Tamara Fetters and Ernestina Coast reflect on their study, Improving adolescent access to contraception and safe abortion in sub-Saharan Africa: health system pathways, which explores how access to contraception and abortion care is perceived and experienced by adolescents in urban Ethiopia, Malawi and Zambia. As part of their study they have produced animations, GIFs, and print-ready comics for each country to be used in formal and informal learning environments and on social media.
“After a 25-year career as a public health researcher, the COVID-19 pandemic has given me some time to pause and ponder my own preconceptions about my work. I have never submitted a proposal without considering “research impact”, “dissemination”, “participation”, “sharing findings”, and “responsibility to research beneficiaries”. I have also never been completely satisfied with my treatment of these complex issues and am forever left with a nagging question about how I might do better.” (Tamara Fetters, Ipas)
As researchers we grapple daily with questions about translating our findings into multiple languages, for multiple cultures and audiences, to influence policy and practice and move beyond peer-reviewed papers. There are new opportunities to democratise access to vital research findings. The landscape of internet access and/or smartphone ownership is changing rapidly in Africa – especially for urban adolescents. Africa is described as a mobile-only continent because nearly all internet use is via mobile, and Facebook-owned WhatsApp is the most used social platform. With improvements in digital access across the globe, we are offered new opportunities for addressing evidence and knowledge gaps, communicating our research to diverse audiences in a more equitable way and democratising information, beyond producing peer-reviewed articles targeting academics and scientists. Finally, we have an opportunity to promote research findings in a unique, digestible and appropriate manner, using social media to amplify our most important messages in ways other than a 12-page manuscript behind a pay wall.
Researching access to contraception and abortion care
Our recent research collaboration was led by the LSE in partnership with the international NGO Ipas, Bwaila Maternity Hospital in Lilongwe, University Teaching Hospital in Lusaka, the African Institute for Development Policy and the Ethiopian Public Health Institute. In a first of its kind study, this work explored how access to contraception and abortion care is perceived and experienced by adolescents in urban Ethiopia, Malawi and Zambia (Improving adolescent access to contraception and safe abortion in sub-Saharan Africa: health system pathways). We conducted interviews with 313 adolescents 10-19 years old who sought safe abortions or care for complications of an unsafe abortion, often resulting from multiple attempts to induce their own abortions with herbs, drugs or poisons because they did not know it could be done safely.
While spending hundreds of hours reading and processing the stories of these adolescents’ fears, hopes, and dreams, we felt the weight of something unique in size and scope. We also felt the weight of our failure to consider our responsibility to them: our mandate was to generate recommendations for policy and programmatic relevance, and our audiences were plentiful. Our skills and funding were focused on analysis and manuscript development and engaging with practitioners and policymakers. While our findings are clearly policy-oriented, our teams’ exchanges with these adolescents on their inability to know when they were pregnant, how to seek help and from whom, and understandings about safety or infertility due to abortion weighed heavily on our minds. Stigma and fear of spurring on foes of abortion has meant there are few if any adolescent-specific communications about abortion in any of the three countries in our study, even as access to abortion is a legal right to young people in two of them. Adolescent-specific communications about family planning and maternal health in Africa tend not to mention abortion, even though it is a common outcome with serious health consequences when done unsafely. The girls we interviewed described their efforts and how few options they had to access reliable information about their own bodies and sexual health. We were convinced that we needed to move beyond the walls of workshops and fact sheets for parliamentarians to the digital spaces where some young people engage and learn.
Taking advantage of knowledge exchange and engagement funds offered to LSE investigators, we jumped at the chance to reconsider our plans for sharing our research findings more widely with adolescents themselves. Recognising the limits of our own expertise, we sought out a partner who would complement and support us with visual communications expertise. The not-for-profit organisation PositiveNegatives produces comics, animations and podcasts and specialises in issues of social justice and stigmatised or controversial topics across cultures. They combine ethnographic research with illustration, adapting personal stories into art, education and advocacy materials. Collaborating on this project provided a unique opportunity to share a low-literacy version of our findings specifically for adolescents. Stepping out of our comfort zones as researchers, we gladly ceded authority to our collaborators at PositiveNegatives as they began to interview us, engage with our findings and work with artists and communicators from within these countries leading the narratives, imagery and, ultimately, script development with teams of far more knowledgeable collaborators.
We embarked on a half-year partnership with PositiveNegatives to create three stories co-designed with writers and artists primarily from the study countries to develop animations for young people and stakeholders for use on- and offline. We agreed on a co-design approach beginning with our research evidence to develop the visual imagery to ensure the stories were highly relevant and informative, and would hopefully be widely shared. Plans for co-production with young people in each country were thwarted by COVID-19; our colleagues in the three countries worked hard to engage with adolescents remotely in the design of our stories. Our collective efforts resulted in a range of materials like the short animation, Mphatso’s Story, from Malawi.
Illustration by Sakina Saidi, produced by PostiveNegatives
Our package of products included animations, GIFs, and print-ready comics for each country to be used in formal and informal learning environments and on social media. Seeking to bring their stories to life, as seen in Mwansa’s Story from Zambia, we have tried to amplify voices of girls most often marginalised because they are young and because the topics being addressed are considered sensitive and stigmatised. This comic, Mwansa’s Story, was selected as one of 15 finalists from hundreds of applicants to the WHO film awards in the ‘Better health and wellbeing category’. You can view the website with all of the finalists here on the WHO Health for All Competition site.
Illustraton by Debasmita Dasgupta, produced by PositiveNegatives
Each of the three stories reflects diverse experiences between the three countries; in Ethiopia where the policy and service environment are most supportive of adolescents exercising agency and autonomy, Kokeb’s Story shows how difficult this can be for adolescent girls.
Illustration by Jacky Sheridan, produced by PositiveNegatives
The three stories are – necessarily – a series of interpretations of our evidence; they do not tell every story, and they are a simplification of some of the experiences that adolescents talked about in our interviews. Working with PositiveNegatives – both experts in knowledge translation across cultures and languages and adept with technology innovations and social networking strategies – provided us with a unique opportunity to share a version of our main findings targeting young people. Helping us to adapt personal testimonies into visual materials, we used our research-driven insights to inform animations in English and Amharic, Chichewa and Nyanja. We know that there is no straight line between information and action or change; we set out to develop the first materials focused on adolescents and abortion in these three countries.
Dissemination of our animations was organic – via Twitter, YouTube and WhatsApp – relying on professional and personal networks of artists, researchers and Ipas staff working in those countries, but it was certainly not without limitations. We were not able to employ influencers or chatbots or public relations firms, or even evaluate the uptake or changes in knowledge and behaviours we hope to have produced. Still, there are almost no communications materials that accurately and reliably discuss abortion in these countries; fewer, if any, do so while reflecting on the lives of adolescents living there, and that gives us pause to be optimistic. We hope this work will be inspirational and provide encouragement to other researchers as well as highlight innovative strategies and approaches for viewing science in creative ways and engaging diverse communities, including adolescents, in the use of research evidence on abortion-related care.
The funding for these animations and comics was provided by the LSE KEI Fund. The original research was funded by the Medical Research Council/FCDO.
This blog also expands on findings from the paper Adolescent sexual and reproductive health and universal health coverage: a comparative policy and legal analysis of Ethiopia, Malawi and Zambia
The views expressed in this post are those of the author and in no way reflect those of the Global Health Initiative blog or the London School of Economics and Political Science.