THE PROBLEM:
Tackling Deep-Seated Family Planning Challenges in Niger
Niger’s 2012 Demographic and Health Survey (DHS) revealed some troubling statistics. Niger had the world’s highest fertility rate with an average 7.6 children per woman, resulting in rapid population growth. Not only was contraceptive use in decline, but data showed men and women wanted substantially more children than they were having— men wanted an average of 11.5 children and women wanted an average of 9.2 children. These trends were contributing to the country’s high maternal and infant mortality rates, and the public health community knew it needed to take action to address the concerns over the impact of population growth on the country’s health and development indicators.
While low modern contraceptive rates could have been attributed to limited access to family planning services, data showed that something bigger was going on as similar rates of contraceptive use were found in areas where contraception was available. In fact, an analysis showed that neither stock outs nor distance were significant drivers of contraceptive non-use. It was clear these issues could not be improved by supply chain solutions alone, but would require a strategy that tackled the deep-seated, social and cultural issues that restricted family planning demand and use.
In response, the Nigerien Ministry of Health worked with the William & Flora Hewlett Foundation to bring together several stakeholders, including Camber Collective (formerly Hope Consulting), nonprofit organizations, and private donors to find a social and behavior change (SBC) solution that could meet Niger’s diverse FP wants and needs and help decrease Niger's high maternal and infant mortality rates.
THE SOLUTION:
Using Advanced Audience Segmentation to Design Better SBC Approaches
After several discussions with stakeholders, the Hewlett Foundation and the Nigerien Ministry of Health partnered with Camber Collective to conduct an advanced audience segmentation analysis in 2013, in order to better understand the family planning wants and needs of the distinct sub-groups – or segments – within Niger. Audience segmentation commonly distinguishes sub-groups using socio-demographic or geographic factors; however, advanced audience segmentation uses behaviors, attitudes, and psychographic characteristics to understand the differences between populations, along with more sophisticated validation techniques to estimate the size of each segment in the population.
By focusing on each segment's wants, needs, values, motivations/intentions, and behaviors, SBC programs can maximize their impact by directly addressing the most significant drivers of family planning decision-making and use. Advanced audience segmentation also gives SBC practitioners the information they need to develop programs, products, services, and messages that are most likely to drive behavior change.
Data Collection
From the start of the data collection process, the team developed and tested a number of hypotheses about a typical Nigerien client’s family planning journey (e.g., primary drivers of contraceptive use, drop off points between stages of change, etc.), which were confirmed or refuted as the team learned more information. The potential drivers identified during the formative research process were included in a quantitative survey administered to 2,000 women aged 15-49. The team then analyzed the significance of approximately 30 drivers using a latent class analysis.
Segmentation Analysis
Next, Camber Collective used a mix of art and science to select the most important variables, often combining characteristics that described similar traits.
Using these variables, the team created six segments that best represented the sub-groups that emerged. They were careful to make sure the segments were distinct enough to show the key differences within the population. They also wanted the segments to feel realistic and true to the populations themselves. Then, they named the segments and created archetype profiles that summarized key characteristics and SBC considerations. They worked with local stakeholders to validate the segments and profiles.
The segments captured the primary drivers of family planning attitudes and use, based on the latent class analysis. While some segments skewed more to certain demographics (e.g., age ranges, particular regions of the country, religions, etc.), the segment descriptions reflected each sub-group's family planning motivations and needs, and included a range of backgrounds. Demographic and geographic traits were not found to be significant drivers.
The team wanted to focus its resources on the segments and strategies that were most likely to create change, so the team prioritized segments and strategies based on their feasibility, scalability, and potential impact. In this instance, they estimated each segment’s potential to change by mapping out the relationship between family planning acceptance, proactivity, husband’s influence, and family planning need (results shown in graphs below).
Based on the findings of the segmentation analysis, the project decided to prioritize Healthy Proactives, Traditional Autonomists, and Sheltered Skeptics for programs aiming at increasing modern method (MM) contraceptive use. Healthy Proactives and Modern Elites were considered for programs encouraging people to shift to a more effective modern method. Conservative Passives were deprioritized due to their deep-seated barriers.
