The perceptions of people about family planning : The social marketing experience in Ethiopia

The study aimed at analyzing the role and practice of social marketing as an approach to address issues related to attitudinal change about family planning. Based on the idea of social marketing and its application to positively influence the behavior through changing attitudes of individuals related to family planning and contraceptive use, the study was developed with the methodology applied for preparing instruments of data collection, sampling and data analysis. Marketing-mix as designed for social issues such as family planning has a key role to play to positively develop the attitude towards the concept and bringing favorable changes in the behavior of individuals. Also, individual’s responsibility towards society and usage of family planning services was also found to be associated with social marketing-mix. Therefore, social marketing activities are contributing favorably to individual’s concerning social responsibility, i.e. increasing the level of individual’s responsibility towards society through usage experience of the services of family planning, and vice versa. In other words, as the social marketing activities and programs increase, the attitude towards family planning will become more favorable among the society members. The study is an attempt to relate the idea of social marketing, as an approach of bringing attitudinal changes in the behaviors of individuals towards the concept of family planning and the use of contraceptives. Therefore, the idea as being tested in the context of Ethiopia, and the factors contributing to behavioral change could be of great importance for policy makers of population control and health related areas. Furthermore, the study maintains relevance to contribute significantly to the existing literature of social marketing and consumer behavior related to family planning.

strategies to expand service delivery across a wider network of healthcare providers.This high impact practice (HIP) has been recognized as one of the fastestgrowing market-based healthcare interventions in the field of reproductive health (Schlein and Montagu, 2012; USAID/HIP, 2013; Population Services International (PSI), 2013).The World Health Organization defined family planning as the practice that helps individuals or couples to attain certain objectives such as avoiding unwanted pregnancies, bringing about unwanted babies, regulating the interval between pregnancies, controlling the time at which birth occurs in relation to the ages of the parents, and determining the number of children in the family.SM/SF are recognized high impact strategies to expand service delivery across a wider network of healthcare providers.Furthermore, SM in family planning uses commercial marketing concepts to promote healthy behaviors and provide contraceptive products and services at subsidized rates, mostly in low-income communities (PSI, 2014;O'Sullivan et al., 2007).SM adopts intense marketing, branding and community mobilization approaches through a standardized protocol (Marice Stopes International MSI, 2011;Schlein and Montagu, 2012;PSI, 2014).Hence, this study aimed at analyzing the perception of people towards family planning with social marketing perspective as an approach to address issues related to attitudinal change about family planning.

MATERIALS AND METHODS
The study examines the perception of people towards family planning from the social marketing aspect with changing attitudes about family planning concept in the Ethiopian context.However, to obtain the necessary data on the practices of social marketing and individuals' attitude towards the concept and practice of family planning, both secondary and primary sources were explored.Various published and unpublished sources were browsed to gather relevant information on the application of social marketing in the family planning perspective.Survey research method was applied to assess the human behavior about family planning and contraceptives use.In order to gather the primary data, structured questionnaire was prepared and tested through a pilot-study which was conducted among 20 respondents with an objective to obtain their perceptions regarding family planning concepts/methods.The responses thus obtained were used to frame the items to measure attitude towards family planning in the final study.Additional items focusing upon the attitudinal changes about family planning and contraceptives use were further added.Finally, all the items related to attitudes and behavioral change, factors affecting, social responsibility, social marketing-mix, and socio-religious influences on family planning and contraceptive use, were placed on a 7-point Likert type scale, and the respondents were asked to report their level of agreement (7 being strongly agree) and disagreement (1 being strongly disagree) associated with each of the statement.Furthermore, the respondents were asked to report on their beliefs from the past about the concept and practice of family planning methods in use.However, to analyze the data obtained through questionnaires, descriptive analysis together with multivariate (factor and multiple regression techniques) analyses was applied.In this way, a sample of 250 individuals (both men and women from Addis Ababa divided equal in proportion) was drawn using stratified random sampling, while contacted personally by the researcher, and ensuring equivalent participation from both the genders and users and non-users of family planning services (being delivered in the research area).All the questionnaire items were exposed to test the validity and reliability (Hayes, 1997), thus ensuring the suitability of the instrument for the study.Factor analysis was carried out and those with a factor loading of 0.5 and above were accepted to be used in the final analysis.Out of 42 initial items, 27 were loaded themselves with a factor loading of 0.5 and above into 6 factors.Furthermore, factors affecting attitudes toward family planning and contraceptives use were obtained, and their contribution was seen in changing behavior through favorable attitudes by computing correlations and multiple regression scores.Additionally, nonparametric procedures were carried out to understand the relationship of demographic variables with attitudes/attitudinal changes and to analyze the differences between attitudes of men and women toward family planning.

