Use of a media campaign to improve access to contraception in Nigeria amid the COVID-19 pandemic: a cross-sectional survey

Introduction

After the first case of COVID-19 infection was reported in December 2019 in Wuhan, China, the infection, which is caused by SARS-CoV-2, has continued to spread rapidly globally.1 By 30 January 2020, the WHO declared the outbreak, a public health emergency of international concern,2 and on 11 March 2020, it was declared a pandemic.3 The impact of the pandemic has caused major disruptions in the healthcare and socioeconomic systems globally; this is more pronounced in low-income and middle-income countries where the virus pushes the already fragile health systems to the brink.4 The continuous spread of the infection, coupled with its fatality and non-availability of confirmed treatment regimen, necessitated the introduction of non-pharmaceutical interventions (NPI) such as physical distancing, ban on public gatherings, closures of schools and workplaces, restrictions in movement and in many cases a total lockdown by governments across the globe.5 All these measures further disrupted access to healthcare services including family planning (FP). Contraception is lifesaving, and is a priority health service in emergencies, as detailed in the 2018 Minimum Initial Services Package for sexual and reproductive health (SRH). It should therefore be made available at the outset of every emergency response, including epidemics and pandemics.6 With the acute disruption in movement, healthcare service delivery and supply chains due to the COVID-19 pandemic, access to contraception becomes an uphill task. In 2020, United Nation Population Fund estimated that the pandemic may disrupt contraceptive use for about 12 million women with a consequence of nearly 1.4 million unintended pregnancies across 115 low-income and middle-income countries.7 WHO reported that 70 of the 102 countries surveyed in 2020, had disruptions in FP services.8 Nigeria, like many other countries, was also severely affected by the pandemic with every sector impacted.

In Nigeria, the first known case of COVID-19 was recorded on 27 February 2020. The Nigerian government through the Nigeria Centre for Disease Control (NCDC) activated a National Emergency Operations Centre. In addition, a Presidential Task Force was set up to collaborate with the NCDC and the various state governments to manage COVID-19 response and coordinate mitigation plans against the infection across the country.9 The NPI to prevent the spread of the infection was also instituted, with lockdown between April and July 2020, and strict restriction in movement or travels. Health facilities and healthcare providers were however allowed to continue their operations, with adherence to Standard Operating Procedures to prevent COVID-19 infection, but patronage of these facilities reduced significantly because of multifactorial issues. The restriction in movement made transportation to the health facilities difficult,9 people were afraid of getting hospital acquired COVID-19 infection,4 and there was a lack of adequate personal protective equipment for use by the healthcare providers.9 While Nigeria has made some improvement in its SRH system, the modern contraceptive prevalence rate among women of reproductive age remains low at 11.7%.10 The lockdown, re-channelling of funds and human resources for healthcare to handle COVID-19 cases, travel/movement restrictions and disruption in supply chain of contraception, all caused by the pandemic further made access to SRH care, including contraception more difficult. This is particularly of great concern in the country, given the unmet need for contraception11 and high rates of unintended pregnancies12 prior to the pandemic.13 Society for Family Health (SFH) through her Delivering Innovation in Self Care (DISC) project came up with strategies to adapt to the changes impacted by COVID-19 scourge, to facilitate access to SRH services. The project implemented an Omni-media campaign with focus on radio, social media and digital marketing from July to November 2020. The DISC project contracted a professional media outfit to roll out the campaign in the four states of project implementation. These were Kano, Oyo, Lagos and Kaduna states. The campaign was aired via common radio stations in each of these states; furthermore, the campaign was advertised on social media platform (Facebook) and on the internet. The campaign, which was aired in Pidgin English, Hausa and Yoruba languages gave information about how to get contraceptives on an online platform, as well as a hotline number to call for further information if, and when necessary. Media campaigns have been shown to be used to influence health behaviours in mass populations. Such campaigns have the capability of reaching large audiences, however, exposure to such messages is generally passive, as it usually results from an incidental effect of routine use of media, such as radio or television. For campaign messages disseminated via the internet or web, it would require to actively choose to seek information such as visiting the website or digital media handle. In addition, mass media campaign may fall short of its expectations as it may not influence the expected positive behavioural change. This may be due to factors such as timing and duration of the campaign, increasingly fractured and cluttered media environment, use of inappropriate or poorly researched format, use of homogeneous messages for a heterogeneous audience.14

We therefore assessed the effect of the campaign on the awareness about SRH among individuals who are 18–49 years of age (reproductive age) in the states where the campaign was held. The project was interested in knowing how effective the media and online platform sales outlet are.

