An Assessment Of Family Planning Communication Approaches In Nigerian Urban Reproductive Health Initiative (nurhi) In Kaduna, Nigeria

ABSTRACT

 The low rate of adoption of modern family methods has long been a bone of contention in Nigeria and especially resisted in Northern Nigeria. Despite huge sums of monies expended in order to enlighten the populace on the need for family planning, the use and access of family planning services has remained relatively low. This apathy by the populace is not unconnected to the fact that the communication approaches that were used have not answered nor conformed to the people‟s cultural and religious beliefs. Furthermore, the people‟s opinions were not sought. The method of the flow of communication was one-dimensional: top to bottom. The Nigerian Urban Reproductive Health Initiative (NURHI) is an organization that aims to increase the demand for modern family planning methods. In order to achieve this, the organization embarked upon a systematic and strategic means of communication. This study therefore sought to review NURHI‟s communication approaches via the use of the Questionnaire, Focus Group Discussion and In Depth Interview with the view to assess the success and or otherwise of the communication approaches and also bring to the fore the need for participatory communication that can lead to sustainable development. One of the findings of this research was the need for intensified participatory communication approaches and not only the use of media as means of communication. This is because, the fear of side effects of modern family planning methods, the need to nurture children and cultural and religious biases are still barriers to accessing modern family planning methods. Thus there is a need for an unconventional approach to attaining sustainable development.

TABLE OF CONTENTS

Title Page ---------------------------------------------------------------------------------------------------- i

Declaration -------------------------------------------------------------------------------------------------- ii

Certification ------------------------------------------------------------------------------------------------- iii

Dedication ---------------------------------------------------------------------------------------------------- iv

Acknowledgements ----------------------------------------------------------------------------------------- v

Abstract ------------------------------------------------------------------------------------------------------ vi

CHAPTER 1:INTRODUCTION

1.0 Introduction---------------------------------------------------------------------------------------------1

1.1  Background of Study -----------------------------------------------------------------------------6

1.2 Statement of the Research Problem ----------------------------------------------------------------- 14

1.3 Aim of the Study --------------------------------------------------------------------------------------  15

1.4 Objectives of the Study ------------------------------------------------------------------------------- 15

1.5 Research Questions ------------------------------------------------------------------------------------ 15

1.6 Justification for the Study----------------------------------------------------------------------------- 16

1.7 Scope of the Study ------------------------------------------------------------------------------------- 16

CHAPTER 2:REVIEW OF RELATED LITERATURE

2.0 Introduction -------------------------------------------------------------------------------------------- 17

2.1 Health Communication ------------------------------------------------------------------------------- 17

2.2 Health Communication, Health Promotion and Health Education ---------------------------- 22

2.3 Strategies of Health Communication --------------------------------------------------------------- 24

2.3.0 The Behavioural Change Approach ---------------------------------------------------------- 25

2.3.1 The Self Empowerment Approach ------------------------------------------------------------ 25

2.3.2 The Collective Approach-------------------------------------------------------------------- ---26

2.4 Historical Origin of Reproductive Health Right --------------------------------------------------- 28

2.5 The Reproductive Health / Family Planning Situation in Nigeria -------------------------------30

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CHAPTER 5:SUMMARY, RECOMMENDATIONS AND CONCLUSION

5.0 Introduction---------------------------------------------------------------------------------------------- 78

5.1 Key Findings -------------------------------------------------------------------------------------------  79

5.2 Conclusion ----------------------------------------------------------------------------------------- 80

5.3 Recommendations-------------------------------------------------------------------------------------- 81

References -------------------------------------------------------------------------------------------------- 82

APPENDIX I: Sample Questionnaire

APPENDIX II: Key Informant Interview Discussion Guide

APPENDIX III: Focus Group Discussion Guide

APPENDIX IV: Picture

CHAPTER ONE: GENERAL INTRODUCTION

 1.0      Introduction

 Reproductive freedom is critical to a whole range of issues. If we cannot take charge of this most personal aspect of our lives, we cannot take care of anything. It should not be seen as a privilege or as a benefit, but a fundamental human right (F. Wattleton, 2011:6).

The term development has over the years evolved to mean different things to different individuals and groups. While some view development as economic growth or rise in Gross Domestic Product (GDP), others view it as a comprehensive growth or rise in an individual‟s life resulting in a total well being of aperson‟s life. (Ideas for Development 2005:186).

