Social and Behavior Change for Youth SRH

© 2014 Prakash Hatvalne, Courtesy of Photoshare

Gatekeepers are people who have influence or control over young people’s access to healthcare; for example, husbands, community and religious leaders, parents, mothers-in-law, male relatives and healthcare workers. Community gatekeepers can strongly influence the value systems of those around them. The support of these gatekeepers can be crucial for young people – particularly young women – to understand their reproductive health and rights, and increase demand for contraceptives and other sexual and reproductive health (SRH) services. Social and behavior change interventions (SBC) can enhance community support and include approaches such as interpersonal communication (IPC), community mobilization, and multimedia and mass media campaigns. Often, these same approaches are used to generate demand for services among young people while also enlisting older community members to encourage support (Denno et al., 2014).

Incorporating a strong community component in social and behavior change initiatives aims to:

  • Encourage parents and other adults in the community to recognize the SRH needs of adolescents and young people in their communities
  • Improve communication between parents and their children
  • Make the community a safer place for young people
  • Enable adults to support young people to reduce their reproductive health risk (Cowan et al., 2008)

What Are the Benefits?

  • Supportive community gatekeepers enable better SRH for young people: When community gatekeepers better understand SRH issues facing young people, they can help address misinformation around contraception, reduce stigma and shame around contraceptive use among adolescents and young people, and address ambiguous policies that result in service providers acting on personal bias.
  • Acceptance of young people’s sexuality results in greater access to preventive health services: Community acceptance of young people’s SRH needs and right to access services allows young people to be more proactive in protecting their own health. There is evidence that in order to increase young people’s access to preventive health care, including contraceptive services, community support and acceptance activities are as necessary as supply-side activities like training of service providers (Denno et al., 2014). Interventions directed at influencing the SRH behaviors of adolescents are significantly enhanced where there are complementary interventions for parents, providers, religious leaders and other influential adults who can foster a supportive environment in homes, health facilities, schools and religious places of worship.

How to Implement?

Mobilize Community Members When Starting the Program
It is important that programs are implemented across a whole community, not geared only towards young women or young men. Building strong and consistent support systems around young people can take many forms, such as:

  1. Getting the support and buy in of community leaders and parents
  2. Including mothers-in-law and co-wives to learn about contraception and healthy timing and spacing of pregnancies
  3. Home visits to young people, their families, and those who influence their health care by community health workers who provide counseling at follow-up sessions, and offer referrals to local youth-friendly health services and accompany them where needed
  4. Community style discussions that are rooted in the day-to-day lives of young people, instead of traditional sensitization programs, i.e., discussions of household workload burdens and pregnancy spacing
  5. Developing strong monitoring and evaluation systems that engage community-based implementers in a participatory process (Pathfinder, 2015)
  6. Employing social mobilizers can also be effective because they are approximately the same age as the intended audience, speak the same language and are easy to relate to
Community Mobilization

The Urban Reproductive Health Initiative in India, Kenya, Nigeria, and Senegal learned that prior community mobilization through community health workers/social mobilizers/volunteers/youth groups or other means, was critical to the success of in-reach and outreach services. Experience showed that without a community mobilization component, turnout for in-reach activities was limited and outreach efforts were less successful. Creating an atmosphere in which talking about norms and openly discussing contraception made communities more receptive to more focused education, training, and outreach efforts. Making connections between community-based workers and community leaders played an important role in addressing norms and spreading accurate information. Refer to the Nigeria ‘Get it Together’ Youth Social Mobilization: from Strategy Design to Implementation for more information.

Identify a dissemination platform
What platforms would be most effective to disseminate information on your AYSRH program? There is no “perfect” platform; it is important to consider the specific communication needs of a given community to know what will work best to reach them. For example:

  • In Nigeria, implementers from Action Health Incorporated (AHI) and FHI 360 faced challenges reaching young people with information at health facilities, so they adapted their approach. Rather than having young people come to the information, AHI and FHI 360 brought the information to the young people where they were: In school. AHI established an integrated curriculum for family health education that heavily on active participation from teachers. Similarly, FHI 360 implemented a program to reduce sexual and gender based violence called 4 Pillars Plus, bringing students, parents, and teachers together to identify signs of abuse, familiarize themselves with reporting mechanisms, and push local government to set up systems for reporting that would be safe and free of judgement.
  • In the Tupange program in Kenya, community radio stations in each of the core cities were an important feature in demand creation. The radio program Jongo Love was targeted to youth, and exposure to it was significantly related to contraceptive acceptance. However, the proportion of the total urban population exposed was small (less than 10%). To reach more young people, the program connected with Shujaaz, a weekly comic insert in the Nairobi newspaper. Shujaaz was linked to Jongo Love and the two were supported by a social media campaign. Overall exposure to mass media messages was significantly related to contraceptive uptake in Nigeria (radio), Senegal (radio for women and TV for men), India (TV) and Kenya (radio) (ExpandNet, 2016).
  • “Wall paintings,” which are informal messages written on the walls of houses in the slums of Uttar Pradesh, India, were widely viewed by residents. Exposure to wall paintings was significantly related to contraceptive use under the Urban Health Initiative (UHI) program (ExpandNet, 2016).
  • In Nigeria, FHI 360 is conducting a research project to explore the best approaches for reaching youth through technology. In previous initiatives, they discovered that non-traditional media – including social media and chat apps such as WhatsApp – were very successful methods of disseminating information such as short video clips that young people could watch and then share with their friends. They found that limited access to data meant that if a video or resource could easily be downloaded rather than streamed, young people were more likely to share it. (Source: Interview with FHI 360’s Mariya Saleh.)