Methods

SFH with support from Population Services International is implementing a project—DISC, which is poised to meet the SRH needs of Nigerians through innovative approaches and leveraging on strategic partnerships. The project was funded by Children Investment Fund Foundation. The SRH campaign was carried out in Lagos, Kano, Oyo and Kaduna states, which were the implementation states at the moment, thus the study was conducted in the four states where the campaign was aired. The study period was between November and December 2020.

It was a community-based, cross-sectional descriptive survey, and the study population was men and women between 18 and 49 years of age. Based on funds availability, the sample size was 3200 across the four states, with 800 respondents sampled from each state.

Each of the selected states has local government areas classified as urban and rural local government. Random sampling technique was therefore used to select, one rural and one urban local government areas, and 400 respondents were thereafter randomly sampled from each of the selected local governments. A structured self-developed questionnaire scripted on a mobile platform was used to obtain data from the respondents by trained research assistants.

Data obtained was exported from the mobile platform and analysed using the SPSS V.21. Descriptive statistics was applied to determine frequency of relevant variables in the study, such as the sociodemographic characteristics of the respondents, while an inferential statistical method using χ² was used to test associations between demographic characteristics and procurement method of contraception (categorical variables). Furthermore, regression analysis was done for significant demographic characteristics, from the χ² analysis to know the contributory factors for procuring contraception online. Level of statistical significance was set at p value of less than 0.05. Verbal informed consent was obtained from all respondents before data collection.

The public was not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Results

Table 1 shows the sociodemographic characteristics of respondents. Among the 3200 respondents that were interviewed, 1604 (50.1%) were females; majority of the respondents were in the age group 30–39 years (870 (27.2%)), and 1690 (52.8%) were unmarried. Based on the highest educational status attained by the respondents, 1995 (62.3%) had secondary education. One thousand six hundred and twenty eight which represented 50.9% were self-employed, and 1883 (58.8%) practiced Islam. Equal numbers of the respondents were from the rural and urban location (1600 (50%)).

In table 2, the extent of reach of the mass campaign among respondents was sought; 1330 (41.6%) of the respondents were found to be aware of the campaign, and 1016 (31.8%) were directly reached with SRH messages via any of the channels of the campaign; among the 1016 reached directly, 637 (62.7%) were reached via radio, 342 (33.7%) were reached via internet and/or social media platforms, while 88 (8.7%) heard of it via other channels. These other channels included SRH information that was either aired on television, or through interpersonal communication with community-based healthcare workers. The type of contraceptive method respondents who were directly reached heard about the most during the campaign was oral contraceptive pills (842 (82.9%)), followed by condoms (490 (48.2%)). How to get contraception and where to get contraception during the lockdown were the two most common messages (43.8% and 44.2%, respectively) respondents remembered hearing; 20 (2.0%) respondents however said they could not recall any of the messages captured by the campaign. During the campaign period, 346 (34.1%) of those reached, procured at least one form of contraceptive method, and 303 (87.6%) of these persons procured theirs online while others (43 (12.4%)) did physical procurement.

Table 3 shows the association of the respondents’ sociodemographic characteristics with procurement channel of contraception. More proportion of the unmarried respondents significantly did online procurement rather than physical purchase (χ²=21.2855, p<0.00001), this was also the experience among persons in the age group 18–24 and 25–34 years (χ²=22.7505, p=0.000011). Respondents from Lagos and Oyo states were also found to get their contraceptives online more, compared with those from Kano and Kaduna states (χ²=49.1808, p<0.00001).

Further analysis in table 4 using logistic regression showed the predictors of contraception procurement channels. Respondents 34 years and below were nine times more likely to procure contraception online compared with the older age groups (OR=3.23, 95% CI 1.01–1.52, p<0.003). In the same vein, respondents that were unmarried were 21 times more likely to procure contraception online compared with the married ones (OR=5.31, 95% CI 1.11–1.32, p<0.001), while respondents residing in the southern part of the country were about 24 times more likely to procure contraception online compared with those residing in the northern part (OR=23.55, 95% CI1.18–1.38, p<0.001).

