Institute for Reproductive HealthContributing to Innovation and Sustainability:Building Evidence throughImplementation and Social Science 1
Scaling up an Innovation:Experience with the Standard Days Method® of Family Planning
Implementation ScienceKey principles of implementation science Systems approach Focus on sustainability Understanding what determines success Sustained focus on human rights, stakeholder participation, gender equity, and local ownership. 3
Standard Days Method® (SDM) Appropriate for women with menstrual cycles between 26- 32 days Identifies days 8-19 as fertile Helps a couple avoid or plan pregnancy Is used with CycleBeads® to help women: • identify fertile days • track cycle length • communicate with partner
SDM is an evidence-based practice Scale-Up Case Studies Integration 2007-2012 Studies 2005 - 2007 Operations Research 2003- 2005 Pilot Studies 2000-2004Method Concept & Efficacy Trial 1999-2002
Scaling up the Standard Days Method® 5-year prospective case study using the ExpandNet model for planning, monitoring, rese arch in: DRC Guatemala India/Jharkhand Mali Rwanda
Hypothesis: Applying the systems analysis framework andscaling-up principles articulated in the ExpandNet model toscaling up the SDM within existing programs and serviceswill lead to more sustainable, quality SDM services.
SDM Scale-up Logic Model Scaling-up Strategy Problem: Gap in availability & access to SDM services Process Outputs OutcomesInputs • Conduct • Providers • Provider• Staff trainings trained competency• Partners • Advocacy • Clinics offering • Awareness and• Funds SDM use • Supervision• CycleBeads • IEC activities • Availability • Supportive policies Impact: increased availability of SDM
Defining success in scale up Availability of SDM at national, sub- national, organizational level Availability of SDM at SDPs Provider capacity
Research questions: Scale-up outcomes Client • What is the experience of women and men with SDM when scaled-up? (Knowledge, attitudes and use) Service • Is SDM offered correctly by providers? provision • How does SDM introduction influence quality, availability and use of overall family planning services? System • To what extent has SDM been integrated into integration training, IEC, procurement and distribution, and HMIS? Is it included in norms, protocols and guidelines? Resource • What is the level of resources dedicated to mobilization SDM?
Research questions: Scale-up process Resource team • Do user organizations assume the roles, responsibilities and ownership of the resource team during scale-up process? Advocacy/ • What is the role of SDM champions? Dissemination What strategies work best? Organizational • Has SDM been offered outside choices traditional public sector service delivery?
Scale Up in the state of Jharkhand, India A new state formed in 2002 27 million people with more than 90% in rural areas TFR is 3.3 CPR is 36% , spacing methods at 8% IMR - 49 and MMR - 371 54% literacy rate Program goal: Scale Up SDM to full coverage in 11 out of 24 districts Source for statistics: NFHS-3 (2005-2006)
Monitoring Performance Benchmarks – India, Jharkhand Selected Indicators (as of 6/10)VERTICALNo. of resource organizations 3 of 8SDM included in key policies, norms, protocols 2 of 2SDM in pre-service training In processCommodities in logistics & procurement systems PartiallySDM in IEC materials 6 of 9SDM in HMIS In processFAM in surveys (DHS) NoFunds leveraged for FAM $360,000HORIZONTALProportion of SDPs with FAM in method mix 38%Providers trained 5,700 of 15,000
Health/FP Program Managers and Policy Makers in Guatemala (n=20)Political commitment to Yes, SDM already integrated (norms, training, materials)SDM scale upPolitical factors in SDM Some not convinced a natural method can be modernscale up and effective and demand is sufficient demand. FBOs and community based NGO networks strong supportersFAM Aware of FAM (but lack specifics, esp. efficacy)knowledge/attitudesAbility of MOH to Within their mandate. If there is demand, they willmanage SDM scale up support it.Integration of SDM Not yet. If high SDM ‗demand proved‘ it would beinto annual planning / integrated.budgeting processes 15
