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RHO archives : Topics : Family Planning Program Issues

Annotated Bibliography

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Logistics and contraceptive quality assurance

Binzen, S. Improving contraceptive supply management. Family Planning Manager 1(4):1-20 (1992). Available in English at: English, in French at:, and in Spanish at:
This article presents basic techniques for storing, managing, and ordering contraceptive supplies. It includes a checklist for assessing a storage facility, describes how to use a FEFO (First-to-expire, first-out) system to prevent stock from expiring on the shelf, and lists specific guidelines to assure the quality of each contraceptive method. The article then describes how to set up and operate a Max/Min system to maintain appropriate inventory levels and order more supplies. Details also are presented on how to use five key management forms (stock cards, status of supplies charts, contraceptive data analysis charts, requisition and issue vouchers, and quarterly reporting forms) to keep track of supplies.

Binzen, S. Pocket Guide to Managing Contraceptive Supplies. Atlanta, Georgia: Centers for Disease Control and Prevention (Revised, February 2000). Available in English, French, and Spanish at:
This reference helps staff manage contraceptive supplies by reviewing essential formulas and principles and by providing worksheets, guidelines, and sample forms. Topics covered include the maximum-minimum inventory control system, ordering supplies, warehousing practices, shelf life, checking contraceptive quality, managing complaints, forecasting, and supervision. A useful table reviews the five most common logistics problems along with their probable causes and possible solutions; the supervision sections includes a complete check list for site visits by supervisors.

Centers for Disease Control and Prevention (CDC) and Family Planning Logistics Management Project (FPLM)/John Snow, Inc.(JSI). Family Planning Logistics Guidelines. Atlanta, Georgia: CDC (December 1993).
This manual is designed as a reference guide for supervisors, managers, and administrative personnel working in family planning programs in developing countries to help them manage contraceptive supplies and analyze logistics problems. It also can be used for training. After reviewing the components and objectives of the logistics system, the manual offers practical instructions on logistics information systems, inventory control, assessing supply status, calculating resupply quantities, warehousing, forecasting, and quality assurance. A final section discusses how to evaluate a logistics systems and identify problems. Several of the chapters contain forms and formulas that can be photocopied for local use or quick reference.

Chandani, Y. and Breton, G. Contraceptive security, information flow, and local adaptations: family planning in the Philippines and Morocco. Electronic Journal for Information Systems in Developing Countries 5(3):1-18 (2001). Available at:
This paper presents case studies from Morocco and the Philippines, where Logistics Management Information Systems (LMIS) have been operational for five to eight years, to illustrate a discussion on how to institutionalize a LMIS. It is critical to customize the LMIS to the specific country and program setting and to encourage users to continue adapting it so that the system meets users needs even in a changing environment. Sustainability also requires local technical expertise and funding to support ongoing adaptation, institutional commitment, and an enabling environment.

Family Planning Logistics Management (FPLM)/ John Snow, Inc. (JSI). Programs That Deliver: Logistics' Contributions to Better Health in Developing Countries. Arlington, Virginia: FPLM/JSI (2000). Available at:
T he objective of this publication is to persuade policy makers and senior managers of the strategic importance of the supply chain, but it also contains practical tips for logistics managers. It explores both the customers' perspective on the supply chain as well as the needs and motivations of program staff. Key components of logistics systems are reviewed, including the logistics management information system, forecasting, procurement, and distribution. The book concludes by explaining how systematic assessment can increase the efficiency and effectiveness of the logistics system and by discussing global trends affecting logistics, such as integrated services and decentralization. The discussion is illustrated with examples from around the world.

Finkle, C. Ensuring contraceptive supply security. Outlook 20(3):1-8 (July 2003). Available at:
Growing demand for contraceptives, shifting foreign aid priorities, lack of in-country capacity, and inadequate coordinating mechanisms at the national and global levels are creating contraceptive shortages worldwide. To achieve contraceptive supply security, programs must address funding problems, lack of government and donor commitment, skyrocketing demand for condoms created by the HIV/AIDS epidemic, and adverse effects of health sector reform. Coordinating committees at the national and global levels offer a promising approach.

Marie Stopes International Global Partnership. Reproductive Health Supplies Security. Position Paper No. 3. London: Marie Stopes International (2002). Available in English, French, and Spanish at:
The problem of securing adequate reproductive health supplies is growing as demand for contraception increases. This position paper outlines three key issues that inhibit the sustained flow of supplies: dwindling donor support for projects and programs, limited capacity of service providers to manage supplies, and poor coordination of activities and funding. Marie Stopes has weathered these problems better than other providers by encouraging programs to adopt sustainable service models (which include user fees and cross-subsidies), providing technical assistance and capacity building on logistics issues, and engaging in international advocacy. Case studies from Zimbabwe and Myanmar are presented to illustrate Marie Stopess approach.

Pandit T, Bornbusch A. Contraceptive Security: Ready Lessons. Washington, DC: USAID; 2003. Individual modules available at:,,,,, and
This series of five modules suggests practical steps to promote and support national programs for contraceptive security based on the experience of USAID Missions, country partners, technical agencies, and donors. The modules present lessons learned, “how-to” information, country examples, and further readings on the following topics: raising awareness and commitment, doing a joint assessment, taking a whole market approach, advocating for sustained commitment, and using data for decision making.

PATH. Contraceptive quality assurance: Findings of a twenty-two country survey. Seattle, Washington: PATH and WHO (March 1997). Available at:
Survey respondents familiar with public sector family planning programs or the national drug regulatory authority in 22 countries provided information on contraceptive quality assurance. The study findings document a widespread shift in developing countries from reliance on donated contraceptives to the purchase of all or part of contraceptive supplies. This shift will require countries to take on more responsibility for assuring the quality of supplies; currently many countries report ad hoc procedures for many critical activities, such as visual inspection or reporting and responding to complaints about contraceptive quality. Half of the countries reported documented contraceptive quality problems within the preceding two years that required return or destruction of product. The report concludes with many specific recommendations for interventions to strengthen quality assurance systems.

Setty-Venugopal, V., Jacoby, R., and Hart, C. Family planning logistics: strengthening the supply chain. Population Reports, Series J, No. 51. Baltimore, Johns Hopkins Bloomberg School of Public Health, Population Information Program (2002). Available in English, French, and Spanish at:
By strengthening their logistics systems, family planning programs can increase the availability of contraceptives, help ensure a steady supply, and deliver better care to meet clients needs. A new focus on clients needs at each step of the supply chain is contributing to improvements. Providing good leadership, management, training, and support for supply-chain staff can improve their skills and motivate them to serve clients better. Developing a logistics management information system that collects and reports accurate data on a timely basis helps managers make accurate forecasts of demand for contraceptives and manage supplies efficiently. Better forecasting and procurement help ensure that programs order neither too few nor too many supplies. Distribution, including storage and transport, works best when it focuses on moving supplies to meet clients needs, not just on storing and shipping. While improving the logistics system contributes to contraceptive security, continued funding by donors and government also is critical. Expanding the role of commercial sector may help pick up the slack.

Tarmann, A. Contraceptive shortages loom in less developed countries. Population Today 29(6):1, 4-5 (August-September 2001). Available at: A conference on "Meeting the Reproductive Health Challenge: Securing Contraceptives and Condoms for HIV/AIDS Prevention" in Istanbul in 2001 focused attention on contraceptive shortages facing developing countries. These shortages are local, rather than global, and reflect distribution rather than production problems. Declines in donor assistance, weaknesses in forecasting and logistics, and growing demand due to the HIV/AIDS epidemic all contribute to the problem. In an effort to overcome local shortages, UNFPA is working on an online system to track contraceptive supplies globally, which also will link with in-country logistics management systems.