RESULTS AND DISCUSSION
Descriptive statistics were applied to summarize means of questionnaire items and demographic profile of the respondents.Factor analysis was carried out to assess the uni-dimensionality, thus suitability of the constructs for subsequent analysis.The principal components method of extraction with varimax rotation was employed, and all 42 items were exposed to the factor analysis.In the first rotation, 35 items were loaded themselves into 11 factors with a factor loading of 0.5 or higher and percentage of variance explained equal to 66.A second run of the analysis was carried out with 35 items, as loaded in the first run.Twenty seven out of the remaining items were found to be loaded into 6 basic factors with very high loadings and communalities, and 67.49% of total variance explained by the obtained dimensions.Therefore, all the 27 items were retained for performing further analysis in the study (Table 1), and 6 factors thus obtained were named as follows: 1. Awareness of FP related issues (AWA) 2. Socio-religious acceptance (SRA) 3. Marketing mix elements (MME) 4. Attitude and decision making (ATT) 5. Responsibility and usage (REU) 6. Health workers acceptance (HWA) However, a few items were found to be loaded into more than one factor, but the logical adjustment of the individual item and the higher value (reflects high correlation with that factor than others) related to a particular factor were considered to place the item in a given factor.

Correlation and regression analysis
Pearson correlation coefficients (r) were obtained in order to see the association between attitude towards family planning concepts and methods applied and various factors affecting/determining it (Table 2).However, to compute the individual contribution by these variables, multiple regression analysis was carried out.Attitude towards family planning and contraceptives usage was found to be significantly associated with the awareness representing information and the knowledge of the respondents about family planning (r=0.263,p<0.001), and responsibility towards society and usage of family planning methods (r=0.217,p<0.001).The reason for this positive association, particular to awareness may be directed to the respondents' positive response on the item stating that there exists better informative and knowledgeable programmes leading to creating awareness about the concept within the public today than in the past.However, negative, non-significant association of attitudes towards family planning were obtained with health workers acceptance  (r=-0.034)and socio-religious influence (r=-0.045).Though correlation analysis is to measure the magnitude of the relationship between two or more factors, the regression analysis can show as the cause and effect relationship and the magnitude of the influence of factors on the dependent variable unlike the correlation analysis.Keeping this in mind, multiple regression analysis was carried out considering attitude towards family planning as dependent and other factors contributing to it as independents (Table 3).Awareness of the family planning concept and practices was found to be contributed significantly (β=0.312,p<0.005) higher than responsibility towards society and the usage of family planning services (β=0.204,p<0.05).Therefore, one can conclude in the situation that attitude towards family planning is more affected by awareness and knowledge about the concept and the methods applied than other variables.However, other than awareness only social responsibility to an individual and her usage of family planning practices was reported as the factor contributing significantly to the development of favorable attitudes towards family planning.The regression equation thus obtained can be written as:

ATTITUDE = 2.202 + 0.312 (Awareness) + 0.204 (Responsibility and usage)
Additionally, an attempt was made to see the influence of such factors upon the responsibility towards society and family planning service usage (REU).Social marketingmix elements and activities together with socio-religious influences on the individuals' attitude towards family planning and overall attitude towards family planning were found to be contributed significantly to estimate the responsibility that an individual is maintaining for the society and his/her usage of family planning services/techniques (Table 4).
However, highest contribution was received from the dimension of socio-religious influence (β=0.252,p<0.003) followed by overall attitude towards family planning (β=0.166,p<0.04) and social marketing-mix elements and practices (β=0.144,p<0.05).Therefore, the regression equation for this construct can be written as:

