Engaging men for improved family planning and nutrition outcomes
Family planning and child nutrition indicators show the least improvement of health indicators across India, and innovative programs are urgently needed to improve these outcomes. Programmatic interventions in these domains have historically focused on women, both as end-users and providers, further alienating men from the "female domain" of family planning and nutrition and reinforcing imbalanced gender roles in this sector. We recognised that engaging men in family planning and household nutrition programming provides an opportunity to move towards better health and gender outcomes.
To meet this goal, we designed two innovative programmatic interventions in rural Bihar, India. Our approach to designing and testing the programs was interdisciplinary, anchored on human-centered design (HCD) research and behavioral science, supported by a literature review, expert interviews, rapid prototype testing and, finally, a learning pilot for each program. We closely collaborated with community representatives as partners during research, co-creation, and testing, and explored multiple program ideas, ultimately arriving at two innovative programmatic solutions:
The first program, Dekh-Rekh ("Care and Nurture") provides young couples with tools to visualize their nutrition habits and relate them to their aspirations. This encourages couples to have more conversations on food choices and make more informed and collaborative decisions on what they purchase, prepare and feed their children.
The second program, Hamari Shaadi, Hamare Sapne ("Our Marriage, Our Dreams") uses a financial education course for newly-wed couples to introduce conversations on contraceptives, delaying, spacing and limiting as a way for couples to reach their financial aspirations.
In both programs, trained couples from the community deliver the programs to enrolled couples, acting as role models for participants, while creating an open and safe environment to talk about sensitive issues.
A learning pilot with 2000 households demonstrated the immense potential these programs have to change health and gender outcomes, and we hope to scale these two programs to achieve lasting behavioral change. Through a public launch event in the capital city of Delhi in 2022, we shared learnings with key stakeholders and policymakers. India's National Ministry of Health and Family Welfare in India has made engaging men in family planning a top priority for their 2030 vision, citing our report as a key resource in support of this mission in their Family Planning 2030 report.
Given the potential of these programmatic interventions to influence family planning and nutrition behaviors and outcomes, we are exploring opportunities to further scale them, both across the state of Bihar and across other Indian states.
Family planning and child nutrition indicators show the least improvement of health indicators across India. The scenario is particularly pressing in Bihar, a state in North India with a population of around 120 million. For instance, the latest National Family Health Survey (2019-2020) found only 19% of children 6-23 months met minimum dietary diversity in Bihar. When it comes to family planning, 14% of currently married women have an unmet need for family planning. Half of men aged 15-49 in the state agreed that contraception was a woman's business and a man should not have to worry about it.
Historically, programs in the sectors of family planning and nutrition have focused on women, both as end-users and as providers. For instance, the country's one-million-strong cadre of frontline health workers, who focus on household health and are a key part of the healthcare system, are all women volunteers. While many of these programs have seen considerable success in their outcomes, challenges have emerged in the long run:
They place a disproportionate burden on women, both as end-users and as the ones delivering health programs.
They reinforce the imbalanced gender norms that underlie women's unpaid care work and time poverty and, relatedly, their mobility and workforce participation.
Men have been further alienated from the "female" domains of family planning and nutrition.
Evidence shows positive improvements in health, nutrition, and gender outcomes when men's engagement increases, but falls short of showing lasting behavior change at scale. To fill this gap, teams from Dalberg and Project Concern International India, with support from a global philanthropic foundation, set out to design programs, answering the question: How might we engage men in nutrition and family planning through innovative and gender transformative programs in rural Bihar, India?
We designed, prototyped, developed and evaluated two innovative programmatic interventions over 2.5 years. We used an interdisciplinary approach anchored on:
1. Human-centered design research and co-creation, including in-depth interviews, small group discussions & ideation sessions, intercept interviews, observations and shadowing with a diverse mix of 92 participants covering couples, their families, and other stakeholders across the ecosystem.
2. Behavioral science frameworks that ensured we account for couples' knowledge, motivations and enabling environments, anchoring our solutions to rigorous impact pathways.
3. Literature review of 40 reports and studies and a previous phase of research on couples' engagement in family planning as well as expert interviews with six sectoral experts to gain a swift understanding of the evidence landscape.
4. Rapid live prototyping of the early programmatic solutions with 10 diverse couples and 11 community stakeholders that enabled us to stress-test the key features and interactions of the programs in real-world conditions and further refine the design.
5. Community participatory research at various points of our research, design, and testing, with community representatives closely involved as partners in the journey. This served not only as a way to gather rich insights and shape the program design greatly, but also to shift power dynamics between stakeholders.
6. Learning pilot of the two prioritized full programmatic interventions with almost 2000 households that helped us make final refinements to the programs and their implementation. We used a qualitative and quantitative data collection approach to assess the programs' effectiveness in delivering on outputs, and get early indications of their influence on behaviors and outcomes.
