Elements of Successful Family Planning
Interview with Ruwaida Salem
Interview Conducted on March 11, 2008 by Rose Reis
1. Why do successful programs need communication and outreach strategies--why can't they just offer contraception and services?
Successful family planning programs need to offer more than just clinical services and contraceptive choices for their clients. These are necessary components of family planning programs of course, but they're not enough. Communication programs are also needed to inform and motivate people about the family planning services that are available and about the contraceptive options that are available to them. So you just can't just assume that people will seek the contraceptives if you simply make them available. You have to go in there and basically market your services and your products. It's the same with a business mindset. Private businesses go out there and develop products, they don’t just put them on the shelves and expect people to come buy them—they market them to show people to benefits of using their specific products. Here 's a concrete example why FP programs need communication campaigns: Around the world over 100 million married women have an unmet need for contraception. In other words, these women want to delay having a baby or they want to avoid pregnancy altogether, but they're not using contraception. The major reasons for this unmet need are 3 fold:
One is that they lack knowledge about contraceptives.
Another reason is that have worries about contraceptive side effects,
And finally some women are opposed to family planning or somebody in their family is opposed to family planning. So communication addresses all of these reasons. They inform people about family planning methods and services, they provide accurate information about side effects and how to manage them, and they encourage couples to discuss their fertility desires and they help to make use of contraception more acceptable socially.
2. How would you define a successful program?
So I'm a firm believer that the goal of family planning programs is to help couples achieve their reproductive desires so for me it's more than just blindly increasing contraceptive prevalence rates or decreasing fertility rates. Instead I would define a successful program as one that helps couples meet their contraceptive needs. So for example, reducing the rate of unmet contraceptive need might be an appropriate indicator of a successful family planning program.
3. What are the most important reasons for family planning programs to undertake communication activities? What does communication need to accomplish at this time?
So what communication needs to accomplish currently really depends on the local situation. I mentioned the major reason for unmet need for contraception worldwide—its lack of knowledge, worries about side affects, and opposition to family planning—but which reason among those three predominates varies from place to place. For example, in some rural areas such as in parts of Sub-Saharan Africa, a lack of knowledge about contraceptive methods is a very prominent reason for women’s unmet needs. In contrast in urban areas in most countries, concern about side effects is more of an issue than lack of knowledge and lack of access to family planning services. So it'll vary from place to place and it's all very dependent on the local context.
4. Who are the stakeholders who create a communication and outreach strategy?
There are a number of stakeholders that should be involved in the communication program process and in developing the strategy for the communication program. Probably the most important stakeholder will be members of the intended audience. Without the audience’s input, the program risks making costly and wasteful mistakes. As a simple example, consider this: without a thorough understanding of the audience’s media habits, for example, how much they listen to the radio, and at what times of the day they listen to the radio—without knowing this, the program risks choosing the wrong communication channels and the wrong products or messages to reach the audience. And you can find examples like this throughout the communication program process.
First and foremost the program should focus on including the audience in the program process.
Other stakeholders may include non-governmental organizations, professional associations, they can be schools or faith based associations, even the media, it all really depends on the program and the context of program. Any organization with a vested interest in program would be considered a stakeholder of your communication program. It is important to include these stakeholders from the very beginning so everyone can be on board with the strategies and the messages and so forth and so they can have ownership in program.
5. Why is it important to use a proven theory in creating a communication campaign?
Behavioral theories are important to use when creating a communication campaign or program. Behavioral theories help programs to understand why people behave as they do and help understand how people change behavior. Behavioral theories give programs a framework to base their work on, and to base their strategies on. They don't have to reinvent the wheel. They can use these theories to provide that framework and to help them work more efficiently and effectively to make sure that they reach the audience with messages that appeal to them and that are that are relevant for them.
6. Should program managers read all the latest research on communication and outreach? If not, what are three key resources you would recommend?
Well there's a lot of research out there about communication programming. So I don't think it would be possible to read every single thing that's written out there about communication. So if you want an overview of communication programming, a good starting point would be the recently published Population Reports issue on behavior change communication called “Communication for Better Health.” Some good resources that describe the communication program process that I drew on to write this issue; one is the National Cancer Institute's so-called “Pink Book” (it's called a pink book because the cover is pink), but the official title is “Making Health Communication Programs Work: a Planners Guide.”
Also, the Center for Communication Programs published an excellent field guide called “A Field Guide to Designing Effective Health Communication Strategy.” This field guide provides detailed step by step detailed instructions for the entire program process, and it has lots of worksheets and other tools to help you along on the process.
If you want to get a feel for other behavior change models that focus more on affecting social change instead of the conventional individual behavior change model, then a good starting point is the Rockefeller Foundation’s position paper, it’s called “Communication for Social Change: A Position Paper and Conference Report.” Finally, if you're looking for information on specific sub-topics within the field of behavior change communication, for example the impact of health communication programs, or the cost effectiveness of them, or how to develop capacity for communication programming, you can always start by turning to the bibliography of population reports issue that I just mentioned, and you might be able to find specific information on those sub-topics.
