INTERNAL TECHNICAL UPDATE - EMERGENCY CONTRACEPTIVE PILL CONSUMER INSIGHTS FROM GHANA, ZAMBIA, KENYA AND UGANDA - Population Services ...
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INTERNAL
TECHNICAL UPDATE
EMERGENCY CONTRACEPTIVE PILL
CONSUMER INSIGHTS FROM GHANA,
ZAMBIA, KENYA AND UGANDA
TAKEAWAYS
• Some contraceptive users want a method that • Long-term changes that allow for on-demand use
allows for greater control and is only used around are likely to require advocacy and investment.
the time of sex. Repositioning ECPs for on-demand
• ECP markets are at different stages of development.
use responds to this preference.
Different messaging may resonate more depending
• Shifting messaging from “Oops” to “I’m in control” on the level of consumer awareness of ECPs and
shows promise in driving behavior change. their use patterns.
• Stigma persists among consumers and providers.
Repositioning ECPs as an on-demand method for
both audiences is essential.
MESSAGES*
REASSURANCE CONTROL/ON DEMAND SIDE EFFECTS/SAFETY
Don’t panic when the unexpected happens. You can’t always plan, but you can be prepared. You can safely use the emergency
The emergency contraceptive pill gives you The emergency contraceptive pill allows you to contraceptive pill which does not have any
a second chance to prevent pregnancy. be discretely ready for the unexpected. bad effect on your body or fertility.
FREQUENCY OF USE EFFICACY STIGMA
Do you know that all women can use the Emergency contraceptive pills reduce Have you heard? Emergency contraceptive
emergency contraceptive pill each time they pregnancy by as much as 80-90% if taken pills prevent pregnancy and don’t cause an
have sex, as many times as they need to in as soon as possible within 5 days. abortion. Discuss myths about the morning
a cycle? after pill with your pharmacist.
*These visual images and messages were developed based on the evidence presented in this document and are
recommended for use among PSI programs. Citations are on the last page of the brief and should be appropriately
referenced in any communication.
1
RECOMMENDATIONS
Based on qualitative research carried out in Ghana the groundwork now through advocacy and
and Zambia, and communication message testing in education that making ECPs an option for regular
Ghana, Zambia, Kenya and Uganda, it is recommended contraceptive use expands method choice which
that PSI SRH programs: is associated with increased contraceptive use.
• Reposition ECPs in the contraceptive market as • Educate pharmacists and health workers that
an on-demand method. This repositioning implies ECPs can be used safely and responsibly as both
shifting consumers’ perception of ECPs from that an on-demand and back-up option. Programs
of an “emergency” method, to one that places ECPs have an obligation to share clinical best practice
within the same category as other short-acting with providers and correct misinformation about
methods, such as an oral contraceptive pill or an methods. This can be achieved through clinical
injectable - methods that consumers confidently education sessions, verbal support provided
plan to use with regularity. The recommendation during medical detailing and through interpersonal
is for programs to strategically focus efforts on communication with consumers. Medical detailing
repositioning, while ensuring that consumers are interventions aimed at pharmacists and chemists
made aware of the back-up attributes of ECPs. should focus on destigmatizing repeated ECP use
and the safety of adolescent ECP use. Consumers
• Adapt or utilize PSI’s consumer-validated, evidence-
should be well aware of ECPs as both a back-up
based ECP messages found in this technical brief
and on-demand option.
to develop new ECP communication messages
and campaigns (for generic or branded messages). • Implement social behavior change (SBC)
To advance consumer-powered health care, ECP interventions at the community level that focus
communication should promote messages that are on destigmatizing ECP use and repositioning the
tailored to the needs and preferences of consumers method as a primary contraceptive method within
specific to a given ECP market. a comprehensive offering.
• Advocate for Ministries of Health and regulatory • Monitor and evaluate which ECP demand creation
guidelines to create pathways to on-demand strategies, SBC messages and program designs
use, adapting guidelines to respond to accepted, effectively increase informed ECP uptake and
clinical best practice. The WHO’s medical eligibility enhance the client experience.
criteria supports repeated use as safe, and several
SRH donors also support (and may be willing to
fund) on-demand ECP positioning. Start laying
2
OVERVIEW
APPLYING THE
KEYSTONE FRAMEWORK
With support from USAID through the Strengthening insights allowed PSI to validate the messages and
International Family Planning Organizations: determine which ones resonated most with consumers
Sustainable Networks 2 (SIFPO2) project, PSI’s Sexual and may potentially motivate informed ECP uptake, in
& Reproductive Health (SRH) and Strategy & Insights the context of broad method choice.
