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Urban Health Initiative

“Every household in Uttar Pradesh will have confident, expert couples who discuss, choose, and consistently use the modern contraceptive method best suited to their needs in order to realize their dreams and achieve their aspirations of a bright future for their families.”– UHI Vision Statement

A UHI TV spot promotes family planning for urban populations.

As envisioned in the statement above, UHI aims to increase contraceptive prevalence by portraying the use of family planning as a positive contribution to a family’s plans for the future.

Positive role models- couples successfully using family planning, helpful and responsive providers, and community members sharing their knowledge of family planning with friends and family in order to support their health and happiness- represented family planning’s positive contributions to a happy life.

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Two girls in Malawi attend a Go Girls! Project event. © 2011 Hilary Schwandt/CCP, Courtesy of Photoshare

Go Girls Initiative

In sub-Saharan Africa, girls are three to five times more likely to be infected with HIV than are boys of the same age. In response to this gender disparity, Go Girls! aimed to shift the focus from individual risk-taking to contextual factors that render girls vulnerable. The analysis stage concentrated on exploring these contextual factors. The results from the analysis informed the implementation of interventions at the various levels of the Social Ecological Framework. An important discovery was the fact that adults seemed aware that girls were vulnerable, but they didn’t feel they could do much about it. To address this, the initiative suggested ways to engender a community-wide response to girls’ increased risk of HIV infection. Findings of the analysis stage are outlined in the Research Findings Report.

Situation Analysis

Findings from a literature review augmented by qualitative research with community members in Botswana, Malawi and Mozambique guided the initiative’s understanding of factors that increase girls’ vulnerability to HIV infection. Formative research included focus groups to understand community perspectives on girls’ vulnerability; stakeholder meetings with government officials, community leaders and NGO/CBO representatives; and community mapping to identify resources and potential partners and to select project communities. Go Girls! combined quantitative and qualitative data collection methods to develop a deeper understanding of girls’ vulnerability.

Go Girls! Literature Review

Community Perspectives on Adolescent Girls’ Vulnerability to HIV in Botswana, Malawi and Mozambique: Summary Report

Social Ecological Approach

Although individual sexual behaviors heighten adolescents’ risk, a complex interaction of social, legal and economic factors outside of girls’ control fuel the epidemic. The Go Girls! Initiative sought to address this constellation of factors by using a social ecological or “whole community” approach to preventing HIV. This approach recognizes that a girl’s ability to protect herself from HIV is influenced by a system of socio-cultural relationships— families, social networks, communities and nations. Thus, interventions were simultaneously implemented to reach out to communities, leaders, teachers and parents/guardians, as well as adolescents themselves. Though the focus was on girls, most interventions were also designed to include men, women and boys.

Using the Social-Ecological Framework, the Initiative focused on structural interventions as well as behavior and normative change and addressed contextual factors that present barriers to accessing education. Interventions included increasing girls’ resilience through building life-skills, strengthening parents’ ability to support girls, and supporting community dialogue and action.

The program components of Go Girls! thus addressed the barriers to structural, normative, social and behavior change and corresponded to the levels of the Social Ecological Framework: individual; family and peer networks; community; and society.

The program interventions were designed to achieve changes at the structural, community, family and individual levels.

Go Communities! – Community mobilization motivated community members to take action to reduce girls’ vulnerability to HIV.

Go Families! – Helped adults strengthen their communication skills and relationships with young people so they can talk to them about their needs and aspirations, as well as about sensitive topics such as HIV/AIDS prevention.

Go Girls! Community-Based Life Skills – Improved the knowledge and ability of vulnerable girls to address the specific factors that put them at risk of HIV.

Go Teachers! – Enabled teachers and school administrators to cultivate a safe school environment for students through the recognition of girls’ vulnerability in schools, gender equitable teaching practices and adherence to the teachers’ code of conduct.

Go Students! – Gave teachers the knowledge and know-how to facilitate life skills sessions for girls and boys that can help reduce their vulnerability to HIV/AIDS.

Economic Strengthening – Linked vulnerable girls and their families to existing economic support programs.

Cross-Sectoral Fora – Brought leaders from the communities and various government sectors together to garner support for Go Girls!

Reality Radio Programming – Used real-life stories to inspire community dialogue and action regarding girls’ vulnerability to HIV. Information about laws, regulations and enforcement was woven into every Go Girls! component to ensure these structural factors are addressed as part of the comprehensive approach.

