1. No category

Workshop Report
Developing and testing strategies for increasing awareness of
the IUD as a contraceptive option
Holiday Inn, Southampton, 18-20 February 2004
Organised by
Frontiers in Reproductive Health Program
(FRONTIERS)
and
Opportunities and Choices Research Programme
University of Southampton, UK
The Frontiers in Reproductive Health Program (FRONTIERS) is funded by the
U.S. Agency for International Development and led by the Population
Council in collaboration with Family Health International. The Opportunities
and Choices Programme is funded by DFID and based at the University of
Southampton.
Copies of this report and further information can be obtained at
www.socstats.soton.ac.uk/choices
FRONTIERS/ Opportunities & Choices Workshop on Intrauterine Contraception
Table of contents
Executive summary ....................................................................................................3
1.0 Introduction ...........................................................................................................4
Presentation 1: Global IUD use: Opportunities, Barriers & Choices ........................5
Presentation 2: Promoting Collaboration Amongst NGOs to Increase Access to the
IUD FHI’s efforts 2003-2004 ...................................................................................5
Presentation 3: Why is IUD use so low? Reasons for low use in Ghana................7
Presentation 4: Availability and acceptability of IUDs in Guatemala .......................9
Presentation 5: Revisiting the IUCD. Reasons for poor use in Kenya ....................11
Presentation 6: IUCD Re-introduction Initiative in Kenya......................................13
Presentation 7: Increasing Access to the IUD in Honduras .....................................14
Presentation 8: Promoting intrauterine contraception in Nepal: Action Research ..17
Presentation 9: Economic Evaluation of Interventions............................................19
2. 0 Draft Proposal Summaries...............................................................................21
2.1 Increasing Access to Long Term Contraception in Bangladesh...................21
2.2 Outline Proposal: Disseminating Information on the IUD in Rural Honduras......26
2.3 Comparing the effectiveness and costs of alternative strategies for improving
access to information and services for the IUD in Ghana ...........................................39
2.4 IUD Reintroduction Strategy in Kenya............................................................60
Appendix A: Agenda ...................................................................................................65
Appendix B: Evaluation report of IUD Workshop 18-20 February 2004 ...................68
Appendix C: List of participants..................................................................................70
Appendix D: List of Workshop materials..............................................................71
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FRONTIERS/ Opportunities & Choices Workshop on Intrauterine Contraception
Executive summary
A workshop on developing and testing strategies for increasing awareness of
the IUD as a contraceptive option was held in Holiday Inn, Southampton
from 18th to 20th February 2004. The aim of the workshop was to identify the
most promising interventions for IUD use and generating standard protocols
for small-scale operations research projects to be undertaken in selected
countries. The participants were academics, policy makers, programme staff
and service providers from Kenya, Ghana, Nepal, Honduras, Guatemala,
India, Bangladesh, the UK and the USA.
The workshop reviewed population perspectives and experiences and
worked on a ‘generic’ protocol for potential interventions. To generate
discussion on different experiences, several papers were presented. The
presentations on first day included a global overview of method mix,
reinventing the IUD, Why IUD use is low in Ghana, Guatemala and Kenya,
experiences with interventions in Kenya, Honduras and Nepal, and service
delivery in Bangladesh. On the second day, there were discussions on a
generic intervention in groups and on third day there were discussions on
adaptations of the generic protocol in plenary sessions. Each country project
group was given the task of formulating proposals for an intervention based
on discussions in the workshop. In this report, a summary of power point
presentations on first day of workshop and summaries of the proposals are
presented.
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FRONTIERS/ Opportunities & Choices Workshop on Intrauterine Contraception
1.0 Introduction
Researchers and program managers from four continents, national and
international organizations met from 18th to 20th February 2004 in
Southampton to review reasons for under-use of the IUD and recent
experiences of increasing awareness about the IUD. The focus for
discussion was identifying the most promising interventions and
generating standard protocols for operations research projects to be
undertaken in selected countries including Ghana, Guatemala and
Bangladesh. The workshop objectives were to:
• Consider international experience of IUD use and decline in use
• Identify population level factors favouring client demand for IUD
• Review barriers to service provision
• Identify issues of access and equity of provision for poor and
under-served groups
• Formulate optimal operations research protocols for
implementation in selected countries and settings
• Generate views of evidence, best practice and experience to be
collated in a workshop report and disseminated to participants and
other interested agencies
The workshop was opened by Dr. William Stones on 18th February. He
welcomed the participants and mentioned that the meeting had an
emphasis on presentations but basically it was a working workshop with
a definite product in mind. This product was a template proposal
advanced to a sufficient stage for implementation at the country level. The
focus was building on what had been done in the field of intrauterine
contraception so as to crystallise new ideas. He expressed satisfaction at
the attendance of people with different background and experiences,
ranging from academics to service delivery personnel. He hoped that with
such a wide experience the workshop would be very fruitful and that it
would impact positively on service delivery.
The themes of workshop were reviewing population perspectives and
experiences of IUD provision on first day, generating a template for
intervention on second day and adaptations of the generic protocol for
specific countries and setting on third day.
Presentations and discussions in the workshop are summarised and
presented in this report.
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Project Presentations
Presentation 1: Global IUD use: Opportunities, Barriers & Choices
The first presentation was by Dr. Sabu Padmadas. His paper was coauthored by Dr. Li Bohua and Dr. William Stones. His presentation
covered a global overview of the method mix with focus on IUD, why
IUD use is high in China, Why IUD is not a method option in India, reinventing IUD and measures and possible strategies.
The paper showed that there is a positive decline in abortion which is a
clear contribution of contraception. The proportion not using
contraceptive methods in the world declined from 46% in 1987 to 38% in
2001 while IUD use increased from 11% in 1987 to 15% in 2001. The same
pattern was observed with tubectomy but not with other methods. In
Asia, the IUD share to any method is 28%. IUD use in more developed
region is lower than the more developed one but the trend is similar.
From the period 1990-1994 to 1995-2001 use of IUD and other methods
increased while sterilization declined. IUD users are mostly urban, have
ever given birth to one child, have been to college. In the example of
China, IUD increased from 41% to 49% from 1995-1998 to 1999-02. The
decision to use IUD was 27% at baseline and 70% at endline. IUD
counselling increased at endline. In Bangladesh, IUD use is still low.
From 1975 to 2000, IUD use, together with vasectomy was the least used
methods. India is a potential country for IUD use. In 1998/99 IUD use was
5%. Ninety five percent of acceptors who suffered from post-insertion
problems had the IUD removed in month.
He said method choices are determined by personal and programme
characteristics, level of personal knowledge gathered from peers,
accessibility, availability and acceptance. The strategies he suggested
were addressing the negative effects of the method, appropriate provider
training, assured pre-counselling and follow-up measures, safe-guarding
ethics and highlighting the importance of dual method. Other measures
are involvement of men, focus on unmarried adolescents, innovative
market strategies, role model marketing and research and monitoring.
Presentation 2: Promoting Collaboration Amongst NGOs to Increase Access
to the IUD FHI’s efforts 2003-2004
The second presentation was by Dr. Erin McGinn of Family Health
International. The objectives of Erin’s paper were to identify specific,
actionable activities among RH organizations to advance provision of and
increase client access to the IUD and to identify gaps in knowledge and
additional research needed to address barriers to IUD access and use.
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The criteria for collaboration with any project were that a project had to be
actionable, feasible, will have impact, is specific to the IUD, can be
accomplished relatively quickly (1-2 years), cost-effective and sustainable.
Each opportunity was classified as being related to provider/Clinic,
client/Community, health systems, policy/advocacy, global/macro and
cross-cutting.
For the clinical/provider group, there is a need for IUD advocacy kit
whose task is to decide whether a generic advocacy kit would be useful
and, if so, how to develop it. One can use FHI’s advocacy kit for Kenya as
a prototype; adapt and field-test it in several countries. Secondly, there is a
need for a level playing field. Brainstorm about how to address this issue
as part of PQI at the country level. Identify missions that might be
interested. Determine how to address barriers to IUD provision at the
provider level in each CA’s existing projects and activities. Thirdly, there
is a need to harmonise and update training materials. The task here is to
determine IUD messages that need to be incorporated into training
materials and link to plans to develop or update various training materials
At the client/Community group, there is a need to raise awareness and
increase receptivity to the IUD. The tasks here are to determine the
parameters of interest for assessments designed to describe individuals
and communities that supported IUD use and expand and enhance media
promotion of IUDs.
For the health systems group, there is a need to harmonize training
materials, level playing field, supervision and logistics. The task would be
to conduct a desk review of the diagnostic studies on IUD access to distill
what has been learned. Based on that analysis, cooperating agencies could
draft a programming guide for long-term methods and field test it in a
few countries.
For the policy group, there is a need for advocacy and “Levelling the
Playing Field”. The tasks are to work with WHO to encourage
implementation of new MEC and to develop guidelines for policy makers
and framing IUDs in the context of contraceptive security. On IUDs for
HIV positive women there is a need to increase awareness of the IUD as a
contraceptive option for HIV-positive women among policy makers and
managers of programs providing PMTCT and other HIV services.
On the global group, the technical update should be made. The tasks now
are to draft (in collaboration with WHO) and circulate a press release
(related to MEC changes) to be issued jointly by interested CAs to be led
by FHI. Secondary, there should be collaboration with WHO on training
materials with tasks to get the IUD and MEC guideline changes on the
agenda of the Implementing best Practices regional meeting in Uganda
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and get the IUD and MEC guideline changes on the agenda of the
WHO/AFRO Reinventing Family Planning Meeting. Thirdly, there
should be an IUD working group comprising FHI and others.
Further research needs can focus on Policy, Health systems,
clinical/providers research needs and community/client research needs.
On policy, one may want to know how effective are efforts to increase
access to IUDs likely to be in different settings (e.g., in settings with low
versus high contraceptive prevalence)? What sort of resources should be
devoted to these based on levels of demand? On health systems, one
needs to know the determinants of success in “positive deviants”. On
clinical/providers’ research needs formative research on disincentives to
IUD provision in specific settings. On community/client research needs
there is a need to know what makes a positive deviant at the client level
and willingness to pay.
The next step should be to have several groups assuming a leadership
role. IUD advocacy kit collaboration is already initiated.
Presentation 3: Why is IUD use so low? Reasons for low use in Ghana
The next presentation was by Dr Ivy Osei and Dr Gloria Quansah-Asare.
The objectives of the paper were to
• assess clients’ and providers knowledge and attitudes about the
IUD,
• identify provider and health system barriers that may affect IUD
use and
• identify policy and program implications for the revitalization of
IUD in Ghana.
The use of IUD is stagnant or declining in many countries including
Ghana
In Ghana, IUD use is stagnant at 1% over a period of ten years (GDHS
1998) despite increase in CPR and FP knowledge.
The study investigated the reasons for the low utilization of IUDs in
Ghana. It was a descriptive study which used both quantitative and
qualitative methods. The first part was a secondary analysis of data from
the GDHS, GSA and existing service statistics and to explore trends in the
use of the IUD. The second part was an analysis of qualitative data
collected using a combination of focus group discussions, in-depth
interviews with providers and visits from simulated clients enacting
several profiles. All the ten regions were grouped on the basis of the
patterns of IUD use (increasing, decreasing and non-use) and three
regions randomly selected from each group. Two districts per region and
two sub districts per district were then randomly selected
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facilities/region: All district hospitals, 1 sub-district public facility, 2
private facilities Service providers on duty.
Results:
The secondary analysis indicated a relatively high knowledge about the
IUD compared to a very low percentage of women ever-users (2%) and
current users (0.5%). Half of the IUD users stopped because of side effects
(1993 DHS). There was a steady rise in acceptance of other comparable
reversible long-term methods e.g implants and injectables. IUD use
declined from 3% to 1.9% from 1999 to 2001.
There was a limited knowledge about IUD among clients. Methods most
frequently mentioned spontaneously were injectable, pill and norplant.
Many of the participants have never seen the IUD before. Fear and
misperceptions could account for low demand for IUDs. There were
women who thought that IUDs lead to abdominal distention, causes heart
disease or heart attack and severe weight loss. Other women feared that
partners would pull on the strings during intercourse or being irritated by
them resulting in marital disharmony
Most providers had a positive attitude to IUD. Twenty eight out of 35
providers would recommend IUD to their friends while 18 out of 35
would use it themselves. The main fear of the provider was perforation of
the uterus (24/35) and not acquisition of infection. The reasons suggested
for low use of IUD include poor product image and misconceptions, poor
infrastructure for IUD service and risk of HIV infection to both client and
provider. There have been limited efforts in making knowledge of the
IUD more widely available. The infrastructure is poor with few trained
staff and lack of equipment. Examination room, proper equipment and
supplies are needed.
Information exchange between provider and client was good. Providers
mentioned a range of methods to the clients. IUD was spontaneously
mentioned in 75% of interactions between provider and client. Providers
always asked the service clients their method preference. In 87 out of 159
interactions the providers said it was okay while in 28 out of 159
interactions the provider disagreed, the others were indifferent.
Advantages of IUD were mentioned in 97 out of 159 interactions.
Disadvantages were mentioned in 88 interactions (irregular or heavy
menses, abdomen Cramps, pain during insertion & removal. None of the
interactions included a discussion on HIV/AIDS.
Contextual issues
There were some contextual issues that could have influenced the results.
There were two types of training provided, the pre-service and in-service.
The number trained (comprehensive FP course) was 7 out of the 26
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midwives. However, there is still low demand of the IUD service. Out of
35 trained staff, 15 had not done any insertions in previous year due to
low demand of the product.
Supplies and equipment were provided. The supplies were available in
91% while 11% reported stock-out in GSA. There were no shortages in
GAR, in ER there were 2, in VOLTA there was 1 out of 3 providing
service. In ER 2 reported shortages, Volta region one out of three
providing service reported a shortage.
Cost, policy and demand generation could have had an effect. The cost of
the services was 30,000 to 200,000 cedis in private and 1,000 to 20,000 cedis
in public. There is a favorable policy environment embracing all FP
method (IUD inclusive). Demand generation is difficult on account of
unbranded nature and there is competition from condom promotion
within the context of HIV/AIDS
The conclusion in the paper is that IUD use is low and clients have
future/intended preference for other methods. Identified barriers include
rumors & misconceptions, product design, side effects, insufficient
promotion, insufficient providers with practical experience and
complexity of service provision.
Presentation 4: Availability and acceptability of IUDs in Guatemala
Drs Edwin Montufar and Jorge Solórzano presented two studies on
availability and acceptability of IUDs in Guatemala. The first was on
diagnostic study and the second an operational research on increasing
access to long term contraceptives in rural areas through the MOH in
Guatemala
Diagnostic study
The diagnostic study was carried out with different components. The
components were a review of service statistics & DHS, a situational
analysis of health facilities, a national survey of supplies and
infrastructure at health centre and clinics, in-depth interviews, focus
group discussions and simulated client visits to health centre and clinics.
The facilities were 141 Health centers (MOH), 9 Clinics (APROFAM) and 7
Clinics (IGSS). The in-depth interviews were 87 service providers, the
focus group discussions were 30 while simulated client visits were 76 to a
health centre and clinics.
According to ENSMI 99 (DHS), the prevalence of contraceptive use in
Guatemala was 38.2%. Those who use modern methods were 30.9% (IUD
= 2.2%). Use of traditional methods and periodic abstinence was 7.2%.
IUD was used more in metro areas (4.6% of FP users) and by women with
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high school education or + (8.3%) than in rural areas (1%) or by women
with primary (0.9%) or no education (0.3%). MOH is the source for only
6.1% of current IUD users; APROFAM is the main source (39.8%). Nearly
a fifth (23%) of women have unmet need for PF services.
More than a half (54%) of the interviewed providers was misinformed
about side-effects caused by IUDs. Twenty nine percent of the providers
were misinformed about counter indications. More than a half (52.9%) of
providers had received IUD insertion training. Of these, 30% had inserted
IUD under supervision in actual clients. The mean duration of training for
insertion and removal was 2.1 days. IUD information received by
simulated clients in FP counseling for spacers and limiters
Women did not know what the method looked like physically, they did
not know the side effects and counter-indications. Other things they did
not know about IUD included time needed for insertion and frequency of
follow-up visits, where the method was available (they believe only in
APROFAM), how much it costs (perceived as expensive), effectiveness
(perceived less effective) and they mentioned 15 different rumors they
believed in.
They recommended that training for providers must include side-effects,
counter indications of the method and strategies on how to handle client's
fears. Two providers should be trained in each health center. The IUD
equipment in health centers that do not provide the method should be reallocated. Community IUD promotion campaigns need to be implemented
and they should always mention it during counseling. Satisfied users
should be asked to distribute IEC materials to friends and advertise
availability of female providers.
Operations research on increasing access to long term contraceptives in
rural areas through the MOH in Guatemala
The intervention included training of nurses and nurse auxiliaries in
health centers and posts and a two day in-group theoretical training
followed by on-site training with clients identified by trainee, minimum of
five supervised insertions. Other aspects of the intervention included
certifying the training after the training period. A checklist was used to
assess quality of service provided and facility-based promotional activities
were implemented in final months. Topics covered in training were
techniques for insertion and removal of IUDs, checklist for ruling-out
pregnancies, decontamination (infection prevention) techniques (added
after first few months), how to determine infection, perforation and
expulsion, review of the aseptic insertion technique based on the practice
of insertions and removals on pelvic models.
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Each district selected its own strategies for IEC. Example of the strategies
a district selected was to:
• Have one brochure and one flipchart describing all methods and
one describing the IUD
• Make a flier announcing the new availability of the method in the
health center/post
• Make radio announcements to inform the new availability of the
method.
• Include IUD in FP counseling and mentioning it in contacts with
women of reproductive age
• Ask satisfied users to present their experience in health talks at
health center.
The intervention registered a number of successes. Sixteen nurses and 36
auxiliaries began theoretical training. Forty five were certified. 389 women
requested services in 8 months after the beginning of the project; Only 301
of these met eligibility criteria and had the IUD inserted. Only one
expulsion detected. There were no lacerations, perforations or infections
identified.
