Scaling up Contraception through Social and Behavior Change Intervention in Low and Middle-Income Countries

Abstract

Despite its benefit and aged long practice, contraceptive use continues to be a problem in low and middle-income countries like Nigeria with one of the highest maternal and child mortality across the globe. This chapter aims to discuss social and behavior change interventions needed to scale up contraceptive use in low and middle-income countries. A review of literature in addition to field experiences in promoting contraceptives was made. Evidence reveals that a well plan and carefully implemented social and behavior change intervention based on formative research is key to improved contraceptive use needed for improved maternal and child health outcomes in low and middle-income countries. Contraception is the right of every woman and a recommended practice for the health and development of any nation.

1. Introduction

The use of contraception is an aged long practice and historically, humans have used their imaginations [1] such as coitus interruptus to prevent pregnancy. Evidence revealed that birth control practices are well documented in ancient Egypt and Mesopotamia [2]. The Ebers papyrus from 1550 BC and the Kahun Gynecological papyrus from 1850Bc have some of the earliest methods of birth control. It documented the use of honey acacia leaves and placement of lint on the vagina of women to block spermatozoa penetration into the female genital tract [2].

One of the most effective antifertility herbs in ancient times that was most famous for birth control was the use of silphium plant, which is a native of Cyrene in modern-day Libya, North Africa. This plant was used as a contraception in ancient Greece and Rome and became extinct as a result of over-cultivation of the plant for contraception [3]. In ancient Greece, several plants are used as contraception, including Asatoetidua, a close relative of the extinct silphium plant. Recent evidence shows that the surviving relatives of the silphium plants exhibit anti-fertility potency in rats [3]. In India, Queen Anne’s lace (Daucus carota) which is a native to Asia, Europe, and North Africa, is commonly used for birth control up to date [3].

Based on the toxic nature of most ancient contraceptives, there was a need to develop more effective and safe forms of contraception. This resulted in a series of inventions such as the male condom in 1564, which was originally developed to address sexually transmitted infections such as syphilis in Europe [4] and the first modern female condom was released in 1993. Hormonal pills as means of contraceptive in the form of Enovid were first approved by the FDA in May 1960 [5].

Despite the safety effectiveness and benefits of these methods of contraceptive, the use in most low and middle countries continue to be low despite the availability of these contraceptive methods.

2. Contraception

2.1 Definition

Contraception can be defined as the intentional means of preventing conception through the use of various devices, sexual practices, chemicals, drugs, or surgical procedures [6]. It is often referred to as birth control and involves the deliberate prevention of conception through various methods, medicine or devices used to prevent pregnancy.

2.2 Types of contraceptives

Contraceptive methods are available for individuals and couples for birth control in various forms. The most appropriate method depends on various factors such as safety, effectiveness, acceptability, availability, affordable and accessible. The number of sex partner, age of the individual, health status of the users desires to have children in the future, and frequency of sexual activities. Generally, the methods of the contraceptive can be group into natural and artificial methods. Natural methods tend to be less effective when compared to artificial methods of contraception.

2.2.1 Natural methods of contraception

This is based on the use of the body physiological changes and symptoms in the identification of the fertile and infertile phases of the menstrual cycle to make decisions on when to be involved in coitus activities that can result in conception. These methods are also referred to as fertility-based awareness methods and they consist of periodic abstinence, coitus interruptus, lactational amenorrhea, and post-coital douche.

2.2.2 Artificial methods of contraception

Five types of artificial contraceptives have been described. These include

1. Barrier method

2. Hormonal method

3. Emergency post-coital contraceptives

4. Long-acting reversible contraceptives

5. Sterilization

2.2.2.1 Barrier method

In addition to its roles in birth control, barrier methods like male condoms are an effective means of preventing sexually transmitted infections such as HIV/AIDs and other ills. They act by creating a barrier between the male spermatozoa and the female ova and therefore prevent fertilization. During sexual intercourse, barrier methods reduce the exposure of both individuals to sexually transmitted infection [4]. Examples of this method include the male and female condom, cervical caps, and diaphragm.

2.2.2.2 Hormonal methods

Hormonal contraception (HC), also known as “the pill”, are currently made up of either estrogen-progestin combinations or progestins alone. Ongoing research to add to this group of contraceptives have focused on the “antiprogestins”, more precisely called selective progesterone receptor modulators (SPRM) [7]. This group of contraceptives were originally administered in the form of daily pills, but in recent times, seven different routes of administration have been developed which include: intramuscularly, intranasally, intrauterus, intravaginally, orally, subcutaneously, and transdermally [7]. Common example of this group of contraception are: oral pills, implant, IUD with progestin, injectables like depo-provera, vaginal rings, and skin patch [8].