Camber Collective recommended several strategies for promoting family planning acceptance and use, which were in line with the goals of the National Family Planning Strategy. They included:
- Tailoring programming and communication to priority segments
- Improving the quality of healthcare worker counseling
- Improving consistency of contraceptive supply to health centers
- Strengthening data coordination and sharing, to track progress by segment
To support data use and partnership, the Hewlett Foundation and Camber Collective created the Communication and Programming Toolkit to provide guidance on incorporating national demand analysis' findings and insights into SBC programming. The toolkit includes strategic concepts, messages for further testing, and programmatic considerations for the two priority segments. It also seeks to reframe demand generation activities as a systematic process whose outputs can be tracked and measured, similar to how supply chain programs are viewed.
Effectively delivering these segment-specific strategies at scale could increase Niger’s modern contraceptive prevalence rate from 12% to an estimated 25–30% by 2020.
Going Beyond the Individual Level: Transform/PHARE’s Male Segmentation Analysis
After seeing the results of the women's national demand analysis, Nigerien stakeholders considered the additional progress that could be made by developing SBC strategies for a secondary audience: male partners. This idea was backed by formative research from the female segmentation work, which found that male partners' approval strongly influenced women's decision-making and use. Seeing men as both an obstacle and an opportunity, Camber Collective partnered with Population Services International, REM Africa, and the Nigerien government in 2017 to conduct a supplementary segmentation analysis of male partners as part of the consortium working on the USAID-funded Transform/PHARE project. Transform/PHARE is dedicated to developing, testing, and adapting leading innovations in marketing, research, and design to address barriers to modern contraceptive use in West Africa.
Data Collection
Adopting the data collection and segmentation analysis processes from the female national demand analysis, the team conducted a literature review and a quantitative survey of 1,144 men aged 15-54 from three regions in Niger.
The study focused on five core themes: masculinity, couple dynamics, faith, knowledge, and immediacy.
- Masculinity: How do men perceive themselves and the role of men in society more broadly?
- Couple dynamics: How do men view relationships, and the role of men and women within them?
- Faith: How religious are men and how does their faith influence their perception of family planning?
- Knowledge: How much do men know about family planning? Are there any widespread misconceptions?
- Immediacy: How important is family planning for men in comparison to other, more immediate and more tangible issues?
The responses revealed that men's general approval of positive couple dynamics and a woman's agency to make decisions about her health were not reflected in their own couple dynamics or family planning behaviors. The factors associated with this discrepancy varied throughout the population and were incorporated into a quantitative survey.
Segmentation Analysis
Using a latent class analysis, the Transform/PHARE team analyzed the quantitative data and identified significant drivers. They combined similar data points to create five key variables, which were used to develop six segments of male partners. The team created archetype profiles for each segment, based on their size, demographics, exposure to family planning, religiosity, gender perspectives, and self-perception.
The team also considered the interaction of the various male and female segments and paired likely segments together, based on observations made from qualitative partnership analysis data.
To prioritize strategies, Transform/PHARE compared the segments based on their propensity to change, which was determined by considering their levels of receptive thinking (i.e., degree of personal agency and flexibility in applying religious teachings), gender progressiveness (i.e., support for female empowerment and belief in balanced gender roles), and exposure to family planning (i.e., extent of current family planning knowledge, use, and intended and perceived used). Because of the feasibility and scalability of the recommended SBC approaches, as well as their potential for impact, the program decided to focus its activities on Novice Youth and Curious Traditionalists.
According to the findings, Novice Youth are strong choices because they represent a large segment that is critical for raising modern contraceptive use. They are also open to limiting family size, and want fewer children then their fathers. Curious Traditionalists want to learn more about family planning, have a high confidence in non-governmental organizations, and are keen to discuss family planning with their partner.
The team developed program recommendations and potential messaging for each of their prioritized segments (shown below).
Transform/PHARE has been working with Nigerien stakeholders to help them use their findings to create evidence-based SBC activities.
Promoting Targeted Counseling: Piloting a Segmentation Tool for the Animas-Sutura Project
After learning more about the contraceptive needs of men and women, Nigerien stakeholders wanted to see how this information could be used to improve family planning counseling sessions. In 2014–2015, the Hewlett Foundation, Nigerien Ministry of Health, and Camber Collective came together with Pathfinder International’s Animas-Sutura project to use the Nigerien segmentation results to develop and pilot a series of rapid assessment tools for community health workers who conduct household visits in health centers in Maradi and Tillabéri, Niger.
The aim of the pilot was to increase family planning acceptance and use by improving the quality and impact of family planning counseling sessions. By giving community health workers the tools to quickly understand and speak to their clients' specific wants and needs, the pilot hoped to personalize family planning and promote acceptance and adoption.