Provider interviews/facility assessments in Rwanda (n=155 and n=109)FAM integration into 2/3 of providers have seen protocolsnorms, guidelines, policies Most unfamiliar with norms (newly introduced in Rw)Status of FAM 60% of providers have offered SDM (42% in last 3 months)services 15% have offered LAM 99% in last 3 months) 70% have been offering SDM between 1-5 yearsCorrectness of SDM Most providers offer SDM competently, do not find SDMinfo counseling difficultService delivery Providers only have 4-10 min for counseling on FP – not enoughenvironmentStatus of FAM 91% of visited facilities offering FP offered SDM. CycleBeadsservices found in most. Only 17% of facilities displayed FP info (SDM/LAM are integrated into IEC) 16
PROCESS TRACKING TOOL SDM/LAM integration Filmed project initiated with counseling UPVHA, an NGO in video Allahabad, UP Government ofJharkhand signs Comic books Debut of MOU with IRH HLL Lifecare Household printed and community Facility level trainings and commits Limited becomes begin in 3 districts in survey in CHW trainings radio $211,000 to licensed Jharkhand scale- begin in programs in manufacturer of Jharkhand SDM and LAM up districts Jharkhand (paid Gumla, Jhark CycleBeads (paid by gov’t) by govt) hand scale up conducted October January February March April 2009 May 2009 June September 2008 2009 2009 2009 2009 2009
What Can Stories ofMost Significant Change (MSC)Tell Us About SDM Scale-Up?
MSC provides an inductive approach tounderstand and document…• scale-up process and outcomes not detected by quantitative monitoring• unanticipated processes/effects of FAM scale up• meanings of scale-up process and outcomes to partners, stakeholders, communities• Intangible aspects of FAM scale up (advocacy, champions, leadership, gender equity, informed choice)And creates a space for…• dialogue and reflection to contribute to improved programming and a shared vision of scale up
FAM Scale-Up in Mali: MSC Stories Collected by MOH Perspectives of SDM UsersSDM User Story Significance of SDM for UsersI have four children. Until I heard about the SDM, the • Helps women and men knowcondom was the FP method that my husband I how the body works (fertile days)used, because we feared the effects of other methods. Butthere were also difficulties with using condoms. Nine • Allows condom use only whenmonths ago, I learned about the SDM during an education necessary (condoms used onlysession organized by AMPPF. Since then, we started using during fertile period)SDM. Its natural-ness was what really interested me.Since starting using the SDM, we have noted a lot of •Dispels common belief in Malipositive changes, at my level as well as within our couple. that men will NOT use condoms• I know better how my body works, when I am fertile andnot fertile. I was never aware of that in my body before.• SDM is a very discreet method. It has given us lots of • Give a ‘breath of fresh air’ in theautonomy in how we manage our sexual life as a couple. couple ‘s sexual relationship andNo need to get resupplies from the community health fertility managementagent or go to the health center.• My sexual life with my husband is more harmonious. • Also shows the importance ofSDM has given us a breath of fresh air in our sexual new method promotion to raiselife, which is the most significant change for me. Since awareness and acceptability ofadopting the SDM, we rarely feel constrained by using SDM and that people want othercondoms. options
Mali – Perspectives of Service ProvidersSocial marketer/service provider story Significance of SDM at serviceI own a small business that sells beauty provision levelproducts, condoms, and the SDM… One day my friend told •Community-level activitiesme that (PSI) promoters of condoms and SDM needed an important for SDM promotion andinterpreter for product promotion…They explained to me use - for women/by womenthat they wanted to help our village by offering methodsfor FP and HIV prevention. They explained… how the SDM •Availability of CycleBeads atworked and who could use it. After this, we went together community level (outside of healthto visit other boutique owners and women’s groups in our centers) is importantcommune and for one week I worked as their interpreter.After PSI left, some of the women who had purchased •Working with/through women’sCycleBeads came to me to make sure that they understood networks important for promotionhow to use them and to ask if I had condoms so they could and acceptance of new methodmanage the fertile days. Some women’s groups alsoapproached me to help their women’s networks for the •New SDM users sometimes wantsame reasons and to help promote SDM to others. reassurance of correct useThis experience has helped me to grow my condomsales, since I offer both products. This also led to an •Women users will actively promoteimportant change in my life; now I am actually very well condom use to husbands (dispellingknown in the village. condom myths)