2.2.2.3 Emergency post-coital contraceptives

This form of contraceptives is not recommended to be the first line of contraceptives for any user. This form of contraception refers to the use of a drug or device to prevent pregnancy after unprotected sexual intercourse. Estimate reveals that the expected risk of pregnancy after unprotected intercourse without emergency contraceptive use is 5.6% [9]. Examples of this form of contraceptives include emergency contraceptive pills (combined and progesterone-only), Copper T380 IUD, Levonorgestrel (Plan B), and ulipristal acetate (Ella).

2.2.2.4 Long-acting reversible contraceptives

Long-acting reversely contraceptives are a group anti-fertility that provide effective contraception that provides extended period without requiring user action. They include injections, intrauterine devices, and subdermal contraceptive implants. They are the most effective reversible methods of contraception because their efficacy is not reliant on patient compliance. Long-acting reversible contraceptives include IUDs and the subdermal implant such as:

• Hormonal intrauterine device is also known as IUC or IUS.

• Nonhormonal intrauterine device with copper.

• Subdermal contraceptive implants such as implanon and jadelle.

2.2.2.5 Permanent method of contraception

Sterilization is considered an elective permanent method of contraception. Although both female and male sterilization procedures can be reversed surgically, the surgery is technically more difficult than the original procedure and the success rate is often low. Vasectomy (male sterilization) and tubectomy (female sterilization) are the two common forms of permanent methods of contraception. Hysterectomy is a form of the permanent method of contraceptive which is not commonly practiced among women.

2.3 Trends in contraceptive use

Trends in contraceptive use have been shown to vary between developed and developing nations, across nations, and within nations. The United Nations (2015) report on trends in contraceptive use showed that contraceptives are used by majority of women of reproductive age group in almost all regions of the world [10]. In 2015, 64% of women of reproductive age worldwide who are either married or in a union were using some form of contraception. However, the report showed that contraceptive use was much lower in the least developed countries with an estimate of 40.0% with the Africa continent having the lowest estimated at 33.0%. Among the other major geographic areas, contraceptive use was much higher, ranging from 59% in Oceania to 75% in Northern America [10]. Furthermore, the report revealed that globally, an estimated 12.0% of married or in-union women have an unmet need for contraceptives [10]. This implies that they wanted to stop or delay childbearing but was not using any method of contraception with the highest figure (22.0%) recorded among the least developed countries [10]. Most of the countries with high unmet needs for contraceptives are in sub-Saharan Africa estimated at 24.0% which doubles the global average in 2015 [10]. In Nigeria, estimates from the National Population Commission revealed that only 14.5% of women use modern contraceptive methods [11]. Paul [12] noted that over 83% of women were not using any form of contraceptives in 2018 with a geographical variation within the country. Yobe State in North East Nigeria has the highest number of women (98.1%) who do not use contraceptives while Lagos State in South West Nigeria had the least number of women (50.6%) who do not use contraceptives [12].

2.4 Benefits of contraception

Contraception is one of the most effective public health interventions of the twenty-first century which is highly needed more than before, especially with the ever-increasing human population and the increase in crime rates. A well-planned pregnancy often enables couples to be able to give the best to their children for them to be productive to the family and the society at large. Thus, contraceptives help in the prevention of unwanted pregnancies among couples and therefore promote planned family size and time of birth for improved reproductive wellbeing of the women. Some contraceptives such as the make condom in addition to prevention of pregnancy are also beneficial in the reduction of sexually transmitted infections such as HIV/AIDs and syphilis. They indirectly reduce the burden of infertility through the prevention of infertility secondary to complications of sexually transmitted infections and abortions conducted with crude instruments in clandestine places by unskilled personnel. Voluntary family planning practices include the promotion of maternal and child health, human right, population and development, and environmental sustainability and development of a nation. These benefits are clearly exemplified in the developed nations unlike in most low and middle-income countries which are yet to maximize the benefits of contraceptives in their society.

2.5 Factors influencing contraceptive use in low and middle-income countries

Despite efforts and availability of contraceptives in low and middle-income countries, uptake continues to be low as a result of several barriers. These barriers can be grouped into client and health services related.

Akamike et al. [13] in their systematic review of literature observed that client-related include the desire for more children, partner disapproval of contraceptive use, religious and culture bias, educational qualification of women, lack of knowledge on contraceptives, and wealth index [13]. Health service-related factors are poor access to contraceptive services, inability to procure modern contraceptive methods and stockouts of modern contraceptives methods [14].

