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.
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.
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.
Next, Camber Collective used a mix of art and science to select the most important variables, often combining characteristics that described similar traits.
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.
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 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.
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.
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.
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 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.
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.
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.