Series J, Number 56
Family Planning Programs

CONTENTS

Home (Key Points)

Communication Motivates Behavior Change
Figure 1. Family Planning Communication Evolves

Spotlight: Ethiopian Radio Serial Follows Process to Success

Box: Theories Inform Behavior Change Communication

Communication—A Process, Not a Product
Figure 2. Defining SMART Objectives
Figure 3. Elements of a BCC Conceptual Framework
Table 1. Many Choices for Behavior Change Communication Programs

Box: Egyptian Project Combines Channels to Reach Families

Planning for the Future

Box: Participatory Approaches Empower Communities

Bibliography

Credits

• Model for a Creative Brief
• INFO Reports: “Tools for Behavior Change Communication”

• What BCC Programs Can Achieve
• Characteristics of Effective BCC Programs
• Planning Documents That Help Guide Implementation

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See companion INFO Reports, "Tools for Behavior Change Communication"
See companion INFO Reports, "Entertainment-Education for Better Health"
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Spotlight
Ethiopian Radio Serial Follows Process to Success

In Ethiopia an Amharic-language radio serial drama, Yeken Kignit (“Looking Over One’s Daily Life”), used entertainment-education as a means to improve women’s and men’s reproductive health and to promote contraceptive use. The radio drama motivated many Ethiopians to use contraception and get tested for HIV. Communication staff followed a systematic process of program planning, implementation, and evaluation (see Communication—Process, Not a Product). Research findings and behavioral theory informed strategy and design. Pretesting and monitoring with the intended audience ensured relevant storylines and sensitivity to sociocultural, gender, and religious differences (42, 146, 191).

In entertainment-education programming, educational content is seamlessly woven into an entertainment format such as dramas on radio or television, animated cartoons, popular music, or street theater. Entertainment-education can contribute to social change and influence people’s awareness, attitudes, and behaviors by showing desirable behaviors rather than describing them, by addressing norms and beliefs that may be too controversial to confront directly, and by reaching populations who might otherwise be difficult to reach, such as youth (122, 172, 173, 214). (For more about entertainment-education, see the companion INFO Reports, “Entertainment-Education for Better Health.”)

Yeken Kignit aired on Radio Ethiopia from June 2002 to November 2004. Population Media Center (PMC), an international organization specializing in entertainment-education, developed and produced the drama. Multiple storylines in the drama addressed HIV/AIDS, family planning, education of girls, and spousal communication.

Step 1: Analysis Provided Foundation for the Program

The radio program grew out of numerous discussions among various stakeholders, including several government agencies, donor governments and foundations, local nongovernmental organizations (NGOs), business leaders, and reproductive health researchers (161). These discussions helped to focus the program’s mission and to assure that objectives and messages were specific and appropriate for Ethiopia (161).

Formative research included a review of previous health communication activities in Ethiopia, identification of audience subgroups, and interviews with technical experts (161, 191, 192). In May 2002 PMC partnered with the research firm Birhan Research and Development Consultancy to survey over 2,000 women ages 15 to 49 and men ages 15 to 59 in two regions and the city of Addis Ababa for baseline data. Questions covered risk perceptions and behaviors, the influence of culture on sexual and reproductive health decision-making, and knowledge of family planning and HIV/AIDS (161, 192). Producers and writers also visited rural villages to learn what issues and problems people discuss, to collect popular sayings and stories, and to see how health and social services were set up. At the same time, they recorded village sounds for use in the drama (161, 192).

Step 2: Strategic Design Established the Communication Channel and Objectives

Discussions with numerous stakeholders identified radio as the communication channel for the program. The program arranged with Radio Ethiopia to air the drama. Only Radio Ethiopia reaches a majority of the country’s population (161).

PMC staff designed the program to address problems identified in the audience research. These problems included high levels of unmet need for family planning, negative attitudes and misperceptions about contraceptive methods, lack of spousal and parent-child communication about HIV/AIDS, lack of knowledge about modes of HIV transmission and prevention, and high levels of stigma and discrimination against people with HIV and AIDS (146).

The overall program objective of the radio drama was to promote family planning use for birth spacing and limiting and to improve the reproductive health of men and women in Ethiopia. Its specific communication and behavioral objectives were to improve among the intended audience: (1) contraceptive knowledge, attitudes, and practices; (2) HIV/AIDS awareness, attitudes, and behaviors; and (3) perceptions regarding women’s status and other broad factors that influence reproductive health and family planning indirectly, such as the value of children and family size.