2.5.1 Client related factors

2.5.1.1 Desire for more children

The desire for large family size is often one of the reasons for refusal of contraceptive use. Couples often ensure continuous procreation and avoid the use of contraceptives until they attain the purported family size they want to actualize [15]. This trend has accounted for high family size of up to 7 above in some regions of low and middle-income countries like Nigeria. This is unlike in regions that prefer a small family size. Despite the need for large family size, couples tend to desire or use contraceptive methods [16].

2.5.1.2 Partner disapproval

Despite the willingness of some women to use contraceptives, partner disapproval and abuse of the right of women continue to negate against the use of contraceptives in low and middle-income countries like Nigeria. Women who desire to delay or limit births often experience strong disapproval and warning from their spouses against the use of contraceptives [17]. They may experience abuse following the discovery of their use of contraceptives without knowledge and approval by their partner.

2.5.1.3 Religious and cultural disapproval

Religious and cultural norms of some groups strongly discourage the use of family planning in low and middle-income countries like Nigeria. Such aversion stems from the fact that these cultures consider contraceptives as means of reducing or controlling their population by the west or an unclean practice. Addressing these fundamental issues through proper education on the benefits of contraceptives in addition to how they work and the need for productive sexual and reproductive health becomes eminent.

2.5.2 Educational qualification of women

Women with a relatively high level of education tend to use contraceptives more than those with little or no form of education. This is because education brings about improve knowledge and rights of women in making decisions that are related to their sexual health and reproductive. This is unlike the women who are less educated and often less empowered to make such decisions and therefore unable to use contraceptives.

2.5.2.1 Contraceptives knowledge

Lack of contraceptive knowledge is one of the barriers to contraceptive use. A high proportion of women of reproductive age group lack adequate knowledge on the benefits of contraceptives. This has adversely affected the use of available forms of contraceptives in low and middle-income countries like Nigeria. Conversely, women with higher knowledge of contraceptives tend to make use of them more for their sexual and reproductive health and wellbeing.

2.5.2.2 Wealth index

Wealth index of women and family often affects contraceptive use due to access to finance and education of the benefits of contraception. The poorer the women, the less likely they will use contraceptives, and those from affluent backgrounds tend to use contraceptives more [18].

2.5.3 Health systems related barriers

2.5.3.1 Access factors

Distance from health facility and source of contraceptive services may hinder contraceptive utilization for most women in rural hard to reach communities of some low and middle-income countries like Nigeria. The absence of functional and effective primary health care systems with modern contraceptive methods may hinder the utilization and result in a higher unmet need for contraceptives within these populations.

2.5.3.2 Cost of family planning methods

A relatively high cost of some modern methods of contraceptives and the inability of some women to purchase these services has negatively affected the utilization of available methods of contraceptives.

2.5.4 Quality of contraceptive services

The quality of contraceptive methods is a prerequisite to its acceptance and utilization. Strobino et al. [19] there are six quality criteria for family planning. Viz: (1) choice of contraceptive methods, (2) information is given to the users, (3) provider competence, (4) client/provider relations, (5) re-contact and follow-up mechanisms, and (6) an appropriate constellation of services [19]. Based on these criteria, high quality in the delivery of contraceptive services is essential for improved utilization of contraceptive methods among couples in low and middle-income countries like Nigeria.

3. Social and behavior change interventions

3.1 Definition of social and behavior change

Several scholars and organizations have defined social and behavior change from various perspectives. Some are defined below.

Mercy Corps [20] defined social and behavior change as a collaborative and transformative process that empowers individuals, households, and communities through improvement in knowledge, shifting norms and perceptions, and modifying structures and policies which facilitate individual and collective behavior change [20].

Prostejov [21] defined social and behavior change as a process that enables individuals, communities, or society to adopt and sustain positive behavior {}. It does so by identifying the various factors that influence people’s behavior and addressing these by using those approaches that are most likely to be effective [21].

USAID [22] stated that Social and behavior change (SBC) programming is an approach that applies systematic insights about why people behave the way they do, and how behaviors change, to effect positive outcomes for and by specific groups of people [22].

3.2 Components of social and behavior change

The components of the social and behavior change intervention include:

1. Social and behavior change communication

2. Community mobilization

3. Community engagement and

4. Advocacy

3.2.1 Social and behavior change communication

Social behavior change communication (SBCC) is the systematic application of interactive, theory-based, and research-driven processes and strategies to effect change at the individual, community, and social levels [20]. SBCC examines challenges from multiple sides by analyzing personal, societal, and environmental factors in order to find an effective way to achieve sustainable change. SBCC also employs strategies that influence the physical, socio-economic, and cultural environment to facilitate healthy norms and choices and remove barriers to them.

