Series J, Number 56
Family Planning Programs

CONTENTS

Home (Key Points)

Communication Motivates Behavior Change
Figure 1. Family Planning Communication Evolves

Spotlight: Ethiopian Radio Serial Follows Process to Success

Box: Theories Inform Behavior Change Communication

Communication—A Process, Not a Product
Figure 2. Defining SMART Objectives
Figure 3. Elements of a BCC Conceptual Framework
Table 1. Many Choices for Behavior Change Communication Programs

Box: Egyptian Project Combines Channels to Reach Families

Planning for the Future

Box: Participatory Approaches Empower Communities

Bibliography

Credits

• Model for a Creative Brief
• INFO Reports: “Tools for Behavior Change Communication”

• What BCC Programs Can Achieve
• Characteristics of Effective BCC Programs
• Planning Documents That Help Guide Implementation

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See companion INFO Reports, "Tools for Behavior Change Communication"
See companion INFO Reports, "Entertainment-Education for Better Health"
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Communication Motivates Behavior Change

In Ethiopia an Amharic-language radio serial drama captivated audiences from June 2002 to November 2004 with tales of love and betrayal, suspense and romance, and suffering and triumph. The gradually unfolding plots of Yeken Kignit (“Looking Over One’s Daily Life”) followed the lives of characters such as Fikirte Gezmu. Fikirte must face the death of her grandfather, help her sister who suffers from fistula after early childbearing, and comfort a friend who seeks medical treatment for infertility only to discover that she is infected with HIV. The drama encouraged use of contraceptive methods, challenged negative attitudes towards people living with HIV and AIDS, and explained how HIV is transmitted. After two and a half years of national broadcasts, the drama had reached nearly half the country’s adult population. The final evaluation found higher levels of contraceptive use and discussion between spouses about family planning and HIV, and lower levels of stigma-related attitudes among Yeken Kignit listeners compared with nonlisteners (146, 203) (see Spotlight: Ethiopian Radio Serial Follows Process to Success).

Yeken Kignit is one of many behavior change communication (BCC) programs that have helped people to adopt healthy behavior. BCC programs motivate people either to change unhealthy behavior or to continue healthy behavior. BCC programs can and have increased awareness of common reproductive health problems. They have influenced attitudes and social norms and addressed myths and misconceptions. They have depicted healthy choices and their benefits. They have moved people to use contraception and to make use of family planning services and HIV testing (6, 50, 101, 105, 116, 144, 165).

Health and development programs use BCC across a broad range of efforts to improve people’s health and well-being. These efforts have addressed, for example, family planning and reproductive health, maternal and child health, prevention of infectious diseases, democracy and governance, and poverty alleviation (55, 56, 91, 134, 136, 200, 225).

To address most health problems fully, BCC programs must be integrated with an overall health program. An overall program usually includes an effective service delivery system and requires a supportive political and policy environment (56, 136, 200). For example, a BCC campaign can motivate people to space births. Family planning services must be ready to respond. This requires convenient clinic hours and locations; a variety of contraceptive choices in continuous supply; competent, helpful providers; and policies that remove unnecessary medical barriers to contraceptive use (see What BCC Programs Can Achieve).

This report focuses on helping family planning and reproductive health program managers establish BCC programs. The basic BCC principles and processes involved are common to all fields of health and development.

BCC Programs Grow Stronger, Smarter

Over the last five decades family planning and reproductive health programs have grown and evolved. Communication programs have grown and evolved with them (see Figure 1). As understanding of communication and behavior has grown, family planning BCC programs have become more strategic. Strategic BCC programs use a systematic process to understand people’s situations and influences. They develop messages that respond to people’s concerns. They draw on behavioral theory, define clearly the specific objectives they want to achieve, integrate these objectives into their program plans, and use them as a basis for measuring success.

Furthermore, larger BCC programs use a mix of three major communication channels:

• Mass media channels, which can reach large audiences. Examples include radio and television, widely circulated newspapers and magazines, billboards and bus advertising, and the Internet.
• Interpersonal channels, often one-to-one communication, such as counseling and telephone hotlines.
• Community channels, which include rallies, public meetings, and folk dramas and also local newspapers and local radio stations.

Each type of channel has its own strengths (56, 136, 200). For example, mass media entertainment and reality programming can depict healthy behavior for large audiences. Interpersonal communication with health care providers helps clients learn the skills to practice new behavior. Later, they themselves may become advocates, speaking to friends, family, and neighbors in favor of the new behavior. Community- based approaches spread new ideas through social networks and, over time, encourage widespread support of them throughout the community. In most BCC programs one type of channel has the lead role (139). Together, the three reinforce each other to achieve changes in behavior.

Today, many BCC programs emphasize the involvement of communities. Community participation can range from assisting with needs assessment, planning, or implementing activities to direct involvement in decisions about all aspects of program management, resource allocation, and evaluations (see Participatory Approaches Empower Communities).

Just as BCC programs have evolved, so, too, have the terms to describe such programs. Previously, organizations used “information, education, and communication” (IEC) strategies to improve people’s awareness and knowledge and to promote positive behaviors (36, 163). BCC builds on IEC, and emphasizes that communication should be strategic and guided by systematic processes and behavioral theories (55, 58, 224). Many organizations now use the term “behavior change communication,” but others use different terms for different emphasis. Examples include “strategic communication,” “communication for social change,” and “participatory development communication” (22, 47, 56, 120). This report uses the term “behavior change communication” to encompass all of these approaches.

Theories and process guide programs. Theories of behavior guide the selection of the most appropriate communication approaches to changing behavior. They also help shape effective messages (see Theories Inform Behavior Change Communication). Additionally, a multi-step process has evolved to guide the development of BCC programs. Numerous models describe a systematic sequence of steps from analysis through design, development and pretesting, implementation and monitoring, and, finally, to evaluation. Alternative models and processes focus on facilitating dialogue among community members to help them define their own problems and develop and implement solutions together in order to effect social change (see Participatory Approaches Empower Communities).