Wolff, J.A. et al., eds. Getting contraceptives to the client. In: The Family Planning Manager's Handbook: Basic Skills and Tools for Managing Family Planning Programs,chapter 8. West Hartford, Connecticut: Kumarian Press (1991). In English, French, Spanish, Bangla, Arabic, and Portuguese. Available at:
This standard text offers practical advice on the entire commodities management system, including product selection, forecasting, distribution, and use of contraceptives. It includes detailed instructions on how to check commodities as they arrive, design storage areas, choose an inventory supply system, calculate the months of supply on hand, prevent contraceptives from expiring on the shelf, and conducting a physical inventory. Also included are sample forms, checklists, guidelines, and other tools to help set up a working logistics system.

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Infection prevention

AVSC International/EngenderHealth. Infection Prevention: Online Course. Available at:
Available in English and Spanish, this online course is designed for health workers in low-resource settings. It provides advice on low cost methods and alternatives for facilities that lack reliable electricity, running water, or basic supplies. The course covers disease transmission, handwashing, gloving, aseptic technique, surgical scrub and surgical attire, use and disposal of needles and other sharps, instrument processing, housekeeping, and waste disposal. Students can test their knowledge on case studies and tests. Checklists and educational aids are provided to help students apply course content to their work.

Huezo, C. and Carignan, C. Infection prevention and control. In Medical and Service Delivery Guidelines for Family Planning, 2nd edition. London: International Planned Parenthood Federation Medical Publications (1997). Cost: US$20; may be requested free of charge.
The second edition of these family planning guidelines added an extensive chapter on how to minimize the transmission of infections to clients and providers during service delivery procedures. The guidelines cover the selection and use of antiseptics, procedures for decontaminating, disinfecting, and sterilizing equipment and instruments, and the storage of sterile or disinfected equipment. Also discussed are handwashing, gloving, injection procedures, cleaning, traffic flow, and waste disposal.

Tietjen, L. et al. Infection Prevention Guidelines for Healthcare Facilities with Limited Resources: A Problem-Solving Reference Manual. Baltimore, Maryland: JHPIEGO (2003). Available at:
This comprehensive and detailed manual is designed to help health care workers, supervisors, managers, and administrators understand the basic principles of infection prevention and recommended processes and practices. It reviews standard precautions to prevent infection, including hand hygiene, gloves, personal protective equipment and drapes, surgical antisepsis, safe practices in the operating room, and waste management. It includes detailed instructions on supplies and procedures for processing instruments, gloves, and other items; for managing traffic flow, housekeeping, clinical lab services, and blood bank and transfusion services; and for preventing nosocomial (hospital-acquired) infections.

Tietjen, L. Preventing infections in health care workers. Outlook 15(4):1-4 (December 1997). Available at:
After examining the risk of infection facing health care workers and their clients, this article describes what health care workers can do to protect themselves and their clients from exposure to infectious diseases.

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Interpersonal communication and counseling

Abdel-Tawab, N. and Roter, D. The relevance of client-centered communication to family planning settings in developing countries: Lessons from the Egyptian experience. Social Science and Medicine 54(9):1357-1368 (2002).
To examine the feasibility and effectiveness of client-centered communication, this study auditotaped 112 family planning consultations with 34 Egyptian physicians, conducted exit interviews with clients, and measured contraceptive continuation at home visits three and seven months later. Based on an analysis of the conversations between physicians and clients, two-thirds of the consultations were classified as physician-centered, and one-third were client-centered. Consultations were more likely to be client-centered when clients were older (35 or more), physicians were younger (less than 30), the method received was an IUD, and the client had been to the clinic before. Clients who experienced client-centered care were three times as likely as other women to be satisfied with the consultation and to still be using their method seven months later.

AVSC International. Informed Choice in International Family Planning Service Delivery: Strategies for the 21st Century. New York: AVSC (1998).
This report is a consensus document resulting from a seven-day meeting of experts around the world that was held in Italy in November 1998. It provides a broadened conceptual framework for change and identifies recommended strategies, objectives, and suggested actions for making the social and political context more supportive of informed choice and for strengthening informed choice practices at the service-delivery level. The full report is available in English, and a four-page executive summary is available in English, French, Portuguese, Russian, and Spanish.

Baveja, R. et al. Evaluating contraceptive choice through method-mix approach. Contraception 61:113-119 (2000).
This study examines the contraceptive choices made by 8,077 women who sought advice on different family planning options at ten hospitals in India over a one-year period; women who had already chosen a method before coming to a hospital were not included. Clinic staff at these facilities were specially trained to provide balanced information on all contraceptive methods available. Women's first choice of method was the IUD (59%), followed by tubectomy (15%) and condoms (8%). In contrast, provider's top choices of method for these same women were the newly introduced Norplant (36%), IUD (33%), and tubectomy (19%). Most women received their first-choice method (the proportion ranged from 85% to 92%, depending on the method chosen). Older women and those with more children were more likely to choose sterilization. Higher parity apparently explains the greater acceptance of sterilization among less-educated women. The authors conclude that, when given balanced information, most women can make an informed choice of method and can override a provider's bias—in this case, a clear bias toward Norplant.

De Negri, B. et al. Improving Interpersonal Communication Between Health Care Providers and Clients. Bethesda, Maryland: Quality Assurance Project. Available at:
The first portion of this monograph presents a conceptual framework for interpersonal communication between providers and clients and its effects on health outcomes. According to this framework, the process of effective interpersonal communication includes encouraging a two-way dialogue, establishing a partnership between patient and provider, creating an atmosphere of caring, bridging social gaps between provider and patients, accounting for social influences, effectively using verbal and nonverbal communication, and allowing patients ample time to tell their story. The authors identify specific provider behaviors that can improve each of the three types of IPC: caring, diagnosis and problem solving, and counseling.  The remainder of the monograph discusses how to plan and implement training activities to improve providers' interpersonal communication skills.  Lengthy case studies, including training manuals and data collection tools, are presented for Egypt, Honduras, and Trinidad and Tobago.

EngenderHealth. Choices in Family Planning: Informed and Voluntary Decision Making. New York: EngenderHealth (2003). Available at:
This tool kit is designed for a wide range of audiences, including service providers, trainers, program managers, policy makers, and donors. It outlines a conceptual framework for informed and voluntary decision-making in sexual and reproductive health (SRH). The framework consists of five elements: service availability, voluntary decision-making, appropriate information, good client-provider interaction, and a supportive social and rights context. Three tools are included: a “Discussion Guide” to facilitate broad discussion of the elements of and conditions that underpin informed choice; a “Preliminary Assessment Guide” to assess the status of decision making in a given program by identifying challenges and supporting factors; and a “Next Steps Guide” to plan strategies to strengthen supports for family planning decision-making.

EngenderHealth. Comprehensive Counseling for Reproductive Health: An Integrated Curriculum. Trainer’s Manual and Participant’s Handbook. New York: EngenderHealth; 2003. Available at:
This curriculum is designed to develop providers’ skills, knowledge, and comfort with discussing sexuality so that they can communicate effectively with clients about a full range of sexual and reproductive health issues, including family planning, maternal health, sexually transmitted infections, and related sexual practices. It encourages providers to take a more holistic view of the client and to seize the opportunity to address all of her or his reproductive health needs.