3.2.2 Community mobilization

A community is a group of people with a common interest who live together in a specific geographical location. Mobilization on the other hand refers to the process of bringing people together to plan, implement and monitor an initiative to obtain an expected goal. Thus, Community mobilization is the process of engaging communities to identify community priorities, resources, needs, and solutions in such a way as to promote representative participation, good governance, accountability, and peaceful change [20].

It is a capacity-building process through which community members, groups, or organizations plan, carry out, and evaluate activities on a participatory and sustained basis with a resultant improvement in their conditions, either on their own initiative or stimulated by others. Community Mobilization is conducted by following some steps known as the Community Action Cycle which is a summary of all the activities needed to be carried out for mobilizing the community in order to ensure success in the implementation of a project. Community members are involved from the beginning and throughout the Community Action Cycle while other individuals and organizations from inside and outside the community provide technical and resource support to the community. The steps for the community mobilization action cycle are preparations for community mobilization, organization of actions for community mobilization, prioritization of needs, activities to be implemented known as the community action plans, monitoring of the plan or projects, and evaluation of the project conducted [22]. Key elements to be ensured during community mobilization include: community participation, setting up a good governance system, ensure accountability and peaceful behavioral change aimed at improving conditions and targets of the project conducted. These are effective in ensuring successful community mobilization and its benefits. For contraceptive use to be optimized there is a need to mobilize community members. Often, respected government officials and traditional/religious leaders who have interest in contraception are mobilized and deployed for supporting the activities. The use of retired and respected health workers within the community is also highly recommended and effective in addressing most of the myths and knowledge gaps that are associated with poor contraceptive use among most communities in low and middle-income countries.

3.2.3 Community engagement

Community engagement is central to any public health intervention, especially in services and products that some cultures show aversion towards. It involves the process of enabling a population at risk to be able to have the right knowledge and skills needed to respond appropriately to a given public health challenge.

Cavaye [23], defined community engagement as a mutual communication and deliberation that occurs between government/partners and its citizens that enables a mutual formulation of policy related to the provision of specific services [23]. This involves the participation of a community rather than an individual in decision-making process and implantation of various activities that are beneficial to the community taking into consideration the diversity and dynamic nature of its population. Community engagement is the process of working collaboratively with and through groups of people affiliated by geographic proximity, special interest, or similar public health challenge that needs to be addressed in order to improve the population’s wellbeing [24]. It is a continuum, ranging from low-level engagement strategies such as consultation to high-level strategies such as empowerment [23, 24]. Engaging communities is therefore important to address the gaps in family planning activities. This can be actualized through women groups, civil society organizations, and community-based organizations that are conversant with contraceptives and the means for promoting their use within the community.

3.2.4 Advocacy

Advocacy operates at the political, social, and individual levels and works to mobilize resources and political and social commitment for social change and/or policy change. Resources can include political will and leadership as well as money to fund the implementation of policies or programs. Advocacy aims to create an enabling environment at the community and society level with a focus on encouraging the use of a service by policymakers and those highly respected in society. For contraceptive use, strong advocacy at the government, institutional, and community level will make the needed difference.

3.3 Formative research and social and behavior change

Formative research is a systematic approach of inquiry and activities conducted before the commencement of a Social Behavior Change intervention. This research seeks to obtain insight into the health issue and specific behavior that a program aims to address. Formative research also seeks to identify relevant characteristics of primary and secondary audiences, the communication access available for the target population, existing habits and preferences of the people, and the various factors that hinder and/or drive behaviors within the community.

It is very important to conduct quantitative and qualitative research before the implementation of a Social and Behavior Change Communication program because without such research, it will be difficult to identify your intended audience, their current level of knowledge, the various health beliefs and attitudes, the channels through which they receive and act on information and the barriers to adopting new healthy behaviors needed for improving health and wellbeing of the population.

Formative research helps program planners to address the first three decisions in designing a Behavior Change Framework. This includes:

• Identification of feasible and effective behaviors to promote, prioritizing a few key behaviors (two or three), rather than many at the same time.

• Prioritization of the group(s) to be influenced for the behavior change. This involves the understanding of the priority group behavior and systematically developing a technique for influencing the behavior.

• Understanding the determinants of the behaviors including knowledge on the existing behaviors, knowledge on the benefits of purported behavior, the barriers towards the new behavior, and the socio-cultural context of priority groups. Researchers must decide what questions must be answered, who can provide the necessary information, how the information will be collected, and how the data will be analyzed and used to address the behavior of concern. A mixed approach involving first consulting quantitative research and then in-depth qualitative research with key informant interviews and focused group discussion is often recommended for obtaining detailed and comprehensive information on the barriers to contraceptive methods within the community.