From the intervention above, a number of lessons were learnt.
• There is a need for a strong training in management of STI’s and
complications needed.
• Decontamination procedures need to be stressed and simplified.
There are problems with equivalences.
• IEC is a weak component. It should be strengthened to bring
more clients and speed up the training process which will
decrease costs.
• Training and follow-up by experts in the region need to be
pursued.
• Logistics/supplies need to be strengthened
Presentation 5: Revisiting the IUCD. Reasons for poor use in Kenya
The next presentation was by Dr. Ndugga Maggwa. He started with
outlining the objectives national reproductive health strategy (1997-2010).
The objectives of the strategy are to:
• To increase access to family planning
• To enhance quality of care and affordability of services
• To review curricula, training needs and basic training to ensure
provision of comprehensive high quality reproductive health
services
• To effect a coordinated system of IEC
In Kenya contraceptives should be provided to clients according to
method specific guidelines and by trained providers. Counseling service
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is important and should be available at FP service points. The client
follow-up must be ensured. There should be adequate facilitative
supervision necessary and efficient logistic system needs to be
maintained.
IUCD prevalence decreased from 13% in 1987 to 2.4% in 2003 (KDHS). The
reasons for poor IUCD use in Kenya include concerns about safety, IUCD
service delivery, provider attitudes, logistics and supplies, training and
policy. Safety of IUCD revolves around fear of increased risk of
HIV/AIDS, risk of STIs and complications among HIV+ individuals.
Some people fear infertility while others believe in myths and rumors
again IUCD. There are several issues in service delivery that need to be
addressed. Firstly, IUCD is not talked about as much as other methods.
Another problem is that rumors are not spontaneously discussed and
benefits of IUCD are rarely discussed during counseling. The counseling
and IUCD insertion takes time and providers are not motivated. The
IUCDs are available but expendables are inadequate. Appropriate
equipment and speculums are not available. The state of facilities is not
optimal for privacy required for counseling, insertion and removal. Lastly,
it is difficult to achieve levels of infection control required for IUCD
insertion and removal.
Many providers still have negative attitudes. Some fear to insert IUCDs
due to lack of experience while others fear being blamed should clients
experience side effects. Providers fear inserting IUCDs in absence of
aseptic conditions. Paradoxically many have used or are using IUCDs. The
equipment is often unavailable. Sterilization procedures not optimal and
expendable supplies are lacking.
There are problems on training that need to be resolved. Training is
fragmented and irregular. It has stagnated and the six-week training has
fallen out of practice. Some on-the-job training is going on but is
inadequate. There are inadequate mechanisms for certification of staff
trained on-the-job and lack of emphasis on pre-service training for IUCD
insertion.
On IUCD policy and guidelines, only women who have delivered one or
more times are eligible for IUCD. Preferably the women should have two
or more deliveries. Secondly, IUCD should not be used after 6 weeks post
partum if client has not resumed menses. Thirdly, physical/pelvic
examination necessary in a clinical setting should rule out pregnancy.
Fourthly, the women should be at low risk and their partners also at low
risk for STIs. Fifthly, women of reproductive age of any parity including
nulliparous with established menses can use the method. The majority of
providers are unaware of policies and guidelines due to poor
dissemination. The policies and guidelines lag behind the scientific
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evidence. The format of guidelines is often not user friendly to the services
providers
The papers makes some recommendations.The service providers must be
encouraged to discuss all family planning methods so clients can make
informed choices. The privacy and infection prevention procedures must
be ensured. Advocacy efforts are needed to improve provider attitudes
towards IUCD. The mechanisms to ensure that expendable supplies and
equipment are available must be established.
Pre-service training should be emphasized. In-service training and
practice for service providers is needed. Certification procedures need to
be reviewed to support decentralized training. Regular and timely
reviews of policies and guidelines are required to keep up with new
information. Secondly, effective dissemination strategies for the guidelines
should be developed. Thirdly, the format of service provider guidelines
should be made more user-friendly
Presentation 6: IUCD Re-introduction Initiative in Kenya
The next presentation was from Dr. Josephine Kibaru. The chart she
presented showed an observed decline in IUCD contribution to Method
Mix. She said there are supportive research results that are ready for use.
IUCD use provides exceptional protection at low cost. It is safer than
previously thought. Continuation rates are higher than with oral
contraceptives. There are service delivery issues which are a barrier in
IUCD provision in Kenya.
The objectives of IUCD Re-introduction initiative are to increase support
for IUCD among policy makers, health care professionals and clients,
increase the provision of quality IUCD services and enhance demand for
IUCDs. The re-introduction process is in three steps.
The steps are issues identification, developing the program and consensus
building.
a. The first step is issue identification. Scientific evidence from FHIs
research on IUCDs and several stakeholders’ meetings should be
identified. At the stakeholders’ meetings The results of IUCD
assessment research is disseminated. Options on how best to
address issues should be discussed. Positive deviants should be
showcased and the meeting should be an opportunity to inform
program managers/ providers of global evidence.
b. The second step is development of the program. The IUCD Task
Force in Kenya developed a strategy based on global and local
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evidence, and IUCD assessment. It presented the strategy to the
Reproductive Health Advisory Board, MOH and transformed into
an implementing body
c. The third step is consensus-Building. Step 3 involves building
consensus with advocacy partners, development of advocacy
briefs, and launch of the strategy and sensitization meetings. The
advocacy partners involved professional associations and both
local and international NGOs. Sensitization meetings involved
provincial and district medical officers/health program managers.
There have a number of achievements especially on advocacy. The
program managed to reach 80 officials at stake holders meeting. It reached
200 people at IUCD launch, 350 people at provincial sensitisation
meetings, 2,663 at distribution IUCD briefs and 1,762 at the network. The
program reached government leadership and created ownership and
partnership among a broad range of stakeholders. It has developed and
received MOH approval of the strategy, advocacy briefs, client IEC
materials and it has launched the strategy at regional meeting OBS/GYN,
hosted provincial sensitization meetings. AMKENI incorporated training
and BCC components in their work plan and it initiated site
orientation/training activities
Lessons Learned
Several lessons were learned after implementation of the strategy. It is
imperative to build consensus right from the onset and move together.
Involvement of the professional associations and use of their forum is
important. There is a need for use of available IEC materials rather than
developing new ones. Advocacy briefs were very strong tools for
dissemination. The leadership role by the MOH is crucial
Presentation 7: Increasing Access to the IUD in Honduras: a Review of the
Experience Since 1998
The next presentation was by Dr. Ivo Flores Flores. He presented results
from three studies, an operational study, a small promotion study another
one on evaluation of performance and quality of services provided by
Nursing Auxiliaries.
Operational study
The objective for the operational research was to test if nurse auxiliaries
(NAux) could safely insert IUDs and provide DepoProvera and Pap
smears. Sixty Nurse Auxiliaries (NAux), 23 nurses and 11 physicians were
trained in 16 districts. 2,030 IUDs were inserted in one year, with only 3
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pregnancies. The cost per new IUD user varied between $2.90 and $18.60
USD per district.
There was a theoretical training in a group. For the high volume clinics
individualized practical training was carried out. Certification was
achieved by demonstrating proficiency during training (observation by
means of checklist). Follow-up supervision in their own clinics by nurse
supervisors using a checklist was not very frequent in practice. There was
a follow-up study in 1999-2000. The numbers of agents trained were 183
NAux, 56 profesional nurses and 24 physicians. The proportion certified
was 62% for NAux, 89% for profesional nurses and 100% physicians. The
main reason for non-certification was not having enough users
demanding services at training centers to conduct supervised practices.
Results
The certified NAux cared for a monthly average of 7.3 new FP users (2.2
new pill, 0.6 IUD, 3.7 injectable and 0.8 condom) and took 5.2 Pap smears.
If these results were extrapolated to the 867 health posts in the country, a
total of 3,300 new IUD users and 36,500 new injectable users would be
obtained. Only 58% of the certified auxiliaries working in rural health
posts reported having inserted an IUD after the training, compared to
over 80% who provided Pap smears and DepoProvera services
Recommendations
There is a need to increase the proportion of NAux who are certified to
insert IUDs by the end of their training by:
• selecting participants more carefully, and
• insuring that training is carried out in places with a sufficient
volume of insertions
It is crucial to increase the proportion of NAux who perform insertions
when they return to their worksites, perhaps by:
• requiring NAux to identify candidates before training, and
• carrying out the first insertions in their worksites
under
supervision
More frequent supervisory visits are needed. Promotional activities need
to be conducted before, during and after supervisory visits.
Uncomplicated, low-cost promotional strategies need to be implemented
A Small Promotion Study
A small promotional study was carried out in 2001. It is objective was to
see if a promotional brochure offering IUD, Depo-Provera and Pap
services increased the demand for these services in rural health posts. The
intervention involved the NAux giving 10 minute talks and asking
participants to distribute the brochures among friends. Twelve health
posts were randomly assigned, 6 in the experimental group (where
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FRONTIERS/ Opportunities & Choices Workshop on Intrauterine Contraception
brochures were distributed) and 6 in the control group (where no activity
was conducted)
Results
IUD insertions increased from 2.8 to 4.5 per month in the exp group, while
they decreased from 1.4 to 0.9. in the control group. The Depo-Provera
users increased by 1.8 users per month in the exp group, and by 0.6 in the
control group. The pap smears increased by 1.6 samples per month in the
exp group, and decreased by 0.1 in the control group
Evaluation of Performance and Quality of Services Provided by NAux
(2003: MOH and EngenderHealth)
The objectives of the evaluation were to determine factors influencing IUD
insertions by NAux, determine user perceptions of contraceptive methods,
especially the IUD and DepoProvera, identify the perceptions of managers
and providers of IUD insertions by NAux and identify strategies to
improve IUD services. In-depth interviews and Focus Group Discussions
were carried out with 3 regional directors and 20 regional, area and sector
chief nurses in regions, 43 family planning users and 20 nurse auxiliaries
that insert IUDs. The regions were the ones where EngenderHealth has
conducted IUD insertion training.
Results
The factors that influence conducting IUD insertions include liking the
activity, referrals from community volunteer health workers, referrals
from other clients, IUD promotion activities and good counselling. All
users were satisfied with reproductive health services received. Regarding
their opinions of the IUD, they said that it causes cancer, it gets stuck
inside, it produces too much bleeding and women get pregnant. About
DepoProvera they said that it causes headaches, women do not see their
menstruation, women get fat and others get thin and they make damage
when breastfeeding as milk is not produced. Program managers think
training nurse auxiliaries in IUD insertion is good because it helps
increase the capacity to respond to the demand by users
Recommendations
To improve NAux IUD Insertion Services and Training the following
must be in place:
• Improve supervision and logistic supply systems
• Promote the IUD by mentioning advantages, tolerance to it and
long duration
• Increase the number of certified NAux
• Have ready the places where practice will take place and train
small groups
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FRONTIERS/ Opportunities & Choices Workshop on Intrauterine Contraception
In April 2004, the strategy was to be extended to 17 new areas and the
strategy would be reinforced in 10 areas where training has been
conducted before
Presentation 8: Promoting intrauterine contraception in Nepal: Action
Research
The above study was carried out by Dr Sally Kidsley, Biraj Bista, Kamala
Thapa and William Stones. It shows that there is evidence to prove that
IUDs are the most widely used temporary method of contraception
worldwide, most cost-effective method available, safe, <1% pregnancy
rate per year, low risk of ectopics and most effective post-coital agent.
His Majesty’s Government stated that in 1966 the IUD was the most
popular and widely used method with 98% of the total new acceptors.
There was a sharp decline in use and 0.1 – 0.3% of married women have
used the IUD between 1976 and 2001. The factors affecting IUD use are
provision of services from static, selected clinics, lack of incentives to IUD
providers, lack of attempts to improve negative images of IUD and lack of
strategic planning and systematic efforts to make knowledge about the
IUD available.
There is high unmet need for contraception – spacing and limiting. There
is poor uptake of long-term reversible methods. Alternative to sterilisation
reduce regret and lowers risks of surgery. Sustainability of national family
planning programmes (reducing donor input) is an important issue.
A study was carried out using qualitative methods. FGDs were conducted
in three districts. The findings on barriers against use of IUD were
background knowledge, myths and rumours, poor accessibility and
availability, husband involvement and physical barriers. The findings on
positive aspects of IUD were that it is hassle/worry free, no requirement
for operation, safe and reliable, no need to remember daily or three
monthly methods and no hormonal effects.
Radio, posters and female community health volunteers were used for
IEC.
There was a 60 second sketch broadcast on a daily basis in the three
districts for two months. Five thousand culturally sensitive and adapted
posters were distributed widely through the three districts. Female
Community Health Volunteers were chosen from the bank of SPN
promoters, 2 days intensive training on the IUD and incentives were given
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FRONTIERS/ Opportunities & Choices Workshop on Intrauterine Contraception
Two clinics of SPN (the Nepal affiliate of Marie Stopes International) were
chosen in Morang and Jhapa. A third clinic was set up in Ilam. Three
nurses were chosen specifically for study, one nurse per clinic attended
Government approved training on IUD. They were supervised initially.
There was a recruitment for counselling, screening, Insertion of IUD by
female nurse. The post insertion instructions were to give a leaflet, a
follow up, provide medications available, give the times to seek assistance
and make a follow up available for the study period.
The outcome measures were continuation at the primary stage and
acceptability and problems at the secondary stage.
Results
The majority of respondents stated they liked the posters. The messages
were correct and very positive. The woman on the poster looked strong
and active, and many clients hoped they could attain that look. However,
the programme was requested to add directions to clinics and add
information about where, how and when to access services. Jingle
messages on radio should be aired when women are free from work – late
evenings. It should be aired more frequently and advert should be shown
on TV before or after news or popular serials.
Twenty five clients had the IUD removed. Two had it reinserted. There
were two expulsions (one partial and one complete) and no pregnancy
was reported. Out of 333 clients who had IUD inserted – 229 were
followed up (68.7%). The reasons for removal were bleeding, pain,
discharge, husband’s insistence, vasectomy and weakness. There were
changes to other methods as pills, DepoProvera, condom, vasectomy, and
female sterilisation.
The final 12 month follow questionnaire revealed that 81% of the clients
had no problems with the IUD. 99% stated follow up was important to
them. 83.5% would not have had the IUD inserted without follow up. A
high proportion (96%) would recommend the IUD to others.
Limitations of the study
The limitations of the study were that incentives were given to the
promoters. The IUD was offered free of charge, No history of whether
client wanted to space or limit family, loss to follow up – what outcomes
did these clients have? No long term follow up.
Policy implications
The IUD is highly acceptable in the three districts of Nepal. The
intervention strategies were effective in increasing the number of new
acceptors. In order to maintain an increase the marketing strategies must
be in place for a longer period of time. Promoters are the most cost-
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FRONTIERS/ Opportunities & Choices Workshop on Intrauterine Contraception
effective method of marketing, but radio reaches a wider audience.
Female providers are important as male providers are potential barriers to
uptake. The involvement of men in decision making is essential
The provision of follow up is vitally important. Thorough counselling
ensures switching of methods if IUD discontinued. The experience of side
effects in a negative predictor of continued use – thorough post insertion
counselling may increase continuance. The use of analgesia for pain may
increase continuance. The symptoms that might indicate PID were noted
in some discontinuers – indicates the need for staff to be alert to this
possibility. The use of analgesia for insertion is a predictor for
discontinuation – more counselling and reassurance. The nature of
menstrual loss prior to insertion was a predictor for continued use. More
counselling and reassurance are needed.
Further research
It is important to know how the programme can be scaled up. Research
should be able to tell in which context the services should be scaled up.
Whether it is through maintaining IEC emphasis, cost per CYP, policy
context or funding context. On the policy context, targets and incentives
must be set. On funding context there is the issue of continued support.
The role of the men in FP decision making is vital. There is a need to know
who is accepting the IUD. It is could be the spacers or limiters.
Understanding the cultural significance of menstruation is another
important issue for investigation.
Presentation 9: Economic Evaluation of Interventions to Increase
Awareness of the IUD
The presentation was made by John H. Bratt of Family Health International. He
said there is a need for worry about costs to encourage effective use of limited
resources and to inform decisions about bringing interventions to scale.
FRONTIERS has had experience measuring the costs of interventions. There is a
global agenda (1998-present) comprising QOC in Eqypt, MIM South Africa,
India, Bolivia Gender, Guatemala PCI (2 studies) and youth in Kenya,
Bangladesh, Mexico and Senegal.
The frontiers approach is focus on intervention phases and activities. The
Planning phase involves design/implementation of formative research and design
of interventions (development of training curricula, job aids and IEC materials,
ToT, establishing supervision schedules). The second phase is implementing the
intervention which involves training of service providers (clinicians,
fieldworkers) and production of IEC materials and job aids. The third phase is the
service delivery, supervision and monitoring. It involves extra provider time and
Additional supervisory visits as needed.
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FRONTIERS/ Opportunities & Choices Workshop on Intrauterine Contraception
He presented a model for estimation of costs involving inputs, processes and
outputs. The inputs are equipment, labour and materials. The processes are
planning, implementation, service delivery, supervision and monitoring. Outputs
are process outputs that include supervision, training and planning, and service
outputs that include clinic visits, visits to other facilities.
The FRONTIERS approach to economic data collection is to focus on increment
costs and prospective data collection. Incremental costs include costs that are
incurred because of the intervention and include both monetary and non-monetary
costs. Prospective data collection include complex spreadsheet-based forms and
require regular updating by providers and study staff. However, there are issues of
staff turnover/lack of continuity/sporadic TA. There is uneven local buy-in to the
economic analysis seen as “add-in”.
Proposed modifications are to continue focus on incremental costs, blend
retrospective/prospective data collection and keep in touch. Blending the
retrospective and prospective methods involves better dialogue at outset of study,
building on information systems already in use and using simple forms to
supplement.
Lessons learnt
An OR intervention usually is more costly per unit than the scaled-up version.
