global health paper.docx

7/24/2019 Global Health Paper.docx

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Running head: FAMILY PLANNING ON WHEELS

Family Planning on Wheels: A Program o Redu!e "n#lanned Pregnan!ies in Rural

E!uador

$aylee %lan&enshi#' Alyssa (ardinal' LeAnna (eglia' Maggie Fa)ry and Noel Sil*eira

(ali+ornia Sae "ni*ersiy' Sanislaus

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FAMILY PLANNING ON WHEELS

Executive Summary

A #re*alen issue in E!uador is he high in!iden!e o+ un#lanned #regnan!y' #ari!ularly

-ihin he rural' adoles!en #o#ulaion. A!!ording o %remner' %ils)orro-' Felda!&er and Lu

Hol' his resuls +rom a la!& o+ a!!ess o !onra!e#i*e measures and a &no-ledge de+i!i in

regards o +amily #lanning /01123. A!!ording o resear!h )y Yoos' Her-e!& and %arne'

im#lemening edu!aional !lini! *isis may lo-er he in!iden!e o+ #regnan!y /01,43. Inegraing

an edu!aional iner*enion ino hese rural lo!aions has he #oenial o in!rease residens5

&no-ledge o+ +amily #lanning -hile de!reasing un#lanned #regnan!y.

A #ro#osal +or a Family Planning on Wheels #rogram has )een !reaed o o*er!ome his

issue in E!uador. 6he #rogram !onsiss o+ a sa++ o+ nurses and *oluneers ha ra*el hroughou

rural areas o+ E!uador. 6he mission o+ his #rogram is o e*aluae indi*idual needs' #ro*ide

edu!aion relaed o +amily #lanning and #ro*ide !onra!e#i*es in order o #re*en un#lanned

#regnan!ies. Edu!aional o#i!s in!lude a)sinen!e' sa+e se7 #ra!i!es' #ro#er use o+

!onra!e#i*es' sel+8eseem' #eer #ressure a*oidan!e' and ho- #arens should a##roa!h se7ual

edu!aion -ih heir !hildren. 6hrough he im#lemenaion o+ his #rogram' i is esimaed ha

here -ill )e an in!reased &no-ledge o+ +amily #lanning' in!reased a!!e#an!e o-ard *arious

mehods o+ )irh !onrol' and a de!rease in un#lanned #regnan!ies.

Background

(ounries in he Andean region o+ Lain Ameri!a ha*e e7!e#ionally high adoles!en

+eriliy raes in !om#arison o )oh indi*idual !ounry andglo)al a*erages /Goi!olea' 01,13.

E!uador' in #ari!ular' has he highes rae among Lain Ameri!an !ounries -ih a saggering

,11 ou o+ e*ery ,'111 adoles!en girls !urrenly or re!enly im#regnaed /Goi!olea' Wul++'

Ohman' 9 San Se)asian' 01123. A!!ording o Goi!olea' Wul++' Ohman and San Se)asian' o+

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all E!uadorian -omen age ,; o ,2' 01< ge #regnan )e+ore age 01= /0112' #. 00,3. >ue o he

#hysi!al and menal healh !om#li!aions asso!iaed -ih early !hild)earing' as -ell as he high

ris& +or #o*ery )eso-ed on hese young mohers' E!uador5s high adoles!en +eriliy rae is a

huge !on!ern. 6he o++s#ring o+ hese adoles!ens are also a an in!reased ris& +or a)use and

negle!' and he ma?oriy are +or!ed o )e!ome a!!usomed o li+esyles o+ hardshi# /Goi!olea'

Wul++' Ohman' 9 San Se)asian' 01123. In Lain Ameri!a' i has )een sho-n ha in+ans )orn o

mohers ,; o ,2 years old are nearly @1 #er!en more li&ely o die during he +irs year o+ li+e

han in+ans )orn o mohers 01 o 02 years old= /Herdman' 011@3. 6his is #ro)lemai! +or he

enire !ounry )e!ause he adoles!en #o#ulaion' in he )igger #i!ure' is he +uure o+ E!uador.

