In Kenya, cultural factors play a significant role in family planning (FP) decisions. These factors include a desire for large families, the relevance of contraception for unmarried girls at risk of unintended pregnancies, and financial and geographical barriers. However, myths and misconceptions about FP persist, along with religious and social norms that discourage the use of MOH approved modern contraceptives, hence leading to the use of unregulated FP methods. These misconceptions arise from a lack of accurate information and are often reinforced by religious and social norms that are not supportive of adopting family planning practices.
Achievements
- Co-creation process and collation of insights to shape context-specific strategies and approaches
- SBC strategies developed for 19 Counties
- Engaged and trained over 2,900 outreach leaders (CHVs, youth champions, religious leaders, male champions, peer
- Social Behaviour Change (SBC)
- Demand Creation
- Religious Leaders Engagement
- Cultural Leaders Engagement
- Male Engagement
- Mass Media
- Social Media
- Community Dialogues
- Youth Engagement
- Manyatta Model
Social and Behavioral Change (SBC) refers to a strategic process designed to shift individual and community attitudes, behaviors, and social norms toward a positive and sustainable acceptance of health behavior (Springer Nature, n.d).
SBCC aims to address socio-cultural barriers, debunk myths and misconceptions, and promote informed decision-making regarding reproductive health. The goal is to increase awareness, acceptance, and usage of modern contraceptive methods, thereby reducing maternal, neonatal, and child mortality. DESIP conducted learning through implementation workshop, with the participation of all the consortium members. The workshop was to have three key steps in the implementation, in step one the workshop participates were to develop the suggested list of intervention, while in step two and three involved prioritization and testing the different prototypes, refining from the consumer feedback to write the SBC strategy for every county.
The SBC workshops were done in seven clusters with the objectives to understand national and regional data trends, inform the design of regional strategy for creating greater demand for FP commodities, deepen our understanding of our user and build empathy towards co-creation of more desirable context specific solutions and support the design and implementation of context solution at the county level. Some of the key barriers that were noticed during the inceptions period, were lack of access to appropriate and reliable information due to misinformation from friends or the social media, fear of infertility or delay return to fertility, cultural and religious beliefs, consumers attitudes towards contraceptives, and lack of youth friendly services for the youth adults. The program also engaged the consumers in what they want, or what they think might work on them for it to come up with the appropriate consumers interventions that will work best for them.
The programme used the Key stone framework in implementation of the SBC workshops with specific consortium partner spearheading in different county. The approach involved the consumers and target market group in the development of appropriate messages for adoption of desired behavior and attitude toward uptake of RH/FP services. The framework follows a four-step guide process from the initial phase where you diagnose the unmet need and identification of the target market, decide where to intervene for greatest impact, designs user centric interventions and deliver interventions to address the health needs.
SBC targets a wide range of stakeholders that includes, the National Ministry of Health and County Governments, Faith-Based Organizations, Private health service providers, health staff at the County and sub-county health facilities, community health volunteers, youth and young women champions, religious leaders and persons with disabilities. The beneficiaries were included in the design of the solution including poor women of reproductive age (adolescents, poor women, and persons with disabilities).
SBC interventions are conducted regularly throughout the implementation phase of the DESIP program. Challenges arose like insecurity and terrorist attacks were experienced in some counties of implementation forcing the closure of some facilities and Staff movement, drought that led to relocation of community members and negative altitude by health care worker toward modern contraceptive despite growing acceptance of FP in the community. Cultural believe whereby men are the sole decision makes and women can't make decisions on themselves hence the need for intensified male involvement in the promoting and acceptance and utilization of FP service. Also, the FP commodity stock out affected the access to FP services. Through all these barriers the project created mitigations process on how to over them as would be discussed throughout in this toolkit.
