A Communications Brief to Increase Awareness and Correct Use of Emergency Contraception

A communications brief to increase awareness and correct use of Emergency Contraception (EC) among at-risk women

Project Background

Introduction

Despite the availability of highly effective methods of contraception, many pregnancies are unplanned and unwanted. These pregnancies carry a higher risk of illness and death, often due to unsafe abortion. Many of these unplanned pregnancies can be avoided using Emergency Contraception (EC). EC includes several methods that can be used by women within a certain time period after unprotected sexual intercourse to prevent pregnancy. Over 30 years of research on EC has established that these methods can substantially reduce the risk of pregnancy after unprotected sexual intercourse with minimal side effects and very few provision requirements for service providers.

EC in Kenya

The 2003 Kenya Demographic and Health Surveyindicates that nearly 20 percent of births in Kenya are unwanted and a further 25 percent are mistimed (wanted later). It is estimated that, on average, 172,000 abortions are procured annually in this country. This translates to 25 abortions per 1000 females and 16 abortions to every 100 live births. Abortion is prohibited by law in Kenya. An accurate tally of abortion related mortality is therefore hard to come by given the clandestine nature of these procedures. However, it is estimated that 14 percent of maternal deaths in the East Africa region are as a result of abortion.

The need for EC is evident. Over the past two decades, Kenya has made significant advances in its efforts to expand awareness, availability and use of EC. It has been widely available through commercial channels since 1992, when the ECPPostinor was first registered and distributed in select pharmacies and health outlets. In 1996, the International Consortium for Emergency Contraception (ICEC) and its partners launched a campaign to broaden EC access in the country, strengthening private sector distribution networks and successfully registering Postinor 2a year later.

In 2005, the Ministry of Health (MOH) procured 700,000 units of Postinor 2 for distribution in public sector facilities. In addition, Marie Stopes Kenya recently launched a program to socially market the Indian-manufactured EC product, Pregnon, in its affiliated clinics, helping to further diversify and expand the market.Currently, the private sectordominates EC distribution in Kenya. According to a recent market analysis, these providers distribute an estimated 420,000 units annually, and availability of Postinor 2 is high in private outlets, with over 80% of pharmacies stocking EC. Demandappears to be sufficient enough to keep the price inelastic, with limited variation in retail pricing for Postinor 2 (ranging from Ksh. 100 to Ksh. 120) andPregnon (Ksh. 80).

Challenges

Despite these promising developments, awareness and use of EC in Kenya remains relatively low. According to the 2003 Kenya Demographic and Health Survey, EC is the least known modern contraceptive method, with less than a quarter of all women (23.7 percent) identifying it as an option and only 2.8 percent reporting ever use. Knowledge of EC in urban areas among certain cohorts of women is thought to be much higher than the national average but this knowledge is scant and often incorrect and has therefore not translated into use. AnECafrique studyin Nairobi among university students found that nearly 75 percent of young women(aged 14-25) knew of EC, only 8.7 percent reported that they or their friends had ever used it, and less than half of the respondents (43 percent) demonstrated correct knowledge of the appropriate timing and conditions for use.

Institutional and social constraints contribute to these low levels of awareness and frustrate efforts to mainstream EC in Kenya. To date, only a handful of public sector service providers have been trained in EC, and MOH officials cite continuing bias among providers as an important factor limiting access. Although EC has been officially incorporated into the national family planning program, the MOH has yet to develop a comprehensive strategy for dispensing EC in public facilities. In the private sector, many pharmacy staff have not received sufficient training on EC, making them unlikely to provide referrals, counseling on proper use and efficacy, and information about routine contraceptive options.

To date, there has been no concerted or consistent media campaign to promote awareness of EC across the country. Concerns over misinformation have reportedly discouraged the MOH from engaging in an intensive public campaign, and private sector providers shy away from advertising EC for similar reasons.Public discourse has focused on unfounded allegations that EC fuels frequent and risky sexual behavior among adolescents. However, recent improvements in positive media coverage suggest that public opinion may not be as volatile as once thought, although public and private institutions still remain reluctant to actively promote EC.

