Projet Tékponon Jikuagou Addressing Unmet Need for Family Planning

Scale-Up Results: Ouémé 12 December 2016

PRINCIPAL INVESTIGATOR: Kim Ashburn, MPH, PhD CO-INVESTIGATORS: Rebecka Lundgren, MPH, PhD; Susan Igras, MPH; Sarah Burgess, MPhil; Fatouma Bintou Chabi Gado, MA; Mariam Diakité, MA, MPH

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TABLE OF CONTENTS

I. EXECUTIVE SUMMARY ...... 2 II. BACKGROUND ...... 2 II.A TJ: PILOT PHASE - OVERVIEW ...... 3 II.B PILOT PHASE FINDINGS - HOUSEHOLD SURVEY ...... 6 II.C PILOT PHASE FINDINGS - COHORT INTERVIEWS ...... 7 II.D PILOT PHASE FINDINGS - COSTING STUDY RESULTS ...... 7 III. SCALE UP STUDY OBJECTIVES ...... 7 IV. METHODOLOGY ...... 8 IV.A REVISED INTERVENTION PACKAGE USED DURING THE SCALE-UP PHASE ...... 8 IV.B STUDY DESIGN ...... 9 IV.C SAMPLE POPULATION ...... 9 IV.D SAMPLING PROCEDURES ...... 9 IV.E SAMPLING DESIGN ...... 10 IV.F DATA COLLECTION ...... 11 IV.G THEORY OF CHANGE ...... 11 IV.H MEASURES ...... 12 IV.I DATA ANALYSIS ...... 13 IV.J INFORMED CONSENT ...... 13 V. ETHICAL CONSIDERATIONS ...... 14 V.A CONFIDENTIALITY ...... 14 V.B STUDY RISKS ...... 14 V.C DATA PRIVACY ...... 14 V.D DATA TRANSFER ...... 15 VI. RESULTS ...... 15 VI.A SAMPLE CHARACTERISTICS ...... 15 VI.B EXPOSURE TO THE TJ PACKAGE ...... 17 VI.C ANALYSIS: HOUSEHOLD SURVEY CHANGES IN KEY FP INDICATORS / INTERVENTION VS. CONTROL SITES OVER TIME ...... 18 VI.D ANALYSIS: CHANGES IN KEY OUTCOMES BY TJ COMPONENT AT ENDLINE ...... 24 VII. DISCUSSION ...... 28 VIII. CONCLUSION ...... 30 APPENDIX ...... 31 REFERENCES ...... 32

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I. EXECUTIVE SUMMARY This report focuses on the most salient results from phase 2 of the Projet Tékponon Jikuagou (TJ Project), the 14-month scale-up research phase operating from May 2015 to June 2016. The initial results from the scale-up phase are striking. If these changes are persistent, it suggests the TJ has the power to bring positive, fundamental change to the social framework of family planning (FP) in Benin.

The results from the TJ scale-up’s household survey strongly indicate that TJ Project’s social network diffusion paradigm is highly effective in catalyzing community changes that create increased awareness, acceptance and use of modern FP methods. Evaluation results of the TJ scale- up phase, multivariate analysis of the participants’ baseline and end line survey data reveals strong positive changes in FP method use linked to exposure to the TJ package, particularly its interpersonal communication (IPC) and radio components. The observed changes in confidence to use a method, access to FP services and information, social diffusion and couple communication suggest from exposure to the TJ scale-up phase highlight the game-changing potential of this social network approach.

Both the TJ pilot phase and scale-up phase illustrate the important influence that social network interactions can have on individual behavior, as revealed by TJ’s household surveys. These interviews have given us an important look into the couple, family and village norms that influence FP method decisions in the program’s Beninese villages, located in the Departments of Ouémé (intervention zone) and Atlantique (control). Indeed, the TJ Project scale-up phase results are a powerful confirmation that the program’s IPC, leaders and radio interventions have the ability to rapidly alter personal and social network FP attitudes and behaviors in profound and, it is to be hoped, lasting ways.

TJ scale up was evaluated using a mixed methods quasi-experimental design. This report details results of the household survey. Results of the analysis of the cohort in-depth interviews conducted as part of the scale up evaluation are written in separate report.

II. BACKGROUND In Sub-Saharan Africa, significant resources have been allocated for family planning programs with activities ranging from improving services to advocating for policy changes, from conducting media campaigns to organizing peer education sessions, and from strengthening contraceptive supply chains to pioneering contraceptive technologies. Yet, unmet need for family planning – that is, the number of women and men who do not want a pregnancy but are sexually active, yet not using an effective means of preventing pregnancy – remains high, and sustained family planning use remains elusive. Interpretation of unmet need has led to an emphasis on “supply side” issues, and significant resources have been devoted to institutional strengthening and provider capacity building.

Benin is a country of approximately 9.4 million people, with a fertility rate of approximately 5.4 children per woman. Its family planning statistics track with this high fertility rate; only about 17% of sexually active adults report using any method of contraception, and the modern method use rate is even lower – about 7% of sexually active adults. The modern method use among married

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adolescents is reported to be less than 5%. When modern methods are used, the male condom, injectable and oral contraceptives make up about 75% of this kind of use.

Reported unmet need for FP is rising in Benin. Between 2006 and 2012, the percentage of Beninese respondents saying they have unmet FP need rose by about 10% for married couples and about 40% for unmarried, sexually active adults ages 15-49. As would be expected, the reasons given for nonuse of contraceptives among women expressing unmet need vary, but side effects/health concerns and opposition made up almost half of the responses for married women. Other data suggest that on the whole, family planning is rarely discussed, access to contraceptives needs to be facilitated and sources of FP information could benefit from being increased and standardized.

Many efforts to reduce unmet need have focused primarily on women and, and in some cases, their partners, without taking into consideration the social networks in which reproductive health decisions are made. Recently, increasing attention has been given to the influence of men on women’s family planning use. Research in African contexts indicates, for example, that partner disapproval (real or perceived) contributes to women’s inability to use family planning successfully and that improved couple communication increases family planning use (Sanusi, et al, 2014; Greene & Barker, 2011; Shattuck et al., 2011). Less attention, however, has been given to other important social influences on women’s health choices, such as family members (e.g., mother in law), friends, and community leaders. Literature on unmet need further underscores the necessity of acknowledging social networks and cultural contexts when addressing unmet need, in particular power relations and gender norms as influencers of reproductive health behavior (Gayen 2007, Bongaarts 1995, Greene & Biddlecom 2000).

Nearly twenty years of family planning programming efforts in Benin have led to the majority of sexually active women and men knowing at least one modern method of family planning, yet unmet need has increased from 28% in 1996 to 33% in 2012 (DHS, 2011-2012), and contraceptive prevalence has only risen from 3% in 1996 to 8% in 2012. Evidently, unmet need does not represent demand for family planning methods, nor does providing an influx of programming translate into sustained use of family planning. What prevents women and men who have an “unmet need for family planning” from using a method? II.A TJ: PILOT PHASE - OVERVIEW The Projet Tékponon Jikuagou (TJ Project) was initially planned for Mali and based on the significant amount of formative research and program development with Malian staff, a skeleton package and content themes for dialogue materials was developed prior to the March 2012 coup. These included the focus on influential groups and influential people identified by social network mapping, and community radio. While still determining where to move the research project post- coup, the project continued work in the US on initial drafting of materials for reflective dialogue based on the formative research results from Mali.

Once the project arrived in Benin, a rapid assessment of social networks and gender and other normative influences around family planning in Benin confirmed similar findings to those from Mali in terms of the development and adaptation of the intervention package to Benin. Some important differences also led to package adjustments, notably a shift from focusing on influential religious leaders (Mali) to a more generalized set of Influentials (Benin); and the addition of a services linkage component (Benin), given findings that health agents were not well-connected to communities (groups and Influentials) as they had been in Mali, where there a FP services improvement project was working in the same area as TJ.

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This project based its program development and documentation on the hypothesis that social network approaches, in tandem with communication for social change approaches, can be used to influence social and gender norms, which in turn influence FP attitudes and practices. The social network approach hypothesizes that once FP has been adopted by a group within a community, social interaction can accelerate the pace of diffusion by providing opportunities for social comparison, support and influence – not only for adopting a method but also for continuation or switching. The communications for social change approach, based on an iterative process in which “community dialogue for reflection” and “collective action” work together to produce social change, hypothesizes that public discussions of fertility and FP will lead to individual and normative social changes. The TJ project proposed a strategy that was based on both theories of change.

Core to the communication for social change approach adapted by TJ is the idea that, in addition to knowledge and messages around family planning, changing gender and other social norms around decision-making roles, communication, and fertility is also essential to improving FP use.

A simple example of how a social research/ communications for social change approach could lead to expected results follow:  women and/or men talk about family planning within their networks  their networks can then be perceived as being supportive of family planning  which results in individuals’ who wish to space or limit births taking steps to obtain family planning  resulting in decreased unmet need for family planning. DESIGNING WITH SCALE IN MIND At each design decision-point, the criterion of scalability was core to the conclusion. Whether considering adoption by government or other partners, the project rigorously held itself to making choices that kept costs down and kept intervention complexity minimal. This criterion became interwoven throughout the implementation science approach to project implementation.

