family planning on wheels: a program to reduce unplanned pregnancies in rural ecuador

8/20/2019 Family Planning on Wheels: A Program to Reduce Unplanned Pregnancies in Rural Ecuador

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Running head: FAMILY PLANNING ON WHEELS 1

Family Planning on Wheels: A Program to Reduce Unplanned Pregnancies in Rural

Ecuador

Kaylee Blankenship, Alyssa Cardinal, LeAnna Ceglia, Maggie Fabry and Noel Silveira

California State University, Stanislaus


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FAMILY PLANNING ON WHEELS

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Executive Summary

A prevalent issue in Ecuador is the high incidence of unplanned pregnancy, particularly

within the rural, adolescent population. According to Bremner, Bilsborrow, Feldacker and Lu

Holt, this results from a lack of access to contraceptive measures and a knowledge deficit in

regards to family planning (2009). According to research by Yoost, Hertweck and Barnett,

implementing educational clinic visits may lower the incidence of pregnancy (2014). Integrating

an educational intervention into these rural locations has the potential to increase residents’

knowledge of family planning while decreasing unplanned pregnancy.

A proposal for a Family Planning on Wheels program has been created in an effort toovercome this issue in Ecuador. The program consists of a staff of nurses and volunteers that

travel throughout rural areas of Ecuador. The mission of this program is to evaluate individual

needs, provide education related to family planning and provide contraceptives in order to

prevent unplanned pregnancies. Educational topics include abstinence, safe sex practices, proper

use of contraceptives, self-esteem, peer pressure avoidance, and how parents should approach

sexual education with their children. Through the implementation of this program, it is estimated

that there will be an increased knowledge of family planning, increased acceptance toward

various methods of birth control, and a decrease in unplanned pregnancies.

Background

Countries in the Andean region of Latin America have exceptionally high adolescent

fertility rates in comparison to both individual country and global averages (Goicolea, 2010).

Ecuador, in particular, has the highest rate among Latin American countries with a staggering

100 out of every 1,000 adolescent girls currently or recently impregnated (Goicolea, Wulff,

Ohman, & San Sebastian, 2009). According to Goicolea, Wulff, Ohman and San Sebastian, “of


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all Ecuadorian women age 15 to 19, 20% get pregnant before age 20” (2009, p. 221). Due to the

physical and mental health complications associated with early childbearing, as well as the high

risk for poverty bestowed on these young mothers, Ecuador’s high adolescent fertility rate is a

huge concern. The offspring of these adolescents are also at an increased risk for abuse and

neglect, and the majority are forced to become accustomed to lifestyles of hardship (Goicolea,

Wulff, Ohman, & San Sebastian, 2009). In Latin America, it has been shown that “infants born

to mothers 15 to 19 years old are nearly 80 percent more likely to die during the first year of life

than infants born to mothers 20 to 29 years old” (Herdman, 2008). This is problematic for the

entire country because the adolescent population, in the bigger picture, is the future of Ecuador.According to Goicolea, Wulff, Ohman and San Sebastian, risk factors for unintended

pregnancies include not only being an adolescent, but also having poor contraceptive knowledge

and use, poor communication among family members, low education levels, early sexual debut,

and low socioeconomic status (2009). To address these concerns, Ecuador created a national

pregnancy prevention plan in 2007 that is “based on the assumption that in order for adolescents

to exercise their reproductive rights they not only need access to a network of services but also

must be empowered to take control of their sexuality” (Goicolea, Wulff, Ohman, & San

Sebastian, 2009, p. 222). Aside from accessibility, education on the proper use of contraceptives

is also important for this population. The most paramount task, however, is reaching out to the

most vulnerable and neglected populations. More specifically, the task at hand involves

providing family planning education to indigenous individuals or those living in rural Ecuador.

Due to a lack of research and attention to the alarmingly high Ecuadorian adolescent fertility

rates, the number of pregnancies continues to increase. Goicolea explains that “while total

fertility rates have been declining, adolescent fertility rates have experienced little change, and in


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countries such as Colombia and Ecuador, they have even increased” (2010). Immediate action is

required for this country in order to decrease fertility rates and prevent the negative outcomes

associated with pregnancies, specifically in regards to the rural and adolescent populations.