The Innovation Scaling-up User Dynamic, requires flexibilityResource Team Strategy Organization(s) in programming and M&E Supportive political environment influenced by results from pilots Health is a state subject, policy changes influenced by centre System requires substantial capacity building Low priority of FP, particularly birth spacing Naxalite affected areas Large cadre of community level providers (30,000 ASHAs & 34,000 AWWs)
Adapt to scale-upThe Innovation Scaling-up Strategy User Organization(s) conditionsResource Team Simplify/adapt/test training materials Develop/test approaches to facilitate ownership, sustainability and scalability Community radio Social marketing Distance learning Magazine tear-outs M-Health approaches (CycleTel)
Lessons Learned: Using research & evaluation methodologies have enabled IRH to: measure scale-up progress, identify needed adjustments, involve stakeholders, provide evidence for advocacy, and maintain momentum & accountability Challenges facing scale-up are many (i.e. shifting policy and resource environments, large number of partners involved) ExpandNet framework has contributed to sustainable, strategic and quality scale-up efforts
“The Role of Need for Contraception in the Evaluation of Interventions Designed to Improve Access to Family Planning” Federico Leon, Rebecka Lundgren, Irit Sinai, Victoria Jennings Evaluation Review Forthcoming● Uses data from study assessing introduction of SDM into existing services in Jharkhand, India● Baseline and endline survey of married women in intervention and control areas● Unmet need defined as: o Not using FP although sexually active, fecund, and wishing to avoid pregnancy o Unintended pregnancy while not using FP
Findings: Significant effect of the intervention was observed on met need (contraceptive use by women who need contraception), but not on Implications for contraceptive use (% of program evaluation: married who are using a FP Programs designed to method). reduce unmet need should use met need as an indicator to evaluate success rather than using Contraceptive Prevalence.
Annual Program StatementsAddressing critical reproductive health issues withnew resources, ideas, technologies and partners: •Addressing unmet need for family planning • Reducing gender-based violence 27
Addressing Unmet Need for Family Planning through Social Networks 28
Terikunda Jékulu Ferdinand Reus from Arnhem, HollandAddressing Unmet Need through Social Networks in Mali 29
OVERVIEW$5.75 million over 5 Guided by ExpandNet model years Partner ConsortiumBeneficiary – IRH Washington population: ~525,000 – IRH Mali people – CARE USA Ferdinand Reus from Arnhem, Holland – CARE Mali – CEDPA – ASDAP Principle Investigator: Rebecka Lundgren, MPH AOTR: Mihira Karra 30
RATIONALE 20 years of FP programming in Mali KNOWLEDGE OF FP DESIRED FERTILITY HAS METHODS VERY HIGH STAYED THE SAME… WOMEN, MODERN METHOD100 Married 2001 90 80 70 60 Married 2006 50 40 2001 30 0 5 10 20 2006 Women Men 10 0 … AND MODERN CPR REMAINS AT 6%
Research Questions ● Why do women (and men) who supposedly have “unmet need” for FP not use any method of contraception? ● Can addressing social factors—and not just women as individuals—increase modern contraceptive use? For example: − Couple interventions? − Religious leader networks? ● What are promising ways to address these social factors?
Objectives• Apply social network analysis framework to assess influence of social groups on: • Fertility attitudes, beliefs, desires, intentions and behaviors • Couple communication • Decision-making regarding timing & number of children • FP adoption & continuation • Method choice and switching
Objectives• Design and test interventions to activate key actors within a social network: – Reduce negative determinants – Strengthen positive influences on fertility attitudes and FP use• Expand interventions to additional communities (if proven successful)
Research-to-Practice: Possible Interventions Hypothetical Research Findings • Few newly married couples use FP. • Women and men reluctant to raise the issue with their new spouse, even when concerned about best way to create thriving family. • Network analysis shows young couples tend to be isolated from the broader social network in the community, although they are tightly linked to their extended family. • One reason it is hard to raise fertility issues is because it is inappropriate to discuss the subject around unmarried friends and elders.
