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Groundwork for Growth: FEM’s Half-Year Report (Jan-Jun 2024)

Jul 16, 202410 min read

Updated: Dec 31, 2024

Big strides toward our RCT and impact in new regions in the first two quarters of 2024 


TL;DR


In the first half of 2024, we completed a 32-week re-airing radio campaign in Kano State, extending access to family planning information in semi-urban and rural areas while saving on production costs. We made significant progress toward launching a rigorous RCT in three regions in Nigeria, creating 5x more content than ever before and conducting technical tests for our custom-built evaluation technology. This ambitious, innovative project is progressing well, though some parts have required more time than initially anticipated. Beyond Nigeria, we conducted scoping projects in five countries and launched a proof of concept in the DRC.


An enumerator speaks with a potential listener outside her home in Grand Kasaï, in the DRC  


Second Long Campaign Complete 


We completed a second rollout campaign in Kano, on Arewa Radio, on March 10th. This 32-week Hausa-language campaign targeted married women and men with at least one child who want to plan their families and safely space births. Our research indicates that this audience segment in northern Nigeria has the greatest likelihood of desiring to plan their families and is most culturally appropriate to engage.


Arewa Radio reached new audiences, particularly in semi-urban and rural areas in Kano. Through this campaign, we expanded the impact of content previously produced for northern Nigeria, eliminating content production costs. One-minute ads aired over 2,240 times and 20-minute shows over 190 times. In one testimonial ad, a mother of three shared how she and her husband chose the injectable contraceptive, which they found easy and effective, and encouraged others to explore family planning options that suit them best. A show co-hosted by a medical doctor emphasised the unreliability of natural spacing through testimonials from women in Kano who faced health and pregnancy challenges. This campaign further extended access to vital health information in this high-impact region.


Randomised Controlled Trial, Nigeria 


We are currently preparing to launch our longest campaigns yet, in three regions in Nigeria, reaching millions for 24 months. To evaluate these campaigns with a randomised controlled trial, we developed radio transmitters which will identify when our ads and shows are on air and replace them with unrelated content. By creating groups of listeners – some exposed to our content and others not— we can evaluate the impact of our campaigns on contraceptive uptake, knowledge, and attitudes. 


In the first half of 2024, we crossed important milestones in preparation. 


Campaign Creation at 5x Scale 


To meaningfully address misinformation and speak to real-life motivations, our campaigns are based on direct audience research: we conducted 176 in-depth interviews and 1,314 surveys with women and men in thirteen states, including health workers. We asked questions about drivers and barriers to contraception, media consumption, role models, and beliefs about childbirth spacing. In addition to interviews, we conducted 13 mystery-client visits: research participants attended medical facilities as clients seeking reproductive health care, and reported on their experience. 


We developed ad and show concepts informed by our research findings. For example, interviews revealed that, to our audience, improving mothers' health and providing better care for children are among the most valued benefits of family planning. In response, we designed a higher percentage of ads and shows to emphasise these key motivators.


Production for the RCT is our largest yet: five times more content will be created than for any prior FEM campaign. Several experienced writers in each region drafted ad and show scripts for fictionalised first person narratives and dramas in the Igbo, Hausa, and Yoruba languages. A 30-minute show currently in development tells the story of a young seamstress in a joyful new marriage. While raising infant twins under one year old, she is concerned to discover she is pregnant again. The narrative follows her journey as she explores options for spacing future pregnancies. Another fictional female character celebrates, in a one-minute ad, how spacing after her first child enabled her to earn a secondary degree. Our campaigns will also include real-life testimonials and Q&A shows with experts. 


Ads and shows undergo a rigorous quality assurance process before reaching the airwaves. Each scripted piece undergoes three rounds of revisions by FEM and partner organisations, whose firsthand knowledge of regional contexts helps ensure the content resonates. The ads and shows are then pre-tested with listeners and shared with stakeholders for further feedback. 


In addition to developing campaigns, we made significant progress with our academic partners on the design of our RCT questionnaire and protocols, and consulted evaluators to ensure we capture the most important outcomes while enabling insights that generalize to future work. We secured critical approvals, including Institutional Review Board (IRB) approval from the National Health Research Ethics Committee in Nigeria, and laid the groundwork for U.S. institutional review board submissions. 