Scaling-up is not a simple multiplier. Just because the scaled-up version of the
intervention is usually less costly does not make it feasible or affordable. An
example is the frontiers study to improve CPI in Egypt. Cost per clinic was
US$4,100 for OR Intervention and estimated to be US$1,234 for scale-up. Using
the lower figure of US$1,234, costs of scaling-up nationwide would be more than
US$6 million. Intervention had no impact on continuation rates. Therefore if
research is to become practice, we should design OR interventions with
affordability and feasibility as key considerations. We can encourage affordability
and feasibility by consulting with end-users and by building interventions on
existing systems. But even an affordable and feasible intervention may be a poor
use of scarce resources.
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FRONTIERS/ Opportunities & Choices Workshop on Intrauterine Contraception
2. 0 Draft Proposal Summaries
2.1 Increasing Access to Long Term Contraception in
Bangladesh
Background
Globally, access to family planning methods has followed different patterns in
different countries. This partly reflects service planning and delivery, but also
client demand and fertility intentions. In South Asia female sterilisation has
become the dominant method. However, in programmes with a strong emphasis
on provision of information about a range of methods such as in Bangladesh there
has been interest in all methods including oral contraceptive pills and condoms.
As in other South Asian and African countries, intrauterine contraception has
declined as a part of the method mix. This seems to be partly because of the
persistence or growth of rumours and misconceptions about intrauterine devices,
but there is also evidence for provider bias against the method. National and
international medical eligibility guidelines have also contributed to a restrictive
view of the safety of IUD for many women. However, IUD represents an
excellent contraceptive choice for women as part of a broad method mix and in
programmes with high quality information provision and follow up. The method
is also associated with a low cost per CYP.
Three recent international workshops examined barriers to access to intrauterine
contraception. In July 2003 Family Health International hosted a workshop to
review issues relating to intrauterine contraception and identified agencies and
issues. At a follow up gathering in November 2003 a strong emphasis was placed
on the need to remove restrictive service factors such as medical eligibility
criteria, a matter taken up at WHO and leading to revised criteria recently
http://www.who.int/reproductivepublished
(see
health/publications/MEC_3/index.htm). On 18-20 February 2004 international
participants attended a workshop in Southampton, UK, co-hosted by the
University of Southampton and the FRONTIERS program of the Population
Council. The aim of the workshop was to develop protocols for interventions to
increase the availability of long term reversible contraception. Participants
developed parallel intervention strategies that could be applied in Latin America,
Africa and South Asia, while recognising the very distinctive service delivery and
reproductive contexts of the different regions. A common feature of the
interventions in each setting was to focus primarily on information and support to
providers and clients rather than to identify specific technical interventions. This
was because participants involved in service provision recognised that demand
generation would provide the necessary dynamic to improved service delivery,
whereas undue focus on technical training might leave trained providers underutilised and hence at risk of losing their new found skills.
The Bangladesh context is of large scale service provision with substantial
contributions from both government and non-governmental agencies on the basis
of agreed national policies and priorities. Intrauterine contraception in the form of
Bangladesh: Marie Stopes International
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FRONTIERS/ Opportunities & Choices Workshop on Intrauterine Contraception
Copper T has been available for many years in all sectors but recently use has
declined (see table). One of the indicators of effective access to family planning is
a reduction in the percentage of short birth intervals. This is an important
indicator as it links women’s reproductive health to the health of young children:
there is a close relationship between short birth intervals, perinatal and infant
mortality. The table shows that despite increased use of contraception, especially
the oral contraceptive pill, there has been no significant change in the proportion
of short birth intervals, ie births occurring within two years of a previous birth.
Thus, the full benefit of child spacing has not reached as many couples as would
be desirable and intrauterine contraception could fill this gap.
There is current policy emphasis on expanding access to long term contraception
with a media campaign to raise public awareness of sterilisation in particular. It is
therefore timely to consider interventions to strengthen awareness and
accessibility of intrauterine contraception through existing service channels and
programmes.
Table: Contraceptive method mix and preceding birth interval
Year
of
survey
Percent (number in survey) using each method
Injections Condom
IUD
Female
sterilisation
Oral pills
1993
1996
1999
5.3(204)
8.1(504)
8.2(561)
17.6(681)
21.8(1347)
24.6(1679)
3.4(133)
3.4(213)
4.1(283)
2.4(93)
1.6(99)
1.0(70)
1.4(53)
1.2(76)
1.0(70)
% (no)
birth
interval
≤ 24
months
20.2(577)
21.9(988)
19.5(936)
Source: Demographic and Health Surveys, Bangladesh 1993, 1996 and 1999.
Proposed intervention
Following the Southampton workshop it is proposed to develop an intervention to
strengthen awareness and accessibility of intrauterine contraception in
Bangladesh, so as to benefit in particular poorer and less well served sections of
the community. In order to profit from shared experience, this would be
developed in co-ordination with similar activities in Nepal undertaken under the
auspices of HM Govt of Nepal and the Population Council. In Bangladesh the
intervention would be taken forward by the Ministry of Health in collaboration
with Marie Stopes Bangladesh and with technical support from the University of
Southampton’s ‘Opportunities and Choices’ programme. The intervention will
largely utilise existing policy and programme structures so as to generate
maximum benefit and assure sustainability.
Study design
An experimental design is proposed. Two comparable rural districts will be
selected on the basis of poverty indicators, one to act as an ‘experimental’ setting
and the other as ‘control’. Within each district two Thanas will be identified,
Bangladesh: Marie Stopes International
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FRONTIERS/ Opportunities & Choices Workshop on Intrauterine Contraception
within which Government clinics and hospitals would be the focus for the
intervention in the experimental district, and for routine data collection in the
control district. In the urban part of the study, two similar slum areas each with a
population of around 20-30,000 will be identified similarly as ‘control’ and
‘experimental’ sites. Within the slum areas Marie Stopes clinics would be the
service delivery context for data collection. In both rural and urban settings a
minimum level of service provision and quality would be specified as a minimum
requirement for entry into the study, so that service delivery issues do not
confound assessment of the impact of the intervention.
The study design is illustrated in tabular form below:
Experimental
Rural (Govt)
Urban (MSI)
Both
Control
Similar rural district; two Thanas
One rural district with adverse
with similar socioeconomic profile
poverty indicators; two Thana
selected within the district
selected within the district
Slum area, 20-30,000 population
Similar slum area
1. Specified minimum quality and access to services in each setting
2. Similar socioeconomic conditions in control and experimental
settings
3. Similar clinic infrastructure
Interventions
A: The rural part of the study.
1. A steering or working committee will be formed through the good
offices of the Directorate of Family Planning. Outputs will include
meeting minutes, notes of administrative actions taken and review/
updating of IEC materials relating to intrauterine contraception. It is
envisaged that many currently available materials will be used but review
is needed to assure their currency and appropriateness.
2. In the ‘experimental’ District, re-orientation sessions on intrauterine
contraception and on the current intervention will be arranged for District
and Thana level service managers. Outputs will include records of
numbers of attendees, the level and quality of participation at meetings,
and documentation of concerns and responses.
3. In the ‘experimental’ District, ‘Technology’ updates and orientation about
the study will be arranged for District, Thana and Union level providers.
Outputs will include records of numbers of attendees, a pre and post test
and subsequent follow up to assess retention of the material discussed.
4. In the ‘experimental’ District, re-orientation sessions to counter myths and
misconceptions about intrauterine contraception and to gain familiarity
with IEC materials and their use will be arranged for outreach workers and
supervisors. Outputs will include records of numbers of attendees, a pre
and post test and subsequent follow up to assess retention of the material
discussed.
B: The urban part of the study.
Bangladesh: Marie Stopes International
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FRONTIERS/ Opportunities & Choices Workshop on Intrauterine Contraception
1. A steering or working committee will be constituted through Marie
Stopes Clinic Services. Outputs will include meeting minutes and notes of
management actions taken.
2. In the ‘experimental’ slum area, re-orientation sessions on intrauterine
contraception, conceptualised as an ‘IUD package of care’ and on the
current intervention will be arranged for clinic managers and supervisors.
Outputs will include records of numbers of attendees, the level and quality
of participation at meetings, and documentation of concerns and
responses.
3. In the ‘experimental’ slum area, ‘Technology’ updates, orientation about
the study and use of IEC materials and the ‘IUD package’ will be arranged
for mini-clinic service providers, paramedics and volunteers. Outputs will
include records of numbers of attendees, a pre and post test,
documentation of concerns and subsequent follow up to assess retention of
the material discussed.
The above series of systematic re-orientation and briefing activities will enable
clients to make a more fully informed choice of method including enhanced
information from staff more fully aware of all aspects of intrauterine
contraception provided as part of a broad method mix. The slightly different
approaches taken reflect the different service delivery contexts of rural and urban
slum service provision.
Outcome measures
The primary outcome measures for the present study are selected so as to be
consistent with those agreed as suitable for use in other international settings in
studies of renewing awareness of intrauterine contraception. These are
1. The number of acceptors of intrauterine contraception, together with
2. The number of women seeking intrauterine contraception but advised not
to use the method following screening.
These data will be collected both in experimental and control settings. While the
number of acceptors would be available from routinely maintained facility
records, it will be necessary to undertake specific data collection in both control
and experimental areas on the number of women counselled and screened but
rejected.
Secondary outcomes will be collected only in experimental areas. These will
include:
- The costs of the intervention (new data)
- The socio-demographic profile of acceptors (routinely collected
and new data)
- Sources of information about the method as reported by clients
(new data)
- Continuation/ discontinuation (new data)
- Process issues in urban and rural settings (new data).
Data management
Bangladesh: Marie Stopes International
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FRONTIERS/ Opportunities & Choices Workshop on Intrauterine Contraception
Process and outcome data will be collected as the intervention progresses. Marie
Stopes will appoint a research officer to act as the study co-ordinator and to
assure the timely collection and inputting of data, reporting to the Steering Group.
The University of Southampton will provide technical assistance in data handling
and analysis.
Study outputs
Findings of the study will be presented in a report to the Government of
Bangladesh and prepared for peer review publication and dissemination in
executive summary form to interested agencies.
Bangladesh: Marie Stopes International
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FRONTIERS/ Opportunities & Choices Workshop on Intrauterine Contraception
2.2 Outline Proposal: Disseminating Information on the IUD in
Rural Honduras
INTRODUCTION
From February 18th to February 20th, 2004, an international congress of
researchers was held in Southampton, England, to study information, education
and communication (IEC) strategies to re-launch the IUD in less-developed
countries. Research teams from Bangladesh, Ghana, Guatemala, Honduras, Kenya
and Nepal were in attendance and exchanged ideas on possible operations
research designs to evaluate the effectiveness of these strategies.
This document presents the proposal made for Honduras. The first part gives
information on recent efforts made in Honduras to increase IUD availability, and
is followed by a presentation of the design and characteristics of the interventions
that will be implemented as part of the operations research.
BACKGROUND: THE IUD IN HONDURAS
According to the ENESF 20011, in Honduras almost 62 percent of married
women in fertile age (MWFA) use a contraceptive method. Eighteen percent of
women use sterilization, 10.4 percent use the pill, 9.6 percent use the IUD, and
11.2 percent use traditional methods. Of the total number of women of
reproductive age who do not want to have children, nearly 45 percent do not use a
contraceptive method. Of the total number of women that have an unmet need for
contraceptive methods, half is for permanent family planning methods. Despite
the fact that 16 percent of MWFA in rural areas use sterilization (compared to
20% in urban areas), access to the IUD is largely restricted to urban areas and to
some extent to private service or social security sources, thus rural users incur
substantial travel and service costs to obtain the method and may choose a
permanent method sooner than preferred given their perceived choices.
Differences in the perceived access to the IUD in urban and rural areas can be
deducted from the three-to-one ratio in contraceptive prevalence (14.7% in urban
areas and 5.3% in urban areas). In the case of other methods, the ratio of use
prevalence is never greater than 1.5 to 1, and it is usually only about 25 percent
higher in urban than in rural areas. Other long-term methods, such as sub-dermal
implants are only marginally available from private sources to urban women of
high socio-economic class. The category “other” methods in the ENESF 2001
accounted for only 0.2 percent of contraceptive users. Thus, greater perceived
access of the IUD is likely to help increase the unmet need for long term methods
in rural areas without affecting the demand for sterilization services.
Several studies have shown that trained nurse auxiliaries and other paramedical
staff can safely provide IUD services and increase access to the method (see, for
1
Honduras Ministry of Health, ASHONPLAFA, USAID, CDC and MSH. 2002. Encuesta
Nacional de Epidemiología y Salud Familiar ENESF-2001 (National Survey on Family Health and
Epidemiology ENESEF-2001). Tegucigalpa, Honduras.
Honduras: ASHONPLAFA, EngenderHealth and FRONTIERS
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FRONTIERS/ Opportunities & Choices Workshop on Intrauterine Contraception
example, Akin, Gray and Ramos, 1980; Eren, Ramos and Gray, 1983; Zeighami
et al, 1976; Bang, Song and Choi, 1968).
The Honduran Ministry of Health (MOH) provides primary health care services
through two types of health units: health centers or CESAMOS, which have at
least a doctor, a dentist, a nurse, a nurse auxiliary and a promoter, and serve
populations with over 6,000 inhabitants; and rural health posts or CESARES,
which only have a nurse auxiliary and usually serve communities with
populations between 1,500 and 3,500 inhabitants. The MOH has a total of 241
CESAMOS and 867 CESARES.
Nurse auxiliaries are women who prepare for this technical career for one year
following the completion of three years of secondary school (some years ago, the
minimum was six years of primary school). The main services provided by
auxiliaries include vaccinations, child growth and development monitoring, pre
and postnatal care, and the prevention and treatment of respiratory and diarrhearelated illnesses. They prescribe antibiotics for cases clearly defined in the
service delivery guidelines and they refer complicated cases to health providers
who are better equipped to handle more serious cases. Nurse auxiliaries also
provide contraceptive methods.
Before 1998, nurse auxiliaries were only authorized to distribute condoms and
contraceptive pills to continuing users of these methods, but not to new pill users,
who had to receive the method from a doctor or a professional nurse. In 1997 and
1998, the MOH conducted an operations research study to test if nurse auxiliaries
could safely provide IUD services, DMPA injections and take vaginal cytology
samples of proper quality. Sixty nurse auxiliaries participated in the experiment.
In addition, 11 physicians and 23 professional nurses who worked in the
CESAMOs and were responsible for supervising the CESARs were trained. The
results showed that auxiliaries offered good quality services in terms of the
information offered to clients, compliance with service delivery guidelines, and
follow-up of users. (Villanueva et al, 1998)2. Based on these results, in 1999, the
MOH modified the Official Service Delivery Guidelines for Integral Care for
Women and explicitly authorized nurse auxiliaries to provide IUDs, provide
injections and take vaginal cytology samples (MOH, 1999).
To verify the results of the previous study, the Honduran Ministry of Health
(MOH) conducted a second project in which 183 nurse auxiliaries were trained in
the delivery of IUD, Depo-Provera and vaginal cytology services. Sixty-two
percent of nurse auxiliaries who underwent training were certified to offer IUD
services. They provided services to a mean of 7.3 new contraceptive users per
month (including 0.6 IUD and 3.7 DMPA users) and took 5.2 vaginal cytology
samples a month. Only 47 percent of trained nurse auxiliaries and 64 percent of
those who had been certified inserted at least one IUD after training, in contrast
2
See Villanueva, Yanira; L. Hernández, I. Mendoza and R. Lundgren. 1998. Expansion of the
Role of Nurse Auxiliaries in Offering Family Planning Services and Taking Vaginal Cytology
Samples. INOPAL III Final Report. Tegucigalpa, Honduras, Population Council.
2 Honduran Ministry of Health. Women’s Health Unit. 1999. Norms and Procedures. Manual for
Women’s Integral Care. Ministry of Health, Tegucigalpa, Honduras, September.
Honduras: ASHONPLAFA, EngenderHealth and FRONTIERS
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FRONTIERS/ Opportunities & Choices Workshop on Intrauterine Contraception
with more than 80 percent of auxiliaries that provided Depo-Provera and 84
percent that took at least one Pap smear. The study concluded that the strategy
could be improved by making sure all auxiliaries that were trained were actually
certified to provide IUD services, and that all certified agents actually put these
skills into practice (especially IUD insertions and removals) when they return to
their health post after training3.
As a consequence of these and other actions, the prevalence of IUD use among
MWFA in Honduras has progressively increased, from 2.4 percent in 1981, to 5.1
percent in 1991 and to 9.6 percent in 20014.
Since 2001 and with support from USAID through EngenderHealth, the MOH has
continued to train nurse auxiliaries in the country’s six health regions. Retraining
activities were implemented in regions 5 and 2 in the first eight months of the
year and in one area in region 1. In September 2004, training started to be
expanded to the entire regions 6 and 3. EngenderHealth is supporting this training
with two medical officers that monitored the training process in regions 6 and 3,
while USAID has provided additional support by means of a medical officer that
supervises family planning programs in the country.
The training model employed and other technical elements are similar to those
used in operations research implemented before the strategy was expanded. This
model consists of theoretical five-day group training, with refresher contents on
contraceptive methods and counseling or patients, as well as infection prevention
procedures5 and practices in IUD insertion and removal in pelvic models. The
training is then followed up by practical training in a service delivery unit with a
large number of IUD patients, where at least three supervised insertions are made.
Trainers evaluate the quality of care during insertions using a structured
observation list. If the quality is considered appropriate, then the auxiliary is
certified to insert IUDs. The sector nurse then has to visit the auxiliary and
observe at least one insertion (and when possible, one removal) to verify technical
competence on site, although this does not happen frequently. It should be pointed
out that all those who enter the IUD training have had previously one week
training in counseling6.
3
Villanueva, Yanira, Irma Mendoza, Claudia Aguilar, Suyapa Rodríguez and Ricardo Vernon.
2001. Expansion of the Role of Nurse Auxiliaries in the Delivery of Reproductive Health Services
in Honduras. Operations Research Final Report. FRONTIERS in Reproductive Health Program,
Population Council, Tegucigalpa, Honduras. June.
