Part 5 - The Centrality of Motivation

Motivation to use family planning and to limit family size has been a missing piece of the strategy for population stabilization. While the percentage of non-users of contraceptives has declined, various studies indicate that the number of adults not using contraceptives remains roughly the same as it was in 1960, a fact stemming from the enormous increase in world population over the past 30 years. Approximately half of the three billion people of reproductive age use no contraception at all. It's time to focus some significant effort on motivating this group to use contraception for the purpose of achieving small family size.

Nearly as important are the desired family sizes of the users of contraception. In many countries, those who do use contraceptives still want more than enough children to replace themselves. Their goals, if achieved, will lead to continued high rates of growth.

A rapid reduction in fertility rates is happening in Kenya, once the world's fastest growing country. Desired family size dropped from 6.3 children in 1984 to 4.8 children per woman in 1989, and actual fertility rates dropped from 7.7 children in 1984 to 5.4 children in 1993 (Demographic and Health Surveys).

According to a 1991 study by Charles Hammerslough of the University of Michigan, his data support "the hypothesis that the rise of [family planning] services has accelerated the fertility transition, but is inconsistent with the notion that service availability initiated the transition." That is to say, desired family size dropped before the rapid increase in contraceptive usage occurred.

Kenya is but one of many examples. Virginia Abernethy (1993) states, "Historical and cross-cultural data confirm that motivation (rather than differential access to modern contraception) is the primary determinant of fertility." Japan has achieved below-replacement-level fertility (1.5 children per woman) in a country where the oral contraceptive pill is still illegal. As mentioned earlier, the United States achieved below-replacement-level fertility in the Great Depression, before the invention of most modern contraceptives. Similarly, a demographic transition in Western Europe and the United States reduced fertility to near-replacement level even earlier, in the 19th century.

Charles Westoff, in a 1988 paper, concludes that, "By and large, contraceptive behavior...is not grossly inconsistent with reproductive intention." Only one to two percent of the women failed to use contraception in a manner consistent with their family size preference in Brazil, the Dominican Republic, Peru, and Liberia. According to Westoff, "The overwhelming majority of women who want no more children or want to postpone fertility, at least in the four countries discussed here, are behaving in a manner consistent with that goal."

Lant Pritchett, Senior Economist at the World Bank, in a 1994 article in Population and Development Review, concluded that family size desire is the overwhelming determinant of actual fertility rates. "The conclusion that follows from the evidence and analysis we presented," he wrote, "is that because fertility is principally determined by the desires for children, contraceptive access (or cost) or family planning effort more generally is not a dominant, or typically even a major, factor in determining fertility differences."

According to Pritchett, desired levels of fertility account for roughly 90 percent of differences among countries in total fertility rates. He argues that reducing the demand for children--for instance, by giving girls more education--is vastly more important to reducing fertility than providing more contraceptives or family planning services.

Not enough is known about family size preferences of the men and women of the world--particularly among those who are not using any method of contraception. Recent papers on family size preferences by John Bongaarts (1990), Charles Westoff (1991), and Warren Miller and David Pasta (1993) point to the need for much more in-depth, interdisciplinary research on the relationships among ideal family size as viewed by men and women at each age level, fertility intentions and actual achieved fertility.

More research is needed to measure the effects of non-medical interventions, such as efforts to raise women's status, mandatory education for children and mass media communications designed to affect desired family size.

According to a 1993 study by Charles Westoff and German Rodriguez, mass media in Kenya may well have played a key role in bringing about the changes in desired and actual fertility rates mentioned earlier. In their concluding sentence, they state, "We are disposed to believe that the mass media can have an important effect on reproductive behavior."

In the United States and throughout much of the world, people get their information and form many of their opinions from the mass media--particularly radio and television. Worldwide, the biggest audiences are to be found during evening (prime-time) hours, tuned into entertainment programs. Throughout much of the world, the most popular format by far is prime-time serial dramas --called telenovelas (television novels)in Latin America--or soap operas. Unlike American soap operas, telenovelas have a beginning, middle and end--and run for a limited period of time.

Entertainment programs can reach large numbers of people very cost effectively. Serial dramas are especially well-suited to showing an evolution of key characters from traditional attitudes towards modern attitudes regarding such issues as the role of women, family size decisions and the use of family planning (Nariman, 1993).

A growing body of evidence bears this out. In 1977, Miguel Sabido, then Vice President for Research of the Mexican network, Televisa, developed a new family planning communication model, using a telenovela. Based on an earlier telenovela that promoted literacy (and which led to a 700 percent increase in registrations at adult education centers in Mexico), the first telenovela to promote family planning, named Acompaname (Accompany Me), showed in dramatic terms over the course of the nine-month series (five days a week at prime time during 1977-78) the personal benefits of planning one's family, by focusing on the issue of family harmony.