A!!ording o Goi!olea' Wul++' Ohman and San Se)asian' ris& +a!ors +or uninended

#regnan!ies in!lude no only )eing an adoles!en' )u also ha*ing #oor !onra!e#i*e &no-ledge

and use' #oor !ommuni!aion among +amily mem)ers' lo- edu!aion le*els' early se7ual de)u'

and lo- so!ioe!onomi! saus /01123. 6o address hese !on!erns' E!uador !reaed a naional

#regnan!y #re*enion #lan in 011 ha is )ased on he assum#ion ha in order +or adoles!ens

o e7er!ise heir re#rodu!i*e righs hey no only need a!!ess o a ne-or& o+ ser*i!es )u also

mus )e em#o-ered o a&e !onrol o+ heir se7ualiy= /Goi!olea' Wul++' Ohman' 9 San

Se)asian' 0112' #. 0003. Aside +rom a!!essi)iliy' edu!aion on he #ro#er use o+ !onra!e#i*es

is also im#oran +or his #o#ulaion. 6he mos #aramoun as&' ho-e*er' is rea!hing ou o he

mos *ulnera)le and negle!ed #o#ulaions. More s#e!i+i!ally' he as& a hand in*ol*es

#ro*iding +amily #lanning edu!aion o indigenous indi*iduals or hose li*ing in rural E!uador.

>ue o a la!& o+ resear!h and aenion o he alarmingly high E!uadorian adoles!en +eriliy

raes' he num)er o+ #regnan!ies !oninues o in!rease. Goi!olea e7#lains ha -hile oal

+eriliy raes ha*e )een de!lining' adoles!en +eriliy raes ha*e e7#erien!ed lile !hange' and in

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!ounries su!h as (olom)ia and E!uador' hey ha*e e*en in!reased= /01,13. Immediae a!ion is

reCuired +or his !ounry in order o de!rease +eriliy raes and #re*en he negai*e ou!omes

asso!iaed -ih #regnan!ies' s#e!i+i!ally in regards o he rural and adoles!en #o#ulaions.

Literature Review

Resear!hers Yoos e al. re!enly !ondu!ed a sudy o e*aluae a ne- a##roa!h on

adoles!en #regnan!y #re*enion /01,43. 6he sudy uiliDed a reros#e!i*e !har re*ie- design

held a he (ener +or Adoles!en Pregnan!y Pre*enion' -hi!h is a #ri*aely +unded !lini!

lo!aed in an ur)an seing in $enu!&y. Su)?e!s -ere )e-een he ages o+ ,, and ,@ years and

-ere seen +rom anuary 011 o >e!em)er 01,1. 6he ou!omes sudied -ere ,08 and 048monh

!oninuaion raes o+ )irh !onrol o#ions' oal lengh o+ +ollo-8u#' ime unil ga#s in +ollo-8u#'

and in!iden #regnan!ies. Resuls -ere )ased on age a he iniial *isi and -ere s#li ino -o

grou#s: early adoles!ens /aged ,,8,; years3 or lae adoles!ens /aged ,8,@ years3. 6here -ere

,0, #aiens and se*en in!iden #regnan!ies' all in he lae adoles!en grou#. 6he early

adoles!ens had a greaer rae o+ !oninuaion o+ )irh !onrol a ,0 monhs and 04 monhs

!om#ared -ih lae adoles!ens. 6he edu!aional a##roa!h used may de!rease adoles!en

#regnan!y among high8ris& adoles!ens ha !oninue o use he !lini! sysem. 6his model may

)e more e++e!i*e +or early adoles!ens han lae adoles!en /Yoos e al.' 01,43

A ma?or srengh o+ his sudy in*ol*es he e7ensi*e edu!aion #ro*ided )y a nurse ha

!o*ers +emale anaomy' he mensrual !y!le' *aginal healh' and )irh !onrol o#ions. Anoher

srengh is en!ouraging he #aiens o +ollo- hrough -ih +ollo- u# a##oinmens e*ery B

monhs. 6he sudy !onained a !ou#le o+ limiaions. 6he +irs is !lassi+ying #aiens -ih

