| Retour à la page d'accueil |
| Back to Home page |
INTERNATIONAL FAMILY PLANNING PERSPECTIVES, March 2000, Vol. 26, N° 1
KIM, Young Mi; PUTJUK, Fitri; BASUKI, Endang; KOLS, Adrienne.
Self-assessment and peer review: Improving Indonesian service providers' communication with clients.
Context: Training alone may not be sufficient to prompt complex and lasting changes in the performance of family planning providers. Affordable and effective reinforcement mechanisms are needed to ensure that providers apply new skills on the job.
Methods: In December 1997 and January 1998, 201 providers working at 170 clinics in Indonesia attended a training course on client-centered counseling. They were divided into three subgroups for follow-up. One group (controls) received no reinforcement, one conducted weekly self-assessments and the third attended peer-review meetings in addition to conducting self-assessments. Data were collected before training, immediately afterward and after four months of reinforcement to measure changes in provider and client behavior.
Results: In the month after training, counseling sessions were about twice as long as before, and providers offered twice as much information and counseling on medical and family planning issues. The frequency of providers' facilitative communication (which fosters rapport and client participation) doubled from 15 to 30 instances per session, and the number of clients' questions increased from 1.6 to 3.3. After reinforcement, providers' facilitative communication, clients' active communication and clients' ratings of self-expression and satisfaction increased in the self-assessment group, but did not change significantly in the control group. Both providers' facilitative communication and clients' active communication improved further in the peer-review group, but this intervention did not affect clients' perspectives on the counseling experience.
Conclusions: Self-assessment and peer review help maintain providers' performance after training and prompt continuous quality improvement.
(INDONESIA, FAMILY PLANNING PERSONNEL, IN-SERVICE TRAINING, METHODOLOGY, EVALUATION, COMMUNICATION TRAINING).
English - pp. 4-12.
Y. M. Kim, A. Kols, Johns Hopkins University, Center for Communication Programs, Baltimore, MD, U.S.A.; F. Putjuk and E. Basuki, Johns Hopkins University, Center for Communication Programs, Indonesia.
***
SPEIZER, Ilene S.; HOTCHKISS, David R.; MAGNANI, Robert J.; HUBBARD, Brian; NELSON, Kristen.
Do service providers in Tanzania unnecessarily restrict clients' access to contraceptive methods?
Context: Even where family planning services are physically accessible and economic barriers to access are few, medical barriers to contraceptive services--such as overspecialization, eligibility restrictions, process hurdles and provider bias--can limit women's use of services.
Methods: Data from the 1996 Tanzania Service Availability Survey are used to analyze the prevalence of medical barriers by type of provider, by type of facility and by urban-rural location.
Results: Relatively high proportions of providers restrict eligibility by age, particularly for oral contraceptives, the most widely used method among Tanzanian women. Between 79% and 81% of medical aides, trained midwives, maternal and child health aides and auxiliary staff (the most common types of family planning service providers in rural Tanzania) impose age restrictions for the pill. Among all providers, 10-13% report that there is at least one modern method they would never recommend, and 13% report having sent a client home until her next menses, an inappropriate process hurdle for the provision of most hormonal methods. In the aggregate, these restrictions severely limit access to contraceptives for certain groups of women. For example, young, unmarried women who are not menstruating at the time of their visit would encounter one or more barriers or process hurdles at more than 70% of urban facilities and at 80% of rural facilities.
Conclusions: If preservice and in-service training and supervisory visits placed greater emphasis on compliance with the Tanzanian National Family Planning Program's service guidelines and standards, providers' unnecessary restrictions on contraceptive use might be reduced, and ultimately eliminated.
(TANZANIA, FAMILY PLANNING PROGRAMMES, FAMILY PLANNING PERSONNEL, CONTRACEPTIVE TRAINING, PRESCRIPTION OF CONTRACEPTIVES, PROGRAMME EVALUATION).
English - pp. 13-20 and 42.
