Home›Discussions›Family Planning›User-centered Communication and Family Planning Decision-making in Nepal›Join the Discussion October 11-13 on Increasing Modern Family Planning in Nepal
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October 3, 2017 at 4:33 pm #96036
Join the team that worked in Nepal under the Health Communication Capacity Collaborative (HC3) on Wednesday October 11 through Friday October 13 for an engaging three-day Springboard discussion reflecting on lessons learned from the program.
HC3 Nepal worked to increase modern family planning among young couples in Nepal. Youth are an increasingly vocal audience in Nepal. This is especially true for young married Nepali couples who want to update the existing traditions and family planning expectations to meet the demands of their modern lives. Recognizing this generational shift, the HC3 Smart Jeewan (Smart Life) program supported young married couples by equipping them to have their own conversations at home.
In Nepal the HC3 team designed a user-driven, aspiration-based campaign that worked to generate interest, spark communication among peer groups, and spur positive action in Nepal. Through this three-day discussion on Springboard for Health Communication HC3 Nepal invites the online community to join a thoughtful reflection and discussion that will touch on a number of questions, such as:
How should programs build in a user-centered approach?
Should all programs incorporate a user-centered approach?
What activities lead to increased to social network communication?
What is the “communicative process”? How can I use it to generate interest in health (as HC3 Nepal did for Family Planning)?
What types of modern family planning do young couples in Nepal seek for themselves?
The team will act as moderators for the discussion and will be available to discuss details and share latest results from end of project research. Moderators include:
Ron Hess, Chief of Party, HC3 Nepal
Caroline Jacoby, Senior Program Officer
Lindsey Leslie, Program Officer
Zoe Hendrickson, Assistant Scientist
All Springboard discussion participants are encouraged to ask questions and share relevant stories and successes from their own work.
To learn more about the work in Nepal before the discussion, read this overview, as well as:
HC3 Nepal Case Study: A Study in User-Centered Communication and Family Planning Decision-Making in Nepal
October 10, 2017 at 4:34 am #96580
October 10, 2017 at 11:13 pm #96673
Hi everyone! The Nepal team is looking forward to this discussion over the next 3 days (Oct 11-13).
Don’t be shy- Introduce yourself and let us know what questions you have about our efforts to improve family planning in Nepal. We’re happy to talk through our approach.
Looking forward to hearing from you!
October 11, 2017 at 2:55 am #96674
What types of modern family planning do young couples in Nepal seek for themselves?
Nepali Newly Young couples (married/unmarried) preferred Condom,Pills and Depo. after the child birth more of the married couple also used Depo and oral pills. Intervention from HC3 Smart Jeevan national campaign and from other efforts increased the No of Long acting methods like Implant and IUCD among Married Women’s.
So Need to focused FP choice,Effective campaigns as a mainstream of government program covering the major population areas.program need to comprehensive ASRH package and individual activities indicating meet the SDG. Its also be useful the learning Smart jeevan campaigns and its indications focusing on newly married,PPFP,Adolescents,young couples and MDAGs.
October 11, 2017 at 1:50 pm #96686
I really like the context you highlight about Nepal, Amish, and the need to take that into account in a user-centered design. Can you explain more about what you mean regarding CIP and how they could be used? What other ideas could be useful in a user-centered design approach to address the contextual factors that you mentioned?
October 11, 2017 at 4:48 pm #96694
October 11, 2017 at 7:34 am #96679
WHAT IS USER-CENTERED COMMUNICATION AND HOW DOES IT WORK? Here’s Poonam’s story:
Poonam and Rabi Kumar Pathak got married in rural Nepal when they were teenagers. They planned to wait several years before having children so they could get to know each other better. But those plans were upended when she became pregnant soon after the wedding. “When it happened, it happened,” Poonam says. “But I don’t want another child for five to six years.”
During a medical check-up when she was eight-months pregnant, Poonam met HC3 Peer Facilitator Arti Pathak and the pair discussed family planning. Even before her first child was born, Poonam was worried that she might have the next one before she was ready. Poonam asked Arti to speak to her husband and mother-in-law. Arti visited Poonam’s home. Poonam’s mother-in-law thought Poonam should have another child right away so that the children would grow up together. But when Arti went over the health risks to mother and child associated with a short interval between births, Poonam’s mother-in-law changed her mind.
After learning about their many family planning options, the couple chose a contraceptive implant to prevent another pregnancy. Arti even accompanied the couple to a distant health center to get the implant when it turned out it wasn’t available at their local clinic.
Now, more than a year later, neighbors come to Poonam – and her mother-in-law! – to discuss the benefits of the family planning.
