Adolescent girls as agents of change: Behavioral design to increase FP Uptake in Senegal, Burkina Faso, and Uganda

Summary:

Pregnancies during adolescence can significantly jeopardize girls health and economic futures, and yet use of family planning (FP) among this population remains low. This is particularly true in sub-Saharan Africa where adolescent fertility is high (101 births per 1,000 women). With the support of in-country and global partners, we applied the behavioral design process to understand the drivers of low FP uptake among adolescent girls and to develop and test behaviorally informed solutions in Senegal, Burkina Faso, and Uganda. Grounded in our formative research finding that girls most trusted sources are each other, each intervention leveraged girls as their own agents of change. In Senegal, girls were invited to bring a friend through a buddy system to a new Wellness Checkup, a low-stigma opportunity to make an informed choice about FP. In Burkina Faso, girls played a board game in which they faced real-life relationship scenarios, experienced consequences, and shared advice. In Uganda, girls received Refer a Friend cards that they filled out with their motivations for learning more about FP. The cards could be given to friends and redeemed at health facilities for FP counseling and friendship wristbands. We found that if presented with the right tools in the right context girls can be a driving force in supporting other girls to overcome behavioral barriers like stigma and risk misperception. Results from user testing and operational pilots are promising, and efforts are underway to evaluate the interventions' impact on health outcomes through randomized-controlled trials.

Background/Objectives:

Pregnancies during adolescence can significantly jeopardize girls health and economic futures, and yet FP use among this population remains low. In Burkina Faso, 42% of women age 15-24 have unmet need for FP (2010 DHS). Existing interventions to increase FP use among youth may fall short because they fail to smartly engage the very population they intend to serve. With the support of in-country and global partners we applied the behavioral design process to understand the drivers of low FP uptake among girls and to develop and test behaviorally informed solutions in Senegal, Burkina Faso, and Uganda.

Description of Intervention and/or Methods/Design:

In all countries, we generated hypotheses about the contextual and behavioral barriers potentially inhibiting girls from using FP, and then conducted in-depth interviews, focus groups, and observations with girls, boys, health workers, parents, and other stakeholders. Data analysis distilled the key behavioral barriers to FP uptake. These barriers included, among others, girls not explicitly considering the consequences of sex and underestimating their pregnancy risk. Through an iterative, participatory process we developed interventions to address the identified barriers and leveraged girls as agents of change. In Senegal, we designed a Wellness Checkup where girls used a buddy system to learn about FP. In Burkina Faso, we designed a board game in which girls faced real-life relationship scenarios, experienced consequences, and shared advice. In Uganda, we designed a Refer a Friend program where girls gave cards to friends to be redeemed at health facilities for FP counseling and friendship wristbands.

Results/Lessons Learned:

The behavioral design methodology yielded novel, girl-centric interventions to increase FP uptake in three sub-Saharan countries. Importantly, each intervention was responsive to the unique context and attitudes of the implementing country. In Senegal, results from the pilot indicate that the design is feasible to implement, increases youth visits to health facilities, and has the potential to shift youth FP behavior. Youth reported feeling more comfortable discussing their reproductive needs and concerns with health workers as a result of the intervention. In Burkina Faso and Uganda, key stakeholders and end users found the designs to be both feasible and acceptable. In Burkina Faso, game simulations demonstrated that the intervention was successful in correcting misperceptions and encouraging open conversations among girls.

Discussion/Implications for the Field:

Because of strong cultural norms around premarital sex and stigmatization of FP use, interventions to increase FP uptake among adolescents often fail to have an impact. However, our work suggests that behaviorally informed, girl-centric interventions have the potential to address behavioral barriers and move the needle on reducing unwanted adolescent pregnancies. Upcoming evaluations in Burkina Faso and Uganda will shed additional light on the effectiveness of these interventions and identify ways to adapt successful solutions to other countries and contexts to achieve impact at scale.

Abstract submitted by: 

Natalie Dabney - ideas42
Jana Smith - ideas42
Zakari Congo - Pathfinder International
Finou Mendy - IntraHealth International
Francis Aucur - Marie Stopes, Uganda