In addition to considering scalability throughout the project refinement process, the Ministry of Health led the establishment of a Technical Advisory Group (TAG) at the national level and a Pilot Advisory Committee at the Zonal level. These entities aimed to create interest and ownership on the part of Ministry staff and other FP stakeholders from the beginning, which could create momentum towards scaling up. Several TAG members and central MOH participated in quarterly field visits to observe and help trouble-shoot issues during the pilot. The project hinged on five key components:

1. Engage communities in social network mapping 2. Support influential groups in reflective dialogues 3. Encourage influential individuals to act 4. Use radio to create an enabling environment 5. Link family planning providers with influential groups

Throughout the pilot, the project went through a series of implementation-learning-adjusting cycles to adjust the materials used by group dialogue facilitators (Catalyzers) and Influential people, and the strategies to encourage social network diffusion by women and men to catalyze shifts in social

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norms around family planning. As already mentioned, a light touch and simple, low-cost approach for improved scalability were emphasized at each decision point along the way. These cycles involved the country team and Headquarters staff. Because all staff members were accountable for learning, they developed a significant sense of ownership of the project, and many expressed the desire to remain on the project until it ended. As a result, there was essentially no staff turnover throughout the pilot development and testing phases, and the sense of cohesion and accountability gave the team a unique dynamic. This cycle development approach also led to some needed component adjustments to ensure the integrity of the change theory, embodied by an innovative community-based social-mobilization approach. BRIDGING THE GAP: NEW APPROACHES VERSUS TRADITIONAL COMMUNITY MOBILIZATION APPROACHES There were several lessons learned that arose out of the development and adjustment of the social network diffusion intervention package during the Pilot phase. These are consistent with the emphasis on critical community reflection on normative issues to create new ideation and behavior models, the use of social networks as key to diffusing new ideas and provoking wider discussion of new ideas, and the emphasis on developing scalable interventions from the very beginning:

Working through social network structures rather than targeting individuals Project metrics and staff recognition has traditionally been measured through reaching individuals and influencing individual behavior. While the ultimate goal in TJ was still individual family planning behavior, a different set of intermediate results was required if this were to be achieved by diffusion through social networks for social norms change. Project support and activities for such diffusion are significantly different than those for individual behavior change – depending on influential people, groups, and other community channels, rather than on staff themselves, to achieve change.

Engaging men more in social network diffusion The role of men in influencing or determining unmet need was critical to gender-synchronized diffusion of new ideas. The project recognized early on that it was easier to find women’s groups than men’s groups. In addition to make explicit during community social network mapping that informal men’s groups could be considered, other strategies were used such as inviting men to participate in women’s group discussions. Prior to scale up, new story lines for group discussion were developed that were more male-centric.

Working in new ways with opinion leaders Staff and community members fell into the expectation that influential people would develop action plans, do activities on behalf of the project, and receive some kind of incentive. It took extra effort to shift the mutual expectation towards creatively thinking about ways to leverage what they were already doing in their influential role, to influence family planning norms.

Using reflective dialogue techniques to catalyze new ideation and diffusion The paradigm shift from providing information and messages towards one of asking questions and catalyzing reflection was significant. Staff needed to go through skills development sessions so they could effectively facilitate this technique by others. Early on simple ‘coaching tools’ were developed to support the process.

Benefits of iterative program development for scalable interventions The feasibility for scaling up, in terms of cost, level of effort, and required capacity; was a primary criteria at each project decision point along the way. This meant continually deciding in favor of

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simpler and less expensive interventions that would enhance family planning and reproductive health in the context of other sectors and priorities.

Helping staff develop scale-up mentality in conjunction with normative change work NGO implementation tends to revolve around projects, deliverables, and funding cycles. Even though TJ still looked like a project, a couple of strategies attempted to offset this tendency by actively planning from the beginning to hand off and scale up. II.B PILOT PHASE FINDINGS - HOUSEHOLD SURVEY Prior to the launch of TJ phase 2 in May 2015, we completed the pilot phase of the TJ study (see IRB #2012-042) in two health districts in Benin. The study included a household survey at baseline and end line with 4,320 men and women (2,160 each) of childbearing age interviewed, and longitudinal in-depth interviews with 50 individuals (25 men, 25 women) who participated in the quantitative survey. The household survey was completed in both Couffo (Pilot phase intervention area) and Plateau (Pilot phase control area).

Preliminary results of pilot phase survey data of the intervention group showed that the TJ Project intervention was effective in increasing discussion about family planning, women and men sharing their experiences, and efforts to seek information about family planning. There was also some evidence of normative change and increased use of modern FP methods. Exposure to TJ intervention components was not as intense as expected, and this could have impacted the effectiveness of TJ in affecting family planning behavior. About half of all study participants in intervention and control communities were exposed to the radio broadcasts. Exposure to other intervention components within the intervention group was relatively low overall, with only 20% of women and 30% of men participating in reflective dialogue sessions. Similarly, only about 7% of men and 16% of women heard local leaders talk about unmet need, gender equity and family planning issues.

Approximately half of women who were members of community groups and exposed to TJ activity cards or stories in these groups said that they discussed TJ topics with neighbors or friends in the three months before the survey. A total of 62% of men in this category talked about TJ topics with at least one other person in the three months before the survey. At end line among the intervention group, significantly more women had either asked a health worker for information about family planning or had visited a health facility to access family planning services, 43% versus 57%, p value = 0.03. Perhaps the most surprising and perplexing finding was that among intervention group women, there was a significant increase in women who thought it was necessary for a health worker to get approval from a woman’s husband before giving her a method – from 42% at baseline to 58% at end line, p value < 0.00. This belief is inaccurate and at variance with the goals of the TJ program.

There was some evidence in the survey data of normative change as measured by the increase in the proportion of members of social networks who were perceived to approve of family planning from baseline to end line (48% versus 58% and 53% versus 60% among women and men, respectively). In terms of family planning use behavior among intervention group women, there were significant decreases in use of a traditional method (62% versus 53%, p value= 0.02) and significant increases in use of a modern method (43% versus 54%, p value = 0.01) among baseline versus end line respondents. Significant decreases in perceived no need (50% versus 39%, p value = 0.02) and perceived unmet need (52% versus 30%, p value = 0.01) in baseline versus end line respondents.

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In post-intervention analysis of the pilot phase data, the control zone participants were found to be significantly different from intervention zone participants in several key background and cultural characteristics that can influence family planning behavior. These characteristics include: polygamy, which was more prevalent in the intervention (45% of women) area versus the control areas (27% of women); family size, with respondents in the control group having significantly fewer children than respondents in the intervention area; and ethnicity, with 90% of respondents in the intervention area being of Adja ethnicity, while in the control group, about 75% were Yoruba and 25% were Fon. There were also significant differences in the proportion of women who reported using contraceptives, with 50% of women in the intervention areas reporting contraceptive use versus 75% of women in the control areas. In addition, the proportion of women who reported currently using a traditional method of family planning was significantly higher in the intervention areas (13.8%) as compared to the control areas (6.6%). II.C PILOT PHASE FINDINGS - COHORT INTERVIEWS The pilot phase evaluation also included ethnographic, longitudinal research on a cohort of 50 men and women with a variety of need statuses in the intervention area. Reported elsewhere, the three- round, 18-month study followed 50 participants from 2013-2014. It provided comprehensive, longitudinal data, shedding light on the fluctuating, complex of factors influencing unmet need operating at the individual level (women and men) and social and structural levels: FP knowledge; FP attitudes; partner relationships; clear fertility intentions; social network support; and access to services. Intervention programs such as TJ were found to be important influences on women and men’s pathways to addressing their unmet need. II.D PILOT PHASE FINDINGS - COSTING STUDY RESULTS A cost study was also conducted during the pilot phase to ascertain the cost to implement the TJ package of activities – using direct and indirect costs and level of effort required to implement the TJ intervention. Also reported elsewhere, IRH collected data on staff level of effort for each of the five TJ intervention components (community social network mapping, group discussions, influential people activities, radio programming, health center links) as well as five general project activities (monitoring/evaluation, administration, advocacy, formative research and staff training). The study indicated it cost $4009 per village to implement the package over 12 months.

III. SCALE UP STUDY OBJECTIVES To test the potential of the social network package to be taken to scale, four ‘new user’ organizations were identified during the pilot phase and agreed to integrate the activity package into their existing community-based programs. None of these programs operated in the FP domain; instead the TJ package was integrated into literacy, savings and loans, WASH, and maternal/child nutrition efforts. In addition, the TJ package was revised just prior to scale up (see Section IV.A), based on pilot results and a final effort to further simplify and make even more relevant the activities to the community context. The project’s scale-up phase – Phase 2 – was launched in May 2015. In terms of research rigor, one of the most important revisions to the TJ study design that took place during this second phase was the selection of a control site comparable in ethnicity, religion, family planning behavior and other key characteristics to the intervention area. This change was made to ensure that the two study areas – departments – of the TJ Project scale-up were more similar to one another than those used in the pilot phase. This should make comparisons between intervention site and control site data more meaningful.

