Revitalizing Underutilized FP Methods
This series of seven 8-page briefs 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. ACQUIRE was a 5-year global initiative launched in 2003 with support from the United States (US) Agency for International Development (USAID) and management by EngenderHealth in partnership with the Adventist Development and Relief Agency International (ADRA), CARE, IntraHealth International, Inc., Meridian Group International, Inc., and the Society for Women and AIDS in Africa (SWAA).
These collaborators have together developed a Supply-Demand-Advocacy (SDA) Program Model for family planning (FP)/reproductive health (RH) service delivery, which is outlined within each of the seven briefs. 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 FP 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 below 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.
Four of the papers focus on the IUD, a modern contraceptive whose use is still very low in many places (e.g., 0.1% of all Ethiopian women) - especially where myths and misconceptions around the IUD are pervasive, and knowledge of provider skills and facility readiness for IUD service delivery is limited.
In 2005, the ACQUIRE Project, in collaboration with the Ethiopian Ministry of Health (MOH), initiated a programme in the Amhara Region. For the purpose of this project, supply-side inputs included provider training, service quality improvements, and development and application of tools and standards. Demand-side inputs included a variety of communication research activities to understand key stakeholders' and potential clients' views on the IUD; to provide information on how the method works and on its benefits and contraindications; and to inform audiences about where services can be obtained. Advocacy refers to efforts to involve key stakeholders from the MOH, other local organisations, and the media in support of IUD efforts.
ACQUIRE competitively selected a local advertising agency to develop the campaign. Focus group participants reported liking the slogan "Reliable as my choice....Reversible when I decide." So, it was featured across all of the creative content, which also included a call to action to encourage clients to contact their nearest health facility or participating private providers. The campaign included 2 radio spots, 4 billboards, and 19,000 posters (for distribution to health facilities and outreach workers). To help support the facilities offering services and to provide counselling aids to health workers, 66 door signs, 25,000 leaflets, and 7,800 technical booklets on the IUD were produced. The June 2007 regional IUD campaign launch featured representatives from the Amhara Regional Health Bureau and USAID/Ethiopia, a satisfied client, and a health worker/provider as guest speakers, and it served to underscore the importance of the IUD as an FP method. Several media owners and media agents provided coverage of both the regional and zonal launch events.
"ACQUIRE's integrated SDA approach significantly increased demand for IUD services in participating facilities....[D]ata indicate that during the period prior to the project's SDA strengthening, the greatest number of IUDs provided was only 182...the number of IUDs provided increased to 338 for the nine-month period for which data were available."
Lessons learned: integration of SDA components should start early on; the SDA approach helped improve providers' and stakeholders' attitudes toward and acceptance of the IUD, which in turn made it easier to address supply-side issues; future efforts in Ethiopia should integrate multiple communication channels; and external creative support can improve the quality of campaign materials and expedite the process when working with advertising agencies with limited capacity.
The ACQUIRE Project provided support to the IUD initiative in Kisii District, Nyanza Province, in western Kenya. For the purpose of this project, supply-side inputs focused on provider training, service quality improvement, and development and application of tools and standards. Demand-side inputs included understanding key stakeholders' and potential clients' views on the IUD; disseminating information about how the method works and its benefits and making special efforts to correct rumours and misperceptions; and publicising where services can be obtained. Advocacy inputs in Kisii focused on identifying and nurturing IUD champions at the district and community levels.
