In January 2020, before “COVID-19” and “pandemic” had even entered most people’s vocabulary, I took a trip to Uganda to help kick off the implementation and evaluation period of a promising project to address unmet need for family planning (FP) services among adolescent girls. By April, the intervention was on hold and we weren’t sure if or when it would restart, nor whether we would be able to collect the necessary data to advocate for future adoption and scale of this behaviorally-informed intervention.
Thankfully, the project did eventually re-launch, and our implementing partner – Marie Stopes Uganda (MSUG) – was able to capture enough data to show that, not only did the intervention work as intended, but it had achieved major impact despite all the challenges of implementing during a pandemic. Through this experience, we learned an important lesson about what it takes to create and carry out a behavioral intervention that could withstand tough circumstances and achieve results despite unforeseen challenges.
BACKGROUND
We knew from our earlier behavioral diagnosis work that a successful intervention would have to use social proof to convince adolescent girls that considering FP is acceptable among their peer group; make the process of visiting a clinic as pleasant as possible; and empower adolescent girls to make decisions and take action around FP use.
To do this, we partnered with MSUG and MSI Reproductive Choices to collaboratively design a peer referral program, which leverages girls who have benefited from FP use or counseling as advocates of FP among their social circles. After receiving FP counseling or a FP method, adolescent girls are given a Refer-a-Friend (RAF) card that illustrates a range of reasons youth may choose FP. They are instructed to deliver the RAF card to a friend who could benefit from learning about FP herself, and when the friend redeems the card at the clinic, she is offered FP counseling in addition to two friendship wristbands – one to keep, and one for the friend who referred her. If she goes through counseling and/or receives a FP method, she receives a new card to give to another friend, becoming an advice-giver herself.
To learn more about the program, the associated materials, and the results of the evaluation, see the program brief here.
HOW BUY-IN GARNERS RESILIENCE
In my 10-year career as a public health practitioner and behavioral scientist, it’s been hammered into my brain that buy-in matters. In fact, ideas42’s behavioral design process puts this front and center, with opportunities to engage partners and end users at every step of the way. In this case, buy-in at all levels was the key to the project’s success.
Through our standard co-design process, we started obtaining buy-in early; not only did the program reflect input from a variety of stakeholders who had direct experience working with adolescent girls, but it addressed the specific behavioral barriers that had been identified through previous formative research as preventing those girls from taking up FP services. The final designs had also been iteratively refined based on feedback received during user testing in some of the clinics where the program would be implemented.
Perhaps most importantly, buy-in was present from the leadership to the front lines – a testament to the success of ideas42’s collaborative process. Dr. Fred Nsbuga, the head of the MSUG Social Franchise channel the intervention was designed for, threw his full weight behind the program and urged the clinic staff to make its implementation a top priority in their day-to-day work. The MSUG staff responsible for training and overseeing the frontline service providers and mobilizers who would implement the program took full ownership of the program. They adeptly trained their own subordinates, adding their own twist and flair to the material in a way that exuded confidence in the program.
Mobilizer training in Masaka, Uganda
Providers and mobilizers walked out of each training session with a palpable sense of excitement. Early feedback from program participants echoed the enthusiasm we felt during training and roll-out:
Friendship wristbands
A STRONG FINISH AND A BRIGHT OUTLOOK
The final results of this randomized controlled field trial showed that, despite a three-month pause in the middle of implementation, and despite ongoing restrictions to movement due to the pandemic, clinics in the treatment group still saw on average a 45% increase in adolescent clients per month. This translates to nearly 2,000 new adolescent FP clients overall during six months of implementation, with an even greater number of girls who received FP counseling only. For more information on the study results, see the program brief here.
Plans for scale-up are in process. MSUG is currently taking steps to re-launch the program within the 60 Social Franchise clinics where the pilot took place, as well as to expand the program to an additional 23 clinics they’ve identified as having the greatest need. Later in 2021, they plan to expand the program to the rest of the Social Franchise channel. Once the intervention is implemented at all 116 Social Franchise clinics, MSUG plans to adapt the program for other service delivery channels within Uganda.
On the international level, MSI is incorporating this program into their work plan for 2021, which will include adaptation for new contexts and implementation within other country programs. We are eager to see how the program designs are adapted and used going forward, and hope that its scale-up will lead to large improvements in FP access among girls and women who need it the most.
If you work in an organization focused on expanding access to FP among adolescent clients and are interested in hearing more about this work, please email us at GH@ideas42.org.