Literature Review

Researchers Yoost et al. recently conducted a study to evaluate a new approach on

adolescent pregnancy prevention (2014). The study utilized a retrospective chart review design

held at the Center for Adolescent Pregnancy Prevention, which is a privately funded clinic

located in an urban setting in Kentucky. Subjects were between the ages of 11 and 18 years and

were seen from January 2007 to December 2010. The outcomes studied were 12- and 24-monthcontinuation rates of birth control options, total length of follow-up, time until gaps in follow-up,

and incident pregnancies. Results were based on age at the initial visit and were split into two

groups: early adolescents (aged 11-15 years) or late adolescents (aged 16-18 years). There were

121 patients and seven incident pregnancies, all in the late adolescent group. The early

adolescents had a greater rate of continuation of birth control at 12 months and 24 months

compared with late adolescents. The educational approach used may decrease adolescent

pregnancy among high-risk adolescents that continue to use the clinic system. This model may

be more effective for early adolescents than late adolescent (Yoost et al., 2014)

A major strength of this study involves the extensive education provided by a nurse that

covers female anatomy, the menstrual cycle, vaginal health, and birth control options. Another

strength is encouraging the patients to follow through with follow up appointments every 3

months. The study contained a couple of limitations. The first is classifying patients with

continued contraception use with the condition of not discontinuing their form of birth control

for one month or longer. This puts the patient at risk for pregnancy because methods could be


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stopped and then resumed within that month and still considered “continued”. Another

limitation includes not recording demographic information such as drug and alcohol use that can

contribute to high-risk activity. Pregnancy ambivalence was also not assessed; all pregnancies

were recorded as unintended. Reasons for discontinuation of birth control methods were not

recorded. All of these limitations affect internal validity. The external validity or generalizability

is affected by the fact that participants were not randomly assigned to participate in the study.

In a recent study conducted by Goicolea, Wulff, Ohman, and San Sebastian, varying risk

factors were analyzed for pregnancy among the population of adolescent girls living in the

Amazon basin of Ecuador (2009). The study was a match case-control study with 140 cases and262 participants in the control group. Cases included females between the ages of 10 and 19

living in Orellana, who were pregnant at the time of the interview or had been pregnant in the

previous two years. The control group included adolescents of the same age group and location,

who had never been pregnant. All participants were surveyed on three different categories of risk

factors for pregnancy among adolescent women including socio-demographic indicators, adverse

events during childhood-adolescence, and sexual and reproductive health variables. The study

uncovered that six factors were statistically significant (p< 0.05) in adolescent pregnancies;

sexual abuse during childhood-adolescence, early sexual debut, living in a very poor household,

experiencing life periods of a year or longer without a mother and father, married or being in a

union, and not being enrolled in school at the time of the interview (Goicolea, Wulff, Öhman, &

San Sebastian, 2009).

The strengths of this study included a high number of participants and also follow-up

with resources for individuals who claimed to have experienced some sort of abuse. There were

many limitations to this study. First, the study focused on a small fraction of the country, with


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participants residing in only a single province of Ecuador. A huge limitation to the study was the

unreliability of reported abortions due to fear in relation to Ecuador’s law forbidding abortions.

This inaccuracy, in addition to the fear of sharing information in the presence of parents, could

have affected the study’s overall results by potentially excluding the most vulnerable population

of girls. Another limitation was the use of the Adverse Childhood Experiences questionnaire,

which was created for the American population and not the Ecuadorian population. The external

validity was also negatively affected by the lack of random assignment of participants for the

study.

