Background

Induced abortion is the most health-threatening choice of ‘family-planning’, especially for women at the beginning of their reproductive life. It is estimated that the maternal death toll due to unsafe abortions, mainly in the developing countries, is approximately 200,000 each year. A large number of pregnancies are unwanted and half of them are due to contraceptive failure or misuse, (yet, access to safe and reliable Emergency Contraception is not available or utilized). Knowledge and attitude of women about EC across different countries has been highly variable as is evident from numerous studies conducted over the last few years. While women in the developed countries were aware of EC, those from the developing countries showed little knowledge. Even those who had heard of EC showed incomplete knowledge as regards timing, source and methods available.

Few baseline surveys and studies conducted in India have revealed an extremely poor awareness of prospective users about Emergency Contraception (2-10% in most studies). These studies also highlighted incomplete knowledge about EC amongst healthcare providers, including doctors and nursing staff. Insufficient information, negligence and poor education are the main causes for under-utilization of the currently available EC methods. Therefore, the provision of detailed information and intensive education of both providers and users remains a very important issue during the pre-introduction phase for safe implementation of EC.

Most women in India following an accidental undesired sexual exposure and not wanting to conceive do not even know that unwanted pregnancy can still be avoided; they just wait with anxiety, for the period to come. A very focussed awareness campaign is required to educate men and women about such possibility as well as to emphasize the need for regular contraception.

The spread of television and radio, the rise of independent press and increasing literacy rates offer new opportunities to communicate information and knowledge on EC to the community. Not only does media reach people earlier and better, it also gets the attention of policy-makers who follow the media closely.

Questions to be Answered

The group needed to decide on:

A. Who will be the target audience for
pre-introduction IEC campaigns?

B. What will be the methodology?

C. What will be the modalities for

- building support from the community

- utilizing the professional bodies

- obtaining support from policy-makers and planners?

Views of the Group

The group deliberating on this issue based their recommendations on the assumptions that, simultaneously, there is :

• Availability of a dedicated product

• EC is launched nationwide

• Service delivery is available

Unless these are ensured, all IEC efforts are going to be wasteful.

A. The target audience for IEC campaigns.

The Group identified the following target audience groups for IEC and awareness campaigns:

I Clients/ Beneficiaries

(i) Women seeking family planning advice or undergoing MTP.

(ii) Users of barrier or other spacing methods.

(iii) Women and their husbands in reproductive age group wanting to space children but using contraceptives erratically.

(iv) Adolescent girls and boys.

(v) Victims of sexual assault.

II Healthcare/ service providers

(i) Medical practitioners including general practitioners, government doctors, registered medical practitioners and practitioners of Indian systems of medicine

(ii) Paramedicals including nurses, pharmacists, anganwari workers, auxillary nurse midwives, primary health centre staff, NGOs, women’s groups etc.

(iii) Police and staff at remand homes, orphanages, missions etc.

III Opinion makers and advocacy groups

(i) Religious leaders

(ii) Gram panchayats

(iii) School teachers

(iv) Policy-makers

(v) Ministry

(vi) Planning Commission

(vii) Professional bodies

B. Methodology of IEC and awareness campaigns

The Group recommended that the message for IEC should be very clear and include its role in preventing unplanned pregnancies i.e. the contraceptive emergencies. Where and how it is available and whom to consult?

Various methods available for IEC were listed for the groups consideration. For reaching the masses, the Group divided the methods in two parts :

I Reaching out to rural people
The methods proposed are :

- IEC by health providers

- street play / folk media

- wall writings / hoardings / posters

- radio / television

- news papers / magazines

- pamphlets / brochures

- health melas

- anganwaries

- word of mouth

- local community groups, Mahila Mandals etc.

- NGOs/ field workers

II Reaching out to urban people
The methods proposed are :

- telephone hotline

- television

- radio – FM

- newsprint

- magazines

- public lectures / seminars / symposia / group discussions

- internet

- NGOs / field workers working in slums

- youth centres

- perfect health melas

Though there is a considerable overlap, but some methods are more specific based on the community setting.

