Encouraging positive shifts in behaviours among couples, community health system actors and actors who discourage and/or penalize behaviours, for instance, panchayat members or older men in the community who disseminate patriarchal ideas and reinforces stigma around topics of sex, contraception, birth spacing and gender norms.
Key Design Challenges
Providing health system actors and couples with gender sensitive training to recognize stigmatizing behaviour in themselves and others. In addition to this, helping couples navigate existing norms and talk openly about sex, contraception, at least with each other and moving away from the silence attached on these issues in society.
The field research suggests deep-seated stigma attached to topics like sex and FP which prevent a healthy discussion from taking place between spouses and health service providers. This has resulted in incomplete or even incorrect knowledge on SRH and FP which gets propagated unchecked into the wider community.
For HSAs, they are often selective in who they interact with in the community. Overcoming personal biases along the lines of caste, religion etc are necessary to minimize stigma from society. Talking to newly married couples on FP and contraception was rare due to the social pressures to have the first child early.Health system actors almost never interacted with men due to normative and contextual constraints.
For men, due to lack of trained health system actors for them, feminization of FP and health at the community level, men have had to rely on informal sources such as pharmacists and rural medical practitioners who did not always possess the correct information.
Key Design Decisions
Health service providers needed to be enabled to discuss topics of SRH and FP amongst themselves in order to have a better understanding of the same, as well as gain insights into how couples could be engaged into such sensitive discussions. This would have to focus on the soft-skills required for engagement, as well as the requisite knowledge of the topics themselves. Once learnt, these must be communicated with both men and women in an open and informal conversation where couples find space to ask questions, discuss issues like sex, contraception without fear of stigma and judgement.
Creating WhatsApp groups for HSAs, wherein learning and training material can be disseminated to assist them in engaging with the couple better. This material would comprise short videos, images or documents on how to do specific tasks, along with skills to communicate effectively with men and women in an open and informal manner. The group will also help HSAs get answers to their queries. (The reason WhatsApp has been chosen as the platform is because, apart from smartphones, it is available on 3G feature phones as well)
The ASHA will be provided with a kit which she can use to interact with couples in an open and visual manner. Physical aids such as leaflets, posters will help them to interact with all couples on matters related to sex, contraception and reproduction. In addition to this, normalizing the conversation around these issues, couples will also play familiar games in public events which link family planning to pleasure, sex, finances and make it easier for health system actors to counsel the couples on these issues.
The couples will also be able to reach out to HSAs anonymously with questions which they would like to know about at these public events through drop boxes placed around the village.
The ID will be integrated with the existing system
There is adequate space and personnel available to train multiple ASHAs at once.
Facilitators have received training and are adept at moderating such training events.
FLWs/HSAs have the requisite time and skill available to engage with the app
The ASHAs have the intent to actively talk to couples and forgo their own personal biases along the lines of caste, religion and other societal factors
If not trained properly, this could be an added burden on the ASHAs
If the ASHAs are not adequately trained in a gender transformative manner, which will help them break the patterns of stigmatizing behavior, this tool could prove to be redundant.
The couple may want to use the app independently without disclosing the information with the ASHAs.
The couples are able to communicate openly with each other and can engage in conversations around sex, contraception without fear of judgement due to prevailing normative constraints.
The couples are able to attend public events and are comfortable participating along with their spouses
Couples with higher gender equitability such as mutuals and functionals would be able to engage in such even more openly. Discordant couples may require another layer of interventions before they are able to openly communicate and participate in such activities
Assumes that the community will be supportive of all these activities
Often the community has rifts with the HSAs, especially frontline workers. FLWs also have a strong stigma attached to talking to couples of a certain caste or religion. Providing ASHA with training to overcome these biases and have effective interaction with all couples within their area is key to overcoming social stigma. Giving ASHAs prompts and accurate training has the potential to ease the relationship between the HSAs and the community, promoting trust and belief in the health system.
Accurate information dissemination by the ASHAs, along with gender transformative training of the cadres will potentially pave the way for accurate and complete knowledge being transferred from the ASHAs to the couples, especially men. This will help couples become more open and comfortable in talking about sex, contraception to each other as well as the health system actors. It is hoped that this will eventually lead to more equitable relationship between couples with the regular and constructive conversation on sex, fertility preferences, making family planning a shared journey of the couple.
An understanding and nurturing health care system alleviates a lot of pressure from the couples, potentially allowing them peace of mind to nurture their own relationship which is usually strained when open conversation about sensitive topics isn’t feasible. This concept has the potential for the ASHAs to ease in these conversations without placing the burden on a sole partner, or those external to the couple. It will also help couples talk more openly to each other and enable shared decision making through comfortable conversations around sex, contraception. It also empowers the couple to become a unit when participating in public events, hence strengthening couple making.