PraxisThe hidden gem of the Cairo Consensus: helping to end population growth with entertainment media
William N. Ryerson
Vol 2, No 2, 2018.
William N. Ryerson is President of Population Media Center (PMC) (www.populationmedia.org), an organization that strives to improve the health and wellbeing of people around the world through the use of entertainment-education strategies. He also serves as Chair and CEO of the Population Institute in Washington, DC (www.populationinstitute.org). In developing countries, PMC creates long-running serialized dramas on radio and television, in which characters evolve into role models for the audience on various social and health issues.
In 1994, the Programme of Action of the International Conference on Population and Development was adopted. The Programme conveys anthropocentric sensibilities when discussing the idea of sustainable development. Moreover, the Programme has largely been interpreted in such a way that it fails to hold the goal of ending population growth at the same level of esteem as the goal of ensuring reproductive health and rights. Despite some unfavorable outcomes, the Programme’s orientation around gender equality is to be celebrated. In section 11.23, the Programme highlights a key tactic to help achieve gender equality: effective use of the entertainment media, including radio and television soap operas and drama. Since 1998, Population Media Center has successfully used mission-driven entertainment to confront the most powerful drivers of ongoing rapid population growth: the social norms, attitudes and behaviors related to the status of women in various societies around the world; misinformation about contraception and cultural barriers to its use (such as male opposition); and perceived norms with regard to ideal family size.
Nearly a quarter century ago, in September, 1994, the Programme of Action of the International Conference on Population and Development (UNFPA, 1994) was adopted. The occasion was heralded as a watershed moment in how UN Member States, non-governmental organizations, and donors would approach questions of fertility and human population growth. The lengthy document, referred to informally as the “Cairo Consensus”, still serves as the philosophical guide-star for most international development efforts related to reproductive health and family planning, whether funded publically or privately.
One way to accurately summarize this consensus is that every individual adult on the planet is thought to have the basic right to decide, freely and responsibly, the number and spacing of their children and to have the information, education, and means to do so (see Principle 8). Moreover, the fundamental pathways to achieving this level of reproductive autonomy are working to establish bona fide “gender equality and equity and the empowerment of women, the elimination of all kinds of violence against women, and ensuring women’s ability to control their own fertility” (see Principle 4).
While the ethical desirability of these pathways is strong and enduring, from a global sustainability perspective, the Programme of Action is not without serious weakness. For example, while recognizing the interdependence of global population, international development and environmental outcomes, the document nonetheless promulgates a decidedly anthropocentric worldview, using phraseology such as, “Human beings are at the centre of concerns for sustainable development”, and “People are the most important and valuable resource of any nation”. Such statements unwisely conceive that humans are at the center of all material and ethical concerns (Crist & Kopnina, 2014).
Pleasingly, recent initiatives and actions housed within the United Nations (UN) have begun constructing a “non-anthropocentric paradigm in which the fundamental basis for right and wrong action concerning the environment is grounded not solely in human concerns” (UN Harmony with Nature, 2018a). Perhaps in the not too distant future, the UN’s Commission on Population and Development can reconsider the Program of Action’s troubling anthropocentric bent in light of a new jurisprudence quickly developing around the rights of nature (UN Harmony with Nature, 2018b) — not to mention many years’ worth of experiences and learning that have taken place in the fields of population and development since Cairo.
Another important criticism of the Cairo Consensus is that it has resulted in a collective failure, in the minds of most development and philanthropic professionals, to hold the goal of ending population growth at the same level of esteem as the goals of ensuring reproductive health and rights (MAHB, 2014). Indeed, history shows that some reproductive health and rights activists hoped to influence the drafting of the Programme of Action so that it would discredit population concerns altogether (Petchesky, 1995). Fortunately, this agenda has and always will remain impossible to realize: human population dynamics are existentially fundamental to both civilization and the natural world. Any efforts to diminish the central importance of human population dynamics to natural history, and humanity’s place within that history, are doomed to fail.