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The purpose of the TJ scale-up phase research was to assess the impact of a simplified and slightly adjusted – but validated – social network diffusion intervention on unmet need for family planning (FP) in the selected health zone, Ouémé department. Specific research questions include:

1. How does exposure to the intervention affect attitudes, access, self-efficacy and knowledge related to family planning at the individual and social network levels? 2. How do changes in attitudes, perceptions and knowledge influence communication at the couple and social network levels? How do they affect individual intention to use family planning and take steps toward using family planning? 3. What is the effect of changes in attitudes, perceptions and knowledge at the individual and social network levels on individual use of family planning services and contraceptive methods? And how do these changes affect reports of unmet need for family planning?

IV. METHODOLOGY IV.A REVISED INTERVENTION PACKAGE USED DURING THE SCALE-UP PHASE Based on the results of the TJ pilot phase endline results, cost data and cohort study, as well as a qualitative process assessment and review of monitoring data, we proposed several adjustments to the TJ scale-up phase intervention package to increase community level diffusion and impact at the community-level:

PARTICIPATORY SOCIAL NETWORK MAPPING Community mapping was adjusted to improve diffusion. Pilot results indicated lower levels of diffusion than expected. One likely reason was linked to the limited number of community groups included in the pilot intervention regardless of village size. In each village, three groups (one men's groups, one women's group, and one mixed sex group) were identified to serve as the base of outward diffusion, regardless of whether a village had 500 or 5000 people. Pilot results also indicated the importance of influentials to reach men and staff observations of mapping activities indicated that there were oftentimes many more than five influentials cited during mapping exercises as well as concerns that smaller villages or hamlets were not being reached via diffusion efforts. Thus, villages could include up to six most-influential groups and 10 influential people, depending on the village size, and mapping identified significant hamlets where an influential would be involved. In addition, staff feedback from mapping exercises indicated points in the mapping methodology to adjust in order to improve ease of use. For example, in some villages, exercises took too long to complete and the utility of one mapping exercise was not well defined. Thus, slight adjustments in directions within specific social network mapping exercises were made.

WORKING WITH MOST INFLUENTIAL GROUPS Group reflection materials were revised to facilitate ease of use and community acceptability. Activity cards that were not popular and/or difficult to facilitate were deleted. Three new story cards were added to address concerns identified during the pilot. New themes addressed family planning from men’s perspectives, understanding perceived met need in relation to actual risks of pregnancy, and side effects of hormonal methods. Activity and story card content adjustments included having fewer reflection questions and further simplifying language to facilitate reading in French.

LEADERS/INFLUENTIALS There were no changes to the protocol used during the TJ pilot phase.

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RADIO Testimonials were no longer used in broadcasts. Moderation of discussions on gender equity and roles were too difficult to manage, and often reinforced messages of male dominance. Broadcasts format and timing remained unchanged: pre-recorded TJ stories were followed later in the week with recordings of community discussions of these stories.

GROUP LINKAGES WITH FP PROVIDERS Linkages with providers were systematized with greater involvement of and direction from the zonal MOH to ensure providers were introduced to influential groups in villages where TJ operated. The ‘Each One Invites 3’ campaign orientation materials were extensively revised to improve implementation by project staff, and in turn, by influential groups and influentials. In addition, the campaign ran for six months (versus the three months of the pilot) to allow time for diffusion. IV.B STUDY DESIGN The TJ Project scale-up phase study used a household survey. Survey data were collected before intervention activities began (baseline), and then again 18 months later (endline) in both intervention and control areas. This study took place from May 2015 through September 2016. IV.C SAMPLE POPULATION The Beninese department of Ouémé was selected as the intervention zone for the TJ scale-up phase study because of the ongoing activities of CARE to allow technical support to new user organizations, as well as the interest of local health authorities. Although scale-up activities also occurred in Couffo department, supported by Plan, due to budget constraints, Couffo was not included in the scale-up effectiveness research study.

Ultimately, the department of Atlantique was selected as the new control zone based on a number of criteria, including levels of unmet FP need, contraceptive use prevalence, and other socio- Table A: Selected statistics for possible control zones Selection Criteria Ouémé Atlantique Plateau Unmet need 40.8% 36.0% 35.5% Population* 730,772 801,683 407,116 Contraceptive prevalence rate 9.2 / 6.8 / 2.4 % 9.9 / 5.2 / 4.7 % 15.0 / 7.6 / 7.5 % (any/modern/traditional methods) Ethnic groups Adja 7.5% 13.8% 1.1% Fon 78.5% 79.7% 28.9% Yoruba 10.2% 4.0% 67.7% Contamination *Based on information from the 2002 General Census demographic characteristics. Comparisons of available data for these criteria indicated that Atlantique was more similar to Ouémé than other departments such as Plateau (See discussion in Section II.B above), which had been used as the control zone in the pilot phase. IV.D SAMPLING PROCEDURES All study activities were supervised by IRH-Benin staff (Project Coordinator and Research, Monitoring and Evaluation Officer) and the US-based staff (TJ Project Director and Research and Monitoring & Evaluation Officer), with guidance from the US-based Principal Investigator, who

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closely monitored all research activities. Routine weekly phone conferencing between the Principal Investigator, IRH-Benin staff, and the Centre de Recherche et Appui Soutien de Développement (CRAD), the research group ensured that study procedures were followed correctly.

IV.E SAMPLING DESIGN HOUSEHOLD SURVEY The final sampling strategy was based on the 2012 Demographic and Health Survey—a nationally representative survey conducted by ICF Macro (Calverton, MD) in partnership with the Benin Ministry of Health.

Sampling Design A large sample was drawn to assess the program effects on two primary outcomes: unmet need and use of a modern method of family planning, as well as a suite of secondary outcomes including couple communication; communication with others about family planning; and perceptions of network approval and use of family planning. Two-stage stratified sampling was used to draw a sample of eligible men and women. Eligibility criteria included:  For women: aged 18-44; in union  For men: aged 18 and above; in union with a woman aged 18-44 Two regions - Ouémé (intervention sites) and Atlantique (control sites) - were purposively selected for scale up study activities. At the first stage, 32 villages (16 out of 44 targeted for scale up in each region) were drawn with a probability proportional to the size estimated of the adult population (15-59 years) according to 2015 national census data. At the second stage, a list of all households was developed and systematic sampling was used to select households. Within each household, a list was made of all household occupants, and from this list one eligible woman and one eligible man was selected for interview.

The sample was stratified by region and by village size (see Table x). A total of 650 households were sampled in Ouémé and 627 in Atlantique A total of 2091 individuals were interviewed with 1046 women and 1045 men.

Region Village Size Adult Sample Size Sample Size Total Sample Population Female Male Size (15-59 years) in 2015 Small 1561 175 174 349 Ouémé (intervention Medium 9762 174 174 348 sites) Large 46641 174 174 348

Total: Ouémé 57964 523 522 1045 Small 1374 176 176 352 Atlantique (control Medium 10708 175 175 350 sites) Large 35290 172 172 344

Total: Atlantique 47372 523 523 1046 Total 105336 1046 1045 2091

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A total of 20 data collectors were organized into 10 teams for data collection. Each team had a team leader and two supervisors were responsible for oversight of data collection including spot checking completed surveys for accuracy and completeness. Handheld tablets were used for data collection with secure submission to a secured cloud server via stable internet connection was used to store collected data.

Interviewers did not have any refusals to participate. In cases where the eligible individuals were not at home, interviewers returned to the home up to two times to conduct the survey. If no eligible person was found the household was replaced with another household. IV.F DATA COLLECTION Data collection was done by Beninese research group Centre de Recherche et d’Appui-Soutien au Développement (CRAD). We worked with CRAD during previous phases of research in Benin, including the baseline and endline household surveys, and a series of cohort interviews conducted over the course of the pilot. All enumerators working under CRAD were trained in human subject research ethics by the IRH Research, Monitoring and Evaluation Officer in Benin.

The questionnaires were developed in English, translated into French and were translated orally to the local languages at the time of data collection, by the enumerators who are fluent in these languages and in French. Interviewer training included exhaustive translation and back-translation exercises, to ensure that this was done as accurately as possible. Male enumerators interviewed male respondents, and female enumerators interviewed female respondents. The enumerators were experienced in obtaining privacy during household interviews and knew not to conduct an interview if privacy could not be ensured.

COMMUNITY INTRODUCTION Our partners CARE Benin and Plan International in Benin had a project presence in these villages; they introduced the TJ intervention and this research to government and civic authorities, as well as community and religious leaders in the villages before the baseline study took place. They asked local leaders for help in making the study known to the village population, so that they knew what to expect from the enumerator’s visit. The leaders did that using whatever means they usually used to spread information – for example community meetings, or a loud speaker in the market. IV.G THEORY OF CHANGE The Results Framework in Figure 2 below shows the main hypotheses being tested in this study. Primary results at the individual and network level test whether exposure to the intervention influences attitudes and perceptions about family planning and knowledge about pregnancy risk. Intermediate results test whether changes in individual and social network level attitudes, perceptions and knowledge affects key intermediate determinants, couple communication about family planning, the intention to use family planning and taking steps toward using family planning services. Ultimate results examine the influence of intermediate determinants on use of family planning services and contraception, and impact on unmet need for family planning.

