Elements of Family Planning Success

Since colonial times, religious institutions in the United States have played a major role in providing social services to the needy. In doing so, churches and synagogues for most of the nation's history either operated without significant support from the government or set up separate nonprofits for their charity work. Over the past few decades, however, a growing movement has developed to expand partnerships between faith-based organizations and the government. The "Charitable Choice" provisions in the 1996 welfare reform law effected the most significant legislative changes to the relationship between government and faith-based organizations in recent history. President Bush has sought to build on Charitable Choice by establishing the White House Faith-Based and Community Initiative and Centers for Faith-Based Community Initiatives across several government agencies. Through these initiatives and an array of policy reforms and outreach, Bush has promoted broader involvement of faith-based organizations in social programs as a core component of his "compassionate conservative" agenda. (excerpt)

As young people grow into adolescence and young adulthood, most will become sexually active and thus be exposed to the dual risks of unintended pregnancy and sexually transmitted infections (STIs), most importantly HIV. Although Uganda's multipronged HIV prevention program - consisting of direct programmatic efforts to promote abstinence, monogamy and condom use, as well as a wide range of other strategies to fight stigma, such as outreach to religious leaders - successfully contributed to a drop in HIV prevalence in the 1990s, that decline may have reached a plateau. Key to Uganda's continued success in reducing HIV/AIDS, as well as unwanted pregnancy and unsafe abortion, is a commitment to focusing on young people, who dominate the country's population. This, however, is no simple task. Those committed to protecting the next generation of Ugandans must recognize the diversity and varying needs of adolescents. For all adolescents, one this is certain: Any program of policy aimed at protecting thesexual and reproductive health of youth will be more successful if it reaches them at the appropriate time, in some cases before they become sexually active. (excerpt)

Although the IUD is an extremely effective and low-cost contraceptive method, its use has declined sharply in Kenya in the past 20 years. A study tested the effectiveness of an outreach intervention to family planning providers and community-based distribution (CBD) agents in promoting use of the IUD in western Kenya. Forty-five public health clinics were randomized to receive the intervention for providers only, for CBD agents only, for both providers and CBD agents, or no detailing at all. The intervention is based on pharmaceutical companies' 'detailing' models and included education/ motivation visits to providers and CBD programmes, as well as provision of educational and promotional materials. District health supervisors were given updates on contraceptives, including the IUD, and were trained in communication and message development prior to making their detailing visits. Detailing only modestly increased the provision of IUDs, and only when both providers and CBD agents were targeted. The two detailing visits do not appear sufficient to sustain the effect of the intervention or to address poor provider attitudes and lack of technical skills. The cost per 3.5 years of pregnancy protection was US$49.57 for the detailing intervention including the cost of the IUD, compared with US$15.19 for the commodity costs of the current standard of care -- provision of the injectable contraceptive depotmedroxyprogesterone acetate (DMPA). The effectiveness of provider-based activities is amplified when concurrent demand creation activities are carried out. However, the cost of the detailing in comparison to the small number of IUDs inserted indicates that this intervention is not cost-effective. (author's) | Although the IUD is an extremely effective and low-cost contraceptive method, its use has declined sharply in Kenya in the past 20 years. A study tested the effectiveness of an outreach intervention to family planning providers and community-based distribution (CBD) agents in promoting use of the IUD in western Kenya. Forty-five public health clinics were randomized to receive the intervention for providers only, for CBD agents only, for both providers and CBD agents, or no detailing at all. The intervention is based on pharmaceutical companies' 'detailing' models and included education/motivation visits to providers and CBD programmes, as well as provision of educational and promotional materials. District health supervisors were given updates on contraceptives, including the IUD, and were trained in communication and message development prior to making their detailing visits. Detailing only modestly increased the provision of IUDs, and only when both providers and CBD agents were targeted. The two detailing visits do not appear sufficient to sustain the effect of the intervention or to address poor provider attitudes and lack of technical skills. The cost per 3.5 years of pregnancy protection was US$49.57 for the detailing intervention including the cost of the IUD, compared with US$15.19 for the commodity costs of the current standard of care -- provision of the injectable contraceptive depotmedroxyprogesterone acetate (DMPA). The effectiveness of provider-based activities is amplified when concurrent demand creation activities are carried out. However, the cost of the detailing in comparison to the small number of IUDs inserted indicates that this intervention is not cost-effective.

