Engaging men for improved family planning and nutrition outcomes
Why engage men?
Engaging men in health and nutrition programming provides an opportunity to move towards better health and gender outcomes
Historically, the development sector has anchored on family planning and nutrition programs that focus on women, both as end-users and as providers (e.g. ASHAs, ANMs, SHGs). While many of these programs have seen considerable success in their outcomes, challenges have emerged in the long run:
A disproportionate burden has been put on women, both as end-users and as the ones to deliver health programs.
These programs reinforce the imbalanced gender norms that underlie women’s unpaid care work and time poverty, and relatedly their mobility and workforce participation.
Men have been further alienated from the “female” domains of family planning and nutrition.
Evidence shows positive improvements in health, nutrition, and gender outcomes when men’s engagement increases, but falls short of showing lasting behaviour change at scale. There is a need for innovative programs that can fill this gap.
PCI India and Dalberg, with support from the Bill & Melinda Gates Foundation, set out in 2019 to answer the question: How might we engage men in nutrition and family planning through innovative and gender transformative programs in rural Bihar? Our over two year journey of research, design and testing culminated in two innovative programmatic solutions. Learn more in the video below.
Final programmatic solutions
1. NUTRITION
Dekh-Rekh
Dekh-Rekh provides parents the tools to visualise their nutrition habits and relate them to their aspirations, along with a financial planning course. This encourages them to have more conversations on food choices and make more informed and collaborative decisions on what they purchase, prepare and feed their children.
2. FAMILY PLANNING
Hamari Shaadi, Hamare Sapne
Hamari Shaadi, Hamare Sapne uses a financial education course to help newly-wed couples better understand how they can achieve their aspirations. This serves as a platform to incorporate conversations on family planning, delaying, spacing and limiting as a way to reach their financial goals.
1.NUTRITION
Dekh-Rekh
Make healthy habits your family goal
Based on our research and testing, we designed features and behavioural nudges that would enable men to adopt the desired behaviours for better household nutrition. 963 couples with a child aged 6-23 months enrolled in the program for the learning pilot. Baseline and endline surveys were conducted in intervention and comparison villages, randomly selected from the same block, to measure changes in nutrition outcomes, behaviours and knowledge, as well as spousal communication and decision-making.
Access the program materials here.
Findings from learning pilot
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Women in intervention villages reported a 30% point increase in MDD for children (aged 12-23 months) and men reported 25% points, significant compared to the 15% point increase reported by women in comparison villages and the 12% reported by men.
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The percentage of mothers (of children aged 6-23 months) eating five or more food groups increased by a net of 14%.
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Women in the intervention villages reported a net increase of 5% points in their husbands providing enough funds to meet their children’s food requirements, compared to those in the comparison. There was a net increase of 20% points in men reporting they “always” or “sometimes” discussed or participated in food preparation in intervention villages, relative to comparison villages. Finally, there was a net increase of 18% points found among women in intervention villages saying their husband’s participated in feeding, relative to comparison villages.
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Awareness among mothers about the minimum dietary diversity for children (aged 6-23 months) increased by a net of 34% among those exposed to program interventions compared to those not exposed. The net increase reported by men was 22% points.
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Couple’s communication about child nutrition increased by 24% among the couples exposed to the program, compared to those not exposed.
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CALENDAR USAGE:
Women were much more likely to fill the tracking calendar than men, but regardless of who put the stickers, women and men reported similarly (44% and 45%) on “always” or “often” discussing what to put on their calendar with their spouses.WATCHING OF VIDEOS:
Participants who watched all 5 videos were more likely to meet MDD requirements for their children.TOTE BAG:
Use of the tote bag was linked with program behaviours and outcomes- 47% of men and 59% of women who used the tote bag had children meet MDD, compared to 38% of men and 46% of women who didn’t. -
In joint families, in-laws were receptive to information on improving their grandchildren’s nutrition and shifting household roles, and some changed their purchasing decisions accordingly.