This story and many others are told in the Nepal Case study, “Entering the Conversation,” developed by NHC3 staff Moon Pradhan and communication expert Dr. Celine Klemm. The study provides a rich account of a process we documented throughout the HC3 project, through observation, monitoring and research: people seeking information to meet their goals and inviting HC3 into their conversations as a cooperative partner.
October 11, 2017 at 9:07 am #96683
How should programs build in a user-centered approach?
Nepal has 15% Himalaya region, 68% hilly region and only 17% plane land in terai region that means here are so many hard to reach area, even regular follow-up also difficult to maintain between educator/referral agent and clients. According to DHS 2016 still 24% unmet need is remaining (In hilly region 25.5%). In my opinion CIP (Community Information Point) approach will be effective for family planning program because CIP can run locally, easy to communicate between service provider and CIP operator/service seekers and it is cost effective as well.
October 11, 2017 at 8:42 pm #96794
I enjoyed Poonam’s story, and I am curious if this was the norm among couples who decided they wanted FP – inviting the health facilitator to their home to help present health information aligned with the mother-in-law’s goal. Was it Poonam’s suggestion to have the facilitator come home with her, or was that built into the strategy to increase FP acceptance and uptake?
October 11, 2017 at 10:13 am #96684
Someone close to me tells me I’m being too indirect – that I’m asking people to ‘read between the lines’ in Poonam’s story. So, to be more direct, what I’d like to emphasize is this:
- Upon getting married, Poonam and her partner wanted to wait to have children but got pregnant earlier than expected because they didn’t act (Couple’s shared goal to delay first pregnancy thwarted)
- Couple accepts current pregnancy, but Poonam is worried about an accidental follow-on pregnancy (actor’s goal is to avoid follow-on pregnancy)
- Poonam goes to her last ante-natal checkup (actor’s parental care-seeking behavior), and engages with Arti, the HC3 Peer Facilitator there (actor’s choice to communicate with a health partner to meet her goal)
- Poonam invites Arti home to communicate with Mother-in-Law (because she found HC3 Program health information relevant to her goal of protecting her child’s health, and needs to coordinate her goal with her family),
- Poonam’s MIL also understands health benefit (meets MIL’s goal for grand-child’s health and care)
- Poonam and her husband, communicating within their family, now seek a solution with HC3 PF Arti’s cooperation. They communicate with Arti to coordinate a health action: obtaining a contraceptive implant.
In all six stages above, Poonam and her husband were the central actors driving a series of communication behaviors: discussing their shared family goals amongst themselves, communicating with a credible health source to meet the goal of avoiding an unwanted pregnancy, inviting the health facilitator to their home to help present health information aligned with MIL’s goal, and, finally, Poonam communicating with HC3 Peer Facilitator to coordinate a health service visit – the adoption of an implant, or a health behavior.
That actors/users choose to give attention to media (they ‘pay’ or ‘give’ attention to goal-relevant content), or that they choose to engage in Face-to-Face community-based communication should come as no surprise. In this era of social media, where new media allow users to seek goal-relevant information and to share it with other discussion partners, the communication paradigm has decisively shifted from a top-down ‘sender-to-receiver,’ media effects, persuasion model of communication to a more horizontal, user-driven goal-directed, networked communication model. And this is how we observe social network communication to work in a natural social setting, leading us to recommend that Communication Programs should recast their role to that of being cooperative partners in providing goal-relevant communication to users in this context, rather than that of social engineers charged with changing the behavior of passive receivers. In short, with user-centered cooperative communication, we must “throw the ball to our partners, rather than at at them.” (Tomasello, M. 2014. A Natural History of Thinking, Harvard University Press) (Abundant communication theory and research backing this paradigm.)
October 12, 2017 at 1:11 am #96799
In answer to Jen’s comment, HC3’s strategy to use peer facilitators (PFs) as CHWs was a deliberate attempt to facilitate horizontal conversations. Most PFs were 1000-day mothers from the community, or peers of those whom they were contacting. The PFs did make routine rounds of home visits in the community, where sometimes they were invited in, other times not. I think this invitation, like others, whether initiated by Poonam or Arti, represents a user-generated/accepted opening to discuss and seek information. (I don’t think the MIL initiated it, but I don’t know for sure.)
