Improving the uptake of post-partum family planning services in Nigeria using the Fogg Model

Country-focus: Nigeria

Theme: family planning

Program Background

The PoPCare program is implemented by the Clinton Health Access Initiative (CHAI), the Centre for Communication and Social Impact (CCSI) and the Tulane University School of Public Health and Tropical Medicine, and aims to bridge the high-unmet need for Post-Pregnancy Family Planning (PPFP) services, including Post Abortion Care (PAC), among younger women often missed by the health care system due to high rates of home deliveries and poor SRH programming for young people.

The program seeks to increase uptake of family planning among women who have given birth outside a health facility with a focus on first time mothers. The program is implemented in 11 Local Government Areas (LGAs) in three states namely Lagos, Nasarawa and Rivers.

What did we want to learn?

Understand barriers to health care workers (HCWs) providing family planning services.

Program implementers wanted to understand how health care workers’ personal beliefs may affect their motivation to offer family planning services. For example, health workers may feel first time mothers are too young for contraception and they should finish having children first.  In addition, we wanted to assess whether they had sufficient capacity to offer these services.

Understand the role of traditional birth attendants (TBAs) in providing family planning services.

Over 50% of women in the project’s target states give birth outside a health facility and are likely to use the services of a traditional birth attendant (TBA). Therefore, TBAs can be invaluable for referring young mothers to a health facility for family planning. Hence, we wanted to understand if TBAs were interacting with first time mothers, and whether they were motivated to refer them for family planning. To ensure that such referrals would be productive, we also wanted to make sure that TBAs were giving the right information about post-partum family planning.

Understand barriers to uptake of modern contraception by young first-time mothers (YFTMs)

Nationwide survey data suggest that young first-time mothers have a high unmet need for family planning. To fine-tune program strategies to address this unmet need, we need a better understanding of demand-side constraints to family planning use after the first birth. In addition, we needed to understand likely motivations, ability and prompts that enables YFTMs to complete referrals and take up a modern contraception method

How did we use responsive feedback?

PoPCare uses the B.J. Fogg Behavior Change Model to help identify areas for program improvement. The Fogg model posits that behavior change is most likely to occur when three factors coincide: 1) the motivation to engage in the behavior, 2) the ability to practice the behavior,3) and a prompt that encourages people to act. Hence, we conducted a rapid assessment study with health care providers to assess their motivation and ability to offer various types of family planning services. In each project state, one fairly typical LGA was selected, and within each of those LGAs a convenience sample of 10-20 health care workers were interviewed using a short structured questionnaire. The results revealed that many health care workers do have personal beliefs that hampered their motivation to provide contraception to young women. The motivation varied considerably by state, with health workers in Rivers being more motivated than those elsewhere. Feedback also revealed some competency issues. Most notably, several providers were not confident in their ability to provide IUD counseling and insertions, largely because they found it difficult to address the potential side-effects of this method.

A similar rapid assessment was conducted with traditional birth attendants (TBA) and community reproductive health influencers (CRHI)[1]. The findings confirmed that few TBA/CRHI had prior training in family planning. Motivation to offer family planning (FP) counseling is generally high, but more so in Nasarawa than elsewhere. While most TBA/CRHI find it easy to provide family planning counseling, those in Rivers State expressed feeling embarrassed providing FP counseling. TBA/CRHI in all three states had concerns about their ability to provide counseling for long-acting reversible methods (i.e., the IUD and implants). These concerns centered largely on the difficulty to counsel women about bleeding and pains that may result from the method.

Given that many women in the project’s main target audience – young first-time mothers – tend to have fairly low levels of education, a rapid assessment study with a structured questionnaire was not deemed appropriate. Hence, feedback from this group was obtained using face-to-face in-depth interviews. Specific discussion topics included the motivation and ability to use family planning, family planning decision-making, community-level factors that may encourage or deter FP use, rumors about negative experiences with FP, and myths and misconceptions. The findings indicated many young first-time mothers need approval from their partner to use family planning. Family planning decision-making can also be heavily influenced by relatives and in-laws. Negative FP experience by peers – typically with respect to side-effects – tend to reduce motivation to adopt modern FP. Key factors that limit young mothers’ ability to use FP include the cost of the method, the availability of different methods, and transportation costs to the family planner provider.