Solid Steps in Transmitter Deployment


To enable robust evaluation of the effect of our campaigns, we will install custom-built transmitter technology that replaces ads and shows with unrelated content in control clusters. We made significant progress toward installation in the first half of 2024. 


This innovation requires a 23-50 foot antenna pole to be installed outside, wired to a briefcase-sized device placed indoors. The transmitter, powered by solar energy, can recognise when our content is on air, and replace it with unrelated content in a 1-8 km radius. Last year, we achieved a 97% replacement rate for five consecutive weeks with the third version of our evaluation technology and manufactured the 75 units needed for the RCT. In Q1, they arrived in Lagos Port.


Also in Q1, we recruited the engineering team who will install and maintain this technology throughout the study. Engineers were selected for their experience, technical competence, and ability to respond flexibly, including traveling to transmitter locations on short notice to conduct repairs as needed. The team was trained by Pavel Strnad, head of design firm UNITRONIC, our co-developer of the transmitters, who travelled from the Czech Republic to Abuja for a week of in-person learning. 


Members of our technical team display the evaluation technology (antennas not shown) and solar panels that power them. L to R: Emmanuel Chinonso, Lia Boldt, Ibrahim Jamilu, John Samuel, Pavel Strnad, Kabiru Abdulkareem, Rahmon Adewale


Before installing the control group transmitters, we must select all clusters in the study. Selection involves five stages of technical testing to ensure the clusters and radio stations meet the requirements for this evaluation method. Below we detail the five stages.

Stage 1: Stereo Tests


First we test whether the most impactful radio station(s) in a state broadcast in stereo. (Impact is measured by the number of people a station reaches who could benefit from our campaigns, relative to the cost per dollar.) Our evaluation technology is designed to work with stereo broadcasts, which use two separate audio channels, rather than mono. 


Stage 2: Range Tests


Next, we contract drivers to travel in all four compass directions where possible, starting from the station’s location. This allows us to determine coverage area, and know the nearest and farthest points where we can effectively place transmitters.


Stage 3: Cluster Selection


Using government-provided lists, we select health facilities in the potential clusters identified in Stages 1 and 2 and ask state governments for more data on each facility. Some are excluded due to security risks, being no longer operational, or being privately owned. 


Stage 4: Cluster Signal Tests


We install radio signal measurement devices in each cluster for at least one week to ensure signal strength is consistent and reliable. We are currently implementing Stage 4. We expect to test more than 200 clusters to identify 165 that are technically suited to our project. 


Stage 5: Installation


After functional clusters are identified, the academic team will randomly assign them as treatment and control and we will install the transmitter technology in control clusters. 


As we finalise preparations in Nigeria, we are also expanding our reach—exploring new opportunities to bring impactful family planning campaigns to more regions and more families.


Expansion Beyond Nigeria 


In 2024, we began expanding our efforts beyond Nigeria, aiming to save and improve more lives today while shaping a strategy for impact in the years ahead. We completed scoping projects in five countries (Uganda, Ethiopia, Niger, the DRC, and Chad) with potential partner organisations. These organisations were selected through a competitive process in late 2023. Together, we charted the radio landscape and estimated reach, analysing what set of stations would lead to the highest impact. We also mapped the stakeholder landscape, assessed political feasibility, and developed detailed budgets. These activities allowed us to better select cost-effective locations for proofs of concept (POCs). Our POCs are small projects to validate that a location will be impactful and test our fit with local partners. 


In the DRC: bright green highlights the coverage of Kasaï Horizons Radio Television, 

a private radio station with three antennas, including in the big cities of Mbuji-Mayi and Kananga. Working with Kasaï Horizons could be highly impactful. 


We chose not to proceed with partnerships in some countries due to factors including limited radio reach, overlap with existing programming, and challenges in identifying suitable partners. After analysing all learnings, we launched a proof of concept in the DRC and also began working on entry to Niger.


Proof of Concept in the DRC


In the DRC, we launched this test project with Les Ailes du Cœur (Wings of the Heart), a Congolese NGO dedicated to development initiatives and health, with a particular emphasis on reproductive health. Operating across 12 of the DRC’s 26 provinces, Les Ailes could co-implement with us to reach multiple regions. 