Heerey, M. et al. Client-Provider Communication: Successful Approaches and Tools [CD-ROM]. Baltimore, Maryland: Quality Associates and The Johns Hopkins Bloomberg School of Public Health Center for Communication Programs (2003). May be ordered at:
Designed for program managers, providers, technical experts and researchers, this CD-ROM presents a wide variety of state-of-the-art approaches for improving the quality of client-provider communication. It covers four different areas: provider performance, client behaviors and community norms, service delivery management, and research and evaluation. The CD-ROM gives an example of how each approach has been applied in the field, describes its effectiveness, offers advice on implementation, and presents the actual tool used. Much of the material has been formatted so users can easily download electronic copies and adapt the tools for their own purposes.

Kim YM et al. Increasing patient participation in reproductive health consultations: an evaluation of "Smart Patient" coaching in Indonesia. Patient Education and Counseling. 2003a;50(2):113-122.
This operations research project tested whether individual coaching can give clients the confidence and communication skills to play a more active role in family planning consultations. Educators met with 384 Indonesian women waiting to see a provider and coached them on asking questions, expressing concerns, and seeking clarification. An analysis of audiotaped consultations found that clients who received coaching articulated significantly more questions and concerns during consultations than other women. Coaching narrowed differentials in active communication by patient type, age, and assertiveness, but it widened differentials by patient education and socioeconomic class. The contraceptive discontinuation rate at 8 months was lower for women who received coaching, but the difference was only marginally significant.

Kim YM et al. Participation by clients and nurse midwives in family planning decision making in Indonesia. Patient Education and Counseling. 2003b;50:295-302.
Researchers developed a family planning decision-making assessment tool to rate provider performance and client contributions during 179 family planning consultations in Indonesia. Clients made important contributions to some elements of the decision-making process, most notably in identifying problems, eliciting information, and expressing their feelings about a method. Because providers’ performance was weak for most elements of the decision-making process, the principle of informed choice was not fully realized. While new family planning clients chose their own methods, they did so based on incomplete information. As for continuing clients, providers rarely offered them any alternatives, so they were neither informed nor given an opportunity to make a decision. Improving the quality of decision-making requires greater participation by clients as well as better communication skills and more positive attitudes for providers.

Kim, Y.M. et al. Informed choice and decision-making in family planning counseling in Kenya. International Family Planning Perspectives 24(1):4-11, 42 (March 1998). Available at:
Family planning counseling sessions with 176 clients in Kenya were audiotaped, transcribed, and analyzed to identify key counseling behaviors and assess the completeness of information provided to the clients. Providers collected information about a new client's marital and reproductive history in 60 percent of counseling sessions, but asked women about their childbearing intentions in only 7 percent. In 55 percent of sessions with continuing clients, providers asked whether the woman was experiencing any problems with her current contraceptive method; providers raised the issue of switching methods in 27 percent of these sessions, and inquired about a continuing client's reproductive intentions in 17 percent. Providers discussed an average of four contraceptive methods with new clients, whereas they typically discussed fewer than two with continuing clients. Providers seldom tailored their discussion of contraceptive methods to the client's reproductive intentions, prior knowledge of family planning, contraceptive preferences, personal circumstances or health risks. In addition, while providers emphasized a woman's right to make the final decision as to method choice, they rarely helped women weigh alternatives or checked if they understood the personal implications of their choices. The authors conclude that family planning providers could enhance the quality of women's contraceptive decision-making if they took a more active role in contraceptive counseling, for example, by relating information on specific methods to women's personal circumstances and helping clients weigh the advantages and disadvantages of various methods.

Kim, Y.M. et al. Client participation and provider communication in family planning counseling: transcript analysis in Kenya. Health Communication 11(1):1-19 (1999).
An analysis of coded transcripts of 176 family planning counseling sessions in Kenya found that providers controlled the length and content of a large majority of sessions, but that clients sometimes worked together with providers as partners and helped guide the conversation. On average, clients spoke half as many sentences as providers, and their sentences were shorter. Only 28 percent of client speeches were active, that is, they volunteered information, requested a method, asked a question, or raised a concern. Given cultural norms that dictate a passive role for clients, the most comfortable way for clients to participate was to elaborate their responses to providers' questions. When clients did participate actively, providers usually responded with technical information (42%) or supportive comments (28%), but they ignored 22 percent of active client communication. Providers promoted client participation by building rapport with clients, tailoring the information they presented to clients' individual situations, and rewarding clients when they participated actively. The authors conclude that mass media campaigns, client education, and provider training all have the potential to encourage greater client participation in Kenya.

Lazcano, E.C. et al. The power of information and contraceptive choice in a family planning setting in Mexico. Sexually Transmitted Infection 76:277-281 (2000).
To test the effect of information about STI risk factors and prevention on the choice of family planning methods, this randomized, controlled trial assigned 2,107 clients at a family planning clinic in Mexico City to one of two groups: (1) a standard practice group in which the provider selected a contraceptive method for the woman or (2) an intervention group in which the woman chose a method after a 20-minute discussion with a nurse about contraceptive methods, STI risk factors, and method choice. Women were less likely than providers to select the IUD (58% versus 88%, P = 0.0000), and the difference was even more marked among women who tested positive for gonorrhea or chlamydia (48% versus 95%, P = 0.0006). The difference remained significant in a logistic regression analysis controlling for sociodemographic variables and STI risk factors. The authors conclude that providing information to women and allowing them to choose a method increased the selection of condoms and reduced the inappropriate and potentially harmful selection of IUDs among women with cervical infections. Clinicians were unable to recognize which women were at risk for STIs, because of lack of training and awareness, limited time, lack of clinical signs, and the strong promotion of the IUD in Mexico. Although self-assessment of risk factors by women was imperfect, it was better than relying on the clinician's judgment.

Léon FR et al. Enhancing quality for clients: the balanced counseling strategy. FRONTIERS Program Brief No. 3. Washington, DC: Population Council; 2003. Available at:
To overcome weaknesses in contraceptive counseling, the Population Council worked with the Peruvian Ministry of Health to develop a balanced counseling strategy that used a series of job aids to help providers quickly match methods to individual client needs and fully inform the client about the method chosen. After testing in Peru, the model was refined and replicated in Guatemala and then scaled up in Peru. Evaluations in the two countries found that the quality of counseling improves when providers use the job aids, but that adequate training, continuing supervision, and institutional leadership are needed to prompt providers to implement the model.

Léon, F.R. et al. Length of counseling sessions and the amount of relevant information exchanged: a study in Peruvian clinics. International Family Planning Perspectives 27(1):28-33, 46 (2001). Available at:
Twenty-eight women posed as family planning clients and opted for the injectable at 19 clinics in urban areas of Peru. The women recorded the topics discussed on a 46-item checklist and estimated the length of the counseling session. The duration of counseling ranged from 2 to 45 minutes. Relevant information-giving increased by 43 percent as session length increased from 2-8 minutes to 9-14 minutes, but there was no further increase in information as sessions grew longer. No matter how long the session, many pieces of relevant information were overlooked. Offering a wide range of contraceptive options was correlated with session length, but discussion of the chosen method was not. The authors conclude that, rather than spending more time with clients, providers should use their time more efficiently by assessing clients needs, minimizing discussion of irrelevant methods, and focusing on the clients chosen method.