teams collaborated with Society for Family Health
DELIVER
Zambia and the Total Health Family Organization in
Ghana to better understand the experiences, needs This brief shares qualitative research results as well
and values of ECP users and non-users. PSI applied as insights into consumers’ behaviors and attitudes
the Keystone Design framework to the process of towards ECP use. The final product is a set of consumer-
designing and testing ECP communication messages, tested, evidence-based ECP communication messages
rooted in insights, so that contraceptive consumers that PSI network members and Social Enterprises can
have greater access to ECPs as one option within a adapt to promote and market ECPs as an essential
comprehensive method offering. and unique self-care contraceptive option.
DIAGNOSE
ECPs remain an underutilized contraceptive method
despite evidence that women and young women value DIAGNOSE
STRATEGY
SET YOUR
this method. To address this gap, PSI conducted a
literature review to identify existing evidence on barriers
and motivators to ECP use, and then implemented DECIDE
LEARN AND SHARE
qualitative research that explored attitudes and
behaviors towards ECPs, and how consumers view
and use ECPs as a regular, on-demand method as DESIGN
INTERVENTION
well as a back-up method.
BUILD YOUR
DECIDE
PSI summarized key learnings from the primary DELIVER
research for technical and program experts within
PSI. After a careful analysis of the research findings,
PSI developed key questions to guide communication ECP SNAPSHOT
message development.
THE OPPORTUNITY
DESIGN ECPs hold a distinct position in the contraceptive
PSI developed evidence-based communication and method mix. Not only are they the only short-acting
marketing messages to test among consumers. contraceptive method available to women, and
Working closely with the digital agency Bean and especially young women, that provide a second chance
research agency IQVIA, PSI tested the messages to prevent unintended pregnancy after unprotected
through virtual outreach among consumers in Ghana, sex, they are also the only short-acting method that
Zambia, Kenya and Uganda. The resulting consumer can be used in an on-demand way as part of self-
managing care.
3
BARRIERS QUALITATIVE RESEARCH
Despite its many unique attributes, in the majority of PSI’s qualitative research study explored women and
countries in Sub-Saharan Africa, knowledge and use men’s attitudes, beliefs and opinions regarding ECPs
of ECPs remains quite low.1 Providers across regions and on-demand use of ECPs. It sought to understand
continue to incorrectly believe that ECP users over- the factors that influence users to choose ECPs as
use or “abuse” ECPs and that users are more likely their primary method as well as the experience and
to engage in risk-taking sexual behavior.2,3,4 Women, perception of stigma when accessing ECPs.
and young women in particular, sense judgment and
stigma related to their ECP use. In addition, ECPs RESEARCH OBJECTIVES
are currently manufactured, branded and regulated • To better understand attitudes, behaviors, opinions
for emergency use only, despite the World Health towards ECPs and towards “regular” or “on-demand”
Organization (WHO) safety classification for repeated ECP use in Ghana and Zambia.
use, along with the evidence that some women and
• To develop evidence-based positioning and
young women prefer to use ECPs repeatedly, as their
communication messages for ECPs, for PSI and
primary method.5
the global community.
KEY ECP FACTS9 effective between 72–120 hours after unprotected
intercourse than ECPs that contain LNG 1.5 mg.
• Studies have shown that ECPs with levenorgestrel
• Side effects from the use of ECPs are similar
had a pregnancy rate of 1.2% to 2.1%.
to those of oral contraceptive pills; they are not
• The primary ECP product formulation most widely common, are mild, and will normally resolve
available in countries where PSI works contain without further medications.
levonorgestrel (LNG) 1.5 mg.
• A copper-bearing IUD is the most effective form
• ECPs with ulipristal acetate (UPA), typically of emergency contraception. The LNG-IUS can
marketed under the brand name “ella,” are also be used as emergency contraception based
sometimes available in PSI countries and on new data demonstrating it to also be highly
typically sold at a higher price point. UPA is more effective.10
MOVING FROM “OOPS” POSITIONING PSI interviewed 80 ECP users, 50 non-users, and 45
TO “I’M IN CONTROL” men in each country through a combination of in-
“On-demand” refers to using ECPs only when needed, depth interviews and focus group discussions.