Additional research, by Goicolea and San Sebastian, investigates the effects of bothindividual and contextual factors on unintended pregnancies in Ecuador (2010). Women

between the ages of 15 and 44 years old were selected with an ongoing community-based cross-

sectional survey. The survey was conducted between May and December 2006 in the Orellana

province. Survey questions were issued as an interview in the participants’ home and in the

participant’s native language. The data was fitted and translated by using a multilevel logistic

regression in which individual-level and community-level factor were adjusted “as fixed effects

and allowing for heterogeneity between communities” (Goicolea & San Sebastian, 2010). The

sample included a total of 1,002 women between the ages of 15 and 44 years old who lived in the

Orellana province of Ecuador. This sample excluded women who were either pregnant or

breastfeeding to avoid respondent bias and only included the women who actually delivered a

child. The results of this study showed that the overall occurrence of unintended pregnancy was

62.7% of the population. A total of 73.7% of indigenous women reported having at least one

pregnancy that was unintended. The significant risk factors found for unintended pregnancies

included being single, young, and indigenous as well as having more than two children and little


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access to education. There was no correlation found between use of contraceptives and

socioeconomic status. All of the variations between the 34 province communities were

explained by individual factors (Goicolea & San Sebastian, 2010).

The strengths of this study included using a large population of participants, having the

interview conducted in the participants’ native language, and obtaining informed consent before

the study was conducted. Also, to avoid respondent bias, the interview excluded women who

were either pregnant or breastfeeding. Limitations of this study include having only interviewed

women between the ages of 15 and 44. Also, the study was conducted in only one province of

Ecuador, limiting their data to only a single population.

A study by Goicolea, San Sebastian, and Wulff gathered information and data on

reproductive health factors such as delivery care, adolescent pregnancy, and contraception

(2008). The data was gathered from a local community based survey as well as from policy and

official sources from the Health Rights of Women Assessment Instrument (HRWAI). The

design was a community-based cross sectional survey that began in 2006. The survey was

conducted as an interview that evaluated three areas of reproductive health including family

planning, delivery care, as well as pregnancy among adolescent girls between the ages of 10 and

19 years. The participants partook in a two-stage cluster sampling procedure. The population

targeted included a total of 2,025 women who were between the ages of 10 and 44 years old and

live in the Orellana province. Of those 2,025 women participants, 1,631 lived in households, 524

were from indigenous communities and 1,107 were from non-indigenous communities. As a

result of the survey, it is evident that women who live in Orellana face lower quality of

reproductive health services compared to other women who live in other areas of the country.

The study also brought forth a wide gap of inequity amongst the women living in Orellana. For


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instance, women in urban areas had a higher percentage of planned pregnancies, modern

contraceptive use and skilled delivery attendance compared to the women living in rural

areas. Indigenous women had the lowest percentage of planned pregnancies, use of modern

contraceptives, and skilled delivery attendance (Goicolea, San Sebastian, and Wulff, 2008).

Strengths of this study include using a large population of participants and using a

credible tool to measure their findings. The researchers also used literature reviews of

international and governmental documents as research on the topics in addition to their

community surveys. However, some limitations of this study included not obtaining any form of

consent from its participants and conducting the survey and research in one province of Ecuador,limiting their data to a single population.

A qualitative study conducted by Tebbets and Redwine evaluated the effectiveness of

Youth Peer Provider programs in Ecuador and Nicaragua (2013). Three evaluations were used

over a seven-year period to analyze the various programs’ effectiveness. In 2004, the first

evaluation was conducted in both Ecuador and Nicaragua and used a 33-item survey containing

questions about pregnancies, births and contraceptive use and history. For this evaluation, 597

program participants were randomly selected. These respondents had been participants of the

program for an average of three years. The second evaluation took place in Ecuador between

2007 and 2009 and utilized the Most Significant Change Technique. This evaluation was

qualitative and assessed the impact of the program on 92 individuals using a six-question survey

tool. The third and final evaluation took place in 2010 and included 15 in-depth interviews

assessing the interviewees’ thoughts regarding the program’s strengths, weaknesses, impacts and

operational issues. The sample of 107 individuals included in the last two evaluations consisted

of past and present Youth Peer Providers or coordinators, organizational staff, staff at


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participating schools, students receiving training through the program, youth receiving methods,

counseling through the program, and parents of the participants. The 2004 survey revealed that

three-quarters of the respondents were currently sexually active and 95 percent of those sexually

active individuals were using contraception. This survey also found that three-quarters of

respondents reported ever having used a condom with the intention of preventing sexually

transmitted infections (STIs). These results compared favorably to the general populations in

Nicaragua and Ecuador. The final two evaluations’ responses revealed that the most commonly

mentioned program impact was an increase in knowledge and the second most common was

personal growth. In addition, twenty-two percent of participants stated an increase in self-esteem, leadership skills and self-confidence and twenty-three percent of participants mentioned

that their communications skills were improved as a result of the program. Lastly, a significant

number of respondents reported that there was an improvement in their relationships with their

family and friends (Tebbets & Redwine, 2013).

