Estimating the Impact of Family Planning Social Marketing Activities on Reproductive Health and Empowerment Outcomes in Chad: A Randomized Controlled Trial for the Family Planning Impact Lab

This randomized controlled trial is an independent evaluation of the social marketing organization DKT International's family planning activities in two Southern provinces of Chad. This trial is part of the Family Planning Impact Lab (FPIL), a five-year research initiative to generate new experimental evidence of the longer-term health, wellbeing, and development outcomes and on the cost-effectiveness of family planning interventions, which includes three randomized controlled trials evaluating family planning interventions in underserved settings in sub-Saharan Africa (RCT1: Chad; RCT2: Somalia and South Sudan; RCT3: Sierra Leone).

Chad is one of the most disadvantaged countries in the world, with 84% of people experiencing multidimensional poverty. Women and girls are disproportionately impacted, with lower educational attainment than boys, and an average age at first marriage of 16 years. Chad has the second highest maternal mortality ratio in the world at 748 deaths per 100,000 live births (2023), as well as higher neonatal and child mortality, and a fertility rate over six children per woman. About 23% of pregnancies are unintended, 29% of which end in abortion. In 2019, the modern contraceptive prevalence rate was estimated at 6.7% among women in union and 7.7% among unmarried sexually active women, with over 30% of married women and 68% of unmarried sexually active women wanting to either delay or limit their births but not currently using a modern method.

Additional investment in the private sector has the potential to provide necessary family planning services that fill existing gaps, under the assumption that people (even in resource-constrained environments) are willing to pay for those services. DKT International is a global non-profit organization working in more than 90 countries across Africa, Asia, and Latin America. They focus on registering a full range of contraceptive and safe abortion products in countries and distributing them through private sector channels, training health providers, and increasing demand for family planning through high-impact mass media marketing activities (billboards, television, radio, and online) and call center support. DKT's Francophone West and Central Africa team delivered over 1.7 million couple-years of protection in the region in 2025. They began operating in Chad in 2022, mostly in the capital city of N'Djamena.

In order to support the availability of additional family planning services in other areas of Chad, DKT will implement a set of programmatic activities in the two Southern provinces of Logone Occidental and Mandoul. These activities will focus on ensuring that health care providers are trained on the full range of family planning methods, that commodities are consistently available at facilities and through pharmacies and retailers, and training a cadre of community-based midwives to provide family planning to women outside of facilities. Additionally, DKT will implement demand generation activities, including mass media advertising, community events, and outreach by community health workers.

This 4-year study will use a two-arm randomized controlled trial design to assess the impact and cost-effectiveness of DKT's activities in the two provinces. Health districts containing randomized private facilities in the control arm will receive no additional services or activities. In health districts containing randomized private facilities in the intervention arm, DKT will implement their activities.

The primary objective of this study is to estimate the impact of DKT's activities on modern contraceptive use. The secondary objectives are:

• To assess the impact of DKT's activities on pre-determined outcomes including contraceptive continuation, preference-concordant contraceptive method use, unintended pregnancies, intimate partner and gender-based violence, women's autonomy and empowerment, child health, children's continuation of education
• To determine the cost and cost-effectiveness of the activities based on primary and secondary outcomes
• To assess the extent to which DKT's intervention activities are delivered with planned fidelity.

The study will comprise 5 main data collection activities:

1. Annual household-based longitudinal surveys of women of reproductive age, with embedded cross-sectional surveys: We will measure intervention effects using four waves of a household survey among women aged 15 to 49. The household survey is designed to have a closed longitudinal cohort, as well as a cross-sectional sample at each wave to capture women newly moved or aged into the sampled households.
2. Extraction of health facility data from DHIS2 system;
3. Collection of cost information for determination of cost-effectiveness of intervention activities;
4. Ongoing reporting of the implementation of activities by DKT;
5. Qualitative exploration of community norms around family planning, exposure to and perceptions of intervention activities, and additional topics as informed by quantitative results; collected among women, men, and health care providers.

The 7 clusters (zones de responsabilité or ZRs) in this arm will not receive any services or activities beyond what is already present.

The 7 clusters (ZRs) in this arm will receive DKT's planned social marketing activities, including partnership with the private and public health sectors.

Behavioral: Social marketing activities

The intervention activities are designed to expand access to and create demand for family planning services among community members, especially women and girls.

Activities include:

• visiting pharmacies to encourage them to stock DKT-branded contraceptives
• training public and private sector healthcare providers
• partnering with existing private clinics to provide training and commodity support
• organizing subsidised contraceptive access days for the community, where DKT provides contraceptives for free and the facilities charge a nominal fee to clients to generate revenue and gradually develop financial sustainability.
• training qualified midwives to provide contraceptive services in remote communities
• advertising contraceptives on billboards, radio, social media and other digital channels, and in pharmacies
• advertising DKT's regional call center
• organizing public events to raise awareness about family planning
• community mobilization by community health workers.