4
ENESF 2001, opus cit
5
Infection prevention contents include washing hands, antiseptics and disinfectants, use and
elimination of sharpe objects, processing instruments and other elements, waste disposal,
decontamination and preparation of chlorine solutions, cleaning of instruments and other elements,
sterilization and stock keeping, cleaning of the facility.
6
Contents of this training include the concept of reproductive health, sexual and reproductive
rights, gender and equity, contraceptive methodology, myths and barriers to contraception,
introduction to counseling: informed consent and user rights; values and attitudes; communication
techniques; types of communication; The ACCEDA counseling interview; counseling for
voluntary surgical contraception and special cases: men, single adolescents, post-partum and postabortion; counseling work-plans
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In 2000, EngenderHealth and the MOH did a qualitative evaluation of the IUD
training program through interviews with 15 nurse auxiliaries7. All respondents
said that 1) they had received one week training in counseling (12 had counseled
users during the previous week); 2) they gave information about all methods, on
how to use the chosen method, on the possibility of changing the chosen method
whenever the client wanted; 3) they provided services in a private space and gave
a follow-up appointment to all clients. They also said they had trained their
volunteers to give information on family planning to community members and to
occasionally give talks in their service delivery units. All had the required
equipment to provide IUD services and to disinfect instruments, although three
only had equipment to do decontamination with chlorine solutions. Regarding
weaknesses, nine providers said they did not explore sexuality issues during
counseling and .two said they did not explore STDs in their patients; six did not
have the service delivery guidelines available, two thirds were unfamiliar with the
concept of informed consent (although they all offered a choice of methods and
knew the purpose of counseling was helping the client make a decision), four said
they had not received training in contraception and information activities seemed
to be irregular.
In 2003, EngenderHealth and the MOH did a qualitative follow up study in three
health regions in which 9 program managers at different levels, 11 sector nurses,
43 family planning clients and 20 nurse auxiliaries that had been trained to
provide IUD services were interviewed8 .The main results of this study
Only about 13 of these nurse auxiliaries said they offered IUD services to their
clients. 60% had been trained in the two previous years, and 85% said they had
inserted less than 50 IUDs since their training. The main reasons for not providing
the service were feeling that their training was insufficient and lack of confidence
in their skills, lack of demand from clients and lack of equipment. Reasons for
providing IUD services mentioned by both those who had inserted more than 50
and less than this number of IUDs since training were good counseling,
promotion of the method, reference of clients from satisfied users and community
promoters and liking the activity. All auxiliaries felt their training in counseling
had been very good. All auxiliaries had positive opinions about their IUD training
in terms of place, contents and trainers. The exception was that two nurse
auxiliaries felt they had had insufficient practice. About 70% had received on-site
supervision after training. To strengthen IUD services, the auxiliaries
recommended improving promotional activities (training community health
workers, providing IEC materials, mentioning the method in counseling and to
clients of other services, giving information to users to clear myths. Other
auxiliaries mentioning obtaining the appropriate equipment and having more
follow up supervision to acquire greater confidence in their skills.
Regarding the 43 family planning clients (including 10 IUD users), the interviews
showed that approximately one third believed at least one of the rumors they had
heard about the IUD, such as that it had low effectiveness, that it got stuck, that it
7
Del Huezo, Flor Alicia. 2000. Report of the Counseling Study. EngenderHealth, Tegucigalpa,
Honduras.
8
Martínez, Laura. May 2003.Consultancy Report. Evaluation of IUD Insertions by Nurse
Auxiliaries in Regions 1, 2 and 5. Tegucigalpa, Honduras, EngenderHealth ,
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caused cancer and that it produced too much bleeding. An approximately equal
proportion believed rumors they had heard about DepoProvera.
Finally, the majority of managers believed that nurse auxiliaries should continue
to be trained to provide IUD services if certification and supervision standards
were maintained. Their recommendations for strengthening the strategy were also
focused on information to potential users, strengthening the training and
supervision components and insuring that providers had the complete equipment
needed to provide the IUD services.
III.
PROBLEM STATEMENTAND SOLUTION
Despite the effort made to train nurse auxiliaries in IUD service provision,
demand for the method in CESAMOS and CESARES is still quite limited and,
therefore, the cost-effectiveness of the strategy is not as positive as it could be. In
the evaluation carried out by EngenderHealth, promotion was defined as one of
the main elements that should be implemented to improve strategy effectiveness.
The challenge would be to find strategies that are compliant with the Tiahrt
amendment and that could be easily implemented at a local level without
compromising resources unavailable to the MOH. For example, in 2001 the MOH
carried out a small-operations research study in six experimental and six control
health posts to see if the use of a flyer with information on the availability of the
IUD, DMPA and Pap smears increased demand for these services. The
intervention consisted of ten-minute talks by a nurse auxiliary on the new
services, where flyers were also handed out and women asked to give them to
relatives and friends who might be interested in these services. The number of
monthly IUD insertions increased from 2.8 to 4.5 in the experimental group and
decreased from 1.4 to 0.9 in the control group. The monthly average of DMPA
users and of Pap tests also increased significantly in the experimental health post9.
This experiment suggested that simple and controlled facility-based interventions
can probably increase the demand for new services in health centers and posts,
and that similar interventions should be developed and tested.
IV. OBJECTIVES
The objectives of this operations research are the following:
•
Design an information model on new reproductive health services in rural
and semi-rural communities in Honduras.
•
Test the effectiveness and cost effectiveness of the model in the generation
of demand for the new services.
V. METHODOLOGY
Design and Geographical Area of the Experiment
9
Mendoza, Irma and Ricardo Vernon. 2001. Promoting Reproductive Health Services in Rural
Communities in Honduras. Mimeo. FRONTIERS in Reproductive Health Program, Population
Council, Tegucigalpa, Honduras, May.
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In this project we will use an experimental pretest/post-test design with a
control group, as shown in the following diagram:
Time
Experimental Group
O1
Control Group
O3
X
O2
RA
O4
Where RA is the random assignment of sectors, O1 and O3 are the initial
observations, X is the intervention, and O2 and O4 are the final observations.
Health sectors will be the sample unit to be randomly assigned10. Seven health
areas in five regions will initially be selected. Two sectors with similar
characteristics will be selected in each health area. Each unit in the pair will be
randomly assigned to the experimental or control group. All health units
(CESAMOS or CESARES) in the sector will participate in the project. Table 1
shows the regions, areas and sectors that will participate.
Table 1
Number of regions, areas and sectors that will participate in the experiment.
HEALTH
REGION
1
2
3
5
6
TOTAL
HEALTH
AREA
3
2
5
1
2
1
3
7
NAME OF THE
AREA
Sabana Grande
La Esperanza
Yoro
Choloma
Gracias
La Ceiba
Olanchito
NUMBER OF SECTORS
EXPERIMENTAL CONTROL
1
1
1
1
1
1
1
1
1
1
1
1
1
1
7
7
7 sectors will participate in total both in the control group as well as in the
experimental group, that is to say, approximately 10 health centers and 30 health
posts will be included in each group.
We believe that this design is appropriate and that no contamination between
groups will be observed because 1) monthly supervision meetings of health
providers occur only at the health sector level, so there is infrequent contact
10
For administrative purposes MOH services are organized into regions, areas and sectors. A
region usually corresponds to a department in the country (the equivalent of a state). The region
has a health team that includes the director, an epidemiologist, a regional educator, a person in
charge of mother-child care, a chief of personnel, a regional nurse and an evaluator. Regions are
divided into health areas. A region has between 4 and 6 health areas. An area has a chief-of-area
doctor, a professional nurse, an educator, an environmental health technician and an administrator.
Areas are divided into sectors. A sector has an average of six health units, one or two health
centers (CESAMOS) and four or five health posts (CESARES). In the sector there is a
professional nurse that offers technical and administrative assistance to health units.
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between providers of different health sectors; 2) although there are quarterly
meetings of head physicians and nurses at the area level, participants in the
experimental group will be advised not to talk about the experiment at these
meetings; 3) only sector nurses and physicians from the experimental groups will
attend the training meetings (see below) and they will directly receive the IEC
materials to be used in their own sectors. No copies of IEC materials will be
available at the area or region level.
Independent Variable
The independent variable to be tested will be the implementation of an
informational model on the IUD in participating health centers and posts, as
described in section VI of this proposal.
The degree or intensity of the intervention will be measured through special
records for the project, kept by the service providers of participating units as well
as their health volunteers. In these records, providers will record the number of
women asked to disseminate brochures, the number of flyers given, the number of
talks given to community members and volunteer field workers, the number of
mini-talks they give, etc. Illustrative record forms are included in Appendix 1.
To monitor the intervention and ensure that informed choice is not being
compromised as a consequence of the IUD community information activities,
simulated clients will visit a sample of posts to evaluate their compliance with
informed choice procedures, the quality of the counseling provided and the
implementation of the intervention. The simulated clients will act in each visit one
of two different profiles of women interested in receiving a contraceptive method.
Once the simulated client leaves the health post, she uses a checklist to record
different provider behaviors related to the information given and the quality of
care provided. This methodology has been used in several FRONTIERS in
Reproductive Health, such as the balanced counseling projects in Peru and
Guatemala, and the methodology has been described in these reports. Each
participant health outlet in the experimental group will be visited two times
during the course of the project (one for each profile, one before the intervention
and one after the training). Three teams of simulated clients will be trained, each
with two persons to act the two profiles. Each team will visit the health centers
and posts in two different sectors. Nurse auxiliaries not providing appropriate
counseling (i.e., giving all the elements to help the user make an informed choice)
will be taken out of the experiment and received additional training in counseling
procedures.
Dependent Variables
The dependent variable will be the number of women that request an IUD, the
number of women that receive an IUD and the characteristics of women that
receive the method, as well as the cost per additional user generated by the
strategy. Finally, we will assess the degree to which providers provide appropriate
counseling to clients.
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The number of insertions will be taken from service statistics (AT1 form). The
number of requests for insertion will be taken from a special record kept by the
service providers. The characteristics of participants will be obtained from the
new client records.
The cost per additional user will be estimated by adding the total costs of training
the service providers, the cost of the time used in implementing the information
activities and the cost of producing the materials, divided by the additional
number of users generated by the strategy. This last number will be estimated by
subtracting the difference in post and pre-intervention averages of the
experimental group minus the control group.
Financial costs will be taken from project accounting records for travel and perdiem of participants, other training expenditures, and design and reproduction of
IEC materials. Non-financial costs will include the amount of time devoted by
service providers in informing community inhabitants about the availability and
characteristics of the IUD. Researchers will record the number of clients informed
about the method during routine service delivery and determine the time required
for this through supervisory observations. In addition, the number of talks and
visits to the community, and the time devoted to these activities will be recorded.
Finally, we will ask supervisors to record the amount of time devoted to project
activities.
Compliance with counseling procedures in experimental areas will be assessed by
means of two visits by simulated clients to each participating health center and
post. Simulated clients will act a profile of two different women, and will record
the interaction in a checklist to assess the degree to which the main components
of counseling and informed choice were followed.
VI. CHARACTERISTICS OF THE INTERVENTION
The interventions that will be implemented in the health centers and posts in the
experimental group sectors have the purpose of informing potential clients about
the main attributes of the IUD, so that they may decide if they are interested in the
method. As explained in the background section, the providers in experimental
and control areas have received training in counseling recently. Women who
attend the health center or post for more information will receive information on
all contraceptive methods and will make a fully informed choice depending on
their circumstances. For this reason, we believe that the proposed intervention is
fully compliant with the Tiahrt amendment. The proposed interventions will be
the following:
Project Presentation visits to Regional, Area and District Authorities
As a first point, there will be a meeting of the research team, which will include
the EngenderHealth and MOH program managers and their participating trainers
and supervisors. The project and materials will be presented in such a way that
supervisors can explain it correctly to region, area and sector chiefs during their
routine visits to sites where work will be carried out.
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Diagnostic Study
An initial diagnostic study will be conducted in both the experimental and control
group sectors to ensure that all health centers and posts included in the study have
the appropriate conditions to offer IUD services (appropriate and complete
equipment and supplies, trained service providers that have inserted or removed at
least one IUD in the last six months, that feel confident in their skills and that
have received training in counseling and infection prevention procedures). If
inappropriate conditions are found in a health center or post, either their service
delivery capacity will be improved before beginning of the project or the health
center or post will be excluded from project activities.
As explained before, EngenderHealth and the MOH have conducted training of
providers in the selected health sectors in the last two years (in fact, in most cases,
during the last year). To ensure that the trainees would be able to use their skills,
they ensured that health centers and posts had the complete equipment to provide
IUD services. For these reasons, we believe that only very few selected posts that
might have had staff turnover will not comply with all the requirements to
participate in project activities. In these cases, we will seek to train the new
providers or to complement the equipment needed. If for some reason this is not
possible, we will ensure that this units do not participate in the project. To avoid
any potential bias due to different number of units in a given zone (which could
affect, for example, the amount of supervision received), we will randomly
exclude a similar number of the control area units in each zone, thereby ensuring
a similar number of units participating in the experimental and control groups.
Development of Information, Education and Communication Materials
The following materials will be developed. Similar materials were developed for
an on-going project in Guatemala (see Appendix 2) and in as much as possible,
these materials will be adapted for use in Honduras. The materials include:
•
A small manual for reproductive health service providers explaining the
characteristics of the strategy and giving advise on how to include the IUD
as an element in health talks, how to seek the help of health center users in
informing their neighbors and friends about the IUD, and how to train
health volunteers in making available the information about the IUD in
their communities.
•
A flyer, highlighting the main characteristics of the IUD or reproductive
health services to be made available. These will be distributed through
health center users. The nurse auxiliary will inform her patients about the
availability and characteristics of the IUD, and will ask the clinic user if
she can help her by distributing the flyer to neighbors and friends whom
she thinks might be interested in this long term method. The clinic user
will be advised to give the handout to their friends, or to invite a number
of them to their house and discuss the materials.
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•
An IUD brochure explaining the characteristics, advantages and
disadvantages of the method. The brochure will be reprinted from existing
leaflets produced by the MOH, the IGSS or ASHONPLAFA.
•
A letter-sized poster highlighting the main characteristics of the method
and promoting the place that delivers the service. Health volunteers and
field workers will place the poster in public places. The poster will invite
women to obtain more information about the IUD and all other methods at
the health center and post.
Training of Trainers, Supervisors and Service Providers
Three training workshops will be held for regional directors, area nurses, sector
nurses and project supervisors. These will be held in Tegucigalpa (for the staff
members from Sabana Grande and La Esperanza), San Pedro Sula (for
participants from Yoro, Choloma and Gracias) and La Ceiba (for participants
from La Ceiba and Olanchito). Topics to be discussed in these workshops will be
how to use the materials produced by the project, how to implement the
interventions, how to record the data in the special formats for the project, and
how to replicate the training for service providers in the health zones. During the
training, the importance of providing appropriate counseling for any women
requesting contraceptive methods will be emphasized.
Zone nurses will replicate the workshop for all service providers in their health
zones. In the case of sectors where research will be carried out, the same points
will be discussed in the workshop. In control group zones, only service delivery
statistics will be collected. All service providers will participate in the
experimental group meetings, as well as the area, region and sector nurses,
educators and technicians in environmental health, and volunteer promoters.
USAID, EngenderHealth and MOH supervisors will also attend the meetings,
which will have an approximate duration of six hours.
Implementation of Strategies
Upon their return to the units, service providers will begin to implement the
activities. The informational campaign will last six months and consist of the
following:
•
Providers will inform all women of fertile age visiting the health center
or post that the IUD is now available at the health unit and will briefly
explain the main characteristics of the method. If the woman shows any
interest in the method, she will be fully counseled and will be given a
copy of the brochure on the IUD.
•
Providers will ask all women visiting the health center or post if she can
inform neighbors and friends who she thinks might be interested in the
IUD that the method is now available in her community. The providers
will give five copies of the leaflet to those who agree to help disseminate
the news. They will also give her one copy of the poster and ask her to
place it in a place where many people go.
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FRONTIERS/ Opportunities & Choices Workshop on Intrauterine Contraception
•
The auxiliary nurse will give a talk to all volunteer promoters, traditional
midwifes and integral child care monitors, and give them a talk on the
IUD. These health agents will be asked to inform all married women of
reproductive age that the method is now available in their health center
and post. Each will be given 10 flyers and five brochures, which they
will give to those women that show interest in the method. In addition,
the nurse will ask them to place the project poster in places where many
people go.
•
The nurse will give all educators and environmental sanitation
technicians a talk on the IUD, and will ask them to end their talks with a
three-minute mini-talk on the IUD, as well as to hand out the flyer to
those that know somebody that might be interested in the method.
•
In places where there are community radio stations, the auxiliary nurse
will ask radio operators to read on air a written text to inform the
community about the availability of the IUD.
The total number of flyers handed out in each center should coincide with the
average number of clients served times six; a total number of leaflets equal to the
monthly average of clients served times three; a total number of posters equal to
the average number of clients served times two. Also, a strategy manual will be
given to each service provider.
Monitoring and Supervision
Specialized personnel from EngenderHealth, USAID and the MOH will carry out
training and supervision of project activities.
As explained earlier, to support the implementation of IUD activities,
EngenderHealth has two full-time supervisors in regions 6 and 3, while USAID
has one national family planning supervisor. Finally, the Dirección de Atención a
la Mujer in the central level of the MOH will assign responsibility to a person
who will supervise project activities. This person will coordinate his or her efforts
with regional, area and sector supervisors who will monitor the progress of
interventions in their routine visits and meetings.