The study had many strengths including the ability of the reader to follow the

researcher’s reasoning. Not only was confidentiality of each client kept and the services

provided in the local language, but participants were able to recognize the experience as their

own. This study had Youth Peer Providers monitor contraceptive records for all of their

clients. Another strength included using a large sample size over a course of 10 years. Ongoing

monitoring and evaluating of the effects was also provided from this program by obtaining

voluntary personal feedback from clients. A limitation of this study, however, was a failure to

mention obtaining consent forms from the participants.

Bremner et al. conducted a study to estimate fertility rates in Ecuador for rural indigenous

women, analyze reproductive health intentions and the use of contraceptives, and contemplate


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why fertility rates remain high among lowland tropic indigenous populations (2009). The authors

hypothesized that, “high fertility is, in large part, due to unmet need for reproductive health

services”, and this hypothesis was tested using primary survey data regarding reproductive

practices. Data collection took place in 2001 in two phases. The first phase was an ethnographic

study of eight communities while the second phase was a survey of 36 communities collecting

data about the household and the community. Qualitative and quantitative data was collected

from both households and certain community leaders. The sample was 564 households from a

two-stages and the sampling was controlled. The interviews of the male and female heads of the

households were lead separately using questionnaires. The questionnaires included questionsabout migration history, age, sex, education level, marital status, languages spoken, assets and

health of the household. The second part of the survey also asked females about their family

planning methods used, the desire for more children, and their own reproductive history. For this

data, only the women of reproductive age were used making the sample size 510 households and

648 women. The Brass-Cole methods were used and estimations were calculated for fertility

rates. Univariate and bivariate descriptive analysis was used in order to compare the reproductive

attitudes, preferences, and contraceptives used among 369 females and the results were then

further compared with the national ENDEEMAIN II survey. Cross-ethnic comparisons were

made using a binary logistic regression model. The results of this study confirmed that fertility

rates are high and that the need for different types of contraceptives are unmet. They found that

there is only one health center in the Ecuadorian amazon that actually focuses on providing

reproductive health services and family planning. This fact helps explain why knowledge and use

of contraceptives are so low and misconceptions are commonplace. There is a lack of access and

a lack of information or education on family planning and contraceptives (Bremner et al., 2009).


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The strengths in this study included having a large sample size in which the sample

population represented multiple communities in an area of Ecuador. To avoid any bias or

misleading answers, men and women were given separate, individual surveys/interviews. Also,

the tools used to measure the surveys were reliable and the same questionnaires were used for

each subject. However, there were also many limitations found in this study. For instance,

there was no mention of any forms of consent obtained from the participants. The survey was

conducted only in the northernmost provinces of Ecuador, limiting their data to only a selected

population. Also, some locations had every household surveyed, while other locations had

households chosen at random, therefore, providing an inconsistency in the obtained data. Withthat being said, this study is not very generalizable since it is focused specifically on indigenous

women of Ecuador, therefore, the external validity is limited.

Project Goals and Objectives

The overall desired impact for Family Planning on Wheels is a decrease in the number of

unplanned pregnancies in rural Ecuador by 2% in five years (See Appendix A: Figure 1).

According to Planned Parenthood, approximately 30% of Ecuador’s population lives in rural

areas, and one in ten adolescents from this rural population give birth each year (2014).

Therefore, this program’s desired impact is to reduce the adolescent birth rate from 10% to 8%.

The implementation of this program is vital for not only the health of this population, but also the

economic prosperity of Ecuador as a whole. Unplanned pregnancies, especially those in

adolescents, increase the likelihood that mothers will experience poverty and low socioeconomic

status (Goicolea, Wulff, Öhman & San Sebastian, 2009, p. 222). This study also communicates

that globally, “early childbearing is associated with higher risk of adverse reproductive outcomes


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and, among the youngest mothers and their newborns, increased maternal and infant mortality”

(Goicolea, Wulff, Öhman & San Sebastian, 2009).

