Determining the Most Significant Changes on Intergenerational Communication and Young People's Family Planning and Reproductive Health Outcomes: Qualitative Evaluation of the Merci Mon Héros Media Campaign in Niger and Côte d'Ivoire

NOTE: There was an oral presentation at the 2022 SBCC Summit in Marrakech, Morocco that focused on this initiative. The abstract for that Summit contribution was:

ABSTRACT FROM 2022 SBCC SUMMIT: Merci Mon Héros (MMH) is a youth co-led multi-media campaign seeking to improve reproductive health and family planning (RH/FP) outcomes among youth living in nine francophone countries. This complex campaign, implemented across multiple settings, required a multi-faceted evaluation methodology, bringing together social media listening, quantitative monitoring surveys, qualitative evaluation techniques, and routine program monitoring data to generate a more complete "big picture" view of the campaign's potential effects. This presentation showcases the use of a multi-pronged evaluation approach to inform complex SBC health campaigns. Three data sources were used to evaluate MMH in Côte d'Ivoire: social listening, quantitative cross-sectional monitoring survey, and complexity aware qualitative study. Social listening showed online conversations related to MMH campaign topics spiked two weeks after topic-specific campaign posts, suggesting potential campaign impact. Exposure survey results showed adults exposed to the MMH campaign were more likely than those unexposed of having spoken with someone about FP in the past five months. Youth exposed to the campaign reported 2.57 times the odds of having spoken to someone about FP, but were significantly less likely than adults to report feeling comfortable discussing FP with family members. Qualitative findings corroborate young people's need for adult guidance and support. Despite the perception that young people have ample access to RH/FP information, they require supportive guidance from trusted adults, yet are impeded by unsupportive social norms. This evaluation shows evidence of MMH's impact in encouraging intergenerational communication. We present recommendations for continued evidence-informed programming.

SUMMARY

"[The Merci Mon Héros campaign] allowed us to find techniques to talk about sexuality with our children, to talk to them earlier about early pregnancies, because before it was not easy..." - adult man, Abidjan

Most strategies to reduce adolescent pregnancies have been designed to educate adolescents directly about aspects of sexual risk taking and benefits of family planning (FP). However, young people often cite peers and parents as their primary sources of sexual health information. With this context in mind, Breakthrough ACTION co-facilitated and co-developed a youth-led mixed media campaign called Merci Mon Héros (MMH) to catalyse young people as co-leaders in improving intergenerational communication and young people's FP and reproductive health (RH) outcomes in francophone African countries. This report presents the results of the qualitative component of Breakthrough RESEARCH's monitoring and evaluation activities of the campaign in Niger and Côte d'Ivoire. Its purpose is to determine the most significant changes in the communities exposed to the campaign in these two countries.

MMH aims to deconstruct the stigma around adolescent and youth FP/RH communication and access to RH information and services through a combination of strategies and information channels to reach youth and adults with youth in their lives. Launched in November 2019 and active in nine francophone countries as of this writing, the campaign includes these key elements:

• Videos: Spotlighting the power of interpersonal and intergenerational communication to improve youth access to FP/RH information and services, MMH collects, curates, and disseminates videos from young people throughout the region about their experiences and needs related to RH and how a "hero" in their life broke taboos and overcame social barriers to support them. These youth testimonials are complemented by "duo" videos, where a young person and their hero tell their story together, and by ally and gatekeeper videos, where adults, community and religious leaders, FP/RH service providers, and others give their own account of why it is important to talk with young people about FP/RH.
• Social media: Videos are shared on the campaign's social media pages (Facebook, Instagram, Twitter). The postings also invite online discussion amidst other content, including FP/RH information, advice, quizzes, and live-streamed sessions with FP resource people.
• Radio and TV: The stories are also broadcast on local and national TV and radio stations in Côte d'Ivoire and Niger adjacent to or in coordination with shows popular with young and adult audiences.
• Community events: The stories are leveraged in community events with youth, parents, FP/RH service providers, community and religious leaders, and others, in discussions about overcoming restrictive social and gender norms to increase youth access to FP/RH information and services.