Plazo: Baseline; Month 12 of intervention; Month 24 of intervention; Month 36 of intervention (Endline)

Proportion of women aged 15-49 who use, or whose partners use, a modern contraceptive method. Modern methods include: female and male sterilization, oral contraceptive pills, IUDs, implants, injectables, male or female condoms, patch/ring, emergency contraception, Lactational Amenorrhea Method (LAM), fertility awareness based methods (FABM) such as standard days method and Billings ovulation method, and other supply methods (diaphram, foam/jelly). Aggregated as a proportion at each round; between-arm effect estimated via difference-in-differences.

Plazo: Baseline; Month 12 of intervention; Month 24 of intervention; Month 36 of intervention (Endline)

Proportion of women aged 15-49 classified as preference-concordant by the Preference-Aligned Fertility Management (PFM) indicator: using contraception and wanting to be, or not using and not wanting to be (adapted from the preference-aligned fertility management indicator developed by Holt and colleagues). A pre-specified sensitivity analysis classifies women reporting any pressure on their use or non-use as discordant.

Plazo: Baseline; Month 12 of intervention; Month 24 of intervention; Month 36 of intervention (Endline)

Proportion of women aged 15-49 who report a new pregnancy that was unwanted or mistimed since the previous round, based on pregnancy history and retrospective wantedness.

Plazo: Baseline; Month 12 of intervention; Month 24 of intervention; Month 36 of intervention (Endline)

Proportion of women aged 15-49 who respond "you alone" or "you and your husband/partner jointly" to the question "Who would you say makes the final decision about you using contraception?" Respondents indicating that a husband/partner, parent/caregiver, a health care provider, another family member, or another person decides alone or jointly are classified as not having decision-making autonomy.

Plazo: Baseline; Month 12 of intervention; Month 24 of intervention; Month 36 of intervention (Endline)

Proportion of non-pregnant women aged 15-49 who respond "entirely my choice" to whether their current contraceptive status reflects their own choice, free from pressure. Current users are asked whether use of their current method was their choice ("that no one pressured you or strongly encouraged you to use this particular method"); non-users are asked whether not using is their choice ("that no one pressured you into not using"). The measure operationalizes freedom from pressure as a component of contraceptive autonomy (Senderowicz 2020)

Plazo: Baseline; Month 12 of intervention; Month 24 of intervention; Month 36 of intervention (Endline)

Mean score on the validated 10-item CSESSA for women aged 15-49. The score is calculated by summing all item values, creating a total score ranging from 0 to 100 across the partner-communication, provider-communication, and choosing/managing-a-method subscales.

Plazo: Baseline; Month 12 of intervention; Month 24 of intervention; Month 36 of intervention (Endline)

Proportion of women aged 15-49 with an unmet need for modern contraception, following the revised DHS definition (Bradley et al. 2012). A woman has unmet need for modern contraception if she is fecund; exposed to the risk of pregnancy (i.e. currently married or in union (assumed exposed), or unmarried and sexually active in the past 30 days); wants to stop childbearing, delay the next birth by at least two years, or is undecided about timing - or is pregnant or postpartum amenorrheic following a mistimed or unwanted pregnancy - and is not using a modern contraceptive method.

Plazo: Baseline; Month 12 of intervention; Month 24 of intervention; Month 36 of intervention (Endline)

Proportion of women who report supply-side unmet need for modern contraceptive methods. Supply-side unmet need classifies women with unmet need (revised DHS definition, any modern method, as above) who report at least one access-related reason for non-use, following Senderowicz and Maloney (Population and Development Review, 2022). Access-related reasons captured by the survey are: knows no method; knows no source; lack of access or distance; cost; preferred method not available; no method available. Women with unmet need who cite only demand-side reasons (e.g., opposition to use, side-effect or health concerns) constitute demand-side unmet need, the complement of supply-side unmet need among women with unmet need. A pre-specified sensitivity analysis instead restricts to women with unmet need who report wanting to use contraception (Senderowicz et al., Studies in Family Planning, 2023).

Plazo: Month 12 of intervention; Month 24 of intervention; Month 36 of intervention (Endline)

The proportion of episodes of modern contraceptive method use discontinued within 12 months of initiation, estimated from the survey's month-by-month contraceptive calendar using single-decrement life-table methods, following DHS analytic conventions. We define the end of an episode at the first calendar month of non-use; a switch to another modern method in the same or immediately following month is treated as continued contraceptive use in the overall rate and as method-specific discontinuation in method-level rates. Overall and method-specific 12-month discontinuation rates will be reported, distinguishing discontinuation while still in need of contraception from discontinuation due to no need (e.g., seeking pregnancy). The calendar administered at each wave covers at least the preceding 12 months, so each assessment reflects use episodes observable in that window.

