Using Behavior Change Communication to Lead a Comprehensive Family Planning Program: The Nigerian Urban Reproductive Health Initiative

"Greater exposure to a comprehensive family planning program in urban Nigeria that emphasized demand generation and communication theory was associated with improved ideation among women (their beliefs, ideas, and feelings about family planning), and more positive ideation was associated with greater contraceptive use, especially among the poor."

This journal article discusses how the Nigerian Urban Reproductive Health Initiative (NURHI), a 6-year comprehensive family planning program (2009-2015) implemented in 4 cities, has integrated communication strategies across its programming in order to increase demand for family planning products and services, with the overall goal of improving family planning behaviours. The approach is one that is demand-led rather than service-led and relies 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." The programme first identified barriers based on these ideational factors, and then developed mass media, social mobilisation, and service delivery interventions to address them.

The NURHI approach involved using communication methodologies to adapt each programme activity to promote sustained demand generation around family planning. As stated in the article, "many large-scale family planning programs tend to be 'service-led', that is, informed by a service-delivery and health systems strengthening approach." In a demand-led approach, "from the outset of design, program planners put potential and current family planning users at the forefront, along with their barriers and challenges to using family planning and their desires and hopes." The theory is that by improving demand creation at family level, family planning will then begin to become a social norm. It is also based on the hypothesis "that when demand for family planning rises, supply will rise to meet the demand over time."

This demand creation priority was identified based on studies showing that a very low percentage of women in Nigeria expressed a desire and need for family planning, but that significant numbers had unmet family planning needs. Overall, there were sufficient sources of short-acting contraceptive methods in parts of the country and in NURHI's urban areas sufficient sites that could provide services, but people were not asking for them.

The article describes NURHI's theory of change, which was based on the communication theory of "ideation". "Some of these ideational factors are personal, such as what a person knows about family planning and how they think it will affect them. Others reflect social norms, such as what people believe other people will think of them if they use family planning." This approach began with identifying barriers related to knowledge, attitudes, and social norms, both among potential users and among service providers. The findings were used to develop an intervention which included mass media (radio, television, and print), entertainment-education radio, social mobilisation, and integrated branding under the tagline 'Know. Talk. Go' - meaning "know" your family planning options, "talk" to your partner, and "go" for service. The article discusses these strategies in significant detail and how they are designed to contribute towards demand-generation.

The article then goes on to discuss the outcomes and impact of the project based on the results of a mid-term assessment and concludes that "NURHI's demand generation activities are indeed significantly associated with increased contraceptive use in the cities". For example, research found that 80% of women in the 4 project cities reported some exposure to the NURHI project and that exposure was associated with fewer beliefs in myths and misconceptions related to family planning. As well, in the four project cities, there was an upward trend of intentions to use contraceptives and increased use of contraceptives among married women, which improved with greater exposure to the campaign messages. "The greatest effects were associated with exposure to the local-language radio entertainment-education programs, social mobilization activities, and television spots." The data was found to support the theoretical foundation that changing ideational factors, such as knowledge, attitudes, and beliefs, increases the chances of changing people's behaviour. Using a combination of communication channels enhances this affect, and, the greater the exposure, the more significant impact on ideational factors. This is enhanced by clinical outreach and using these same ideational approaches to identify and respond to barriers among service providers.

In conclusion and based on the success of the NURHI programme, the article makes the point that demand-led family planning programmes, rather than the conventional, service delivery-oriented approach, may be more suitable in places where expressed demand and desire for contraceptives is low - where some services are available but people are not asking for them.