I. S. Speizer, D. R. Hotchkiss, R. J. Magnani, K. Nelson, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, U.S.A.; and B. Hubbard, Centers for Disease Control and Prevention, 1600 Clifton Rd., Atlanta, GA 30333, U.S.A.
***
SINGH, Susheela; WULF, Deirdre; SAMARA, Renee; CUCA, Yvette P.
Gender differences in the timing of first intercourse: Data from 14 countries.
Context: Early initiation of intercourse and the context within which sexual activity begins are key indicators of adolescents' potential risk for unplanned pregnancy, abortion and sexually transmitted diseases. Comparative information on the sexual behavior of male and female adolescents in different countries assists health planners and service providers in meeting adolescents' needs.
Methods: Data from the most recent nationally representative surveys of reproductive behavior in 14 countries throughout the world were used to assess regional variations in young people's sexual behavior. Analyses focus on 15-19-year-olds, but also use data from 20-24-year-olds to provide a more complete picture of gender differences in behavior during adolescence.
Results: In most countries, roughly one-third or more of teenage women have had intercourse; in four countries (Ghana, Mali, Jamaica and Great Britain), about three in five are sexually experienced. Between about one-half and three-quarters of adolescent males in seven countries have ever had intercourse, but the proportion is one-third or less in Ghana, Zimbabwe, the Philippines and Thailand. In most countries, sexual intercourse during the teenage years occurs predominantly outside marriage among men but largely within marriage among women. Never-married young people are considerably less likely to be currently sexually active than to be sexually experienced. For example, in Ghana, 49% of never-married adolescent women have had intercourse, but only 23% have done so within the past month.
Conclusions: In most of these countries, a high proportion of adolescents are potentially at risk for a range of poor reproductive health outcomes. Program planners must find ways to help sexually active adolescents consistently use effective means of protection against both pregnancy and sexually transmitted diseases.
(ADOLESCENTS, SEXUAL BEHAVIOUR, SEX DIFFERENTIALS, COITUS, COMPARATIVE ANALYSIS).
English - pp. 21-28 and 43.
S. Singh, The Alan Guttmacher Institute, 120 Wall Street, 21st Floor, New York, N.Y. 10005, U.S.A.
***
ZAVIER, Francis; PADMADAS, Sabu S.
Use of a spacing method before sterilization among couples in Kerala, India.
Context: Many couples in India never use a reversible method to delay or space births, and instead adopt sterilization as their first and only method. Little is known about the factors that distinguish sterilized couples who have used spacing methods from those who go directly to using a permanent method.
Methods: Data on 2,029 ever-married women protected by sterilization are taken from the part of the 1992-1993 Indian National Family Health Survey that was conducted in the state of Kerala. Multivariate logistic regression techniques are used to assess the socioeconomic, demographic and behavioral characteristics that determine prior temporary method use among sterilized couples.
Results: Once all significant variables are controlled for, higher educational attainment (of either partner) independently increases the likelihood that a couple will have used a method to delay or space births, as does middle socioeconomic status. That likelihood is also significantly higher among respondents who experienced an abortion, among Christian women and among those who were older than age 25 when either they or their partner were sterilized. However, the likelihood of temporary method use before sterilization is significantly reduced among respondents who preferred shorter birth intervals and among relatively older women (age 31 and older). The median interval between the first and second children born to sterilized couples who had ever used a reversible method was longer than that among children born to couples who had relied only on sterilization (32 months vs. 26 months).
Conclusions: In Kerala, both small family size ideals and a desire to shorten the period of exposure to the risk of pregnancy might explain the tendency for couples to go directly to sterilization at a relatively young age and bypass temporary method use altogether. An approach that emphasizes clients' choice of methods and high-quality services that cater to their needs would enhance the use of methods to space births.
(INDIA, STATE, SEXUAL STERILIZATION, CONTRACEPTIVE METHODS, BIRTH SPACING, CONTRACEPTIVE USAGE).