October 12, 2017 at 3:27 am #96801
Very interesting read. The whole approach of user centered cooperative communication holds the promise of, as very aptly stated by Ron, recasting the role of program implementers in the coming times from being social engineers to more of cooperative partners facilitating/catalyzing adoption of desired behaviours- more so with the increasing mobile penetration and use of internet among youth. I would be interested in knowing more about the norms which existed when the program started and how they were addressed. In India, although the TFR has decreased over the last decade, there exist several deep rooted social barriers among the rural and urban poor populations (especially in the North). There is immense pressure on newly- weds to complete their family at the earliest. There is high preference for sons as a family is considered complete only after the woman gives birth to a boy. Any delay in giving birth to the first child raises suspicions on the woman fertility. And in terms of spousal support, as per some dated national level data, around a quarter of rural men and a fifth of urban men state that contraception is a woman’s business and he need not worry about it. It would be interesting to know if similar barriers exist in Nepal and, if yes, how the program addressed them. I would also be eager to hear more on how social media was used in the intervention and about the platforms used to generate discussions.
October 12, 2017 at 12:36 pm #96815
Since you’ve mentioned social media, I’m inviting you to take a look our Facebook page: https://www.facebook.com/smartjeewan/
Scrolling through the Smartjeewan wall, videos and photos will give you a better sense of how social media served to support conversation on a variety of topics ranging from family planning to tobacco cessation to breastfeeding and others. Over the course of the project, we’ve also held couple-focused contests and special promotions during love-related holidays (such as Valentine’s day) to create opportunities for increased partner communication.
Social media is an opportune medium for user-centered communication efforts. There are numerous opportunities for two-way communication and multiple voices and perspectives can easily be expressed. What is most critical, of course, is finding ways to synthesize the perspectives, experiences, feedback, and recommendations etc so they can feed into building stronger, more user-centered programs.
October 13, 2017 at 4:38 am #96910
Thanks for sharing the link, Lindsey.
October 12, 2017 at 7:26 am #96803
Very interesting discussion so far. Well articulated Ron, I agree that this user-centered approach of communication in SBCC is very timely and appropriate in an age of information abundance where people typically consume information and media very selectively.
Something that was really interesting for me during the interviews with beneficiaries was to observe the longer-term process of knowledge acquisition, attitude change and ultimately behaviour change, which requires multiple communicative exchanges alongside the process. I think this is something oftentimes not sufficiently reflected in our behaviour change models. If we – as Ron discussed – acknowledge that communication is driven by the beneficiaries’ information needs and that they reach out to us for information or “pay attention”, it follows that as a program, we need to be accessible and tailor information to the beneficiaries’ needs at their different stages. Here the role of peer facilitators, who do this easily and naturally by adapting their information to whatever concerns a beneficiary, really comes into play. But in general, I feel that’s something worthwhile considering. And with the possibilities of new, increasingly personalized technologies, perhaps something that can be provided on a larger scale (besides peer facilitators).
October 12, 2017 at 3:35 pm #96818
Nokafu Sandra ChipantaModerator@nkc32
In response to Celine, I think you are right on. Interesting discussion all. Regarding your point Celine, what we have found in Nepal through the use of a user-centered design to increase FP is to use a game approach with embedded critical reflection questions. Through our project (Fertility Awareness for Community Transformation — FACT) in Nepal, we designed a series of 9 games with critical reflection questions on fertility awareness, family planning, and social morns (especially son preference, and childbirth immediately after marriage). The games are implemented at the community level by Female Community Health Volunteers (FCHVs) who hold meetings with health mothers groups every month, Health mothers groups champions, and male champions to ensure we are reaching men. The games are designed to bring the community together and catalyze conversations about difficult topics related to fertility awareness (menstruation, fertility, etc.), family planning, and existing norms with the inclusion of all stakeholders in the community. You can find more info in the attached brief Pragati Brief Final_8.23.17
Also, the topics of discussion were selected through formative research with the results validated by the community. We are currently in the pilot phase and are looking forward to collect qualitative and quantitative information based on user experience with the games. Stay tuned!
October 12, 2017 at 7:28 am #96804
October 12, 2017 at 8:53 am #96805
Thanks for your comment. All the norms you mention in India do exist in varying forms and degrees in Nepal. Norms, as social rules of cooperation and of control provide a social road-map, often posing barriers to positive change in the process. I guess our approach to tackle such barriers in Nepal was to look for the margin where positive change was occurring and identify the social goals driving the change. Then we sought to engage our participants to build forward from that goal. A fundamental goal shared by all parents (and grandparents), was the goal to have the child (grandchild) survive and thrive. We recognize that people have different definitions of how to get there socially, but there are a few basics. What we heard from young people consistently was their goal to give their child good care and nurture, a safe secure home, and education (albeit, within their means). We started with these goals and introduced fertility management as a ‘smart’ way to get there — right now, with the child at hand. Even in marginalized communities, people observed others in their own reference group who were achieving these goals to greater or lesser extent and so we used this differential as a point-of-the-wedge, so to speak, to advance positive fertility management behaviors (approaching “kinare-kinare,” as it were).