In trying to increase the total well being of an individual, it has been deduced that reproductive health is a fundamental aspect of one‟s well being. This is because it is linked to ones emotional and physical needs. According to the Reproductive Health Journal, reproductive health is defined „as a state of physical, mental, and social well-being in all matters relating to the reproductive system at all stages of life. (http://www.reproductive-health-journal.com/about/faq/whatis). Having good reproductive health implies that people are able to have a satisfying and safe sex life, the capability to reproduce, and the freedom to decide if, when, and how often to do so.

With the high rate of maternal and child mortality, high poverty rate, death from Malaria and Human Immuno Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), many conferences have been held to debate andproffer solutions to such problems. The International Conference on Population and Development (ICPD), 1994 which had a Programme of Action aimed at empowering women and providing them with more choices through expanded access to education and health services, skill development and employment. The ICPD also aimed to empower women through ensuring that they were fully involved in policy- and decision-makinprocesses at all levels. One of the primary goals of the Programme of Action was to make familyplanning universally available by 2015 as part of a broadened approach to reproductive healthand rights. It also addresses issues pertaining to population and includes goals to further reducelevels of infant, child and maternal mortality. This is because population, maternal child healthand mortality are all dependent on Sexual Reproductive Health.

Based  on  the  global political reaffirmation of the  ICPD  agenda,  reproductive  rights, including universal access to reproductive health through their life cycle, are now considered a human right for all people. The term reproductive right has been further explained in the Beijing

Platform   for   Action   (BPFA1995)   and   theInternational   Conference   on   Population     and

Development ICPD (2005) documents as:

Therefore,   family   planning    is   now   understood  within   the   broader   framework   of

reproductive health and rights and not just as a population control instrument. This led to many

countries adopting the ICPD policies and implementing reproductive policies in their countries.

Although there has been considerable progress since the ICPD, especially in terms of

reproductive health, millions of people – mostly disadvantaged women and adolescents, still lack

access to information and services as it pertains to reproductive health. In developing countries,

about 201 million married women lack access to modern contraceptives. There are about 340

million new cases of sexually transmitted infections (STIs) each year and 6,000 young people are

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infected with HIV every day, (United NationsProgramme of Action, 1994). Also, the document reveals that millions of women and adolescent girls continue to suffer from death and disabilities during pregnancy and childbirth.

Reproductive health is seen as an intrinsic part of development.Indeed if the reproductive health of a people is improved then there will be a higher capacity for productivity that will enable people to live satisfying and fulfilled lives. With the realization that development is neither static nor about economic growth alone, but rather a process of involving and empowering the people, there led to the development of various theories that are aimed at involving the people that will lead to people‟s empowerment. This led to the growth of what is now called development support channels or development communication. Development communication, though diverse in nature, has grown from just providing information through mass media to involving the people and due to its important and dynamic features, it can be applied to a myriad of social and behavioural issues that will lead to people being empowered and ultimately lead to sustainable development.

Although people‟s perception of reproductive health is faced with a myriad of challenges, it is gradually accepted as a necessary aspect of life especially in terms of population growth of Nations. In 1979, China as a result of its population boom enacted a National Policy that limits the number of children that a couple can have to one. In Nigeria, former President Goodluck Jonathan on 26^th June, 2012 while inaugurating the newly constituted National Population Commission board said the government was contemplating a legislation to control population growth (The Nation Newspaper 27^th June, 2013). After the news broke, there was a lot of outcry especially as it pertained to people‟s beliefs.

men  and  women  are    informed  about   and  have  access  to   safe,  effective,  affordable,  and

acceptable methods of family planning of their choice, and the right to appropriate health-care

services that enable women to safely go through pregnancy and childbirth.