English - pp. 29-35.
F. Zavier, Department of Demography, University of Kerala, Trivandrum, India; S. S. Padmadas, Population Research Center, Faculty of Spatial Sciences, University of Groningen, Netherlands.
***
ORTAYLI, Nuriye; BULUT, Aysen; NALBANT, Hacer; COTTINGHAM, Jane.
Is the diaphragm a viable option for women in Turkey?
Context: In Turkey, where contraceptive prevalence is about 65%, a large number of couples rely on withdrawal and the IUD. Although the country has had a national family planning program for 35 years, the diaphragm has not been introduced as a contraceptive option.
Methods: Diaphragms were offered to women as a contraceptive option during counseling sessions at four family planning clinic sites in western Turkey: two public-sector clinics (one in Çapa, Istanbul, the other in Izmir) and two private-sector clinics (one in Incirli, Istanbul, the other in Denizli). Women who chose the diaphragm were interviewed at enrollment and were invited for follow-up visits with a physician at two weeks and at any time thereafter. Demographic information was also collected from an additional 740 women who chose another contraceptive method, and focus-group discussions were conducted with diaphragm users and their partners, with users of other methods and with service providers.
Results: Overall, 166 women selected the diaphragm, and 161 enrolled in the study. Initial acceptance rates were higher at the two private clinics (14% and 6%) than at the public clinics (3% and 1%). At the public-sector clinics, diaphragm users were better educated and more likely to be professionally employed than were women who selected other contraceptive methods. In Çapa, 42% of women who chose the diaphragm were university graduates, compared with 7% of those who chose another method. Despite differences between the two private clinics in clients' educational levels, no such differences existed between diaphragm acceptors and users of alternative methods at each site. Among women who chose the diaphragm, 47% said they had sex four times or more per week, compared with 29% of those using another contraceptive. More than half of the women who selected the diaphragm (59%) cited safety and freedom from side effects as the reason for their choice of contraceptive. A similar percentage of clients who used other methods (58%) cited effectiveness. Fifty percent of diaphragm users had discontinued by six months, and 66% had done so by 12 months.
Conclusion: A small proportion of clients in both private- and public-sector clinics were interested in using the diaphragm and found it acceptable. In less-developed countries, the diaphragm may be a viable contraceptive option when providers are able to provide adequate information and support.
(TURKEY, FEMALE CONTRACEPTIVE AGENTS, VAGINAL DIAPHRAGM, CONTRACEPTIVE METHODS, METHOD ACCEPTABILITY, CHOICE).
English - pp. 36-42.
N. Ortayli, A. Bulut, H. Nalbant, Woman and Child Health Training and Research Unit, Medical School of Istanbul, Turkey; J. Cottingham, World Bank Special Programme of Research Development and Research Training in Human Reproduction, WHO, Geneva, Switzerland.
***
INTERNATIONAL FAMILY PLANNING PERSPECTIVES, June 2000, Vol. 26, N° 2
WESTOFF, Charles F.; BANKOLE, Akinrinola.
TRENDS IN THE DEMAND FOR FAMILY LIMITATION IN DEVELOPING COUNTRIES.
Context: While most developing countries have at least begun the transition from high to low fertility, the process has occurred at very different rates in various regions. The pattern of change in sub-Saharan Africa differs from that of other regions, a factor that has implications for family planning programs there.
Methods: Data from 108 Demographic and Health Surveys, World Fertility Surveys and Contraceptive Prevalence Surveys were assembled for 41 developing countries, covering the period extending from the mid-1970s to the late 1990s.