A thorough understanding of the community – its culture and beliefs, including myths and misinformation; its norms and practices with regard to SRHR in general and adolescents’ and young people’s sexuality in particular; and its preferred methods of seeking and sharing information – is necessary before deciding on which tools or approaches to use to generate community support. Below is a table of possible tools or approaches, with examples where they have been used successfully.

Entertainment education and offline activities In the Tupange Project in Kenya: A Multifaceted Approach to Increasing Use of Long-Acting Reversible Contraceptives, youth groups played a key role in demand generation for contraception in Nairobi (Tupange, 2016). They used entertainment education and other activities to reach fellow youth and the general population. Activities included magnet theater (a form of interactive community theater that typically takes place in outdoor, public spaces); mini caravans (small vehicles mounted with a public address system, using actors to create demand for contraception in the community); acrobatic shows; posters; letters to churches and mosques; information, education, and communication materials; Miss Tupange beauty pageants; puppeteers; and football tournaments. A key lesson learned was that common myths and misinformation about long-acting reversible contraceptives (LARCs) can be addressed by community health workers, youth groups, religious leaders, local leaders and local radio stations.
Intergenerational dialogue A multi-component community-based HIV prevention intervention for rural youth in Zimbabwe addressed the lack of dialogue between parents and children. Community mobilization took place at national, provincial and district levels with learning sessions that included “the use of proverbs and bible verses to support new ideas that community members may be wary of or have difficulty understanding.” The program also used traditional games to help support and clarify learning points. Community nurses facilitated information and discussion sessions between young people and parents; these dispelled myths around contraception and publicized the accessibility of the SRH clinic to the community (Cowan et al., 2008).
Social and behavior change communication (SBCC) According to the The Health Communication Capacity Collaborative’s “Social and Behavior Change Communication (SBCC) Implementation Kit”, SBCC is “an approach that promotes and facilitates changes in knowledge, attitudes, norms, beliefs and behaviors… refer to a series of activities and strategies that promote healthy patterns of behavior.” SBCC approaches can be a useful framing for mass media campaigns to disseminate of AYSRH information. For example, the Nigeria Urban Reproductive Health Initiative (NURHI) in collaboration with its partner Association of Radio Drama Artist (ARDA) produced weekly radio programs with entertaining hosts, drama, songs, experts, quizzes, “vox pop” interviews, user testimonials and live call-in sessions. An analysis of these media platforms concluded that interventions that incorporate media, such as radio or mobile phones, could be viable means for systematically and consistently disseminating information (Bajoga et al., 2015). The tone and creative approach for most of these products was aspirational, meaning that the content encouraged people to look ahead and plan. The style was often funny and urban–selected to appeal to a broad audience. A family planning song by P-Square and Tiwa Savage was designed for a youth audience; it has passed 3 million views on YouTube, which we presume (due to the demographics of YouTube users in Nigeria, includes a large number of young people. See NURHI, 2017.)
Interpersonal Communication (IPC) Interpersonal communication (IPC) is “personal interaction with the intended audience that can be done one-on-one, in small groups, large groups or as a forum.” (See HC3, 2016). IPC can be delivered in many formats — in person, over the phone (e.g. hotline), or through social media. Many types of practitioners can be involved, including health providers, peers and near-peers, community health workers, pharmacists and teachers. At the community level, IPC can help address an individual or group’s specific situation, and is effective for discussing sensitive topics in a private setting. In NURHI, Community Health Extension Workers and non-clinical providers were trained on IPC and and counseling skills (ExpandNet, 2016). Training was supplemented with a mobile app for refresher trainings, as evidence points to IPC’s greater effectiveness when program facilitators are comfortable with the subject matter and committed to the program (Mwaikambo et al., 2011).
Plan a community support approach
  • Adapt to local environment: Even the most successful programmatic approaches will need to be adapted for context, including local customs, traditions, power dynamics, gender norms and available communication channels.
  • Create an enabling environment: Activities should have the support of adults in the community and create an environment in which the individual lives, promoting protective factors and removing barriers to beneficial behaviors.
  • Integrate community approaches with national health strategies: Standalone projects with no tie to national health strategies have been shown to be neither cost-effective nor sustainable. With no direct integration, once the funding runs out, the government may not be in a position to simply take over the project and keep running it. However, when new initiatives are deliberately integrated into existing structures and service models, they can create change from the inside-out, and then the government is able to more easily adopt new practices. (Source: Interview with Margaret Bolaji, NURHI.)
  • Develop ways of mainstreaming activities: Finding openings in existing systems and structures where SBCC activities can be incorporated will allow for greater sustainability. For example, SRH activities can be integrated into school curricula, community events or other significant occasions that mark community life.
  • Encourage youth involvement and engagement: In all contexts and environments, when youth are actively engaged throughout the entire process—from design, to implementation, to monitoring and evaluation—they are more likely to participate, share and feel ownership over a project or initiative (Source: Interview with Margaret Bolaji, NURHI) and the intervention is likely to be better-tailored to youth.
Community-Led Total Sanitation (CLTS), Kalyani, India

