Next month, a new and improved contraceptive product will be marketed to urban, young adults with some disposable income, using billboards, Facebook, and WhatsApp messages. These millennials are living in Lusaka, Zambia, and right alongside this marketing campaign will be a group of health researchers who know that making a new product available doesn’t mean it’ll actually get used. The product is the Maximum Diva Women’s Condom, a new and improved female condom, with a better design, in a sleek new package and at a slightly higher price point.
IPA researchers are collaborating with PATH, Society for Family Health (the Zambian subsidiary of Population Services International), WomanCare Global through USAID’s Expanding Effective Contraceptive Options (EECO) project in order to test whether new contraceptives and approaches impact use. Despite universal access to family planning being essential to the health and well-being of women and communities, the family planning research community still only has a handful of high impact practices with evidence behind them, such as integrating and supporting trained community health workers into the healthcare system, and providing post-abortion family planning counseling and services. While about 380,000 maternal deaths a year are averted because of access to family planning, an estimated 220 million women who want this ability to delay childbearing still lack it, and Zambia is no exception. Twenty-seven percent of Zambia women and men have an unmet need for family planning. Female condoms in particular have the unique property of both a woman-initiated contraceptive with the dual ability to prevent pregnancy and stop STIs/HIV; in Zambia the prevalence of HIV is 13.3% nationally, double in urban cities.
We have glimpses into behaviors around reproductive choices from previous research, for example, we know that having more choices of kinds of contraception increases the chances of using some form, but we still know frustratingly little. One of the reasons is that while the biological efficacy or safety of new products is often well established in clinical trials, there are very few rigorously evaluated studies on how to improve service delivery or to understand demand for these interventions in different cultural or economic contexts. The introduction of a new contraceptive with a well-defined marketing campaign is a wonderful opportunity to understand how it does or doesn’t change people’s preferences and behavior.
IPA Zambia is taking advantage of this opportunity to gather data and try to understand what aspects of a campaign and product have the highest impact on use. After a baseline study of contraception use, Maximum Diva will be introduced throughout the city, along with its mass media campaign. Forty urban wards in Lusaka will be randomly assigned to receive just the mass media campaign or an additional interpersonal communication (IPC) program. Young adults (18-24 years old) of both genders will be recruited to participate in the IPC program in selected areas. Led by trained local, young adults from these neighborhoods, the sessions will include information on the importance of contraceptive use, demonstration of how to use the Maximum Diva female condom (on a plastic model), and dramatic skits and role-playing to teach participants how to negotiate with sexual partners about condom use. This will all take place against the backdrop of a city-wide campaign using radio, billboards, news media, social media, and a mobile website (smartchoices.co.zm). In smaller, less rigorous studies, IPC has been shown to change knowledge and behavior because it creates a dialogue and allows people to ask questions they might be too embarrassed to ask. This can increase knowledge, and also increase acceptability in the community since groups of individuals attend together. However, it has never before been studied rigorously and in a general population of young adults for a new contraceptive product.
Researchers will compare participants in the areas that did or didn’t participate across a range of factors, including contraceptive knowledge, preferences, and use to try to better understand how the IPC sessions may or may not have affected their choices, along with general popularity and use of the Maximum Diva Woman’s Condom. Again, we know from studies that human choice is complicated – introduction of a new option, even if not relevant can change people’s attitudes towards their existing choices, and choices about sex and reproduction are more complicated than most.
This study is important not just to understand use of a particular contraceptive, but because it addresses some gaps in knowledge for improving family planning programs:
- Innovation in contraceptives themselves: The Gates foundation offered a million dollar prize for a better condom, which will probably never be claimed, even after promising ideas were given $100,000 to further develop. Even if new products successfully make it to market, how they will be received is not well understood. Investments need to be made in the development of new contraceptive methods and in better understanding innovative interventions that can improve behavior around contraception choices and uptake.
- Integrate rigorous testing of interventions: Only a few interventions are considered “proven” high impact practices, based on the quality and consistency of evidence. This is because many interventions are not tested using an experimental study design. It is time to invest in designing rigorous impact evaluations with multiple sites (where possible) to understand whether an intervention truly works and how to successfully adapt and scale it in different settings. There has been reluctance to spend time and money collecting data on a program when the product or intervention is biologically proven; however, it would be well worth the investment to identify programs that demonstrate measurable impact.
- Invest in evidence-based solutions: Hundreds of local, NGO, and government groups are all designing and implementing programs around family planning, but often the interventions they implement are not based on rigorous evidence. Successful intervention are not often tested more than one time; therefore, it is important to replicate them in different settings, with different populations, to make sure we truly understand how and when they work. It is equally important to implement right-fit monitoring and evaluation system of their projects and programs as they are running, in order to be adaptive and facilitate learning. Replication and monitoring and evaluation are strategic to understand where and when a program works and how to tailor it to maximize its impact and cost-effectiveness.
The FP2020 Global Partnership support governments, civil society, multi-lateral organizations, donors and the research and development community to focus on family planning needs worldwide. As experts gather in Indonesia on January 25th, 2016 at the International Conference for Family Planning to discuss how to attain the goal of universal access to family planning, the three issues highlighted above should be prioritized as they are key to how the FP2020 Partnership to reach its goals.
Young people in Zambia and across the world are ready to become productive members of society. They deserve to have access to a wide range of quality contraceptive methods as well as proven health programs that are appropriate to their choices and lifestyle.