Results: The percentage of women who want no more children has risen slowly but steadily in sub-Saharan Africa since the 1970s, having reached a level of 20-40% in many countries by the late 1990s. Yet overall levels remain far below those seen in Asia and in North Africa, where the level of demand for limiting births clusters in the 40-60% range. The proportion of women wanting to stop childbearing is also high in Latin America, and shows more evidence of leveling off than in Asia. Unmet need for the means to limit births is increasing fairly uniformly for most sub-Saharan African countries; in contrast, in Asia and North Africa and Latin America and the Caribbean, it is generally declining with the adoption of contraceptive use. While the evidence indicates that most women in sub-Saharan Africa who practice contraception do so to space rather than to limit births, trend data suggest that the proportion of users practicing contraception to limit births has been increasing in recent years; in some countries, this proportion approaches half of all method use, and is higher than expected elsewhere. In contrast, there has been little change in this balance in Asia and North Africa and in Latin America and the Caribbean, with the great majority of users in both regions seeking to limit rather than space births.
Conclusions: While demand for contraception is increasing throughout the developing world, most of the demand in Asia and North Africa and in Latin America is already being met, while much of the demand in sub-Saharan Africa is not. In both Asia and Latin America, where contraceptive use is already high, providers need to gear their services toward helping clients to continue use and to improve the effectiveness of their contraceptive practice. In sub-Saharan Africa, where use is low, programs must aim to encourage adoption of modern methods.
(DEVELOPING COUNTRIES, FAMILY PLANNING PROGRAMMES, NEEDS, CONTRACEPTIVE USAGE, CONTRACEPTIVE PREVALENCE, DEMAND).
English - pp. 56-62 and 97.
C. F. Westoff, Office of Population Research, Princeton University, Princeton, NJ 08544-2091, U.S.A.; A. Bankole, The Alan Guttmacher Institute, 120 Wall Street, 21st Floor, New York, N.Y. 10005, U.S.A.
westoff@princeton.edu.
***
WILLIAMS, Timothy; SCHUTT-AINÉ, Jessie; CUCA, Yvette.
MEASURING FAMILY PLANNING SERVICE QUALITY THROUGH CLIENT SATISFACTION EXIT INTERVIEWS.
Context: Because of the widely recognized importance of quality of care in the provision of family planning and sexual and reproductive health services, there is a great need to develop simple means of evaluating quality of care. Of particular interest are approaches that take into account clients' satisfaction with their care.
Methods: A model client exit interview developed by the International Planned Parenthood Federation, Western Hemisphere Region, was used to measure levels of client dissatisfaction with various components of quality. From 1993 through 1996, 89 surveys of more than 15,000 clients were conducted in eight Latin American and Caribbean countries.
Results: The areas of quality that most often received more than 5% negative response from clients (termed negative response cases) were waiting time (mentioned in 70% of surveys, with a mean dissatisfaction level of 20%), ease of reaching the clinic (in 54%, with an average dissatisfaction level of 12%) and price of services (47% and 10%, respectively). Using the survey results, participating family planning associations made changes to improve quality in these areas, ranging from improving appointment systems to relocating to implementing sliding fee scales. Results from 16 subsequent follow-up surveys showed a decline in each country in the number of negative response cases, as well as in the mean level of dissatisfaction. For example, in Brazil, the mean number of negative response cases per survey declined from 2.7 to 2.2, and the mean level of dissatisfaction among them fell from 19% to 11%.
Conclusions: Well-known problems of measuring client satisfaction may be addressed by focusing on a low threshold of dissatisfaction as a way to uncover shortcomings in service quality. Although declines in dissatisfaction cannot be attributed entirely to the changes made as a result of the use of the questionnaires, client surveys can provide a quick and inexpensive way of determining areas of service where quality could be improved. These kinds of improvements will be necessary if service providers hope to become more sustainable and if they are to help clients meet their reproductive health needs.
(LATIN AMERICA, FAMILY PLANNING PROGRAMMES, PROGRAMME EVALUATION, METHODOLOGY).
English - pp. 63-71.
T. Williams, John Snow International, Arlington, VA, U.S.A.; Y. Cuca, International Planned Parenthood Federation, Western Hemisphere Region.