7. What is the difference between communication and outreach strategies, in practice?
Outreach activities are just one component of a broader communication strategy. A communication strategy is the overall approach that the program is going to take to reach their audience. It includes defining who the audience is, it includes defining what the desired behavior change is for the audience, and what communication channels the program will use, and so on and so forth. Outreach activities are an example of one specific type of communication channel that the program may use. Typically in the family planning field, outreach usually pertains to health workers going out to the field and informing and motivating people about contraceptives and how to use them correctly through home visits and community visits. This would typically be classified as a community based communication channel so this would be one type of channel that your program could use as part of your overall communication strategy.
8. Can you briefly describe the evolution of family planning communication, from the 1960s to the present day?
Family planning communication has evolved over the past five decades or so alongside with family planning programs in general. So in its early years starting from around the 1960s, family planning communication was part of the so-called clinic era of family planning. Usually communication took on the form of physicians lecturing to patients. The family planning program model was of the mindset that if you make services available, that people will come to them automatically. Over time communication programs gradually became more sophisticated. For example, during the1970s, family planning communication focused on using field workers to inform and motivate people to use contraception. So rather than just staying inside the clinic they would go out and visit people in their homes and in their own communities to inform them about contraceptive use. Then during the 1980s, there was growing use of social marketing approaches, so at this point people were now asked to pay for family planning if they could afford it. Then, as understanding of communication and behavior continued to grow, family planning communication programs started to become more strategic. This started around the 1990s. By strategic, I mean that programs pay more attention to using theory and research to base their programming on, and they pay more attention to evaluating communication programs to find out the most effective approaches to use, and also to using more participatory approaches involving the community in the program, and using more communication channels, multiple communication channels if they can afford to, and also they are of increasing scale—meaning that they are bigger and larger, trying to reach more people, and hopefully to have greater impact.
10. Some forum participants mentioned enlisting influential community members to promote services, such as sport stars or religious leaders. What are the benefits and drawbacks of using people outside health services to promote family planning? Can you give specific examples?
Choosing the right people to deliver your program’s messages is very critical to a communication program. Your spokesperson should be someone that the audience trusts. Among the most trusted sources are religious leaders. Religious leaders have participated in communication programs for family planning and reproductive health in many countries. Celebrities can also be trusted sources, especially among the youth. As an added bonus, celebrities attract news media coverage, which essentially is free publicity for your program. It’s also important to keep in mind that this only works if the celebrities practice in their private life what they advocate in public. So for example if you are using a celebrity for a family planning program, then that celebrity would ideally be using family planning in their own life, or if is for a program that advocates sexual responsibility for youth, then that celebrity should also exemplify sexual responsibility in his or her private life. So if your audience starts to see a discrepancy between these two spheres, then the credibility of that celebrity is lost, and also then that spills over into the credibility of your program. So again, it is very important that the spokesperson is somebody that the audience trusts.
Q. Can you give any specific examples of effective programs that have used celebrities and/or religious leaders?
You know, there is a host of programs out there that have used celebrities. Off the top of my head, I can’t pinpoint one specific program. We had discussed this in a previous version, in an older draft of the Population Reports issue, but we didn’t get into it in the published version, so I don't have anything at my fingertips. If you wanted me to look something up I could, but I can’t give you a specific example.
11. How should family planning program managers in resource-poor settings decide how much of their budget to invest in communication?
So it's difficult to give an across the board answer to the question of how much of a family planning program's budget should be invested in communication. It really just depends on the specific family planning program, their overall budget, their goals and objectives, and so forth. I can say that some communication experts I've talked to have recommended that around 10-25 % of a family planning budget should be allocated to communication programming, but again, it really just depends on size and scope of family planning program.
Does that include outreach?
Most likely yes, because outreach would be included in your overall communication strategy, if you choose that as one of your strategies.
What's the difference between outreach and IPC?
Interpersonal communication? Well outreach typically is listed under community based channel but it could be a form of interpersonal communication as well. So IPC generally means that it is one-on-one communication. So for example, between a provider and client, that would be IPC. Between two peers like peer to peer counseling, that would be IPC. So you could also kind of list outreach as a form of IPC because the outreach worker would then be speaking directly to a client or a person in the community, but it is kind of listed under community based approaches because you’re going out there in the community—it’s more than just the actual conversation taking place, it's the strategy of going out into the community.
12. How should programs divide up funds between the three channels of behavior change communication?
It's hard to say how a program should divide up its funds between the three major communication channels without knowing first the specific program in question and the context of that program, but in general if the communication program has enough resources it's good for the program to use a mix of the three channels—mass media, IPC channels, and community based channels. So by doing that the three would then reinforce each other and hopefully have a greater impact. Each channel has its own strengths and its own limitations, so some questions a program might want to ask before choosing a specific channel would be, for example; which channels will reach the intended audience? which ones does the intended audience trust? which channels are appropriate for conveying the information that you want?, if the information in your message is very complex, which channel will best deliver that complexity of information? How many people will be exposed to the channel? And of course, can your program afford the channel?