Reproductive health is usually seen as a woman‟s sole prerogative.       Ladan (2003) posited that

the state of a woman‟s health is very importantin order to bring about a reduction in“maternal

mortality and morbidity and their impacts on infant mortality” (Review of Existing Reproductive

Rights and Health in Nigeria:2003). In the consideration of reproductive health of women,

certain  indices  readily  come  to  mind,  like  family  planning,  abortion,  sexually  transmitted

diseases including HIV/AIDS, premature and early marriage, safe motherhood comprising pre

and post natal care. Other issues include safe sex and gender equality, sexual dysfunction in

women such as infertility, female genital mutilation, marital rape, other sexual violence against

women, and reproductive health problems associated with menopause. All of these are sexual

and reproductive issues which women usually face or are at the receiving end, which explains

why reproductive health is mostly viewed as a problem associated with women. Ladanin his

paper Review of Existing Reproductive Health Policies and Legislation in Nigeria:(2006: 26)

Reproductive and health rights are of paramount importance as a vital aspect of general health. It

is a central feature of human development as it reflects health at childhood, adolescent and

 adulthood. The mismanagement of the reproductive health of an individual whether male or female, affects the health of the next generation. Although reproductive health is a universal concern, it is of special importance to women especially in their reproductive years. The health of a newborn is largely determined by the state of its mother‟s health which includes nutritional status and her access to healthcare services.

Reproductive health is highly connected to many of young people‟s issues such as completing education, finding employment, securing their economic position, making secure relationships and eventually founding a family of their own. Reproductive health is an important component of general health; it is a prerequisite for social economic and human development. This is because since human energy and creativity are the drawing forces of development, the highest attainable level of health is essential because of social and economic reasons ().

With the high incidences of maternal mortality especially in developing countries, there is an urgent need for increased investments in Sexual Reproductive Health (SRH) information and particularly the most vulnerable as:

i.            Poor SRH accounts for an estimated one third of the global burden of illness and early death among women of reproductive age (UNDP. Public Choices, Private Decisions: Sexual and Reproductive Health and the Millennium Development Goals. Berstein, Millennium Project, 2006)

ii.             About 201 million married women in developing countries still have an unmet need for modern contraceptives. Data from 94 national surveys indicate that the unmet contraceptives need among sexually active adolescents is more than two times higher than among married women. In sub Saharan Africa for example, as many as 46 % of women face this problem. Globally 37 countries have an unmet need for family planning

that is greater than 20% and 24 countries have a prevalence rate for modern methods that is less than 10% (UNFPA and the UN Population Division. 2008)

Couples and individuals need access to improved SRH information and services to be able to participate in the social development and economic life of their countries as well as for improved quality of life. Many organizations believe that the realizations of reproductive rights through improvements in SRH is a necessary condition to achieve poverty reduction at both household and macro levels. The influence of reproductive rights on population dynamics such as fertility, mortality and age structure and their influence on social and economic development support a strong argument for policymaking on poverty reduction to increase in reproductive investments. Nigeria, for example, with a Maternal Mortality Ratio (MMR) of 800 per 100,000 live births (UNDP Report on Reproductive Health 2008), still has an extremely high maternal mortality ratio, one of the main indicators of the state of reproductive health in the country.

1.1         Background to the Study

Nigeria is a country with One Hundred and Sixty Seven Million People (Nigerian Population Commission). It is viewed as one of the foremost African countries with the fastest rate of economic growth. Despite this positive assessment, this does notnecessarily translate into a total wellbeing in the life of an average Nigerian. Many development workers argue that several indicators noted in the life of a Nigerian show that the economic growth of the Nation is yet to impact positively on the life of the Citizens. Foremost among these indicators is the totally unacceptable high maternal mortality in the Country. A major development and health challenge in Nigeria is the high level of maternal deaths arising from complications related to pregnancy and childbirth. The current maternal mortality ratio is estimated to be 800/100, 00 live births

Over the years in Nigeria and indeed developing countries, it has been determined that various reasons account for this high rate of maternal mortality. These issues range from cultural and socio economic reasons, mal-nutrition and inadequate access to and use of reproductive health, inadequate birth attendants, live birth without the assistance of skilled birth attendants and doctors. Also key to the high prevalence of maternal mortality is the inadequate knowledge and access to reproductive health. According to the World Health Organization (WHO) ”Reproductive Health accounts for the 20% of the global burden of ill health for women, and 14% for men” (Reproductive Health Strategy – World Health Organization 2008).

The steady death toll of women during childbirth led to the listing of one of the Millennium Development Goals as improving maternal mortality. The Millennium Development Goal is a strategy document which is aimed at prompting actions from federal and states government to ensure that policies, infrastructure and enlightenment are carried out to ensure the development of the developing world especially in terms of the standard and quality of life of its populace. Achieving universal access to reproductive health is one of the two targets of Goal 5 – Improving Maternal Health. To monitor global progress towards the achievement of this target, the United Nations has agreed on the following indicators:

5.3: Contraceptive prevalence rate.