Research-to-Practice: Possible Interventions Possible Intervention ►Grandmothers influence young married in their extended families • Grandmothers are an under-appreciated resource. • High social status in extended families and are key decision-makers in fertility and FP use in their households. • Even grandmothers who support FP often do not know how to support younger couples because things have changed so much. ►Support Grandmothers’ Social Networks to Influence Extended Family Decision- making on HTSP and FP Use within Household • Invite Grandmothers to gatherings to discuss changes –today versus the past - in family roles and fertility. In gender roles in families and communities. Provide FP information and dispel FP myths. • Encourage dialogue and debate: Mix grandmothers who oppose FP and who support FP to enable sharing of differing viewpoints. • Help these women support young couples in their families use FP and maintain the vitality of lineage in changing environment.
PHASE 1:FORMATIVE RESEARCH Year 1 October 2010 – September 2011 37
PHASE 1: FORMATIVE RESEARCH Ethnographic research • Meaning & value of fertility-related Ferdinand Reus from Arnhem, Holland communication • Communication channels & social influence • Language people use to talk about fertility • Distribution of social influence within community groups How do men and women communicate about fertility and family planning? What words do they use? Where do they talk about it? Do they use different languages with women than with men? Are there nonverbal cues?
PHASE 1: FORMATIVE RESEARCH Household surveys to map networks • All married women 18-45 • Men married to these women • Nominate up to five individuals who have influenced their fertility Ferdinand Reus from Arnhem, Holland attitudes, beliefs, desires, intentions, and behaviors • Create network map • See where the centers of influence lie
PHASE 1: FORMATIVE RESEARCHHousehold surveys to map networks (cont.) ● Analysis to determine: ● High prestige: Identified frequently as influencers ● High betweenness: Brokers between network subclusters ● Degree of centrality: Extent to which actor is connected to others ● In-depth interviews to corroborate quantitative findings
PHASE 1: Develop Interventions Design network-based interventions with stakeholders and partners • Based on formative research (ethnography & social network analysis) • Use WHO/ExpandNet model to ensure potential for scale up • Develop monitoring & evaluation system to evaluate process and project
PHASE 2: test interventions Years 2 – 5 October 2011 – September 2015 43
Phase 2: Test Interventions• Case control study design – Before & after intervention implementation • Social network map of each health district • Household questionnaire to determine fertility attitudes, beliefs, desires, intentions, and• Observe changes in: – Fertility desires – Contraceptive use – Social connections
Phase 2: Test Interventions• Potential Indicators ● Changes in contraceptive prevalence ● Changes in unmet need ● Changes in method continuation ● Changes in FP use among central network actors ● Changes in connectors between subgroups ● Changes in couple communication ● Perception of community and family support for FP use
Transforming Gender Roles: An Ecological Approach 47
THE GENDER ROLES, EQUALITY ANDTRANSFORMATIONS (GREAT) PROJECT October 2010 48
OVERVIEW• 5-year, $5.5 million project • Principal Investigator:• Partner Consortium: Rebecka Lundgren, MPH o IRH • AOTR: Mihira Karra o Pathfinder International o Save the Children• Beneficiary Population: o Adolescent boys and girls, ages 10-19 o Emphasis on very young adolescents, ages 10-14 49
Rationale● Years of war have scarred northern Uganda‘s youth and adult population – many have experienced or witnessed violence, many fled their homes are now re-establishing their lives.● With peace and stability and re-establishment of social structures and institutions, opportunity exists to help communities work towards more equitable social and institutional structures.● Focusing concurrent interventions on different youth segments - Very Young Adols, Older Adols, Married Adols, Adol Parents- can help create basis for later, more equitable and non- violent norms, relationships, and SRH outcomes.● Recognizing the larger normative context, work with media, institutions, etc, to create supportive environment to sustain change.● Focus on scale-ability of gendered SRH interventions to achieve maximum impact.