***
CHANGES IN FAMILY-BUILDING PATTERNS IN EGYPT AND MOROCCO: A COMPARATIVE ANALYSIS.
Context: Although both Egypt and Morocco experienced important declines in fertility over the past few decades, the pace of that decline was much faster in Morocco than in Egypt. Relatively little is known about the extent to which patterns of family building in both countries explain differentials in the pace of fertility decline.
Methods: The data for analysis come from the 1980 and 1979-1980 World Fertility Surveys conducted in Egypt and Morocco, respectively, and from each country's 1995 Demographic and Health Survey. These data are used to calculate life-table estimates of the cumulative proportions of women who progressed to each successive parity within five years of the previous one. The data are also used to calculate singulate mean age at marriage and the median length of birth intervals.
Results: From the late 1970s to the mid-1990s, fertility declined by 44% in Morocco and by 28% in Egypt, reflecting a drop in both the level and pace of childbearing. The cumulative proportions of women progressing to each successive parity fell by at least 25% at each parity transition after the transition between a third and fourth birth in Egypt; the pattern was more mixed in Morocco, with declines fluctuating between 11% and 27%, starting at the transition between a second and third birth. Moreover, the median length of time between births increased over the period, especially in the intervals between births at parities 2-4 in Morocco (increases of 4.2-4.7 months) and at parities 1-3 in Egypt (increases of 3.0-3.6 months). Among the factors contributing to these fertility declines was a rise over the period in the singulate mean age at marriage (by five years in Morocco and by one year in Egypt).
Conclusions: The adoption of effective family planning programs by both countries, which are increasingly enabling women to meet their desire for smaller families, may be responsible for the significant changes in the reproductive behavior of married women in Egypt and Morocco.
(EGYPT, MOROCCO, FAMILY FORMATION, COMPARATIVE ANALYSIS, FERTILITY DECLINE, FERTILITY DETERMINANTS, PARITY PROGRESSION RATION, BIRTH INTERVALS, AGE AT MARRIAGE).
English - pp. 73-78.
E. E. Eltigani, Social Research Center, American University, Cairo, Egypt.
***
EGGLESTON, Elizabeth; LEITCH, Joan; JACKSON, Jean.
CONSISTENCY OF SELF-REPORTS OF SEXUAL ACTIVITY AMONG YOUNG ADOLESCENTS IN JAMAICA.
Context: Adolescents' sexual behavior is an important issue in developing countries and a focus of programmatic efforts for reducing pregnancy and sexually transmitted disease. Yet the accuracy of young people's reports of their sexual activity has rarely been carefully examined.
Methods: Data from a three-round longitudinal study of 698 young adolescents in Jamaica were used to examine consistency in the reporting of first sexual intercourse. Adolescents were asked to respond to multiple questions about their first intercourse within each round of the survey, and the items were repeated in subsequent rounds. A multivariate logistic regression analysis was conducted to examine the factors independently influencing the likelihood that adolescents would report their sexual experience inconsistently.
Results: The vast majority of respondents (95-100%) reported their sexual experience status consistently within a given survey round. However, when agreement of responses between rounds was examined, 37% of respondents--12% of girls and 65% of boys--responded inconsistently. Multivariate logistic regression analysis indicated that boys were nearly 14 times as likely as girls to report their sexual experience inconsistently.
Conclusions: Pervasive inconsistency in the reporting of sexual activity, especially among boys, highlights the limitations of relying on self-reported data to identify sexually active adolescents and to quantify that activity. Using such data to evaluate the impact of interventions designed to delay first intercourse may also be problematic.
(JAMAICA, ADOLESCENTS, SEXUALITY, DATA COLLECTION, QUALITY OF DATA).
English - pp. 79-83.
E. Eggleston, Population Leadership Program, US Agency for International Development (USAID), Paraguay; J. Leitch, Mona Information Systems Unit, and J. Jackson, Fertility Management Unit, University of the West Indies, Kingston, Jamaica.
***