5.4: Adolescent birth rate.

5.5: Antenatal care coverage.

5.6: Unmet need for family planning(United Nations2008 Millennium Development Goals, http://www.un.org/millenniumgoals).

·         Child spacing by self-determination of periods between the childbirths.

·         Professional care during pregnancy and childbirth.

·      Timely access to hospitals where complications can be treated by Caesarean cut (WHO factsheet, 2008).

It is however important to note that the above stages will be unachievable and futile

without effective adequate communication. Effective communication with the participation of the people will serve to empower them with the right information, clearing misconception and perceptions, and drawing upon their knowledge and inherent wisdom to bring about a reduction of maternal and child health in their families and communities at large.

Despite the several benefits embedded in good reproductive health, many factors however hamper the promotion, use and access to good reproductive health services. The challenges to the protection of reproductive health rights on the other hand include lack of awareness, lack of political will, poverty, religious and cultural beliefs.

Another vital area of challenge to Reproductive Health is communication. Many governments, organizations and Non Governmental Organizations embark on campaigns aimed at promoting reproductive health rights but instead of an increase of people accessing reproductive care, it rather pushed them away because it did not reflect their cultures, traditions and religions. This was as a result of ineffective communication with the people to understand their perceptions, environment and cultural and religious knowledge and belief about reproductive health.

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With the use of the Diffusion Theory of communication where information was passed to the people with the hope that the messages embedded in the information will be adopted by the people, it turned out to be less effective. This was because the communication model was a one way linear communication. The people whose development was needed were not involved in the communication but were rather passive receivers and stakeholders.Thus the improper use of communication exacerbated the people‟s resistance to accessing of reproductive health methods.

With the evolving nature of communication in the 21^st century, an apt definition as captured by Em Griffin in his book A First Look at Communication Theory (2011), is that “Communication is the relational process of creating and interpreting messages that elicit a response”. This definition clearly explains that a process is surely needed for effective communication. Griffin tried to make the point that until there is a process which results in a response between parties, communication has not taken place. This response of course can be discussion between audiences.

In trying to ensure that there is a process of communication many communication experts have tried to develop processes or a medium in which communication can take place. One among such is participation.Development Communication Source book (2008) describes the benefits of participation as such:

The adoption of two-way communication to involve stakeholders as partners inthe problem-analysis and problem-solving processes of development initiatives,rather than treating them as mere receivers of information, is fundamental for makingchanges effective and sustainable. (pg 16)

It is thought that when there is participation, it is able to bring about a response in communication swiftly, efficiently and sustainably. It is however apt to note that there are different forms of participation. One of such forms is partial participation; where individuals are asked questions or for their inputs but the ultimate power remains with the experts.

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In 1988, the Federal Government of Nigeria embarked upon a campaign for the Nigerian people with the aim of bringing about the reduction in the number of children one has. This was an attempt at curtailing population explosion. Also, the policy was embarked upon in order to serve as a basis for population planning. Thus it embarked on mass media campaign providing information and messages, and promoting family planning. Even though, the campaign was widely reached, there were some resistance to the information and messages especially in the Northern Region of the country. Foremost among this was the involvement of foreign organizations in the implementation of the campaign. There has always been a suspicion when the West is involved in campaigns especially in terms of population. In the report Child Spacing Attitude in Northern Nigeria, it was noted that issues pertaining to population and child spacing was viewed as “just an American propaganda to reduce thepopulation of Moslems in the world so that they can conquer the world...” This view perhaps still persists and thus the low adoption of family planning messages/campaigns in Northern Nigeria.

Culture and religion also play vital roles especially for the Northern Muslims in Nigeria. Enang and Ushie (2012) noted that there was a boycott in some parts of the country against polio immunization in the early 2000s. The cultural and religious belief that the polio vaccine was contaminated with anti-fertility drugs so that young girls would be unable to reproduce affected the exercise. This point was reiterated by Dike (2004) who explained that Islamic northern Nigeria refused government vaccines imported from the western world alleging that the vaccines were laced with other deadly poisons meant to depopulate the Muslim community in Nigeria as part of a war against terrorism. This is a case in point for the 1988 family planning communication campaign which did not take into cognizance the people‟s cultural, traditional and religious belief before embarking on the media campaign. This led to rejection of messages by the people who also physically tore down posters in some parts of the Northern States(Enang and Ushie 2012).