Social marketing: Changing attitudes towards family planning
As is visible from the correlations obtained between variables, social marketing-mix pertaining to family planning practices was found to be significantly associated with awareness and knowledge about the concept.This association guides toward the idea that as marketing activities in the domain of family planning improves the awareness about the issue and practices will also increase.Also, positive relationship has been obtained between respondents' awareness and knowledge about the issue of family planning and their attitudes toward it.This further indicates that as awareness about the concept increases, the attitude towards the idea of family planning will be favorable.To sum up the above, as marketing activities (supported by marketing-mix elements and practices) such as the communication associated with initial idea or promotion increases, awareness increases, and finally it will contribute to the development of favorable attitude towards family planning.Therefore, marketing-mix as designed for social issues such as family planning has a key role to play to positively develop the attitude towards the concept and brining favorable changes in the behavior of individuals.Also, individual's responsibility towards society and his/her usage of family planning services was also found to be associated with, and contributed by, social marketing-mix.Therefore, social marketing activities are contributing favorably to individual's concerning social responsibility, i.e. increasing the level of individual's responsibility towards society through his/her own usage experience of the services of family planning, and vice versa.In other words, as the social marketing activities and programs increase, the attitude towards family planning will become more favorable among the society members.However, the dimension of socio-religious influences on individual decision-making regarding family planning concept and practice was found to be inversely associated with social marketing practices.This brings to us the idea that socio-religious factors are maintaining an inverse (negative) impression for the social marketingmix elements, that intern maintains a favorable association with towards family planning.Therefore, socio-religious factors are influencing negatively the attitudes toward the concept of family planning and contraceptive usage for the purpose.
Additionally, the respondents reported with the idea that there exist better mechanisms to create awareness about family planning and the usage of contraceptives today than in the past.Also, they reported that they are now more interested in adopting family planning methods/techniques than in the past.This may infer to the idea of social marketing as being practiced within the society pertaining to family planning by government and non-government organizations, in brining changes to the attitudes, thus behavior of the individuals concerning the issue.
Furthermore, the overall attitude towards family planning was found to be negatively associated with the acceptance of health workers.Respondents were found report with a negative perception towards health workers concerning non-caring and non-understanding attitude/behavior associated with them.This seems to affect inversely, the overall attitude towards family planning concept and practices, and must be improved on the part of treatment (behavioral and educational) that individuals are maintaining with them to make the idea (family planning) a big success.However, almost all (96%) of the respondents were reported with a willingness to have more types and better quality of contraceptives available in the market, to be used in carrying out family planning.Also, they did admit that the price and differences in various contraceptives use are less likely to influence their decision to buy.However, the usage was addressed through the fact that most of the contraceptives are available in the areas where respondents live, and distributed across the city to make family planning experience easy for the individuals.

Conclusions
Based on the previous discussion pertaining to overall attitude towards family planning and its association with social marketing-mix and other factors, the following concluding statements may appear.
1. Attitude towards the issue of family planning was found to be positively affected by two factors-awareness and social responsibility and service usage.However, the former is reported to have contributed more than the later.2. Almost all of the respondents approved that there exist much better awareness on the issues related to family planning than in the past.3. Responsibility towards the society and the usage of family planning services and related products were found to be positively affected by the socio-religious factors together with social marketing elements and overall attitude towards family planning.4.There exists a positive relationship between respondents' awareness and social marketing-mix elements, i.e. the higher the social marketing activities, the better will be the awareness about the issues like family planning.5.There exists a positive association between respondents' awareness of family planning practices and overall attitude towards family planning.Therefore, as awareness increases, the attitude towards family planning will increase.6. Almost all of the respondents were found to be happy on the issue of more and better types of contraceptives to be made available in the market, to help in family planning.7. Respondents were found to be more interested in opting for family planning now than in the past.Also, there exists better awareness today than in the past.8.As marketing activities like promotion increases, awareness will increase and finally attitude towards family planning will increase.Therefore, there exist a link between attitudinal profiles of individuals and social marketing activities/elements. 9. Respondents claimed that their buying behavior for family planning products/contraceptives is not affected by the price and differences among various methods.10.The availability and distribution of the contraceptives and family planning services were reported to be as good, as can be obtained from many places in the city.11.Finally, negative attitude towards health workers was reported among respondents, as they were not treated well by the health workers on the issue of family planning.

