Elevating Social and Behavior Change as an Essential Component of Family Planning Programs

Investment in strong health systems and supply chains is still needed, but the supply-driven approach dominant in family planning fails to address individual, relational, and social barriers faced by women and couples in achieving their reproductive intentions and desired family size. Overcoming these barriers requires a better understanding of behavioral drivers and the social environment in which family planning decisions are made, and an increased investment in social and behavior change (SBC) approaches. SBC is a discipline that employs a deep understanding of human behavior and uses evidence-based interventions at the individual, community, and societal levels to support the adoption of healthy practices. SBC approaches also influence underlying social and gender norms that may facilitate or inhibit individuals from making and acting on their decisions. SBC programs aim to create a supportive normative environment for women, men, girls, and boys to set their own reproductive intentions and access modern contraception. The discipline draws on areas including communication, social psychology, anthropology, behavioral economics, sociology, human-centered design, and social marketing. Critical barriers to increased and sustained investment in SBC include a lack of awareness of the body of supporting evidence, a misunderstanding of what constitutes high-quality SBC, and a focus on short-term results. Consequently, global and national strategies to increase family planning use often fail to sufficiently acknowledge the essential role of SBC. For example, while all Costed Implementation Plans (CIPs) include a "demand creation" component, a recent analysis of 36 CIPs revealed that the budget for demand creation as a percentage of the total CIP budget varied significantly, from less than 1 percent to just over 30 percent. Further analysis of 27 country CIPs revealed the budget for demand creation per woman of reproductive age (WRA) ranged from less than US$0.50 (Bangladesh, Ethiopia, Burundi) to over US$6.00 (Liberia, Mali, Zimbabwe) with an average of US$2.80. The countries with the higher demand creation budget per WRA have the most detailed descriptions of SBC strategy with multiple activities described. Countries with the lowest demand creation budget per WRA either did not cite an SBC strategy or mentioned that it was being developed and included only limited descriptions of activities. While the right balance of funding depends on country context, low investment in demand creation is likely limiting the impact of investments in service delivery. Significant social and behavioral barriers to family planning uptake and continuation remain in many settings. For example, concerns about side effects or the inconvenience of methods were a primary reason of nonuse among 35% of married women in Latin America and the Caribbean, 28% in Africa, and 23% in Asia. A substantial body of evidence also demonstrates the importance of social and gender norms on family planning and contraceptive use. Women and girls may derive social and economic status by conforming to social expectations about womanhood and motherhood, and fear of social stigma and disapproval, as well as fear of active opposition, are also reasons given for nonuse of contraception. A range of research has further documented a strong link between a woman's level of empowerment in the domestic and social spheres and her ability to make and act on reproductive decisions. The maximum contraceptive prevalence "demand curve" provides a simple assessment to help inform the balance needed between investments in expanding family planning services and investments needed to address social norms and behaviors. For countries that sit far below the curve (large potential use gap), growth in modern Contraceptive Prevalence Rate (mCPR) is likely to be less constrained by low levels of demand, though integration of SBC into service delivery could still strengthen programs.