For the young cohort, these fertility decisions were motivated by more effective (smarter) “use dynamics” to achieve a positive outcome for the child at hand, rather than being expressive of an ultimate family size decision. And with respect to son preference, we found not just a parental love of their daughters, but a recognition that daughters remain very much part of the family even in a partilocal social setting. So we find a growing, rather than lessening will to invest in the education of daughters as well as sons. It is these directions of change that we sought to support with the program. And we were somewhat surprised in our formative research among the young family cohort to see the degree to which young couples really considered fertility decision-making to be their domain, rather than that of parents and other community influentials. (I think it’s fair to say that some change is in the air for the new generation.)
PS: We haven’t had the chance to use our endline data to analyze the relationship between respondents’ descriptive/ injunctive norms and their preferences and FP ‘use-dynamics’ practices (uptake of FP post-partum, reduction of narrow birth intervals, etc.), but we are looking forward to doing so.
October 12, 2017 at 9:05 am #96806
Many thanks for your comment — I do think we are in much more of a user-selected media environment than in the past and that our programs need to turn that corner (quickly).
I also really appreciate your observation made during preparation of the case study “Entering the Conversation,” that people really relied on multiple communicative exchanges to work their way around important decisions. Very important point, and one that I agree must be built more strongly into future programs!!
In fact, I’ll add that in our monitoring data for contacts and referrals, when we dis-aggregated it by ‘single contact’ vs ‘repeat contact’ generating referrals, we found that repeat contacts were the greater drivers of change.
October 13, 2017 at 4:05 am #96909
Very useful insights, Ron. Thank you so much.
October 12, 2017 at 9:28 am #96809
Hi Zoe and Celine, Thank you for you query.
In Nepal, commonly we go to shop every day to buy daily necessary goods. Usually costumers’ rapport is good with shopkeeper. In the context of hard to reach areas, same theory is applied. They go to shop, at the same time they talk on different issue with shopkeeper as well. So our concept is why not to capture that communication opportunity regarding to the family planning issue. One interesting thing is shopkeeper knows their costumer’s social/economic status too. They can talk about social economic condition and link with family planning. To do this task, shopkeepers don’t need to go anywhere to provide FP message. They talk with their costumer who will come to their shop. At that time they can explain about smart life, smart future for their family and child etc.
As I have already mentioned that communication between field worker and targeted population is not always easy because field workers have to cover their all geographical coverage and also allocate to time for reporting etc. In other side, targeted population has also their own priority work and here we are talking about hard to reach area and it is not possible to travel frequently in that area due to different circumstances, so if we set the CIP in hard to reach area, CIP operator can interact with targeted population, they provide necessary information, brochure, commodities like condoms etc. and inform to service provider about the weekly progress and situation by telephone and even they can directly link between service provider and service seekers.
How can we set the CIP?
No need to extra space for CIP. CIP is just communication point and information providing point. We can set CIP in shop, club, beauty parlor or anywhere where targeted population will go.
Step of CIP setting:-
- Select the shop, club, beauty parlor
- Provide orientation for CIP operator in subject matter
- Provide brochure FP commodities like condom etc.
- Provide referral directory, stakeholders’ mapping etc.
Cost of CIP setting:-
Just one time, small bamboo rack to keep SBCC materials, registers/diary for service record and monthly cell phone recharge card. So it is cost effective also.
Role of CIP operator:-
- Provide necessary message/commodities to targeted population
- Support to service provider to set FP camp if necessary
- Provide FP related ground reality of their community to service provider
- Link between service provider and targeted population
I try to illustrate CIP model which is attached with this message. Hope it will easy to understand.
October 12, 2017 at 10:01 am #96812
October 13, 2017 at 8:03 am #96915
<span class=”handle-sign”>@</span>Amish thanks for sharing the CIP model. Good innovation for hard to reach areas. if i understand you clearly, the shop keepers are the direct contact with the clients/women in the community? if yes, how are they trained to be able to pass these information appropriately and secondly, i will like to know your modalities for monitoring to ensure that accurate messages are shared to these clients.
October 15, 2017 at 2:23 am #97042
@amish Ji thank you very much for elaborating the CIP concept so nicely. In hard to reach area CIP can play a vital role to meet family planning expectations. I found the whole concept interesting and productive. Following the discussion feed to learn more.
