsellors discussed the importance of FP, as well as the dangers and merits of certain traditional practices, such as those that lead to early pregnancy and young motherhood, thereby possibly compromising the health of young girls.
For more information about the Reaching Out to Teen Mothers Initiative in Malawi, click here.
9.Preventing Student Pregnancy in Guinea's Forest Region
Produced by USAID's Flexible Fund (Flex Fund) in August 2009, this evaluation examines a school-based family planning intervention carried out in Yomou Prefecture within Guinea's forest region by Plan International and the Association Guinéenne pour le Bien-Etre Familiale. By equipping secondary school teachers and peer educators with the information to increase teens' knowledge and use of FP, organisers hoped to reduce unwanted pregnancy and allow teen girls to complete their secondary education.
The rationale for the project and its strategies are detailed within the document. In brief, strategies included in-school FP curricula, training of teachers as peer educators and community-based services agents (CBAs) for behaviour change FP messaging and support, FP posters, FP leaflets, and public awareness FP messaging.
As this evaluation indicates, the number and proportion of teenage students who experienced pregnancy in Yomou dropped from nearly 9% to just under 3%, and remained in that lower range for the two most recent school years. Project records show that the number of people of any age who adopted a modern FP method increased in Yomou from about 700 to more than 7,800 users.
The evaluation finds that Plan International's participatory processes, including community consultation with religious leaders, elected officials, village elders, and parents, allowed adults and teens to openly discuss and agree on the importance of the problem of unwanted pregnancies in schools. The intervention's success may also be attributed to the synergy between the school-based information and communication activities and the availability of FP methods via the CBSAs. The role of school-based peer educators was found to be especially important. Plan International notes that the intervention's success was also helped in part because its objectives mirrored those of the Guinean government, which had recently outlined the importance of sexual and reproductive health education in schools.
For more information about the Forest Region Sustainable Community-Based Reproductive and Sexual Health Project in Guinea, click here.
10.Reaching Youth Through Community Strategies
Published in July 2009, this USAID Technical Update discusses steps for designing community-based youth family planning programmes, strategies to reach youth, and advantages of linking with larger community mobilisation efforts. Strategies for reaching youth through community members referenced in this resource include:
- Involve youth themselves. Because youth experience different barriers to access and choice, their perspectives need to be included in programme interventions, e.g., as peer educators.
- Ensure that youth participation is authentic and meaningful. Work through existing youth-oriented organisations, centres, or infrastructures that are accepted by the community.
- Involve both genders. For example, a model developed in Brazil meets weekly with groups of young men to discuss gender, sexuality, and reproductive health; evaluations of the model have shown positive impact.
- Involve parents. Programmes trying to reach youth should include supporting parents in their roles as caretakers.
- Involve religious leaders. Young people look to religious leaders for guidance on decision making. Organisations should work with religious leaders to examine their role in sharing accurate information that will help youth make healthy decisions and to identify appropriate ways to discuss sexual and reproductive health.
- Involve health care providers. Privacy, confidentiality, and provider attitudes towards serving young people are important dimensions of understanding young people’s experiences with health care providers.
- Community mobilisation, a capacity-building process through which individuals, groups, or organisations plan, carry out, and evaluate activities on a participatory and sustained basis, may be useful to help those involved reach youth.
11.Postpartum Family Planning for Healthy Pregnancy Outcomes: A Training Manual
Produced by the USAID-funded Extending Service Delivery (ESD) Project, this manual is intended to promote positive health outcomes for mothers, newborns, and infants by improving health workers' skills in fostering healthy timing and spacing of pregnancy (HTSP). It provides practical information and guidance on how to conduct a two-day training for primary health facility-based health workers in providing postpartum family planning information, education, and counselling, and in increasing postpartum women's access to all FP methods and services. The manual is designed for health trainers, nurses, health supervisors, and community health workers who already have basic understanding of and experience with FP/RH.
12.Constructive Men's Engagement in Reproductive Health: A Training-of-Trainers Manual
This publication features the curriculum developed as part of a USAID Health Policy Initiative, Task Order 1 project focused on building an enabling policy and institutional environment for constructive men's engagement (CME) in reproductive health in Mali. This document contains the manual used in pilot workshops with community peer educators. It is designed to enable community health educators to incorporate activities related to CME in RH in their daily work. This includes promoting dialogue among men and women to increase couple communication and shared decisionmaking related to FP/RH. As such, it can be adapted in other settings, based on local needs.
13.Basics of Community-Based Family Planning: Facilitator and Participant Guides
Developed by the Child Survival Technical Support Plus (CSTS+) Project, funded by USAID and published in April 2009, this curriculum is intended for the implementation of a two-week workshop designed to bring together middle- to senior-level managers and specialists working in the areas of programme design, monitoring, and evaluation (PDME) of community-based family planning programmes or interested in integrating community-based FP programming into their current projects. This curriculum explains the key elements of a quality community-based FP programme and technical and programmatic concepts of FP service. It explains a six-step process for developing a project design using a results framework and a monitoring and evaluation plan that is linked to the project design.
14.Programming for Training: A Resource Package for Trainers, Program Managers, and Supervisors of Reproductive Health and Family Planning Programs
This resource package provides an overall approach to programming for training health care providers in family planning and reproductive health. It draws on the training experience of the ACQUIRE Project, as well as that of EngenderHealth and other organisations providing training in FP/RH for improving service delivery. Funded by USAID, the document includes the ACQUIRE training model and discusses the three primary training subsystems: pre-service education, in-service training, and continuing education, as well as "commonly used" and "useful" training methods for FP/RH, including group-based training, structured on-the-job training, self-paced training, technology-assisted training, distance learning, blended learning, and whole-site training.
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. 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 SBCC planning, programming, and monitoring and evaluation, 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 visit 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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