Luck, M. et al. Mobilizing demand for contraception in rural Gambia. Studies in Family Planning 31(4):325-335 (2000).
This quasi-experimental trial tested two interventions designed to increase family planning use. One intervention sought to mobilize latent demand for family planning by having trained women visits fellow clan members at home (the kabilo approach) and by having imams lead village meetings explaining that Muslim texts promote child spacing. The second intervention increased the availability of family planning services by assisting community health nurses to visit satellite villages regularly. Three primary health care circuits in The Gambia participated: one received only the demand-mobilization intervention, one received both interventions, and one served as a control. Baseline and follow-up surveys of approximately 1,000 women each were used to assess the impact of the interventions. Nonusers in the two intervention groups were almost four times as likely as those in the control group to adopt a modern method over the study period, controlling for ethnicity and parity. Similarly, contraceptive prevalence accelerated significantly in the intervention groups but not in the control one. There was no significant difference between the two intervention groups on either measure. A visit or discussion with a kabilo member significantly increased the likelihood that a woman was currently using a method, but no differences were found in the proportion or women who believed that Islam allows family planning. The authors conclude that the barriers to contraceptive use in rural Gambia are primarily psychosocial and can be overcome with socially appropriate counseling to potential users.

Mtawali, G. et al. Contraceptive side effects: responding to client's concerns. Outlook 12(3) (October 1994).
This article suggests clinical and counseling strategies to respond to side effects of reversible contraceptives and outlines decision pathways for addressing common side effects of progestin-only injectables, combined oral contraceptives, and IUDs.

Murphy, E. and Steele, C. Client-provider interactions in family planning services: guidance from research and program experience. MAQ Paper 1(2) (2000). Available at:
This paper summarizes lessons learned about the process and content of the client-provider interaction (CPI). In terms of process, six key principles create an atmosphere of trust that allows sharing between provider and client: treating the client well, providing the client's preferred method; providing individualized care, aiming for dynamic two-way interaction between client and provider, avoiding information overload, and using memory aids. As for content, the challenge is to avoid information overload while providing adequate information for informed choice. Providers must cover the following six content areas: understanding effectiveness, knowing advantages and disadvantages, preventing sexually transmitted infections, using the method, managing side effects, and knowing when to return and how to handle complications. The authors identify areas of need: prospective research to identify good CPI, improvements in training, effective program management for CPI, and policy that supports sound CPI.

PATH (Program for Appropriate Technology in Health). Family planning counseling: meeting individual client needs. Outlook 13(1):1-7 (May 1995). Available at:
This article explores the role of counseling in meeting client needs and suggests elements of effective counseling and counseling training programs.

PATH (Program for Appropriate Technology in Health). Improving interactions with clients: a key to high-quality services. Outlook 17(2):1-8 (July 1999). Available at:
Improving the quality of the client-provider interaction increases clients' understanding of the issues discussed, their ability to follow through on the contraceptive decisions made, and, as a result, their satisfaction with the counseling session. This article endorses a client-centered approach to counseling which places clients needs and preferences first. The emphasis is on treating clients with respect and personalizing sessions to meet their needs, no matter what social group they come from. Training providers is an important first step in improving the client-provider interaction; in addition to teaching providers new communication skills, training can help providers clarify their values and overcome biases. The article also includes useful messages for providers, counseling tips when time is limited, and recommendations on personalizing interactions to meet the needs of special groups, such as adolescents, men, refugees, and homosexuals.

Rinehart, W. et al. GATHER guide to counseling. Population Reports, Series J, Number 48. Baltimore, Marlyland: Johns Hopkins University, Population Information Program (December 1998). In English, French, Portuguese, and Spanish. Available at:
This step-by-step guide follows the mnemonic "GATHER" to help reproductive health care providers cover all of the essential elements in good counseling. For each step (Greeting clients, Asking clients about themselves, Telling clients about their choices, Helping clients choose, Explaining what to do, and Returning for follow-up), the article explains what information to cover and why, gives examples of questions and comments, and offers practical advice for providers. The guide also addresses common weaknesses in family planning counseling such as talking about sex, offering advice with controlling clients' decisions, and helping clients remember key information. A series of reference charts compiles the technical contraceptive information needed for each counseling step in easy-to-use form. Also included are STI and AIDS information for reproductive health clients, suggestions on how to overcome common counseling challenges, and a rating chart to help providers check their counseling skills.

Rudy S et al. Improving Client-Provider Interaction. Population Reports, Series Q, No. 1. Baltimore: Johns Hopkins Bloomberg School of Public Health, the INFO Project; 2003. Available at
To improve client-provider interaction (CPI), family planning programs need to address the client’s as well as the provider’s role in consultations. This means engaging clients in decision-making, understanding clients’ concerns and perspectives, and encouraging clients to play a more active role in consultations. Programs also need to move beyond training and address other factors that affect providers’ ability to interact with clients. These include job expectations, performance feedback, the work environment, rewards and recognition, and the match between workers and jobs. Using proven training practices is also important, as is evaluation. Lessons learned concerning family planning counseling can be effectively applied to other types of reproductive health counseling.

Schuler, S.R. and Hossain, Z. Family planning clinics through women's eyes and voices: a case study from rural Bangladesh. International Family Planning Perspectives 24(4):170175, 205 (1998). Available at:
In-depth interviews were conducted with 34 family planning clients in Bangladesh, and researchers observed how providers and clients interacted at eight clinics. Hierarchical modes of interaction and poor communication dominated many of the encounters, and women had to beg for services in some clinics. Providers appeared to selectively apply interpersonal skills and common courtesy; rudeness to clients was not merely a reflection of ignorance, since the paramedics appeared to know the basic principles of counseling. Limited access to medication and often arbitrary ways of determining when to dispense it created suspicion and tension between providers and clients. Most clients expressed a willingness to overlook rude treatment, long waits, and unhygienic conditions, saying that because they were poor, they could not expect better care and had no service alternatives. The authors conclude that training and other technical solutions may not be enough to improve the quality of care. Institutional policies, norms, and incentives need to become more client-oriented if the transition from in-home delivery to clinics is to be a success.

Upadhyay, U. Informed choice in family planning: helping people decide. Population Reports Series J, Number 50 (2001). Available in English, French, and Spanish at:
The principle of informed choice is important in family planning to ensure that contraceptive decisions reflect individual desires and values, are based on accurate information, and are medically appropriate. This comprehensive review examines what every stakeholder can do to promote informed choice, including policy makers, program managers, service providers, clients, the media, and donors. The report concludes that five elements are key to a successful informed choice strategy: (1) supportive policies that set appropriate standards and guidelines for service delivery, (2) communication programs that inform the public about their family planning options and their right to choose, (3) ready access to as many contraceptive methods as possible, (4) leadership and management that make informed choice the organizational norm, and (5) effective client-provider communication during individual sessions.

Worsley, K. Focus on confidential counselling in sexual and reproductive health. EC/UNFPA Initiative for Reproductive Health in Asia, Fact Sheet 10 (2001). Available at:
Using programs from southeast Asia as examples, this fact sheet offers practical advice on two elements of counseling: assuring complete confidentiality for clients and encouraging self-determination by clients. 

Xinh TT et al. Counseling about contraception among repeated aborters in Ho Chi Minh City, Vietnam. Health Care for Women International. 2004;25(1):20-39.
Qualitative interviews with 30 repeat abortion clients in Ho Chi Minh City, Vietnam found that few regularly used contraception and most had limited and often incorrect knowledge about contraceptives. Only half of the women were counseled about contraception during previous abortions, and that counseling did not discuss specific methods. Some women were given pills or IUDs during a previous abortion but without explanation. Most women wanted in-depth contraceptive counseling, preferably by a physician at a hospital using leaflets and pictures.