3.4 Rationale for social and behavior change in contraception

Experience and several reports have shown that social and behavior change intervention is an effective means of scaling up contraceptive use. One of the studies that have demonstrated the implementation of this intervention is the landscape analysis demonstrated which clearly showed that social and behavior change is an essential component in achieving global development goals. The Social and Behavior Change in Family Planning Programming: Global Influence Strategy notes that “Increasing the quality and quantity of SBC investments in FP programming will be critical for the Family Planning sector to reach its high-level goals of ensuring that 120 million additional individuals use contraceptive by 2020 and the third Sustainable Development Goal of ensuring universal access to sexual and reproductive health services and rights by 2030. Studies have shown that complementing investments in commodities and supplies with strong SBC campaigns yield higher usage.” [25]. The Business Case for investing in SBC for FP shows that SBC increases the use of FP, provides a strong return on investment, and costs less than $200 per disability-adjusted life years averted [26]. This is very important in public health as it is economic and effective in actualizing the global goal of improved access for the sexual and reproductive health of women which is also key to their improved wellbeing across the globe.

3.5 Implementing the social and behavior change intervention

Social and behavior change intervention is a critical component of program design for positive impacts. USAID stated that improving the quality or coverage of healthcare products and services alone is insufficient to improve the health and wellbeing of individuals, families, and society [22]. This is because the health-seeking behaviors of individuals and communities as well as their culture are known to influence the uptake of good services and products despite their availability, accessibility, and affordability.

Changing behavior to promote a positive attitude towards health becomes very important in programs like family planning where cultural factors have limited its utilization in low and middle-income countries. Hence the need for interventions that seek to change behaviors by addressing factors such as knowledge, attitudes, and norms, known collectively as social and behavior change interventions. These interventions often complement and enhance the role played by services such as health promotion and education for health care services like family planning, antenatal care, delivery in a skilled birth attendant, and postnatal care. Social and behavior change interventions are critical to ensure that populations that are most in need can access available services and products. This is often achievable through a well-planned and systematically implemented social and behavior change intervention that is based on formative research. Through social and behavior change interventions, various organizations have been able to raise awareness, reduce misinformation, and address barriers to various life-saving and health promoting interventions among individuals, families and communities. It is an important component of successful program implementation that often ensures a positive behavior change needed to influence a specific habit for great health outcomes.

An SBC approach is a strategic, interactive process that aims to change not only individual behaviors but also social conditions. It requires understanding the situation, designing a focused strategy, developing interventions and materials, implementing, monitoring, evaluating, and adjusting. The process allows program staff, communities, and other key stakeholders to approach a problem from various angles to define key determinants (both positive and negative) of behaviors and to plan and implement a well-planned, comprehensive set of interventions that focuses on these determinants at multiple levels to achieve a health objective.

Thus, for promoting contraceptive use through social and behavior change, a well plan strategic plan that is based on formative research which identified the barriers, mode of communication to the population, and tailored messages to address specific behaviors is the means for scaling contraceptive use among women in low and middle-income countries like Nigeria where religious and cultural norms, as well as gaps in knowledge, continue to negate against the use of contraception among these populations. Addressing inequalities and promoting the right of women through advocacy, community engagement, community mobilization, and a social and behavior change communication approach that addresses barriers at the three levels of influence which include individual level, group, and societal level will be critical to achieving improved utilization of family planning methods despite existing oppositions from some quarters of the community.

At the individual and group levels, community health influencers and promoters can be used for a one on one and group sessions of educating individuals and families on the benefits of contraceptives and the methods available. Group sessions based on women to women support group with 5-15 members can be design to promote contraceptive use. This can be done during antenatal and post-natal care. It can also be done using a peer to peer meeting approach where contraceptives use and their importance is discussed and women are encouraged to use contraceptive methods of their choice that best suits their needs.

Advocacy visits to government, religious, traditional leaders and other key stakeholders in the community as well as the use of mass media to promote contraceptive use among women of reproductive age can go a long way in scaling up contraceptive use in low and middle income countries like Nigeria.

4. Conclusion

Contraception or birth control methods are an important component of the reproductive health and wellbeing of women across the globe that despite its benefits, utilization in most low and middle-income countries remain low. The implementation of a social and behavior change intervention based on formative research has been successful in most programs that promote contraceptive use among populations. This approach involves a well-planned social and behavior change communication with specific key messages that target the barrier to the utilization of the contraceptive method, community mobilization, community engagement, and advocacy made to obtain political support for the program. This comprehensive approach is highly recommended to actualize the benefits of contraception across all populations, countries, and continents in the globe.