The Counseling Approach
For the pilot, community health workers were trained to create a welcoming environment, walk clients through a series of questions to determine their segment, use the segment-specific discussion cards to counsel clients, physically show clients the various family planning methods, clarify any questions, and thank clients for their time.
The Results
Evaluation data collected during monthly visits with community health workers and family planning clients found that those who were trained were able to successfully incorporate the tool into their work and were motivated to continue using it. Additionally, women who received counseling from the trained health workers were more knowledgeable, satisfied (i.e., would want the same counselor),and more open to using a modern method of family planning. They also felt they had enough information to make a good decision and were more likely to be interested in using oral contraception (42% compared to 34%).
“Thanks to this tool, we can directly evaluate the effect of our actions on our community – that is what is most interesting. We do not say the same thing to everyone: each segment receives personalized counseling. Thanks ANIMAS for your help!” – Community Health Worker, Madarounfa
Based on these results, Pathfinder International has expanded this strategy to its Reaching Married Adolescents project. There is an interest on the part of the Ministry of Health to determine the operational and financial requirements for scaling up the approach to all national health centers.
THE ADAPTATION:
Applying Advanced Audience Segmentation to Women in Cote d’Ivoire
Unlike Niger, Côte d'Ivoire was making progress in fertility and modern contraceptive use indicators. However, national stakeholders were discouraged by estimates that showed that these strides were not enough to reach the country’s ambitious Family Planning 2020 (FP2020) goal of 36% modern contraceptive use. They knew they needed to work together to reframe the family planning conversation to focus on demand generation and the need to accelerate progress. To this end, in 2015, the Transform/PHARE project decided to adapt the national demand analysis approach developed in Niger to the Ivorian context.
Data Collection
For this activity, the Transform/PHARE project implemented a multi-stage segmentation process, designed to gain a richer understanding of why different Ivorian sub-groups do or do not use family planning and how to effectively reach non-users. They conducted qualitative research, including literature reviews, expert interviews and focus groups with 1,000 women to better understand the drivers of contraceptive use and non-use. They also administered a quantitative survey to 1,049 women in 14 districts to identify the key contraceptive needs, attitudes, behaviors, and barriers.
Even from the early stages of the literature review and qualitative research analysis, the team saw that Ivorian women’s life stages, frequency of sex before marriage, and reasons for family planning use and non-use were vastly different than that of the Nigerien women they surveyed. It was clear the segments developed for Niger could not simply be adapted. Transform/PHARE would need to develop unique segments to represent the women of Cote d'Ivoire.
Formative research revealed three additional challenges to increasing contraceptive use that would inform their work:
- Many women in Cote d’Ivoire were having the number of children they ideally want to have (approximately five).
- There were two critical life stages to reach women, based on need and demand: young women in their late teens and early twenties (high demand/risk, low use) and older women entering higher-risk pregnancy phase (not aware of risk, low demand)
- Quality of service might be lacking. For example, women did not consider community health workers to be a primary source of family planning information.
Segmentation Analysis
To identify these segment-specific motivations, the team conducted a quantitative survey and latent class analysis. They combined the most significant drivers into five key variables.
The team used these variables to develop and name six segments.
The project created archetype profiles that summarized segments’ average age, remaining parity, stage of adoption, barriers to use, desired method characteristics, current engagement with family planning, and SBC programmatic considerations. To prioritize resources, the team then compared each segment’s agency, risk, and unmet demand to estimate which groups were more likely to change and which strategies had the largest potential impact.
The project determined that activities should focus on Pre-family, Struggling Aspirationals, and Family Limiters. They recommended strategies based on the needs of the priority segments, and focused on strategies with high opportunity for innovation and empowerment.
The team prioritized SBC approaches that could bridge the gaps in the user continuum, particularly between awareness and consideration and consideration to trial by educating youth, as well as challenged social norms around trust among couples and couple decision-making. These strategies included:
- Improving the reputation of the HCW as a trusted source of guidance and services
- Counseling all women by segment and ID High Low high-risk women through spacing beliefs
- Increasing easy accesss to modern contraception ,through traditional and non-traditional channels, for youth and Struggling Aspirationals
- Introducing tools to facilitate recognition of client concerns and needs
- Better educating providers on addressing fertility concerns, aligning need w/ method(s)
- Developing interventions to support women in finding the right modern contraceptive method and maintaining use
- Supporting the introduction of new contraceptives in Cote d'Ivoire and expanding access where needed
The results of this process demonstrated the adaptability and value of advanced audience segmentation. Estimates predict that implementing the recommended segment-specific SBC strategies would be enough to move target populations from family planning awareness to use, and enable Côte d’Ivoire to meet its FP2020 goal.
