Scale-Up and Capacity Building in Behavioral Science to Improve the Uptake of Family Planning and Reproductive Health Services (SupCap)

In order to address barriers women and men face in using contraception during the extended postpartum period, SupCap implementers pursued a behavioural design methdology that involved the following steps: define, diagnose, design, test, and scale. After defining the challenge as low PPFP uptake, IntraHealth and ideas42 moved to the diagnose phase, which entailed conducting interviews with postpartum women, male partners of postpartum women, and health workers. Based on these interviews, they identified 6 behavioural barriers: Couples typically do not discuss number or spacing of their children; couples typically do not discuss whether to use FP or not; couples underestimate the cost of having a child or overweigh the benefits; couples think their current actions to avoid pregnancy are sufficient; couples are not consistently prompted by health workers to consider FP; and couples fear health consequences of FP. Based on these barriers and the scarcity of dedicated FP programming for men, IntraHealth and ideas42 designed an intervention for male partners of postpartum women.

The intervention comprised 3 components: an interactive game called "Together We Decide," a child spacing planning card, and SMS messages. The idea was that male partners of postpartum women would play Together We Decide in small groups facilitated by village health teams and receive a planning card to take home and discuss FP with their partners. Through the game, male partners would learn more about different contraceptive methods, better understand the financial implications of having children, discuss FP with their partners and engage in joint decision-making, dispel myths and misconceptions about contraception, and make a plan to go to a health facility to receive additional information about FP. SMS messages sent over a period of several weeks to postpartum women, male partners, and health workers included information about contraception and the benefits of FP, as well as reminders to health workers to speak with clients about FP.

From January to March 2020, IntraHealth and ideas42 tested the intervention through a quasi-experimental study in 3 intervention districts (Kapchorwa, Kibuku, and Serere) and 3 control districts (Kween, Pallisa, and Amuria). Men in each of the intervention districts played 1-6 sessions of the game and received a planning card. The study found that men in the intervention group were more likely to say that modern methods are a good choice to space children compared to men in the control group. Also, men in the intervention group were less likely to say they were the sole decision-maker for contraceptive use in their household compared to men in the control group. Contraceptive use increased among men in the intervention group, although this result was not statistically significant (perhaps due to couples not being able to get to a health facility because of COVID-19 lockdown policies).

Based on the positive results from the test phase, the project used a training of trainers approach to scale 2 components of the intervention - the interactive game and planning card - in all 6 study districts from October 2021 to February 2022. At the end of this period, the team had:

• Conducted 4,618 game sessions, reaching 20,576 men;
• Distributed 19,271 child spacing planning cards, 41% of which were returned to a health facility by a man, woman, or couple for counseling on FP;
• Connected clients to 7,434 contraceptive methods;
• Contributed to 61.5% of total PPFP uptake in the 6 project districts; and
• Helped increase the range of methods clients chose, including a significant increase in permanent methods.

The intervention transitioned to district health teams in March 2022 for continued implementation.

Family Planning, Gender

The eastern region of Uganda has some of the highest fertility rates in the country, ranging from 5.1 to 7.9 children per woman. During the postpartum period, women are more likely to interact with the health system, providing an opportunity for health workers to discuss FP and offer contraceptive methods. However, PPFP use among women in Uganda is still relatively low, ranging from just 5% of women using modern contraceptives at 2 months postpartum to only 12% at 6 months postpartum. Men play an important role in decisions about contraceptive use and family size, yet they are often left out of education and outreach programmes.

Among the lessons learned throughout SupCap are these examples:

• Involving a wide range of stakeholders (ranging from community members to district officials) at every stage of the methodology ensured shared ownership and agreement about the intervention. It is important to involve all health workers at the facility to prevent confusion when people arrived with planning cards.
• Using human-centred design principles resulted in an intervention that was relevant to the community and produced a sustainable mechanism for continued implementation.
• The lighthearted game was designed to be played in a friendly, competitive atmosphere, which was a non-threatening way for men to become more comfortable with a sensitive topic.
• Some unanticipated gains that emerged from SupCap included: improved reporting in health facility FP registers thanks to training from the project; decreased reports of gender-based violence in intervention districts due to improved couples' communication, as reported by the health facility teams and district health officers; and increased demand for contraceptive methods.