The purpose of this report is to increase global understanding of the complexities related to HIV prevention. By sharing best practices as well as challenges encountered, PSI and its partners hope to inform and encourage continued programming efforts to address HIV/AIDS. Lessons documented in this report cover a broad and diverse group of prevention approaches, including social marketing of the female condom, using different service delivery models to expand consumer access to CT and establishing unique and nontraditional male condom sales outlets. The papers also describe AIDSMark's contributions to cutting-edge communications efforts, including large-scale interpersonal outreach among high risk groups in India and mass media campaigns promoting abstinence in Kenya. AIDSMark also dedicates a paper to detailing the lessons from 10 years of research to inform and evaluate HIV prevention social marketing programs. (excerpt)

In the mid-1970s, a Bangladeshi woman had more than six children on average. In combination with poor nutrition and lack of access to quality health services, this high fertility rate jeopardized the health of both the woman and her children. Beyond the health impact, high fertility and rapid population growth represented a major constraint to the country's economic development and social progress. More than 150 million women in the developing world who would like to limit or space their pregnancies do not currently use a contraceptive method. So, for example, about 16 percent of married women in India have this "unmet need." In sub-Saharan Africa, where services are in relatively short supply, the unmet need is the greatest. Intervention or program: The Bangladesh family planning program has depended on a large cadre of female outreach workers going door to door to provide information, motivate clients, and provide commodities; the program has used mass media to stimulate a change in attitudes about family size. The program both contributed to and benefited from improvements in women's status in Bangladesh during the past 30 years. The program is estimated to cost about $100 million to $150 million per year, with about one half to two thirds of the funding coming from external donors. Cost-effectiveness has been estimated at about $13 to $18 per birth averted, a standard measure for family planning programs. As a result of the program, virtually all women in Bangladesh are aware of modern family planning methods. The current use of contraceptives among married women increased from 8 percent in the mid-1970s to about 60 percent in 2004, and fertility decreased from an average of more than six children per woman in 1975 to slightly more than three. Although social and economic improvements have played a major role in increasing demand for contraception, the provision of services and information has been shown to have had an independent effect on attitudes and behavior. (author's)

Programs can provide clients with a continuum of care if they adopt a life-stage perspective. From the life-stage perspective, clients who want to switch contraceptive methods are not just discontinuers of one method or new users of another one but continuing users whose family planning needs have changed. Similarly, from the life-stage perspective women who stop contraceptive use in order to become pregnant can be viewed as clients whose reproductive intentions have changed, and who may use contraception again in the future. In a continuing-client strategy, programs realign goals and adapt activities to support continuing contraceptive users, as well as attracting new clients. The strategy focuses on reducing unintended pregnancies among current clients, extending follow-up and outreach within communities, integrating services and creating links with other organizations to avoid gaps in service delivery, and supporting these approaches with focused communication that encourages community support for continued contraceptive use. (excerpt)

Family Life Education: Teaching Adults to Communicate with Youth from a Muslim Perspective includes a manual containing six day-long workshops and this Participant Handbook. This handbook is referenced in the workshops and is designed for participants to keep and use when talking about reproductive health and HIV with youth. Every participant should receive a copy of the Participant Handbook to enhance and strengthen outreach to youth following the workshops. Participants will use them repeatedly and will want to share them with youth. If possible, the handbook should be reproduced on durable paper and laminated. The objectives of the six day-long workshops are to: Learn and practice the "Five Muslim Family Life Education (MFLE) Communication Steps" and the accompanying skills to discuss family life topics with young people; Learn essential youth reproductive health information, including sexual development, sexually transmitted infections (STIs), HIV and AIDS, pregnancy, family planning, and gender roles; Build communication skills to guide youth to make informed decisions about having sex, seeking professional medical services when needed, choosing a marriage partner, using drugs or alcohol, continuing one's education, and developing a livelihood; Examine personal beliefs and use insights from the Qur'an and Sunnah to discuss values about reproductive health and HIV prevention with young people; Identify and map local resources in the faith and medical communities; Develop an individual action plan for outreach with youth following the completion of the workshops. (excerpt)

Along with governments from around the world, African leaders agreed at the International Conference on Population and Development (ICPD) in 1994 to address unsafe abortion as a major public health problem. At the five-year review of the ICPD, they decided further that health systems should make safe abortion services accessible for legal indications. Based on this mandate, the World Health Organization (WHO) developed norms and standards for quality abortion services, Safe Abortion: Technical and Policy Guidance for Health Systems, released in 2003. While abortion-related maternal mortality and morbidity remains very high in many African countries, stakeholders are increasingly using WHO recommendations in conjunction with other global and regional policy frameworks, including the African Union Protocol on the Rights of Women in Africa, to spur new action to address this persistent problem. Efforts include: reforming national laws and policies; preparing service-delivery guidelines and regulations; strengthening training programs; and expanding community outreach programs. This paper reviews progress and lessons learned while drawing attention to the fragility of the progress made thus far and the key challenges that remain in ensuring access to safe abortion care for all African women. (author's)