!oninued !onra!e#ion use -ih he !ondiion o+ no dis!oninuing heir +orm o+ )irh !onrol

+or one monh or longer. 6his #us he #aien a ris& +or #regnan!y )e!ause mehods !ould )e

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so##ed and hen resumed -ihin ha monh and sill !onsidered !oninued=. Anoher

limiaion in!ludes no re!ording demogra#hi! in+ormaion su!h as drug and al!ohol use ha !an

!onri)ue o high8ris& a!i*iy. Pregnan!y am)i*alen!e -as also no assessed all #regnan!ies

-ere re!orded as uninended. Reasons +or dis!oninuaion o+ )irh !onrol mehods -ere no

re!orded. All o+ hese limiaions a++e! inernal *alidiy. 6he e7ernal *alidiy or generaliDa)iliy

is a++e!ed )y he +a! ha #ari!i#ans -ere no randomly assigned o #ari!i#ae in he sudy.

In a re!en sudy !ondu!ed )y Goi!olea' Wul++' Ohman' and San Se)asian' *arying ris&

+a!ors -ere analyDed +or #regnan!y among he #o#ulaion o+ adoles!en girls li*ing in he

AmaDon )asin o+ E!uador /01123. 6he sudy -as a ma!h !ase8!onrol sudy -ih ,41 !ases and

00 #ari!i#ans in he !onrol grou#. (ases in!luded +emales )e-een he ages o+ ,1 and ,2

li*ing in Orellana' -ho -ere #regnan a he ime o+ he iner*ie- or had )een #regnan in he

#re*ious -o years. 6he !onrol grou# in!luded adoles!ens o+ he same age grou# and lo!aion'

-ho had ne*er )een #regnan. All #ari!i#ans -ere sur*eyed on hree di++eren !aegories o+ ris&

+a!ors +or #regnan!y among adoles!en -omen in!luding so!io8demogra#hi! indi!aors' ad*erse

e*ens during !hildhood8adoles!en!e' and se7ual and re#rodu!i*e healh *aria)les. 6he sudy

un!o*ered ha si7 +a!ors -ere saisi!ally signi+i!an /# 1.1;3 in adoles!en #regnan!ies

se7ual a)use during !hildhood8adoles!en!e' early se7ual de)u' li*ing in a *ery #oor household'

e7#erien!ing li+e #eriods o+ a year or longer -ihou a moher and +aher' married or )eing in a

union' and no )eing enrolled in s!hool a he ime o+ he iner*ie- /Goi!olea' Wul++' hman' 9

San Se)asian' 01123.

6he srenghs o+ his sudy in!luded a high num)er o+ #ari!i#ans and also +ollo-8u#

-ih resour!es +or indi*iduals -ho !laimed o ha*e e7#erien!ed some sor o+ a)use. 6here -ere

many limiaions o his sudy. Firs' he sudy +o!used on a small +ra!ion o+ he !ounry' -ih

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#ari!i#ans residing in only a single #ro*in!e o+ E!uador. A huge limiaion o he sudy -as he

unrelia)iliy o+ re#ored a)orions due o +ear in relaion o E!uador5s la- +or)idding a)orions.

6his ina!!ura!y' in addiion o he +ear o+ sharing in+ormaion in he #resen!e o+ #arens' !ould

ha*e a++e!ed he sudy5s o*erall resuls )y #oenially e7!luding he mos *ulnera)le #o#ulaion

o+ girls. Anoher limiaion -as he use o+ he Ad*erse (hildhood E7#erien!es Cuesionnaire'

-hi!h -as !reaed +or he Ameri!an #o#ulaion and no he E!uadorian #o#ulaion. 6he e7ernal

*alidiy -as also negai*ely a++e!ed )y he la!& o+ random assignmen o+ #ari!i#ans +or he

sudy.