Discussion

Having access to SRH information and contraception cannot be overemphasised in a country like Nigeria where there are unmet contraceptive needs.15 The use of media campaign, via the likes of television or radio, which has been said to be able to reach large audiences may therefore be an important way of disseminating information. One of the aims of any campaign is to directly affect decision-making processes at the individual level,16 however, individual may also lack resources or access to resources that will support their decision-making process. The media campaign carried out on this project therefore did not just provide information about SRH and contraception, it also gave information of how to procure contraception via online platform.

In this survey, about 9 out of 10 of the respondents were in the age group 15–39 years, this is similar to a community-based study carried out in Edo state, although the Edo study was among only women of reproductive age.17 Even though, the reproductive age of women is from 15 to 49 years, many women complete their procreation before the age of 40, thus the age-group less than 40 years may be more interested in SRH services that are related to fertility issues, thus given the explanation of having most of the respondents to be less than 40 years. About half of the respondents were aware of the campaign messages on SRH during the period, however only about a third were directly reached with the messages. This is different from a study by Bajoga et al, where about 7 out of 10 of the respondents were exposed to FP messages via the media tools assessed18; the younger age group (15–24 years) and the urban region focus in the Bajoga study may make more respondents to have access to media, compared with our study that was inclusive of older age-group and rural parts of Nigeria.

Almost two-thirds of the respondents reached got their information via radio, while one-third were reached via internet/social media. Radio was said to be the most widely consumed media in Nigeria because of its accessibility and affordability,19 20 which is consistent with our study. The use of radio and television as means to spread reproductive health awareness in sub-Saharan Africa has been extensive, and its impacts significant.21

With improved access to internet and digital banking system, people around the world are connecting to the internet and finding a world of products and services available at their fingertips.22 Given this revolution, having SRH services, including products available via online channel in Nigeria is one of the innovative ways of bridging the gap of unmet needs, especially, during peculiar times such as COVID-19 pandemic. Part of the information provided by the project during the campaign was how and where people can get contraception during the lockdown, among which online channel was one. In our study, about one-third of the respondents procured at least one form of contraception online, and it was also observed that being young, unmarried and resident in the southern part of the country were seen as predictors of the likelihood of procuring contraception online. Similar sociodemographic characteristics were also predictors of being reached with SRH information online. A study by Bajoga et al showed that respondents who were exposed to FP messages were also likely to use modern contraceptives18; thus we may infer that respondents with similar characteristics who got their SRH information via the internet likely did the online purchase of the contraception too.

Furthermore, studies have shown that young persons may prefer online platform for accessing SRH services because of other incentives that comes with it. Young people were said to go to such source for their SRH services because of social stigma associated with visits to conventional healthcare clinics, poor treatment/hostility by healthcare providers, inaccessibility of health facilities and lack of information about policies concerning youth reproductive health needs. Adolescents who approach health clinics for SRH services have reported to be berated, denied information or given misinformation, or turned away because facility staff objects to addressing young people’s reproductive health concerns.18 23 24 This challenge may also be applicable to the unmarried respondents, as being unmarried and having no legal partner, has been reported as a cause of discrimination in health facilities.25 Thus, in addition to convenience, and the inaccessibility of physical health facilities as a result of the lockdown from the consequences of COVID-19 pandemic, the online platform also provide a ‘safe space’ for young and unmarried persons to access SRH services without any fear of prejudice from service providers. Confidentiality may also be another reason why the young and unmarried may prefer online access.25

Conclusion

With about one-third of respondents reached by the campaign procuring contraception via online platforms within the period, it is apparent that online platforms are viable potential avenue for contraceptive access for many Nigerians. Moving beyond the crisis moment of the pandemic response, our findings suggest that online distribution systems may be an innovative way to close the gap of unmet need for contraception in Nigeria. Online platforms may also be a particularly effective strategy for making contraception more accessible to unmarried and young people, who face more acute barriers to care, and are often more comfortable engaging in these spaces. Exploring innovative ways to make contraception available beyond formal health facilities can increase SRH service points, address issues around contraceptive equity and improve access to contraceptive uptake generally, especially amid other competing health challenges such as the COVID-19 pandemic.