Operations Research Project
Determining and effective and
replicable communication-based mechanism for improving
young couples' acess to and utilization of RH information
The present operations research (OR) study seeks to determine an effective and replicable communication-based mechanism for increasing the involvement of community based groups in improving young married couples' (under 25 years) access to and utilization of reproductive health services and information. The OR employed quasi-experimental design with two experimental (Treatment) and two non-equivalent control groups. The OR tested these two models in Udaypur district where NRCS had been implementing its REWARD project under USAID/CEDPA support. These two models were 1. Young Communication Action Group (YCAG) and 2. Mothers' Group (MG) (Treatment I and Treatment 2). The pre and post- tests surveys were carried by CREHPA. The surveys interviewed young married women aged 24 years and below. The Baseline survey conducted in October 2000 covered a total sample of 1000 respondents from the two treatment sites and 400 each from Control sites. The End line survey was conducted in October -November 2002 and covered 744 in the two Treatment and 268 from one Control sites. A separate survey of 237 YCAG members was also conducted as a part of the End line study to assess the effectiveness of YCAG model in enhancing the RH knowledge and behavior of the group members.
A. Background Characteristics of Study Population
characteristics of the young married female respondents,
such as age and caste/ethnicity are more or less similar
(no significant differences) between the baseline and
End-line samples and also between the treatment and
control samples. However, the End line study sample
represented a higher proportion of literate respondents
than in the baseline survey.
Knowledge and Practice
Awareness about at least one family planning (FP) method was already universal during Baseline survey. The End line survey recorded an increase in the mean number of FP methods known by the respondents in all the three study sites. The increase, however, is more pronounced in YCAG Area (7.5) as compared to MG Area (6.4) and Control (5.9). Likewise, the proportion of those who are able to cite all three temporary FP methods (Condom, Pills and DMPA) has increased significantly in YCAG (96%) and MG (94%) than in Control (83%) sites.
Knowledge on correct use of pills has increased significantly in Treatment sites. Correct use of Pills was measured in terms of when to start pill ( YCAG Area = 74%; MG Area =58% as against 45% in Control) and What to do if missed for one day (YCAG Area = 72%; MG Area =53% as against 33% in Control). The knowledge on another indicators of correct use of Pills "What to do if missed for two consecutive days" is the highest among respondents in MG Area (53%).
Similarly, knowledge among the respondents about correct use of DMPA measured in terms of "when to start DMPA" and "when to go for next injection shot" has increased significantly in both the Treatment sites. The increase has been almost two folds in YCAG Area. However, increase in respondents' knowledge about the advantage of initiating DMPA within 1.5 months by a lactating mother has remained modest in YCAG (17%) and MG (11%) but declined in Control site (4%).
The proportion of respondent with correct knowledge about 'what to do if a woman is unable to receive the DMPA on date specified' has increased more than two folds in the two Treatment sites. No such change was observed in Control site.
Respondents' awareness about sources of information on FP in the village has increased significantly in both the Treatment sites. In YCAG area, the majority of the respondents' cited YCAG (54%), Depot holders of NRCS (52%) and FCHVs (42%) as the source of FP information in their village. During Baseline, only around 21-22% of the respondents had sited FCHV and Depot Holders as sources of FP information. Likewise, in MG area, FCHV (65%) was mentioned by nearly two-thirds respondents (as against 15% in Baseline). In this area, MG as the source of information was mentioned by nearly two-fifths (38%) of the respondents (as against 0.2% in Baseline) while another one-third cited Depot holder as the source of information (34%). In the Control site, only around one-fourth of the respondents' cited FCHV (25%) and Depot holder (27%).
Contraceptive prevalence rate (CPR) among young married women has increased in all the three study areas. The increase has been sharp in MG Area (19% in Baseline to 37% in End-line) and modest in YCAG Area and Control site. The reasons for non-use of FP method as explained by the respondents are genuine ones and one cannot expect a very high CPR among young couples in their prime childbearing years.
Contraceptive method mix indicates on the growing popularity of condoms among the young couples in YCAG (37%) and MG area (38%). However, DMPA was the most popular method in MG area (49%) and in Control site (52%).
to unplanned pregnancies (current pregnancy being unintended)
declined in YCAG area only from a high of 52% to a low
of 30%. On the contrary, it increased in MG area (47%
to 59%) and in Control Site (42% to 74%).
C. Safe Motherhood
Knowledge and Practice
Although the awareness about the need of ANC check-ups during pregnancy was almost universal in all the three study sites, the number of times a pregnant woman needs to undergo ANC has remained low (below 40%). Comparatively, however, the proportion of respondents knowing that a pregnant woman should undergo at least 4 times ANC increased in Treatment sites only.
Respondents in both Treatment sites have become increasingly aware about the various cares to be taken for ensuring safe pregnancy. In Baseline survey, nearly a third of the respondents did not know about any pregnancy care. Such proportions declined steeply in both the treatment sites but they remained unchanged in Control site. The proportion of respondents citing minimum three danger signs during pregnancy, during labor and during delivery have also increased significantly among the respondents in both the treatment sites but remained low in Control site.