We chose to conduct a POC in the Grand Kasaï region because, after detailed budgeting with our partner and mapping the radio landscape, our analysis suggested cost-effectiveness at 10x cash transfers, even with somewhat conservative effect size assumptions. Factors contributing to this assessment included a smaller number of stations with larger audiences, lower airtime costs, language homogeneity (Tshiluba), a particularly strong partner, and significant information needs. 


In the Grand Kasaï region, we conducted user conversations with nine potential listeners (five women, four men). These initial conversations revealed concerns about contraception that mirrored those our Nigerian research has shown: fear of contraception causing side effects such as sterility, and religious opposition. 

As in Nigeria, women and men expressed that their primary motivations for seeking access to family planning are the desire to better provide for their children and to enhance mothers’ health.


An enumerator speaks with a potential listener in the DRC  


In one interview, a 27-year-old woman who is pregnant with her eighth child revealed, “I have so much pain in my thoughts. Raising children is not an easy thing, feeding the children, sending them to school. Now all this burden is on my shoulders. With that, how should I sleep? … I make the effort to stock up [with necessities] for two weeks before I give birth, because if I don’t do it, no one will do it for me.”


We contracted two writers who drafted two short ads, which were shared at a stakeholder workshop. The workshop had 40 attendees, including the governor and Minister of Health of Kasaï-Central. We produced the ads and tested the material in urban and rural regions before broadcasting to around one million listeners for one week in July on Radio Katanda in Kasaï Oriental, DRC.  


The availability of contraceptive stock – an important condition for the impact of our demand generation activity – was our greatest uncertainty about working in the DRC. Access to each country’s DHIS2 data is managed by the respective Ministries of Health; we have found that approval is best gained through the engagement of local partners with stakeholders. Through our POC, we obtained access to DHIS 2 data, which showed a prevalence of contraceptive stockouts. 


Given the feasibility of operations in the DRC otherwise and the significant need, we met with supply-side public and private actors to learn about the contraceptive supply chain. We sought to understand whether we could align our intervention with a supply-side NGO, or if it might be cost-effective to support the supply chain sufficiently to serve the Grand-Kivu, Grand-Kasaï and Lubumbashi regions with campaigns. We will share the outcome of this investigation in future updates. 


Growing Pains Navigated


  • We under-estimated timelines - The RCT is our largest, most intricate, and innovative project to date: a mass media RCT in three regions of a complex, security-challenged country, using novel technology. We underestimated the time that various aspects of this project would require, particularly where third parties were involved, and previously made launch estimates that proved overly optimistic. 


  • We lacked research capacity - This year, we brought on a researcher to explore our expansion opportunities, both geographically and into new health topics. In retrospect, we should have made this hire sooner.


Successes Unlocked 


  • We improved our location selection process - The five scoping projects we conducted this year in new countries marked an addition to our location selection process. Last time, we moved directly from location selection into the POC. But we realised this short and inexpensive project could reduce uncertainties before involving stakeholders or spending more than 500 USD in direct costs. We are committed to finding the most effective processes to gather information needed to expand effectively. We are thrilled with how this went and may include this step going forward.

 

  • We completed the vast majority of RCT fundraising - We successfully closed our largest funding gap for the RCT, securing our largest grant to date. This ensures financial support for the study and strengthens our capacity to deliver on our ambitious goals. The grant comes from a new funding partnership which we will share in Q4.   


Team Growth 


We are thrilled with the ownership, kindness, agency, and rapport in our team culture, and are thinking carefully about how to preserve it as we grow. We conducted our first team retreat, in Abuja, with employees and partners. In a feedback form, 100% of our implementing partners in Nigeria agreed with the statements: “I enjoy working with FEM more than with most other organisations I have worked with,” and “FEM respects the culture in my region.” 


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Thank you for being with us on this journey. Every step we take in preparing for the RCT and expanding to new countries helps us create a world in which more women and families have the knowledge and access needed to make empowered, healthy choices. Our impact and growth are only possible because of the partnership of funders and supporters. By joining us, you invest in a future where no woman faces death or hardship due to an unintended pregnancy. Together, we can build a healthier, more hopeful world for all.


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