Q. What’s the most expensive channel?
It depends on how you look at it. Usually people tend to think that mass media is the most expensive channel because it involves large upfront costs, but one of the strengths of a mass media channel is that it reaches largest numbers of people. So if you divide the total cost by the total number people you have reached, and hopefully the number of people then who have changed their behavior, the cost per person reached is very low. But again, it does usually involve large upfront costs. IPC channels, on the other hand, might not cost as much up front, but you are reaching only a small number of people at a time, so it costs more in the long run. So again, that's why each channel has its own strengths and limitations so you'd want to use a combination of all three if you can, to piggy back on each other.
13. What are some of your favorite communication campaigns, and what made them successful?
This is difficult for me to answer because there are so many out there. We didn't look at every single communication campaign, or a great deal of them for the report. Jen might be better able to answer this one than I would because she looked at individual programs, whereas I looked more at syntheses of research, so it would be hard for me to answer this one.
Q. What about just things that have caught your eye? For example the Annie Lenox campaign? It doesn't have to be your favorite in the world but just something you noticed recently and felt was an effective or interesting campaign.
One campaign that I’ve noticed recently is the Annie Lennox "Sing" campaign. So Annie Lennox has teamed up with a number of other singers, I think something like 20-22 superstar female singers to record a song that she wrote called “Sing,” and the proceeds of the CD will go to the Treatment Action Campaign which is an HIV/AIDS organization based out of South Africa. The campaign also encourages people to get involved in improving awareness about HIV/AIDS and in other ways, for example by hosting seminars about HIV/AIDS awareness in schools and other locations so this one caught my eye because so many superstar singers came together to record the song. So you're using pop stars and celebrities to spread the message about HIV/AIDS, which has been used in the past. So hopefully they’ll be able to be successful, and what's nice about it too is that all the proceeds of the CD are going to the Treatment Action Campaign which is a great organization in South Africa. They’ve done a lot of good work. For example, they're the ones that advocated that the South African government to provide ARV through the governmental system so that people with HIV/ADIS could access treatment through the government system, and after months of advocating the government to do this, the government finally decided to go ahead and do it. So they’ve done a lot of great work, and I hope this enables them to continue their work.
14. Can you discuss some communication and outreach strategies you worked on at the Birzeit University Institute of Community and Public Health? I don't actually know that you worked on any but could you talk about your work with them? If you did any communication outreach research?
Well the institute of Community and Public Health at Birzeit University in Palestine, I used to work for that several years ago. It's been almost 10 years now, but it was largely a research based institution so I wasn’t really involved in any communications programs while I worked there, I was more involved in evaluation of a clinic based reproductive health programs throughout the West Bank, and I also conducted an assessment of the training needs of traditional birth attendants across the West Bank. As for being involved in specific communications programs there, I didn’t have the opportunity while I was there.
Q. How many years have you worked at INFO? What kind of issues have you written about here?
It has been now almost 7 years in July. In July I will have finished 7 years working for the INFO project. I started off as a research analyst providing support for developing population reports issues. After a year or two of working as a research analyst I became a writer, so I worked on several issues of Population Reports. So one of the first reports I worked on was the Urban Population Report, meaning the urban challenge, and I also worked on the Population Report called “When Contraceptives Change Monthly Bleeding,” about the bleeding side effects of contraceptive methods and how to manage those side effects and a number of different Population Reports issues. Also I contributed to the Family Planning Handbook that was recently published. I’ve also written other types of INFO products and publications like INFO reports issues and Global Health.
15. Arvind Singhal wrote a provocative editorial this week in the Pop Reporter on BCC (behavioral change communication). What was his argument, in a nutshell, and how should program managers respond?
Dr. Arvind Singhal recently wrote an editorial about behavioral change communication for the Pop Reporter, and in his editorial he disagrees with conventional approaches that focus on the individual and that assume that individuals make rational choices that are predictable and follow a step by step manner. Rather, he argues that people are very complex individuals, and that these complex individuals are also part of a complex social system. People’s behaviors are not always as rational as we would like them to believe that they are. People have feelings and aspirations that might prompt them to act in a haphazard or unpredictable way. So the essence of Dr. Singhals editorial is that the interaction between a social network of connected individuals is what affects people’s behaviors. He also adds that little changes in inputs can lead to big outcomes. Some people see the conventional individual behavior change models and social change models that Dr. Singhal advocates as black and white, and perhaps at one time they really were in different ballparks, but I think more and more we are starting to see some convergence between the two models. So for example, many of the conventional individual behavioral change models have a much greater emphasis on social networks, similar to what Dr. Singhal and social change theory support. So the advise I would give to program managers is to develop an understanding of a broad range of behavioral change theories, because the appropriate mix of behavior communication approaches really is going to depend on the goals of your program and on the needs of your community, so it’s not a one-size fits all solution, it is going to vary on the local context.