VII. INTER-INSTITUTIONAL COLLABORATION
This will be an inter-institutional collaboration project with the participation of
the Honduras MOH, EngenderHealth, the Population Council’s FRONTIERS
Program, ASHONPLAFA and the USAID mission in Honduras. Respective
responsibilities will include the following:
•
The MOH will organize training workshops; supervise activities from the
national, regional and area levels; and implement activities in health
centers and posts. In order to achieve this, it will name an institutional
coordinator for the project. The MOH will also ensure that the data needed
to evaluate the project is appropriately registered and collected. Finally,
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FRONTIERS/ Opportunities & Choices Workshop on Intrauterine Contraception
with technical assistance from the Population Council, will analyze the
data and prepare the progress and final technical reports. If the experiment
proves successful, the MOH will also extend the strategy to other health
zones and areas in the country
•
EngenderHealth will provide technical assistance through its two medical
officers in regions 3 and 6, and will fund supervision time and expenses of
its supervisors. It will also help pretest the communication materials and
coordinate the production of these materials, as well as help ensure the
registration and collection of the service statistics information. If the
intervention proves successful, EngenderHealth will incorporate this
element into the training and re-training activities.
•
ASHONPLAFA will serve as administrative and financial agency for the
project. Dr Ivo Flores, the principal investigator, will advise the
ASHONPLAFA administrator on disbursements and purchases.
ASHONPLAFA will also prepare the quarterly financial reports.
•
The Population Council’s FRONTIERS program will be in charge of
designing the general strategy, and providing technical assistance for
producing the IEC materials, designing data collection instruments,
analyzing the data and preparing technical and financial reports.
FRONTIERS will also provide funding for printing IEC materials,
conducting meetings and implementing research activities.
VIII
DISSEMINATION AND UTILIZATION
If the information strategy is successful, the MOH will inform regional, area and
zone managers about the project results, will seek that the IEC materials are
reprinted and used in the health system. EngenderHealth will help extend the use
of the strategy by including this information component in their system.
FRONTIERS will help in these efforts by producing a small brochure presenting
the full strategy and results, and by disseminating this brochure to other CAs and
to family planning programs in the region.
IX.
TIME-LINE OF ACTIVITIES
The duration of the project will be 11 months. Informational activities for regional
and area managing personnel will be held during the first two months, when the
diagnostic study will also be conducted. Personnel training will be carried out in
the third and fourth months. IEC materials will be adapted and printed in the first
two months. Implementation of interventions will begin in the fourth month and
will last six months. The last two months will be dedicated to the production of
the final report and the diffusion of the project activities.
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REFERENCES
Akin, A.; R.H. Gray and R. Ramos. 1980. Training auxiliary nurse-midwives to
provide IUD services in Turkey and the Philippines. Studies in Family Planning,
Vol 11, No. 5 (May), pp. 178-187
Bang, Sook; S.W. Song and C. H. Choi. 1968. Improving access to the IUD:
Experiments in Koyang, Korea. Studies in Family Planning, Vol 1, No. 27
(March), pp. 4-11
Del Huezo, Flor Alicia. 2000. Report of the Counseling Study. EngenderHealth,
Tegucigalpa, Honduras
ENESF 2001. Encuesta Nacional de Epidemiología y Salud Familiar (ENESF)
2001. Informe Resumido. Tegucigalpa, Honduras, Secretaría de Salud,
ASHONPLAFA, USAID, CDC and MSH
Eren, N; R. Ramos and R.H. Gray. 1983. Physicians vs. auxiliary nurse-midwives
as providers of IUD services: a study in Turkey and the Philippines. Studies in
Family Planning, Vol. 14, No. 2 (February), pp.43-47.
Honduran Ministry of Health (MOH). Women’s Health Unit. 1999. Norms and
Procedures. Manual for Women’s Integral Care. Ministry of Health, Tegucigalpa,
Honduras, September.
Martínez, Laura. May 2003. Consultancy Report. Evaluation of IUD Insertions by
Nurse Auxiliaries in Regions 1, 2 and 5. Tegucigalpa, Honduras, EngenderHealth
Villanueva, Yanira; L. Hernández, I. Mendoza and R. Lundgren. 1998. Expansion
of the Role of Nurse Auxiliaries in Offering Family Planning Services and Taking
Vaginal Cytology Samples. INOPAL III Final Report. Tegucigalpa, Honduras,
Population Council.
Villanueva, Yanira, Irma Mendoza, Claudia Aguilar, Suyapa Rodríguez and
Ricardo Vernon. 2001. Expansion of the Role of Nurse Auxiliaries in the
Delivery of Reproductive Health Services in Honduras. Operations Research
Final Report. FRONTIERS in Reproductive Health Program, Population Council,
Tegucigalpa, Honduras. June.
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2.3 Comparing the effectiveness and costs of alternative strategies
for improving access to information and services for the IUD in
Ghana
Background
Utilization of the intrauterine device (IUD) is very low in Ghana and indications
are that levels of use have either stagnated or are declining in most parts of the
country. Available evidence suggest that in a period of one decade, current use of
the IUD declined nationwide by 30 percent, from a level of 4.0 percent in 1988 to
2.8 percent in 1998 among women of reproductive age, despite relatively high
awareness (49 percent) of the method among these women (Gyapong et al, 2003;
GDHS, 1998). IUD use varies among the ten regions of Ghana, with use
increasing over the ten-year period in the Greater Accra, Central, Brong Ahafo
and Upper West regions, and clear evidence of a decreasing trend in the Eastern,
Ashanti, Upper East and Northern regions; there is almost negligible use of the
method in the Volta and Western regions.
The concern here is that only few alternative method choices exist for long-term
birth spacing or limiting. These are implants (specifically Norplant), male and
female sterilization and the IUD. Current use of implants and sterilization in
Ghana follows the trend observed for the IUD. For example, the use of
sterilization among current female contraceptive users was 6.7 percent in 1988
but declined to 4.3 percent in 1993 and then rose slightly to 4.9 percent in 1998
(1988, 1993 and 1998 GDHS). Implants were introduced in Ghana in the early
1990s and in 1993, the prevalence among female users was almost negligible (0.1
percent), rising only to 0.7 percent in 1998. The need to encourage adequate birth
spacing to improve maternal and child health as well as respond to the needs of
couples who wish to limit their births calls for the effective promotion of longterm contraceptive methods.
Efforts at improving access to family planning services in Ghana have been
fraught with problems. In the area of service delivery, the Ghana Health Service
(GHS) is faced with many challenges such as inadequate staff, insufficient
facilities, inadequate promotional activities and health IEC materials, as well as
misconceptions, rumours and barriers against the use of the method. For example,
in 1992, it was observed that not all Family Planning (FP) delivery sites had the
requisite capacity (in terms of trained personnel and facilities) to perform IUD
insertions (MOH, 1992). Recommendations were thus made to train all private
and government sector midwives (including Community Health Nurse Midwives)
in IUD insertion techniques and to intensify FP campaigns. As of December
2002, a total of 1365 nurse midwives drawn from static health service institutions
across the country had received training in family planning clinical skills with
emphasis on IUD insertion and removal. A number of providers (1430) had also
been trained in counselling skills as a way of improving the quality of service
delivery and enabling clients to make informed choices regarding contraceptive
methods. To further improve the quality of service delivery, IEC materials were
also regularly revised to suit the Ghanaian context and to include messages that
counter rumours that against family planning. In addition, satisfied clients were
continuously identified and trained in public speaking and communication skills
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FRONTIERS/ Opportunities & Choices Workshop on Intrauterine Contraception
to enable them support outreach efforts. Nevertheless, available service statistics
and survey data indicate that acceptance of the IUD continues to show a
downward trend (MOH/GHS, 2001; GDHS, 1999; GDHS, 1994).
These findings have prompted the Ghana Health Service (GHS) to explore ways
of increasing the use of the IUD in the country. The IUD is a highly costeffective reversible method of contraception, with an effectiveness level of 9899% and potential use duration of ten years. The per-unit commodity cost of an
IUD is US$1.60 and it lasts up to ten years compared with DMPA, which costs
US$1.30 per injection, or oral contraceptive pills that cost US$0.22 per cycle.
However, ways for enhancing awareness about and supply of the IUD could not
be developed until the causes of low utilization were known. Consequently, in
2002, the GHS and FRONTIERS undertook a study to investigate the
acceptability of the IUD by clients and providers in three regions of the country
(Greater Accra, Eastern and Volta regions). The results showed that the major
reason that discouraged both old and new clients from using the IUD was fear of
side effects (Gyapong et al, 2003). However, such knowledge about side effects
was mostly based on the clients’ own perceptions and rumours about the method,
and not on actual experience. For example, the design of the IUD and fear of
weight loss associated with its use were noted as some of the reasons that
discouraged potential acceptors. Other barriers that were found to impede IUD
use were insufficient promotion of the product (i.e. poor demand creation) and an
insufficient number of providers with practical experience. The study also found
that, contrary to general belief, providers did not have any biases against the
method but rather intimated that their skills had deteriorated due to lack of clients.
In February and March 2004, the study results were disseminated through three
zonal workshops to district-level family planning managers, with
recommendations to improve the supply of and demand for the IUD. The
recommendations focus on increasing awareness about the method via
interpersonal channels and through enhanced marketing strategies, and improving
service delivery through ensuring adequate supplies and other logistical support at
the clinic level.
This dissemination of the study findings came shortly after the launch of a
national family planning educational campaign (in October 2003) with the
objective of increasing use of contraceptives. The campaign, entitled the Life
Choices Behaviour Change Communication Campaign, is implemented by a
consortium including the Ghana Health Service, Ministry of Information,
National Population Council, Ghana Social Marketing Foundation (GSMF),
Planned Parenthood Association of Ghana (PPAG) and the Johns Hopkins
University Population Communication Services (JHU/PCS), and is funded by
USAID. Life Choices is a multi-media campaign, which seeks to reposition the
idea of family planning within society, both at the national level and community
levels by focusing on all contraceptive methods using generic family planning
messages. To date, however, Life Choices has not addressed the myths and
misconceptions surrounding individual methods and the campaign tends to focus
primarily on pills and condoms, leaving the IUD and other methods much less
visible.
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Possible solutions
Projects conducted elsewhere to reinvigorate the IUD as part of expanding
method choice have placed emphasis on provider training, supply issues,
advocacy to dispel myths, provision of accurate information about the method and
demand creation. For example, with support from a consortium lead by FHI, the
Division of Reproductive Health in Kenya’s Ministry of Health has developed a
comprehensive program of interventions. These include: establishing strong
partnerships with the professional medical associations to enhance support for the
IUD; increased provider training; a focus on resolving supply constraints; and
continuous monitoring to identify problems and solutions as they arise (Network,
2003).
Advocacy efforts began at the provincial level and are extending to the district
level, targeting policy-makers, service providers, and family planning clients.
These efforts were designed primarily to dispel myths and provide accurate
information to increase provider interest in and client demand for the IUD. Tools
developed and used include an IUD ‘Advocacy Kit’ and briefing materials for
program managers and providers, information, education, and communication
(IEC) materials for potential users, collections of scientific briefs and articles for
the medical associations, and a media program. In Tanzania, Jato et al (1999) also
conclude that multiple sources of information on contraception reinforce one
another and extend the reach of a family planning campaign.
Capacity building involves training providers and ensuring availability of
expendable supplies (such as lotions and gloves) and equipment (such as light
sources and specula). To ensure sustainability, the Kenya MOH is supported by
EngenderHealth's AMKENI Project (the USAID bilateral reproductive health
support project) at 96 facilities in the eight districts, and uses a decentralized
system to train trainers to implement an IUD in-service refresher course; also it is
not limited to the public sector (which delivers about half of all Kenyan health
services) but extends to the private sector as well.
Other components include helping managers at family planning facilities to
schedule services more efficiently so that providers feel that they have adequate
time to insert and remove IUDs, and creating client demand for the device after
IUD training and supply issues have been addressed. Increasing client interest in
the method is a multi-step process that involves working with communities, local
leaders, and providers to respond to community concerns about the IUD. Two
strategies are currently being tested through operations research. First, MOH
supervisors are being trained to make the IUD available and known using the
methods employed by pharmaceutical representatives during visits to clinic nurses
and community-based distributors. Second, a project supported by Marie Stopes
International and by the German development bank Kreditanstalt für
Wiederaufbau (KFW) is socially marketing the IUD through a network of
franchises.
A project in Guatemala that sought to increase interest in another underutilized
method, vasectomy, compared three communications strategies (Bertrand et al,
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1987): using a radio only campaign, using a community-based health promoter
alone, and using a combination of both strategies. The results indicated that all
three strategies had a significant effect on vasectomy rates; however, the greatest
effect was in the promoter only area while use of radio alone or radio plus
promoter produced similar effects.
In another operations research study, Mendoza and Vernon (2001) tested the
effect of raising the profile of the IUD, Depo Provera and Pap smears through
clients of rural health centres (RHCs) in Honduras. The intervention consisted of
nurse auxiliaries in six RHCs giving ten-minute talks to RHC clients and
providing them with informational brochures to distribute to interested friends in
their communities. The services delivered three months before and after the
intervention were compared to those observed in the control group of six clinics
where no special activities were taking place. The results suggest that the
experimental group had significantly higher change rates than the control group.
For example, new IUD users increased by 50 percent in the experimental group
compared to a decline of 42 percent in the control group. Also, whereas new
injectable users increased by 36 percent in the experimental group, the control
group registered an average increase of 19 percent.
Drawing from these experiences, and taking into account the situation in Ghana,
this study will test and compare two approaches that seek to increase awareness of
the IUD and improve the appropriateness of the contraceptive method mix in
Ghana. The evidence presented indicates that interpersonal communication and
messages tailored to community beliefs and fears about the method are likely to
be effective in encouraging interest in currently underutilized methods. Moreover,
the method needs to be easily accessible and readily available upon demand if this
interest is to be translated into actual and sustained utilization. Underlying any
effort to improve demand creation and supply at the community level, however, is
a need for commitment to ensuring supply of the method at all levels of the
reproductive health system. IUD service delivery efforts will certainly not be
undertaken to the exclusion of other methods but will cover all available
contraceptive methods to enhance the client’s options and informed choice. The
marketing of the IUD should therefore not affect access to or information on other
methods.
The Ghana Health Service has begun a process of reorganizing health services
nationwide, so that the focus of information and service delivery is at the
community level, rather than at the clinic. The Community based Health Planning
and Services (CHPS) initiative seeks to make effective use of both health sector
and community resources and is currently being implemented in 95 out of the 110
districts in Ghana (Awoonor-Williams et al, 2003). The program consists of reorienting and redeploying community health nurses from static clinics to live in
underserved communities and provide primary health care under the designation
of “Community Health Officers” (CHO), living and working in ‘Community
Health Compounds’ built or renovated by the community. The work of these
CHOs is supported by resident volunteers (Community Health Volunteers) and
supervised by village health committees. The study will be undertaken, therefore,
in districts where the CHPS initiative has already been introduced to take
advantage of the community networks that have been established.
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It would make little sense to carry out an intervention to increase awareness of the
IUD as a contraceptive option, if capacity to satisfy increased demand does not
exist. Therefore, the study will be conducted in areas where the IUD is already
available in a clinic or hospital, through trained staff, commodities, and infection
prevention equipment and supplies.
An educational campaign emphasizing the IUD will first be mounted by the
CHOs and Community Volunteers in two intervention areas, followed by the
provision of services. The difference between these two interventions will be in
how the IUD (or other long-term contraceptive) will be supplied to the interested
client. In one intervention, the client will be referred to the nearest health center
that offers the method by the CHO for insertion at a later date and by another
provider. The other intervention will train the CHO to insert and remove the IUD,
and enable the CHO to do so safely at the Community Health Compound. In order
to ensure that there is adequate infection control in the CHCs, efforts will be made
to provide the necessary materials for creating a sterile work area. Where, there is
not much space within the CHC to provide the service, clients will be scheduled
in groups and accompanied to the health facility to which the CHO is affiliated
for the IUD insertion or removal by the CHO. In another area which serves as the
control, the routine services and counseling offered by family planning providers
will continue. The two intervention groups will be compared with the control site
where no awareness-raising activities are introduced, but the IUD is available and
accessible.
Both interventions will be compared in terms of their effectiveness and cost.
Both interventions will involve training CHOs and the community volunteers in
educational activities focused on creating a more informed awareness of, and an
interest in, long-term contraceptives, and particularly the IUD, as a means of
family planning.
Through these activities and design, this study will answer the following
questions:
1. Does improving access to accurate information provided by a respected
community-based source (the CHO) increase awareness and interest in longterm methods, including the IUD, as a contraceptive option?
2. Does increased awareness and interest in these methods translate into
increased use of all methods, as well as of long-term methods?
3. Does training CHOs to deliver the IUD themselves increase its use over and
above referral of the client to another clinic and provider?
4. What is the incremental cost-effectiveness of each strategy?
5. What is the overall cost saving to the Ghana Health Service of increasing
long-term method use, taking into consideration commodity, IEC, and training
costs?
Policy Implications
The study has clear implications for reproductive health program implementation.
The Reproductive Health Policy of Ghana emphasizes that “all couples and
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individuals have the basic right to decide freely and responsibly their reproductive
goals and have the information and means to do so” (Ghana, 2003). The findings
of this study will thus contribute to the achievement of the reproductive goals and
general reproductive health of couples and individuals by increasing access to
family planning. It will also address the policy objective of improving the quality
of reproductive health services by providing affordable contraceptive services as
well as the full range of safe and effective methods through information,
education and counseling to persons wishing to space their births or limit their
family size. If the interventions prove successful and cost effective, emphasising
the use of IUD through the CHOs would be a convenient way of expanding
access to a long-term acting method of contraception. Finally, clients choosing
IUDs incur lower commodity costs than do users of other methods (assuming
continuation of at least one year), which can help to promote the goal of
contraceptive security.
Goal
The overall goal is to increase the use of long-term family planning methods
among those wanting to limit or prolong spacing of births through increasing
access to information and services about long-term methods, including the IUD,
with a subsequent increase in the overall use of contraception.
Objectives
The specific objectives are:
1. To test the effect of giving information updates on long-term methods on the
CHOs’ knowledge on use effectiveness, mode of application, mode of action,
duration of use and eligibility criteria for each method.
2. To test the effect of training CHOs and community volunteers to educate
community members about long-term family planning methods (including the
IUD) on community member’s knowledge of, perceptions about, and intention
to use long-term methods.