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Supporting correct and continuing contraceptive use

Ali M, Cleland J. Determinants of contraceptive discontinuation in six developing countries. Journal of Biosocial Science. 1999;31(3):343360.
This study uses data from Demographic and Health Surveys in six countries to investigate the determinants of contraceptive discontinuation. About 40 percent of couples discontinue their method within 24 months for reasons other than wanting a child. Discontinuation rates are lower for IUDs than other methods, perhaps because having the device removed requires a positive effort. Neither education nor urban-rural residence has much influence on discontinuation rates. Factors related to motivation are the strongest predictors: older women with larger families who do not want any more children are more persistent and successful contraceptive users than others.

Bhat PNM, Halli SS. Factors influencing continuation of IUD use in south India: evidence from a multivariate analysis. Journal of Biosocial Science. 1998;30(3):297319.
Interviews with 713 IUD acceptors in south India found that 75 percent of rural and 58 percent of urban women chose the IUD to space births. Forty-five percent reported side effects such as irregular bleeding. Only 35 percent of respondents still had their original IUD at the time of follow-up; 57 percent had requested its removal, primarily because of side effects. According to a logit model, the most significant determinants of IUD continuation were womens motivation to use the method and the experience of real or perceived side effects. The quality of services had much less impact on continuation, although medical check-ups at insertion did reduce the experience of side effects somewhat. Women who chose the IUD for spacing reasons had significantly higher discontinuation rates at three months and were more likely to complain about side effects than those who chose the method for other reasons. The authors suggest a change in policy so that the IUD is recommended to older women who want to limit childbearing but are reluctant to accept a permanent method.

Blanc AK et al. Monitoring contraceptive continuation: links to fertility outcomes and quality of care. Studies in Family Planning. 2002;33(2):127140.
This study analyzes contraceptive failure and discontinuation rates in 15 countries based on data from Demographic and Health Surveys. The total fertility rate (TFR) would be between 4 and 29 percent lower if there were no contraceptive failures resulting in births. The TFR would be between 28 and 64 percent lower if there were no births following discontinuations (excluding discontinuations because women wanted to become pregnant). Within one year of starting use of a method, between 7 and 27 percent of women stop practicing contraception for reasons related to the quality of the service environment; these include contraceptive failure, desire for a more effective method, side effects, health concerns, lack of access, cost, and inconvenience of using the method. Results suggest that family planning programs should shift their emphasis from providing methods to new clients toward reducing discontinuation rates.

Canto De Cetina, T.E. et al. Effect of counseling to improve compliance in Mexican women receiving depot-medroxyprogesterone acetate. Contraception 63:143-146 (2001).
Half of 350 new users who chose Depo-Provera as their contraceptive method received structured counseling, while the other half received routine counseling. Structured counseling employed audiovisual materials to communicate uniform messages on the risks and benefits of the method and its mode of action; it included extensive information on the likelihood of common side effects and their harmlessness. Discontinuation rates were lower in the structured counseling group (17%) than the control group (43%). Side effects were equally common in the two groups, but only in the control group was it the most common reason for stopping the method.

Cotton N et al. Early discontinuation of contraceptive use in Niger and The Gambia. International Family Planning Perspectives. 1992;18(4):145149.
Prospective studies followed 650 new contraceptive users in Niger and 570 in the Gambia for six to eight months after they accepted a method. Approximately 30 percent of new family planning clients discontinued contraceptive use within that time. In both countries, the main reasons for discontinuation were side effects (including excessive bleeding, abdominal pain, nausea, and headache) and, to a lesser extent, travel by partner, spousal disapproval, and desired pregnancy. Clients who felt they did not receive adequate counseling were more likely than others to discontinue.

Henry R. Contraceptive practice in Quirino Province, Philippines: experience of side effects. Presented at: 24th IUSSP General Conference, August 1824, 2001; Salvador, Brazil. Available at:
Semi-structured interviews with 81 married women in the Philippines examined their understanding and use of contraceptives. Womens understanding of health and menstruation was based on humoral rather than biomedical perspectives, and this perspective profoundly influenced their contraceptive experience, including their choice of method, interpretation of side effects, (mis)use of methods, and decision to discontinue. Providers contributed to misunderstandings because they were not fully informed about side effects, did not always treat side effects as real, and lacked a sufficient variety of methods to satisfy clients who had trouble tolerating side effects. The author concludes that providers need training (along with job aids and a more varied supply of methods) so that they understand, respect, and respond to clients understanding of the body, are knowledgeable about the full range of possible side effects, are prepared to counsel clients on side effects, and consider side effects as an important factor in choosing or switching methods.

Henry-Lee, A. Womens reasons for discontinuing contraceptive use within 12 months: Jamaica. Reproductive Health Matters 9(17):213-220 (2001).
Focus group discussions and multiple interviews with family planning clients in Kingston, Jamaica, over the course of a year provided information on method continuation rates as well as womens reasons for discontinuing. At one year, 57 percent of the women interviewed were still using the same method, 19 percent had switched methods, and 24 percent were not using any method. Although cost and long waiting times at clinics discouraged women from continuing, side effects were the most common reason for discontinuing. This can only be addressed by improvements in the quality of care: providers must do a better job of counseling women about the safety and side effects of methods, especially in addressing common rumors.

Hodgins S. Contraceptive discontinuation and the client's experience of method use and services. PRIME Technical Report No. 17. Chapel Hill, North Carolina: INTRAH; 1999. Available at:
In-depth interviews with contraceptive users and providers, focus groups with men, and observations of client-provider interactions were conducted to examine contraceptive discontinuation in Togo. Most women who stopped using a method did so for a combination of reasons, generally involving side effects (especially menstrual changes), fertility and health concerns, and, to a lesser extent, husbands opposition and provider issues. More important than pain, discomfort, or inconvenience associated with side effects were womens beliefs that side effects were signs of sterility or serious illness. Inadequate counseling by providers exacerbated the problem. Recommendations include: focusing services on clients, increasing access to services, making counseling more interactive and more individualized, counseling clients on menstrual changes and other fertility and health concerns, and equipping providers to manage side effects.

Huezo C. and Malhotra U. Choice and Use-Continuation of Methods of Contraception: A Multicentre Study. London: International Planned Parenthood Federation; 1993.
Clinic administrators, staff, and new clients were interviewed at ten clinics in Guatemala, Trinidad and Tobago, Hong Kong, Jordan, Nepal, and Kenya to investigate contraceptive continuation rates. In all countries, continuation rates at 12 months were higher for the IUD than either oral contraceptives or injectables. Except in Hong Kong, side effects were the most common reason for discontinuing a method. Among those women who were still using clinic services a year later, about half had continued using contraception. Personal motivation, getting the method the client intended to use before coming to the clinic, and partners agreement on using the chosen method were associated with contraceptive continuation.

Khan MA. Do women know about what to do with skipped pills: evidence from rural Bangladesh. Journal of Health & Population in Developing Countries. Chapel Hill, NC: University of North Carolina at Chapel Hill, Department of Health Policy and Administration; 2003a. Available at:
This study analyzes data from a nationally representative cross-sectional survey of 1,600 current and past pill users in rural Bangladesh. Eighty-six percent had correct knowledge about what to do if they skipped one pill, while 3 percent had no idea. Women were more likely to know what to do if they had some education and their husband encouraged their use of the pill. Only 9 percent had correct knowledge about what to if they skipped two pills, while 24 percent had no idea. Women were more likely to know what to do if there visited by field workers. Only 7 percent had correct knowledge about what to do if they skipped three pills, while 36 percent had no idea. Women were more likely to know what to do if they were educated, had fewer children, used another contraceptive before the pill, had access to television or radio, and owned land. The author concludes that women need more comprehensive, reliable, and updated information about pill use, especially from service providers and the mass media.