By involving women and girls in the design, decision-making and implementation of the CLTS initiative in Kalyani, and ensuring buy-in from local community leaders, the municipality was finally able to be deemed open defecation free (ODF). Due to the success of the initiative, the municipality’s political leadership now engages more actively with community members and takes into account the needs of those living in low-income urban settlements (Institute of Development Studies, 2015).

What Is the Evidence?

  • Community-involvement interventions in AYSRH programs are highlighted in a publication from the Inter-Agency Working Group on the Role of Community Involvement in ASRH. Community Pathways to Improved Adolescent Sexual and Reproductive Health documents a quasi-experimental study conducted in Nepal, one of very few published rigorous studies of AYSRH programs. The study tested the hypothesis that involving communities (particularly youth and adult gatekeepers) would result in better health outcomes behavior-change communication and service delivery approaches with no community component. The findings clearly demonstrated that the intervention with significant community participation yielded more positive results than the control sites; the most apparent results were changes in community norms and values that influence AYSRH (IAWG, 2007).
  • Social support networks have been found to reduce experience of non-consensual sex amongst young people. For example, a study in low-income areas of three Ethiopian cities found that socially isolated girls had nearly twice the experience of non-consensual first sex compared to girls with strong social affiliations (Erulkar et al., 2012).
  • Community support has been found to improve condom usage in slum areas of Ibadan municipality in Nigeria; knowledge and access were not issues, whilst young people identified social support as crucial to their usage (ExpandNet, 2016).
  • Religious leaders have proven to be integral to disseminating information with the support of the URHIs. They have become facilitators for URHI outreach in several instances (ExpandNet, 2016):
    • NURHI facilitated the establishment of an Interfaith platform for Muslims and Christians to interact and understand the importance of contraception based on their faiths, thereby supporting FP uptake at the community level.
    • Nairobi Tupange worked with Christian leaders who became FP champions in their communities, informing their congregations of upcoming activities and making their churches available as sites for outreach.
    • The four URHIs developed materials based on the Quran, including support for contraception in general and birth spacing specifically.

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Helpful Tips

  • Expand the definition of community to include females who influence young women’s healthcare, including mothers-in-law, co-wives and close friends.
  • Inform/educate parents, teachers, faith leaders, and other community members on issues related to adolescent and youth SRH, and train them disseminate information regarding sexuality and SRH within their homes, communities, and congregations.
  • Facilitate community dialogues to provide community members with a structured discussion guide including a specific topic for consideration. Provide a space for open, safe discussion, then allow time for members to absorb and process new information before reconvening. Changing longheld beliefs is not easy, or quick, so it’s important to leave ample time before follow-up. (Source: Interview with Mariya Saleh, FHI 360, Nigeria)
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Challenges

  • How do you provide family planning services to someone who legally cannot give consent? Educating young people’s parents is key to ensuring that they are allowed to consent to their own health care and receive family planning services, and also for the parents to understand the importance and be able to consent on their behalf as necessary.
  • A prominent health concern among poor urban young people worldwide is a lack of safety. Urban young people may not seek healthcare because they feel isolated and fearful within their community. Treatment and health services are not able to address safety concerns; there is a mismatch between a perception of health and the mechanisms for addressing health concerns. Programs may address this mismatch by designing initiatives that work to improve urban decay and sanitation within these poor communities, and involve the community so that social support and services might be better aligned to serve poor urban young people’s highest health priorities.
  • Urban young people and their communities tend to be more mobile, meaning it is challenging to reach the same adolescent more than once with a stationary message. Informal settlements can make messaging difficult and lack of traditional family structures for many urban adolescents means they may not get the support they need at home to reinforce messages about healthy behaviors.

Tools Related to This Approach


Related Approaches

References

See a listing of all AYSRH references.