PSI’s mandate

PSI has been tasked with designing and implementing a targeted awareness campaign that will increase informed demand and appropriate use of Emergency Contraception among at-risk women in Kenya. The goals of this initiative are to:

• Lower the incidence of unsafe, illegal abortions;
• Help women to avoid unwanted and mistimed pregnancies and;
• Increase the percentage of women using routine contraceptive methods

The campaign will be implemented over a one and a half year period with a targeted launch date of August 2007. Itis expected to be national in scope with a special focus on urban and peri-urban areas where a strong private sector supply network exists and where demandfor ECisanticipated to increase the most. The awareness campaign will be complimented by private and public sector capacity building activities and stakeholder advocacy coordinatedbyThe Population Council.

Summary of target audience research

In order to develop a campaign strategy that would positively influence EC use, PSI conducted formative research among at-risk women to understand the key barriers to use among thoseaware of EC but had never used it and the motivations for use among those who had at one time used EC. The results of this study are summarized below:

Non-users

Negative factors:

• Low knowledge levels: Although aware of EC, most of the respondents knew very little about its composition, mode of action or when and how it should be used.
• Uncertainty about EC efficacy: Perhaps as a result of this low knowledge, perceptions of EC’s efficacy were split with half of the respondents unsure whether it really worked and the other half believing it was effective.
• Fear of long term side effects: Another consequence of low knowledge and what appears to be a key barrier to EC use among non-users was the widely held suspicion that it may have significant negative health effects in the long term; effects such as sterility and deformation in unborn fetuses.

Positive factors:

• Positive attitudes towards EC: Despite reservations about its efficacy and long term side effects, non-users generally held positive beliefs about EC. Majority perceived it to be affordable, did not think it caused abortions or that it was associated with a careless lifestyle.
• Strong perceptions of peer support: When asked if they thought their friends would be supportive if they decided to use EC, majority of respondents felt that they would.
• High perceived self efficacy: Perceptions of partner support for EC use were generally low among both single and married respondents with parental support thought to be even lower. The latter was especially true among single women based on the belief that, given their single status, their parents would not approve of them engaging in sex and therefore, by extension, using EC. However, while partner and parental support were perceived to be low, this does not appear to be a significant barrier to use because a large majority of respondents felt they were capable of avoiding a pregnancy if they chose to. In addition, interviews with users showed similar low perceptions of partner and parental support yet this had not deterred them from using EC when they wanted to.

Users

Positive factors:

• Positive attitudes towards EC: Like non-users, users of EC held positive attitudes about EC with an even larger majority perceiving it to be affordable and safe to use. Users also did not think EC caused abortions or that its usewas an indication of a careless lifestyle.
• Strong belief in EC’s efficacy: Unlike non-users, users believed in the effectiveness of EC. Even among respondents who had become pregnant or who knew of someone who had become pregnant after EC use, failure to prevent the pregnancy was attributed to incorrect use rather than any fault in the product.
• High perceived self efficacy: Like non-users, users believed they were capable of preventing a pregnancy if they chose to and were able to use EC despite the perceived lack of parental or partner support.
• Strong perceptions of peer support: Users also believed that their friends would be supportive of their decision to use EC.

Negative factors:

• Low levels of knowledge on EC mode of action: While users were aware of when and how to use EC, like non-users, they admittedly knew very little of its composition or its mode of action. Though they held strong beliefs that it was effective at preventing pregnancy, almost all did not know how it accomplished this.
• Fear of long-term side effects: Since they knew little of how EC worked to prevent pregnancy, they too worried that it may have negative health effects in the long term similar to those mentioned by non-users. However, unlike non-user, this fear did not deter them from using EC. The short term benefits of its use seemed to outweigh the fear of long term consequences.
• EC used as a planned rather than emergency method of contraception: One most worrisome factor about users is that they viewed EC as a regular contraceptive method rather than an emergency measure. Many had made the conscious decision not to use a regular method in favor of EC and even planned in advance to use it. This poses some health risks:

a)EC’s effectiveness in preventing pregnancy is slightly lower than routine contraceptive methods like the oral contraceptive pill or injectable (see annex I), and gets even less effective the longer it is taken after intercourse. Its use as a regular form of contraception mayin the long term put the user ata higher risk of pregnancy.

b)More importantly, women who use EC in this manner expose themselves to the risk of contracting HIV and other STDs.