The primary, intermediate and ultimate results diagramed in the Results Framework guide the analysis. Analysis was conducted to answer each of three main research questions:

1. How does exposure to the intervention affect attitudes, access, self-efficacy and knowledge related to family planning at the individual and social network levels?

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2. How do changes in attitudes, perceptions and knowledge influence communication at the couple and social network levels and affect individual intention to use family planning and taking steps toward using family planning? 3. What is the effect of changes in attitudes, perceptions and knowledge at the individual and social network levels on individual use of family planning services and contraceptive methods (any method and modern methods), and ultimately on unmet need for family planning? including proportions, means, and standard deviations will be used to an Figure 2

IV.H MEASURES HOUSEHOLD SURVEY Measures were created for key constructs included in the survey instruments. The results for these measures, or indicators, are collated in Tables 2a and 2b below. They were created using factor analysis of relevant items included in the baseline questionnaire:

Self-efficacy in using family planning A single variable was used to measure confidence in using a family planning method, “I am confident in using a family planning method all the time.” Response categories for this indicator are, “Strongly agree, Agree, Disagree, and Strongly Disagree”.

Access to family planning services This indicator covers knowing where to access services, ability to reach the service locations, and having the means to pay for the services including a method. Three variables were used to measure

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the access to FP services indicator; “I know where to obtain FP”, “I am able to reach this place without too much difficulty” and “If I wanted a method, I have the mean to purchase one.” Response categories were “Strongly agree, Agree, Disagree, and Strongly Disagree”.

Attitudes toward gender norms and family planning This concept measures a range of beliefs, including women’s role in the family and society, responsibility of men and women for family planning, decision making roles of men and women in the household and as related to family formation and family planning use, and the value of having many children. Variables used to measure this concept included statements such as, “Do you believe your husband (wife) approves of using a modern method to delay or avoid getting pregnant? ”, and three statements under the “Social Diffusion” indicator; “In the past three months, have you asked friends or family about using FP,”; “In the past three months have you shared knowledge or any positive experience with friends and family?“; and, “In the past three months have you corrected someone if hearing something incorrect/untrue about use of FP methods?”. Possible response options were Yes/No.

Couple communication Three questions were used to measure this indicator; “Do you feel comfortable talking with your partner about the use of FP?”, “Have you discussed with your spouse about which method to use to prevent pregnancy (past 12 months)”, and “Have you discussed with your spouse on how to obtain a FP method?” Response options were Yes/No.

Unmet need for and current use of family planning methods Unmet need for family planning was measured using a simplified version of the DHS standard measure of unmet need. This measure included a series of questions asking about current pregnancy status, pregnancy intention, current use of a family planning method, if so which method, where applicable, if the current pregnancy was a desired pregnancy, and reasons for not using a method. If the person had previously used a method and if so, the method used was also included in the questionnaire.

Perceived met need for family planning This measure was developed to account for those women who do not want to become pregnant, and are doing something to avoid or delay pregnancy but are using an ineffective method. IV.I DATA ANALYSIS Descriptive statistics including proportions, means, and standard deviations were used to analyze men and women’s demographics, and other key variable such as family planning behaviors and intentions to use a method.

Logistic regression models were used for binary outcomes and linear regression for outcomes that are continuous. Multivariate logistic regression models were adjusted for age, education, religion, number of children and number of co-wives. IV.J INFORMED CONSENT All those who agreed to participate in the scale-up phase were informed by survey enumerators hired by the research organization before beginning the interview. Since most participants were illiterate, to document their consent we presented informed consent information in conjunction with the short form written consent document (which states that the elements of consent have been presented orally). The written informed consent document was in French, the official language of Benin. However, an oral presentation was given in the local language in front of a

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witness who was fluent and literate in French. The witness could be a village resident, such as a teacher, or a visiting relative. Ethical clearance for the scale-up phase protocol was granted by the Institutional Review Board of Georgetown University and the Research Ethics Committee of the Institute of Applied Biomedical Science in Benin.

V. ETHICAL CONSIDERATIONS V.A CONFIDENTIALITY All interviews took place in a private place of the respondent’s choice. This could be in the home, in public facilities, or in any other private place that the respondent preferred. Male enumerators interviewed male respondents, and female enumerators interviewed female respondents. The enumerators were experienced in obtaining privacy during household interviews and knew not to conduct an interview if privacy could not be ensured. V.B STUDY RISKS There are few risks for participating in this study. Some of the information obtained in the household surveys is quite personal, and the household survey included questions about others. There was a small risk for a breach in confidentiality. However, we took all possible precautions to ensure privacy and confidentiality, both of the research subjects and the people they named. All study investigators and co-investigators are certified in human subject ethics, and survey enumerators were trained in human subject research ethics before beginning any survey activities. Finally, strict data privacy procedures were followed (outlined in section VI.D).

In addition, there was a small risk that talking about sensitive issues such as family planning could make respondents uncomfortable or embarrassed. To minimize this risk, it was made clear to respondents that participation was entirely voluntary, that they did not need to respond to any question that made them feel uncomfortable, and that they could stop the interview at any time. V.C DATA PRIVACY HOUSEHOLD SURVEY Households for the household survey were selected from a list of all community households where local partners were currently implementing programs (our sampling frame). On the list, each household was given a code. The master list of household codes was held in the office of the leader of the research team in Cotonou, the economic capital of Benin, which is far from the research communities. This electronic document was stored in a password-protected file on a password- protected computer. She only provided applicable sections of this list to the survey enumerators. No identifying information was included in the household survey form – only the code from the list. After analysis of the baseline data, the master list that contained addresses of selected households was deleted and wiped from the hard drive of the research lead's computer. Only codes were used, not names.

The privacy of individuals named by respondents in the social network questions of the household survey was also maintained. We asked only for first names (or nicknames or codes, as the respondent preferred). In addition, the ‘name’ variable was deleted from the data set before it was uploaded to the server.

Data from the household survey were collected on password protected, mobile hand held devices (tablets) such as the Samsung Galaxy tab 4 with restricted rights for data collectors for only

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entering and storing data, and no network connection. Enumerators carried their tablets on their person at all times while in the study villages. At the end of each day, enumerators returned their tablets to their team leader, who backed up completed surveys on an encrypted, password- protected laptop computer. All data were transmitted to an encrypted, password protected local server using a wireless internet connection from the field, if available. If no wireless internet connection was available, the team leader used a secure mobile hotspot to transfer the data. The server was backed up daily on a password-protected external hard drive. Both the server and the external hard drive for backup were housed in a locked cabinet in the local IRH office in Cotonou, far from the research communities. All data were deleted from tablets once data collection was completed. V.D DATA TRANSFER Once data collection is complete, data were transmitted from the local server in Cotonou to the IRH- Box, part of GU Box, Georgetown University’s encrypted, password protected server. We created a sub-directory (folder) in IRH-Box to house the data. The folder was encrypted and password protected, and accessible only to research team members. Data was transferred via a one-time link given to the leader of the enumerator team, who uploaded the data files to the folder from the local server in Cotonou. The link was set to expire once the data was uploaded. Once analysis was completed, the data on the local server and in the IRH-Box folder was deleted and destroyed. Data will be kept for seven years on the UIS Phoenix server, as per US government data requirements for publically-funded projects.

VI. RESULTS VI.A SAMPLE CHARACTERISTICS Socio-demographic characteristics of women and men recruited into baseline and endline surveys are presented in Tables 1a and 1b. Women assigned to control and intervention groups were not significantly different for the most part. Higher percentages of intervention women were from the Fon ethnic group as compared to the control group women. There were significant differences in religious affiliation with more Christian women in the intervention group and about a quarter of women in the control group were Traditionalists. Nearly half of the women were between the ages of 25 and 34, and a small percentage, less than 12% had attended secondary school. The majority of women did not have a co-wife.

Table 1a: Sample Characteristics among Women Baseline (N=1043) Endline (N=1046) p--value Control Intervention Total Control Intervention Total Variables (n=524) (n=519) (n=523) (n=523) % % % % % % Age Mean 29.5 30.3 29.1 29.9 18-24 24.1 21.8 22.9 25.8 24.3 25.1 25-34 50.8 47.4 40.1 47.6 46.7 47.1 0.493 35-44 25.2 30.8 28.0 26.6 29.1 27.8 Education No 62.8 66.9 66.8 72.5 65.0 68.7 education 0.083 Primary 25.6 25.1 25.3 19.7 27.7 27.7

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Secondary 11.6 8.1 9.9 7.8 7.3 7.3 and above Religion a***, b***, c** Christian 67.9 89.6 78.7 77.8 90.8 84.3 Traditional 25.2 5.8 15.5 17.0 6.1 11.6 <0.001 Muslim 1.9 4.1 3.0 0.6 1.7 1.2 None/ other 5.0 0.6 2.8 4.6 1.3 2.9 Ethnicity a***, b***, C* Adja 6.5 0.8 3.7 5.8 0.4 3.1 Yoruba 1.9 2.7 2.3 0.6 1.3 1.0 0.036 Fon and 91.5 96.5 94.0 93.6 98.3 95.9 other Number of living children None 6.5 3.9 5.2 3.6 6.9 5.3 0.419 1 14.3 11.6 12.9 15.1 14.9 15.0 2 21.6 19.8 20.7 18.7 17.4 18.1 3 16.8 19.9 18.3 20.3 20.5 20.4 4 17.0 19.5 18.2 17.9 17.8 17.9 5-11 23.8 25.4 24.6 24.3 20.6 23.4 Had co-wife a***, b***, c*** No co-wife 70.8 60.5 65.7 81.3 75.3 78.3 <0.000 Had co-wife 29.2 39.5 34.3 18.7 24.7 21.7 Notes: a: comparing control vs. intervention at baseline b. comparing control vs. intervention at endline c: comparing baseline vs. endline *: significant at p<0.05; ** significant at p<0.01; ***: significant at p<0.001

Similarly, sample characteristics among men did not differ significantly across control and intervention sites, measured at baseline and again at the Phase 2 endline (Table 1b). Men were about six years older than women in the study and most men were aged 35 to 44. A higher proportion of men had some secondary education than women, but between 28 and 59% reported receiving no education. The percentage of men who had co-wives was higher in the control group than the intervention group at baseline and at endline. Religion number of living children, and ethnicity were not significantly different.