What changed as a result?

Health care workers received a values clarification and attitude transformation (VCAT) training exercise alongside their PPFP training so they can offer unbiased services to clients particularly YFTMs. We also conducted HF peer-led mentoring for these trained health workers to help them build their counselling and LARC insertion skills. Practical sessions with arm and pelvic models were conducted during mentoring; this provided all HCWs the opportunity to practice what the learnt during their classroom didactic training. Community health volunteers were also engaged to identify and link clients to health facilities during the mentoring sessions so competent HCWs could demonstrate to their less skilled peers how to provide FP services to live clients.

Also, to increase HCWs confidence in their ability to provide IUD counseling and insertions and address the potential side-effects of this method, the mentoring sessions on IUD insertion and management of side-effects included role plays and HCWs were provided with detailed information on the management of side-effects.

We also trained TBAs on how to interact with mothers and provide them with accurate information regarding FP as well as other MNH services. For example, we are making sure that TBAs refer young mothers to those facilities that provide the family planning services that they are interested in. TBAs are also encouraged to focus their counseling sessions on Women of Reproductive Age (WRA) particularly YFTMs.

Following the training of TBAs, mentoring sessions commenced at linked HFs, TBAs who found it difficult to counsel women about bleeding and pains that may result from the FP method were provided with detailed information about normal side-effects by their mentors. A TBA PPFP handbook (mostly pictorial) was developed and shared with TBAs to aid their sessions with women in their communities.

In addition, the community volunteers were empowered through field mentoring to emphasize the benefits of modern FP and to provide clarification about normal side effects that are not a reason for concern; and to follow up with all their clients to encourage uptake of contraception at the nearest health facility.

Next

A second round of feedback data will track improvements in health worker attitudes and skills, and the number of clients referred for family planning.

Our next RFM will test whether sending text message or making phone calls to women who were referred for family planning by a Community Volunteer (CV) or TBA are effective prompts that will encourage them to follow up on that referral and visit a family planning provider.

Lessons for others in using responsive feedback

Small studies can yield big lessons. Small samples can still provide a lot of information. These insights can be useful for making program course corrections in between bigger studies.  MEL specialist Dominique Meekers of Tulane University commented, ‘A lot can be done with fairly minimal resources compared to what we usually spend on surveys, and it allows rapid adjustment.’

MEL teams and program implementers make a good team. MEL teams can detect patterns and anomalies in feedback, and implementers can interpret the feedback in context. Regular review of program data and previous RFM data by MEL and program teams provides a good context for institutionalizing responsive feedback mechanism.

Feedback helps you see the real reasons instead of making assumptions. Feedback means we can hear directly from the target audience, revealing the true factors that affect our programs.

[1] In Rivers State, community reproductive health influencers play the same role as traditional birth attendants in other states.

Authors

  • Nneka Onwuasor, Clinton Health Access Initiative Nigeria
  • Rosemary Ayu, Clinton Health Access Initiative Nigeria
  • Adolor Aisiri, Centre for Communication and Social Impact, Nigeria
  • Dominique Meekers, Tulane University
  • Katherine Andrinopoulos, Tulane University
  • Owens Wiwa, Clinton Health Access Initiative Nigeria
  • Olufunke Fasawe, Clinton Health Access Initiative Nigeria
  • Bukola Toriola, Centre for Communication and Social Impact, Nigeria
  • Kanayo Precious Omonoju, Centre for Communication and Social Impact, Nigeria
  • Babafunke Fagbemi, Centre for Communication and Social Impact, Nigeria