Khan MA. Factors associated with oral contraceptive discontinuation in rural Bangladesh. Health Policy and Planning. 2003b;18(1):101108.
A survey of 1,600 current and past users of oral contraceptives in rural Bangladesh found that the average duration of use was 27.5 months; 32 percent of respondents used OCs for less than a year. Among discontinuers, 47 percent cited side effects as the main reason for stopping the pill while 24 percent said they wanted more children. The strongest predictors for discontinuing OCs were not being visited by a fieldworker, followed by lack of husbands support for OCs, never purchasing OCs, and experiencing side effects. Among women who had discontinued OCs but did not want any more children, about 70 percent were not using any method of contraception; husbands education and occupation were the only factors that affected the likelihood of continuing with some other form of contraception. To increase effective OC use, the authors recommend more thorough counseling on side effects and alternative methods, counseling husbands along with their wives, and improving provider-client relationships.

Lei, Z.W. et al. Effect of pretreatment counseling on discontinuation rates in Chinese women given depo-medroxyprogesterone acetate for contraception. Contraception 53:357-361 (1996).
This study compared 204 women who receive detailed counseling on the hormonal effects and probable side effects of DMPA with 217 women who received only routine counseling. Discontinuation rates at one year were significantly lower in the intensive than the routine counseling group (11% versus 42%, P < 0.0001). The most common reason for terminating DMPA were menstrual changes. Menstrual changes were reported more frequently by members of the intensive counseling group (40% versus 26%), but they were less likely to terminate DMPA use for that reason (5% versus 22%). The authors conclude that counseling women about expected side effects beforehand increases their satisfaction with the method and their willingness to continue using it.

Oakley, D. Rethinking patient counseling techniques for changing contraceptive use behavior. American Journal of Obstetrics and Gynecology 170(5):1585-1590 (1994).
International data on oral contraceptive (OC) use behaviors has identified a series of common errors in pill taking, including missing pills without making them up, overdosing, and not making the transition from one cycle to the next on time. Inadequate counseling contributes to these problems: although OC use requires a complex sequence of behavior, most counseling focuses only on taking a pill every day at the same time. The author recommends making counseling more effective by modifying the style of interpersonal communication, tailoring the content to the individual, mobilizing women to plan their own use intentions, and identifying those women who need more extended counseling.

Pariani S. et al. Does choice make a difference to contraceptive use? Evidence from East Java. Studies in Family Planning. 1991;22(6):384390.
This prospective study of contraceptive discontinuation interviewed 1,945 new family planning clients in Indonesia about their preferred method and the method they received. Follow-up interviews twelve months later gathered data on contraceptive continuation. Eight-six percent of the women received the method they wanted. Getting the method desired was strongly and significantly related to sustained use. According to calculations, giving people the method they want would have increased the continuation rate from 83 to 91 percent in this sample. Husband-wife agreement on a method also contributed to continuation.

Rosenberg MJ et al. Use and misuse of oral contraceptives: risk indicators for poor pill taking and discontinuation. Contraception. 1995:51(5):283288.
This study analyzed oral contraceptive (OC) use in a convenience sample of 6,676 women between the ages of 16 and 30 from Denmark, France, Italy, Portugal, and the United Kingdom. Results show that 81 percent of the women used OCs consistently. According to logistic regression, inconsistent use was associated with a lack of an established routine for taking the pills (RR = 3.3), failure to read and understand written materials that came with the OC package (RR = 2.2), not receiving adequate information or help from the provider (RR = 1.5), and certain side effects (RR ranged from 1.2 to 2.1). Inconsistent pill use tripled the likelihood of an unintended pregnancy. Side effects, especially multiple side effects, significantly increased the likelihood of women discontinuing OC used even though they wanted to continue protecting against pregnancy. Providers can improve compliance by emphasizing the need to continue taking OCs consistently even if side effects occur.

Saha UR et al. Determinants of pill failure in rural Bangladesh. Journal of Biosocial Science. 2004;36(1):3950.
This case-control study involved 334 pill users in rural Bangladesh, half of whom had experienced a pill failure. Focus group discussions provided additional information. Both quantitative and qualitative data suggest the following risk factors for pill failure: limited mobility of the woman (which limits her access to knowledge about correct pill use), poor knowledge about the consequences of irregular pill use on the occurrence of side effects, low confidence in the pill, waiting too long before starting a subsequent pill cycle, not starting the first pill cycle on the correct day, not taking appropriate measures after missing a pill, and not taking the pills in proper sequence. Confusing, incorrect, and incomplete information contributes to incorrect and inconsistent use as does poor management of side effects. The authors recommend strengthening training and supervision for providers.

Wells E et al. The side effects of contraceptives. Presented at the XI International Meeting of the Society for the Advancement of Reproductive Care, 2001. Available at:
Providers can reduce the negative impacts of side effects on family planning satisfaction and continuation by discussing side effects before method selection, managing them promptly, and allowing method switching. Most contraceptives have some side effects, although their type and severity varies with the method, brand, and client. Providers may not discuss side effects with clients because they are too busy, fear the client will reject the method, or are not aware of how common they are. It is important, however, that providers counsel clients on what to expect before they adopt a method and make them feel comfortable returning for help. Providers should consider the impact of side effects on clients lives, their positive and negative consequences, cultural beliefs and taboos, and partners concerns. When side effects occur, providers should manage them promptly in order to increase the clients satisfaction, find out whether the client is using the method correctly, and discover whether the client has a more serious condition. Providers can advise treatment, suggest changing the formulation or brand, or help the client switch methods.

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Information, education, and communication (IEC) activities

Babalola, S. et al. The impact of a community mobilization project on health-related knowledge and practices in Cameroon. Journal of Community Health 26(6):459-477 (2001).
The Njangi community mobilization project in Cameroon selected two influential members in each community and trained them as "relais" or mid-level trainer/supervisors. They, in turn, trained members of existing community organizations as mobilizers to encourage positive attitudes and practices with regard to family planning, HIV/AIDS, and STIs. Service statistics and a comparison of baseline and follow-up indicators suggest that the project had a significant impact in the rural but not the urban location. The authors conclude that training credible community members as change agents is a quick and effective way to communicate new ideas and behaviors in a culturally appropriate and understandable manner.

Babalola, S. et al. The impact of a regional family planning service promotion initiative in sub-Saharan Africa: evidence from Cameroon. International Family Planning Perspectives 27(4):186-193, 216 (2001). Available at:
Panel data and service statistics from Cameroon were used to assess the impact of the Gold Circle campaign to promote and improve family planning service delivery sites in West Africa. More than one-third of women were exposed to the campaign, largely through television. Exposure was significantly higher among women with some education. Women who were exposed to the campaign had higher levels of family planning ideation (defined as knowledge of contraceptive methods, attitudes of self and partner toward contraceptive use, and discussion of family planning with peers and partners). They were also 80 percent more likely to use a modern contraceptive method. Service statistics show that the number of new clients more than doubled at Gold Circle clinics immediately after the campaign launch.