On the other hand, while the Programme of Action’s various weaknesses are real, and important to guard against, its strengths are also numerous. One little known strength, which at first glance may strike the casual observer as esoteric, comes in the realm of entertainment media. On this score, the drafters of the Programme wisely highlighted a key strategy for any who are concerned with unsustainable population size and growth. In section 11.23 of the Programme of Action, it is noted that “Governments, non-governmental organizations and the private sector should make greater and more effective use of the entertainment media, including radio and television soap operas and drama, folk theatre and other traditional media to encourage public discussion of important but sometimes sensitive topics related to the implementation of the present Programme of Action”.
Indeed, for the past two decades, Population Media Center (PMC) has produced entertainment programming to promote social and cultural change directly related to population dynamics – while improving the lives of millions of people around the world.
While dramatic radio and television shows may seem far-removed from a serious response to humanity’s well-documented global overshoot, when such programming is based on social and behavior change communications theory, results can be both substantial and cost-effective. More importantly, such programming can be customized to confront the most powerful drivers of ongoing rapid population growth: the social norms, attitudes and behaviors related to the status of women in various societies around the world; misinformation about contraception and cultural barriers to their use (such as male opposition); and perceived norms with regard to ideal family size.
Certainly, the Programme of Action did well to focus attention on gender inequality. Arguably, rampant and severe gender inequality – deeply rooted in social norms – does serve as the most fundamental and powerful driver of humanity’s already oversized total population and ongoing growth. For example, when a female’s personal autonomy is socially constrained or totally absent – from lack of education, lack of opportunity, or outright oppression – family size decisions are often controlled by husbands or in-laws (Agha, 2010), and families end up being larger than if women could truly decide for themselves how many children to have and when.
Of course, gender equality cannot be achieved without the backing of legal conventions. Far too many governments have failed to guarantee women equality in basic legal and human rights, in access to or control of resources, in employment or earnings, or in political participation. Men continue to occupy most positions of political and legal authority. Globally, only about 22% of parliamentarians are women. Laws against domestic violence are often not enforced on behalf of women.
However, at a fundamental level, all forms of gender inequality and discrimination are rooted in the socially constructed belief that girls and women are somehow inferior to boys and men. Until broad based normative change around the social status of women is achieved, it will remain impossible for the majority of the world’s women to responsibly decide the number and spacing of their children. Their low social status precludes the conditions necessary to do so. Certainly, the ability to obtain both contraceptive supplies and services, and the full range of supporting information women need to manage childbearing will continue to be compromised in oppressive social situations (Campbell, Prata and Potts, 2013).
Another example of how addressing social norms is key to slowing down and stopping population growth is the concept of “unmet need” for contraception. This condition is defined as when women are fecund and sexually active and report not wanting any more children within the next two years – but are not using any method of contraception.
It is well known that there are 214 million women in the developing world who meet the definition of having such an “unmet need” (Guttmacher Institute, 2017). A persistent current of commentary from some family planning advocates and other development experts — and the popular media discourses following their lead — attribute unmet need to a “lack of access” to contraception.
However, Population Media Center’s analyses of Demographic and Health Survey reports from nearly 100 countries over the last two decades have consistently described a different reality: women with unmet need for contraception rarely cite cost, convenience or a “lack of access” as the reason they are not using contraception. In many countries, lack of access and cost are cited by less than 5% of the respondents. Rather, the primary barriers to use of family planning are large desired family size, fear of health effects (including misinformation about safety and effectiveness of contraceptives), and various forms of opposition, based on religion, fatalism, or patriarchal social norms.
Increasingly, new analyses are pointing to similar conclusions. In June 2016, for example, Guttmacher Institute researchers scrupulously analyzed a decade of data related to reasons for non-use in 52 developing countries (Sedgh, Ashford, and Hussain, 2016). They found non-users who actually “lack access” comprise 5% of the reasons for non-use. Meanwhile, based on the authors’ reporting, fear of health effects and personal or spousal opposition to contraception account for 49% of non-use. In other words, non-use related to informational and socio-cultural barriers out-numbers non-use related to a lack of access by a factor 10.