3. To measure the impact of increasing awareness about long-term
contraceptives on the overall use of contraception, as well as on changes in
the proportionate share of long-term methods in the contraceptive method mix
in CHO work zones.
4. To measure the incremental impact of training CHOs in IUD service delivery
in zones where the educational intervention has already occurred on use of
IUDs and other contraceptive methods.
5. To calculate the incremental cost-effectiveness of the educational intervention
and the intervention to train CHOs to provide IUD services themselves.
6. To model the cost savings to the Ghana health program and to couples
practicing family planning resulting from increased use of the IUD.
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Hypotheses
1. Women and men living in communities where CHOs and community
volunteers have been trained to educate community members about long-term
family planning methods (including the IUD) will have significantly higher
levels of knowledge, more positive perceptions about, and be more likely to
use or intend to use a long-term method than women and men living in
communities where CHOs and community volunteers have not been trained.
2. CHOs who were given information updates about long-term family planning
methods (including the IUD) will have significantly higher levels of
knowledge and more positive attitudes towards these methods than CHOs
who did not receive the training.
3. CHO work zones in which CHOs and community volunteers have been
trained to educate community members about long-term family planning
(including the IUD) will have significantly higher levels of contraceptive use,
as well as proportionately more long-term methods in their contraceptive
method mix, than CHO work zones in which CHOs and community
volunteers have not been trained.
4. CHO work zones in which CHOs have been strengthened in providing IUD
services on-site will have significantly higher proportions of current and new
IUD users than CHO work zones where CHOs have not been strengthened in
providing IUD services on site.
5. The cost per IUD client in CHO work zones where CHOs have been
strengthened in providing the IUD on-site will be lower than the cost per IUD
client in CHO work zones in which CHOs refer IUD accepters elsewhere for
service.
6. The average cost per Couple-Year of Protection will be lower in CHO work
zones where CHOs and community volunteers have been trained to educate
community members about long-term family planning (including the IUD)
than in those CHO work zones where they have not.
Operational Definitions of Key Variables
Knowledge of long-term contraceptives including the IUD:
• Proportion of males and females who have ever heard of individual long-term
methods, including the IUD, implants and male/female sterilization.
•
Proportion of providers with correct knowledge of use effectiveness,
application, mode of action, duration of use, side effects and eligibility criteria
for each method.
Perceptions and attitudes about long-term methods:
• Proportion of providers and male and female respondents who agree with
statements describing common misconceptions about the IUD, including its
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use-effectiveness, mode of action, shape, and side effects such as weight loss,
blood loss, and return to fertility.
•
Proportion of providers who impose wrong restrictions on specific long-term
methods.
Current use of long-term methods
• Proportion of males and females who are currently using a long-term
contraceptive method (IUD, implants and male/female sterilization)
•
Number of new IUD acceptors in intervention and control sites
Intention to use a long-term method:
• Proportion of females who intend to delay current birth interval to at least 36
months
• Proportion of females who intend to have no more children
• Proportion of males who intend to have no more children
• Intended method to use for long term birth spacing and limiting by both males
and females in the reproductive age group
• Proportion of female non-users of contraception who would use the IUD if
they start to practice family planning
• Proportion of female current users of contraception who are not using the IUD
but who will switch to the IUD in the next 12 months
Share in the contraceptive method mix:
• Distribution of type of method among all current family planning clients
recorded by CHOs and in referral clinics
• Distribution of type of method among women and men reporting current
family planning use
Overall contraceptive prevalence:
• Proportion of females who are currently using modern contraceptive methods
• Proportion of males who are current users of modern contraceptive methods
Cost:
• The incremental cost of community sensitization activities carried out in all
research areas
• The incremental cost of training CHOs to insert and remove IUDs.
• The cost savings associated with reduced provision of other methods due to
increased uptake of the IUD.
Intermediate results addressed
FRONTIERS: the study contributes directly to FRONTIERS’ Intermediate
Result 1: “Designing innovative interventions for improving services”.
USAID/Accra: the study will contribute to the Mission’s Intermediate Result 2:
“Expansion of access to health services” and Intermediate Result 3: “Improved
quality of health services.”
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Ghana Health Service: Within the Ghana national reproductive health service
policy, priorities include: ensuring safe motherhood, provision of family planning
services, prevention and management of unsafe abortion and post abortion care,
prevention and management of reproductive tract infections including
STI/HIV/AIDS, prevention and management of infertility, prevention and
management of cancers of the reproductive system including the breast,
responding to concerns about menopause and andropause, as well as the
prevention of and management of harmful traditional reproductive health
practices.
Interventions to be tested
a) Increasing awareness of the IUD and other long-term contraceptives
Awareness about the advantages and disadvantages of the IUD will be increased
among female and male community members, and particularly those in the
reproductive age group, through a combination of strategies that build upon the
community-based structures and processes developed through the CHPS
initiative.
As a first step, existing IEC materials on family planning, and especially on longterm methods including the IUD, that have been designed for interpersonal
communications between providers and community members (from Ghana as
well as other countries as appropriate) will be reviewed and revised for their
content. In particular, the leaflets to be given during interpersonal discussions that
have been developed and tested in Kenya and in Honduras will be adapted and
tested for their acceptability in Ghana. Attention will be paid to ensuring that the
materials contain messages that directly address the concerns identified by the
diagnostic study on IUD use in Ghana (Gyapong et al, 2003), as well as
highlighting the low commodity cost of the method, the low cost per year of use,
the long-term effect on birth spacing and the recent changes in medical eligibility
criteria concerning STIs and HIV agreed on by WHO.
These materials will then be produced on a limited basis for use in the
experimental sites. The Health Promotion Unit (HPU) of the Ghana Health
Service will mainly be responsible for executing this task. The Reproductive and
Child Health Unit (RCHU) of the GHS will closely assist the HPU. A system
will be put in place to track the costs of adaptation and production of the IEC
materials.
Within the 12 experimental communities, meetings will be held with community
health committees and other community elders to introduce the study and to
solicit their assistance in organizing the study activities. Following this, formal
training sessions will be organized for the 12 CHOs and the 12 community
volunteers to educate them in detail about the IUD and to dispel myths and
misconceptions. There will be two separate training sessions: one for the CHOs
and the other for the volunteers. The 3 district and 6 sub-district supervisors will
be asked to sit in the CHO training sessions for information updates. All the
training sessions will be conducted off site, at one of the established IUD training
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centers. The Reproductive and Child Health Unit will be fully responsible for the
training of these personnel but will receive technical support from
EngenderHealth. Each of the training sessions will be undertaken over a period of
two days, focusing on a technical update, values clarification, and role-plays so
that the CHOs and volunteers can practice handling different situations that may
arise. The CHOs and community volunteers will also be given IEC materials that
can be discussed with and given to individuals or couples interested in having
more details about the IUD.
Once these preparatory activities have been completed, the community-based
campaign will begin in all 12 experimental communities. The overall campaign
will emphasize the benefits to be derived from using the IUD or other long-term
methods (such as long-term peace of mind; savings in terms of time and money
for travel; a non-hormonal method; immediate return to fertility; limited side
effects), as well as the limitations in terms of dual protection.
Over the initial three-month campaign period, the CHO and community
volunteers will be expected to organize and undertake special activities within
their community to ‘launch’ the educational campaign. These will include using
existing community communication channels and resources such as durbars
(community meetings), and requesting to be allowed to address existing women
and men’s groups to sensitize members about the role of long-term
contraceptives. CHOs are expected to make regular monthly visits to all
households in their catchment areas so awareness creation will be fostered during
these visits.
If possible, CHOs will be encouraged to identify any satisfied clients and their
partners within their communities who could also be asked to give supportive
statements during such meetings. These people will be given an orientation by the
CHO so that they can communicate their experiences to the audience, both as a
group and individually if they are approached outside the group meeting. Given
the low prevalence of use, and the sensitivity around discussing personal
experiences of contraception in rural Ghana, it is anticipated that this component
of the campaign may not be easily implemented.
Starting during this three-month campaign period, CHOs will be expected to
ensure that whenever they discuss contraceptives with a client, whether as part of
a family planning consultation or another reproductive health consultation during
which contraceptives are discussed (e.g. third trimester ANC, postpartum, infant
and child health, and STI), they should ensure that they raise the issue of longerterm birth spacing or limitation, and the role that methods such as the IUD can
play. Discussions will be facilitated by use of the IEC materials developed, and if
appropriate, a leaflet given to the woman which she can take home to discuss with
her partner and friends. CHOs will be given additional 5-day training in the
following to strengthen their ability to counsel their clients on family planning in
a more comprehensive manner:
Balanced counseling on those methods relevant for the woman’s situation
Screening women using the latest medical eligibility criteria
Screening for pregnancy using the FHI-developed or RCH checklist
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Systematically screening for other reproductive health needs using the
FRONTIERS-developed screening tool
Six of the 12 experimental communities will serve as the first intervention arm.
Clients in this intervention area who express the desire to use the IUD will be
referred to the nearest health center where the method is offered. In order to
ensure accessibility to the method, appointments will be scheduled for a group of
clients to meet the provider of this facility on an appointed date to receive the
service.
b) Increasing access to IUD delivery
In addition to the educational campaign, the CHOs in 6 of the experimental
communities will be technically and materially equipped to provide the IUD in
their community health compounds. These 6 study sites will be purposively
chosen to ensure that the IUD is already available at the health facility located
within the CHO work zone, that is, the facility has at least one provider trained
and qualified in IUD insertion and removal, and the basic equipment and supplies
are in place. It is anticipated, however, that although it will be possible to select
sufficient intervention sites according to these criteria, a degree of ‘upgrading’
may be necessary at some of the sites to ensure that they are able to offer the IUD
routinely and on demand. Immediately after the sites have been identified, there
will be a needs assessment visit, following which the capacity to offer the IUD
will be upgraded. The Ghana Health Service will be responsible for ensuring that
there is at least one trained provider on duty. EngenderHealth, on the other hand,
will provide a fully functioning IUD kit in all the health centres and clinics in
each intervention and control site. Minor equipment and supplies needed to
ensure a fully functioning capacity will be procured for the duration of the project
only.
Although CHOs may have good skills in community mobilization and dispelling
myths and rumors, and they have been trained in the comprehensive family
planning consultation approach described above, for this second intervention they
will also need refresher training in the technical skills of inserting and removing
IUDs, and in infection prevention procedures. In accordance with the national
policy, only CHOs with midwifery skills will be eligible for the second
intervention, as these nurses will already have skills and experience in pelvic
procedures. Study sites for this intervention will be purposively selected to
include those CHO work zones where the CHO is known to already provide the
IUD.
Refresher training in these three issues (IUD insertion and removal and infection
prevention procedures) will last for one week. Because of the small numbers of
women currently using the IUD, it will be necessary to send the CHOs to the
nearest training hospital in order to practice 2-5 IUD insertions and removals
(after practicing for sometime on a pelvic model). Quality control will be
maintained through the sub-district supervisor closely monitoring insertions for
several months, and then more routinely every quarter. Arrangements will be
made for the sub-district supervisor to be present at the scheduled monthly IUD
insertions so that she can monitor the insertions. Again, EngenderHealth will
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supply IUD kits to the CHCs and health centres and clinics in this second arm of
the intervention.
To enable the provision of services to proceed smoothly in the health centers
closest to the intervention and control sites, the family planning providers in these
facilities will be given refresher training to improve their skills and boost their
confidence in IUD insertion and removal.
Study Design
The study will use a pre- and post- intervention multistage cluster randomized
design to test the hypotheses stated above. In order to assess the effect of each of
the interventions, the magnitude of change in the dependent variables for both
intervention groups will be compared with those for the comparison group over
time, i.e. at baseline and at endline based on two separate cross-sectional surveys.
The difference in outcomes based on the two intervention strategies will also be
tested by comparing the magnitude of change in intervention group 1 with
intervention group 2 over time.
------Time-----------
Intervention group 1
O1
X1
O2
Intervention group 2
O3
X2
O4
Comparison group
O5
O6
Where:
X1
=
Community education campaign with referral to existing IUD
supply clinic
X2
=
Community education campaign with IUD provision by CHO
O1, O3, O5
=
Baseline measures of key dependent variables
O2, O4, O6
=
Endline measures of key dependent variables
Study sites
The intervention and comparison areas will be the catchment area served by each
CHO, termed a ‘work zone’ by the CHPS initiative. To control for possible
contaminating factors, including existing levels of IUD use, all work zones
included in the study will be located in a maximum of three districts. Because
CHOs will interact occasionally, either directly or indirectly through their
supervisors, it will be necessary to select the intervention and comparison work
zones so that only similar zones are geographically and administratively
contiguous. Intervention and comparison zones will be ‘matched’ in terms of
criteria such as population size and density, socio-cultural and economic
similarity, health status, and family planning prevalence. The comparison and
intervention groups will each comprise 6 CHO work zones, giving a total of 18
work zones. This calculation was based on the fact that in the 1998 GDHS, the
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highest coefficient of variation of the true rates of current IUD use between
clusters in the three regions was 0.696. Thus, in order to detect a 70 percent
difference in IUD use between the first and second intervention areas, a minimum
of 6 clusters are required in each arm. The mean catchment area for a work zone
is 5,000 people of which approximately 47 percent are males and females in the
reproductive age group15-49 years, and so each intervention and comparison
group is expected to serve approximately 14,000 people, which is large enough to
make an impact.
The study will focus on three districts: Abura Asebu Kwamankese in the Central
region, Birim North in the Eastern region, and Nkwanta in the Volta region.
These districts have been chosen as they currently have adequate numbers of fully
functioning CHPS zones as well as CHOs who are well established in the
communities within which they work. As at December 2003, there were 5 fully
functioning zones in Abura Asebu Kwamankese, 8 in Nkwanta and 9 in Birim
North. It is expected that two more zones (one in Nkwanta and one in AAK) will
be fully operational by June 2004, prior to the start date of the study. Available
information also indicates that in the three study districts, five CHOs who are also
qualified midwives are already offering IUD services in their Community Health
Compounds. These CHOs are located in the Bonakye and Tutukpene zone in the
Nkwanta district, the Gyabankrom zone in the AAK district, and Nkwarpeng and
Adausena zones in the Birim North district. The CHO in Agoufie zone in the
Nkwanta district is also expected to start offering the IUD in her CHC in June
2004. The first five zones will be purposively selected as sites for the second arm
of the intervention, where CHOs are required to provide IUD services to clients
who opt for the method. This will mean that Birim North and Nkwanta districts
will each have the two CHOs who are currently offering IUD services
automatically assigned to the second arm of the intervention while in AAK, there
will be only one such CHO. To obtain the second CHO for this second
intervention arm in the AAK district, arrangements will be made to provide the
CHO at Putubiw, who is a trained midwife, with the IUD kit and other essential
materials to offer the method. For the control site and the first arm of the
intervention, 4 CHO zones will be randomly selected from the remaining fully
completed zones in each of the three districts and allocated to the control area and
the first arm of the intervention.
Data collection and sampling
a) Testing hypothesis 1 and 2
In testing these hypotheses, the main outcome variables will be the proportion of
males and females who have ever heard of individual long-term methods; the
proportion of male and female respondents who agree with statements describing
common misconceptions about the IUD, including its use-effectiveness, mode of
action, shape, and side effects such as weight loss, blood loss, and return to
fertility; and the proportions of women and men who want to use long-term
contraceptive methods in the future. Other indicators to be examined include the
proportion of providers with correct knowledge of use effectiveness, application,
mode of action, duration of use, side effects and eligibility criteria for each
method; and the proportion of providers who impose wrong restrictions on
specific long-term methods.
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For the cross-sectional study, the units of analysis will be all females aged 15-49
and all males aged 15-59 years living in the study communities. All adults,
married and unmarried, will be included because the 1998 Ghana Demographic
and Health Survey found that 10 percent of women and 17 percent of men in the
reproductive age group have never been married but are sexually active.
Questionnaires will be administered to samples of women and men living within
the selected CHO work zones at baseline and endline.
The sample sizes for testing this hypothesis will be calculated taking into account
that the unit of implementation for the interventions is the CHO work zone (i.e. a
group or ‘cluster’ of individuals) and not individual persons. A formula for
calculating the number of respondents needed per CHO work zone (i.e. per
‘cluster’) to compare unmatched proportions is11:
 π (1 − π 0 )   π 1 (1 − π 1 )  2 2
2 
2
c = 1 + f  0
 + k (π 0 + π 1 ) /(π 0 − π 1 )
+
m
m

 


where π0 is the proportion with the outcome in the first model and π1 is the
proportion with the outcome in the second model, m is the number of individuals
in each cluster (assumed equal in all clusters), f is the factor depending on the
required study power, and k is the coefficient of variation in the true proportions
between the clusters in each model.
•
As noted above, to be able to understand the implementation process and to
allow for variability between the CHOs, as well as to be able to implement the
study among the limited number of CHOs available, 18 CHO work zones
have been identified and six assigned to each of the three study groups, i.e.
two intervention and one control group. Thus in the formula above, the
number of CHO work zones will be held constant at six per group, and the
number of individuals in each work zone will be calculated assuming a type I
error of 0.05 a power of 80 percent, and a coefficient of variation (k) of 0.25.
In determining the size of the study sample, the proportion of women and men
who want to use long-term contraceptive methods in the future has been used
as the main outcome variable.
For this variable, the 1998 GDHS shows levels ranging from 7.1% to 9.6% for
women in the three regions included in the study. As shown below, with these
assumptions and interviewing 100 women per CHO zone at baseline and at
endline, the study would be able to detect a 60 to 65% change in this indicator,
i.e. an increase of approximately five percentage points.
Region
11
Confidence
level
Power
π0
% change
π1
# of
women
per work
zone
# of work
zones per
group
k
Hayes RJ and S. Bennett. 1999. Simple sample size calculation for cluster-randomized
trials.
International Journal of Epidemiology, 28:319-326.