Brieger, W.R. et al. West African Youth Initiative: outcome of a reproductive health education program. Journal of Adolescent Health 29:436-446 (2001).
This paper evaluates the efforts of multiple community-based, youth-serving organizations in Nigeria and Ghana to implement peer-education projects. While each organization selected its own target audience and activities, they received the same outside support and technical assistance. Most of the projects included peer counseling, involving youth in live dramas, the provision of contraceptives, and the development of information, education, and communication (IEC) materials. An evaluation based on cross-sectional surveys found significant change over time and significant differences between control and intervention groups with regard to reproductive health knowledge, contraceptive use, readiness to buy contraceptives, and self-efficacy in contraceptive use. Peer education proved more successful when used in schools than in out-of-school settings.

Collumbien, M. and Douthwaite, M. Pills, injections, and audiotapes: reaching couples in Pakistan. Journal of Biosocial Science 35:41-48 (2003).
Because of restrictions on women’s mobility, men in Pakistan often purchase hormonal contraceptives for their partners. To reach women with accurate information about these products, an operations research project (since scaled up nationwide) distributed audiocassette tapes discussing the methods via pharmacies and Lady Health Visitors. Listeners were far more knowledgeable about correct use of hormonal methods than those who did not listen to the tape. Contraceptive use also increased among listeners after they received the cassette. Attending a women’s discussion group centered on the audiotape was the strongest predictor for adopting the pill or injectable.

Ellertson, C. et al. Information campaign and advocacy efforts to promote access to emergency contraception in Mexico. Contraception 66:331-337 (2002).
Efforts to introduce emergency contraception (EC) in Mexico included a public information campaign, provider training, and advocacy. The focal point of the information campaign was a toll-free telephone hotline with a recorded message describing EC; this was later complemented by a website. Legal and political opposition delayed efforts to advertise the hotline on television and radio for nearly two years. However, the campaign generated considerable media coverage with interviews, talk-show appearances, and press conferences. Also successful was the distribution of free postcards via racks placed in bars, restaurants, discos, shopping malls, and the like. Alternative media channels included overlaying condom packaging with an EC message and distributing flyers, pens, and other novelty items at special events. The information campaign generated a large volume of hotline calls and website hits.

Gupta, N. et al. Associations of mass media exposure with family planning attitudes and practices in Uganda. Studies in Family Planning 34(1):1-31 (2003).
The Delivery of Improved Services for Health (DISH) project in Uganda mounted several communication campaigns to promote the use of modern family planning methods. These multimedia campaigns used radio, television, posters, and print materials. A multivariate analysis of three successive household surveys found that, after controlling for socio-demographic characteristics, reported exposure to campaign messages was strongly associated with increased contraceptive use and the intention to use a method in the near future. These effects increased with the number of mass media channels respondents were exposed to. Two channels proved especially effective: reproductive health logos that marked where services were availability and radio advertisements for family planning services and socially marketed contraceptives.

Jato, M.N. et al. The impact of multimedia family planning promotion on the contraceptive behavior of women in Tanzania. International Family Planning Perspectives 25(2):60-67 (1999). Available at:
This study uses data from the 1994 Tanzania Knowledge, Attitudes and Practice Survey to assess the impact of a mass media family planning campaign on women's contraceptive use. More than half (55%) of the 4,225 women surveyed recalled hearing or seeing family planning messages in the media; more than a third were exposed to three or more channels. Radio had the greatest reach: it was recalled by 49 percent of all women. Exposure to multiple media channels increased the impact of the campaign: women exposed to one channel were 1.5 times as likely to use contraception as those not exposed to the campaign, and women who recalled six channels were 9.2 times as likely to use contraception. Campaign exposure had a stronger impact on the use of modern than traditional methods. Exposure to radio and newspapers also increased the likelihood that women discussed family planning with their spouses. The authors conclude that using multiple media to promote family planning extends the reach of a campaign, intensifies its impact, and creates the sense that contraceptive use is a social norm.

Johns Hopkins University Center for Communication Programs (JHU/CCP). A Report on the Second International Conference on Entertainment-Education and Social Change. Baltimore: JHU/CCP (1997). Available at:
These conference proceedings examine how entertainment formats have been used in programs around the world to deliver pro-social educational messages. Presentations discuss building and maintaining partnerships between entertainment and social development entities, using research to guide program design, reaching young people, new technology and participatory media, mass media, designing and implementing campaigns involving multiple communication activities, and evaluating entertainment-education programs.

Kabir, M. and Amirul Islam, M. The impact of mass media family planning programmes on current use of contraception in urban Bangladesh. Journal of Biosocial Science 32:411-419 (2000).
To assess the impact of family planning messages disseminated via the mass media on contraceptive use, a nationally representative sample of 871 married Bangladeshi women living in urban areas was surveyed. Overall, 84 percent had access to radio, 58 percent to television, and 11 percent to newspapers. Among these women, exposure to family planning messages within the past three months was 38 percent for radio, 19 percent for television, and 9 percent for newspapers. A multivariate analysis found that exposure to family planning messages on radio was significantly associated with current contraceptive use (OR = 1.45), controlling for age, number of children, education, religion, and employment.

Kane, T.T. et al. The impact of a family planning multimedia campaign in Bamako, Mali. Studies in Family Planning 29(3):309-323 (1998).
Baseline and follow-up surveys of 1,692 men and women were used to evaluate the impact of a 1993 television and radio campaign on family planning knowledge, attitudes, and practices in Bamako, Mali. During the six-month interval between surveys, the proportion of men and women who intended to use modern contraception in the future increased from 54 percent to 75 percent for men, and from 46 percent to 63 percent for women. Exposure to a television spot on Islam and family planning led to a sharp drop in the proportion of women who believed that Islam opposed family planning, from 57 percent to 17 percent. Contraceptive knowledge changed little from high baseline levels. Modern contraceptive use among married couples increased from 12 percent to 15 percent among women, and from 27 percent to 30 percent among men. According to a multivariate analysis, contraceptive use was associated with the intensity of campaign exposure among educated respondents. The authors recommend that future activities continue to use traditional theater, music, and proverbs, which provided the content for this campaign, to help bridge the gap between established cultural values and new ideas about family planning.

Kincaid, D.L. et al. Impact of a mass media vasectomy promotion campaign in Brazil. International Family Planning Perspectives 22(4):169-174 (1996).
During a 1989-1990 mass media campaign promoting vasectomy in three Brazilian cities, monthly calls and visits to clinics increased from 133 percent to 261 percent, and the mean number of vasectomies per month increased from 59 percent to 108 percent. After the campaign, the numbers of calls, visits, and vasectomies fell, in some cases to levels lower than those before the campaign began. A longitudinal analysis of the impact of three media promotions (in 1983, 1985, and 1985) on vasectomies at the PRO-PATER clinic in São Paulo found that each promotion increased the number of vasectomies for a short time only, and that the 1989-1990 campaign temporarily reversed a long-term downward trend in the number of vasectomies performed. The authors conclude that some kind of ongoing or periodic promotion is needed to maintain clinic volume.

Knebel, E. et al. The Use of Manual Job Aids by Health Care Providers: What Do We Know? QA Issue Paper No. 1. Bethesda, Maryland: Quality Assurance Project (February 2000). Available at:
This literature review exhaustively examines quantitative and qualitative research on job aids and their impact on health care providers' performance. Because there has been little research on job aids in developing countries, most of the studies reviewed involve U.S. doctors and nurses. However, the paper does focus on less expensive, non-computerized, manual job aids that may be suitable for the developing world. Job aids of this kind are a cost-effective way to promote provider compliance with guidelines. The authors identify a series of key research questions for future investigation: Do providers actually use job aids? Are they appropriate for community health workers? What factors promote their use? What is their cumulative impact on providers? How do they affect patient outcomes? And what is the best way to develop and apply them?