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Loss of income in the early stages of the pandemic impacted baseline MDD rates in both comparison and intervention villages, and recovery before the endline survey explains improvements in the comparison village. The depletion of savings during COVID-19 means that some families might still have a hard time adopting new habits that involve re-allocation of budgets. Yet, the fear of disease has parents prioritising their children’s health.
Program Journey
“Earlier, only I looked after the children. My husband used to get irritated if he had to look after them. But now he plays with them, shows them affection and feeds them if they have not eaten.”
- Woman participant
“After joining the program, we started saving more to fulfill our dreams. Earlier, we would purchase Rs. 100 worth of vegetables but now we purchase a small quantity of a variety of vegetables in Rs.60. Now we save money and also buy the food groups.”
- Participating couple
“My daughter-in-law started asking me to buy specific food items from the market, like banana, egg, meat, fish for the children, which she never used to do earlier.”
- Father/father-in-law of participating couple
“The calendar is in my mind when I go to buy vegetables.”
- Male participant
2. FAMILY PLANNING
Hamari Shaadi,
Hamare Sapne
Build savings, build a 'happy family'
Based on our research and testing, we designed features and behavioural nudges that would enable men to adopt the desired behaviours for better family planning. 1083 couples with zero or one parity enrolled in the program for the learning pilot. Baseline and endline surveys were conducted in intervention and comparison villages, randomly selected from the same block, to measure changes in family planning outcomes, behaviours and knowledge, as well as spousal communication and decision-making.
Access the program materials here.
Findings from learning pilot
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There was a net increase of 16% points in current use of contraceptives among women exposed to program interventions, compared to those not exposed.
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There was a net increase of 18% points in the proportion of women in intervention villages reporting that they had discussed delaying or spacing with their husbands in the preceding 3 months, and a net 25% point increase in men reporting discussing delaying or spacing in the intervention village, relative to the comparison village.
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A significantly higher number of women (16%) from intervention villages reported increased support from their husbands on contraceptive use, and men similarly reported support for their wives’ views around family planning and contraceptive use.
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As a result of the program, 48% of women and 82% of men knew about family planning at endline in the intervention villages, a net increase of 33% points for women and 31% points for men.
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WATCHING OF VIDEOS:
Most men and women reported watching videos, with the majority watching most of the six videos in the program. 58% of women who watched a video reported having seen six or more, compared to 51% of men.VIDEOS AND OUTCOMES:
The number of videos was correlated with the likelihood of talking with a healthcare worker about family planning, although the total number of men and women reported talking to an ASHA or ANM was small. -
Parents-in-law were receptive to new information around spacing and delaying. These messages particularly resonated when put in the context of long-term savings and future grandchildren’s education.
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Heightened financial pressures leading to affordability constraints, as well as concerns about visiting a health centre/hospital to access contraceptives during the pandemic might have influenced the rates of contraceptive use in both intervention and comparison villages.
Program Journey
“I knew about contraceptive methods earlier, but I never talked about or had seen it. After the CRP visit, I had a discussion about this with my husband.”
- Woman participant
“Earlier we never used to talk about family planning methods. We were afraid of what our father and mother will say. Mother would say, if you use this (modern contraceptives) you may not be able to have children in the future. But now we all discuss, and they say do as you feel right.”
- Participating couple
“Our goal is to make savings, we want to have two children only. We don’t mind having two children, but if both children are daughters then we will have pressure from our parents to have three children.”
- Male participant
“In my times, nobody was there to explain planning and budgeting to us, like how to be financially strong and then plan for a family, which is why we had children so early and couldn’t save much. I will make sure not to put pressure on my daughter-in-law to have children early, just after marriage.”
- Mother/mother-in-law of participating couple
Key insights from programs
1.
Financial planning as a gateway
Using financial planning as an entryway offers couples the license to discuss family planning without the stigma.
Financial planning also shifts the perception that nutrition habits are rooted in affordability, and hence unchangeable.
2.
Spousal communication and decision making
Couples get their information on child nutrition and family planning in silos, with little opportunity to discuss and make decisions together. This, along with strictly divided household gender roles, drives the gap between awareness and action.