Family Life Education: Teaching Adults to Communicate with Youth from a Christian Perspective includes a manual containing six day-long workshops; and this Participant Handbook. This handbook is referenced in the workshops and is designed for participants to keep and use when talking about reproductive health and HIV with youth. Every participant should receive a copy of the Participant Handbook to enhance and strengthen outreach to youth following the workshops. A copy is included with the manual to be reproduced for participants. Although photocopying may be a quick and inexpensive way to reproduce the handbooks, participants will use them repeatedly and will want to share them with youth. If possible, the handbook should be reproduced on durable paper and laminated. The objectives of the six day-long workshops are to: Learn and practice the "Five Christian Family Life Education (CFLE) Communication Steps" and the accompanying skills to discuss family life topics with young people; Learn essential youth reproductive health information, including sexual development, sexually transmitted infections, HIV and AIDS, pregnancy, family planning, and gender roles; Build communication skills to guide youth to make informed decisions about having sex, seeking professional medical services when needed, choosing a partner, using drugs or alcohol, continuing one's education, and developing a livelihood; Examine personal beliefs and use the Bible to discuss values about reproductive health and HIV prevention with young people; Identify and map local resources in the faith and medical communities; Develop an individual action plan for outreach with youth following the completion of the workshops. (excerpt)

This study analyzes the use patterns of www.medicationabortion.com, an English-, Spanish-, Arabic- and French-language web site dedicated to three methods of early pregnancy termination: mifepristone/misoprostol, methotrexate/misoprostol and misoprostol alone. This study examines both the overall and language-specific use patterns of the web site from October 1, 2004, through September 30, 2005. Data were recorded using Wusage 8.0, a web site statistics program. Over the 12-month study period, www.medicationabortion.com received more than 78,000 visits and nearly 240,000 page requests. The English version is the most popular version of the web site (accessed in 46.1% of all visits), followed by the Spanish (35.0%), Arabic (10.4%) and French (8.8%) versions. Spanish-language visits are nearly three times as likely to access the misoprostol-only section of the web site when compared with the other language versions (p < .001). This study confirms that multilingual, medically accurate online resources have the potential to expand information about medication abortion to both providers and women considering the option of abortion in diverse communities. Analysis of the languagespecific use patterns highlights the different priorities of various types of web site visitors and suggests future priorities for educational outreach, collaboration and research. (author's)

The objective of this research was to track selected health behaviors and their determinants among the MSM population in Moscow from 1999 to 2004, and to evaluate the effect of the "Protect yourself" IEC intervention implemented with this population. An additional aim was to conduct a one-time survey among the MSM population in St Petersburg (in 2004) to provide a comparison for the Moscow research, and to provide a baseline for subsequent programs with the MSM population in St Petersburg. The "Protect Yourself!" project aimed to raise awareness of safe sexual behavior as well as to motivate MSM aged 18 to 29 living in Moscow and St. Petersburg to use condoms and lubricants in each sexual contact. Main activities implemented in the framework of this project were street, nightclub and beach outreach work, training sessions with MSM, a crisis hotline, a variety of club events, internet outreach and advertising, IEC materials development and distribution, also distribution of condoms and lubricants during outreach, club events and in gay clubs and saunas. (excerpt)

UYDEL is a non-governmental organization whose mission is to empower disadvantaged youth with the skills needed to live happy and meaningful lives and to contribute to and become better citizens of Uganda. Under the 3-year Health Matters for Vulnerable Children project, UYDEL aimed to reduce HIV/STI transmission, sexual exploitation, and incidence of unwanted pregnancies among street children and Commercial Sex Workers (CSWs) between the ages of 12 and 24 by increasing their access to high-quality youth friendly services. UYDEL provided services through five youth friendly drop-in centers, 17 mobile clinic outreach posts, and through Peer Service Providers (PSPs) in five divisions of Kampala District: Rubaga, Central, Makindye, Nakawa and Kawempe. Youth received family planning, Voluntary Counseling and Testing (VCT) services, treatment of STIs, and counseling and guidance services. Because many of the target group are ineligible for health care benefits, unfamiliar with youth-friendly services and programmes and are unable to easily obtain information, UYDEL also established a strong referral system for legal aid, counseling, health care and other social support services in the five divisions of operation. In April-June 2004, Pathfinder undertook the initiative of documenting UYDEL's experiences to highlight best practices and lessons learned for stakeholders throughout Uganda and globally. This document summarizes interviews held with individuals and groups and highlights personal experiences and views of the target group from a human-interest angle. (excerpt)