Mbananga, N. and Becker, P. Use of technology in reproductive health information designed for communities in South Africa. Health Education Research 17(2):195-209 (2002).
A survey of rural and urban communities in a poorly developed region of South Africa was conducted to examine how well posters and pamphlets convey reproductive health information. Results show that images on posters do not perform well in communicating the intended message; 81 percent of respondents felt the images were not relevant to the caption. Prior exposure to reproductive health information helped people understand the messages on the posters, a fact that may have contributed to urban dwellers higher levels of comprehension. Pamphlets seem to convey the intended information better than visual materials, although rural dwellers again were at a disadvantage in understanding the material. The authors conclude that print materials currently used in South Africa are ineffective in conveying health messages to poor communities.

Parr, N. Family planning promotion, contraceptive use, and fertility decline in Ghana. African Population Studies 17(1):83-101 (2002).
Using data from the 1998 Ghana Demographic and Health Survey, this study examined whether exposure to family planning promotional messages increased contraceptive use and lowered fertility. Exposure to messages disseminated by radio, television, posters, brochures, and leaflets significantly increased the likelihood of women using contraception but did not make an impact on fertility levels—perhaps because of traditional birth spacing practices, because pregnancy and childbearing increase women’s exposure to family planning messages at clinics, or because of the overwhelming impact of age, education, and residence on fertility. Exposure to messages in newspapers and magazines did not significantly affect either contraceptive use or fertility.

Piotrow, P.T. et al. Health Communication: Lessons from Family Planning and Reproductive Health. Westport, Connecticut: Praeger (1997).
This book explains why and how systematic communication strategies can improve health behavior and offers advice on designing communication programs to promote family planning and reproductive health in developing countries. It is based on the experience of the Center for Communication Programs at the Johns Hopkins School of Public Health. After reviewing theories of communication and behavior change, a series of six chapters discuss each step in the process of designing and implementing a family planning campaign, including: (1) preliminary analysis for program planning: (2) strategic design; (3) the development, pretesting, and production of materials; (4) management, implementation, and monitoring; (5) impact evaluation; and (6) planning for continuity. These chapters are organized into a series of lessons learned, and they offer practical advice for program managers. Each lesson is illustrated with case examples and empirical data from developing countries. The book ends with a discussion of future trends in health communication.

Rogers, E.M. et al. Effects of an entertainment-education radio soap opera on family planning behavior in Tanzania. Studies in Family Planning 30(3):193-211 (1999).
An entertainment-education radio soap opera was introduced in Tanzania in 1993. Data about the effects of the soap opera were collected in five annual surveys of about 2,750 households in areas of the country that did or did not receive the broadcasts. In addition, a sample of new family planning adopters in 79 health clinics was surveyed. Household survey data suggest that the radio program increased: listeners' sense of self-efficacy with respect to family size determination, the ideal age at marriage for women, approval of contraceptive use, interspousal communication about family planning, and current practice of family planning. Clinic data found that the soap opera was the source of referral for about one-quarter of all new family planning clients.

Sharan, M. and Valente, T.W. Spousal communication and family planning adoption: effects of a radio drama serial in Nepal. International Family Planning Perspectives 28(1):16-25 (2002). Available at:
Three rounds of panel data from 1,442 women were used to assess whether exposure to a radio serial drama in Nepal influenced spousal communication and whether that, in turn, was associated with family planning use. Women who heard the program were nearly twice as likely to believe their spouse approved of family planning and to have discussed it with their spouse. Women who talked with their spouse about family planning were ten times as likely to use family planning. Spousal communication also contributed, over time, to joint decision-making. Among those women who had not discussed family planning with their spouse at baseline, exposure to the drama led to communication and subsequent family planning use. It is more difficult to assess the programs effects on women who had already discussed family planning with their spouse at baseline.

Storey, D. et al. Impact of the Integrated Radio Communication Project in Nepal, 1994-97. Journal of Health Communication 4:271-294 (1999).
This study evaluates the impact of a two-part radio communication project in Nepal that broadcast a soap opera, spots, and musical jingles to the general public and a distance education serial to clinic-based health providers. Data come from tests of providers' knowledge, observations of counseling sessions, client exit interviews, client flow at two sentinel sites, and a longitudinal panel survey of 1,905 married women. The entertaining, dramatic format used in both the soap opera and distance education serials proved appealing and effective. Providers' test scores increased from 57 percent to 74 percent after training; the number of positive provider communication skills per session doubled from 5 to 10, and client participation increased. Client flow increased markedly during the radio campaign. Survey data show that exposure to the radio programs was responsible for a 11.7 percent gain in contraceptive adoption and a 7.4 percent gain in continuation, although the impact of the radio serials on contraceptive use was largely indirect. The radio serials encouraged interpersonal communication with health workers and spouses as well as positive attitudes toward and perceived normative support for family planning. These changes in behavior and ideation, in turn, increased contraceptive use.

Villanueva, C.L. Focus on innovative IEC materials on reproductive health. EC/UNFPA Initiative for Reproductive Health in Asia, Fact Sheet 9 (2001). Available at: in Asia, Fact Sheet 9 (2001). Available at:
This fact sheet reviews innovative approaches to IEC in reproductive health, including broadcast media, folk media and street dramas, hotlines, school curricula, training materials, information technology, and advertisements.

Westoff, C.F. and Bankole, A. Mass media and reproductive behavior in Pakistan, India, and Bangladesh. Demographic and Health Surveys Analytic Report Number 10. Calverton, Maryland: Macro International (1999).
DHS data on women's exposure to general media programming and to explicit family planning messages on radio and television was analyzed for Pakistan, India, and Bangladesh. According to logistic regression analyses of the most recent surveys, which controlled for women's social and demographic characteristics, women exposed to family planning messages on radio and television were 1.5 to 2.2 times more likely than other women to approve of family planning, 1.3 to 1.5 times more likely to have discussed family planning with their husbands, and 1.1 to 1.7 times more likely to currently use a method. Exposure to general radio and television programming had similar effects, but the associations were less strong and less consistent. The impact of media exposure was heightened when women were exposed to more types of media (data from Pakistan) and when both husband and wife were exposed to family planning messages (data from Bangladesh).

World Health Organization (WHO). Communicating Family Planning in Reproductive Health: Key Messages for Communicators. Geneva: WHO, (1997).
This booklet outlines a series of key messages, backed up by supporting examples, to help reproductive health advocates develop clear, consistent, positive messages about the benefits of family planning. These messages are synthesized from years of research and practical experience from family planning programs around the world. The prototype messages are intended to be adapted by local organizations to meet cultural and information needs of different audiences. Information in this booklet would be helpful in conversations with policy makers, family planning counselors, potential users, family members, religious leaders, and other influential members of the community.

World Health Organization (WHO). Health Benefits of Family Planning. Geneva: WHO (1994).
This booklet summarizes key findings about the health benefits of family planning and explains how offering a choice of contraceptive methods benefits clients as well as programs. The booklet is addressed to policy makers, program managers, and community leaders. It offers concise, up-to-date information about the benefits of family planning and the need for adequate human and financial resources at all levels.

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