3.
Program delivery through couples
Young couples find comfort in speaking with other married couples, who they perceive as “role models”, about topics like child health, financial and family planning.
Receiving information on these topics together as a couple opens up a trusted space for spousal communication.
4.
Cross-generational behaviour change
Food and family planning are household decisions, with older family members influencing young couples’ choices.
At the same time, older family members are amenable to change, and are particularly motivated when they can see how family planning and food choices relate to financial goals and improvements in child health.
5.
Generating social proof
Young couples are influenced by the opinions of their peers and socio-cultural norms that protect existing gender roles.
Providing visual cues of the program in the community and the support of other community members can generate social acceptance of new behaviours, lead to sustained change and mitigate backlash.
6.
Edutainment for deeper engagement
Gamification of program features makes it easier for parents to stick to the habit of tracking their children’s nutrition and offers visible cues of progress. Weekly feedback on parents’ progress keeps them accountable and motivated.
Introducing family planning concepts through relatable characters and audio-visual stories makes it more engaging and accessible for couples and their families, and helps them apply these concepts to their own lives.
7.
Digital channels for wider reach
Digital channels help override the tentativeness that communities feel about welcoming outsiders and attending group meetings during the COVID-19 pandemic.
Digital channels ensure that couples are not left out of programs when one partner migrates, or families have to travel during special events.
Our journey
We developed and tested these programs over two and a half years and six phases. Soon after we began ideating on potential programmatic ideas, the COVID-19 pandemic began. The pandemic shaped the prototyping and proof-of-concept phases in critical ways, prompting us to adopt a hybrid between remote and in-person research. During these phases, we worked with community resource persons to prototype and pilot the programs and gather nuanced learnings from their program delivery experience. Furthermore, persistent fear of transmission and increased migration due to COVID-19 led us to use digital platforms to implement certain program features that would have otherwise needed in-person interaction.
Our interdisciplinary approach
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1. HUMAN-CENTRED DESIGN RESEARCH AND CO-CREATION
We conducted in-depth interviews, small group discussions & ideation sessions, intercept interviews, observations and shadowing with a diverse mix of 92 participants in two districts of Bihar. We engaged with couples, their families, and other stakeholders across the ecosystem to uncover their needs, behaviours and aspirations, understand their reactions to early ideas, and generate nuanced insights.
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2. BEHAVIOURAL SCIENCE
We used behavioural frameworks to understand couples’ aspirations and motivations. We ideated rigorous behaviourally-informed solutions for male engagement to drive nutrition and family planning outcomes, organised around knowledge, motivation, and enabling environments, and developed impact pathways to keep us anchored to the behaviour change frameworks.
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3. LITERATURE REVIEW & EXPERT INTERVIEWS
We conducted a literature review of 40 reports and studies, as well as learnings on couples’ engagement in family planning generated by ICRW and Vihara. This helped us identify actionable learnings on program design and men’s behaviour that formed the basis of our program ideas. We also interviewed six sectoral experts to gain a swift understanding of the evidence landscape.
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4. RAPID PROTOTYPING
Rapid prototyping enabled us to stress-test the key features and interactions of the programs in real-world conditions and further refine the program design. We conducted this live prototyping of the programs with 10 diverse couples and 11 community stakeholders.
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5. PROOF-OF-CONCEPT
We rolled-out and assessed the full programs with almost 2,000 couples participating, and used a qualitative and quantitative data collection approach to assess the programs’ effectiveness in delivering on outputs, and get early indications of their influence on behaviours and outcomes. Learnings gathered during this stage helped us make final refinements to the programs and their implementation.
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6. COMMUNITY PARTICIPATORY RESEARCH
At various points in our journey, we collaborated with community representatives as partners for research, design, and testing. Community representatives were closely involved with gathering feedback and sharing their learnings to inform refined programs during the prototyping and proof-of-concept phases. Community participatory research served not only as a way to gather rich insights, but also to shift power dynamics between stakeholders.