The Effect of Community-Based Reproductive Health Communication Interventions on Contraceptive Use Among Married Couples in Bihar, India

Published in International Family Planning Perspectives (Volume 34, Number 4), this 9-page paper explores the impact of a Pathfinder International/India programme aimed at promoting contraceptive use for delaying and spacing births by involving the whole community. A response to the fact that contraceptive use among young couples in India is low, and early childbearing and short birth intervals are common, the Promoting Change in Reproductive Behavior in Bihar (PRACHAR) Project is an ongoing communication intervention in Bihar. Changes were made in 2006 in the project design, intervention areas, and population covered. This article reports on activities conducted under the original project design.

Between 2002 and 2006, 19 Bihar-based non-governmental organisations (NGOs) worked with Pathfinder to implement the intervention. Each of these partners carried out the project in one intervention cluster that comprised 25–35 villages and approximately 30,000 residents; 7 of the intervention clusters were in Nalanda, 7 in Nawada, and 5 in Patna. A detailed description of PRACHAR interventions can be found elsewhere (please see Related Summaries, below). In short, the programme's interventions were designed to educate youth aged 15-24 about reproductive health issues and to raise community awareness and support for delaying marriage and childbearing. Briefly, a favourable social environment was created through the orientation and training of reproductive health teams of community leaders and influential residents, and through group meetings with young couples' parents and in-laws; messages were disseminated through street theatre performances and wall paintings; and formal and informal rural health service providers were trained on reproductive health issues and contraception. In addition, unmarried adolescents received information through a 3-day workshop, and newlywed couples via infotainment parties; group meetings were held for young married women and, separately, young married men; and young married women and men were counselled, separately, at home. In short, the project selected media appropriate for the audience and the message being delivered. Change agents and cluster supervisors (local residents) were responsible for providing information and referrals, but they did not distribute contraceptives or provide other medical services.  The first phase of PRACHAR lasted 21 months in Patna, 24 months in Nawada, and 27 months in Nalanda.

The baseline survey was conducted 1–2 months prior to the initiation of intervention activities, in April-May 2002 in Nalanda, and February 2003 in Nawada and Patna. The follow-up survey was conducted in all communities in October-December 2004. The samples were drawn independently, and the sampling techniques were identical, in the baseline and follow-up surveys. In total, 1,995 women were interviewed in the baseline survey, and 2,080 were interviewed in the follow-up survey.

Results indicate:

• At baseline, the demand for contraception in the comparison areas was similar to that in the intervention areas: Approximately one-fourth of women indicated that they wanted to wait at least 2 years for a child (or their next child) or wanted no more children. By follow-up, demand for contraception had increased to 40% in the intervention areas. In contrast, demand showed little change in the comparison areas.
• Contraceptive use was similar in the 2 areas at baseline: 3% of women in the comparison areas and 4% of those in the intervention areas reported using a method. At follow-up, contraceptive use had risen only slightly, to 5%, in the comparison areas, but had increased significantly, to 21%, in intervention communities.
• Contraceptive use increased in the intervention areas regardless of parity. At baseline, contraceptive use among childless women was low in both the intervention areas (3%) and the comparison areas (2%). At follow-up, it had increased to 16% in the intervention areas (p<.01), but to only 3% in the comparison areas (change not statistically significant). Similarly, among women with one child, contraceptive use increased fourfold, from 6% to 25% (p<.001), in the intervention areas, but the change in the comparison areas (from 4% to 7%) was not statistically significant.
• At baseline, contraceptive demand and use did not differ between the intervention and comparison areas, and they remained virtually unchanged between surveys when data from both areas were combined. But both measures increased significantly between surveys in the intervention area. The increase in demand for contraception between surveys in the intervention area was 1.5 times that in the comparison area, and the increase in contraceptive use was even more pronounced (odds ratio, 3.8).
• Knowledge improved over time in both the intervention and the comparison communities. Women in the intervention areas showed improvement in knowledge of the fertile days in the menstrual cycle. At follow-up, 39% of women knew about fertile days in the cycle, compared with only 18% at baseline. In the comparison areas, the level of knowledge remained essentially unchanged, at around 20% in both surveys.
• Knowledge about fertile days did not differ between areas at baseline, and did not differ significantly between surveys. However, the interaction term showed that knowledge increased to a greater extent in the intervention area than in the comparison area (odds ratio, 3.0).
• Attitudes improved over time in both the intervention and the comparison communities. For example, the proportion of respondents who agreed that early childbearing is injurious to another's health increased from 12% to 65% in the comparison areas and from 17% to 74% in the intervention areas. The proportion of women who agreed that contraceptive use is safe and necessary for delaying a first birth increased in both areas. However, at follow-up, this agreement was significantly higher in the intervention areas than in the comparison areas.
• Attitudes toward early childbearing were more favourable in the intervention area, and improved from baseline to follow-up; the increase in the intervention area was 2.6 times that in the comparison area. Similarly, findings for the other attitudinal measure show that attitudes toward contraceptive use improved between surveys (odds ratio, 5.0) and improved by a greater degree in the intervention area than in the comparison area (1.6).

In the Discussion section, the authors point to several significant elements of the initiative:

1. PRACHAR behaviour change communication (BCC) interventions were directed not only at youth and young couples, but also at their parents, their in-laws, and influential community members - all of whom may shape the reproductive decision making of young people. This strategy was necessary in light of some of the contextual issues outlined in the opening section of the paper; that is, community taboos against discussion of reproductive health and sexuality were expected to pose significant challenges.
2. The project emphasised generating demand for family planning services without actually providing contraceptives: "our results suggest that this approach can increase method use for spacing purposes."
3. "...[C]ommunities in the intervention areas moved further along the behavior change spectrum - beyond attitudinal change to actual use of contraceptives - than did those in the comparison areas. We believe that this was because young couples who were exposed to the full range of behavior change communication methods used by PRACHAR were better able to interpret and evaluate information. Our findings indicate that ideational change may not be sufficient to promote behavioral change unless specific information is provided and a supportive environment is created, as was done in PRACHAR."

In conclusion, the authors assert that, although tested here in rural areas, the PRACHAR model is replicable throughout Bihar and has relevance in other contexts where youth fertility is high and delaying and spacing children is important.