BCC Key in Addressing Family Planning and Other Reproductive Health Issues

Effective BCC programs can help family planning programs meet their central goals, including reducing unmet need for contraception and helping couples choose and use suitable methods. Almost one-fifth of married women in developing countries—over 100 million women—have an unmet need for contraception (157, 168). That is, they want to avoid or delay pregnancy, but they are not using contraception.

Communication addresses the major reasons for unmet need: lack of knowledge about contraceptives, worries about contraceptive side effects, and opposition to family planning, whether their own or from others (26, 31, 168, 218). BCC programs inform people about family planning methods and services. Also, BCC programs help people to make good family planning choices. For example, they provide accurate information about side effects and how to manage them. They encourage couples to discuss their fertility desires and contraception. Also, they help make the use of contraception socially more acceptable (168).

In addition, BCC programs are crucial for changing the behaviors that spread HIV. To reduce risky behaviors, HIV prevention programs have made considerable efforts to educate people about modes of HIV transmission and prevention strategies (58). HIV-related BCC programs also play an essential role in changing societal attitudes such as reducing stigma. The stigma of HIV/AIDS discourages people from being tested and from getting treatment (120). To broaden and sustain their impact, however, many HIV prevention programs also address social norms that foster the pandemic. These include norms that condone having multiple sex partners and norms that tolerate sexual coercion and violence against women (166, 199). Community participation and sense of ownership of the program are vital for accomplishing such social changes (166, 198).

Research Documents Influence on Reproductive Health Behavior

BCC programs have motivated people to visit health clinics, discuss family planning, use contraception, advocate abandonment of female genital cutting, protect themselves against HIV infection, and to get tested for HIV (6, 50, 101, 105, 116, 144, 146, 147, 165).

For example, one review analyzed 39 international family planning BCC programs funded by the U.S. Agency for International Development (USAID) and conducted between 1986 and 2001 by the Center for Communication Programs at the Johns Hopkins Bloomberg School of Public Health (179). The programs assessed used a variety of communication channels, including broadcast and print media; interpersonal communication through outreach workers, schools, health care centers, the workplace, and door-to-door activities; and community-based approaches such as group meetings, folk drama, and rallies. Generally, these programs had a large reach. On average, nearly 70% of the intended audience reported exposure to the programs. One-third were nationwide programs (179).

The review found increases among the intended audience in knowledge of family planning, communication between sexual partners, approval of family planning, and use of modern contraceptives after the programs ended. After taking into account exposure to the programs, the review found that some 40% of people exposed to the programs were using modern contraceptive methods, compared with 28% of those who said they had not been exposed (179). Similar findings come from an analysis of international family planning BCC programs conducted by other organizations (179), BCC programs promoting safe sexual behavior, smoking cessation, and other public health initiatives in the United States (181), and an earlier analysis of 16 small family planning programs with communication components in developing countries (14).

Also, analyses of data from Demographic and Health Surveys found that people who were regularly exposed to family planning messages, and to radio and television in general, had greater knowledge of family planning methods and were more likely to use contraception and to intend to use contraception in the future than people not exposed (219, 220). These analyses took into account many other factors that might influence reproductive behavior, such as place of residence, education, ethnicity, economic status, age, and number of children.

HIV-related mass media campaigns also have changed specific behaviors. Two major reviews of HIV-related mass media programs in developing countries found that such campaigns influenced people’s knowledge, attitudes, and behaviors. The campaigns did not affect every possible outcome, however, and not every campaign succeeded (17, 21). For example, one review assessed 15 mass media campaigns for young people conducted between 1990 through 2004. The review found positive impacts on several outcomes, such as social norms about the acceptability of young people discussing reproductive health; discussing HIV/AIDS, abstinence, or condom use with someone else; feeling capable of using condoms; and condom use itself. The campaigns, however, did not have much impact on certain other outcomes, such as age at first sex, number of sex partners, or feeling capable of practicing abstinence (17). Reports on more recent individual campaigns continue to find that mass media campaigns generally improve HIV-related behavior, such as condom use, testing for HIV, and interpersonal communication about HIV (103, 104, 109). (To help ensure BCC programs contain the major components needed for success, see Characteristics of Effective BCC Programs)

A good investment. A recent review of 45 BCC programs in both developed and developing countries suggests that, in general, such programs change health behavior cost-effectively (90). The review focused on programs with large mass media components. Some programs also involved community-based approaches and interpersonal communication. Among the programs reviewed, there was great diversity in types of evaluation designs, how the studies calculated costs, and what outcomes they measured (85, 90, 213). Therefore generalizations must be made with caution.

The review found that BCC programs in many health areas have been cost-effective, particularly when they have reached large portions of the population (90). For example, in the Philippines a family planning mass media campaign aired four television spots between August and December 2000. This national campaign cost US$546,720 and persuaded an estimated 348,695 women to start using a modern contraceptive (110). Thus the cost for each new user was $1.57.

Maternal and child health and HIV/AIDS campaigns have also reported low cost-per-user-reached. In Bangladesh the Smiling Sun program, a national multichannel mass media campaign, encouraged women to use family health services at good-quality clinics identified with the Smiling Sun logo. The campaign cost about $832,000. Among all rural areas of the country, the campaign potentially covered 927,466 children under the age of five and 1,072,299 pregnant women. The campaign cost only $0.05 for each additional user of antenatal care and only $0.30 for each additional child vaccinated for measles (89). Mass media campaigns usually involve large initial costs. The cost for each person motivated to change behavior is low because mass media reach hundreds of thousands of people.