Transform/PHARE

Overall, Transform/PHARE sought to empower individuals - male and female - and couples to make informed and supported choices about the number, timing, and spacing of their births, which will have ripple effects on women's and girls' life outcomes. Specifically, the objectives were to:

• Increase demand for FP products and services.
• Enhance the active support for FP among key secondary audiences.
• Address social norms, thus creating a favourable environment for FP.

Many of the projects developed under Transform/PHARE used HCD principles and therefore followed a 3-phase process:

• Inspiration phase: This involves research and learning directly from the people one is designing for in order to understand their needs, motivations, and behaviours. This phase ends with a selection of intervention ideas for the prototyping phase.
• Prototyping phase: This phase involves the development of a prototype to further test and refine the intervention ideas. The prototyping phase ends with the selection of one or two interventions being selected for a pilot.
• Pilot phase: Non-governmental organisations (NGOs) involved in the process receive support from Transform/PHARE to pilot their interventions over a number of months.

The following are the 4 thematic areas in which Transform/PHARE was active, as well as some examples of the piloted interventions that were developed and implemented (a cross-cutting gender lens underlies all themes):

1. Audience Segmentation - This involved identifying sub-groups of the population most likely to change their behaviour, based on their current attitudes and behaviours. Traditionally, audiences are segmented using demographic indicators such as age, gender, and marital status; however, Transform/PHARE used non-traditional and views of the audiences, based on attitudes and behaviours. This technique has historically been used by the private sector to position products and services that appeal to preferences and address market needs or to create demand based on aspirations and desires. It is considered a robust, scalable approach that is readily transferable to global health and development. The Transform/PHARE audience segmentation attempts to identify segments or groups of people who are likely to adopt a behaviour, change an opinion, or use a product or service according to specific desires. The analysis of attitudes and behaviours is then used to increase the demand for FP products and services. Examples of projects implemented under this theme:

• National Demand Analysis, Cote d'Ivoire - A literature review and qualitative investigation with men and women age 15-49 was conducted. This served to characterise the forces shaping FP use and non-use, in addition to understanding what it takes to close the intent-to-use gap and identify groups most likely to increase their use of FP. A nationally representative survey of 1,000 women age 15-49 was also conducted. The customised survey data was analysed to identify overall trends and context, as well as sub-groups of women with acute FP demand and/or risks, and to develop a statistical segmentation of women based on their needs, attitudes, and behaviours. Recommendations for priority groups as well as promising near-term strategies to help the country meet its 2020 FP target were developed.
• Male Segmentation in Niger - This intervention, led by Camber Collective, was centred on an analysis of male FP demand, including a statistical segmentation analysis. Quantitative research, analysis, and key informant discussions identified men who were willing to change their FP behaviour and identified key activities required to facilitate their behaviour change, correlating to the activities already identified to reach segments of women (Healthy Proactives, Sheltered Skeptics, and Traditional Autonomists). Camber Collective and PSI/Niger then worked with RISE consortium members to design specific interventions, which were trialed over a period of 3 months with direct support from PSI/Niger. This project led to the engagement of religious leaders, discussed below under the cross-sectorial SBC theme.

2. Male Engagement - Male engagement and gender transformative approaches are meant to address men as users of FP methods, partners, service providers, influencers, and decision-makers. Men may be seen as a barrier, or they can be seen as a support to increase the use of modern contraception, to improve birth spacing, and to foster decreased/healthier family size. Interventions focused on promoting dialogue amongst couples and religious leaders, stimulating conversations about the negative impacts of rigid gender roles, and actively addressing gender inequalities during project design and implementation. For example:

• Promoting Male Engagement and Partners' Dialogue in Côte d'Ivoire Using Human-Centered Design - This initiative sought to provide insights into the young male perceptions on contraception, as well as their attitudes, beliefs, and barriers to engaging with their partners around FP. The project prototyped ways to increase debate and interest on male involvement in contraception. The objective was to positively influence young male willingness and ability to communicate on the use of contraception in FP with their partners and peers. This project ended up developing the Didier comic series to engage young men in the informal sector in discussions around sexuality, FP, and relationships. (See Related Summary below.)
• Innovations Lab in Burkina Faso - Research shows that significant socio-cultural and structural barriers to creating demand for FP persist. Cultural norms value high fertility, and gender equity issues prevent many women from making decisions regarding their own health and fertility. Thus, the overall objective of this work, which involved HCD, was to design quality FP programmes reaching out to men, and to connect them with non-traditional actors who might provide new perspectives that strengthen male engagement interventions. One of the projects piloted under this intervention was Père Burkinbila. This activity consisted of organising fathers' clubs in 4 villages. Fathers were trained on ways to talk to their adolescent sons about sexuality, gender equality, and contraception. The project included some visual aids to help the fathers discuss these topics with their sons, and trained facilitators conducted house visits to help participating fathers engage with their sons.