DESIP project implementation began in June 2019, and it was able to engage all the 19 counties during the first quarter of implementation being able to conduct over 40 outreaches in those counties. These efforts are strategically timed to coincide with community gatherings, outreach activities, and religious meetings to ensure continuous engagement and reinforcement of messages while creating demand FP service.
Resources and Tools
Demand creation is the process of stimulating consumer interest in a product or service that they might not have previously considered or needed. It involves creating a desire or need for a product or service through marketing and promotional activities. This can be achieved through creating awareness and interest through different channel like radio or social media platforms or engaging with the potential customer on face- to- face activities promoting the product or the service (Kotler & Armstrong, 2023).
During the inception period, DESIP project began demand creation activities by defining the type of agents that would be used to reach the communities. These were identified as CHPs, CBOs, CHEWs, Youth champions, PWDs Champion, Cultural & Religious Leaders and Male engagement. The CHPs were to reach Women of Reproductive Age (WRAs) age between 20-49yrs, Youth group are to support adolescents and young adults on matters FP services, cultural and religious FP champions to talk to men on the need to support women in FP matters and the PWDs champions to engage the community on social inclusion and empowerment of PWDs on FP matters.
The agents were identified as per the county's requirement according to their specific needs and cultural beliefs. The CHEWs were preferred for sparsely populated areas while the CHPs and CBOs for densely populated areas. Strengthening the uptake of FP by utilizing the trained CHPs in providing family planning information at community level, counselling, strengthening supply chain planning and management, quality improvement and whole site facility orientation.
The agents were used to reach primary target that is general women of the reproductive age, poor women, youth/adolescent and PLWDs and the secondary target who are the men, religious leaders and the mother- in- laws. The objective was to generate strategies and interventions that drive greater and more equitable access to and update of FP services in the focus counties.
Engaging the communities in creating more awareness on RH/FP the project worked closely with all the agents in their respective counties. Mobilization and training of the agents was done gradually. By the end of year one, 33 county level faith leaders from 11 counties had received TOT training in faith/religion and SRH. The four-day training was with six master trainers who are respectable theologians with background in SRH and FP advocacy. Community health workers are another critical link between the informal and the formal health system through community dialogues, household visits and referrals to health facilities. The project worked closely together with county/subcounty communities' strategy focal person and community health Assistant (CHAs) to train CHPs and CBDs on the FP technical module in the DESIP counties. As a result of this very intense engagement with the CHPs and the CBDs, outreaches were conducted in 19 counties with an inclusion of PWDs being able to access the SRH service.
Resources and Tools
Religious leaders are individuals who have recognized authority within a specific religious community. They are responsible for providing spiritual guidance, interpreting religious texts, conducting religious ceremonies, and fostering moral and ethical behavior among followers. Religious leaders include priests, imams, rabbis, pastors, monks, and other clerical figures who are often seen as intermediaries between the divine and the human (Smith, 2020).
DESIP Engaged the religious leaders to leverage their influence and platforms within communities to promote positive sexual and reproductive health (SRH) and family planning (FP) practices. The Muslim beliefs around family planning are centered around the Quran. At the inception the project team conducted faith briefing and mapping assessments. The project held dialogues with religious leaders, traditional birth attendants, Ulama’s and county officials to demystify FP myths and misconception using scriptural messages from the Sheiks. The key message was on importance of child spacing and health of the mother, reiterating the Islamic perspective as stated in the Quran that promotes the wellbeing of a family and that contraceptive are effective way of ensuring spacing. Religious leaders were a very important component of FP delivery and update in the community representing more than 30% of all the demand creation agents supported by the project. The project continues to facilitate re-sensitization session for active leaders to provide an opportunity for religious leaders to share learning, challenges and successful strategies for community engagement
Cultural leaders are individuals who play a significant role in preserving, promoting, and shaping the cultural identity and traditions of a community or society. These leaders can include elders, chiefs, artists, storytellers, educators, and community organizers who are often regarded as custodians of cultural heritage. They are instrumental in maintaining social cohesion, promoting cultural values, and guiding their communities in navigating social changes and challenges (Jones, 2019).