Conceptual Framework • Ecological model SOCIETY recognizes that health COMMUNITY behaviors and norms are influenced by RELATIONSHIPS multiple individuals and social factors INDIVIDUAL • Employs a gender relational perspective 51
Goal & Strategic Objective● GOAL: Improve gender equity and reproductive health outcomes in Northern Uganda● STRATEGIC OBJECTIVE: Boys and girls aged 10-19 form equitable gender norms and adopt attitudes and behaviors which positively influence health outcomes and reduce gender- based violence 52
Key FormativeResearch QuestionsUnderstand: How are gender norms learned, internalized and passed on; and,What would motivate adolescents and adults to change these norms? 53
Research-to-Practice:Possible Intervention–Married Adolescents Hypothetical findings – • During later adolescence, young men and boys focus on sexual relationships and establishing a family. • They perceive that it is important to be physically strong and earn a good income to attract women. • They are concerned that their partners will be unfaithful and feel that it is their role as ―real men‖ to control women. • They describe close friendships with men and monitor the behavior of their friends whenever possible to keep them from getting HIV.
Research-to-Practice:Possible Interventions – Married AdolescentsPossible Interventions►Married adolescent men and women as role models, peer educators, and advocates• Participatory, reflective process to deepen awareness of the causes of violence and its cost to society and role of masculinity in perpetuating violence.• Affirmative inquiry into healthy relationships, sexual and reproductive rights and responsibilities.• Train peer educators to raise awareness of violence as a development and health issue for men as well as women.• Working with women‘s groups to monitor violence.►Supported by community/enabling environment interventions through local Churches• Train leaders and support advocacy efforts to bring issues to public discussion, including use of Church-supported radio programs
Research-to-Practice:Possible Intervention – Very Young Adolescents Hypothetical findings – • Young boys feel real men should be fighters. They look up to their brothers and older relatives who fought during the conflict. Others have no adult men in their lives. • Boys feel pressured to drink to show that they are tough. • Girls expect to follow the path of their older sisters and aunts who had their first baby while still quite young. • Neither boys nor girls see the relevance of going to school to their future. • Both boys and girls lack information about puberty and are not comfortable asking for information. • Past ways of learning about sex and relationships from adults no longer exist in post-conflict communities.
Research-to-Practice:Possible Interventions – Very Young AdolescentsPossible Interventions►Create youth-facilitated spaces for learning, reflection, discussion• Young adults lead sessions using age-appropriate games and activities to engage boys and girls in exploring concepts of gender, masculinity, and femininity within their puberty experiences.• Sessions are implemented through community-based child clubs, in-school clubs and sports clubs.• Workbooks containing puberty and self-care information and ―coming of age‖ stories that challenge societal gender norms are distributed.►Supported by parent /enabling environment interventions• Parents are offered similar information and tips on how to communicate and be more supportive of their children moving through puberty.
Phase I: Formative Research • Life histories (months 3-6) • In-depth interviews (months 3-6) • Preliminary report (months 6-7) • Targeted behavior change research (months 8-9) Life histories with 40 individuals (5 males & 5 females) at different stages in the life course Life Very Young Older Newly Married Pregnant with 1stCourse Adolescents Adolescents child/ Parent with 1Stages child 40-80 in-depth interviews with “significant others” selected by life history participants:Parents/Guardians Teachers Peers Siblings Religious/Community Extended Family Leaders
Phase I: Program Review ● Program review to identify promising strategies to transform gender norms and improve health outcomes with potential for adaptation and scale-up through existing networks o Desk review + site visits o Local Technical Advisory Group
Phase I:Adapt & Design Interventions ● 3-4 day workshop with PC and TAG to review formative research results & program review o Identify promising strategies to be proposed for testing & implementation in Phase II o Assess feasibility, efficiency, cultural appropriateness, degree of adaptation, opportunities & constraints of promising strategies o Apply WHO/ExpandNet framework for systematic scale-up
Phase II:Implementation Trial & Scale-up● Phase 2(a): Implementation Trial (yrs 2-3) o Package of interventions piloted in 3 districts● Phase 2(b): Large-Scale Implementation Trial (yrs 4-5) o Expand interventions to 3 additional districts● Phase 2(c): System-Wide Roll Out o Guidelines, tools and materials will be made available o Trial organizations to lead expansion● Rigorous M&E strategy to be implemented throughout
Institute for Reproductive Health Georgetown University Susan Igras, email@example.com Rebecka Lundgren, firstname.lastname@example.org Victoria Jennings, email@example.com