as a planned, primary method, as opposed to as a
RESEARCH QUESTIONS
back-up method. Data from various studies and across
settings suggest that women, and young women • How are consumers currently using ECPs? What
in particular, value ECPs as a regular contraceptive are the barriers and motivators to using ECPs?
option used to prevent pregnancy, similar to how a • What are the key attitudes towards ECP use (and
condom or diaphragm is used.6,7 It is often assumed repeat ECP use)?
by providers, as well as consumers, that it is not safe
• How do we best position ECPs in the market? Is
to use ECPs more than once in a cycle; however, the
there an opportunity to position ECPs as an ‘on-
WHO has classified repeated ECP use as Level 1 in
demand’ method?
their Medical Eligibility Criteria, indicating “a condition
for which there is no restriction.”8 • How do we best communicate the benefits of ECPs?
4
RESEARCH RESULTS MYTHS AND MISCONCEPTIONS
ARE PREVALENT
ANALYSIS OF MAJOR THEMES
• A common concern was with the level of hormones
ECPS ARE VALUED FOR THEIR in ECPs. Many feared the lasting repercussions of
EFFECTIVENESS AND EASE OF USE long-term use of hormonal methods such as the
• Commonly cited benefits included that the method destruction of one’s reproductive system or womb,
works fast and that it was simple and easy to use. alteration of one’s menstrual cycle, and infertility.
• Participants in both Ghana and Zambia perceived • Many perceived ECPs to contain a high level of
ECPs as an effective method of preventing hormones which they believed could cause negative
pregnancy and as a unique alternative to other consequences; yet others felt that other methods
methods of contraception. had higher hormone levels and that relying on
these methods for long periods of one’s life could
• Respondents liked that ECPs give them an option to lead to damage.
prevent pregnancy when they have unprotected sex.
• Participants were generally unclear how ECPs
• ECPs were seen as a way to reduce the stress prevented pregnancy and common beliefs included
and worry of pregnancy that normally comes with that ECPs have a high acidity which destroys sperm
unprotected intercourse. Many participants also or that ECPs causes sperm to “flush out” of the
saw the benefits of preventing pregnancy using system.
ECPs in comparison with abortion, as ECPs were
an easier and less expensive alternative. • There were common myths surrounding side
effects, such as the perception that one does not
“
experience side effects when taking ECPs once,
It is an emergency pill so the moment you take it, it only when taking ECPs frequently or that ECPs’
works fast and you are free. side effects are dangerous if you take the method
-Unmarried Woman, 18-24, Non-User, Ghana after its effectiveness period.
“
I was so grateful. I was so happy because I wasn’t
expecting that it [was] going to work on me like that...
“
I think you using it several times is going to affect
her, because the pill is taken in to react toward the
sperms. And as it is reacting, it tries to kill sperms.
I didn’t feel like... of being guilty of anything. I just felt And I believe it contains some acidic substance
it has prevented my life and also everything body’s which if care is not taken may pour on the flesh in
life, cause once I get pregnant of an unwanted child, the womb.
it’s not just me who is going to suffer... -Man, 18-30, User, Ghana
-Unmarried Woman, 18-35, User, Zambia
5
ON-DEMAND USE IS FAVORED • Participants felt that ECPs could be abused (i.e.
AND A BEHAVIOR THAT CONSUMERS using ECPs more frequently than they believe is
ARE ENGAGED IN recommended), and frequently exposing the body
to its hormonal content would permanently damage
• The on-demand benefits of ECPs were attractive
menstrual cycles and lead to infertility.
to many participants, especially for those that have
“
infrequent intercourse.
• For married women with husbands who travel I think [ECPs users] would be willing to pay for a
frequently, or young unmarried women not in a package of multiple doses of ECPs, looking at the
committed relationship, a desirable benefit of fact their spouses are usually away and it can be best
ECPs was that ECPs can be taken only when one that they buy and stock these pills so that they will not
has intercourse. have to be visiting the pharmacy or the health clinics
• ECPs allows a user to avoid common errors that frequently whenever their husbands come home.
come with using other methods, such as forgetting But when you look at it the concept of these ECPs I
a dose, and to avoid “wasting” other methods (i.e. think they were specifically made for the purpose of
using a method and experiencing its side effect emergency situations. So, for it to be sold in multiple
despite not having any intercourse). doses, it’s going to cause a situation where people
will just be taking it whenever they have unprotected
• Many participants expressed interest in the multi- sex, so it could be today and the next day which
pack because purchasing ECPs this way would follows and that is going to cause an effect on the
allow them to always be prepared. people consuming the ECPs this way.