Briefly, the results of Acompaname, as described in a report by the Mexican Institute for Communication Research (1981), were:

a) Phone calls to Mexico's national family planning office requesting family planning information increased from zero to an average of 500 a month. Many people calling mentioned that they were encouraged to do so by the television soap opera.

b) More than 2,000 women registered as voluntary workers in the National Program of Family Planning. This was an idea suggested in the television soap opera.

c) Contraceptive sales increased 23 percent in one year, compared to a seven percent increase the preceding year.

d) More than 560,000 women enrolled in family planning clinics, an increase of 33 percent (compared to a one percent decrease the previous year).

Following Acompaname, Televisa developed four additional family planning soap operas. All produced by Miguel Sabido, they were Vamos Juntos (We Go Together), Caminemos (Let's Walk), Nosotros las Mujeres (We the Women), and Por Amor (For Love).

During the decade 1977-1986, while the five family planning programs were on the air, Mexico underwent a 34 percent decline in its population growth rate. As a result, in May 1986 the United Nations' Population Award was presented to Mexico as the foremost population success story in the world.

The role of the soap operas in this success was significant. Thomas Donnelly, with the United States Agency for International Development (USAID) in Mexico until 1983, wrote, "Throughout Mexico, wherever one travels, when people are asked where they heard about family planning, or what made them decide to practice family planning, the response is universally attributed to one of the soap operas that Televisa has done." Donnelly also stated, "The Televisa family planning soap operas have made the single most powerful contribution to the Mexican population success story."

Following a meeting David Poindexter (at that time with The Population Institute and now honorary chair of Population Media Center), and Miguel Sabido held with Indira Gandhi, and training by Miguel Sabido, Doordarshan (Indian Television) went on the air in July 1984 with India's first social-content soap opera, Hum Log (We People). The program included promotion of family planning and elevation of the status of women, through the words and actions of the key characters.

Over 17 months of broadcast, the programs achieved ratings of 60 to 90 percent of the viewing audience. Research conducted by Professor Everett M. Rogers and Arvind Singhal, then of the Annenberg School of Communications of the University of Southern California, found, through a sample survey, that 70 percent of the viewers indicated they had learned from Hum Log that women should have equal opportunities; 68 percent had learned women should have the freedom to make their personal decisions in life; and 71 percent had learned that family size should be limited. Among other things, the program stimulated over 400,000 people to write letters to the Indian Television Authority and to various characters in the program, stating their views on the issues being dealt with or asking for help and advice.

A second Indian soap opera, Humraahi (Come Along With Me), went on the air on January 14, 1992, airing at 9:00 p.m. on Tuesdays. The focus of the first 52 episodes was on the status of women, with particular attention to age of marriage, age of first pregnancy, gender bias in childbearing and child-rearing, equal educational opportunity, and the right of women to choose their own husbands.

By May 1992, Humraahi was the top rated program on Indian television. A conservative estimate is that the program was seen by over 100 million people each week.

In the series, a young girl who wanted to be educated and to become an attorney, instead is forced into an arranged marriage at age 14 by her father. Despite her pleas to her husband to delay consummating her marriage, she becomes pregnant and dies in childbirth. Following that key episode, the other characters lament what is happening to the young women of India and the tragedy of early marriage and pregnancy. A study of viewer response by the Annenberg School of Communications of the University of Southern California found many interviewees stating that after seeing the death of this character, they had decided not to marry their own daughters off at puberty, but to send them to be educated.

A study of over 3,000 people in the Hindi-speaking region of India, carried out by Marketing Research Private Group, Ltd., of Bombay, identified numerous significant shifts in attitudes while Humraahi was on the air, particularly related to the ideal age of marriage for women. The shifts in pro-social directions were dramatically greater for viewers than non-viewers.

A similar story occurred in Kenya. After training Kenyan television and radio personnel in Mexico, David Poindexter helped in the development of two programs: a television series, Tushauriane (Let's Talk About It), and a radio series, Ushikwapo Shikamana (If Assisted, Assist Yourself). Both programs went on the air in 1987. The programs were aimed at opening the minds of men to allowing their wives to seek family planning. The programs also effectively linked family size with land inheritance and the resulting ability or inability of children to support their parents in their old age.

Both programs were the most popular programs ever produced by the Voice of Kenya. The television series ran for 60 episodes and then went into reruns. The radio series ran for two years with two episodes per week, with each episode playing twice during each day for most of the broadcast series.

By the time the series ended, contraceptive use in Kenya had increased 58 percent and desired family size had fallen from 6.3 to 4.8 children per woman. While many factors undoubtedly contributed to these changes, a study conducted by the University of Nairobi's School of Journalism at rural health centers gave evidence of women coming in for family planning saying that the radio program had caused their husbands to allow them to come for family planning. In addition, a midpoint survey conducted during the radio series indicated that over 75 percent of the program's listenership had accepted the concept of smaller families.