Safe motherhood practices
in terms of undergoing ANC check-ups, receiving TT injection,
intake of Vitamin A and Iron folic tablets have also
shown spectacular improvement in the End line survey.
Comparatively, the increase in safe motherhood practices
has been sharper in YCAG area than in the remaining
two sites. The proportion of deliveries assisted by
trained birth attendants (TBA), increased by 3 folds
(from 14% to 43%) in YCAG Area and modest in the remaining
Awareness about HIV/AIDS
Awareness level about HIV/AIDS among young married women in YCAG area has almost reached universal (97%), while it has increased sharply in MG area (45% to 71%) and recorded just a modest growth in Control site (50% to 63%).
The proportion of respondents' citing minimum two high-risk behaviors of contracting HIV/AIDS increased steeply in YCAG area (21% to 89%). In control area, the proportion of such respondents is less than one quarter. The knowledge that "condom use prevents HIV/AIDS" is quite high in both the experimental areas. In MG area it is 72% and almost universal in YCAG area (94%). On the contrary, it is low in Control site (46%). However, the proportion of respondents citing "avoiding sex with commercial sex workers" (CSWs) as a way to prevent the spread of HIV/AIDS is the highest in Control site (71%) as compared to the two Treatment sites.
E. Knowledge about and Participation in Community Based Groups
Over two-thirds (68%) of respondents in YCAG area are aware of the presence of CAG/YCAG in their villages. This percentage is more than four times the Baseline percentage (15%) which is noteworthy. Likewise, awareness among the respondents of MG area on the presence of mothers groups in their villages have increased sharply from 21% in Baseline to 89% in End line survey. In contrast fewer than 30% of the respondents in Control site are aware of mothers groups in their villages.
Roughly a third of the respondents in YCAG area mentioned that they are enrolled as members of CAG/YCAG. Likewise, one in five respondents in MG area mentioned that they are members of mothers' group of their village. In Baseline survey respondents' membership to these groups was almost negligible (2% or even less). Respondents' knowledge about groups' activities in the village increased sharply (16 to 77% in YCAG area and from 27% to 83% in MG area) while less than half (46%) of the respondents know about group activities in their villages.
Young married women's participation in group activities of YCAG/CAG/MG have increased in all the three sites. Comparatively, the increase in participation rate among these women has been noteworthy in Treatment sites (20-34 percentage points) than in Control site (12 percentage points).
The majority of the respondents in both YCAG and MG areas reported about the group members provide counseling and motivation for FP and RH practices in their villages. In Control site, the corresponding proportions are low; approximately one-third. It may be mentioned that in baseline survey the proportion of respondents in Treatment sites mentioning about group members providing counseling and motivation on FP and RH issues was low; below 22%.
YCAG Survey: The results of YCAG survey are encouraging. Members of the YCAG demonstrate a very high level of awareness about different FP methods and almost all of them (98%) had received FP information from their leaders and fellow members of the group. A significant proportion of them is currently using a method (33%).
Nearly all YCAG members (95%) perceived that they were benefited by enrolling themselves as members, which is noteworthy. All the group members (79-97%) mentioned about discussing a wide range of topics related to sexual and reproductive health (SRH) including the right age for marriage (65%), abortion (48%) and infertility (41%). Information gained by the members was shared with their friends and neighbors (79%), husbands (76%) and to some extent within the group members (39%) and other family members and relatives (36%). It is encouraging to find a very high percentage of YCAG members (70%) having correct knowledge about frequency of ANC required (4 times or more) by a pregnant woman. Moreover, awareness about HIV/AIDS (97%) and some of the preventive measures against HIV/AIDS are nearly universal among YCAG members.
Usually, husbands of YCAG
members (92%) and their mothers-in-law (79%) are the
two family members knowing about YCAG membership. Communication
with husband on FP methods (97%) is nearly universal
but less than half of the YCAG members had discussed
on other SRH topics with their husbands.
The OR clearly demonstrates the effectiveness of communication based mechanisms such as formation/reactivation of YCAG and MG, training, group interaction and social events in creating enabling environment for young married couples to learn and interact on SRH issues among themselves. The increase in RH related knowledge and practice among the young married women (YMW) has been remarkably high in both YCAG and MG areas. However, the changes in practice of family planning and antenatal care have not shown consistent trends probably because of the conflict situation in the project sites during the implementation phase.
Comparatively YCAG model has proved to be relatively more effective in enhancing knowledge among YMW on family planning and safe motherhood. Building confidence among YCAG members, improvement in their RH knowledge and behavior as well as their ability to share and communicate on SRH issues with their spouses, friends and neighbors are good examples of the impact of YCAG model.
MG model have demonstrated to be more effective among YMW in improving family planning acceptance and in enhancing awareness about MG group activities related to FP/RH and encouraging their participation in such activities.
Both the models tested in the present OR can be replicated in the country. Comparatively MG model is easy to replicate since mothers group concept in not new and it exists in most of the districts of the country. Re-activation of mothers group, induction of young women members in the group, training and regular monitoring of their activities by local bodies could make the difference. Replication of YCAG model is possible in areas where non-governmental organizations are already engaged in RH programs.