Although Latin American countries have seen a decline in fertility rates, there are still

rural areas and sub-populations that are experiencing high fertility rates and generally, “a lack of

access to family planning and reproductive health services” (Bremner, Bilsborrow, Feldacker &

Holt, 2009). In a study conducted by Jennie L. Yoost, it was found that education and multiple

clinic visits decreased the number of pregnancies in adolescents (2014). Due to the limited

availability and occurrence of transportation to higher populated areas with health clinics,

indigenous and rural communities will greatly benefit from the proposed clinic on wheels. The program aims to decrease the number of unplanned pregnancies by increasing knowledge related

to family planning and increasing accessibility to contraceptives. The following section will

elaborate on the overall plan, including key stakeholders and end beneficiaries, inputs, activities,

outputs, effects, and assumptions that contribute to the overall desired impact; all of which are

outlined in Appendix A: Figure 1.

Key Stakeholders and End Beneficiaries

The end beneficiaries of this program, or those who will benefit from the services

provided, include the individuals and families of rural communities in Ecuador, health care

providers, and the local government’s economy. The residents in these communities will be the

ones who experience the most benefits from this program. This is because they will gain the

knowledge and resources necessary to prevent unplanned pregnancies and create a family plan

that is specific to their own individual wants, needs, and beliefs. Through referrals, clients will

have a direct line to physicians closest to their homes.


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The key stakeholders in this program include registered nurses, peer support volunteers,

local government officials, community leaders, physicians and potential clients. With the support

of community leaders, potential clients will be more willing to take part in these educational

family planning meetings, thus making the program more effective. Registered nurses will be the

stakeholders providing family planning education and resources necessary to reduce unplanned

pregnancies. The key to this program’s success, however, depends on the participation of the

clients. Without their involvement, registered nurses are unable to make home visits, thereby

affecting the anticipated outcome.

Inputs

There are several resources needed in order to carry out the necessary activities for

Family Planning on Wheels. American registered nurses will be needed to train all staff, while

Ecuadorian nurses will be needed to provide family planning education, distribute condoms,

orient volunteers and make referrals to physicians. Peer support volunteers will be needed for

assisting in program activities. Tebbets and Redwine claim “youth who discuss sexual and

reproductive health with peers are more likely to display positive health-seeking behaviours than

youth who discuss it with adults” (2013, p. 144). Based on this knowledge, young adults will be

hired as volunteers to create a more comfortable atmosphere for clientele in order to enhance

learning.

Contracts with local health care facilities and physicians will need to be made in order to

make referrals for family planning methods and related health assessments. Materials, including

pamphlets and reproductive models, are needed to illustrate and explain different family

planning methods. Vehicles, insurance, registration, and fuel for travel are also essential. These

vehicles will contain all supplies necessary for making home visits and provide transportation for


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nurses and volunteers. Information and maps for clinics closest to the area that provide different

types of contraceptives will also be needed. Lastly, funds for all essential materials and activities

are necessary for implementation.

Activities

In order to reach the overall impact, there are a number of activities that need to be

carried out in a specific order. American nurses will interview and hire qualified Ecuadorian

nurses and peer support volunteers. A teaching plan and schedule will be created specific to each

rural community and its needs. Next, nurses and volunteers will be trained on program guidelines

and how to effectively present family planning education to rural communities. The next activityis to purchase 20 vehicles in Ecuador as well as insurance, registration and fuel cards for each

vehicle. The next activity that needs to be performed in the Family Planning on Wheels program

is an assessment of attitudes and knowledge on family planning among rural Ecuadorian

residents. This will be done by visiting individual homes, providing information about the

program, inquiring about the residents’ interest in program services, quickly assessing family

planning needs using questioning, pre-tests and surveys, and encouraging them to spread the

word to the rest of the community. A meeting should be held with local officials and community

leaders to communicate the family planning issues in each community and establish rapport in

order to develop a partnership (A. Aleman, personal communication, November 4, 2014). In the