In an attempt to promote the benefits of accessing reproductive health by the Nigerian government to its people, the Government embarked upon a National campaign that was targeted at providing information to the public. The communication was modeled upon the Sender – Message – Channel – Receiver (SMCR) model. The mass media was used to provide information to the public with the hope that the information embedded in the messages will serve to encourage behaviours and attitudinal change. This however was not successful because of its linear mode of operation and also the inability of the campaign to involve the people in assessing and addressing perception, religious and traditional concerns harboured by the people.

With the afore-mentioned problems of reproductive health, it is obvious that there is a need for a behavioural change amongst the populace. If indeed progress needs to be made in ensuring that the reproductive health rights is being accessed by Nigerians, there is a need to review the communication strategies that will address issues that lead to barriers against and resistance of family planning. This can be done through participatory methods of communication. Participation is needed in communication for various reasons foremost among such is that the people will be able to be involved not just by being passive or by being asked questions but to be involved in a two-way communication on what are their thoughts, perceptions, cultural, traditional and religious beliefs on reproductive health. Also important is for them to come up with reasons and an understanding on why they need to access family planning.

With this in mind, the Nigerian Urban Reproductive Health Initiative (NURHI) embarked on a campaign that was aimed at increasing the access and use of family planning methods by

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the public. The project started in 2009 and is being implemented in select cities of the federation with various communication strategies constitutes the focus of this study.

The Nigerian Urban Reproductive Health Initiative (NURHI) is a Non Governmental

Organization that isfunded by the Bill and Melinda Gates Foundation. With project duration of

2009 – 2014, NURHI was funded to reduce supply and demand barriers to the use of family

planning services in urban Nigeria. Tasked with increasing contraceptive prevalence rate by 20

percentage points, NURHI aims to harness the potential of Nigeria‟s dynamic services and

healthful lifestyles now, before pressures on the urban health infrastructures lead to systems over

load and breakdown. The programme brings together private and public sector resources to

strengthen the delivery of family health services while gradually increasing demand for such

services across project sites. The project is focused on six urban centres – Abuja, Benin City,

Ibadan, Ilorin, Kaduna and Zaria. NURHI is developing workable approaches that will provide

rapid scale –up models for other urban areas in Nigeria and the African continent. (Nigeria

Urban Reproductive Health Survey 2011:5).

The objectives of NURHI include:

-          Develop cost effective interventions for integrating quality planning with maternal and new born health, HIV and AIDS, post partum and post abortion care programmes.

-          Improve the quality of family planning services for the urban poor with emphasis on high volume clinical settings.

-          Test novel public – private partnerships and innovative private-sector approaches to increase access to and use of family planning by the urban poor.

-          Develop interventions for creating demand for and sustaining use of contraceptives among marginalized urban populations.

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-          Increase funding and financial mechanisms and a supportive policy environment for ensuring access to family planning supplies and services for the urban poor.

By reaching urban women with the greatest need, this comprehensive strategy is expected to increase contraceptive use among women in urban and pre-urban areas and potentially to diffuse to rural areas to which urban women are linked. (Nigeria Urban Reproductive Health Survey 2011).

The accomplishments of NURHI so far include:

-          Joint advocacy efforts resulted in Federal Ministry of Health‟s National Policy announcement on availability of free contraceptive commodities in all states. Commodities continue to be available free of charge at all public health facilities including primary health centres.

-          NURHI engages prominent religious and traditional leaders who in turn have publicly endorsed family planning/child spacing, encouraging Nigerian men and women to find a method that will help them care for their desired family size and protect each mother‟s health.

-          „Know. Talk. Go‟ mass media campaign encourages Nigerians to „Know‟ about family planning, „Talk‟ to their partner about family planning and „Go‟ for services. This Multi channel campaign includes a radio drama for youth, television and radio spots, and posters, billboards and promotional items for community members.

-          A novel public-private partnership, the Family Planning Providers Network (FPPN) was developed as an innovative approach to connect all family planning providers in Nigeria-clinical and non clinical as well as public and private. (www.nurhi.org).