Table 1b: Sample characteristics among men Baseline (N=1030) Endline (N=1045) p--value Control Intervention Total Control Intervention Total Variables (n=525) (n=505) (n=523) (n=522) % % % % % % Age a*, c* Mean 43.4 38.5 36.0 36.0 18-24 5.5 2.4 4.0 6.1 5.8 5.9 25-34 34.5 36.6 35.5 36.3 39.7 38.0 0.038 35-44 60.0 61.0 60.5 57.6 54.6 56.1 Education a***, b***, c**

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No 42.3 27.5 35.1 58.7 28.9 43.8 education Primary 35.4 43.4 39.3 28.7 42.2 35.4 <0.000 Secondary 22.3 29.1 25.6 12.6 28.9 20.8 and above Religion b***, c*** Christian 50.7 57.9 56.7 52.4 59.4 56.2 Traditional 38.2 34.5 36.2 32.8 34.1 33.5 Muslim 3.5 2.7 3.0 12.4 2.5 7.0 <0.000 None/ other 7.7 4.8 6.1 2.4 4.1 3.3 Ethnicity a**, b** Adja 3.6 0.6 2.1 5.7 0.8 3.3 0.231 Yoruba 1.7 2.2 1.9 0.8 2.3 1.5 Fon and 94.7 97.2 95.9 93.5 96.9 95.2 other Number of living children None 6.3 2.4 4.4 3.6 6.9 5.3 1 14.3 9.5 11.9 10.9 12.7 11.8 2 15.2 15.3 15.2 15.8 15.4 15.6 3 14.9 15.5 15.2 16.3 17.7 17.0 0.635 4 13.7 13.4 13.6 13.6 14.2 13.9 5-11 35.6 44.0 39.7 39.8 33.2 36.5 Presence of a**, b***, c*** more than one wife One wife 75.1 61.0 68.2 86.0 75.3 80.7 More than 24.9 39.0 31.8 14.0 24.7 19.3 0.000 one wife Notes: a: comparing control vs. intervention at baseline b. comparing control vs. intervention at endline c: comparing baseline vs. endline *: significant at p<0.05; ** significant at p<0.01; ***: significant at p<0.001 VI.B EXPOSURE TO THE TJ PACKAGE Overall women had more involvement with the TJ intervention than men. A total of 505 women (48%) reported exposure to any of the TJ components in the endline survey. This compared to 495 (47%) men who reported being exposed to at least one of the TJ package components. Among men, the highest level of exposure, followed by 26% who heard a leader talking about TJ topics and 24% heard the TJ radio broadcasts. A total of 180 men (17%) had been in a group that discussed TJ topics or activities, of which 87% had been in a group where activity cards were used and 33% were in groups where story cards were used. Less than 10% of men (101) had seen any of the, infographs or invitation cards.

For women, 35% reported listening to the TJ radio broadcasts, the most commonly reported exposure to any intervention component. Following the radio broadcasts, 32% (332 women) had heard a leader talking about TJ topics and 22% (234 women) had been in a group meeting where TJ topics were discussed. Of those who had been in a TJ group, almost all had been in groups where story cards, 94% (220 women) or activity cards were used, 95% (222 women). More women than men had seen the infographs or invitation cards, 17% of women versus 9% of men.

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VI.C ANALYSIS: HOUSEHOLD SURVEY CHANGES IN KEY FP INDICATORS / INTERVENTION VS. CONTROL SITES OVER TIME Overall, the household survey revealed a number of remarkable positive changes from baseline to endline across control and intervention group women and men.

Table 2a presents the results of bivariate analyses comparing key family planning indicators from baseline to endline among control and intervention group women. On the whole, these indicators showed positive results that were surprising in their size and consistency, including a particularly large percentage increase in use of a modern method (25.2%) and reported met need for family planning (24.1%) among intervention group women from baseline to endline. The intention to use family planning did increase over time, but not significantly.

Important determinants of family planning use and unmet need also changed in positive directions. Significant increases in the number of women who felt confident in using a method all of the time increased from 63% at baseline to 91% at endline (p-value <.000). Even more striking, the access to FP indicator values showed notable baseline-to-endline increases (ranging from 17% to 34%) in stated ability to access and purchase family planning methods after participating in TJ. This increased capacity to find and use FP was between 2 and 30 times greater than any increases in capacity reported by members of the control group.

Gender attitudes regarding negative perceptions of women who use family planning declined. The proportion of women in the intervention group who agreed with the statement that women who use family planning have multiple sex partners reduced by 13% from baseline to endline. Interestingly, attitudes about the role of men and women in using contraceptives did not improve in the intervention group. Fewer women at endline agreed that if the couple does not want to get pregnant and the wife was not using a method, then the husband should use a method.

Couple communication increased significantly among intervention group women. At baseline 16% said they had discussed which method to use with their spouse. At endline this had increased to 51%. Control group women become substantially less comfortable talking about FP with their partners at the end of the scale-up period. Less than half of control group women reported being comfortable talking about FP at endline, a decline of nearly 6 percentage points from baseline.

Similarly, only 18% of women in the intervention group said their spouse approved of family planning at baseline and 31% reported their spouse approving at endline. In contrast, fewer women in the control group believed that husbands definitely approved of FP use decreasing from 24% to 20%.

Measures of social diffusion also showed positive signs of increased public discourse on family planning topics. All three of the social diffusion indicators saw substantial positive moves toward greater inquiry concerning and discussion of FP methods within the participants’ social networks. These increases range from about 20% for correcting FP inaccuracies when overheard in conversation, to almost 33% for asking friends or family about FP use. As with the indicators discussed earlier, these intervention site results are remarkably large and positive. Among women in the intervention group, women who had asked friends or family about their experiences with family planning went from 14% at baseline to 47% at endline.

Table 2a: Comparing changes in women respondents - key family planning indicators across intervention and control groups (women; bivariate)

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Control (N=1043) Intervention (N=1046) Indicators Difference p- Baseline Endline Change Baseline Endline Change in changes value % % % % % % Self-efficacy for FP Confident in using a FP 62.0 70.8 8.8 63.4 91.0 27.6 18.8 <0.000 method all the time Gender attitudes Women who use family planning have 22.9 10.2 -12.7 31.5 18.5 -13.0 0.003 0.9 multiple sexual partners Men whose wives use 23.8 8.9 -14.2 23.1 14.9 -8.2 6.0 0.07 family planning lack authority It is shameful to be associated with 15.8 4.8 -11.0 6.9 4.6 -2.3 8.7 <0.001 a woman who is known to use family planning In this village, it is acceptable to discuss 57.8 64.4 -6.5 60.6 50.9 -9.8 -16.3 <0.001 family planning in public In the home, a man must have the final word 86.8 92.5 5.7 80.9 55.6 -25.2 -30.9 <0.001 in decision- making A woman must always obey 84.2 91.5 7.4 78.4 66.0 -12.4 -19.8 <0.001 her husband It’s a woman’s responsibility to bring up the topic of family 6.7 19.1 12.4 11.9 17.0 5.2 -7.2 0.015 planning for discussion with her husband If a couple does not want to get pregnant 62.4 59.7 -2.7 59.1 43.2 -15.9 -13.2 0.002 and the wife is not using contraceptives,

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her husband should do so Access to FP I know where 52.3 62.0 9.7 64.6 92.0 27.4 17.7 <0.000 to obtain FP I am able to reach this place without 52.1 53.0 0.9 56.8 88.2 31.4 30.5 <0.000 too much difficulty If I wanted a method, I have 50.7 44.0 -6.7 56.1 83.8 27.7 34.4 <0.000 the mean to purchase one Husband/wife approval of FP use: 23.7 20.0 -3.7 17.7 31.2 13.5 17.2 <0.000 definitely approve Couple communicatio ns Feel comfortable talking with 60.7 55.1 -5.6 47.2 63.5 16.3 21.9 <0.000 your partner about the use of FP? Discussed with spouse about which method to use to 23.1 13.0 -10.1 16.0 50.9 34.9 45.0 <0.000 prevent pregnancy (past 12 months) Discussed with spouse on how 22.5 11.5 -11 16.0 47.6 31.6 42.6 <0.000 to obtain a FP method? Social diffusion Asked friends or family about 17.8 8.8 -9 14.3 46.5 32.2 41.2 <0.000 using FP? Shared knowledge or any positive 11.6 9.2 -2.4 16.6 42.6 26 28.4 <0.000 experience with friends and family? Corrected someone if 6.9 7.5 0.6 7.5 27.2 19.7 19.1 <0.000 hearing something

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incorrect/untru e about use of FP methods? Intention to use FP 57.1 61.4 4.3 66.6 76.5 9.9 5.6 0.212 methods? Currently use a method to 16.7 12.6 -4.1 38.3 59.4 21.1 25.2 <0.000 prevent pregnancy Actual met 17.3 13.3 -4 39.9 60.0 20.1 24.1 <0.000 need for FP Perceived met 30.1 23.9 -6.2 45.0 33.3 -11.7 -5.5 0.54 need Note: p-value corresponds to the comparison of changes between control and intervention groups Difference in changes were calculated by subtracting change in the intervention to changes in the control groups.

