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Story and Perspective

A Powerful Approach

Pathfinder and Busara Center for Behavioral Economics

Sarah Peck

India

Engaging community-based frontline workers to promote family planning

It’s a lazy Sunday morning and men in a small town in Maharashtra gathered in their barber shop to groom themselves for the week and discuss the hottest gossip. The men chattered about the Janamashthami festivities that took place earlier that week. As Ashok (name changed) went to the billing counter, the barber offered Ashok a pack of male condoms along with his change. The chatter in the room was suddenly interrupted by silence. Ashok, unsure of how to react, fumbled and looked down at his feet. He puts his hands on the table, still looking at the floor, and swiped the table clean, taking the receipt, change, and the pack of condoms. Hoots and screams broke the silence, as the men teased Ashok for being a pleasing husband. As Ashok left the shop, the other men crowded around the barber to get their hands on the condoms of their choice.

Sangita Dilip Awalle, Savita Shukraj Kamble, Pushpa Vikas Kurne, Aruna Pramod Kamble, Anita Raut, ASHAs in Kolhapur, India. Photo: Sarah Peck

A community health worker called an “Accredited Social Health Activist” (ASHA) had brought the condoms to the salon where she knew men gathered. She convinced the barber to discreetly distribute her stock of free condoms to patrons.

In a neighboring village in Maharashtra, Preeti and Ram (names changed), a young couple with one child, received counseling from a social worker about family planning.  Ram’s mother knew the social worker, Usha, who used to be the Accredited Social Health Activist (ASHA) for the village. When Usha realized that she was not getting through to the young couple, she turned to Ram’s mother for support. But Ram’s mother, to Usha’s dismay, agreed with the couple, adamant that Preeti should have three children and give the family at least one grandson.

Usha was persistent. She met with the family numerous times, building the relationship and discussing family planning options. She made numerous visits and had numerous discussions – and ultimately, the family decided on their own to use an intrauterine contraceptive device, determining it would help with family finances and the challenges of having a third child.

The power of community-based frontline workers.

As family planning practitioners, we continue to ask ourselves: How do you provide contraceptives, and information, to women who rarely step out of their house?

Community-based frontline workers like Usha and the ASHA who dropped the condoms at the barber shop—that’s how. Community-based frontline workers are trusted by their communities and have the local expertise to sustainably drive changes in beliefs, values, and norms that encourage openness to family planning and improve health and well-being.

Pathfinder applied this approach through its Youth Voices for Agency and Access (YUVAA) program in five districts of each Bihar and Maharashtra. The program recruited and trained a cadre of social entrepreneurs, called Yuvaakaars, to work across communities,  promoting family planning and providing livelihoods to young married couples.

Busara conducted a qualitative assessment of YUVAA’s performance and applied an independent behavioral lens to look at the work, interactions, and behaviors of Yuvaakaars and the young married couples they reached for more than a year. Busara’s assessment found that the ingenuity and innovation of the Yuvaakaars, who challenged the deeply embedded perceptions and social practices of community members, contributed to the success of the program. Yuvaakaars crafted their own ways to overcome the barriers they faced and drove social change. Some conclusions from the assessment follow.

1. Nothing beats persistence for successful behavior change.

Ruksar Aftab Patharaat, a Yuvaakaar, with her Mother in Law, Rukaiya Sayyad Patharaat (in purple) and grandmother, Lailab Sayyad Patharaat. Photo: Sarah Peck

Consider Usha’s success. Remarkable in its own right—she pushed against one of the most common challenges to delivering family planning counseling and services—gatekeeping by mothers-in-law. Even though Usha had a good relationship with Ram’s mother and could argue her points about the value of family planning to financial well-being, she attributed the best outcomes to the repeated touch points with Preeti and Ram over a long period of time. Because she was a frontline worker based in the community, she could have multiple interactions with families at regular points. These repeated interactions helped to build trust and reinforce the information being discussed.

2. Knowledge of local and personal context helps deliver relevant, well-received family planning.

Community-based frontline workers know their target audience well—their needs, preferences, context, and environment. In the story of Usha, we saw that framing family planning as an economic decision was successful as it was well-timed with the economic challenges faced by the family members. The experiential real-life cue allowed Usha to provide information that directly related to the couple’s  situation. Using similar contextual triggers can help people realize their intentions and change mindsets and attitudes that keep them from reaching their goals. 

3. Innovation builds and propels community health worker networks.

Yuvaakaars used communication channels like WhatsApp groups to discuss issues and seek advice. This allowed Yuvaakaars to learn from each other and develop skills, solutions, and strategies from approaches that had been successfully tested in other areas. Platforms such as WhatsApp are valuable because they enable information to be shared quickly and cost-effectively among different cadres of community workers, like Yuvaakaars, who tend to trust information coming from their peers.

Pinki Kumari, a Yuvakaar, shares a short informational video with participants in a group discussion. Photo: Sarah Peck

4. Leveraging local connections can build enthusiasm for family planning.

Female health care workers often face difficulties engaging with men directly due to existing attitudes and norms that bar men and women from discussing family planning outside of marriage. This did not stop the ASHA at the barber shop, who helped men navigate the possible social costs of being seen buying contraceptives at the pharmacy by allowing them to access condoms discreetly where they gathered to socialize. This approach demonstrates the potential that lies in leveraging local knowledge and connections.

Read more about YUVAA and findings from Busara’s assessment in this report.

Authors: Pathfinder: Lopamudra Paul, Manish Mitra, K. Laxmi Rao. Busara Center for Behavioral Economics: Aditya Jagati, Jaspreet Singh

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