Behavioral change communication is critical for the success of voluntary and choice-based family planning programs

Guest post by Banchiamlack Dessalegn, Ph.D., Senior Technical Advisor for Monitoring, Evaluation and Research, Family Health International 360 (FHI 360), Addis Ababa Ethiopia

Knowledge and awareness of available family planning (FP) methods, as well as of their benefits and side effects, is a prerequisite for informed decision making (Bongaarts et al., 2012). Behavior change communication (BCC) is a tool for increasing knowledge and awareness. In this way, BCC can be seen as critical to facilitating successful voluntary, choice-based FP.

FP options

The Government of Ethiopia aims to increase the modern contraceptive prevalence rate (mCPR) to 55% by 2020, as stated in Ethiopia’s new Health Sector Transformation Plan. To achieve this, the Federal Ministry of Health (FMOH) is putting emphasis on improving the FP method mix, including by increasing demand for and access to long-acting and permanent methods of FP (LA/PMs) without compromising informed and free choice. While target-setting at the national and subnational levels might lead to the erosion of choice-based FP services, the FMOH has given clear direction that services must be based on proper counseling and free choice. As a result of the concerted efforts and results-oriented policies of the FMOH, impressive achievements have been made in recent years, with the mCPR increasing from 28.6% in 2011 to 41.8% in 2014 and the total fertility rate dropping from 4.8 to 4.1 lifetime births per woman during the same period (CSA [Ethiopia] & ICF International, 2012; CSA [Ethiopia], 2014).

However, data show a lack of an integrated BCC strategy, which has in turn created a gap in efforts to improve the method mix and increase use of LA/PMs in Ethiopia. A recent mid-term evaluation of the FMOH’s intrauterine contraceptive device (IUCD) revitalization initiative, conducted by the FMOH and FHI 360’s PROGRESS project, showed high levels of provider readiness and interest, as well as high levels of available IUCD stocks, yet minimal demand for and use of IUCDs and other long-acting methods (FMOH & FHI 360, 2014). From the clients’ perspective, among the 1,186 women interviewed, 96% could name at least one FP method, yet only 60% spontaneously mentioned IUCDs. Moreover, 75% of the women reported ever using a modern FP method, but only 4% of the women reported having ever used an IUCD. Only 3% reported currently using an IUCD.

The low proportions of ever and current IUCD users among Ethiopian women using contraception and the relatively high levels of unmet need stand in significant contrast with the readiness and interest of providers to provider IUCDs. Of the 184 providers interviewed, 92% said they were ‘very interested’ in providing IUCDs and 80% said they are ‘comfortable’ providing IUCD services. An audit of which FP methods were available on the day of the survey showed that 79% of the health facilities had IUCDs in stock and trained providers present to offer services. This gap between supply and demand may be related to lack of knowledge about IUCDs; in particular, providers reporting ‘lack of knowledge’ as the main challenge to the IUCD revitalization efforts. This lack of knowledge will also prevent women and couples from making an informed FP choice.

Recognizing this gap, the FMOH is designing future programs with strong BCC components, paying particular attention to important demographic variables to ensure the appropriateness of BCC messages. As Bongaarts and colleagues (2012) point out, such campaigns should be guided by formative research, as well as strong monitoring and evaluation processes, to enable mid-course corrections, to track BCC message effectiveness and to ensure the realization of choice-based FP. BCC is an essential part of any voluntary and choice-based FP program to ensure informed decision making by women and couples, as well as to align supply and demand.


Bongaarts, J., Cleland, J. C., Townsend, J., et al. 2012. Family planning programs for the 21st century: Rationale and design. New York: The Population Council.

Central Statistical Authority (CSA) [Ethiopia] and ICF International. 2012. Ethiopia Demographic and Health Survey 2011. Addis Ababa, Ethiopia, and Calverton, Maryland, USA.

CSA [Ethiopia]. 2014. Ethiopia Mini Demographic and Health Survey 2014. Addis Ababa.

Federal Ministry of Health (FMOH) & FHI 360. 2014. The intra-uterine contraceptive device revitalization initiative: Results and lessons from the initial phase. Addis Ababa.

Photo caption: A health provider shows a poster that she uses to counsel women on their family planning options at a health center in Holeta, in the Oromia Region of Ethiopia. © 2013 Sarah V. Harlan/JHU•CCP, Courtesy of Photoshare

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