Cultural beliefs are still deeply rooted in our communities, there are a lot of myths and misconception associated with family planning like for example in Wajir, Garissa and Mandera, cultural and religious beliefs continue to be the predominant barriers to uptake of family planning. Cultural leaders were also facilitated in making progressive SRH and Gender- based violence declaration on behalf of community.
Male engagement refers to the active involvement and participation of men in various aspects of
social, economic, and family life. This concept is often discussed in the context of gender equality, health, and development programs, where the goal is to encourage men to support and participate in initiatives traditionally seen as women’s roles, such as caregiving, reproductive health, and education. According to Smith (2020), male engagement involves the active participation of men in various social, economic, and family roles. Male engagement is a very crucial approach in influencing and promoting the uptake of family planning methods especially in patriarchal societies such as DESIP implementing counties. Men are the strong hold mantle for decision making at both the community and household level, henceforth their perception, altitude and behaviors toward FP service will influence access and uptake of family planning methods. The male engagement approach looks at creating space for dialogue and engagement of men and boys according to age groups using a theological underpinning and linkage to prevalent community issues by integrating men champions and duty bearers who are trusted and respected in their community.
Male engagement approach objective includes creating awareness among men on the importance of FP, address misconception that surround the use of FP among the local community and increase the acceptance of FP through increased male support. The activities were linked to cultural activities that aimed at catching men at their frequent hangout spot. The approaches were conducted in varies DESIP implementation counties like Narok, Homabay, Baring, Isiolo, Kilifi and Mombasa.
In Kwale county men were trained as FP champions in a three-day training forum to equip the with the knowledge on short- and long-term FP methods as well as their side effects. The men will use various platforms and focused group discussions to sensitize the public on FP such as chief barazas, in churches/mosques among others.
In Garissa township, male dialogues were conducted to discuss the relationship between Islam, Child spacing and moder contraceptive methods. The project involved SUPKEM office, CIPK, Council of preaches- Kenya, young Muslim association, Mustaqbal university, Umma University, Al-lhsan, Madrasatul (Najah, Khadija, Salam), Imams of prominent mosques and other Islamic scholars in county. They were sensitized on the importance allowing their women to using the modern contraceptive based on the Quran.
In Homa bay county, a targeted dialogue forum for men was held at Mbita sub county hospital to understand their challenges and demystify myths and misconception they have about family planning. They actively participated in the session and appreciated the need to encourage partners involvement in matters FP.
In Turkan county, Turkana North, the project used the ‘tree of men’ approach. The “Tree of Men” in Turkana traditions refers to a significant cultural practice among the Turkana people. This tradition involves a specific tree, often a large acacia, which serves as a central meeting point for the men of the community. Here, they gather to discuss important matters, make decisions, and resolve conflicts. The tree symbolizes unity, wisdom, and the collective strength of the community. It is a place where knowledge is shared, and traditions are passed down from one generation to the next. The engagement of the cultural and traditional leaders kanakurudio in FP sensitization during the ‘tree of men’ meeting shared and understand the importance of FP and agreed to mobilize women for the services and requested for more meeting for a better understanding of the moder contraceptive.
In Tana River, the dialogue meeting was held at Bangale Assistant commissioner's office, Bangale ward in Tana North sub-county. It was attended by the religious leaders (Sheikhs and pastors) from the area. After sensitization on FP, one of the religious leaders who is the chair to Muslim in the area committed to support family planning and to increase creating of awareness in the community to help raise the general wellbeing of the community.
Resource and Tools
Mass Media, on the other hand, encompasses a variety of communication channels, such as television, radio, newspapers, and magazines, that are designed to reach large audiences simultaneously. Mass media aims to disseminate information, news, entertainment, and advertisements to the public, often through a one-way communication model where the audience consumes content produced by media organizations (McQuail, 2010).
