Creating a Behavior Change Communication Program for Family Planning Among the Urban Poor In Uttar Pradesh: Formative Evaluation Findings

Theoretical Background and research questions/hypothesis:  Uttar Pradesh (UP), most populated state in India has high maternal mortality ratios (440); infant mortality rates (67); fertility rates  (3.8); and low contraceptive prevalence rate (CPR) of 29%. Urban Health Initiative (UHI) is a concerted effort by various partners to contribute to increase in demand and supply of family planning (FP) services and supplies in UP. Prior to launch of a state-wide urban family planning Behavior Change Communication (BCC) program, an extensive formative evaluation was conducted with the objective of determining urban couples' readiness to adopt modern FP methods / services; understand the facilitators and barriers to adoption and use of FP methods; and identify communication behaviors of various stakeholders.

Methods:  Forty-eight focus group discussions (FGDs) with three categories of couples  - without children (newly-married), with 1 child, and with multiple children - and more than 70 in-depth interviews (IDIs) with mothers-in-law, opinion leaders, and health care service providers were conducted in four cities in UP in the second half of 2010. The four cities were Agra and Aligarh in Western UP, and Allahabad and Gorakhpur in Eastern UP.

Results:  Newly married couples experienced pressures from family to produce first child soon after marriage to demonstrate reproductive ability. Weak couple bonding, absence of spousal communication, and notion that discussion of sex implies promiscuity left the couple without access or intention for delaying the first child.  Amongst older couples, despite high need, there were fears, concerns, and myths about side-effects of modern methods which resulted in non adoption or high dropout and reliance on traditional methods. Non adoption was aggravated as reproductive decisions were delegated to women and male “irresponsibility” reinforced by the health care workers targeting only women for counseling. There was a gap between need and service delivery as health care providers held stereotypical beliefs about target audiences and could not relate family planning as a way to achieve life aspirations.

Conclusions:  Couples hold strong aspirations for children – to provide them with education to jump on the “new India” bandwagon characterized by economic opportunity. Couples need guidance for adoption and consistent use of contraception. Use of integrated media platforms, TV-based programs on positive deviants and experiential marketing methods using community events that bring together target audience with local service providers to facilitate personal counseling, frank discussion about FP methods and their side-effects, and personal/couple-specific issues in adoption and consistent use appear to be viable methods for behavior change.

Implications for research and/or practice:  Tremendous gap exists between awareness and action with respect to FP methods / services among urban poor. Although, problems in uptake of services arise from the service-provision side due to crowded hospitals and unresponsive service providers, there are decision-making problems at the household level. Men consider FP method use in the domain of women and women, largely power-less within the household, are afraid to take action for fear of social repercussions. BCC programs have to focus on helping couples with decision-making.