Ecuadorian culture, sex and family planning are not always openly discussed and religious

beliefs often play a role in attitudes and behaviors regarding contraceptive use (Bremner,

Bilsborrow, Feldacker and Holt, 2009). Therefore, it is important to have community leaders in

support of the initiative to aid in gaining the trust of the community. Next, family planning

educational materials, including pamphlets and reproductive models, need to be purchased for in


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home teaching sessions. After all necessary supplies are gathered and stocked in vehicles, initial

visits will begin, followed by monthly visits. All staff members will be divided in to teams,

consisting of one nurse and one volunteer, and will travel in vehicles purchased through program

funding. Teams will travel to assigned areas for community home visits according to residents’

geographic location. A home base will be established in a centralized location that houses client

records and extra materials. Depending on the distance to this base from their last home visit of

the day, teams will either stay the night in funded hotels, or travel back to the base. Regardless,

client documentation from the visits will need to be taken to the main office no later than 48

hours following the visit. The initial visit will determine the household’s family planning needs,knowledge deficits, and will last no longer than one hour. A general pre-test, post-test and

survey, in the family’s primary language, will be distributed for evaluation of teaching methods.

Follow-up visits will elaborate on the previously determined needs of the household and last

approximately thirty minutes to one hour. Pre-tests, post-tests and surveys will be distributed at

each home visit and will be specific to the topic for that particular visit. Topics for education will

include abstinence, safe sex practices, proper use of contraceptives, promotion of self-esteem,

peer-pressure avoidance, and how best to foster communication regarding sexual practices

between children and their parents. Education is one of the essential elements of this program.

Research shows that “among indigenous women, the most common reasons for not using modern

contraceptive methods were lack of knowledge, fear of side effects, and cost. The ethnographic

study also revealed widespread misconceptions and fears about negative impacts of modern

family planning methods on women’s health” (Bremner, Bilsborrow, Feldacker and Holt, 2009).

Referrals may also need to be provided to doctors or nurse practitioners concerning family

planning, as well as providing information on health clinics closest to each community.


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Throughout the progression of this program, the effectiveness of visits will be evaluated by

monitoring birth rates, comparing pre and post-test scores for each visit, and reviewing survey

feedback.

Outputs

One expected output is a partnership between program members, community leaders, and

clientele. Ecuadorian nurses and peer support volunteers will be equipped with the necessary

skills and knowledge to educate rural residents on family planning matters. Teaching topics and

itineraries for home visits will be created and distributed to each staff member and client. Twenty

vehicles will be purchased, insured, registered and outfitted with all required supplies. It isanticipated that through the efforts and cohesiveness of this program’s interdisciplinary team,

communication will be improved between family members and peers, as well as between clients

and staff.

Effects

This program hopes to change the knowledge, attitudes, and practices of rural

Ecuadorian communities in relation to family planning practices. Desired effects of this program

are specific, measurable, achievable, realistic and time-specific (SMART). One of the desired

objectives is by year five of the program, the clients will demonstrate increased knowledge of

family planning and contraceptive methods as evidenced by higher scores on post-tests. By year

five, clients will demonstrate enhanced awareness of which contraceptive method best suits their

lifestyle as evidenced by attitudes reflected through survey responses. This is relevant because

“total fertility rates for Ecuador have been steadily declining, and this has been regarded as a

direct indicator of the success of interventions aimed at improving access to contraception across

the country” (Goicolea & San Sebastian, 2010). Another desired outcome is that by the end of


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the program, clients will demonstrate an increased awareness of facilities that provide family

planning methods and related healthcare services, which will be demonstrated through the use of

survey responses. In addition to increasing knowledge, this program aims to develop progressive

attitudes among rural residents and community leaders regarding various family planning

methods. Furthermore, the program hopes to foster more open-mindedness of parents and

children toward discussing family planning and sexual practices in the home. By year five, the

increase in accepting attitudes toward family planning practices will be measured through survey

feedback. The practices that will theoretically change due to the implementation of this program

include: prolonging abstinence among adolescents, increasing proper and consistent use ofcontraceptives among all sexually active individuals, and increasing communication between

parents and children regarding sexual practices and family planning. By year five of the program,

the change in these practices will be determined by evaluating the change in birth rates among

adolescents living in rural Ecuador.