Step 3: Development Used Theory and Evidence, Pretesting Ensured Relevance

PMC developed Yeken Kignit following the Sabido methodology, created by Mexican television producer Miguel Sabido of Televisa (Mexican television) originally for commercial programs (114, 145, 162, 173, 174). Programs in several countries have used this methodology successfully (145, 162, 173, 174), and the U.S. Centers for Disease Control and Prevention recently adapted it (41, 70, 141). The Sabido methodology draws from five theories of communication and behavior change: Shannon and Weaver’s Communication Model, Bentley’s Dramatic Theory, Jung’s Theory of Archetypes and Stereotypes, Albert Bandura’s Social Learning Theory, and MacLean’s Concept of the Triune Brain, supplemented by Sabido’s Theory of the Tone. These theories provide a foundation for the structure and design of messages, settings, characters, and plots. They also provide a framework for predicting how and why the drama will affect the knowledge, attitudes, and behaviors of the listening audience (12).

In the Sabido methodology, statements expressing values identified by formative research help to define three types of characters: positive characters, negative characters, and transitional characters. The transitional characters start out uncertain but adopt more positive behaviors during the course of the drama. Transitional characters are the real role models for the audience. They encounter real-life barriers and challenges while changing their behavior, and they alternate between negative and positive values while doing so—a process that audience members themselves would undergo (11, 162).

To ensure high quality, the program recruited program coordinators with experience in radio broadcasting and theatrical arts and scriptwriters familiar with family planning and HIV/AIDS issues (161). Then, along with selected stakeholders, the staff including producers and scriptwriters participated in a five-week training workshop on designing an educational and entertaining radio serial. During training researchers presented findings from the audience research. Producers and scriptwriters used these findings to help them develop relevant characters, including Fikirte, the key positive character (161, 191). Fikirte talks to her friends and family about the benefits of family planning and encourages her stepfather to send her sister to school. Damte, the key negative character, has multiple sex partners and is involved in drug trafficking. Wubalem, one of the transitional characters, is caught between her husband wanting a child now and Fikirte’s advice to avoid getting pregnant for awhile. Fikirte urges Wubalem to give her body time to heal after her fistula surgery and to wait until she and her husband are more financially stable. Later, Wubalem convinces her husband that it would be good for her to use contraception for some time (192).

An advisory committee, created during the formative research phase, consisted of scriptwriters, program producers, gender and health experts, communication experts, and theater arts advisors from the community. The committee guided the creation of program content and coordinated with health services to ensure that providers were prepared when the drama brought in more clients (11, 161, 191). A technical advisory committee also reviewed each script for medical accuracy (161).

Program staff created four pilot episodes. They pretested the pilot episodes in focus group discussions with members of the intended audience to ensure that the different storylines were clear and relevant, that the language used in the serial drama was suitable, and that the characters were appealing and engaging (161, 191).

Step 4: Implementation and Monitoring Improved Storylines

Radio Ethiopia broadcast new episodes of Yeken Kignit twice a week in the evenings and rebroadcast the episodes in the afternoons. Between June 2002 and November 2004 Radio Ethiopia aired 257 new episodes.

The program monitored audience response in various ways (11, 161). For example, the program established listener groups and collected listening diaries, conducted three waves of focus group discussions, analyzed a sample of letters from listeners, and conducted exit interviews at hospitals and clinics.

Scriptwriters used the audience feedback continuously to shape the scripts (161). For example, the audience felt that the key negative character, Damte, was too devilish and the key positive character, Fikirte, was overly pious and angelic. Therefore scriptwriters toned down both characters to make them more realistic and credible (192).

Step 5: Evaluation Found Reproductive Health Behaviors Improved

Just after the last broadcast between November and December 2004, researchers from the research firm, Birhan, surveyed nearly 3,000 men and women in the same areas where the initial survey took place (42, 146). Among survey respondents who listened to the radio, 77% of men and 78% of women said that they heard Yeken Kignit. Youth and young adults listened more often than any other age group (146, 191).

Study results indicate that the radio program contributed directly and indirectly to use of reproductive health and family planning services. Before the radio drama aired, 12% of currently married women were using a modern contraceptive method (146). After the radio drama aired, married women who had listened to Yeken Kignit were significantly more likely than married women who had not listened to the drama to be using a modern contraceptive method (40% compared with 25%) (160). This difference remained even after the analysis took into account other possible influences on contraceptive use, such as age, education, and religion.

In addition Yeken Kignit contributed to improved HIV-related behaviors. For instance, listeners were twice as likely as nonlisteners to have been tested for HIV even after taking into account such factors as education and ethnicity. Also, listeners consistently had lower levels of stigma-related attitudes than nonlisteners. For example, among men, 82% of listeners said they would feel comfortable spending time with an HIV-positive friend compared with 57% of nonlisteners, and 86% of listeners felt there is nothing to be ashamed of if a family member has HIV or AIDS compared with 60% of nonlisteners (146).