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Nigerian Urban Reproductive Health Initiative

A patient medicine provider attends to a client after a family planning prescription in her outlet at Iwalesin district, Omuaran township, Kwara state, Nigeria.
© 2012 Akintunde Akinleye/NURHI, Courtesy of Photoshare

Nigeria had a promising national family planning program (boosted by a national family planning/child spacing logo) in the late 1980s and a robust behavior change communication and advocacy program. Significant investments designed to increase the quality and availability of services have since declined, including contraceptive supplies and management capacity. Overall, total unmet family planning need is 21% (2008 NDHS) and higher in urban areas compared with the rural areas.

Exposure to mass media messaging on family planning is a strong predictor of contraceptive use and intention to use contraception. Currently, intention to use contraceptives averages about 28 percent in the selected cities (Abuja FCT, Ibadan, Kaduna, Ilorin, Benin City and Zaria) targeted by the Nigerian Urban Reproductive Health Initiative (NURHI). This indicates the potential that exists to raise contraceptive prevalence rate in Nigeria with the right combination of resources and strategy. The current landscape for family planning in Nigeria engenders optimism. Commitment among public health and reproductive health professionals and organizations runs deep. Private sector (NGO, faith-based and for-profit) service delivery capacity is extensive, and most Nigerians already access some form of health care from them.

Core Challenge

Focus group discussions and the NURHI baseline assessment showed that among those of reproductive age, family planning is framed by fear, misconceptions and mistrust. Challenges that emerged include:

• Women and men have a number of misconceptions about family planning and some methods in particular. The fear of negative health impact proves to often be a serious barrier in considering family planning.
• The fear of family planning persists on a number of levels: fear of discussion and approval of spouse, fear of destroying relationships, fear of testing, and fear of health consequences and side effects.
• Burden of FP use is on the woman. Once the woman has the information and is convinced, she still has to convince her husband/ partner about family planning. It was unanimously felt that if family planning is adopted without the husband’s knowledge/ approval, there would be suspicion of infidelity if the woman was discovered.
• Family planning is felt to be difficult to discuss and discussion requires lots of knowledge.
• Family planning is seen as not easy to use and highly ‘medicalized’. Only doctors can prescribe or tell a woman what method to use. She needs many tests and exams before a choice can be recommended.
• Family planning is considered to be very risky compared to other risks related to pregnancy. Sterilization and IUDs are considered especially risky. Modern family planning methods are seen as riskier than the risks related to child bearing such as having a child before the age of 18, having closely spaced births or having more than six children. Natural family planning methods were seen as less risky in comparison to modern methods.

Core Challenge Statement: To address the core challenge of fear and mistrust, the NURHI communication strategy will focus on opening a public dialogue on family planning; establishing the social acceptability of family planning; increasing accurate knowledge about the methods and access points; bringing family planning discussion into everyday life, particularly among couples; and ultimately increasing and sustaining use. To this end, the NURHI communication strategy will operate at multiple levels, will be closely tied to supply side activities, and will center on making family planning a part of everyday life.

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Tchova Tchova, Juntos Vamos Mudar

Members of a Tchova Tchova outreach effort visit the homes of HIV/AIDS patients every week.

Formative research in Mozambique found that men and women would like to establish more equitable gender relations and engage in lasting relationships where dialogue, harmony, and understanding prevail. They are unable to behave differently in their relationships, however, due to their need for social validation and peer recognition and to their assumption that their community would not accept changes in gender relations. This finding suggests that gender relations in Mozambique are in a process known as the “Spiral of Silence ”

Developed by Elizabeth Noelle-Neumann, the Spiral of Silence posits that people tend to remain silent when they feel their views are in the minority. People have a fear of isolation and know what behaviors will increase their likelihood of being isolated or criticized. This fear pushes them to stay away from behaviors and to not express opinions they feel will not be accepted by the majority. Traditional gender norms still guide the behavior of the majority so it is to be expected that this fear is strong in those who think or behave in ways that go against tradition. The Spiral of Silence, however, is an indicator of change underway in both social norms and in the scale of values.

With a program theory based on the Spiral of Silence and Bounded Normative Influence  which suggests a minority position can develop into a social norm,Tchova Tchova built upon this nascent shift in norms to develop a communication strategy that worked to strengthen social validation and peer support for more equitable social behaviors which in turn reduce the risk of HIV transmission.

Women and men realize that there is high risk of HIV associated with multiple concurrent partners and know that such relationships bring conflicts not only to the couple but to the extended family, but they are afraid to express these opinions or change their behavior. Tchova Tchova identified this window of opportunity where a shift in thinking was silently underway and focused activities on changing social norms and gender factors that directly fuel the HIV/AIDS epidemic in Mozambique.

Communication for Healthy Living