“
-Unmarried Woman, 18-24, Non-User, Zambia
Unplanned sex is why I was saying you need to buy
in bulk, because you don’t know when fire will come. STIGMA
It is always better to prevent than to cure. • Women using ECPs rarely reported experiencing
-Man, 18-30, User, Ghana stigma when procuring them. Participants reported
feeling nervous, scared, or shy, expecting stares
“
from others and rude providers prior to procuring
ECPs for the first time, but very few ended up having
Sex just happens, its unpredictable, you could not the unpleasant experience they feared.
predict it. So, it is better it is just home or in your
• Most women from both countries reported
handbag wherever you go, and that is not a problem...
procuring ECPs from pharmacies or drug stores and
-Unmarried Woman, 18-24, User, Zambia
found pharmacists and chemists to be generally
nice and helpful.
FEAR OF THE HEALTH EFFECTS • However, young women reported that it would be
OF FREQUENT USE likely for them to experience stigma procuring ECPs,
• Negative attitudes toward the method as an on- particularly from clinics, as young people would
demand method largely originated from beliefs likely be treated poorly for being sexually active
about the method’s hormonal content and perceived before marriage. They cautioned that providers
side effects. might even have young patients leave the clinic
• “Frequent use” was defined differently by different without providing them with any method.
participants (definitions ranged from taking ECPs
more than twice a month to more than once a year).
6
“
I normally don’t like buying these from the pharmacy
in my area so that people will not have much to say
about me... I don’t want the pharmacist to see me
“
R1: Sometimes when they find you young, they don’t
like to sell to you.
and say that I am a spoilt girl... But some time ago R2: When [the pharmacists] look at your height and
I bought it here because it was an emergency and I body and feel you aren’t old enough they won’t sell
thought the person will not be nice, but interestingly to you.
the person was very nice. So my expectations were -Unmarried Women, 18-24, Users, Ghana
that I thought the person will be rude, but I didn’t
get any of that.
-Unmarried Woman, 18-35, User, Ghana
COMMUNICATION PSI developed the six communication messages
presented on the front page of this brief to respond
MESSAGE DEVELOPMENT to the six key themes that emerged from the qualitative
GUIDING QUESTIONS AND OBJECTIVES research results.
After an in-depth analysis of the qualitative research MESSAGE TESTING
results, PSI developed a guiding question for each PSI tested the communications messages in four
theme that emerged to inform the development of countries working with the market research agency
communication messages: IQVIA and digital agency Bean. Two different
methodologies were employed. In “targeted A/B
QUESTIONS THEME testing” in Kenya and Zambia, consumers recruited
online were asked to choose between paired messages
How might we reassure her that to determine which was more successful across
she has a safe option to prevent
pregnancy when the unexpected Reassurance a range of metrics (relevance, interest, motivation
‘oops’ moment happens? to change behavior, etc.). In Kenya and Uganda, a
questionnaire was shared with consumer panels
How might we demonstrate that through email and Whatsapp. In all countries, the
Control/
ECP’s allows her to be prepared for
the unexpected?
On demand messages were tested across low, middle and high
income consumer segments.
How might we reassure her that
Side effects CONSUMER INSIGHTS
using ECP will not harm her body?
UGANDA
How might we reassure her that Repeat/
using ECP (on a frequent basis) is Frequency of use
a positive choice?
How might we explain the level
of effectiveness (as lower than
other contraceptives) without Efficacy
discouraging her from using • A majority (60%) of respondents (N = 78) were
anything? between the ages of 25 and 34 and all were female;
40% had used ECPs at least once in the last 12
How might we give confidence months
& demonstrate that ECPs are
Stigma
a responsible choice that the
provider/pharmacist will support?
7
• Respondents reported liking the messages for their KENYA
clarity, conciseness and instructiveness.
• Respondents most disliked the lack of information
on the effects of frequent ECP use.
• The messages that performed the best across all
parameters* were “User control/On demand” and
• A majority (67%) of respondents (N = 156) were
“Efficacy.”
between the ages of 18 and 30 and all were female;
• The majority of respondents reported that they 63% of respondents considered themselves to be
would be likely to do what all messages indicated ECP users (with 33% of all respondents reporting
(with a mean rating score of 6 out of 10, with 0 that they use ECPs “often.”)
meaning “not likely” and 10 meaning “very likely”)
• The majority of respondents reacted positively to
suggesting that the messages offer the potential
the concept of ECPs overall and expressed the
to motivate behavior change.
most concern around fertility and the negative side
GHANA effects after taking the pill.