Distinguishing characteristic of users

• Infrequency of sex: Both single and married users of EC tended to have sex infrequently. Insingle women, this infrequency of sex is not uncharacteristic. Single women, especially among the younger age cohorts, often tend to live at home with their parents which, given existing social norms, curtails their ability to engage in sex frequently. Among married women, thosewho used EC where mostly those whose husbands worked away from home. It is this infrequency of sex that makes EC appealing to women in these situations due to its convenience. Because of the obvious lack of understanding ofits limitations and proper use, most of these women are ignorant of any exposure to higher risk of pregnancy and therefore mistakenly assume that they are receiving as much protection as they would if they were using routine forms of contraception.

Product Information(Annex 1 & 2)

Agency scope of work

1. Campaign objectives

The campaign’s overall objective is to increase demand and appropriate use of Emergency Contraception among at-risk women. The specific communication objectives for the mass media campaign are:

1. Increase EC awareness

While awareness of EC among some cohorts is high, the percentage of women who have ever heard of EC is generally low. A very basic task of this campaign is to increase general awareness of EC and its benefits among at-risk women.

1. Increase awareness of the risks engendered in EC use

While increased awareness and adequate knowledge about EC is vital to reducing the incidence of unplanned pregnancies, it is important that potential users are warned of EC’s limitations and the risks that a woman exposes herself to by the time she is in need of EC. From the research, it is clear that the women using EC fall under one of the highest HIV infection risk categories - single women engaging in intermittent and unprotected sex and married women with absent or migrant partners. A critical role of this campaign is to increase users’ awareness of their elevated risk of HIV infection. Women should understand that EC does not protect from by HIV and STI infection and that they need to take appropriate steps to prevent infection.

The agency will also be required to produce point-of-sale material for use in private sector pharmacies and clinics. The main objective of the POS material is to:

1. Equip potential users with appropriate knowledge on EC.

As noted in the research summary, current users mistakenly view EC as a routine form of contraception. Users should be made aware of EC’s efficacy limitations over the long term and that it should only be used as an emergency measure. They should be encouraged to switch to routine forms of contraception that are more effective. In addition, POS materials should seek to dispel myths and misperceptions about its side effects and equip users with the skills to use the method effectively.

1. Target audience

The primary target audience for this campaign is sexually active womenliving in urban and peri-urban areasfrom C1- D SES,between the age of 18-30 years who have had unprotected or inadequately protected sex and wish to prevent a pregnancy.These women typically have infrequent sexual intercourse (by their own definition).

A secondary audience is women of similar characteristics who reside in rural areas.

1. Creative guidelines/considerations:

• Given the sensitivities of this campaign and the potential for negative backlash, a subtle,low key and professional approach should be taken when developing concepts. Radio, point-of-salematerial and targeted publications will be the primary vehicles of communication during the introduction phase of this campaignto avoid drawing the attention of anti-EC proponents who either fear that EC is an abortifacient or view its promotion as equivalent to encouraging sexual risk taking among young women.

1. Campaign tone

• Authoritative, empathetic, reassuring

1. Expected outcomes

• Given that EC is a fairly new method in the market, the campaign needs to build confidence in its credibility and encourage potential users to seek more information from providers.

Key message take out:

• “EC can prevent pregnancy after unprotected sex”
• “EC does not protect against HIV or STI infection”
• “EC should be used only as an emergency method and not as a regular form of contraception”

1. Geographic scope

• National

1. Pitch deliverables

• 3 campaign concepts
• Cost proposal
• Work-plan, timelines and a description of key personnel

1. Campaign Deliverables

• Pre-testing materials for each concept presented
• The final concept developed into3 radio executions in five languages, 2 print executions andpoint-of-sale material. POS material will include, but not be limited to, posters, consumer brochures, brochure dispensers, availability signs and provider aides.
• Radio executions developed for English, Kiswahili, Luo, Luhya and Kikuyu audiences

1. Pitch presentation

Two weeks from receipt of this brief.

PSI/Kenya: EC briefPage 19/30/2018