Mass media are powerful tools for disseminating reliable, consistent, and high-quality information to a broad audience, while also encouraging community participation and dialogue. DESIP, in collaboration with health management teams and SRH experts, conducted an intervention targeting adolescents, young people, and communities interested in reproductive health. The aim was to promote healthy reproductive behaviors and increase awareness and usage of contraceptives. The intervention utilized various mass media platforms, including radio, social media, and YouTube, across several counties with diverse demographics. Its objective was to provide accurate and reliable SRH information, eliminate misconceptions about contraceptives, promote community involvement and empower educated reproductive decision-making. During the period under review, using immersion insights from various counties, radio activation was carried out in varies radio stations like Watchman FM- Samburu, Kalys FM- West Pokot, Nosim FM- Kajiado and Narok, Isiolo Ranet FM- Kwale, Sifa Lamu FM- Lamu, Taach FM- Baringo and Elgeyo Marakwet, Namolwe FM- Homabay, Radio Saalam- Marsabit, Star FM- Garissa, Radio Sifa- Wajir, Radio Atanyeche- Turkana and Hekima FM- Mandera. They had on air discussion and interview with various SRH experts from the county as well as on ground activation where the target audience was engaged in the community by the radio activation crew and live links shared on air as a way of encouraging meaningful engagement around reproductive health and specifically use of contraceptive.
The theory of change in supporting reproductive behaviors by the used of mass media are barriers such as lack of knowledge, low risk perception, negative attitudes, low self-efficacy and norms that discourages Family Planning and contraceptive use. DESIP is planning to a high impact practice by using the mass media platform, the radio on air and on ground to support uptake and consistent use of family planning and contraceptives. For the social behavioral changed expected would be an increase in the community dialogues around family planning and contraceptive use and in steal norms that support family planning and contraceptive use. After this we expect some individual changes to happen like increased awareness of family planning and contraceptive in the market, knowledge and self-efficacy on matters contraceptives, have a reduced perception and have supportive attitudes, beliefs and value while increasing the intention to use contraceptive. The outcomes to be expected are increased uptake of contraceptives, increased correct and consistent use of contraceptives and reduction in number of untended pregnancies.
Resources and Tools
Social media refers to digital platforms and technologies that enable users to create, share, and exchange content in a virtual network. Social media platforms, such as Facebook, Twitter, Instagram, and TikTok, allow individuals and organizations to communicate, interact, and build communities online through the sharing of text, images, videos, and other multimedia content (Boyd & Ellison, 2007).Here are some of the social media platforms that the project used to display its works and its engagement.
Community dialogues are structured conversations that bring together diverse groups of people to discuss issues of common interest, share perspectives, and work towards mutual understanding and solutions. These dialogues often aim to foster social cohesion, address community concerns, and promote collaborative problem-solving (Smith, 2020).
Fear of negative side effects from family planning remains a significant barrier to their use, as myths and misconceptions continue to deter women from seeking these essential services. The DESIP program implemented community dialogue sessions in all twelve countries to address pervasive social and cultural factors that influence health and contraceptive service uptake. At the inception the project engaged the communities in creating more awareness on RH/FP uptake and sensitization. The project included and worked closely with religious/cultural leaders, community-based organizations, CHPs, and the CBDs. The project also included the youth groups of ages between 15-24yrs that their total focus was on the adolescents by using edutainment such as localize drama, mimes and song that converges the FP/RH information. They were equipped with county specific audio-visual facilitation tools that will be used to spin conversation around the usage of family planning and reproductive health with the target market.
