A demand creation model for family planning services
Mozambique’s modern contraceptive prevalence rate remains low at 25.3%, with only 14.1% among 15-19 years old.
These are facts that dramatically impact the opportunities and experiences open to girls and young women in this part of Africa.
The unmet need for family planning is further accentuated in rural areas, partially due to the lack of knowledge, as well as strong cultural factors.
ThinkPlace is working with Population Services International in Mozambique, on a project aimed at developing a “demand creation model” to increase uptake of family planning services among adolescent girls aged 10-19 years in rural areas.
Our task is to build an inclusive and scalable model, which is tailored to respond to the wide-ranging needs and behaviours of adolescent girls, and ultimately results in a 33,650-net increase in current users of family planning. Rather than supply family planning services to an unwelcoming cohort we used behaviour change techniques to try and create demand for such services.
We began by conducting 3 weeks of immersive research in Gaza and Nampula provinces. Our primary target was adolescent girls age 10-19 years old, and our aim was to understand different profiles of girls including married versus non-married, children versus no children, in school versus out of school, current family planning users versus non-users.
Our secondary target group aimed at getting a better understanding of the influencers in their lives, which included individuals in positions of power (community and religious leaders), partners, parents or caregivers, health service providers and individuals involved in family planning education (community health workers, teachers).
Through this research we gathered insights about our users’ intrinsic motivators and obtained information on a wide range of barriers and enablers within their ecosystem, which included knowledge of influencers in their lives.
These findings revealed gaps in trusted and consistent information around family planning. Sexual and reproductive health (SRH) is a taboo topic, only openly discussed when a girl gets her first menstruation.
In Nampula province in northern Mozambique, this conversation occurs through traditional initiation ceremonies lead by a “madrona” or matriarchal female figure in the community. In Gaza in the south, adolescent girls are taken by their mothers to the health facility to receive information and often family planning methods before fully comprehending the purpose.
If I would have known that my daughter had her first menstruation, I would have taken her directly to the hospital. - Mother of an adolescent girl, Gaza
Mothers and female influencers are considered key role models in a young girl's life; however, when it comes to helping a girl make informed choices about her health and future, mothers lack the confidence and information to navigate difficult conversations with girls.
Mothers expressed an interest in learning ways to engage with their daughters, and daughters shared a need for approval or consent from their mothers in order to uptake new services. Additionally, peers serve a source of influence in a young girl's life, but adolescents hold a set of ‘truths’ about SRH and FP methods that are plagued with myths and misconceptions based on rumours leading many girls to make misinformed choices.
I started having sex because my friends told me I was missing out, so I tried it and I liked it. Adolescent girl, Nampula
It became clear through our conversations with girls around sex and interactions with the health facility that girls wanted to feel informed and confident in making decisions about their health and their bodies, but most information they trust lacked technical accuracy.
We discovered that while the strength of cultural beliefs varies by region, fertility remains an important aspect, promoting a young women’s status within her family circle and community.
In both areas, girls highlighted having children as their primary goal. Once a woman has her first child, she has proven her fertility and worth in a community. Therefore, messaging aimed at young girls with no children using the term “family planning” does not resonate with our target group, and aspirational messaging pertaining to the future and beyond family does not resonate because children are considered to be every girl's future.
Family planning is mostly seen as an option for married women who already had their first child.
I don’t have any children, so I don’t want to take FP. (Adolescent girl, Nampula)
HOW WE DID IT
Once we identified emerging themes and uncovered insights, we entered the ideation phase where we built upon the insights to form potential interventions to address the needs and desires of our user. These ideas were then further developed into prototypes for multiple rounds of user testing and iterations in Nampula and Gaza province.
Our prototypes focused on the following areas
- Providing private and confidential spaces where girls can access youth friendly information and services,
- Improving parental consent and engagement in discussions with adolescent girls around SRH and FP, and
- Leveraging peer influence to disseminate accurate information and inspire positive behaviour.
We achieved the first objective through mobile events, which took girls on a journey through sessions teaching them entrepreneurial skills, life planning and then an interactive health session highlighting the link between their dreams and the choices they make.
All sessions led to a private opt-out counselling session with an on-site nurse. In the last design sprint during medium fidelity prototyping we reached a total of 396 adolescent girls in rural Mozambique, of which 43% of the eligible girls (211 who had had their first menstruation) went for family planning services on the same day as the events.
We discovered the success of such events in these rural communities relied heavily on parental buy-in meetings held one week before and mobilization through existing trusted networks in the community.
We also tested two other interventions during medium fidelity prototyping. The first of these was the +Mãe kit. This kit is a tool designed to give mothers and female influencers the training and information they need to initiate conversations with their adolescent daughters (included a bag or purse with condoms, information brochure for mothers and daughters and a calendar for girls to track their next method use).
The second of these prototypes was testimonial videos featuring characters who represent different girls in their communities talking about the decision-making process they followed to uptake family planning methods.
We discovered all of these prototypes can complement each other by either creating pre-awareness amongst peers/parents and/or a referral system to other ongoing activities such as events in the communities.
The next steps include handing over this set of demand creation interventions and tools to be integrated into the existing service delivery system and piloted across Mozambique.