Behavioural Aspects Impacting Family Planning

India continues to have a fertility rate of 2.2 per cent per year despite years of work on family planning. Though our growth rate was slower than in 1970s-1980s. It was 2.5 per cent during 1971-81, which has come down to 1.3 per cent as of 2011-16. However, there are pockets in the country that still have a very high fertility rate especially in the northern states. We have made significant progress but still, need significant work in certain areas.

The contraceptive prevalence is almost stagnant for some time now and does not show any signs of growth in certain pockets despite years of work. Family Planning (FP) as a phrase is still a taboo and is typically treated with derision. We have made significant gains but these need to be sustained so that we do not lose what we have gained.

We have seen two broad FP marketing milestones in the Indian context. First, Nirodh era which was driven by ‘Hum Do Hamare Do’ messages and next phase initiated by a leading condom brand whose advertising led to the dawn of ‘Sexuality and Pleasure of Sex’ era albeit restricted to the urban markets.

Despite a radical shift, the under-served markets still remain ‘underserved’. In these areas, instead of trying new things, several firms are still pushing old fashioned preachy messages resulting in poor compliance. On the other hand, brands at times unintentionally hurt the sensibilities while aiming to titillate the audience, which again leads to alienation at best and rejection at worst.

Having spoken to a number of people who have worked and travelled extensively across the country to understand the barriers to adoption of modern FP methods, it made me think why FP programs do well in certain areas while lagging in the others. Are there any cultural factors which can have a significant impact on the outcome of FP programs and may imply restructuring of existing communication approaches?  Well, I do not have definitive answers, but I have tried to hypothesize a list of factors that can have a favourable or an adverse impact and need to be kept in mind while designing the communication and/ or program approaches:

Patriarchy

It is one factor that seems to have some definitive impact on the outcomes. We all know patriarchy defines Indian culture. There is significant societal pressure on the male heir to prove his fertility by extending the family lineage within a year of marriage. This seems to be one defining factor that has led to increase in adoption of FP methods like female sterilization and has successfully(pun intended) kept men out of the gambit of family planning. Traditional approaches consisting of preachy messages, inter-personal approaches seem to fall flat if a region is over-indexed on patriarchy. The approaches may need to be redefined after getting an initial understanding of the region and then defining the communication approaches. Instead of attacking the patriarchal mindset, it may be prudent to play it appropriately in the communication by focusing on the ‘Male-Provider’ ego while subtlety highlighting the importance of feminism. It may be advisable to leverage patriarchal moral authority and social privileges to achieve the goals while gradually promoting gender equality.

Migration

India is migrating to urban places at a rapid pace. Temporary or employment-related migration is the biggest contributor to people moving from rural to urban areas. This temporary migrants typically float between the city and their village depending upon the availability of employment. These people, exposed to the urban way of living, have the potential to be the harbingers of change. This presents a huge opportunity for the FP ecosystem stakeholders to change behaviours and attitudes by leveraging these populations. This segment is uniquely positioned to be an agent of behaviour change due to their access to the newer way of thinking in the urban areas while retaining significant influence in their communities. If properly targeted, this segment can help in achieving what generations of marketers have not been able to achieve, bring down the fertility rate by increasing the involvement of men in family planning by ensuring that they become the harbingers of modernity in their homes. It may be critical to understanding the extent of migration in a community before launching the program as well as designing programs exclusively targeted at the migrant populations.

Entertainment avenues

It is a well-known fact that rural areas lack avenues for entertainment. Despite strong community living, there seem to be very few avenues to release the steam. The public health initiatives also seem to be too strongly hinged on inter-personal communication approaches which typically lead to monotonous one-on-one interactions. Such a monotonous structure of the interactions and uninviting messages seem to significantly dilute the impact. If one were to look for alternatives, one would find that there are proven opportunities to leverage folk-art, street theatre to bring the desired behaviour change, but are seldom used due to cost and reach constraints. Conversations initiated through such methods can lead to significant and long-lasting impact. It is not essential to do street theatre or entertainment events every time to effectively communicate the behavior change messages. One can leverage the oral traditions that have been traditionally used to disseminate messages for centuries; involving folktales and fables, epic histories and narrations, proverbs or sayings, and songs. This can make the entire interactions more entertaining and informal rather than being too moralistic.

Reducing the focus on instant results and redefining results criteria

We all know the ‘quarterly results’ feature of the corporate world where the managers are too focused on maximizing the profits and revenue every quarter. The same seems to hold true for the professionals managing the family planning programs. There is a focus on measuring the outcome in the region within a given period of time through various sophisticated approaches. This is, of course, required to ensure that the teams work in the right direction and no one wastes resources. However, given the multitude of variables, it is often impossible to accurately quantify the success in the given geography in a limited period of time. At times, it leads to rejection of a perfectly good strategy, which could have worked provided all the extraneous variables had been handled correctly. Therefore, it is critical to have a robust results framework in place which takes into account both macro and micro factors provisions for qualitative/ directional understanding apart from pure quantitative approach to ensure those good strategies are not rejected due to ‘obsessive quarterly focus’ since behaviour change takes time.

Nature of work women/ girls are engaged in

It is well established now that women/girls are often burdened with a significant degree of household work, including cooking, cleaning, collecting drinking water, nurturing children in the BPLareas. Despite this being a general norm, one notices significant regional differences in this aspect India. The Southern and Western Indian women seem to be more independent while they are homebound in some of the North Indian states. It is possible that the nature of work of women could have a significant impact on the family planning choices. In some of the North Indian districts and villages, girls are married off at a very early age and have limited voice in the household matters. Limited mobility along with rigid role definition typically leads to low compliance. On the other hand, place, where women are more empowered, would seem to have better compliance.

Strict gender-based roles

It seems that places which have a very strict definition of male vs female roles and responsibilities may have poorer family planning outcomes. The families which seem to have very strict demarcation of male Vs female worlds, tend to have poor intra-family communication leading to lack of ownership as far as family planning is concerned due the negative emotions associated with it like shame, embarrassment, guilt, etc. As soon as there is a discomfort in discussing a particular need/requirement, it often results in poor compliance and a tendency to brush it under the carpet. This perpetuates a vicious cycle leading to poor compliance and outcomes.

Understanding the above factors and ensuring that the teams act on these are critical to ensure that we continue to sustain the significant progress made so far. It is extremely important to ensure continued compliance as India accounts for a meagre2.4 per cent of the world surface area of 135.79 million square kilometres yet it supports and sustains a whopping 17.75  per cent of the world population. We are still on the way to become the most populous country in the world soon. The only way to ensure that we continue to control the population growth is by understanding the cultural nuances to leverage those effectively to keep the growth under check.