A local advertising agency created a campaign that focused on discrediting myths by asserting the truth while leveraging the IUD's safety and efficacy. The message (visit a healthcare provider) was proactive, the tone was positive, and the images featured men and couple interaction. Regional and local radio stations broadcast ads were broadcast in local languages during peak listening periods, and a specially developed 15-minute weekly talk show was created to discuss the IUD in greater detail. A brochure for use by health care workers, community agents, and peer educators was developed to provide more in-depth technical information about the IUD and to facilitate dialogue with and education of clients. A "consumer-friendly" leaflet that listed the locations of the 13 pilot sites was also created, for distribution at events with large audiences. Also, 1,200 posters featuring messages that challenged myths about the IUD and corrected rumours were placed throughout Kisii District. T-shirts reading "COIL" were distributed to providers, peer educators, and event staff to further publicise the IUD. In addition, mobilisation and sensitisation of community leaders was carried out to create awareness of and support for IUD promotion efforts, to solicit input, and to facilitate peer education and referral activities. For example, "edutainment" road shows, featuring fun, educational performances through drama, dance, and comedy, were held at marketplaces. A launch event was broadcast on Kenya's national TV channels and national and regional radio stations and was featured in newspapers.
IUD insertions rose from 58 at the start of the intervention period (January-March 2005) to 484 in the same time period 2 years later. One year later (January-March 2008), IUD uptake was still high - 453 insertions, an 8-fold increase over the baseline number. In addition, a consumer survey was conducted among 346 men and women 20-49 years of age who lived in Kisii; one finding was that 93% of women reported being aware of the IUD as a method of FP (In comparison, a secondary analysis of the 2003 DHS data showed that 68% of women in Kenya had knowledge of the IUD). Attitude and behaviour changes were also observed; for example, 3 out of 5 people attending the community sessions reported talking to their partner, almost half reported talking to friends and family, and more than 40% went to a health facility to receive more information.
Lessons learned: consumer and provider research should be used to clarify barriers to uptake; the "real life" people featured in the creative content and at the community outreach events helped instill confidence among potential clients and affirmed that the IUD is a safe, effective, and viable FP option; speaking directly and candidly about myths and rumours improves potential clients' knowledge; male involvement and gender-appropriate messages facilitate FP decision making; communication vehicles have differing strengths in contributing to goals; cohesive and mutually reinforcing campaign activities enhance the programme's efforts; and local agencies work best.
In 2005, the USAID Mission in Uganda arranged for the ACQUIRE Project to partner with the bilateral project, UPHOLD, in Mayuge and Hoima Districts. For the purpose of this project, supply-side inputs included provider training, service quality improvement, and development and application of tools and standards. Demand-side inputs involved understanding key stakeholders' and potential clients' views on the IUD, disseminating information about how the method works and its benefits, and making special efforts to correct rumours and misperceptions; and publicising where services can be obtained. Advocacy refers to efforts to ensure support for and acceptance of IUD services within the larger sociocultural, socioeconomic, and political environment. Focus group testing led the locally selected ad agency to choose the campaign slogan "Coil: Find out the Truth" as the unifying element throughout all materials. The call to action for all messages was "Talk to your health worker about the Coil and other family planning options." IUD demand creation was pursued through a comprehensive, integrated marketing strategy consisting of mass media (especially radio), posters, and printed material. Throughout the initiative, ACQUIRE/Uganda met repeatedly with district-level health officials to support their involvement in the overall programme. To ensure that local-level stakeholders and spokespersons were ready to speak positively about the project, ACQUIRE provided training and a media kit on to providers, satisfied FP clients, media, community reproductive health workers (CRHWs), and local leaders. Subsequently, various representatives of these groups participated in the public launch event, which included a road show, demonstrations and counselling on various FP methods, drama shows, speeches from district personnel and satisfied users, and media briefs.
In August 2007, the ACQUIRE Project conducted focus groups. Despite the relatively low IUD uptake, some district-level stakeholders felt that revitalising the IUD had worked, and the majority of respondents attributed the increased demand for and use of IUDs to awareness generated by the radio advertisements and community mobilisation.
Lessons learned: Demand activities should use a broader spectrum of communication channels regarding the IUD and should incorporate more in-depth testimonies from satisfied IUD users. Also, launch activities that increasingly focus on potential IUD acceptors serve to better inform and mobilise the larger community in support of IUD services.