Plazo: Baseline; Month 12 of intervention; Month 24 of intervention; Month 36 of intervention (Endline)

Proportion of women aged 15-49 who report experiencing physical, emotional, sexual, or economic intimate partner violence in the past 12 months as assessed using the DHS domestic violence module

Plazo: Baseline; Month 12 of intervention; Month 24 of intervention; Month 36 of intervention (Endline)

Mean score on a nine-item self-reported measure of general agency covering decision-making over daily life, voice, capacity to act on life choices, and freedom of movement. Items were adapted from established frameworks for measuring women's and adolescent girls' agency. Each item is rated on a five-point scale from strongly agree to strongly disagree and combined into a mean score, with higher scores indicating greater agency. Administered to all women aged 15-49 at each survey wave.

Plazo: Baseline; Month 12 of intervention; Month 24 of intervention; Month 36 of intervention (Endline)

Proportion of women aged 15-49 reporting any of the five reproductive-coercion behaviors on the validated 5-item short-form Reproductive Coercion Scale (or the mean item count) in the past 12 months. Coercive behaviors include: being told not to use contraception; having birth control taken away or being kept from obtaining it; being made to have unprotected sex in order to become pregnant; condom removal during sex; and deliberate condom damage. Items are adapted to ask about coercion by any person, not only an intimate partner.

Plazo: Baseline; Month 12 of intervention; Month 24 of intervention; Month 36 of intervention (Endline)

At baseline, this is the proportion of respondents' youngest children over age 5 who are not currently enrolled in school, but who attended school at some point in the most recent school year. For subsequent rounds, it is the proportion of respondents' youngest children over age 5 enrolled in school at the last round who are no longer attending by current round.

Plazo: Baseline; Month 12 of intervention; Month 24 of intervention; Month 36 of intervention (Endline)

Proportion of respondents' children who are reported to be in the same or better health than children their own age. This will be assessed by asking "Compared to other children of this age, would you say \[child\]'s health is: Same; Better; Worse?"

Plazo: Baseline; Month 12 of intervention; Month 24 of intervention; Month 36 of intervention (Endline)

Proportion of respondents' who respond "Strongly Agree" or "Agree" to the statement that most people in their community think that "Women should ask their husbands for permission to use contraception."

Plazo: Baseline; Month 12 of intervention; Month 24 of intervention; Month 36 of intervention (Endline)

Proportion of respondents who respond that they have heard of at least one DKT branded contraceptive product.

Plazo: Baseline; Month 12 of intervention; Month 24 of intervention; Month 36 of intervention (Endline)

Proportion of women aged 15-49 who respond "completely agree" or "agree" to the statement "If I wanted to use contraception, the cost would be a barrier for me." The item is administered to all women regardless of current contraceptive use.

Plazo: Baseline; Month 12 of intervention; Month 24 of intervention; Month 36 of intervention (Endline)

Proportion of female contraceptive users who report being satisfied or very satisfied with their method.

Plazo: Baseline; Month 12 of intervention; Month 24 of intervention; Month 36 of intervention (Endline)

Mean score on the Desire to Avoid Pregnancy Scale (DAP-4), comprising four hypothetical statements on thoughts and feelings about the idea of having a baby in the next year, with 5 scaled response categories of "strongly agree" "agree" "neither agree nor disagree" "disagree" "strongly disagree".

Plazo: Baseline; Month 12 of intervention; Month 24 of intervention; Month 36 of intervention (Endline)

Mean score on 10 hypothetical statements from the Gender-Equitable Men (GEM) Scale, assessing support for equitable vs inequitable gender norms across several domains, with 3 scaled responses: "Agree", "Partially agree" and "Do not agree"

Plazo: Baseline; Month 12 of intervention; Month 24 of intervention; Month 36 of intervention (Endline)

Proportion of women aged 15-49 who rate their own health as "very good" or "excellent" on a 5 scaled response categories of "excellent", "very good", "good", "fair" and "poor".

Plazo: Baseline; Month 12 of intervention; Month 24 of intervention; Month 36 of intervention (Endline)

Mean score on the PHQ-4, comprising four questions about how frequently symptoms of mental health disorders are felt. The proportion screening positive for anxiety or depression is defined for each subscale as a total score \>=3.

Plazo: Baseline; Month 12 of intervention; Month 24 of intervention; Month 36 of intervention (Endline)

Mean score on the BRS, a series of six statements representing both positive and negative indications of resilience.

Estimating the Impact of Family Planning Social Marketing Activities on Reproductive Health and Empowerment Outcomes in Chad: A Randomized Controlled Trial for the Family Planning Impact Lab