Using behavior change communication to lead a comprehensive family planning program: the Nigerian Urban Reproductive Health Initiative

Abstract

Background: The Nigerian Urban Reproductive Health Initiative (NURHI), a 6-year comprehensive family planning program (2009-2015) in 4 cities, intentionally applies communication theories to all program elements, not just the demand generation ones, relying mainly on a theory called ideation-the concept that contraceptive use is influenced by people's beliefs, ideas, and feelings and that changing these ideational factors can change people's behavior.

Program description: The project used multiple communication channels to foster dialogue about family planning, increase social approval for it, and improve accurate knowledge about contraceptives. Mobile service delivery was started in the third year to improve access to clinical methods in slums.

Methods: Data from representative baseline (2010-11) and midterm (2012) surveys of women of reproductive age in the project cities were analyzed. We also used propensity score matching to create a statistically equivalent control group of women not exposed to project activities, and we examined service delivery data from NURHI-supported clinics (January 2011-May 2013) to determine the contribution of mobile services to total family planning services.

Results: Three years into the initiative, analysis of longitudinal data shows that use of modern contraceptives has increased in each city, varying from 2.3 to 15.5 percentage points, and that the observed increases were predicted by exposure to NURHI activities. Of note is that modern method use increased substantially among the poorest wealth quintiles in project cities, on average, by 8.4 percentage points. The more project activities women were exposed to, the greater their contraceptive use. For example, among women not using a modern method at baseline, contraceptive prevalence among those with no exposure by midterm was 19.1% vs. 43.4% among those with high exposure. Project exposure had a positive dose-response relationship with ideation, as did ideation and contraceptive use. By the end of the observation period, mobile services were contributing nearly 50% of total family planning services provided through NURHI-supported clinics. Propensity score matching found that the increase in contraceptive use in the 4 cities attributable to project exposure was 9.9 percentage points. Intention to use family planning in the next 12 months also increased by 7.5 to 10.2 percentage points across the 4 cities.

Conclusion: Demand-led family planning programs, in which demand generation is the driving force behind the design rather than the conventional, service delivery-oriented approach, may be more suitable in places where expressed demand for contraceptives is low.

Figure 1.

Ideation Model of Communication Source: Health Communication Capacity Collaborative (2014).

Figure 2.

Nigerian Urban Reproductive Health Initiative (NURHI) Interventions Abbreviations: FP, family planning; FPPN, Family Planning Providers Network; PMVs, patent medicine vendors.

A poster produced by the NURHI project for the “Get It Together” campaign encourages partners to discuss family planning together.

A couple attends a family planning counseling session in Ibadan, Nigeria.

Figure 3.

Percentage of Women Not Currently Using Contraception Who Intend to Use a Method in the Next 12 Months at Baseline (2010/11) and Midterm (2012), by NURHI Project City *** P < .001.

Members of a radio listeners' club listen to and discuss the family planning radio magazine and drama, Second Chance, produced by NURHI.

Figure 4.

Contraceptive Prevalence at Midterm Among Married Women Who Were Not Using a Modern Method at Baseline, by Level of Exposure to NURHI Activities, N = 1,992 Significance of differences across groups: P < .001.

Figure 5.

Change in Perceived Peer Support for Family Planning Between Baseline and Midterm, By Level of Exposure to NURHI Activities, N = 4,331 Significance of change in perceived peer support is P < .05 for zero exposure and P < .0001 for low, medium, and high levels of exposure.

Figure 6.

Contraceptive Prevalence at Midterm Among Married Women Who Were Not Using a Modern Method at Baseline, by Level of Ideation at Midterm, N = 1,992 Significance of differences across groups: P < .001.

Figure 7.

Family Planning Users Served by NURHI-Supported Clinics and Through Associated Outreach Visits, January 2011–May 2013 On average, outreach visits contributed, in the third year of the project, 15.2% of total family planning services provided by NURHI-supported clinics and 31% in the fourth project year.