Impact projections suggest the targeted strategies would help move more women through the family planning stages of change.
Incorporating the Ivorian National Demand Analysis into an Evidence-based SBC Strategy
Inspired by the rich results that came out of the Nigerien national demand assessment, EngenderHealth’s AgirPF project decided to work with Transform/PHARE in 2015 to develop an evidence-based SBC strategy using the advanced audience segmentation work being done in Côte d'Ivoire. AgirPF implements activities in Niger, Togo, Côte d’Ivoire, Burkina Faso, and Mauritania that are aimed at increasing awareness, access, and use of quality family planning services among women of reproductive age in urban areas.
While the quantitative results were not yet available at the time of the strategy development, the group conducted focus groups and message testing with all of the segments that had been identified through the formative and qualitative research.
AgirPF used a multi-step process to develop their strategy.
Through focus groups with each prioritized segment, the AgirPF team identified the primary attitudinal factors and behavior change needs, as well as their corresponding segments of male partners. They also created and tested messages for religious leaders.
Using this process, AgirPF developed its overall message framing: “Sophisticated love, rich life.” The formative research on barriers highlighted powerful social norms that drove family planning consideration and use, such as a strong mistrust among partner, but also a deep desire for honest and loving relationships. The team wanted a campaign that encouraged partners to be “courageous” and start the conversation about their health and life. As such, the message framing speaks to the desire to use family planning as a path to social and financial success (i.e., that family planning is a sign that someone is intelligent and discerning, frank and interested, and cares about themselves and others.). These themes came out of the focus groups and message testing.
The AgirPF team ultimately decided to focus their efforts on three activities designed to speak to the needs and preferred channels of the three prioritized segments:
1) Group discussion with couples (designed for Family Planners/Family Limiters): Multi-day guided sessions, facilitated by midwives that were designed to foster couple communication around family planning. Midwives used a guide and five videos featuring professional actors to stimulate discussion among participating couples.
2) Group discussion with teen groups (designed for Pre-Family): Discussion sessions with teenagers and young people, facilitated by the non-profit Mouvement des Jeunes pour la Promotion de la Santé Sexuelle et Reproductive (MJP-SSR). Conversations were centered around the comic strip "Safi and Leo," an entertainment education tool created by AgirPF, which covered topics of sexual and reproductive health. Photos and discussion summaries were posted on Facebook resulting in 1,200 comments.
3) "Plan My Life" app (designed for Family Aspirationals/Struggling Aspirationals): A "Choose Your Own Adventure" style Android app, available on Google Play, which asks the user to make decisions based on a variety of sexual and reproductive health related scenarios. Every time the user makes a decision, they are given a new scenario based on the consequences of their last choice. Challenges are designed to help young people make informed sexual and reproductive health decisions, as well as encourage them to have open and honest conversations with their partners.
The Scale Up: Understanding Family Planning Demand in sub-Saharan Africa and Southeast Asia
Beyond Bias' Segmentation Analysis of Family Planning Providers
In 2017, Camber Collective partnered with Pathfinder International, YLabs, the Center for Effective Global Action’s Behavioral Economics in Reproductive Health Initiative, Aga Khan Health Services Tanzania, and Greenstar Social Marketing as part of the Beyond Bias consortium. Beyond Bias is a Bill & Melinda Gates Foundation-funded project that uses human-centered design to identify scalable solutions that address provider bias and improve young people’s access to and experience with contraceptive counseling and services. Beyond Bias works in in Burkina Faso, Pakistan, and Tanzania. For this project, the Beyond Bias consortium conducted a segmentation analysis to identify global and country-specific priority audiences of providers (doctors, nurses, midwives, other) and develop SBC programmatic recommendations.
First, the team created a bias driver tree from the insights they gained through formative research, which informed a quantitative survey aimed at identifying the most significant drivers of providers’ attitudes and behaviors. After analyzing the survey data, the team created four core variables, developed six provider segments, and summarized findings through segment-specific archetype profiles and programmatic recommendations.
Results showed that Beyond Bias should consider targeting the Detached Professional in Burkina Faso, as it is the most common segment (79%). This segment consists primarily of midwives who are apprehensive about providing services to youth despite frequently interacting with them. While there was a low acute need for reducing bias, the team found their services could be improved by focusing on emotional connectivity.