The largest constituency of non-users of contraception in the world are those who are simply not seeking to avoid pregnancy. Statistics from the developing world, for example, show that of 1.6 billion women of reproductive age living in these regions, only about half (885 million women) want to avoid a pregnancy at all (Guttmacher Institute, 2017). Evidence suggests social norms related to high-desired family size are major drivers of this type of non-use, especially in West Africa, where “ideal number of children” often exceeds actual fertility rate.
Here, a glance at some examples of country specific data from USAID’s Demographic and Health Surveys (DHS) is helpful (see – https://dhsprogram.com/Where-We-Work/Country-List.cfm). In 2012, the ideal number of children for women in Niger was 9.5 – for men, it was 10.9, while fertility was 7.6. Notably, but unsurprisingly, 47% of women in Niger expressed an intention to never use contraception in the future (DHS, 2012). Similarly, in 2014, the ideal number of children for women in Senegal was 5.6 – for men, the ideal number was 7.5, while fertility rate was 5.0. Over 60% of women in Senegal expressed an intention to never use contraception in the future (DHS, 2014).
Changing these troubling dynamics will require helping people understand the personal benefits in health and welfare for them and their children of fewer, spaced births and delayed childbearing. It will require a major shift in societal attitudes and knowledge. It involves role modeling small family norms and making them popular and ending child marriage.
The good news is that progress on these issues is not impossible; even the most damaging, deeply-rooted social norms can be changed. However, social norms are, by definition, deeply entrenched. Patient and determined approaches to change are necessary. Direct messaging, talking points, and “quick fix” interventions that are contrary to dominant social norms are usually insufficient to create change and may even be counter-productive.
Meanwhile, high-quality entertainment is in demand nearly everywhere on the planet. Likewise, as the vast majority of people on Earth have access to some form of broadcast media (whether radio, TV, internet or other), the delivery of entertainment via mass media outlets can reach large audiences cost-efficiently and reliably. Decades of work has shown that education can be combined with entertainment, attracting enthusiastic audiences and informing, empowering, and motivating normative change. One powerful intervention in the quest to end population growth, therefore, involves broadcasting entertainment-education serial dramas. These powerful, emotionally compelling entertainment products can catalyze normative change around the status of women, perceptions of the safety and efficacy of contraception (and cultural barriers to their use, such as male opposition), and perceived norms with regard to ideal family size.
The unique entertainment strategy deployed by PMC is constructed from multiple scientifically validated communication, psychosocial, and psychological theories. Bandura’s (1977, 1986) Social Learning and Social Cognitive Theories play a fundamental role in PMC’s creative process. According to these theories, much of human behavior is learned through observation of role models, whether in person or through the media. Meanwhile, sufficient time is necessary for observational learners to engage in a “mediating process” – to incrementally reflect upon an observed behavior and its consequences and in turn develop sufficient self-efficacy to enact the new behavior.
PMC’s entertainment products always honor and advance the hallmarks of great episodic story-telling, such as captivating characters, cliffhangers, multiple/interwoven storylines, and unexpected plot twists. The shows are delivered in long-running episodic format, usually broadcasting for a duration of 1 to 3 years. The programs are socially relevant, with fictional settings accurately reflecting the existing world of the audience. Production and writing teams, sourced from the country where the show will air, embed three character types into the story: positive, negative, and transitional. The positive and negative characters represent the extremes of behavior on one or more particular issues as practiced in the audience’s own community, while also serving as positive and negative role models for the transitional characters.
The methodology portrays the transitional character moving through a sequence of experiences. First the transitional character encounters a situation that requires or forces a decision on their part (e.g., “Life cannot continue as before”). At this point, both the positive and negative characters — purposefully designed to exhibit polarized and opposing values — make attempts to influence the transitional character’s decision so that the decision coincides with their own outlook and worldview. The transitional character then makes a decision, wholly and completely of his or her own accord. The transitional character experiences a reward or punishment based on whether her or his decision was good (aligned with the positive character) or bad (aligned with the negative character).
