Impact Data - Community Education Interventions in Sexual and Reproductive Health Services
This research project was carried out by the Centro de Información y Desarrollo de la Mujer (CIDEM) with financial support from the Frontiers in Reproductive Health (FRONTIERS) Small Grants Program. The investigation was initiated in February 2000 and had a 2-year duration. The project was developed to continue support of a series of reproductive health interventions to improve quality of care in Bolivia initiated by the Ministry of Health and Prevention (MSPS), with a methodology proposed by the World Health Organization (WHO). This approach was pilot-tested between 1995-98 in areas throughout Bolivia, including Health District I of the city of La Paz. Evaluation of the MSPS/WHO project showed that the interventions improved services but did not increase demand among underserved populations. It was concluded that the intervention's impact would continue to be low unless the project could reach community members and create more demand for services. The purpose of the new research was to evaluate the impact of a community intervention on utilisation of and community satisfaction with sexual and reproductive health (SRH) services.
Four health centres participated in this research project, which addressed adult and adolescent men and women:
- Chamoco Chico - intervention site
- La Portada - intervention site
- Alto Mariscal Santa Cruz - control site
- Obispo Indaburo - control site
Methodologies
CIDEM collected both qualitative and quantitative data for this study with a quasi-experimental design. Four health centres were selected, with two assigned to receive the intervention and two monitored as control sites. (All four centres previously participated in the MSPS/WHO quality improvement programme.) A baseline analysis was conducted during the first phase of the project. After 15 months, staff conducted a post-intervention impact evaluation, using the same qualitative and quantitative methodology applied to the baseline survey. When possible, researchers interviewed the same focus groups and individuals who participated in the baseline survey and educational sessions; however, migration caused some variation in both the participants reached and the methodology.
Knowledge Shifts
After the educational sessions, the adolescents of Chamoco Chico and La Portada had broader knowledge about the health centres in their neighbourhoods and the services they offer. In La Portada, a community health fair publicised health centre services; however, adolescents' demand for services remains low.
Practices
The number of women client visits to the health centres in Chamoco Chico and La Portada increased dramatically, while there were no significant changes in the number of visits to the 2 control clinics. One possible reason for the greater increase in visits in the experimental clinics was that women came to trust these health centres more, as evidenced by the focus group discussions.
More adolescents visited health centres in the intervention sites than in the control sites. Although improvements in service utilisation are less dramatic when considered as a ratio to all adolescents, both intervention health centres outperformed the control centres serving male adolescent clients, and the La Portada health centre has a substantially higher number of visits by female adolescents: approximately 250 prior to the intervention, as compared to 450 after. Adolescents in Chamoco Chico gained trust in the health centre, reflected in the increased number of consultations.
This study shows that modern contraceptive method use in the experimental clinics increased dramatically among adult women during the intervention period, compared to the control. For example, the number of women using modern contraceptive methods in both experimental sites increased from less than 200 to nearly 1200 in the course of the intervention. As a comparison, in the control sites, the number of women using these modern methods increased from approximately 100 to approximately 650 in the control sites. Interestingly, the increase in new modern method users did not diminish the number of women clients using natural methods. Instead, natural method use also improved during the intervention, in both experimental and control clinics, presumably due to the increased number of clients seeking services and the quality of care activities implemented in each of the sites.
The number of adolescent contraception users increased in all four health centres during the intervention. For example, the use of the injectable synthetic hormone called depot medroxyprogesterone acetate (Depo-Provera or DMPA) at Chamoco Chico increased from approximately 7 users (pre-intervention) to 33 users (post-intervention). Evaluators explain that improvements at the Alto Mariscal Santa Cruz control site can be attributed in part to efforts by the youth centre, which had been operating there since 2001 with the support of an NGO specialised in working with this age group.
Beginning in January 2001, the national basic health insurance system (SBS) incorporated Pap smear testing into its services. As expected, the number of clients increased, particularly in the intervention clinics. But the figures were not consistent from one semester to the next. Among possible explanations: women mentioned that even though the service is now offered for free they were charged for the associated consultation. Many women mentioned that their Pap smear test results arrived late or were lost, and that the exam did not lead to a timely diagnosis.
Despite the attitudes reflected in the post-intervention interviews, statistical information shows that few men go to health service centres for contraception. However, there has been an increase in couple consultations at the clinics.
More adolescents visited health centres in the intervention sites than in the control sites. Although improvements in service utilisation are less dramatic when considered as a ratio to all adolescents, both intervention health centres outperformed the control centres serving male adolescent clients, and the La Portada health centre has a substantially higher number of visits by female adolescents: approximately 250 prior to the intervention, as compared to 450 after. Adolescents in Chamoco Chico gained trust in the health centre, reflected in the increased number of consultations.
This study shows that modern contraceptive method use in the experimental clinics increased dramatically among adult women during the intervention period, compared to the control. For example, the number of women using modern contraceptive methods in both experimental sites increased from less than 200 to nearly 1200 in the course of the intervention. As a comparison, in the control sites, the number of women using these modern methods increased from approximately 100 to approximately 650 in the control sites. Interestingly, the increase in new modern method users did not diminish the number of women clients using natural methods. Instead, natural method use also improved during the intervention, in both experimental and control clinics, presumably due to the increased number of clients seeking services and the quality of care activities implemented in each of the sites.
The number of adolescent contraception users increased in all four health centres during the intervention. For example, the use of the injectable synthetic hormone called depot medroxyprogesterone acetate (Depo-Provera or DMPA) at Chamoco Chico increased from approximately 7 users (pre-intervention) to 33 users (post-intervention). Evaluators explain that improvements at the Alto Mariscal Santa Cruz control site can be attributed in part to efforts by the youth centre, which had been operating there since 2001 with the support of an NGO specialised in working with this age group.
Beginning in January 2001, the national basic health insurance system (SBS) incorporated Pap smear testing into its services. As expected, the number of clients increased, particularly in the intervention clinics. But the figures were not consistent from one semester to the next. Among possible explanations: women mentioned that even though the service is now offered for free they were charged for the associated consultation. Many women mentioned that their Pap smear test results arrived late or were lost, and that the exam did not lead to a timely diagnosis.
Despite the attitudes reflected in the post-intervention interviews, statistical information shows that few men go to health service centres for contraception. However, there has been an increase in couple consultations at the clinics.
Attitudes
Evaluators claim that there was an important change in women's perceptions and use of contraception. Before the educational interventions, few women reported using a contraceptive, and others did not know about or had not even heard about particular methods. Due to experiences recounted by friends and relatives, many participants thought that contraceptives caused health problems. The educational sessions were shown to increase women's knowledge about contraceptive methods, with health facility data showing changed use patterns.
Other Impacts
Results showed that pedagogic methodologies based in popular education, which emphasise "knowledge dialogue", are very useful to promote changes in health behaviors and knowledge. Improving knowledge based on the subjects' own experiences with SRH was an important mechanism to introduce new concepts, clarify doubts, and sensitise the participants to the importance of SRH. The educational sessions on SRH, rights, knowledge of contraception, violence, and gender were important channels to improve clients' access to SRH services and help them make informed decisions.
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