The team also found that Average Passives were the most likely to have the biggest impact among all three priority countries. This segment consists of primarily nurses and midwives who feel strongly that it is not their role to teach young people how to behave. The team suggested their barriers could be reduced by deepening their understanding of adolescent and youth sexual and reproductive health and building empathy through narratives and informal educational moments outside of official trainings.
The Beyond Bias project is currently discussing how to best integrate the findings and recommendations from the segmentation analysis into its program strategy and messaging.
Family Planning initiatives from several countries are using advanced audience segmentation approach to inform their work. Check back later for more information and updates.
Voices From the Field
There is no need to re-invent the wheel! Learn from those who have been involved in the advanced audience segmentation process.
“Advanced audience segmentation helps coordinate SBC efforts by giving government and implementing partners a shared language and solid data on which to design segment-specific strategies. Without robust audience segmentation, you risk making erroneous assumptions about a population or sub-populations. This can lead to different projects and partners designing and targeting campaigns in disparate ways, which means you miss out on a lot of complementarity, opportunities for collaboration, and a more effective use of limited resources. Now, with a consensus around the different audience segments, when we meet with the Ministry and partners, we can refer to the different segments by name when discussing strategies, and everyone is on the same page.” - Jim Malster, Transform/PHARE
"Audience segmentation lets you work together with relevant stakeholders to develop strategic programs. Rather than send random messages to everyone and hope they stick, segmentation helps you identify the channels or campaigns to reach your prioritized segments. For example, women who are more likely to use a contraceptive method. But identifying the segments is not enough. Once we had the results, it was important for us to hold convening workshops that brought together key actors who were best positioned to apply the findings into their work. We discussed how they could build the findings into work plans and make them operational.” – Luis Martinez, Transform/PHARE
"This process can take time, so it is important to really understand the context in which you are working before you begin your segmentation analysis. First, you should determine if supply, service quality, or demand is at the heart of the issues you are seeing. Once you know you should focus on demand, you should carefully choose the population that you are going to survey because it changes depending on the context. In Côte d’Ivoire, men had less influence on family planning attitudes and use. However, in Burkina Faso, we focused our segmentation on male partners because of the critical role they play in women’s health decision-making." - Aboubacar Sawadogo, EngenderHealth
“It is critical to engage the government and partners from the very beginning — from initial project design right through to the end, with frequent, on-going updates throughout the process. For example, we held workshops to share initial research findings, to discuss the draft segments and archetypes, collect feedback, and make adjustments when appropriate. This means the entire process goes a bit slower, but it’s worth it. While engagement takes time, it pays big dividends. These surveys come at a cost—if you are going to invest the resources, then you need to ensure buy-in of all partners and stakeholders to fully benefit from the results.” - Jim Malster, Transform/PHARE
“Sometimes SBC practitioners struggle with attitudinal and behavioral segmentation, because it is more difficult to visualize. This is because we are human and it’s in our nature for our first questions to be around how old these women are, where they live, their income level, etc. But in Niger, for example, although one of our segments skews younger, many ages are actually represented in the same segment. Advanced audience segmentation pushes SBC professionals to focus away from demographics and rather on the elements that truly motivate behavior change.” - Jessica Vandermark, Camber Collective
Conclusion
Family planning decision-making and use is a personal and sensitive topic. In order to effectively develop programs around these personal wants and needs, SBC practitioners must have a sophisticated understanding of their intended audience. Through advanced audience segmentation, practitioners are given the insights to both design targeted programs and messages that can effectively speak to their target audience’s situation, but they can also focus their resources on the sub-groups with the highest potential for change or the strategies with the greatest potential for impact.
The advanced audience segmentation process is incredibly context-specific. The segments developed for one population may look very different than the segments developed for another. Use the Advanced Audience Segmentation for Social and Behavior Change How-to Guide to follow the process on adapting it for any context or population.
Contacts:
- Cori Fordham, Breakthrough ACTION: corifordham@jhu.edu
- Jessica Vandermark, Breakthrough ACTION: jessica@cambercollective.com
This Spark Page is made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the Breakthrough ACTION Cooperative Agreement #AID-OAA-17-00017. Breakthrough ACTION is based at Johns Hopkins Center for Communication Programs (CCP). The contents are the sole responsibility of Breakthrough ACTION and do not necessarily reflect the views of USAID, the United States Government, or Johns Hopkins University.