All in all, these results are striking in their consistency and magnitude, appearing to demonstrate that the TJ scale-up phase had a powerful positive FP effect in the intervention zones.

Table 2b presents results for these same indicators for men during the TJ Phase 2 program –

Table 2b: Comparing changes in Key FP indicators across intervention and control groups (men; bivariate) Control (N=1048) Intervention (N=1027) Indicators Difference p- Baseline Endline Change Baseline Endline Change in changes value % % % % % % Self-efficacy for FP Confident in using a FP 62.3 75.5 13.2 57.8 81.4 23.6 10.4 .009 method all the time Gender

attitudes Women who use family planning 28.8 37.6 8.9 58.1 35.8 -22.3 -31.2 <0.001 have multiple sexual partners Men whose wives use family 22.7 40.2 17.5 65.0 36.2 -28.8 -46.3 <0.001 planning lack authority It is shameful to be associated with a woman 8.6 10.9 2.3 15.7 11.1 -4.6 -6.9 0.014 who is known to use family planning In this village, it is acceptable to 76.2 34.7 -41.5 28.5 80.5 52.0 93.5 <0.001 discuss family

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planning in public In the home, a man must have 85.3 84.4 01.0 46.1 72.4 26.3 27.3 <0.001 the final word in decision-making A woman must always obey her 91.4 73.3 -18.2 44.0 82.4 38.4 56.6 <0.001 husband It’s a woman’s responsibility to bring up the topic of family 11.6 25.5 13.9 8.4 32.0 23.6 9.7 0.004 planning for discussion with her husband If a couple does not want to get pregnant and the wife is not using 52.2 25.3 -26.8 21.8 42.3 20.5 47.4 <0.001 contraceptives, her husband should do so Access to FP I know where to 61.0 50.3 -10.7 62.4 84.7 22.3 33.0 <.001 obtain FP I am able to reach this place 59.6 36.7 -22.9 54.3 81.0 26.8 49.7 <.001 without too much difficulty If I wanted a method, I have 59.4 34.4 -25.0 52.1 74.7 22.6 47.6 <0.001 the mean to purchase one Wife approval of FP use: 10.5 26.2 15.7 22.0 28.5 6.6 -9.2 0.01 definitely approve Couple communications Feel comfortable talking with your 58.5 60.8 2.3 45.1 64.8 19.6 17.3 <0.001 partner about the use of FP? Discussed with spouse about which method to 15.8 38.2 22.4 26.7 43.7 16.9 -5.5 0.17 use to prevent pregnancy (past 12 months) Discussed with spouse on how to 14.5 21.6 7.1 22.8 39.8 17.1 9.9 0.007 obtain a FP method? Social diffusion

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Asked friends or family about 2.1 18.2 16.1 13.5 32.6 19.1 3.0 0.33 using FP? Shared knowledge or any positive 3.2 14.7 11.5 15.6 33.0 17.3 5.8 0.064 experience with friends and family? Corrected someone if hearing something 3.6 17.0 13.4 7.5 11.9 4.4 -9.0 0.001 incorrect/untrue about use of FP methods? Intention to use 37.9 57.8 19.9 58.8 59.8 1.0 -18.9 <.001 FP methods? Currently use a method to 38.9 60.5 21.6 60.4 64.3 3.9 -17.7 <0.001 prevent pregnancy Actual met need 38.9 60.5 21.6 60.4 64.3 3.9 -17.7 <0.001 for FP Perceived met 23.3 47.3 24.0 45.7 7.0 -38.7 -72.7 <0.001 need Note: p-value corresponds to the comparison of changes between control and intervention groups Difference in changes were calculated by subtracting change in the intervention to changes in the control group

While the extraordinary numbers seen for female responses in Table 2a overshadow the male numbers here, it is important to remember that most of the results for men in Table 2b are also moving in a desirable direction, displaying large positive changes in FP attitudes and behavior in a very short time frame.

Primary outcomes of current use of a modern method and met need both declined among intervention group men but increased among control group men. The intention to use FP methods increased among intervention group men but declined among control group men. These responses differ dramatically from women’s responses and merit further exploration.

Self-reported confidence to use FP went up both for men in the control group and in the intervention group, with the TJ phase 2 intervention men seeing an extra 10 percentage point increase. As a consequence, by the end of phase 2 more than 80% of the men at the intervention sites were confident in their ability to always use an FP method.

Changes in gender attitudes among men were similar in several ways to responses among women. Intervention group men had less agreement with statements about Women who use family planning having multiple sex partners; Men whose wives use family planning lack authority; and It is shameful to be associated with women known to use family planning. There was a decline in agreement with these negative attitudes among control group men. Men in the intervention group were less often supportive of traditional views of male authority and women’s roles in the household from baseline to endline. Changes among control group men increased over time in agreement with these statements. Interestingly, intervention group men who felt that it was acceptable to discuss family

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planning in public increased by 94 percentage points. Among women in the intervention group, agreement with this statement declined by 16 percentage points.

As with the corresponding data for women (Table 1a), increases in the access to FP subset indicators for men were extraordinarily positive. Male confidence in the ability to access and pay for FP methods went up by almost 50% at the intervention sites, so that 75% or more reported these improvements by endline. This substantial increase was in sharp contrast to changes in the access to FP responses from males at the control site, where between 10% and 25% of the men reported a drop in their access to FP satisfaction during the study period. Perhaps demographic shifts or new media messages led to these changes in the control zone, but at this time the reasons for these declines are unknown.

One surprising finding was that the percentage of men who believed their wives definitely approve of FP method use grew more at the control site than at the intervention site. While the intervention site saw about a 40% increase in the number of men who believed this to be true, the number of men at the control site believing this almost tripled, so that the absolute percentages of men in both zones - about a third – ended up being the same at endline.

The couple communications indicators increased in the percentage of intervention group men who felt comfortable talking with their partner about FP. A smaller increase was seen in those reporting they had spoken with their spouses about how to obtain an FP method. While these increases were much smaller than those seen in the data among women, more than 17 percentage point increase in the proportion of men who had talked to their spouse about how to obtain a method was observed in the intervention group men. There was an unexpected finding here as well; the absolute percentage of control group males reporting that they had discussed FP methods to prevent pregnancy in the last 12 months increased by almost 25%, a good 10 percentage points better than the increase seen at the intervention sites.

The social diffusion data are the scale-up’s weakest set of intervention versus. control numbers, besting the same increases seen in the control zone by just a few points and, in one case (Corrected someone if hearing something incorrect/untrue about use of FP methods), faring about 10 points worse than the men in the control zone. These results bear further analysis and study, especially when they are compared with the extraordinarily powerful positive changes seen in the results for this same indicator in the intervention site among women’s responses. VI.D ANALYSIS: CHANGES IN KEY OUTCOMES BY TJ COMPONENT AT ENDLINE Another valuable way to analyze the TJ scale-up program’s results is to compare the experience of exposed and unexposed participants, i.e., those in the intervention sites who were actually exposed to components of the TJ program versus those at these same sites who did not participate in the program in any way. This analysis helps us get a better handle on how likely it is that the TJ program actually initiated any personal or social changes observed. We begin this analysis with a look at results among women.

