East African countries like Kenya have made great strides in recent decades in increasing access to modern contraception, leading to marked declines in fertility rates. But disparities remain.

The 2014 Kenya Demographic and Health Survey showed that rural women have a total fertility rate of 4.5 children per woman versus 3.1 for urban women, and the poorest women have more than twice as many children on average than the wealthiest. Meanwhile, unmet need for contraception among poor and rural Kenyan women is higher than any other groups. Clearly, innovative solutions are needed to support women and couples in poor, remote rural areas in achieving the number and timing of pregnancies they desire.

FHI 360 was pleased to collaborate with the Green Belt Movement in testing one such solution. Founded in 1977 by the late Nobel laureate Wangari Maathai, the Green Belt Movement is a non-government organization best known for its volunteers who have planted an estimated 51 million trees throughout Kenya to reduce the impact of climate change and preserve and restore ecosystems. Rapid population growth has been directly linked to diverse forms of environmental degradation and depletion of natural resources. Accordingly, in a special report for International Perspectives on Sexual and Reproductive Health, we presented our results on the feasibility, acceptability, and perceived value of Green Belt Movement volunteers also incorporating family planning promotion into their community development activities.

An Effective Messaging Strategy

The approach employed falls into the category of integrated development known as population, health, and environment, or PHE, whereby a single intervention combines components on the environment, community health, and family planning to achieve mutually beneficial goals. We found environmental agents can play an important role in disseminating family planning information, even without being trained as community health workers who provide methods.

The volunteers used a flipbook to conduct community education about the health, economic, and environmental benefits achieved through well-timed, well-spaced pregnancies, and worked in close collaboration with the governmental health sector to refer women and men to seek further counseling and methods at health facilities.

Our evaluation revealed that the volunteers conducted these activities effectively. A survey conducted at the end of the intervention found 80 percent of the trained volunteers had retained essential job knowledge about PHE and family planning. Green Belt Movement supervisors, who observed nearly 50 community meetings, found the volunteers prepared well for meetings (98 percent of observed meetings), used the flipbooks (87 percent), had effective presentation skills (94 percent) and provided clear and simple answers to questions (96 percent).

The evaluation included 16 focus group discussions with community members where volunteers were supposed to conduct PHE education. Participants in every group spoke favorably about the way volunteers conducted education sessions on the connections between family planning, healthy timing and spacing of pregnancies, and the environment. Further, participants reported sharing with others the family planning information they had received from volunteers in all 16 groups. In all but one group, participants personally knew someone who had sought family planning services after hearing PHE talks.

Analyzing the Green Belt Movement PHE project provided fresh perspective on how to extend family planning services to hard-to-reach communities. Broadly, these observations can be distilled into three recommendations:

Highlight Benefits Beyond Health

We in the health sector typically promote family planning first by emphasizing the health benefits achieved through use of modern contraception. Yet even when expressed in simple terms, arguments about infant and maternal mortality and morbidity may be intangible – and largely irrelevant – to the poorest, who are often coping with more immediate daily needs and many other health threats.

Working with the Green Belt Movement, we witnessed the motivational power of linking discussions about family planning to broader household wellbeing. Community members participating in the PHE intervention spoke knowledgeably about the relationship between contraceptive use and family size, and the ultimate benefits on household economics, food security, children’s education, land management, conservation of natural resources, women’s health, marital harmony, and women’s ability to work.

Deliver Messages Through Trusted Sources

Consistent with other research, our study found that misconceptions about contraceptives and fear of side effects continue to be important impediments to uptake. We also found that education by a volunteer who works in the community regularly was a powerful means of refuting misconceptions and reducing fears. Importantly, Green Belt Movement volunteers created opportunities for nurses to visit communities and deliver more technical information about contraceptive methods. The combined efforts of a trusted community volunteer complemented by a clinical authority proved to be an effective strategy for combating myths, rumors, and misconceptions.

Engage Men in the Dialogue

In contrast to delivering messages in health facilities, which are most frequented by women, conducting educational activities in the community allowed us to reach men just as well. Regular talks with ample opportunity for open dialogue built up men’s family planning and reproductive health “lexicon” so they better understood the issues at play and felt more comfortable discussing them. The experience of women and men hearing messages together reportedly opened communication channels within couples as well, enabling them to discuss pregnancy aspirations and family planning choices more openly.

—

This evidence on the value of a new PHE model is highly encouraging. FHI 360 invites other development partners to adapt and apply the programmatic tools developed in collaboration with the Green Belt Movement and share those experiences.

Our results complement other findings produced by the USAID-funded PROGRESS Project showing the power of integrated, multi-sectoral solutions for bringing family planning to traditionally hard-to-reach populations. The field would nonetheless be well served by greater investment in more rigorous evaluations of PHE interventions. Future evaluations should assess community-level impacts on family planning knowledge, service use, and contraceptive prevalence. They should also assess the other side of the integrated equation: indicators of natural resource conservation, levels of participation in environmental activities, and community-level knowledge and attitudes.

Expanding our understanding of this promising multi-sector approach will be a powerful tool for improving well-being and empowering women in some of the poorest, most rapidly growing, and environmentally fragile regions of the world.