Our interdisciplinary approach gave us rich learnings from stakeholders across the ecosystem.
We gained insights on young couple's desires and aspirations, and their relation to family planning and nutrition behaviors. This led us to create a financial planning course that offers couples the license to discuss family planning without stigma, as well as shifts the perception that nutrition habits are rooted in affordability, and hence unchangeable.
We noticed couples get their information on child nutrition and family planning in silos, with little opportunity to discuss and make decisions together, and are also beholden to rigid household gender roles. This drives the gap between awareness and action when it comes to family planning and nutrition, and led us to design a unique couple-to-couple delivery model in our programs.
We also gained an understanding of the ecosystem beyond the couple. Food and family planning are household decisions, with older family members influencing young couples' choices. At the same time, we heard that older family members were amenable to change, and are particularly motivated when they can see how family planning and food choices relate to financial goals and improvements in child health. So, we built in features that would appeal to older family members' desires and spark cross-generational behavior change.
Finally, we engaged closely with local institutions like women's self-help groups, health workers and healthcare officials. We built their trust and support from the very start of our research process, while being sensitive towards their existing burdens and activities, so that they were actively involved in the program design and implementation.
Our rich learnings, through HCD research, rapid prototyping, and inputs from sectoral exports, led to 30+ program ideas. We narrowed this down to 2 final programs, whose target audience was young, zero- or one-parity couples in rural Bihar, India.
Our nutrition-focused program, called Dekh-Rekh ("Care and Nurture"), leads couples towards making more healthy, informed food choices and purchases for their children.
Our family planning-focused program, Hamari Shaadi, Hamare Sapne ("Our Marriage, Our Dreams"), creates a comfortable environment for couples to discuss the often taboo topics of contraception, delaying, spacing and limiting by using a financial planning course as an entrypoint.??
Findings from our learning pilot with 2000 households showed how the programs improved health outcomes as well as gender outcomes. To evaluate the programs, we gathered data on the exposure of the enrolled couples to the programs, using a mixed-methods design to compare baseline and endline data from randomly chosen samples of women and men in intervention and comparison villages.
In the nutrition program (Dekh-Rekh):
Minimum dietary diversity (MDD): Women in intervention villages reported a 30% point increase in MDD for their children (aged 12-23 months) and men reported 25% points. These are significant compared to the 15% point increase reported by women in comparison villages and the 12% reported by men.
Men's involvement in nutrition: There was a net increase of 20% points in men reporting they 'always' or 'sometimes' discussed or participated in food preparation in intervention villages, relative to comparison villages. Finally, there was a net increase of 18% points found among women in intervention villages saying their husband's participated in feeding, relative to comparison villages.
Knowledge: Awareness among mothers about the minimum dietary diversity for children (aged 6-23 months) increased by a net of 34% among those exposed to program interventions compared to those not exposed. The net increase for men was 22% points.
Spousal communication: Couple's communication about child nutrition increased by 24% among the exposed couples compared to those not exposed.
In the family planning program (Hamari Shaadi, Hamare Sapne):
Contraceptive use: There was a net increase of 16% points in current use of contraceptives among women exposed to program interventions, compared to those not exposed.
Joint goal-setting: There was a net increase of 18% points in the proportion of women in intervention villages reporting that they had discussed delaying or spacing with their husbands in the preceding 3 months, and a net 25% point increase in men reporting discussing delaying or spacing in the intervention village, relative to the comparison village.
Spousal support: A significantly higher number of women (16%) from intervention villages reported increased support from their husbands on contraceptive use, and men similarly reported support for their wives' views around family planning and contraceptive use.
Knowledge: As a result of the program, 48% of women and 82% of men knew about family planning at the endline in the intervention villages, a net increase of 33% points for women and 31% points for men.
Cross-cutting learnings for other programs:
Our programmatic interventions took a unique approach to healthcare delivery by having a couple-to-couple delivery model. 40 married couples living in the villages where the programs were running were recruited and trained to do the delivery. Unlike most health services that presently rely on women to deliver them, our couple-to-couple approach provides a model that can shift gender norms, by signaling that achieving a family's health goal is a shared responsibility between a couple, and offering men and women a platform to discuss their roles in achieving these goals, rather than defaulting to established norms. Couple facilitators also give younger couples positive role models to learn from.
Lastly, our cross-disciplinary and iterative approach to designing, developing and implementing programs with a behavior change pathway could serve as a model for other public health sectors, while our strong gender lens provides lessons for gender-sensitive programming. Our partnerships with community members and local institutions during research and implementation offer lessons on the potential of community participatory research, and building system capacity and inter-community trust and cohesion.