For the past two decades, female and male outreach workers (ra?aidat rifiat and mothekaf sekany, respectively) have been acting as community-based family planning educators in Egypt. They started with the Egyptian Family Planning Association, the International Planned Parenthood Federation?s affiliate in Egypt. Then, in 1994, inspired by their success and by the International Conference on Population and Development, the Egyptian Ministry of Health and Population (MOHP) decided to scale-up use of these workers. Now the MOHP hires and trains outreach workers, under the auspice of the local MOHP clinic, to act as family planning educators in every community. In rural areas, these female outreach workers deliver family planning education and counseling to women through home visits, while male outreach workers conduct education sessions in public venues. In urban areas, both men and women conduct home visits and public education activities. The involvement of these well-regarded members of the community has contributed immensely to improving the acceptability of family planning in Egypt, once a controversial topic. However, because of budgetary considerations, the MOHP is able to provide on average only two outreach workers per community. These workers? role is limited to family planning, which ultimately limits their usefulness to clients. Moreover, the potential of these leaders to mobilize Egyptians to change reproductive health and family planning behaviors and encourage appropriate service use has not been tapped. (excerpt)

Condoms play a special role in combating the spread of HIV/AIDS because of their ability to protect against the sexual transmission of HIV. Since condoms also prevent pregnancy, couples can use them for dual protection against infection and unintended pregnancy. To encourage people to use condoms, programmes need to raise awareness of HIV/STI risks, make good-quality condoms readily available, teach people how to use condoms correctly, work to eradicate the social stigma associated with condoms, and advocate for HIV prevention and condom use in the community. This manual is intended for the health care workers, peer educators, and other outreach workers who counsel clients on HIV/STI prevention and condom use; the sales clerks, bartenders, gas station attendants, taxi drivers, and others who sell condoms as part of their jobs; and the shop owners, store manages, and clinic staff who run condom outlets. (excerpt)

In this article, the attitudes, needs and priorities of adolescents in family planning, as articulated by them during focus group discussions, are presented. Findings indicate that: (a) Ugandan adolescents face numerous barriers to accessing family planning information and services; (b) they hold an alarming number of misconceptions about modern contraceptives; (c) they lack reliable, trusted and non-judgemental sources of information, privacy and confidentiality during family planning counseling, and (d) they don?t know about contraceptive services available from the community-based distributors. Suggestions are provided on how community-based distributors could improve their outreach to adolescents and provide youth-friendly family planning services. (author's)

From 2000 to 2003, FRONTIERS supported a study by the Center for Research on Environment, Health, and Population Activities (CREHPA) to test communication-based models for improving young couples? access to and use of reproductive health information and services in the Udaypur district of eastern Nepal. The 14-month intervention, undertaken as part of a reproductive health project implemented by the Nepal Red Cross Society (NRCS) and the Center for Development and Population Activities (CEDPA), sought to improve social norms that leave young women vulnerable to health risks related to early marriage and childbearing and limited access to reproductive health services. The study compared two experimental models with two control groups. In the experimental models, information, education, and communication (IEC) materials were provided for: (1) ?youth communication action groups,? formed in ten village development committees (VDCs) made of young married women under the age of 25; and (2) existing or reactivated village mothers? groups in ten VDCs made of women aged 15-49 (formed as part of government health services). The two experimental groups received training, assistance with group interaction, outreach, and educational materials about sexually transmitted infections (STIs) and condom use. Members of both groups met monthly and were encouraged to organize special events such as health fairs, talk programs, and educational events for husbands. (excerpt)

Credit: © 2005 Amrita Gill-Bailey/CCP, Courtesy of Photoshare Country: Egypt

Credit: © 2005 Amrita Gill-Bailey/CCP, Courtesy of Photoshare Country: Egypt

Credit: © 2005 Amrita Gill-Bailey/CCP, Courtesy of Photoshare Country: Egypt

The International Center for Research on Women (ICRW) is leading a large-scale, collaborative initiative, DISHA, to improve the reproductive health and well-being of young people in the states of Bihar and Jharkhand, India. Assessments by ICRW and local and national stakeholders indicate that programs focusing on the delivery of reproductive health information and services are too narrow and inadequate to address youth reproductive health concerns in Bihar and Jharkhand. DISHA (meaning “direction” in Hindi) takes a more comprehensive, multi-sectoral, and integrated approach that addresses not only the health, but also the socio-cultural and economic factors that have an impact on youth reproductive health. The DISHA initiative aims to enhance the outreach and effectiveness of adolescent reproductive health programs in Bihar and Jharkhand. It also seeks to build the capacity of youth-serving organizations to implement and evaluate high-quality programs, while at the same time building leadership and widespread commitment in Bihar and Jharkhand to address the needs of youth. (excerpt)