The Fertility Awareness for Community Transformation (FACT) Project fosters an environment where women and men can take actions to protect their reproductive health throughout the life-course by testing strategies to increase fertility awareness and expand access to fertility awareness-based methods (FAM) at the community level. As a research, intervention, and technical assistance project, FACT is testing two primary hypotheses:
Increased fertility awareness increases family planning use and the intention to use family planning.
Expanding access to FAM increases uptake of family planning and reduces unintended pregnancies.
Marginalized communities in Nepal have reduced access to reproductive health services due to geographic or social exclusion factors. Specific communities including the Dalit, Janajati, Chhetri, and Muslim have strong social and gender norms. These norms can limit family planning use and influence how couples make family planning decisions. These communities often have a high preference for sons over daughters. Across Nepal, early marriage is commonplace.
In the last decade, male migration has skyrocketed in Nepal. It is estimated that 1.92 million Nepalis are currently living outside of the country for work and an estimated 32% of married women have a husband who does not live in the country. With many men migrating for work, social structures are changing with their wives, sisters, and mothers becoming household decision makers. Our research found that women with migrant husbands are more likely to desire pregnancy, yet general knowledge about fertility is low, impacting their chances to become pregnant when their husband is visiting from his work life.
Certain reproductive health topics are difficult to discuss openly. Community engagement activities suggested that games may provide a way to open conversations informally and challenge social and gender norms (unspoken rules that govern behavior). Pragati actively promotes critical reflection. Questions embedded in the games ask participants to critically reflect on social barriers and their personal values.
Pragati games were implemented in five districts: Bajura, Nuwakot, Pyuthan, Rupandehi, and Siraha. These districts represent the three regions of Nepal (Terai, Hill, and Mountain), particularly within areas with large marginalized communities (i.e.; Dalit, Janajati, Muslim).
Formative research identified several barriers to FP use that included a general lack of knowledge about fertility and misconceptions about family planning methods and their side-effects.
A series of Solution Design Workshops engaged communities and 1) used research to describe the family planning context, 2) identified gaps and opportunities related to the promotion of fertility awareness and fertility awareness-based methods (FAM), and 3) facilitated the development of a locally relevant solution that aims to increase overall family planning use.
Continuing this iterative process, a proof of concept phase tested games to assess their acceptability, the relevance of key messages, and the ease of implementation. The games were then launched in 30 Pragati communities in each of the five districts in a stepwise approach that provided new opportunities to revise and refine trainings, materials, and key messages.
To understand the impact of Pragati on family planning use and intention to use family planning, a mixed-methods, quasi-experimental study was conducted.
Participants were recruited across the five districts at baseline and endline. Qualitative data was collected through focus groups and in-depth interviews. Researchers measured fertility awareness, spousal communication, perceived community norms towards FP use, couple communication, fertility desires, FP use, and intention to use among married women.
Sustainability being the aim of this project, Pragati was implemented by local community health volunteers and champions identified from local mothers groups in each Pragati community and trained to implement the games. Local health care providers were involved to maintain linkages between communities and health services. Additionally, during the proof of concept testing, community members demanded games should be played with men in each site. As a result, Male Champions were identified in each community, trained and implemented Pragati games.