Work by Poindexter in Brazil led to inclusion by TV Globo of family planning in several programs, including news and information programs and six prime-time telenovelas. Between 1989, when these programs began including family planning messages, and 1998, total fertility rate in Brazil fell from 3.4 to 2.5 children. Three of the Brazilian novellas have been dubbed into Spanish and sold to numerous Spanish-speaking countries of Latin America, where they have been playing since early 1992. They have also played in other countries in Europe and the Middle East--a total of 55 countries in all.

The most extensive evaluation of the effects of a family planning serial drama occurred from 1993 to 1997 in Tanzania. There, Radio Tanzania broadcast a serial melodrama that attracted 55 percent of the population (age 15 to 45) in areas of the broadcast. In one region of the country, the area surrounding the city of Dodoma, a music program was substituted for the soap opera during the first two years of the project.

Independent research by the University of New Mexico and the Population Family Life Education Programme of the Government of Tanzania measured the effects caused by the program with regard to such issues as ideal age of marriage for women, use of family planning, and AIDS prevention behavior. Because the population of the Dodoma comparison area was more urban than the rest of the country, a multiple regression analysis eliminated the influence such differences might have accounted for. Nationwide random sample surveys of 3,000 people were conducted before, during and after the broadcast of the program.

Among the findings were a significant increase in the percentage of listeners in the broadcast area who believe that they, rather than their deity or fate, can determine how many children they will have; an increase in the belief that children in small families have better lives than children in large families; and an increase in the percentage of respondents who approve of family planning.

The study also provided evidence that the Tanzanian radio serial stimulated important behavioral changes. There was a strong positive relationship between listenership and the change in the percentage of men who were currently using any family planning method. Similar evidence was found for changes in other important behaviors, including an increase in the percentage of Tanzanians who discuss family planning with their spouses and a decrease in the number of sexual partners for both men and women.

In regions where the show was broadcast, the percentage of married women who were currently using a family planning method increased by more than one-third, from 26 percent to 33, percent in the first two years of the program, while that percentage stayed flat in the Dodoma area where the program was not broadcast. In regions where the program was broadcast, the average number of new family planning adopters per clinic, in a sample of 21 clinics, increased by 32 percent from June 1993 (the month before the show began airing) to December 1994. Over the same period, the average number of new adopters at clinics in the Dodoma area remained roughly the same.

Independent data from Ministry of Health clinics showed that 23 percent of new adopters of family planning methods cited the soap opera by name when asked why they had come to the clinic. Counting all of the costs of the radio serial, the cost per new adopter of family planning was under 80 cents (U.S.), a cost-effectiveness unmatched by any other known strategy.

The program was also effective in AIDS prevention. Over half the population of the areas where the serial was broadcast identified themselves as listeners, with more men than women in the audience. One of the key characters in the soap opera was a truck driver with many girl friends up and down the truck route. In the program he contracts AIDS. Of the male listeners, 88 percent said the program had caused them to change their own behavior to avoid HIV infection, through limiting the number of sexual partners and through condom use. Independent data from the AIDS control program of the government of Tanzania showed a 153 percent increase in condom distribution in the broadcast areas during the first year of the soap opera, while condom distribution in the Dodoma non-broadcast area increased only 16 percent in the same time period.

As a double control for any socio/economic differences between the population of the Dodoma region and the rest of the country, the program was broadcast in its entirety by the Dodoma transmitter, starting in 1995. Data collected since that time has shown that roughly the same changes occurred there as had been experienced in the rest of the country during the soap opera's broadcast. This data is summarized in a paper by Dr. Everett M. Rogers and Dr. Peter Vaughan, et al (in print).

Because entertainment programming (radio or television, depending on the coverage of each medium in any country) attracts the largest audiences, it is particularly important to utilize entertainment media for disseminating information about family planning and family size issues. Along with that, many communications experts state that the most effective way of bringing about changes in attitudes and behavior with regard to any social issue is to utilize as many channels of communication simultaneously as possible, including print and broadcast, news and information, various formats of entertainment programs, and the communication activities of governmental and non-governmental organizations. Examples of successful media campaigns that have utilized this strategy include the designated driver campaign of Harvard University and the smoking prevention campaign carried out by a coalition of organizations in the United States. Measuring the effects of such multi-faceted efforts is made more difficult by the inability to isolate the campaign's effects from other influences in society. But it is logical to infer that people learn and change behaviors more quickly when they are hearing consistent information from a variety of sources.

Widespread research and serious attention to motivational communications is called for, since motivation must be a key element in solving the population problem. It is not possible to say with certainty that a radio or television soap opera will move any particular country or group of people from large family size norms to small family size desires in a certain time frame. A lot depends upon the quality of the audience research used to design the programs and on the quality of the writing and acting. Programs that capture the attention of a large audience because of the entertainment quality of the drama and that create characters with whom the audience can identify have great potential to provide role models that the audience will follow as those characters evolve from traditional attitudes to modern attitudes regarding status of women, family size decision making and the use of family planning.

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