RECOMMENDATIONS
Keeping in mind the aforementioned discussion and conclusions, the following recommendations are drawn by the researcher.
1. Special social marketing campaigns and programs should be designed and launched to the followers of Islam, in order to first develop and then the positive attitude towards family planning in the country to further balance population growth with that of economic development.To do this, different stakeholders participating in the campaign of family planning and social marketing such as NGOs and related government organizations may be used effectively to work on an integrated programme (as marketing-mix is a collection of elements to be applied in an integrated manner).2. As attitude towards the concept was reported as positively associated with the individual's awareness, an increase in which leads to a favorable increase in the attitude towards family planning.Therefore, NGOs and government units would better work on increasing the awareness to help develop favorable attitude towards family planning.3.As most of the respondents would like to have more and better types of contraceptives to be used for the purpose of family planning, an attempt could be made in order to develop new products in line with the expectations and interests of the individuals.4. The distribution and availability of contraceptives and family planning services is reported as good, and can be found in most of the places in the city.However, an uninterrupted supply of the products and/or solutions should be ensured for future too.Additional distribution outlets specific to certain solutions to be delivered, pertaining to family planning, can further be explored.5. Finally, respondents were reported with unfavorable attitude towards health workers, as not being treated well in the past by them.Therefore, health workers should be trained in line with the behavior of care and understanding shown to the individuals approaching them for family planning.Thus, changing and improving the quality and the responsiveness, caring behavior, and emphatic attitude of service workers should be seen with great seriousness to make the family planning and social marketing experience practical and successful.

Limitations of study and direction for future research
The scope of the study area is limited to the residents (users and non-users of family planning services/methods) of Addis Ababa (the capital city of Ethiopia).Additionally, there are limits to which the research can reveal the most appropriate path for the future course of actions, as the study did not attempt to explore other approaches to change social behavior.There can be variations in the characteristics and attributes of the respondents across various social and cultural groups in terms of education, income, perceptions, attitudes etc., which may affect the findings of the present research if exceed on the sample size and sampling technique.Therefore, before generalizing the results of the study across the nation, an in-depth research targeted to areas other than the capital city (Addis Ababa) is required.However, the current study may be found to be relevant for future researches while providing solid foundation and directions on the attitudinal profile and factors affecting family planning and contraceptive use to explore further.Additionally, it is both of theoretical and practical importance to extend attitudinal dimensions of changing behavior towards social issues like family planning, while incorporating variables from varying disciplines, other than marketing.

CONFLICT OF INTERESTS
The author has not declared any conflict of interests.
Extraction Method: Principal Component Analysis.Rotation Method: Varimax with Kaiser Normalization.

Table 2 .
Summary of correlation coefficient.Correlation is significant at the 0.01 level (2-tailed); * Correlation is significant at the 0.05 level (2-tailed); ATT-Over all attitude of the respondents towards FP; HWA-Health workers acceptance among the society; AWA-Information and knowledge of respondents about FP; REU-Responsibility toward the society and family and usage of the FP services; SRA-Socio-religious influence on the attitude towards FP; MME-Social marketing-mix elements.

Table 3 .
Regression summary-Attitude as a dependent variable.
Dependent Variable: Attitude.Note: AWA-Information and knowledge of respondents about FP; REU-Responsibility toward the society and family and usage of the FP services.

Table 4 .
Regression summary-Responsibility and usage as a dependent variable