• The majority of respondents found out about
the pill through friends and social media. Other
popular channels included a pharmacist, websites,
a significant other and the local provider.
• A majority (63%) of respondents (N = 96) were • The messages and visual images that performed
between the ages of 25 and 34 and all were female; the best in A/B testing as determined by the “click
43% had used ECPs at least once in the last 12 through rate” were: “Reassurance as a back-up
months. method”, “Frequency of use” and “Safety of side
effects / no harm to fertility.”
• Messages were viewed as informative and concise.
Most respondents clearly understand what the ZAMBIA
messages were telling them to do and also found
the words used in the messages simple.
• The messages that performed the best across all
parameters* were “User control/On demand” and
“Safety of side effects.”
• A majority (88%) of respondents (N = 62) were
• Similar to the findings in Uganda, the majority of between the ages of 18 and 30 and all were female;
respondents reported being likely to do what the 69% of respondents considered themselves to be
messages they were exposed to were telling them ECP users (43% of all respondents said they use
to do with a mean score rating of 6 out of 10. ECPs “often.”)
• The study parameters* included: acceptability, • In Zambia, the majority of respondents found out
relevance, likelihood to do what the message about ECPs through friends; other popular channels
indicates, likeliness of other people to do as the included the clinic, school, significant others, media
message indicates and if the message is liked. and YouTube.
• The messages and visual images that performed
the best in A/B testing as determined by the “click
*The study parameters included: acceptability, relevance, likelihood to through rate” were: “Safety of side effects / no harm
do what the message indicates, likeliness of other people to do as the to fertility,” “Stigma / non-judgment from providers,”
message indicates and if the message is liked.
8
“and “Reassurance as a back-up method.” • Assurance of future fertility was interesting to
• In Zambia, the average click through rate was 0.4% respondents. Results showed little difference
which is significantly above the national average of in framing this as positive (i.e. protects your
0.2% - this demonstrates that overall the messages future fertility) vs. negative (i.e. does not harm
were performing very well to drive interest. your fertility).
KEY TAKE AWAYS ACKNOWLEDGMENTS
FROM CONSUMER PSI wishes to acknowledge those who contributed to
MESSAGE TESTING the development of this brief or to the implementation
of the research activities.
• The messages and visuals did not necessarily share
new information; however, the positive imagery From Total Family Health Organization (TFHO), Ghana:
was liked and drove above average engagement Rachel Lawreh and Selase Adje
and interest (scoring relatively high on the scale).
From Society for Family Health (SFH), Zambia: Melvin
• Above average click through rate (CTR) levels were Mwansa
recorded in both Kenya and Zambia. The Kenyan
CTR for the ECP campaign was 0.94% above the From the PSI/Washington Sexual & Reproductive Health
benchmark 0.23%. The A/B testing for Zambia Department: Christine Bixiones, Dr. Amanda Kalamar,
had an average CTR of 0.41% against the CTR Abi Winskell, Agnes Ngure, Sarah Thurston, Dr. Eva
benchmark of 0.21%. This suggests that these Lathrop, Alison Malmqvist, and Pierre Moon.
messages are likely to attract interest in ECPs. This brief was prepared by Population Services
• Generally, messages and visual images performed International (PSI), made possible by the support of the
consistently across metrics suggesting that an American People through the United States Agency for
ECP program could utilize any of the messages International Development (USAID) under the Support
depending on the program’s communication for International Family Planning Organizations 2
objective. In addition, ECP markets are in different (SIFPO2) Project (Cooperative Agreement No. AID-
stages in different countries. In a more developed OAA-A-14-00037). The contents of this brief are the
market where there is more awareness and use sole responsibility of PSI and do not necessarily reflect
of ECPs, a program may seek to reposition ECPs the views of USAID or the United States Government.
as an on-demand method; in this situation, the For more information on this body of work, reach
“user control / on demand” and “frequency of out to Christine Bixiones, Senior Technical Advisor,
use” messages and visuals should be considered. Sexual and Reproductive Health Department
• New concepts around “On-demand” and “Frequency (cbixiones@psi.org).
of use” were interesting in Kenya and Ghana;
however, acceptability was lower (likely driven by
stigma and social norms).
• “User control” messaging wasn’t the most “liked”
message but demonstrated the highest likelihood to
drive behavior change (based on stated intention).
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