IMPACT: Nigerian Urban Reproductive Health Initiative (NURHI)

Nigerian women have an average of six children over the course of their lifetime and the national population – already the largest in Africa – is expected to double within the next two decades. As populations in urban centers swell, the strain on infrastructure and unmet health needs continue to rise. Low access to modern family planning (FP) methods has invariably factored into high fertility, maternal, and child mortality rates across the country.

This has colossal implications for urban dwellers, especially those most vulnerable – women and children living in crowded slum areas.

The Nigerian Urban Reproductive Health Initiative (NURHI), led by the Johns Hopkins Center for Communication Programs (CCP), set out to rewrite this troubling equation. Working across six cities, the team contributed to an impressive 10.9 percentage point average increase in modern contraceptive use among women of childbearing age over four years of project implementation. As a result, over 350,000 more families are now using family planning methods.

The 2013 Demographic Health Survey (DHS) found no other regional or national trend that would otherwise predict or explain the increase in NURHI cities. What’s more, these findings were confirmed by the Measurement, Learning & Evaluation Midterm Survey.

NURHIgraph1How did the NURHI team increase the use of contraceptive methods in a country where family planning efforts were halted for over a decade? By leading with demand.

In NURHI cities, researchers found that Nigerians approve of the idea of planning their lives and their families, but held widespread myths and misconceptions about contraceptive use. NURHI’s demand generation strategy put potential and current family planning users at the forefront of all activities, demystifying family planning. The team focused on fostering conversations on the subject in the home, on the street, at work, in the clinic, and through the media.

Researchers found that a set of particular ideas and feelings about family planning predicted whether a woman would or would not use contraceptives. The more of these predictors a woman had, the more likely she was to use family planning. This concept, called ideation, was the basis for all messaging and communications activities.

A branded, coordinated media campaign encompassing radio, television and community mobilization ran in each NURHI site, tailored to cultural norms and the predominant language. The “Know, Talk, Go” campaign paired mass media messaging with face-to-face communication led by social mobilizers. A popular radio program also aired, weaving in family planning topics with dramatic story lines and interactive call-ins. The percentage of women who reported having seen FP message in the media jumped across project sites.

Figure 2In such a devout country it was essential to involve religious leaders in project implementation. NURHI engaged prominent religious and traditional leaders who in turn publicly endorsed family planning/child spacing. These leaders testified that their religions did not in fact ban family planning (which many men and women believed). They encouraged Nigerian men and women to find a method that would help them care for their desired family size and protect each mother’s health.

While positive attitudes toward family planning were increasing, it was for naught if clinicians were not offering high quality services. To address this, NURHI trained service providers on family planning counseling and provision of long-acting contraceptive methods. The endline survey showed that the number of health care providers who had ever attended an in-service training on FP increased from 3-18 % points across five of the six cities.

The NURHI service delivery team also conducted outreaches in hard to reach areas, providing FP where otherwise individuals had no access to such services. By the third year of implementation, outreach visits contributed to nearly half of total clinical family planning services supported by NURHI.

The team also innovated by introducing 72-hour makeovers. The goal of the makeovers was to provide rapid improvement to infrastructure and equipment in family planning clinics. The effort, conducted over a single weekend, transforms clinics from a dilapidated state to a fresh, modern environment without disrupting services. By the end of the project, 81% of NURHI facilities attributed infrastructure renovations to the 72-hour makeovers. Overall, at endline, over 95% of clients were satisfied or highly satisfied with their visit to an FP clinic, which is a few points higher than at baseline.

By the end of the project between 17.1-27.7% of all women in project sites not currently using contraceptives reported their intention to use FP within the next 12 months.

Beginning in fall 2015, project staff are leveraging their experience and lessons learned in NURHI II. The add-on initiative is replicating the project and expanding statewide in Kaduna and Oyo as well as adding a new state – Lagos. They continue to seek opportunities to work with partners to accelerate the impact of ongoing and future FP work in Nigeria.

Funded by the Bill and Melinda Gates Foundation, NURHI was implemented by CCP in partnership with the Association for Reproductive and Family Health and the Center for Communication Programs Nigeria. To learn more, visit