A Study in User-Centered Communication and Family Planning Decision-Making in Nepal

The case studies from Nepal in this report detail conversations that took place between young couples and Health Communication Capacity Collaborative (HC3) health workers and family members, also sharing their reflections on campaign-related media. The case studies demonstrate the complex process by which communicative exchanges intermingle to influence family planning (FP) decision-making and use.

In the context of HC3, communication is understood as a unified communicative field with the interested user-actor at the centre of the circle. The communicative field spans three types of exchange, all of which coexist and interact:

• communication between spouses, among family members, and with discussion partners to coordinate attention to relevant information and to form joint intentions and decisions with regard to FP;
• face-to-face communication with the health system - in particular, with health service providers and community workers (such as peer facilitators, or PFs); and
• individual or joint attention given to project-generated health communication materials and interventions, such as mass media, social media, or events, and large group interactions - often generating discussion.

This approach can be illustrated through the "Smart Life" behaviour change communication campaign (see Related Summaries, below), which approached the communicative act as a largely user-driven, goal-oriented behaviour. Considering that unplanned pregnancies take a toll on women's health and affect the life plans of couples, and that certain segments of Nepal's population have an unmet FP need, HC3 worked in collaboration with Nepal's National Health Education Information Communication Center (NHEICC) and Family Health Division (FHD) to implement an integrated communication programme to increase FP use, especially among youth and young couples, marginalised and disadvantaged groups, and migrants. In this initiative, the programme communicator's role is to serve as a cooperative partner in the user's decision-making, rather than as a disengaged expert giving one-way directives.

The "Next Generation" FP communication campaign was branded with the slogan "Pariwar Niyojan Smart Banchha Jeewan" (Family Planning Makes a Smart Life). "Smart Life" used a life-stage approach offering couples practical FP solutions around key life-events such as their wedding, the birth of their first child, and when they reached their desired family size. These teachable moments were designed to reduce couples' uncertainty, thus enabling them to make smarter decisions regarding appropriate contraceptive timing and method choice. The campaign was implemented nationwide through the media and in 13 focal districts using face-to-face communication. The media campaign used an integrated mix of channels such as TV, radio spots, magazine format radio shows, outdoor shopboards, and transit ads, as well as social media (mainly YouTube and Facebook content) and large-scale entertainment events. At the local level, HC3 implemented a district model to maximise contacts and referrals and to optimise the counseling service that beneficiaries receive in community health facilities. Systematic personal contacts were made among youth and eligible couples at the grassroots level by PFs.

The report includes a series of stories highlighting a few individuals and showing how their FP choices were made through a process of cooperative communicative exchanges with HC3. For example:

• Jit and Amrita are an example of the growing number of young couples that choose to delay their first birth after marriage. Their case shows how interacting with HC3's communication programme reinforced a new norm of "delay" and aligned with the couples' life goals, generated family discussions, and enable Jit and Amrita to take the action of their choosing. For example, soon after they were married, the couple attended an HC3-organised "Smart Life" mela, or fair, whose theme was "We are Today's Smart Couples". Jit felt that he learned a lot: "Since there were popular comedy artists giving messages, it was very entertaining and effective. These artists are idols and have many fans - whatever they say will be followed."
• Poonam Pathak got married when she was 17 years old and her husband Rabi Kumar Pathak was 18. This story shows that FP decisions take time, and the role of the PF often went beyond informational support to that of a trusted discussion partner, offering practical support in reaching shared goals. Through this process of exchange, HC3 enabled Poonam to overcome the reservations of her mother-in-law, reach a joint decision with her family on using an appropriate method, and navigate the health system to get support when she needed it.
• Ruby Bagwan from Banke got married at the age of 14, leading her to drop out of school. It becomes evident from this story how conversations with health workers are not one-directional but represent active information-seeking by a beneficiary. The process may take multiple communicative exchanges, such as repeated contact with health workers, events, and exposure to mass-mediated campaign messages, for beneficiaries to arrive at their decisions and implement them successfully.
• Pooja's story shows how multiple communicative exchanges with HC3 health workers and the media campaign helped the couple to choose the right methods for their individual life-stage, their special need as migrant worker family, and for achieving their goals through both short-term and, later, longer-term FP solutions.
• Sangita Yadav comes from a marginalised community in Banke district and was 16 when she got married to Sri Ram, who was one year older. Their story demonstrates how HC3 operates in a wider communicative field, in which FP decisions are a result of active information-seeking by the beneficiaries, exposure to HC3's media campaign, and the programme's informational and practical support.

According to the report, HC3's community-based programme in 13 districts resulted in more than 354,557 couples being contacted and more than 76,930 FP services referrals (as of June 2017). As these stories have shown, this includes people and couples who are members of some of the most marginalised groups. A Sharecast Survey conducted in December 2015 indicated that the "Smart Life" campaign was recalled by 58% of the population, roughly 7.6 million adults. In addition, HC3 sees a normative shift as a result of the campaign, suggesting that delaying marriage and first child is becoming increasingly accepted by young girls and boys. As a conversation with a group of young girls in grades ten and eleven from a marginalised community in the Kaski district showed, many young people have started to identify themselves as "smart". Laxmi Pariyar said, "If I get married now, my life will be damaged. First I need to settle and stand on my own feet." These girls met with a PF and expressed their desire to be both mentally and physically strong enough before having children.

"Many conversations are taking place among couples and families across Nepal, each considering FP in light of their own dreams and goals. These cases show that the HC3 program has been able to enter these conversations in a variety of ways, helping and enabling many to take action and make informed, healthier choices."