Leveraging Responsive Feedback to Redesign a Demand Generation Strategy: Experience From the IntegratE Project in Lagos State, Nigeria

"Using pause-and-reflect sessions promoted learning and allowed project implementers to course correct during activity implementation, resulting in the adaption of the interpersonal communication strategy to better fit the local context."

Despite very high knowledge of modern methods (92%), use of modern contraceptives in Nigeria remains low (12%). Demand generation approaches have been used to increase uptake of family planning (FP) by providing information, addressing myths and misinformation, increasing awareness, and generating discussion about contraceptives. This paper describes how the IntegratE project in Nigeria adopted an interpersonal communication (IPC) strategy as a demand generation activity to encourage contraceptive uptake, using a responsive feedback approach to understand the needs and preferences of the audience, tailor strategies accordingly, and ensure that activities aligned well with intended goals.

Implemented by the Society for Family Health (SFH) Nigeria, with funding from the Bill & Melinda Gates Foundation and MSD for Mothers, the IntegratE project (2017-2021) built the capacity of private-sector providers (community pharmacists (CPs) and  patent and proprietary medicine vendors, or PPMVs) to provide high-quality and expanded FP services. The project goal was to meet the modern contraceptive needs of 1,759,577 clients (both new and repeat clients) in Lagos and Kaduna States. CPs and PPMVs were not traditional outlets for contraceptive methods, especially the long-acting reversible methods, so SFH Nigeria needed to create awareness and generate demand. Strategies included an online communications campaign, mobile phone technology in marketing (sponsored health advertising messages, short videos, and newsletters), and community interpersonal communication agents (IPCAs) who were trained to offer individual and group sessions.

Data on IPC sessions were collated and analysed monthly to monitor the performance of the demand generation strategy. These data were discussed during monthly pause-and-reflect sessions held between IPC supervisors and IPCAs to review mobilisation data, discuss challenges with mobilisation activities, and ensure actions were promptly taken to address the issues identified. The monthly reportedly helped build IPCAs' confidence and improved coordination in contributing toward their shared goal of improving contraceptive method uptake.

Pause-and-reflect sessions during the IPCA monthly forums helped to identify factors responsible for incomplete referrals, where individuals who were referred failed to show up at the providers' facilities despite indicating interest during contact, and what could be done to improve performance. Thus, a course of action was implemented to improve the number of referrals that were redeemed: 2 additional IPCAs were recruited to increase the total to 6, and they were paired with experienced IPCAs as part of a comprehensive training exercise. During this phase, the collaborative performance among both new and seasoned IPCAs yielded better outcomes compared to their individual efforts. This observation led to the proposed establishment of a group IPC model, which encompassed the participation of all 6 IPCAs collaborating on outreach activities collectively.

Per IntegratE, the group IPCA strategy increased the visibility of the IPC agents. Their presence became more noticeable to community members, thereby attracting greater attention and engagement. IPCAs engaged in discussions with CPs and PPMVs to determine the periods when they were available, which coincided with community mobilisation activities. This synchronisation allowed clients to conveniently complete their referrals because the trained providers were present and accessible at the shops and premises during their visits. There was also increased information flow between IPCAs and programme managers. However, there is a need for further considerations and potential adjustments to ensure that the increased number of referrals can be adequately handled and attended to by the providers involved.

The referral success rate showed a noteworthy improvement over time. In quarter 1, the referral success rate stood at 14.3% (95% confidence interval [CI]=13.2, 15.4). However, by quarter 4, there was a significant increase of 16.3% (95% CI=14.5, 18.1), resulting in a referral success rate of 30.6% (95% CI=29.4, 31.9). Per SFN Nigeria, these data indicate a substantial increase in the effectiveness of the group IPC strategy. "Using a responsive feedback approach helped to systematically gather evidence that informed a timely course correction of the strategy and led to improved contraceptive uptake."

Selected lessons learned include:

• It is important to incorporate pause-and-reflect sessions into existing activities rather than conduct them as standalone activities. Incorporating pause-and-reflect sessions creates a forum for the successful adoption of responsive feedback as part of regular project implementation.
• Pause-and-reflect sessions should engage both project staff and external stakeholders to ensure collaboration and group reflection on strengthening project implementation.

In conclusion: "Applying the same intervention strategy to different geographies without considering the socioeconomic and cultural environment may not provide the best outcome. Although an individual demand generation strategy worked well in Kaduna (Northern Nigeria), it did not work that well in Lagos (Southern Nigeria)....Using a responsive feedback approach by incorporating pause-and-reflect sessions can be an effective way to improve the performance of interventions."