The community dialogues were led by the CHPs, who are a very critical link between the informal and the formal health systems. The messages passed were on Family planning and reproductive health, the discussions were based on the negative perception on family planning, religious and cultural practices that hinders the uptake of family planning and the myths and misconceptions around family planning. Some of the dialogues sessions were coordinated by the local popular cultural and religious leaders and focused on creating awareness and acceptance of family planning as a lifestyle, “Traditionally, after birth, men used to go far away distance herding till the child reaches two years, hence this was considered and worked as a way of Family planning in the past. With the changes into the ways of life this is no longer practical and call for a shift into the use of modern family planning methods for the health and well-being of the mother and child” are some of statement mostly used by the leaders as a way of creating awareness and sensitization of the community hence increasing the uptake of family planning.
Resources and Tools
Youth engagement is the active involvement of young people in decision-making processes, community activities, and social change initiatives. It empowers youth to contribute their unique perspectives, skills, and energy to address societal challenges and build a better future. "Youth engagement is essential for fostering civic participation and addressing societal issues" (Smith & Jones, 2023, p. 45).
Adolescent and the youth comprise of 66% of Kenyan population that are vulnerable to unintended pregnancies, unsafe abortions, female genital mutilation and child marriage among other issue. To be able to reach them DESIP supported the training of health care workers in collaboration with the minister of health, Division of Reproductive and Maternal health (DRMH). The training provided an opportunity to build the capacity of HCW to effectively manage adolescents and the youth on matters SRH. They were trained in how young people wish to be served equally and with no discrimination, challenges that the young people face and the challenges the HCW might face and how to manage them that can encourage for the services.
The project also trained the youths as peer educators to reach more adolescents and youth. They created and activated AfRika youth dialogues forums to engage the youth in SRH discussion including the use of contraceptives. These forums provided a ‘safe space' for the youths to discuss their SRH issues without fear or judgement. The outcome of the participation of these spaces was being experienced through the increased number of youths and adolescents who are accepting and accessing the SRH service including FP. The project used online forum and localized skits to create awareness and hold discussion on SRH issues.
Resources and Tools
A manyatta is a traditional homestead used by various pastoralist communities in Kenya, such as the Samburu and Maasai. It typically consists of a group of small houses arranged in a circular pattern and enclosed by a fence made of thorny branches or brushwood. The manyatta is more than just a physical structure; it embodies the communal and cooperative lifestyle of these communities. Families live closely together, sharing daily tasks and responsibilities, which fosters a strong sense of kinship and mutual support.
Initially, the model was in Samburu North sub-county, then it was expanded to reach nomadic communities in south Horr, Nachola, Anderia and Lesirkan sub counties. At the inception, the county and sub-county health management team of Samburu and Samburu north held a manyatta model concept meeting. The model brings influential community member together including men and elders together with women, adolescents and youth to identify barriers to acceptability and uptake of family planning services. The aim is to link communities through the manyatta to the formal health system with a focus on providing accurate and culturally sensitive information about family planning.
The project trained community health volunteer to provide information and referrals using a mix of interpersonal communication and group participatory methods and work closely with key county and sub-county health management teams members to ensure modern contraceptive methods are available and health care worker trained to provide quality, family planning services.
It was noted that when CHVs would work independently with randomly selecting the manyattas, they would walk for long hours and distance and used a lot of time speaking to difference manyatta some of whom notably men and adolescent's mothers were unwilling or unable to wait for their turn to participate in the health talks. The project then introduced the Tag- Team approach to optimize planning and mobilization of community health volunteers to be able to reach more efficiently to the manyatta members. The tag-team approach refers to a collaborative method where two or more individuals work together, typically alternating roles or responsibilities, to achieve a common goal. The Tag- Teams approach was centered around mixed-gender teams of 3-4 CHVs who worked together to reach the pre-mobilized manyattas. At the manyatta, the CHVs would hold general talks on healthcare with the full community then followed by the targeted sessions with tailored information for specific groups made up of women, adolescent and elders.
Through the model, CHVs engaged cultural leaders, community elders and key decision maker at the community level leveraging structured dialogues to shift perceptions about family planning and women's empowerment, thereby promoting positive behaviors related to family planning and reproductive health in the target counties.
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