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FRONTIERS/ Opportunities & Choices Workshop on Intrauterine Contraception
Central
0.95
0.80
7.1%
65%
11.8%
100
0.25
5.63
Volta
0.95
0.80
9.5%
60%
15.2%
100
0.25
5.54
Eastern
0.95
0.80
9.6%
60%
15.4%
100
0.25
5.51
For men, the 1998 GDHS shows levels ranging from 0.5% to 7.6% for the three
regions for this indicator. As shown below, with these assumptions and
interviewing 100 men per CHO zone at baseline and at endline, the study would
be able to detect the expected (60-110%) change in this indicator.
Region
Confidence
level
Power
π0
% change
π1
Central
Volta
Eastern
0.95
0.95
0.95
0.80
0.80
0.80
0.05%
1.40%
7.60%
60%
110%
65%
0.08%
2.80%
9.50%
# of
men
per
work
zone
100
100
100
k
# of work
zones per
group
0.25
0.25
0.25
6.05
5.51
5.39
Allowing for a 10% non-response rate, 1,980 women and 1,980 men will be
interviewed during the baseline and endline surveys.
Face-to-face, private interviews will be held with the samples of women and men
in each CHO work zone. The sampling frame will be drawn from the household
listing developed as part of the National Immunization Day (NID) programme,
during which all housing structures in every community in the country were
listed. Since there are approximately 5,000 people in each work zone and the
average household size in the three study regions is 4.6 persons, there will be a
little over 1,000 households per work zone. Depending on the total number of
housing structures in each work zone, a sampling interval will be calculated and
used to select the houses to be visited. The field teams will then begin their work
by first listing the members of each household in the selected housing structure.
All eligible men and women (i.e. those who fall in the reproductive age group)
will then be asked for their informed consent to participate (see Appendix), and
those agreeing will be interviewed.
One interview team, made up of five interviewers and one supervisor, will be
recruited and trained for each region. The training will involve both
demonstration interviews and field practice to help trainees develop confidence
with the data collection instruments. The trainees will also be trained in the
principles and application of informed consent. Each interview will be through a
structured instrument and is expected to last approximately 30 minutes, and every
interviewer will be expected to complete an average of 11 interviews per day.
Thus, the data collection will take a maximum of 24 days to complete.
In addition to their supervisory responsibilities, the supervisors will be required to
conduct in-depth interviews with each of the six CHOs in their region. All indepth interviews will be recorded on audiotape and summarized on paper.
The principal investigator and study coordinator from the HRU will be fully
responsible for supervising all three teams on a continuous basis. They will pay
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FRONTIERS/ Opportunities & Choices Workshop on Intrauterine Contraception
unannounced supervisory visits to ensure that the interviewers are following
defined protocols and guidelines. They will also be responsible for checking the
quality of data collected. The collection and entry of data will be going on
concurrently. Thus, the data collection and analysis are expected to span a period
of eight weeks (six weeks for data collection, data processing and tabulation, and
two weeks for data analysis).
b) Testing hypotheses 3 and 4
The two hypotheses relating to contraceptive use will be tested by comparing
contraceptive prevalence rates as measured through the population-based
questionnaire surveys administered at baseline and endline, as well as through
analyzing information about contraceptives delivered and recorded on standard
service records by the CHOs at the health facilities in the CHO work zones. Preintervention measures will be obtained through reviewing records for the 12month period prior to initiating activities and calculating a mean monthly number
of family planning clients and the proportion of these using the IUD. Postintervention measures will be generated using the service statistics recorded
during the 12 months of implementing the intervention. The number of new IUD
users at both baseline and endline will also be obtained from these service
statistics.
c) Testing hypothesis 5
The focus of the cost component will be on incremental costs, or those costs that
are incurred specifically to undertake intervention activities that were not carried
out previously. Incremental costs of the interventions include the cost of training
CHOs, volunteers and supervisors; preparing IEC materials; organizing
orientation workshops for the Regional and District Directors of Health;
organizing media campaigns; organizing community durbars to launch the study;
and supervising CHOs after the training. In addition, the intervention may result
in higher costs of expendables such as additional IUD Kits, minor equipment and
supplies. Items to be considered under training and workshops include travel
allowances and per diem for training participants, cost of renting training venue;
allowance for resource personnel, fuel, stationery and other training materials,
communications and photocopies.
All expenditures incurred under each of the listed items will be documented and
the average indirect and direct cost per IUD insertion calculated to determine how
much it costs to provide an IUD in a clinic already offering the service, as well as
the incremental costs for a CHO to provide IUD services on-site. These costs will
be then compared to test the hypothesis.
d) Testing Hypothesis 6
Hypothesis 6 will be tested by estimating the average cost per couple-year of
protection (CYP) through any method of contraception, and comparing these
costs for the control and both intervention groups. Since the IUD has the lowest
commodity cost per year of any reversible method, it is hypothesized that any
increase in its use through substituting for higher cost methods such as the
injectable and oral contraceptives would lead to a lower overall cost per CYP for
that CHO work zone.
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Monitoring and Supervision of the interventions
To ensure that the intervention activities are proceeding according to plan, routine
monitoring and supervision of the participating CHOs and heath clinics will be
undertaken using the current system. The District Public Health Nurse and
Management Team, along with the CHO supervisor from the sub-district level
and personnel from EngenderHealth, will be responsible for monitoring the
educational campaigns, supervising CHOs’ compliance with the revised family
planning counseling approach, and (in both intervention and comparison sites)
ensuring that service records are kept accurately. All of these supervisors will be
included in the update training provided to the CHOs. With assistance from
personnel of EngenderHealth, these staff will also supervise and monitor IUD
insertion and removal procedures. To ensure that the CHOs are undertaking
family planning consultations using the new guidelines, follow-up visits will be
paid to the compounds that have been visited by the CHO to find out the kind of
messages that were given on family planning, focusing specifically on the IUD.
The Principal Investigator and Study Coordinator from the Reproductive and
Child Health Unit will ensure that the intervention activities are well implemented
and monitored.
Data Analysis
Cross-tabulations will be used to determine the proportion of women and men
who have heard about the IUD in the intervention and comparison areas, the
proportion of IUD acceptors among female family planning clients seen by
CHOs, IUD prevalence rates among females aged 15-49 in intervention
communities, proportion of clients that are referred to other service delivery
points, proportion of female non-users preferring the IUD, and general uptake of
family planning. These key indicators will be compared between the intervention
and comparison groups, both at baseline and after the intervention using the z-test
function to determine whether any observed changes between the intervention and
comparison areas are greater than what we would expect by chance. In addition,
analysis of variance test (ANOVA) will be used to assess whether the before and
after changes in the intervention and comparison groups are statistically
significant. In addition, the difference in the mean number of IUD insertions per
month recorded during the pre- and post intervention studies will be examined
using the t-test to determine whether the intervention areas drew more clients than
the control area.
The in-depth interviews will be analyzed using qualitative techniques of data
analysis. The recorded interviews will first be transcribed, coded and organized
according to study themes. For coding purposes, labels will be developed after
review of the data. Data that belong to the same code or have similar patterns will
be listed together under the respective label. The output will then be summarized
to shed light on the key research themes. Quotations from the data, using
respondents’ own words will also be used to illustrate the main findings.
As part of the evaluation, the implementation costs of the interventions will be
documented and analyzed to give an idea of the direct and indirect costs of
supplying an IUD to a client. These will be compared to direct and indirect costs
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FRONTIERS/ Opportunities & Choices Workshop on Intrauterine Contraception
incurred in established health facilities. A cost-effectiveness analysis will then be
carried out to test whether the number of new IUD acceptors justifies the
additional cost of expanding IUD services through the CHO. This incremental
cost-effectiveness measure is calculated as the additional cost per unit of IUD
insertion by a CHO (i.e. additional costs/additional outcomes). This incremental
cost per acceptor will help to determine how much the expansion of IUD services
to CHPS zones will cost per year. The cost savings experienced during the
intervention period with respect to each of the contraceptive methods will also be
calculated to determine whether increased use of the IUD and other long-term
methods reduces costs.
Ethical Issues
Ethical Clearance
Written permission to undertake the study has been sought from the Director
General of the Ghana Health Service. The protocol will be presented to the Ethics
Review Committee of the Ghana Health Service for their comments and approval.
Following this, orientations will be organized separately for the relevant Regional
and District Directors of Health Services to solicit their consent and support.
Informed Consent
Because this study is being implemented at the request of and with the approval
of the Ghana Health Service, the CHOs do not have to give consent to be
interviewed or observed concerning assessments of the technical competence.
However, confidentiality is important when asking for their opinions concerning
the services being offered, and so prior to interviewing providers, an informed
consent form (see Appendix 1) will be read out to them outlining the risks and
benefits of being interviewed and giving them the opportunity to decline to be
interviewed or to discontinue the interview at any time.
In this study, there will be no risk of injury to study participants. However, some
respondents or discussants might have reservations reporting on their
contraceptive knowledge, behavior and perceptions since they might feel that
their privacy is being invaded. To reduce any possible feeling of discomfort
about giving information regarding their practices, experiences and opinions in
relation to the IUD, participation in the interviews will be completely voluntary;
moreover, those who agree to be interviewed will be given the option to
discontinue the interview at any time. An informed consent form (see Appendix
2), which describes the risks and benefits associated with participating in the
interview, will be read out in the local language to interviewees prior to the
interview to obtain their individual informed consent. Those who give their
consent will be asked to sign or put their thumbprint on the consent form to
indicate their willingness to participate in the study. Respondents who are unable
to sign or thumbprint may give their verbal consent and have the interviewer sign
on their behalf. In such circumstances, the interviewer will have to clearly
indicate that s/he signed on behalf of the respondent.
Confidentiality
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Study participants will be assured that the information collected will be kept
confidential and will not be divulged to anyone. Also, in order to minimize
participant’s discomfort about the issues being discussed, all interviews will be
conducted in a private place. During training, field staff will be made aware of
the importance of protecting interviewee’s privacy and confidentiality of
information obtained from them. Interviewees will not be required to give their
name and no identifiers will be recorded beyond a serial number.
All data collected will be kept under lock in of the Health Research Unit and
access will be strictly limited to the project team only. This includes the Principal
investigators, the Study Coordinators, the Data Manager and the FRONTIERS
Monitor. One of the principal investigators (i.e. the Director of the HRU) will be
responsible for ensuring that the data is stored in a safe and confidential place.
Due to the advantages of the IUD over other methods for spacing purposes, the
study is expected to benefit study participants in several ways. For example, it is
expected to improve couples knowledge about the IUD and to enhance its usage
among female partners who need to limit or space their births. Also, the
community-wide campaign will increase women’s ability to discuss family
planning issues with their partners and also gain their support in decisions
regarding contraception.
Dissemination and Utilization
The results of the study will be discussed at various health fora and specially
planned dissemination meetings to which policy planners, program managers,
health partners and providers (including private practitioners) and other
stakeholders such as PPAG and GSMF will be invited to elicit their views on the
policy implications. A summary of key findings on the pre- and post intervention
studies will also be prepared and presented to the CHOs who were involved in the
study for their feedback. These inputs will be used in preparing a more
comprehensive report which will then be disseminated to all stakeholders:
providers and management staff of the Ghana Health Service, collaborating
agencies, and other stakeholders. These dissemination meetings will consist of
two separate zonal workshops (one each for the southern and northern zones) will
then be organized to share the findings with senior program managers and MOH
policy makers, Regional and District Directors of Health Services, and Subdistrict Supervisors. The national Medical Association, Nurses and Midwives’
Council, USAID and other donors, technical assistance agencies, and other
stakeholders will be invited to these workshops.
Following the dissemination meetings, small and individualized follow-up
meetings will be held with program managers of the Reproductive and Child
Health/Family Planning Unit and the Health Promotion Unit of the Ghana Health
Service, MOH senior policy makers, USAID/Ghana, and relevant technical
assistance organizations to identify ways in which the most cost-effective
intervention can be institutionalized and scaled up to other CHPS zones.
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Institutional Arrangements
This study will be a collaborative effort between the Health Research Unit, the
Reproductive and Child Health/Family Planning Unit (the main implementers of
the public sector reproductive health program), and the Health Promotion Unit of
the Ghana Health Service, with technical assistance from FRONTIERS in
coordination with EngenderHealth and the Policy Planning, Monitoring and
Evaluation (PPME) Unit of the Ghana Health Service. The Health Research Unit
and the Reproductive and Child Health Unit who have been involved in the
development of the study proposal will be mainly responsible for the overall
management of the project. They will ensure that all activities outlined in the
proposal subagreement are implemented. These activities include obtaining local
research clearance and authorization, carrying out baseline and endline studies,
implementing and documenting the intervention process, processing and
analyzing data, writing a full report on the study and disseminating the findings.
The Health Promotion Unit will assist the Reproductive and Child Health/Family
Planning Unit and HRU to revise and produce copies of the IEC promotional
materials for use in the experimental areas. The Health Promotion Unit will also
work together with the RCHU, District and Regional Directors of Health and
EngenderHealth to provide information updates about the IUD to the CHOs and
Community Volunteers and to dispel myths and misconceptions surrounding the
method.
FRONTIERS will provide technical assistance in the design and implementation of the
project while EngenderHealth will help to train the CHOs and volunteers in IUD
insertion and removal and will also assist the Reproductive and Child Health Unit and the
Health Promotion Unit to launch and monitor the interventions.
References
Awoonor-Williams, John K., Tanya C. Jones, Frank Nyonator, and James F.
Phillips (2003). Utilizing successful research in community-based
services with constrained resources: The Nkwanta experience catalyzing
organizational change in rural Ghana. A paper presented at the 2003
conference of the Population Association of America. Population Council
Media Centre.
Bertrand, Jane T., Roberto Santiso, Stephen H. Linder, and Maria Antonieta
Pineda (1987). Evaluation of a Communications Program to increase
adoption of Vasectomy in Guatemala. Studies in Family Planning,
Volume 18, Number 6, November/December 1987.
Ghana (2003). Reproductive Health Service Policy. Part I. Ghana: National RH
Service Policy and Standards. Second Edition, June 2003.
Ghana Statistical Service (GSS) and Macro International Inc. (MI), (1999). Ghana
Demographic and Health Survey, 1998, Calverton, Maryland: GSS and
MI.
Ghana: HRU, RCH/FPU and HPU, Ghana Health Service and FRONTIERS
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FRONTIERS/ Opportunities & Choices Workshop on Intrauterine Contraception
Ghana Statistical Service (GSS) and Macro International Inc. (MI), (1994). Ghana
Demographic and Health Survey, 1993, Calverton, Maryland: GSS and
MI.
Gyapong, John et al., (2003). An Assessment of Trends in the Use of the IUD in
Ghana. Ghana Health Service in collaboration with Population Council
(FRONTIERS) and USAID. Sub contract No. AI02.06A.
MOH (1992). 1992 Annual Report. Maternal and Child Health and Family
Planning Technical Co-ordination and Research Division, MOH.
MOH/GHS (2001). 2001 Annual Report. Reproductive and Child Health Unit,
Public Health Division, MOH/GHS.
Network (2003). Research to Practice: ‘Rehabilitating’ the IUD. Network: 2003,
Vol. 23, No. 1. FHI’s Quarterly Health Bulletin Network.
Jato, Miriam N., Calista Simbakalia, Joan M. Tarasevich, David N. Awasum,
Clement Planning promotion on the contraceptive behavior of women in
Tanzania. Family Planning Perspectives, Volume 25, Number 2, June
1999.
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FRONTIERS/ Opportunities & Choices Workshop on Intrauterine Contraception
2.4 IUD Reintroduction Strategy in Kenya
Background
The Family Planning program in Kenya is a well-known success story. Use of modern
contraceptives has risen from 4% to 32% among married women between 1978 and
1998. During this same time period, the total fertility rate (TFR) decreased from 8.1
to 4.7. The program, however, faces many challenges in order to meet the needs of a
growing population. Nearly one quarter (24%) of married women have an unmet
need for family planning. Nearly half of the population (12.5m) is under 15 years of
age and an estimated 100,000 young people turn 16 years of age annually, a pattern
that will continue for over a decade. This large cohort is putting a heavy demand on
reproductive health services. To address this problem, the MOH has developed a RH
Strategy whose key objective is to improve on the achievements of the MCH/FP
program.
A key component of the MOH’s Reproductive Health Strategy is to make available
quality and sustainable family planning services to those who need them in order to
reduce the unmet need for family planning. To achieve this, the MOH needs a family
planning program that provides a balanced method mix, which relies on both short
and long term, and permanent contraception. Available evidence shows that the
provision of IUCDs would help the MOH in achieving this balance as compared to
one in which IUCDs were under-utilized.
The IUCD has been shown to be safe for most women. There is some evidence that
even women who are HIV infected may safely use the device. It is cost effective,
reversible and long lasting. The probability of pregnancy over 10 years of use is only
2.6 %, which makes the IUCD among the most effective methods available.
Compared to the DMPA and Norplant, the cost per CYP is lowest for the IUCD.
Despite these facts, the position of the IUCD in the contraceptive method mix in
Kenya has declined over the past 15 years. Given the declining resources and
expanding FP needs in Kenya, the IUCD should be an important component of the
contraceptive method mix in the national program.
Response
For these and other reasons, policy makers in Kenya seek to rehabilitate the position
of the IUCD in the national program. The MOH convened a stakeholders’ meeting
in October 2001, following which a Task Force has been established and mandated to
develop an action plan for rehabilitating the IUCD within the national family planning
program. The MOH mandated FHI’s Population and Reproductive Health Program to
lead and facilitate the activities of the IUCD Task Force.
The Task Force recognizes that the focus of this initiative needs to incorporate all
MOH facilities. However, initially activities will be targeted to a limited set of
Service Delivery Points (SDPs) to gain experience with the IUCD rehabilitation
process. Lessons learned and emerging opportunities for leveraging additional
resources will permit a wider rehabilitation effort.
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IUD Re-introduction Program
The overall goal of the IUCD rehabilitation action plan is to assist the MOH to
achieve a sustainable family planning program.
Purpose
The purpose of this plan is to increase and sustain access, demand and utilization of
high quality IUCD services offered by the public and private sectors.