Table 3a: Comparison of key outcomes across exposed vs. unexposed participants (endline; female; N=1046)

Adjusted Odds Ratio (95% CI) Exposed to radio Exposed to leaders Exposed to IPC (35%) (38%) (25%) Self-efficacy for FP

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Confident in using a FP method all the time 7.0 (4.2-11.5)*** 3.8 (2.5-5.7)*** 13.4 (5.9-31.0)*** Gender Attitudes Women who use family planning have multiple 0.38 (0.28- 0.66 (0.49)0.90)** 0.30 (0.20- sexual partners 00.54)*** 0.46)*** Men whose wives use family planning lack 0.31 (0.21- 0.63 (0.45-0.88)** 0.41 (0.26- authority 0.46)*** 0.64)*** It is shameful to be associated with a woman 0.68 (0.37-1.23) 0.88 (0.51-1.56) 0.98 (0.52-1.84) who is known to use family planning In this village, it is acceptable to discuss 0.73 (0.56-0.96)* 0.77 (0.59-0.99)* 0.97 ().72-1.30) family planning in public In the home, a man must have the final word 0.69 (0.52- 0.60 (0.46-0.79)*** 0.43 (0.32- in decision-making 0.91)** 0.59)*** A woman must always obey her husband 1.25 (0.93-1.68) 0.97 (0.72-1.30) 0.87 (0.63-1.19) It’s a woman’s responsibility to bring up the 0.82 (0.56-1.21) 0.59 (0.40-0.87)** 0.94 (0.61-1.44) topic of family planning for discussion with her husband If a couple does not want to get pregnant and 1.1 (0.83-1.41) 0.75 (0.58-0.97)* 0.96 (0.72-1.28) the wife is not using contraceptives, her husband should do so Access to FP I know where to obtain FP 6.8 (4.4-10.7)*** 3.8 (2.6-5.4)*** 9.0 (4.8-16.8)***

I am able to reach this place without too much 5.6 (3.9-8.2)*** 3.7 (2.6-4.9)*** 11.9 (6.5-21.7)*** difficulty If I wanted a method, I have the mean to 5.3 (3.8-7.3)*** 3.4 (2.5-4.5)*** 7.4 (4.8-11.5)*** purchase one Husband/wife approval of FP use: definitely 1.9 (1.4-2.5)*** 1.3 (0.9-1.7) 2.6 (1.9-3.6)*** approve Couple communications Feel comfortable talking with your partner 2.1 (1.6-2.8)*** 1.4 (1.1-1.8)* 2.6 (1.9-3.5)*** about the use of FP? Discussed with spouse about which method to 3.3 (2.5-4.3)*** 2.9 (2.2-3.9)*** 6.2 (4.5-8.5)*** use to prevent pregnancy (past 12 months) Discussed with spouse on how to obtain a FP 3.3 (2.5-4.4)*** 3.0 (2.3-4.0)*** 5.4 (3.9-7.4)*** method? Social diffusion Asked friends or family about using FP? 5.1 (3.8-6.9) 4.4 (3.3-6.0)*** 6.8 (5.0-9.4)*** Shared knowledge or any positive experience 5.1 (3.7-7.0)*** 5.2 (3.8-7.1)*** 7.0 (5.1-9.8)*** with friends and family? Corrected someone if hearing something 4.2 (3.0-6.0)*** 3.8 (2.7-5.4) 5.8 (4.1-8.3*** incorrect/untrue about FP methods? Intention to use FP methods? 1.8 (1.3-2.5)*** 1.7 (1.2-2.3)** 2.7 (1.8-4.0)***

Currently use a method to prevent 6.7 (4.7-9.6)*** 4.9 (3.5-7.0)*** 5.1 (3.5-7.4)*** pregnancy Actual met need for FP 6.7 (4.6-9.6)*** 4.9 (3.5-7.0)*** 5.1 (3.5-7.4)*** Perceived met need 0.74 (0.32-1.60) 0.51 (0.24-1.07) 0.82 (0.35-1.94) Notes: 1) Multiple logistic regression adjusting for age, education, religion, # of living children; # of co-wife. 2) *: sig at p< 0.05; **Sig at p<0.01, and ***: sig at p<0.001

Both Table 3a and Table 3b reflect multivariate analyses of the relationship between program exposure and key family planning outcomes at endine, showing adjusted odds ratios (AOR) at a

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95% confidence level. They look at how exposure to the three main TJ Project outreach components – radio broadcasts, social leaders and IPC – improved respondents’ assessment of their FP status, as measured using the 8 indicators discussed earlier in Table 2a (Self-efficacy for FP, Access to FP, Husband/wife approval of FP use, Couple communications, Intention to use FP methods, Currently using an FP method and Actual met need for FP).

First and foremost, Table 3a results powerfully and consistently indicate that the TJ scale-up program’s elements increased female TJ participants’ FP method communication, access, self- efficacy and use. These are remarkable findings, indicating that the TJ scale-up increased the odds of these positive FP behaviors by substantial increases and at highly significant levels.

More specifically, those female participants exposed to the IPC component (TJ groups, stories, cards and infographs) of the scale-up consistently showed the largest improvement in FP status and at the highest confidence level. The only exception to this pattern were the slightly lower aORs for the currently use a method to prevent pregnancy and actual met need for FP indicators, for which radio generated a slightly higher FP aORs at the same confidence level. These results suggest that perhaps it is the interactive experience of a TJ group – the power of storytelling, the reaction of peers and the persistence of graphic information – that are the most effective means of improving FP awareness and outcomes. Whatever the crucial mechanisms are, the IPC component proved to be extraordinarily effective with those intervention site women who were exposed to it.

Self-efficacy for FP and access to FP showed the biggest increase in odds from exposure to the IPC component. Finally, the indicators that were least affected by exposure to any of the three TJ components were husband/wife approval of FP use, couple communications – comfortable talking with your partner about the use of FP? and intention to use FP methods. In summary, the indicator results in Table 3a show that exposure to components of the TJ scale-up package were associated with significantly improved levels of reported FP access, couple communication, social diffusion and met need.

In Table 3b, we turn to the data for intervention site men, comparing those who were exposed to parts of the TJ scale-up package with those who were not.

Table 3b: Comparison of key outcomes across exposure vs. unexposed participants (endline; male; N=1045) Adjusted Odds Ratio (95% CI) Exposed to radio Exposed to leaders Exposed to IPC (23.7%) (31.1%) (25.1%) Self-efficacy for FP Confident in using a FP method all the time 2.1 (1.35-3.19)** 1.3 (0.91-1.84) 2.2 (1.4-3.3)*** Gender Attitudes Women who use family planning have multiple 0.47 (0.34- 0.83 (0.62-1.11) 1.0 (0.8-1.4) sexual partners 0.66)*** Men whose wives use family planning lack 0.47 (0.34- 1.2 (0.87-1.55) 1.0 (0.7-1.3) authority 0.65)*** It is shameful to be associated with a woman 0.79 (0.49-1.29) 0.77 (0.50-1.18) 0.9 (0.6-1.5) who is known to use family planning In this village, it is acceptable to discuss family 2.8 (1.97-3.97)*** 2.1 (1.54-2.85)*** 1.9 (1.3-2.6)*** planning in public In the home, a man must have the final word in 1.4 (1.0-1.9)* 2.1 (1.51-2.79)*** 1.9 (1.4-2.6) decision-making

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A woman must always obey her husband 2.4 (1.7-3.4)*** 1.9 (1.39-2.62)*** 1.4 (1.01-2.0)* It’s a woman’s responsibility to bring up the 1.3 (0.92-1.91) 2.7 (1.90-3.74)*** 2.1 (1.5-3.0)*** topic of family planning for discussion with her husband If a couple does not want to get pregnant and 2.0 (1.44-2.74)*** 0.88 (0.64-1.18) 1.0 (0.7-1.4) the wife is not using contraceptives, her husband should do so Access to FP I know where to obtain FP 5.4 (3.45-8.43)*** 2.1 (1.48-2.85)*** 3.4 (2.3-5.0)***

I am able to reach this place without too much 5.7 (3.73-8.65)*** 2.1 (1.52-2.86)*** 3.0 (2.1-4.3)*** difficulty If I wanted a method, I have the mean to 4.1 (2.83-5.91)*** 2.1 (1.51-2.77)*** 1.7 (1.2-2.3)** purchase one Husband/wife approval of FP use: definitely 1.9 (1.33-2.64)*** 0.74 (0.54-1.03) 1.4 (0.98-1.9) approve Couple communications Feel comfortable talking with your partner 2.3 (1.57-3.25)*** 1.0 (0.73-1.34) 1.3 (0.95-1.9) about the use of FP? Discussed with spouse about which method to 2.3 (1.67-3.21)*** 1.8 (1.35-2.44)*** 2.2 (1.6-3.0)*** use to prevent pregnancy (past 12 months) Discussed with spouse on how to obtain a FP 2.7 (1.97-3.82)*** 1.8 (1.31-2.40)*** 2.2 (1.6-3.1)*** method? Social diffusion Asked friends or family about using FP? 1.8 (1.27-2.48)** 4.4 (3.14-6.03)*** 3.5 (2.4-4.8)*** Shared knowledge or any positive experience 1.8 (1.25-2.49)** 3.5 (2.51-4.85)*** 4.7 (3.3-6.6)*** with friends and family? Corrected someone if hearing something 1.3 (0.88-1.98) 2.2 (1.50-3.17)*** 2.5 (1.7-3.7)*** incorrect/untrue about FP methods? Intention to use FP methods 1.6 (1.12-2.16)** 1.2 (0.91-1.64) 0.8 (0.6-1.1)

Currently use a method to prevent 1.2 (0.84-1.83) 0.68 (0.47-0.98)* 0.9 (0.6-1.4) pregnancy Actual met need for FP 1.23 (0.82-1.84) 0.71 (0.50-1.04) 1.0 (0.7-1.5) Perceived met need 0.1 (0.01-0.84)* 0.23 (0.09-0.65)** 0.1 (0.03-0.42)*** Notes: 1) Multiple logistic regression adjusting for age, education, religion, # of living children; # of co-wife. 2) * Sig at p< 0.05; **Sig at p<0.01, and ***: Sig at p<0.001

While the men’s results also demonstrate the ability of the scale-up program to positively influence FP beliefs and behavior, the magnitude of the shifts are smaller, and the most effective TJ component is more varied. In addition, significance levels are slightly lower and less consistent for the results among men than they were for women.