As audience members listen or watch the transitional characters experience this sequence of events, spread over successive episodes, their emotional ties and identification with the transitional characters sparks an emotive, psychological desire to adopt similar values and actions in their real life. Simultaneously, as they follow the transitional characters successfully navigating the challenge of repeated decision making and the resulting consequences, the audience gains a vicarious experience of self-efficacy on the process of implementing change.
A good example of PMC’s transformational entertainment is the condensed story of Ngendo, a character in PMC’s 208-episode radio serial drama, Agashi. This hit program aired from January 2014 to January 2016 in the country of Burundi, which has an annual population growth rate of over 3%. This program reached more than two million people and cost a mere $0.74 US per loyal listener.
Ngendo is a 30-year-old farmer (and is also a transitional character in this fiction). He and his wife, Tengenge, have already had 3 children in 4 short years. They are quite poor in a financial sense. Unfortunately, Ngendo’s mother (who is a negative character) insists the couple should have as many children as possible.
Early in the story, Tengenge (who is a positive role model for the audience) begs Ngendo to allow her to use family planning. Ngendo refuses and, as a consequence, Tengenge gets pregnant again. This time, it is announced that she will have triplets. Tengenge becomes very weak and requires frequent visits to the health center – which consumes the family’s already tight budget. With three children and triplets, the family can’t afford food and Ngendo is forced to steal. He is caught and seriously wounded during his capture.
During his night in the hospital, his brother (who serves as a positive character) convinces Ngendo about the benefits of family planning. When he returns home, Ngendo surprises Tengenge by saying that they should use contraceptives. With his brother’s help, Ngendo finally stands up to his mother and refuses to have another child. Shocked by this “betrayal”, his mother tries to poison Tengenge. When she is caught in the act, the villagers chase her, vowing to burn her alive for trying to murder her daughter-in-law. She is driven out of the village and never seen again.
Agashi aired two new episodes per week on seven radio stations in Burundi with national coverage. At one point, over 80% of Burundians, aged 15-49, were listening to the show. As measured by an end-line survey, after controlling for other variables (such as income, education, and place of residence), Agashi listeners were: 2 times more likely than non-listeners to say they know a place to obtain a method of family planning; 2.3 times more likely than non-listeners to report that their partner/spouse is open to the discussion of family planning; and 1.8 times more likely than non-listeners to say that they generally approve of family planning for limiting the number of children.
At clinics in Burundi during the broadcast, 20% of new reproductive health clients cited Agashi by name when they were asked what inspired the visit to the clinic. Similarly, in Sierra Leone, 50% of new reproductive health clients cited PMC’s program Saliwansai as the source of information that brought them to the clinic.
It is worth pointing out that the transitional character in this story was a fictional Burundian man – not a woman. In Burundi, the ideal number of children is over 4 for men, and the percentage of currently married men aged 15-49 who want to have another child either sooner or later is over 60%. Moreover, over 20% of married women in Burundi do not make decisions about their own health care — rather the husband does. Clearly, if gender equality is to be fully realized in Burundi, changing the attitudes and behaviors of men will be instrumental. Likewise, to ease socio-cultural barriers inhibiting the use of contraception – such as mother-in-law opposition – there will need to be a critical mass of empowered individuals who are motivated to adopt behaviors that contradict age old norms.
Finally, there may be no more important aspect to the goal of ending human population growth than helping people around the world understand the health benefits for them and their children of fewer, spaced births (Johns Hopkins Bloomberg School of Public Health, 2016). This is especially true in East, Central, and West Africa where the average number of children per woman still ranges between five and six– and the number of children per man is likely even higher (Schoumaker, 2017). Whether, and how quickly, fertility rates decline in these regions over the next few decades will be the major factor in determining the peak of world population (Madsen, 2015).
As we look towards the quickly approaching 25th anniversary of the Programme of Action of the International Conference on Population and Development, we can find comfort in recognizing the power ensconced in section 11.23. After all, theory driven entertainment media are particularly well suited to tackle the most acute needs in global family planning programs and related efforts to end population growth: interventions that can challenge and spark change in long-established and widely practiced social norms around gender equality, contraceptive uptake, and ideal family size.
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