Assumptions

Certain assumptions or beliefs were made about the program’s interventions and

resources utilized through its development. Assumptions were made “based on research, best

practices, past experience and common sense” (Department of Health and Human Services,

Centers for Disease Control and Prevention, 2013). The following assumptions were made: there

will be an adequate number of volunteers, educational content will be presented consistently,

laws and policies will support the program, funding will be remain secure, all supplies will be

delivered without error, staff will possess necessary skills and abilities, and the clientele and

community leaders will be receptive to the education and care provided. An awareness and plan


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of action in regard to these assumptions is essential in order for the Family Planning on Wheels

program to be successful.

Technical Approach and Gantt Chart Work Plan

This program is scheduled to start on January 1st of 2015. The first task will involve five

American nurses hiring and facilitating the training of twenty Ecuadorian nurses. After this

training has been completed, these five nurses will be responsible for evaluating successes and

failures through statistical data analysis for the remainder of the program. Eleven days have been

dedicated to hiring and training nurses, as well as 20 peer support volunteers on educational

content and program goals. The same amount of time has been given for training volunteers asnurses because their role is, perhaps, equally important. As peers of rural Ecuadorian

communities, volunteers will play an important role as young individuals are greatly influenced

by their peers in relation to matters of sexuality and reproductive health (Tebbets & Redwine,

2013). After the training process is complete, almost a month will be devoted to purchasing the

20 vehicles and obtaining registration, insurance and fuel cards. At this point, four weeks will be

devoted to exploring the rural areas of Ecuador, assessing communities, and evaluating the

knowledge base and attitudes of the residents who live in these areas in regards to family

planning. A month has been devoted to this evaluation process due to its importance as

evidenced by the deficiency in knowledge of the indigenous population in Ecuador (Bilsborrow,

Bremmer, Feldacker & Holt, 2009). At this point, specific communities will be selected for

initial visits and a rough schedule will be drafted based on location. Time has been allotted for

revising and finalizing the schedule, which may be necessary as nurses and volunteers are hired

and trained. Due to the anticipated increase and fluctuation of clientele, the schedule will remain

flexible. From February 16th to February 26th, materials such as reproductive models, pamphlets,


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referral paperwork and condoms will be purchased and organized within the vehicles. The next

two weeks will be allotted for ensuring that the team and the materials are organized and ready

for community visits. This extra time can be used to account for any of the above items that take

longer than expected or can be used as last minute preparation time. In the event that program

coordinators face resistance from community leaders or individual community members,

difficulty arises in finding and hiring nurses and volunteers, or there is a failure to obtain

necessary materials, additional time will be allotted and community visits will be delayed

accordingly. On Monday March 16th, community visits will commence. Although the Gantt

chart only conveys the first year of the program, community visits, in-home meetings and clientreferrals will continue for five years. In addition to the on-going evaluation process beginning at

the start of community visits, two months will be dedicated to constructing a written program

evaluation after the completion of this initiative. Refer to Appendix B: Figure 2 for the detailed

Family Planning on Wheels Gantt Chart.

Evaluation Summary

Previous studies have highlighted that being raised in an environment with little chance

of social and economic advancement can cause adolescents to be uneducated about pregnancy

and have unintended pregnancies at a young age (Yoost et al., 2014). This alone implies that

education is crucial in decreasing pregnancy rates in young populations. The Family Planning

on Wheels program is able to provide this needed education. However, participation in this

program does not guarantee that learning will occur or that attitudes about birth control use will

change. Measures must be implemented to evaluate whether the program is effective and

accomplishes the impact that it intended.


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The Family Planning on Wheels program will be evaluated using both qualitative and

quantitative measures. Before any education on family planning can be implemented, the nurses

must first assess their clients’ baseline knowledge regarding family planning and contraceptive

methods. A pretest will be distributed at the start of each visit and will be specific to the

education provided that day. At the end of each visit, a post-test will be distributed and later

compared to the pre-test in order to determine the effectiveness of teaching. Comparing the

average scores of these tests for each client will indicate whether learning took place and if the

intervention or teaching was effective. Pregnancy rates of clients before, during and following

participation in the program will be monitored and compared to overall pregnancy rates in ruralareas of Ecuador. Monitoring changes biannually will determine whether the program has

affected, or more specifically, lessened the number of unplanned pregnancies as intended.