3. Provider Behaviour Change - This involved a focus on provider values, attitudes, and beliefs to promote better FP service provision. As healthcare providers (HCPs) are often limited by their own misconceptions and biases in offering quality RH information related to FP and contraceptive counselling and services to women or couples, the key to improving the supply and use of contraceptive methods is to help HCPs overcome their own biases and offer client-focused services. The following is a project that was implemented under this theme:

• Healthcare Provider Barriers to Family Planning Service Delivery in Côte d'Ivoire - This project involved an analysis of HCPs' barriers that interfere with quality FP service provision and the identification of positive deviants, who despite the challenges are still able to meet the needs of clients. The project concluded that positive deviant providers are characterised from the point of view of the client by the quality of their service, confidentiality, effective communication, and their availability to prescribe and accurately provide information about the methods. The elements that enable positive deviant providers to overcome barriers were found to be related to their motivation (the love of the trade), continuous capacity building, exceptional work experiences, and innovative communication strategies. Based on these findings, the project tested tools to improve service provision.

4. Cross-sectoral SBC - This approach aims to provide information, to educate, and to encourage dialogue in settings outside the traditional health-related context. The approach could focus on educating in agriculture, trade (vocational) schools, businesses, or any area within the environment of the intended audience, but outside the health-related sphere. Transform/PHARE applied this approach in Benin, Niger, and Cote d'Ivoire, and the intention of the pilot activities was to understand if men and women who do not usually express interest in learning about FP and contraception from HCPs would be more inclined to do so in non-health-related environments. For example:

• The Académie de l'Artisanat - Using HCD, Transform/PHARE designed a prototype craft academy to reach young, out-of-school women with information on and referrals for modern contraceptive methods. A handcraft academy model was selected based on the insight that young, out-of-school women were interested in learning income-generating skills, such as making crafts, that also allow them to earn modest income. During the Académie workshops, beading specialists taught the young women how to make a variety of beaded handicrafts, including necklaces, bracelets, and bags. At the end of the workshop, a community facilitator provided lessons on modern contraceptive methods and referrals to contraceptive services. (See Related Summaries below for more information on this project.)
• Engagement of Religious Leaders in Niger Using Human-Centred Design - Drawing from different research methodologies, the team sought to uncover youth and religious leaders' perspectives and knowledge on RH services and products in several villages in the Zinder region of Niger. While there were religious leaders who supported birth spacing, they perceived a significant amount of risk in publicly supporting FP on their own. Furthermore, both religious leaders and youth shared a desire to improve their knowledge and ability to dispel myths about RH in a public forum so that the larger community could benefit from candid discussions. Transform/PHARE research showed that the primary determining factor to contraceptive uptake among married women in Zinder was support from their husband. Yet, despite men being the main decision- makers on contraceptive use (and essentially every household decision), the project found that men lacked sufficient knowledge on the financial implications of raising children to inform their choices. Building on the design research findings, the team designed 10 low-fidelity prototypes that were subsequently rapidly field-tested and iterated with 41 religious leaders, 26 youth, and 5 healthcare workers. A scorecard methodology was used to evaluate the final 3 solutions, which were implemented during a 6-month pilot programme called Sarari (meaning spacing in Hausa). The pilot programme, for example, included Leaders Engagés, an initiative that involved identifying religious leaders who are champions of the practice of birth spacing in their communities, connecting them through a collective, and providing them with religious justifications to support their position during their sermons or other forms of public advocacy. Click here for more information about Sarari.

Click here for more information, videos, and materials related to the different projects that were piloted under Transform/PHARE.

Gender, Reproductive Health

FP is a priority in West Africa, which is home to countries with some of the world's highest fertility rates - in large part due to social norms favouring large family size. In Niger, for example, the average woman has 7.6 children, yet both men and women desire more children than they have, according to Demographic and Health Surveys (DHS).