October 15, 2017 at 8:38 am #97043
October 12, 2017 at 12:08 pm #96814
Thanks so much for sharing, Amish! I really like this model and think it has the potential to be quite sustainable. What are some of the ways that we can monitor these CIP and make sure that they are sustainable? Is there a concern about the time burden it places on those working there and the potential need for renumeration? What about existing differences by social status and who might be included or excluded from such an approach?
October 12, 2017 at 6:47 pm #96819
In response to Nokafu, the integration of media, especially a game approach, with community level by Female Community Health Volunteers sounds very promising. Thank you for sharing that and also the brief! I’d love to hear about the findings on user experiences, looking forward.
October 12, 2017 at 6:59 pm #96820
And thank you for sharing this additional information Ron! Great to hear that the quantitative findings underpin the importance and effectiveness of repeated interactions.
October 13, 2017 at 5:30 am #96911
Thanks for this interesting discussion.
The project’s use of User centered approaches were key in a paradigm shift in how family planning was presented in Nepal: as a smart life choice hooked to people’s personal/family aspirations rather than to a menu of choices of clinical methods. In doing so, Family planning became smart life planning for the young couples which made sense and seemed to fit into what they wanted out of life.
I think the user centered approach is critical as this approach taps into the ‘true needs (their needs)’ of the audience and helps promote the behavior through multiple touch points. The audience has to see value in practicing the behavior and see that the practice has benefits/ helps better their lives or their loved ones’ lives.
I am working on an assignment on generating demand for institutional delivery in rural Nepal and according to the 2011 NDHS (2016 NDHS still not released yet. Waiting anxiously!) the majority seem to perceive no need for institutional delivery. They see home delivery as normal and customary. There are a lot of discussions about access (distance, cost), preparedness but as long as there is no perceived need for institutional delivery by the audience, the practice will not take place.
So I would strongly argue for a user centered program approaches similar to the one implemented by the Nepal HC3 family planning project that helps link intended behavior to values, aspirations of the audience.
October 13, 2017 at 5:56 am #96912
October 13, 2017 at 6:04 am #96913
Thanks, Nokafu, for sharing the FACT game-based approach. We’ll be very interested in your further qualitative and quantitative observations. Keep us posted!
October 13, 2017 at 6:29 am #96914
Thanks, Pranab, for underscoring the importance of starting with user aspirations or goal-relevance in health communication.
Your work on institutional delivery sounds really interesting.
A primary insight of the Smart Jeewan campaign (which you know well, and I’m using this chance to re-emphasize), was that we viewed fertility management as one of a suite of parental care/investment behaviors. This led us to use ante-natal visits and post-natal immunization visits (also parental care behaviors), as key link-points to discuss family planning (same big goal, different ‘tactical’ behaviors to get there). And we know that ANC and EPI practice as very high in Nepal, so people are acting on this goal! I wonder if medically-assisted delivery couldn’t be brought into this ‘smart parenting’ frame as well. Of course, medically-assisted delivery is a costly, higher-stakes event so there are many barriers competing with peoples’ goals to have a safe, healthy delivery. But I think that it’s safe to start with their parental care goal in the search for ways to change customary perceptions.
October 14, 2017 at 1:29 am #96971
Thank you Ron, Zoe and Chizoba. Sorry for delay response due to internet problem.
CIP approach is always tied up with social responsibly. Its’ concept is “Social contribution by local people”. Every human can contribute for the development of their social condition either they are poor or rich or involve in social sector or private sector. Usually NRs. 1500/- (US $ 15/-) per month is given as communication charge and register update. This is a type of volunteer work so there is no hard and fast rule apply for monitoring but supportive monitoring is done in monthly basis through checklist, feedback collection from community and data analysis, for example: If there are 1200 numbers of MWRA and among them 600 from marginalized in that area, how many would contact through CIP and among them how many from marginalized group? After collection of checklist, social feedback and data analysis, service provider will give feedback to CIP operator in positive way.
As I already mentioned in previous discussion that CIP operator submits the report in weekly basis so service provider knows the ground reality and also knows what types of activities are necessary for that month as well as what types of coordination and collaboration is necessary for other line agencies. So the service provider will reach that place with other line agencies so that effective result will come and people from hard to reach area also will receive best services.
And Key message will develop for correct and consistent information.
October 16, 2017 at 9:45 pm #97155
Thank you to everyone who participated in this lively discussion last week. We very much appreciated hearing your experience and perspectives related to family planning in Nepal. We hope these insights will continue to feed into high-quality, community-centered, socially responsible work in Nepal.
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