Lessons Learned from the Global Agenda of the Frontiers in Reproductive Health Program

This 26-page report summarises the experience of the Frontiers in Reproductive Health Program (FRONTIERS) in implementing a coordinated set of operations research (OR) studies, collectively referred to as the "Global Agenda" (GA). The purpose of these studies, carried out in diverse settings around the world with U.S. Agency for International Development (USAID) funding, was to address policy questions with global, rather than local, relevance. By asking the same questions, testing the same hypotheses, applying similar designs, and using core indicators and instruments, FRONTIERS hoped that more comprehensive answers to the original questions would be reached.

The report describes 3 of the GA studies and reports key findings and challenges:



1. Improving the Reproductive Health of Youth - Bangladesh, Kenya, Mexico, Senegal

Goals: to determine the feasibility, effectiveness, and cost of a systematic intervention to foster a supportive environment to address adolescent reproductive health (RH), to make existing services more accessible to youth, and to provide information and skills on RH, gender attitudes, and use of health services in schools and communities.

Findings: reaching adolescents with RH information is feasible despite the sensitive nature of this issue. The interventions seem to have had an effect on limiting sexual activity but not on protection through the use of contraceptive methods or a condom. Values such as abstinence and faithfulness to one partner are the main reference and source of protection among young people.

2. Involving Males in their Partners' Antenatal and Postpartum Care: Impact on Family Planning Use and the Prevention of Sexually Transmitted Infections at Six Months Postpartum (Men in Maternity Care) - India, South Africa

Goals: to investigate the hypotheses that exposure to the intervention would positively affect: 1. Men and women's knowledge of family planning (FP) and contraceptive practices 2. Sexually transmitted infection (STI) preventive behaviours 3. Syphilis testing and management, and treatment of male urethritis and genital ulcer disease 4. Inter-spousal communication and support on RH matters 5. Selected indicators of infant health (e.g., immunisations, breastfeeding practices) 6. Satisfaction of service providers and clients.

Findings: the intervention was feasible in both settings, although in South Africa "appreciable change needs to take place in the wider social context concurrent with" increasing male participation in pre-and post-natal care. In India, men accompanied their wives to the clinics and participated actively in the intervention. There were significant changes in FP knowledge and behaviours of both men and women. Clients who participated in the intervention reported more discussions with providers and more satisfaction with FP methods. There was little acknowledgement of STI risk (although knowledge and use of dual protection did increase).

3. Impact of Improved Client-Provider Interaction (CPI) on Women's Achievement of Fertility Goals - Egypt, Peru

Goals: to answer the following questions: 1. How much can client-provider interaction be improved by introducing practical systems-oriented, provider-oriented, and client-oriented interventions? 2. Will the intervention package improve job satisfaction of providers? 3. If CPI is improved, will there be measurable improvements in: i. continued use of any method? ii. knowledge about available contraceptive choices? iii. prompt switching to another method? iv. ability to achieve fertility goals?

Findings: the intervention caused consistent, yet small, improvements in client outcomes in both countries. In Peru, findings suggested that better impacts could be achieved in provincial primary health facilities than in larger settings. Egyptian researchers made several recommendations based on results there, including the provision of continuous training to providers to enhance their understanding of women's contraceptive needs and fertility preferences. They also suggest widening the audience for improved CPI among providers in other programmes, given that women frequently shift among service facilities.

The report examines lessons learned from the above studies, including:

• It is feasible to investigate the same questions in different locations.
• Differences in sites, implementation of interventions, and variations in the interventions render the study findings not directly comparable on all key variables.
• The studies are generalisable.
• Although the GA does not warrant strict replication as it was implemented, lessons have been learned about carrying out a cluster of studies on a common theme, at a similar moment in time.

Challenges are also explored, and recommendations offered. For example, Adamchak draws a number of conclusions related to personnel and training. In a few cases, application of the research design and data analysis exceeded the technical capacity of local researchers. In this context, coordination to ensure adherence to common design, data collection protocols, and timelines is important; "technical support should be included in work plans in the future". She also makes several observations related to evaluation. For instance, she asserts that it is difficult for many researchers to be responsible for the implementation of interventions, for they are too invested in demonstrating success and are sometimes too willing to interpret small changes positively. Adamchak suggests that process monitoring is essential in conducting OR in order to determine what elements of the system can be manipulated, and with what effect. All the projects, she states, would have benefited from more systematic process monitoring and reporting. Other recommendations offered here include continued research to understand multi-sectoral influences on youth RH, and more intensive investigation of the factors affecting discontinuation within the first one to three months after adopting an FP method.

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