In 2004, the ACQUIRE Project, in partnership with the Guinea MOH, undertook supply-side inputs including clinical provider training, service quality improvements, and development and application of job aids and standards of practice. Demand-side inputs included mass media, print materials, and community outreach. Through various talk show formats, such as roundtables and question-and-answer programmes featuring a variety of viewpoints (including those of physicians, religious and community leaders, and satisfied clients), the community received information about the IUD, its benefits, and the various myths and rumours associated with it. Starting in April 2006, more than 2,700 consumer brochures and 500 posters were disseminated. In addition, ACQUIRE disseminated messages through community engagement activities, using the Participatory Learning Approach (PLA), whereby facilitators worked with 18 communities to help them analyse their needs, identify solutions, and develop and implement action plans. "Animateurs" (community motivators) were also trained and given messages to promote a positive image of the IUD for the community. In March 2006, ACQUIRE convened a 2-day meeting of religious leaders to garner their leadership support for FP. This dialogue aimed to create an enabling environment to facilitate information-sharing about the IUD with married couples. The meeting received coverage on the local radio.
Facility records showed that 700 new IUD users were served in ACQUIRE-supported facilities during the interventions in 2006, compared with only 37 clients in 2004 and 82 in 2005 - the years before the intervention. In addition, awareness of and knowledge about the IUD was found to have increased, and message recall was strong.
Lessons learned: integration of SDA components needs to be identified and started early in the programme planning process; a low-resourced communications effort can still generate momentum; qualitative research yielded valuable insights for campaign development (e.g., "Messages were made more culturally appropriate (matching the slogan 'an ideal contraceptive to space births' to Guinea's cultural viewpoint for using FP to space, not limit), more appealing to potential clients' concerns (in featuring a female health provider rather than a male), and more relevant (featuring families both in traditional and in modern clothing)."); and efforts need to be directed to key influences, such as religious leaders, to help create a favourable environment.
Three of the papers focus on vasectomy, an FP whose use is still very low in many places (e.g., 0.1% in Honduras) - especially where myths and misinformation give vasectomy a negative image, and knowledge of and public-sector capacity in no-scalpel vasectomy (NSV) service delivery is limited.
From 2003 to 2007, the ACQUIRE Project provided technical assistance to the Honduran MOH to strengthen its FP programme the country's 2 major cities, Tegucigalpa and San Pedro Sula. Based on formative research results, a campaign theme was chosen to reassure men that vasectomy does not affect their relationship with their partner. The tagline, "Get Yourself a Permanent Smile" appeared in materials including a 30-second radio spot, a poster, a brochure, and billboards. In addition, vasectomy as a topic was addressed on major television and radio stations, in editorials, and in trainings for vasectomy spokespersons. In anticipation of negative reactions or objections from conservative and/or religious groups, the project set up a crisis communication plan; there were no negative reactions to the campaign.
The number of NSV procedures provided by public-sector facilities grew from zero in 2002 to 14 in 2004 (when providers were initially trained in NSV) and to 92 in 2005, when the integrated SDA strategy was fully implemented. In 2006 and 2007, the overall demand for vasectomies decreased slightly, but remained relatively high. Monthly service statistics were tracked against communication activities to determine their impact on service use. These show a 152% increase in services during the launch period of the campaign (July to October 2005) compared with the preceding 4 months. Later, during the period January to May 2006, when there was no promotional support, the average monthly number of NSV procedures decreased by 43% compared with the campaign launch period.
Lessons learned: most significant increases in demand for vasectomy correspond to campaign periods where multiple communication channels are used; supply-side readiness determines whether demand can be met; and communications efforts need to be sustained over time.