Approach
The Task Force recommends a phased approach to the re-introduction of the IUCD.
The initial phase will involve AMKENI Centres of Excellence (8) and the Ministry of
Health Decentralised Training Centers (13) and will rely heavily on available
resources and synergies available through pre-existing systems or programs. It is the
intention of the Task Force that a phased scaling up of the re-habilitation into a
national program will follow as additional opportunities are identified.
To launch the IUCD rehabilitation process in Kenya, the following key issues need to
be addressed.
Establishing policy support.
Correcting the demand/supply imbalance.
Improving capacity and capability of facilities to provide IUCD services.
Correcting user perception of the IUCD.
The Task Force has developed the above key elements into four objectives:
Objective 1: Increase support for IUCD among health care professionals
Output: Advocacy process through policy review, sensitization and IEC activities
established.
In order to accelerate the efforts to develop and implement a more effective family
planning program that includes the use of IUCD, the MOH will provide leadership,
coordination and advocacy. The following activities will build upon these efforts and
further enhance the MOH’s ability to achieve this output.
1.1
Create a shared vision that enhances synergy and harmonization of all efforts
by stakeholders towards IUCD rehabilitation;
1.2
Review existing IUCD policies, guidelines, standards and strategies and
present a draft revised version for review and adoption.
1.3
Conduct a 1 day workshop for 20 representative stakeholders at national level
to review and adapt revised IUCD policies, strategies and service provider
guidelines and produce a final version for approval by MOH;
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1.4
Hold 2 one-day meetings to launch and disseminate the revised IUCD policies,
strategies and guidelines with 40 participants each at the Provincial level.
These will be high profile meetings attended by either the Director of Medical
Services (DMS) or MOH Permanent Secretary (PS) and will bring together
PHMTs and DHMTs, Provincial Obs/Gynae and key leaders from NGOs and
private practioners;
1.5
Institute a revised policy regarding IUCD insertion;
1.6
The DMS will send circulars to PMOs and DMOs in the 2 Provinces stating
revised policy and MOH’s intention to encourage uptake of the IUCD;
1.7
Conduct ½ day sensitization meetings with 8 DHMTs on re-introduction of
IUCD and develop action plans and follow up with ½ day sensitization at
SDPs;
1.8
Disseminate the new IUCD scientific updates developed by FHI at the launch
meetings and to all appropriate providers and MOH managers;
1.9
Use existing channels including media to develop and strengthen IUCD
message through existing or upcoming campaigns.
Objective 2: Increase supply of quality IUCD services at pilot sites.
Output: Supply of quality IUCD services improved in selected sites via capacity building and
ensuring commodities, supplies and equipment are available to support IUCD service
provision.
The MOH and its implementing partners will conduct the following activities to
achieve this objective.
2.1
Capacity Building
2.1.1
Conduct a quick review of existing curriculum and training materials as relates
to IUCD. The documents will be reviewed by a group of experts in a 5 day
workshop facilitated by a consultant and produce a revised curriculum and
training materials as relates to IUCD;
2.1.2
Conduct a 5-day workshop to review and update existing IEC and counseling
materials on IUCD and develop action plans for implementation;
2.1.3
Conduct a 2-day on-site re-orientation seminars on IEC and counseling
materials for service providers in the 21 sites.
2.1.4
Reproduce and distribute IEC and counseling materials (2 posters and 1 job
aid) for use in each SDP;
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2.1.5
Conduct two 5-day sessions of TOT and re-training workshops of service
providers at provincial level built into ongoing training activities that are being
carried out by the MOH and AMKENI;
2.1.6
Conduct a 1 day facilitative supervision visit 3 months after the training to 21
AMKENI/MOH sites and NGO facilities around selected sites and quarterly
visits thereafter and provide update reports on implementation status;
2.1.7
Conduct supportive supervision visits by the Provincial
Obstetrician/Gynaecologist as part of the DRHT and provide update reports on
implementation status;
2.2
Provision of Expendable Supplies, Commodities and Equipment
2.2.1
Provide additional and start-up expendable supplies for IUCD insertion and
removal at all sites based on findings from the needs assessment.
2.2.3
Provide 2 additional IUCD kits and start-up equipment for IUCD insertion and
removal for 21 sites;
2.2.2
Provide IUCD commodities in all selected sites. The Task Force will work
together with MOH to ensure that they are available in the SDPs;
Objective 3: Establish enhanced demand creation approaches at pilot sites.
Output: Demand for IUCD services improved via IEC and CBD workers.
Clients’ awareness of the existence and advantages of the IUCD are major
determinants of demand. To address the client perspectives, the MOH will carry out
the following activities:
3.1
Review AMKENI's and other cooperating agencies BCC strategy and seek
opportunities to integrate, as appropriate, IUCD specific messages and other
messages promoting LT/P contraception. Develop an IUCD flyer for IEC and
distribution through the AMKENI project;
3.2
Develop and strengthen IUCD message through existing campaigns
3.3
Strengthen GTZ, FPAK and MYWO’s CBRH and Peer Educators Programs to
create a link in sharing information with communities and create a referral
system for IUCD by conducting 8 one-day seminars in Western Provinces for
peer educators and distributing IUCD/IEC materials.
Kenya: IUCD Task Force, Ministry of Health and FHI
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Objective 4: Collect data to continuously improve the program and provide
Data for scale-up decisions
Output: Sufficient MIS, M&E systems and research mechanisms established.
Monitoring and evaluation of program performance requires that good data are
collected, stored, analyzed and presented in formats that facilitate its use at all levels
of the program to monitor implementation, quality and achievements.
The whole process of rehabilitating the IUCD provides several operations research
opportunities that will be beneficial to the process itself, and the family planning
program in Kenya as a whole. This will be addressed through the following activities.
4.1
Monitoring and Evaluation
Using existing MOH and AMKENI monitoring systems ensure IUCD services are
supported and monitored. This will be done by:
4.1.1
Conducting a complete desktop review of all available data on clinical service
delivery in Kenya to examine readiness for IUCD rehabilitation.
4.1.2
Developing indicators to be used in monitoring the implementation, quality
and achievements of the action plan;
4.2
Operations Research
4.2.1
Compile lessons learnt from MOH/JHPIEGO efforts to strengthen QOC in
SDPs towards successful provision of IUCD services;
4.2.2
Conduct QOC/needs assessment of all the IUCD sites (8 COEs and 13 DTCs)
to establish the quality and needs for IUCD service provision and make
recommendations for improvement;
4.2.2
Explore options for research on Social Marketing of IUCD kits;
4.2.3
Explore options for "incentives" related studies with MOH and other
colleagues;
Decision on scale up will be made throughout this rehabilitation process. Lessons
learnt will be identified and avenues for efficient scale up and expansion will be
explored. The aim is to eventually re-establish IUCD services in the MOH system.
Kenya: IUCD Task Force, Ministry of Health and FHI
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Appendix A: Agenda
AGENDA
Wednesday 18th February
Theme: reviewing population perspectives and experience of IUD provision
8.30 am
Welcome, introductions and agenda briefing: Dr William Stones (Southampton)
8.40 am
A global overview of method mix, with special reference to:
- IUD contribution to the method mix in low, medium and high CPR countries
- The case of China
- Demographic implications of young mass sterilization in South Asia
Dr Sabu Padmadas, Southampton
9.10 am
Reinventing the IUD: an overview of recent initiatives and developments based on
two recent FHI workshops. Dr Erin McGinn, FHI North Carolina
09.40 am
Why is IUD use so low? Presentations and discussion on reasons for low use in:
- Ghana (Dr Ivy Osei/ Dr Gloria Quansah-Asare)
- Guatemala (Dr Edwin Montufar, Jorge Solórzano)
- Kenya (Dr Ian Askew)
11.00 Coffee
11.30 What are our experiences with interventions to increase awareness?
Presentation and discussion of case studies from:
- Kenya (Dr Josephine Kibaru)
- Honduras (Dr Ivo Flores/ Dr Ricardo Vernon)
- Nepal (Dr Sally Kidsley)
1 pm Lunch
2 pm
Continue discussion of case studies of increasing awareness
3.15 pm Tea
3.30 pm Service delivery issues
(co-ordinated by Dr Ricardo Vernon with input from MSI Bangladesh)
covering:
• Provider training and confidence
• Lack of equipment
• Provider bias
• Inappropriate selection criteria
Southampton Workshop Appendix A
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FRONTIERS/ Opportunities & Choices Workshop on Intrauterine Contraception
5.00 pm Review of Day 1 and conclude
Dinner at leisure
Thursday 19th February
Theme: Can we generate a template for a ‘generic’ intervention?
08.30 am onwards
Drawing from the lessons of the day before, small-scale interventions will be
developed that focus on rendering potential family planning clients in the clinic
catchment areas aware of:
- The availability of a wider range of methods at selected clinics
- The characteristics and appropriate use of each method (and possibly other
reproductive health services offered at the clinics)
Potential interventions to be considered may be community-level communication
strategies focused on increasing the community’s understanding about reproductive
health, the role of family planning in contributing to improved reproductive health,
and the contraceptive options that are available for women with different needs,
depending on their personal situations.
For discussion 1: should we pay more attention to identifying strategies for
increasing awareness of and interest in the method that service delivery outlets
themselves can have under their direct control? These facility based strategies could
include activities such as distribution of flyers and brochures through clinic clients
and satisfied method users, systematically informing all women visiting the health
facility about the service available, inclusion of this announcement in all contacts
made by field workers, establishment of referral systems and assessment of other lowcost, low-effort informational channels.
Facility-based strategies, including community outreach, could be the core of the
interventions to be tested because public health providers in most countries rarely
have a budget for advertising in the mass media, and because method-specific
advertising in electronic mass media is not allowed in some countries.
However, the potential for mass media information campaigns in interventions will be
a basis for discussion as some of the workshop participants have had experience of
this approach (eg Nepal).
For discussion 2: To what extent do supply side factors need to be a part of the
interventions to be tested? Although decisions will be made to ensure that the
interventions be as homogeneous conceptually, if not operationally, as possible, while
allowing for the differences between the countries involved. Some issues that may be
discussed include:
- Type of service delivery outlets to be included in the projects: those currently
providing IUD services, currently not providing them, or both.
- If training new providers is needed, the protocols required (e.g. ethical
considerations; duration of training; number of live practice insertions; who,
how and where will the competence of the trained providers be certified;
characteristics of trainers; where will the training of new IUD providers will
Southampton Workshop Appendix A
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-
be conducted.) Includes consideration of new FHI provider checklist (Jennifer
Wesson)
Type of outreach workers to be trained (if appropriate).
Supervision frequency, mechanism, contents, job-aids, as well as referral
networks.
Mix of services.
Cost-effectiveness and sustainability of strategies.
For discussion 3: How should interventions be configured so as to engage underserved, poor and marginalized groups within facility catchment areas and more widely
(given that in some settings clients travel quite long distances to access particular
services)? Are there aspects specific to IUD or will a general strategy aiming to
engage poor/ under-served groups be sufficient to reach them?
Coffee available from 10.30 am;
Lunch 1 pm
Tea 3.30 pm.
Thursday evening Workshop Dinner: HMS Warrior, Portsmouth Historic
Dockyard
(Hosted by the University of Southampton)
Dress: informal
6.00 pm Coach leaves Holiday Inn
7.00 pm Drinks reception and tour of the ship
8.00 pm Dinner
11.00 pm Coach departs for Holiday Inn
Friday 20th February
Theme: Adaptations of the generic protocol for specific countries and settings.
8.30 Briefing
9 am Group work (coffee available from 10.30)
1 pm Lunch
2 pm Reporting back from groups
3.30 Tea
4 pm Review and future action agenda
5 pm Workshop concludes
Dinner at leisure
Southampton Workshop Appendix A
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FRONTIERS/ Opportunities & Choices Workshop on Intrauterine Contraception
Appendix B: Evaluation report of IUD Workshop 18-20 February
2004
Summary
Most participants were happy with the general organizational matters. Out of
17, five would have liked more information prior to the workshop. four were
disappointed with the workshop venue and the lack of a Business Centre. All
participants said the workshop was relevant for policy in their country or
agency. The organisation of the workshop was good, although some found
the schedules were not tight enough and some would have liked summaries
at the end of each session.
For the interest, clarity and relevance of the workshop materials 88% gave a 5
and 4 rating on a scale of 1-5 and 12% gave a 3 rating. (5 =top rating). The
workshop material was interesting and well presented.
The organisations that thought the workshop was relevant were MOH
Guatemala, Engender Health, Ghana Health Service, Population Council,
Population Council FRONTIERS Programme and Family Health
International, University of Southampton.
The following areas indicated that the material might inform policy.
•
•
•
•
•
•
•
•
•
•
Guatamala – IEC Family Planning
Honduras – To incorporate the updated versions
Ghana – Training, funding for poor. Community service delivery
India - Reintroducing an effective contraception method – IUD
Reinforce the value of a model workshop that involves programme
people, research and funders and that has as its main objective
preparation of caf-proposal.
FHI – IUD interventions/promotions.
Will help re-introduce IUDS
FRONTIERS – Sharing different experiences and ideas to guide and
refine research.
Information dissemination of intervention strategies to improve the
uptake of IUDs.
Family Health International – Partnerships between CAs.
The following were suggestions for future research from the material
presented.
•
•
•
IEC strategies – low cost new approaches – vasectomy – IUD advocacy
to professional association.
A contraceptive option for HIV-positive clients
How to raise the profile of the IUD among service providers
Southampton Workshop Appendix B
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•
•
•
•
•
•
•
•
•
Supply side: Integration of training (updates/new skills) in existing
monitoring and supervision systems. Demand side.
Community demand generation and service delivery and its impact on
FP service coverage
How do program managers measure success?
Male attitudes towards IUDs
Impact of branding or pre-packaging of IUD and expendables (as a
measure to reduce cost) on its uptake.
Discontinuation issues
Reasons for different continuation levels of IUDS IN different countries
Improving Access for the poor and disadvantaged
Testing some of the demand creation ideas singly (rather than in one
group) so as to determine their relative effectiveness.
The following were suggestions for future dissemination workshops.
•
•
•
•
•
•
IUD operative research and findings
Meetings – International/National & sub-national in–country)
Publications in journals
Project publications
Follow-up meeting in one year to see how projects are progressing
Scientific publications of research findings in journals
Southampton Workshop Appendix B
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FRONTIERS/ Opportunities & Choices Workshop on Intrauterine Contraception
Appendix C: List of participants
Name
1. John Pile
Institution and country
Engender Health
USA
2. Erin McGinn
USA
3. John Bratt
Address
[email protected]
[email protected]
Tel: 1 212 561 8067
[email protected]
Tel :1 919 544 7040/
1 919 544 7261
Family Health International
USA
[email protected]
4. Ivy Osei
6. Shabnam Shahnaz
7. Yasmin Ahmed
8. Sally Kidsley
9. Will Stones
10. Martin Rew
11. Sabu Padmadas
12. M.E.Khan
Health Research Unit
Ghana Health Service
Ghana
Marie Stopes International
Director - Asia
UK
MSI Dhaka
Bangladesh
Opportunities and Choices
Research Fellow
University of Southampton
Highfield, Southampton SO17 1BJ, UK
Opportunities and Choices
Director
University of Southampton
Highfield, Southampton, SO17 1BJ
UK
Opportunities and Choices
Research Fellow
University of Southampton
Highfield, Southampton
SO17 1BJ, UK
University of Southampton
Teaching Fellow
University of Southampton
Highfield, Southampton SO17 1BJ
UK
Population Council
India
[email protected]
[email protected]
shabnam.shahnaz@mariestopes
.org.uk
[email protected]
[email protected]
Tel: 44-23-80 59 7988
[email protected]
Tel: 44-23-80-59-5763
[email protected]
Tel: 44-23-80-59-7988
[email protected]
Tel: 44-23-80-59-4382
[email protected]
13. Ricardo Vernon
14. Ian Askew
15. Gloria QuansahAsare
Population Council
Mexico
Population Council Regional Office
FRONTIERS in Reproductive Health
Reproductive and Child Health Unit
Ghana Health Service
Ghana
Southampton Workshop Appendices C-D
[email protected]
General Accident House
Ralph Bunche Road
P O Box 17643
Nairobi, Kenya
[email protected]
Tel. 254-20-2713480
Fax 254-20-2713479
[email protected]
[email protected]
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FRONTIERS/ Opportunities & Choices Workshop on Intrauterine Contraception
16. Jane Wickstrom
USAID Ghana
17. Sarah Harbison
18. Josephine Kibaru
USAID,
Kenya MOH
Kenya
Institute for Family Health
Regional Director
Family Health International
Nairobi, Kenya
Institute for Family Health
Senior Research Associate
Family Health International
2224 E NC54
RTP
NC 27713
USA
Salud Project, Calidad
Guatemala
APROVIME
Guatemala
Ministry of Health
Honduras
19. Ndugga Maggwa
20. Jennifer Wesson
21. Jorge Solórzano
22. Edwin Montufar
23. Ivo Flores
Health & Population Office
Accra, Ghana
[email protected]
[email protected]
[email protected]
[email protected]
254-020-2713913/4/5/6/7/8/9
245-020-2721360
[email protected]
Tel 919 544-7040 ext 373
Fax 919 544-7261
[email protected]
[email protected]
[email protected]
[email protected]
24. Jane Edmonsdon
25. Sofie de Broe
DFID Adviser
University of Southampton
26. Joanne Gleason
Population Council
Administrator
Washington , DC, USA
[email protected]
Appendix D: List of Workshop materials
FHI and USAID, (2003) Increasing Access to the IUD, An inter agency
workshop on 21 July 2003, Chapel Hill, North Carolina. A report.
Montufar, E. (2003). Increasing access to long term contraceptives in rural
areas through the MOH in Guatemala. FRONTIERS in reproductive health
Final technical report
Stanback, J, Omondi-Odhiambo, Omuodo, D (1995). Why Has IUD Use
Slowed in Kenya? Final report for Family Health International.
Southampton Workshop Appendices C-D
71