Delving into specifics, reported improvements in self-efficacy for FP were most likely to come from those participants who had been exposed to the IPC or radio components of the scale-up phase. This tracks the female experience, but with slightly lower odds than among women.

Men exposed to any of the three the radio, influential leaders or IPC showed the biggest increased odds in access to FP services. This contrasted with the female results for this indicator, where exposure to the IPC component of the program continued to be the greatest predictor of positive FP responses. Exposure to influential leaders or IPC had more of an effect on social diffusion than among radio listeners. Although exposure to any of these components increased odds of talking to

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others about family planning, compared to the unexposed men. Only among men exposed to the radio program had increased odds of perceiving their wife approved of family planning, as compared to unexposed men.

The couple communications results for males were mixed, with only those exposed to radio more likely to say they were comfortable talking about FP methods than any other TJ component, while it was radio and IPC exposure that led to the highest AOR values for the likelihood of discussing how to prevent pregnancy and how to actually obtain an FP method. These AOR values are lower in general than those seen in the corresponding female data. In terms of family planning use, men who were exposed to influential leaders were actually less likely to use a method than men who were not. TJ did not have any effect on actual met need, but was associated with reduced odds of perceived met need. The measure of perceived met need is based on respondent’s use of a less effective method and therefore can be interpreted as a positive change in assessing how well the method being used will delay or avoid unwanted pregnancy.

VII. DISCUSSION SOCIAL NETWORK PACKAGE TAKEAWAYS In brief, results of the household survey showed that all three of the TJ package components (radio, leaders, IPC) appeared to bring about dramatic positive changes in intervention zone FP attitudes and behaviors. This notably occurred in the context of package implementation by new user organizations that were not previously working in the FP sector. Moreover, because of changes to the scale-up study protocol suggested by lessons from the pilot phase, including adding a comparison group, the data detailing these changes is more extensive, targeted and reliable than before. Diving down a layer, there are another set of observations suggested by the data analysis to date:

1. While the Atlantique Department was demographically a better choice as the control zone than the Plateau Department, there were some noticeable differences in education level and number of co-wives for men.

2. When comparing intervention and control zone experiences, both women and men in the intervention zones displayed far greater increases in their FP communication, use and met need than their counterparts in the control zone. This positive disparity was generally stronger for women, with absolute changes in the population for various indicators often ranging between 20% and 45%. For men at intervention sites, this positive disparity was less pronounced and less consistent, though the odds were still impressive and p values were highly significant.

3. With regard to multivariate analyses comparing intervention site participants who were exposed versus not exposed to TJ scale-up components, exposure to the IPC component of TJ scale-up was far more effective in influencing women than men, and that effectiveness was extraordinary. On balance, for females, IPC worked best.

4. In contrast, while the male access to FP AOR values for radio exposure were quite similar to the those among women, AOR values for men who were exposed to leaders and men who were exposed to IPC were substantially lower than the corresponding female data. On balance, for males, radio worked best.

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5. For both women and men, the self-efficacy for FP and access to FP indicators appeared to get the biggest result from exposure to any component (radio, leaders, IPC) of the TJ Project package. Women who were exposed to any component were also far more likely to have positively modified their couples communications and social diffusion behavior, but this effect was muted for the intervention site men. Perhaps these indicators are affected more by emotional, financial and social factors inherent to each couple, factors that are more resistant to outside influences.

6. The indicator that appeared least altered by TJ scale-up phase exposure was the one that the TJ Project was designed most to influence: intention to use FP methods. Perhaps the terminology is confusing, perhaps there are cultural issues of determinism or fatalism when contemplating family size and pregnancy, or it may be that many couples are currently trying to become pregnant and thus they have little interest in using FP methods at this time. We will look to the cohort interview findings to see if they can shed light on this apparent inconsistency.

7. The remarkable results should be explored to determine what aspect of changes in the intervention model could be responsible for such impressive results. For example, did the change in the number of influential groups and individuals per village boost diffusion and hence the results or were there other plausible reasons. During the pilot phase, regardless of village size, only three influential groups and five influential individuals per village were supported by the project. During scale up these numbers were increased to up to six groups and up to 10 influential individuals. Additional analysis is required to understand the mechanism behind such remarkable results. ISSUES OF SCALABILITY 1. The data indicate that while radio does remarkably well at diffusing modern FP method messages, the IPC component of the TJ program is the most effective in creating positive social diffusion changes, as we measured it particularly for females. It is, however, also the most resource intensive. While the cost per village must be factored into plans to expand, it is important to assess the benefits, which can be challenging to capture accurately. Looking forward, could a single village that participates successfully in the TJ scale-up program serve as a “seed” village that influences FP behavior in several villages nearby for what is essentially no additional cost. How can these benefits and avoided costs be most accurately assessed?

2. Geography and infrastructure in other regions of Benin vary and some will have a less- developed physical infrastructure than the scale-up intervention and control zones. So TJ’s radio component may encounter more distribution challenges but, conversely, may be more effective if it is one of a much smaller pool of listening options. Similarly, the power of social gatherings and expectations may be greater in rural regions, which could give the influentials’ component more efficacy – and more economic efficiency – than what it displayed in the scale-up phase data from Ouémé. Conversely, if the baseline social norms (as propagated, in part, by influentials/leaders in the region) in rural areas are less open to FP method discussion and change, the leader component could turn out to be a far less effective and economical option. These same contextual issues will need to be weighed when assessing the scalability of the IPC component as well.

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3. New socio-economic contexts may also influence scalability. Approximately 60% of the country’s population is estimated to practice some form or aspect of Voudoun. Understanding how this belief system tends to influence FP decisions - and how these beliefs interact with Christian and Muslim teachings – could also be tremendously helpful. The religion’s center is Ouidah, about 40 km west of Cotonou, and its influence is less keenly felt in the northern half of the country, a belief gradient that will need to be considered in any effort to expand the TJ program precept beyond its current southern coastal location. There are marked differences between in infrastructure level, access to digital media, economic resources and dominant ethnicity between northern and southern regions, and between the country’s coast and its interior. Will the FP responses, behaviors and attitudes of Beninese citizens in coastal, economically-powerful and Christian-predominant areas near Cotonou be similar to their compatriots in Djougou, for example, where the economy is based on transit and trading, where Islam is the predominant religion and where the Fon ethnic group is distinctly in the minority? Or farther north and east in Kandi, with an economy dominated by agriculture and mining and where Yoruba and Bariba are the predominant ethnic groups?

These socio-economic and structural variables will need to be considered when the TJ Project is expanded; it may be necessary to not only adapt the approach programmatically, but also to assess effectiveness in new contexts.

VIII. CONCLUSION In the end, all of the research and analysis was designed to answer three fundamental questions about effectiveness of the intervention when new user organizations offered the slightly-revised social network package under non-pilot conditions. Did exposure to the TJ program: (1) increase social diffusion and discussion of accurate FP information, (2) enhance modern FP use, and (3) reduce unmet FP need?

The results from the Tékponon Jikuagou Project scale-up research phase strongly indicate that its social network diffusion paradigm is highly effective in catalyzing community changes that create increased awareness, acceptance and use of modern FP methods. Multivariate analysis of the participants’ baseline and end line data reveals strong positive changes in FP method use linked to exposure to the TJ package. It also reveals a significant association between the participants’ perception that their social network accepts and uses FP methods, and their own use of modern FP method and expression of FP met need. The fact that changes in self-efficacy, access to FP, social diffusion and couple communication all saw extraordinarily substantial benefits from exposure to the TJ scale-up program highlight the game-changing potential of this program.

Both the TJ pilot phase and scale-up phase illustrate that a programming approach focused on social network interactions can rapidly influence individual behavior. The cohort study findings have given an important look into the couple, family and village norms that influence FP method decisions in these Beninese villages. TJ’s promising social network approach challenges us to think differently about the demand side of family planning programs, indicating that a light-but-steady approach to personal behavioral change via changing community norms can be a primary FP option. Indeed, the Tékponon Jikuagou scale-up phase results are an extraordinarily promising confirmation that the program’s IPC, discussion and radio components have the ability to rapidly alter personal and social network FP attitudes and behaviors in profound and, it is to be hoped, lasting ways.

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APPENDIX: PHASE 2 SCALE-UP TIMELINE

Activities Apr May Jun Jul Aug Sept Oct Nov Dec Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sept 15 15 15 15 15 15 15 15 15 15 15 16 16 16 16 16 16 16 16 16 Submission of USAID Approval form to GU IRB & Benin IRB (ISBA) Contracting with CRAD BASELINE Enumerator training Pre-test of community survey (CS) and social network census questionnaire (SNA) CS & SNA Quantitative analysis – CS & SNA baseline data Baseline report preparation MIDLINE (Qualitative only) Pre-test of in-depth interview tools In-depth Interviews Qualitative analysis ENDLINE Refresher training - CS & SNA CS & SNA Quantitative analysis – CS & SNA impact evaluation Final Report preparation Final Dissemination

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