KIGALI, Rwanda — Human-centered design has the potential to transform family planning for young people, but it comes with unique risks and challenges which mean the rights and well-being of adolescents and health workers involved need to be protected, advocates have said.
The Family Planning 2020 partnership has admitted it cannot meet its goals in an update at the International Conference on Family Planning in Rwanda.
While reaching adolescents with family planning is now a priority despite political challenges in many countries, there is still a long way to go when it comes to understanding and meeting the contraceptive needs of young women aged 15-19, experts said.
According to latest data, 20 million young women in low-income countries who would like to avoid or delay becoming pregnant still do not have access to modern contraceptive methods. At the same time, complications linked to pregnancy and childbirth are the biggest killer among this age group and teenage mothers are also more likely to drop out of school — often perpetuating a cycle of poverty.
In response, some organizations, such as Population Services International and Marie Stopes International, are using HCD processes to find new ways of making birth control products and services more accessible and appealing to teenagers. This has been supported by the Bill & Melinda Gates Foundation, William and Flora Hewlett Foundation, and Children’s Investment Fund Foundation.
HCD was pioneered in 1991 by American design and innovation firm IDEO which later launched IDEO.org to apply the approach to development problems. The approach puts the user perspectives at the center of the design process by working closely with service users to co-create, rapidly test, and then adapt different approaches so they are better tailored to meet users’ needs.
However, some aspects of what makes this approach unique can also mean it brings additional risks not seen when using traditional research and design methodologies, Jessa Blades, managing director of IDEO.org’s Health program, told Devex.
“HCD in this context is about leading with conversations with girls, playing games … trying to spark a different kind of conversation … but we’re not necessarily following a script or a survey .. and we are also prototyping to make ideas tangible early on and putting them out in front of people to react to and build on,” Blades said. “But because it’s a newer approach for partners, we need new co-accountability around ethics.”
To address the risks, a group of organizations launched a “commitment to action on ethics in youth-powered program design” Wednesday, during the International Conference on Family Planning held in Rwanda this week. The commitment calls on actors to adhere to 20 principles when applying HCD approaches to adolescent-focused family planning programs. Initial signatories include PSI, MSI, Family Planning 2020, Pathfinder International, Restless Development, IDEO.org, Y-Labs, AVAC, and Dalberg Design.
On the sidelines of the conference, Devex spoke with some of the groups behind the commitment to find out more about the potential and risks of using HCD to improve family planning for young people.
‘An eye-opening moment’
PSI has been applying the HCD process in some of its family planning work for the past five years. It likes the approach so much that it has developed its own spin-off, known as EIP, which stands for empathy, insight, and prototyping, Karl Hofmann, CEO of PSI told Devex.
“We’ve come to see HCD as this fantastic new tool which we can use in our social marketing toolkit to ... really unpack the motivations and behaviors and the reality our consumers face,” Hofmann said.
But what really convinced the NGO was the impact HCD had on PSI’s flagship “Adolescents360” program, which aims to increase voluntary, modern contraceptive use and reduce unintended pregnancy among adolescent girls in Ethiopia, Nigeria, and Tanzania. Using HCD and other research methods, the NGO learned that it had been sending girls the wrong message about their fertility and that was preventing many from taking up contraceptive methods, Hofmann explained.
“For years, we’d given the message, ‘don’t you want to stay in school .. surely you don’t want to get pregnant, therefore your future depends on contraception,’ … but for many of these young women, their future was so intimately tied with their fertility that any perceived risk to that was just a no go,” Hofmann explained.
“This was such an eye-opening moment for us … [but] … you’d think we could have figured that out long ago,” he added.
This insight led PSI to change its approach and to highlight how contraception can actually protect fertility, for example by preventing unsafe abortions which could harm fertility.
“It helped us change the way we position contraception within our messaging and counseling of girls. We now lead with [the message that] contraception is protective of fertility … and talk about how quickly you can return to fertility when describing the different options,” Rena Greifinger, technical adviser for youth and girls at PSI, explained.
Keeping girls and health workers safe
Talking about the potential risks, Blades said HCD’s participatory approach to prototyping, if not handled carefully, can create problems for potential users of the family planning product or service, and also for the health workers delivering it.
She recounted a past instance when IDEO.org ran an information session with the local community health worker to tell girls about contraception. After the session, some of the girls said they wanted to start using birth control, upsetting their parents who became angry and confronted the health worker, she said.
“When we’re going out in the community and prototyping … we are trying to make it feel real as we want to observe actual behaviors rather than what people say … but in doing so, if we haven’t done proper community sensitization … then it’s a risk … [and] we’ve had an angry mother take her daughter back to the [health] provider,” she said.
Another risk is around “expectation setting,” Blades said, especially in the later phases of HCD when girls could be involved in testing.
“We could be testing a product or service that feels real to the group, but it’s actually still just part of the design process and so there’s no guarantee it will come to fruition … We have to be careful we are not getting young people’s hopes up,” Blades said.
The 20 principles outlined in the commitment to action are intended to help address these risks, and others. The principles call on HCD actors to show respect for the young people they are working with, treat them as equal partners in program design and delivery, and safeguard their well-being while carrying out HCD activities.
Specific commitments include creating safe and private spaces for young people taking part in HCD activities to express themselves freely, a promise that participants are “recognized and appropriately compensated for their time and work,” and that they are fully informed about what they are being asked to do, and that they can stop at any time.
“Young people have a critical role to play in every aspect of developing solutions for family planning, from designing and implementing programs to engaging in advocacy with local decision-makers,” said Nomi Fuchs-Montgomery, deputy director of family planning at the Gates Foundation.
“However, we must ensure that young people understand their rights to make their own decisions about their participation.”
Update, Nov. 14: This story was updated to clarify that the commitment to action contains 20 principles