Qualitative measures will be implemented using short answer and multiple choice survey

questions that allow patients to voice their opinions on the educational content presented to them.

They will also have the opportunity to provide advice on how the program or their individual

experience could have been improved. In this survey, clients will share whether or not their

attitudes regarding contraceptive use and family planning were changed as a result of the

interventions of this program.

Extensive literature exists depicting interventions that have been effective in lowering the

rates of unintended pregnancies. This proposal was designed with the intent to incorporate

components that have been proven effective through extensive research. Family Planning on

Wheels was modified to reflect this population’s particular culture and inhabitance across the

rural regions of Ecuador. This program has the potential to make improvements in Ecuador by


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decreasing birth rates and can only be put in to action if adequate funding is granted. In short, the

ability to lower birth rates in Ecuador is in your hands.


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References

Bilsborrow, R., Bremmer, J., Feldacker, C., & Lu Holt, F. (2009). Fertility beyond the frontier:

indigenous women, fertility, and reproductive practices in the ecuadorian amazon.

Population Environment . 30, 93–113. doi:10.1007/s11111-009-0078-0

Department of Health and Human Services, Centers for Disease Control and Prevention (2013).

Evaluation guide: Developing and using a logic model . Retrieved from

http://www.cdc.gov/dhdsp/programs/nhdsp_program/evaluation_guides/docs/logic_mode

l.pdf

Goicolea, I (2010). Adolescent pregnancies in the Amazon Basin of Ecuador: A rights andgender approach to adolescents’ sexual and reproductive health. Global Health Action, 3.

doi:10.3402/gha.v3i0.5280

Goicolea, I., & San Sebastian, M. (2010). Unintended pregnancy in the amazon basin of

ecuador: A multilevel analysis. International Journal for Equity in Health. 9:14.

Retrieved from http://www.equityhealthj.com/content/9/1/14

Goicolea, I., San Sebastián, M. & Wulff, M. (2008). Women's reproductive rights in the amazon

basin of ecuador: Challenges for transforming policy into practice. Harvard School of

Public Health/François-Xavier Bagnoud Center for Health. 10, 91-103. Retrieved from

http://www.jstor.org/stable/20460105

Goicolea, I., Wulff, M., Öhman, A., & San Sebastian, M. (2009). Risk factors for pregnancy

among adolescent girls in Ecuador's Amazon basin: A case-control study. Revista

Panamericana De Salud Publica, 26 (3), 221-228. Retrieved from

http://web.b.ebscohost.com.ezproxy.lib.csustan.edu:2048/ehost/pdfviewer/pdfviewer?sid

=25b3f36e-9372-4a2f-9dd9-562d38fb1596%40sessionmgr112&vid=4&hid=106


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Herdman, C. (2008). The impact of early pregnancy and childbearing on adolescent mothers and

their children. Retrieved from

http://www.advocatesforyouth.org/publications/publications-a-z/432-the-impact-of-early-

pregnancy-and-childbearing-on-adolescent-mothers-and-their-children.html

Planned Parenthood (2014). Ecuador country program. Retrieved from

http://www.plannedparenthood.org/about-us/planned-parenthood-global/ecuador-

country-program.html

Redwine, D. & Tebbets, C. (2013). Beyond the clinic walls: Empowering young people through

youth peer providers programmes in ecuador and nicaragua. RHM Journal . 21, 143-153.doi:10.1016/S0968-8080(13)41693-2

Yoost, J., Hertweck, S., & Barnet, S. (2014). The effect of an educational approach to pregnancy

prevention among high-risk early and late adolescents. Journal of Adolescent Health. 55,

222-227. doi:10.1016/j.jadohealth.2014.01.017


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Appendices:Logic Model and Gantt Chart

family planning on wheels: a program to reduce unplanned pregnancies in rural ecuador

Documents