This study used the Most Significant Change (MSC) methodology, a qualitative evaluation method based on the collection of stories about the intervention being evaluated. In both Niger and Côte d'Ivoire, the West Africa Breakthrough ACTION team helped mobilise people who had been exposed to MMH activities. Participants were invited to share personal narratives during focus group discussions (FGDs) in Niamey, Niger, and in Abidjan, Côte d'Ivoire. In March 2021, local research partner CERA Group held 48 FGDs, 24 in each country, stratified by age and sex. Thirty stories of change were extracted in Abidjan and 59 in Niamey. In each country, an independent selection committee was formed from various sociodemographic profiles (adolescents, youth, and adults) to review the stories, define what significant change means in their local context, and select stories of most significant change.

The diverse stories collected in both countries demonstrate how the MMH campaign can create an enabling environment for young people and adults to begin communicating about FP/RH and access the information, support, and services they need. Below are some overall findings from the evaluation; see the report for country-specific stories, many in the words of participants themselves.

Stories of change related to adult-youth communication: Adult participants' stories showed that after exposure to MMH campaign activities, they had a better understanding of and empathy for others' concerns about adult-youth FP/RH-related communication. The use of testimonies allowed participants to compare other people's experiences with their own. The report presents stories that demonstrate behaviour change, such as parents taking it upon themselves to discuss issues of FP/RH with their young people due to the new understanding that it is not counterproductive to talk about sexuality with their children. Among adolescents, the MMH campaign raised their perception of the importance of communication with adults/parents on sexuality issues. The campaign also encouraged some to initiate conversations with their peers and their parents on these topics.

Despite the support and enthusiasm of some participants for communicating more with youth or adults, the study noted a continued reluctance on the part of many to talk about sexuality, with overarching social norms still acting as barriers to communication. Some adults noted they knew they needed to communicate about FP/RH with their youth but did not do so simply because they did not know how and when to talk about it. Youth indicated that it was easier for adults to talk to young people than it is for young people to talk to adults, as bringing up sexuality and FP/RH still has negative connotations. However, young participants recognised they are now part of the generation that is aware of the importance of communication about sexuality and that raises awareness for future generations.

Stories of change related to access to and use of FP/RH services: Breakthrough RESEARCH finds that the MMH campaign, through its community engagement and other activities, contributed to disseminating accurate information about contraceptive methods, how to access and use them, and how to communicate about the usefulness of FP/RH services. This study found evidence of adults changing their personal perceptions and attitudes, which can contribute to normative change related to young people's access to FP methods in the future.

For women in all age groups included in this study, MMH was found to have removed some of their misunderstandings about contraceptive methods and clarified the importance of adopting these methods. The acquisition of this new knowledge facilitated communication in the community, leading to changes in misperception of contraceptives, the usefulness of FP/RH services, and the benefits of going to health centres. As a result, participants reported adopting FP to space pregnancies and avoid early pregnancies and sexually transmitted infections. Young people's accounts collected through this study also show improved self-efficacy in seeking FP/RH services when sexually active.

Stories of change related to other outcomes: Stories of change related to other outcomes include: (i) improved relationships between parents and youth, which as reduced intergenerational distance and promoted non-violent communication, (ii) renewed confidence and feeling reassured by the MMH campaign in the choice to be abstinent until marriage, (iii) feeling encouraged to follow their curiosity about issues of concern to them, and (iv) contributed to some participants' willingness to become widespread advocates who are able and willing to help break taboos and sensitise others.

There were no detectable negative consequences to the campaign, although there were lingering fears that access to information and FP services may encourage promiscuity among youth. Breakthrough RESEARCH urges more local research to dispel this myth and document effects of intergenerational communication.

FGD participants offered several suggestions to improve the campaign or widen its potential impact. Select examples of those presented in the report include:

• Scale up MMH to other regions and departments, especially in rural areas.
• Further involve religious leaders, and contextualise the MMH campaign to fit sociocultural realities.
• Intensify MMH outreach in universities and high schools.
• Improve the services of healthcare providers.

In conclusion: "While there is still a long way to go to eradicate taboos around FP/RH for adolescents and dispel myths that access to information promotes promiscuity, this evaluation found that some youth and adults exposed to the MMH campaign are contributing to a more enabling environment for others around them to talk about and access FP/RH information and quality services."

Editor's note: Click on the video below to watch a June 2021 60-minute webinar (in English with French interpretation) that examines the role digital platforms have played in creating, monitoring, and adjusting MMH campaign content and strategy.