HIGHLIGHTS

• Injectable contraceptives are one of the most widely used family planning (FP) methods in the world. Yet, high discontinuation rates mean that injectable contraceptive users are not consistently able to follow through with their reproductive intentions.
• Strengthening contraceptive uptake counseling and providing simple tools to support client follow-up are, together, promising approaches to increase contraceptive continuation for women seeking to avoid pregnancy.

The Challenge

Injectable contraceptives are one of the most widely used family planning (FP) methods in the world, attractive because they are discrete, non-invasive, and highly effective. However, in Ethiopia, as in many other countries, users of injectable contraceptives are more likely to discontinue use shortly after taking them up. While some women discontinue contraceptives because their reproductive intentions have changed, many discontinue use due to side effects or forgetting to return for subsequent injections. In these cases, the health system has not met the needs of these women, leaving them at increased risk of unplanned or unintended pregnancy.

To design a behavioral solution that promotes contraceptive continuation among women who wish to delay pregnancy, we partnered with the Last Ten Kilometers (L10K) project of the JSI Research and Training Institute, Inc. (JSI). The L10K project supports the Government of Ethiopia’s flagship community health program—the Health Extension Program (HEP)—which provides basic health services, including family planning and reproductive health services at the community level.

Our Approach

We sought to understand how different aspects of service delivery, client and health extension worker (HEW) interaction, and the surrounding environment (people, places, norms) may be influencing decision-making and behavior. We interviewed clients and HEWs, observed family planning provision at health posts, analyzed service statistics, and spoke with health program administrators. From these activities, we identified several insights about why women discontinue use of injectable contraceptives: 

• Women face hassles and lack reminders to attend re-supply appointments.
• Women fail to connect with health providers and do not explore method-switching when experiencing side effects.
• HEWs have limited time and attention to devote to client tracking and case management. 

Based on these insights and an iterative process that involved co-design with local experts, early prototyping, and iterative user-testing with clients and HEWs, we arrived at a solution package with three components:

1. Appointment Card—A simple, discrete appointment card distributed by HEWs to all clients requiring a return visit (for any service, not only FP). The card prompts HEWs to indicate a holiday or local event close to the appointment date to help clients remember future dates.
2. Client Care Checklist—A simple guide to support HEW provision of FP counseling. The job aid emphasizes the discussion of potential side effects and what to do if they are experienced.
3. HEW Planning Calendar—A desktop calendar booklet utilized by the HEWs to input and track client appointments and manage tasks across the HEWs staffed at the health post.

Results

We introduced the intervention package within the L10K project’s FP focus area and conducted a randomized controlled trial to test its impact. 

We found that HEWs in the intervention areas generally liked and utilized the appointment cards and the client care checklist, but the use of the planning calendar was limited. One possible explanation is that the first two designs seamlessly integrated within existing processes and systems, while the planning calendar served as a duplicate data tracking system that placed additional cognitive load on HEWs. 

Despite the incomplete usage of the full package, the intervention had the intended effect. Women who initiated the use of injectable contraceptives in the intervention area were significantly more likely to continue using injectables than women in the comparison area. In the intervention area, 41% of new injectable users discontinued use within 12 months, compared to 51% in the comparison area. Clients in the intervention area recalled more side effects, were more likely to have been told about side effects, and were more likely to recall being told about a local holiday or event as a reminder for an appointment.

Takeaway

These results suggest promising, low-cost approaches to promote contraceptive continuation both in Ethiopia and other countries across the globe using solutions informed by behavioral science.

Interested in our work applying behavioral science to global health? Email gh@ideas42.org or tweet at @ideas42 to join the conversation.