Details of methods suggested are as follows :

• Public lectures/seminars : Lack of knowledge and awareness on EC use and availability can be improved through lectures given by family planning doctors, social workers etc. They should give factual, frank, fair and friendly guidelines citing experience of patients who have taken EC.

• Group discussions : at schools to target adolescents and parents as a part of health education, in Mahila Mandals, Anganwaries, Youth Centres, Health Melas etc.

• Telephone hotline : This is a very informal and educating method, found to be extremely popular in a number of countries, as the victims of sexual accidents usually feel safer to talk on phone.

• Internet services : EC consortium should periodically publish a newsletter which should be available on the internet, and which can provide sufficient information for providers and users. Such websites should be freely available at all family planning clinics. Some international websites already exist, but an India-specific website needs to be created.

• Published material : Handouts, posters and billboards for Family Planning OPDs and general OPD. Handouts/brochures for general public seeking MTP and family planning advice. Such a material can be also used in health camps, melas, fairs etc.

• Radio : Awareness campaign can be included as part of news, features, talk shows, interviews and panel discussions.

• Television : Situational documentary or telefilms, small informative spots as well as weaving into the matrix of soap operas can generate a lot of awareness. TV makes a better impact in terms of understanding and can be successfully used even with illiterate masses. Talk shows involving policymakers, doctors (including GPs), nurses and community are also good sources of information. Since television relies more heavily on events rather than sound, featuring location and pictures tells a better story.

• Newspapers/magazines : Features, articles, editorials and advice columns can bring about periodic information, and can also help by answering queries of the public. Again, people are less shy writing about the problem than speaking in front of someone. Besides reporting ‘hard’ breaking news, the newspaper coverage can target educated clients.

• Street Plays : Impact on the male partner can be achieved as the will and decision of a woman to go for EC is governed by her husband.

• Word of Mouth : Clients already using EC can be instructed to tell others about its advantage. Usually, hearing from someone who has already been benefited, takes away the fear of unknown.

C. Modalities to obtain support from the community, professional bodies and policy makers.

There is power and influence in number. Involving all stake-holders including community leaders and professional bodies along with policy makers in a collaborative approach for public awareness will result in better planning and more realistic IEC activities.

Discussion

In principle, all agreed that there is a great need for pre-introduction IEC. Unless there is awareness about the method, it cannot be utilized. The Expert Forum accepted most of the techniques listed by the Group discussing this issue during presentations. The following were also suggested:

• As there is a very low level of awareness across the country, the information needs to be very clear and precise.

• Announcing the availability of EC by Hon’ble Health Minister/Secretary in the news itself will lead to nationwide awareness about the method.

• IEC has to be linked with availability. Unless the product is simultaneously made available, all awareness campaigns are futile.

• IEC needs to be focussed depending on the product being marketed. There is need to show the ‘pack’ on television, while talking about the method, so that lay public is not confused about dosage etc.

• More often, women have an emergency when they have missed a period. Thus the use of EC as a contraceptive needs to be clearly brought out.

• Before IEC, client and providers’ perspectives may need to be evaluated. A study by Population Council revealed very different perspectives in different populations. Thus we need campaigns to be very culturally-specific in different areas of India. The similar campaigns may not be applicable to the whole country.

• Audio-visuals need to be made in different languages. Due precautions need to be taken when translating anything as the technical contents-validity and clarity should not be distorted by such translations.

• The content and language of messages need to be very subtle, requiring elaborate planning.

• Just translating the messages in different languages will not be enough. The translation is to be done by a subject as well as a language- expert, as the meaning may completely change if only a literal translation is done.

• There is also need to develop pictorial messages and posters for illiterate masses.

Unresolved Issue

Till a dedicated product is made available, focussed IEC and awareness campaigns are not possible.

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