Publications

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Communication Impact! 11

Community Participation is Key to Supporting Quality in Gold Circle Clinics (March 2001)

Jeanne no longer worries about going to the family planning clinic in Cameroon. She enjoys her visits now because the nurses and doctors welcome her. They care about her. They make the 26 year-old feel like a person with needs, expectations and questions, all of which are fulfilled when she visits a Gold Circle (GO) clinic.

In December 1998, the Family Health and AIDS in West and Central Africa project, also known as Santé Familiale et Prevention du SIDA (SFPS) launched the GO Campaign in four countries: Burkina Faso, Cameroon, Côte d'Ivoire and Togo. Funded by the United States Agency for International Development, the SFPS project uses a multifaceted approach to increase the use of modern contraception, condoms, and oral rehydration salt within West and Central Africa, and to increase the capacity and sustainability of regional and national African institutions. Four US-based institutions, with help from others, work synergistically to meet SFPS project goals and objectives: Tulane University in Operations Research, JHPIEGO Corporation in Training and Service Delivery, Population Services International in Social Marketing, and the Johns Hopkins Center for Communication Programs (JHU/ CCP) in Behavior Change Communication.

The GO campaign promotes quality family planning services, other reproductive health issues, and HIV/ AIDS prevention in accredited clinics that take into consideration clients' expectations. Research by JHU/ CCP in four countries indicates that for clients, a helpful smiling provider who takes care of their needs typifies quality. By promoting quality, the GO campaign aimed to contribute to project objectives by increasing: 1) use of modern family planning methods, 2) clinic attendance at GO and family planning clinics, 3) favorable attitudes about family planning methods and providers, and 4) discussion by couples about family planning. The primary audience is urban or peri-urban women of reproductive age (20-49) living with a partner and at least one child. The secondary audience includes the women's partners and family members.

STRATEGY & IMPLEMENTATION

The GO strategy is based on the premise that to increase the use of clinic services two complementary forces - demand and supply - must work together. The supply side was addressed through improved quality of services, which involved increasing the availability of family planning methods, improving provider competence and client/ provider relations, and instituting better infection prevention practices. Through an accreditation process, the SFPS Resident Advisor, Service Delivery Partners and Supervisors determine which clinics will be presented with the GO quality award in each country. The criteria for the GO quality award were standardized and require that the clinic stock a range of family planning methods, employ competent and informative counselors, require minimal client waiting time, regularly report clinical data and practice proper infection prevention techniques.

Community participation was a unique aspect of the GO strategy. A team of providers and community representatives formed GO Quality Teams in each clinic area. The teams planned local campaigns, including open clinic days, market days, and health talks. These teams established a dialogue between providers and community representatives that gave the community a sense of ownership and helped empower them to demand and maintain clinic improvements.

Through community participation, the GO campaign encouraged local creativity. Each launch incorporated a standard clinic visit and speeches and all had promotional materials such as T-shirts, key chains, and calendars. Beyond that, each site-launch varied. One site had hostesses wearing sandwich boards with family planning messages; another featured a comedy choir of elderly women singing about GO; another featured a proud hospital director receiving his framed copy of the GO quality award from the Ministry of Health.

Mass media also addressed the demand side. JHU/ CCP promoted GO sites through the mass media by broadcasting TV and radio spots and displaying posters and sign boards with the GO logo - a smiling provider with outstretched hand - and the GO slogan," We are here to listen to you."

During Phase I of the campaign (December 1998 - May 1999) 56 clinics, out of 206, received the GO quality award, while in Phase II (April - August 2000) another 29 clinics earned the award. During Phase III (February - April 2001) 15 more clinics will have received the GO award, for a total of 100 accredited GO clinics.

IMPACT

JHU/ CCP used a variety of methods to measure exposure to the campaign and impact on attitudes and behavior as a result of that exposure. In Cameroon, both a national omnibus survey and a panel survey involving a follow-up of the 1998 Demographic and Health Survey in selected clusters were conducted. Client exit interviews and service statistics were conducted in Burkina Faso, Togo and Cameroon. The political situation in Côte d'Ivoire made it impossible to collect evaluation data.

Overall, the GO campaign has had wide reach. In Cameroon, for example, results of the omnibus survey, conducted six weeks after the national launch, indicate that 58% of women and 45% of men of reproductive age were aware of the campaign. Among these, electronic media were the major source of exposure, with 58% reporting exposure through radio and 52% through television.

A panel study made it possible to document that the campaign had a positive impact on contraceptive use and on ideational factors influencing the use of family planning methods, including knowledge of various methods, discussion with peers, and spousal/ partner approval of family planning. The data revealed a significant increase in discussion of family planning with others: from 35% at the baseline to 43% at follow-up. Approval of family planning appears more widespread than prior to the campaign: at follow-up 45% said they approved of family planning as opposed to 28% at baseline. Moreover, the data indicate that campaign exposure is associated with a favorable shift toward the use of modern family planning methods. Among women exposed to the GO campaign who were previously not using a modern method, 23% began using a modern method, compared to only 8% among those who were not exposed to the campaign (Table 1).

Service statistics from ten GO clinics in Cameroon revealed that the number of new clients increased significantly subsequent to the launch (Figure 1). Six months after the GO launch, the number of new clients was still substantially higher than its pre-launch level. Similar trends were observed in Togo. Data from the client exit interviews in Togo, Burkina Faso and Cameroon also indicate that clients were well pleased with the services they received at the GO clinics with more than 98% indicating that they were well satisfied with their reception at the clinics. More than 90% of the clients stated that the waiting time was acceptable while about 92% of new users reported that privacy was observed during the consultation.

Together with efforts from service delivery, training, and operations research components of the same project, GO has become a recognized quality program. The use of community mobilization efforts in concert with the GO Quality Teams helped consolidate the gains achieved through the electronic media, so that more people now discuss and use modern family planning methods.

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