The ACQUIRE Project worked in 4 districts - one in Rajshahi Division (in northern Bangladesh) and 3 in Chittagong Division in the south. ACQUIRE's technical assistance included meeting with upazilla- and district-level managers and providers; orienting health care field workers; organising special service days; holding skills-based refresher training of family welfare visitors; and providing skills-based training on management of complications related to FP services. To maximise the visibility of the effort and to reinforce messaging, all creative materials (television commercials and posters) contained the same key communication points and visuals that addressed "barriers to acceptance": misperception of vasectomy; stigma of vasectomy; lack of male involvement in FP; and engagement with health workers. The theme, as preferred by the focus group participants, was "My Husband Is Best" (e.g., the image of a happy family tested strongly because it placed the husband with his family and not alone). While television was the medium selected as the campaign's foundation, 100,000 posters were also printed and distributed. Health service providers complemented the mass media campaign with interpersonal communications and community outreach. In addition, the ACQUIRE Project developed and produced a book entitled Family Planning in the Eyes of Islam to engage imams in encouraging FP. ACQUIRE also sponsored interactive community forums with imams, teachers, businessmen, and local politicians and local FP service providers.
Evaluation data show that ACQUIRE's NSV project was successful at achieving its objectives in districts where the SDA model was operationalised. For example, in 2 of the districts (Chittagong and Cox's Bazar), 74% of respondents reported being aware of vasectomy, of which 95% had heard information on or seen a message about NSV in the past year. With the increase in awareness came a 15% increase in NSV demand during the first full month of television support. Ninety-five percent of those who were aware of vasectomy could correctly report that it is a permanent FP method; 81% agreed that vasectomy is a trusted form of FP; 72% agreed that vasectomy is a good option for those who do not want any more children; and 63% knew that vasectomy was performed through an operation or surgery. For a market such as Dinajpur, where service provision was limited, supply could not meet demand.
Lessons learned: the potential for vasectomy acceptance is strong; advocacy among government stakeholders can help overcome provider problems, and can remove social barriers to acceptance; resources are needed to monitor and manage activities on a continuous basis; and - since only 13% of 180 respondents reported having had a discussion on FP or NSV with their partner - other communications elements are needed.
In 2003, the Ghana Health Service, the USAID Mission in Ghana, and EngenderHealth collaborated on an initiative in the Accra and Kumasi metropolitan areas to improve acceptance of vasectomy. In early 2004, ACQUIRE launched the first phase of the demand strategy through a communications campaign called "Vasectomy: Give Yourself a Permanent Smile." In 2008, in collaboration with the Ghana Health Service, ACQUIRE relaunched that campaign with support from the Reducing Maternal Mortality and Morbidity (R3M) Project. To strengthen the supply of vasectomy services, physicians were trained in NSV and whole-site training was carried out to create "male-friendly" service sites. The demand-side activities included a mass media campaign (radio and television), distribution of various print materials (question-and-answer brochures, leaflets, posters, and small folded leaflets called Z-cards), community outreach by clinic staff, use of satisfied clients as spokespersons in the community, and a telephone hotline. The "Permanent Smile" concept focused on the benefits of vasectomy and promoted "satisfied users" through a testimonial approach. The campaign was designed to position vasectomy as a viable FP option for men in stable relationships - a choice that can help them to thrive at home and in their careers.
During the first phase of the demand strategy in 2004, the number of vasectomies increased threefold compared with the previous year. Then, in 2007, concurrent with the additional clinical trainings that were conducted for new providers, the number of vasectomies began to increase again. Once the communications activities began, the number of vasectomies more than doubled. During both phases of the campaign (in 2004 and in 2008), the hotline proved to be an important element for generating interest in vasectomy, with the most calls received during the periods of the mass media campaign. The results of the 2008 survey suggest that the February and May 2008 media bursts produced improvements in men's knowledge of, and attitudes regarding, vasectomy
Lessons learned: a well-integrated supply-demand approach is critical to sustaining the demand for vasectomy services over time; improved knowledge about, awareness of, and attitudes toward vasectomy can be achieved with fewer resources when media activities are efficient and well-targeted; and increases in awareness can be perceived immediately, whereas changes in knowledge and attitudes start to occur after multiple exposures.
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