Addiional resear!h' )y Goi!olea and San Se)asian' in*esigaes he e++e!s o+ )oh

indi*idual and !one7ual +a!ors on uninended #regnan!ies in E!uador /01,13. Women

)e-een he ages o+ ,; and 44 years old -ere sele!ed -ih an ongoing !ommuniy8)ased !ross8

se!ional sur*ey. 6he sur*ey -as !ondu!ed )e-een May and >e!em)er 011 in he Orellana

#ro*in!e. Sur*ey Cuesions -ere issued as an iner*ie- in he #ari!i#ans5 home and in he

#ari!i#an5s nai*e language. 6he daa -as +ied and ranslaed )y using a mulile*el logisi!

regression in -hi!h indi*idual8le*el and !ommuniy8le*el +a!or -ere ad?used as +i7ed e++e!s

and allo-ing +or heerogeneiy )e-een !ommuniies= /Goi!olea 9 San Se)asian' 01,13. 6he

sam#le in!luded a oal o+ ,'110 -omen )e-een he ages o+ ,; and 44 years old -ho li*ed in he

Orellana #ro*in!e o+ E!uador. 6his sam#le e7!luded -omen -ho -ere eiher #regnan or

)reas+eeding o a*oid res#onden )ias and only in!luded he -omen -ho a!ually deli*ered a

!hild. 6he resuls o+ his sudy sho-ed ha he o*erall o!!urren!e o+ uninended #regnan!y -as

0.< o+ he #o#ulaion. A oal o+ B.< o+ indigenous -omen re#ored ha*ing a leas one

#regnan!y ha -as uninended. 6he signi+i!an ris& +a!ors +ound +or uninended #regnan!ies

in!luded )eing single' young' and indigenous as -ell as ha*ing more han -o !hildren and lile


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a!!ess o edu!aion. 6here -as no !orrelaion +ound )e-een use o+ !onra!e#i*es and

so!ioe!onomi! saus. All o+ he *ariaions )e-een he B4 #ro*in!e !ommuniies -ere

e7#lained )y indi*idual +a!ors /Goi!olea 9 San Se)asian' 01,13.

6he srenghs o+ his sudy in!luded using a large #o#ulaion o+ #ari!i#ans' ha*ing he

iner*ie- !ondu!ed in he #ari!i#ans5 nai*e language' and o)aining in+ormed !onsen )e+ore

he sudy -as !ondu!ed. Also' o a*oid res#onden )ias' he iner*ie- e7!luded -omen -ho

-ere eiher #regnan or )reas+eeding. Limiaions o+ his sudy in!lude ha*ing only iner*ie-ed

-omen )e-een he ages o+ ,; and 44. Also' he sudy -as !ondu!ed in only one #ro*in!e o+

E!uador' limiing heir daa o only a single #o#ulaion.

A sudy )y Goi!olea' San Se)asian' and Wul++ gahered in+ormaion and daa on

re#rodu!i*e healh +a!ors su!h as deli*ery !are' adoles!en #regnan!y' and !onra!e#ion

/011@3. 6he daa -as gahered +rom a lo!al !ommuniy )ased sur*ey as -ell as +rom #oli!y and

o++i!ial sour!es +rom he Healh Righs o+ Women Assessmen Insrumen /HRWAI3. 6he design

-as a !ommuniy8)ased !ross se!ional sur*ey ha )egan in 011. 6he sur*ey -as !ondu!ed as

an iner*ie- ha e*aluaed hree areas o+ re#rodu!i*e healh in!luding +amily #lanning' deli*ery

!are' as -ell as #regnan!y among adoles!en girls )e-een he ages o+ ,1 and ,2 years. 6he

#ari!i#ans #aroo& in a -o8sage !luser sam#ling #ro!edure. 6he #o#ulaion argeed in!luded

a oal o+ 0'10; -omen -ho -ere )e-een he ages o+ ,1 and 44 years old and li*e in he

Orellana #ro*in!e. O+ hose 0'10; -omen #ari!i#ans' ,'B, li*ed in households' ;04 -ere

+rom indigenous !ommuniies and ,',1 -ere +rom non8indigenous !ommuniies. As a resul o+

he sur*ey' i is e*iden ha -omen -ho li*e in Orellana +a!e lo-er Cualiy o+ re#rodu!i*e

healh ser*i!es !om#ared o oher -omen -ho li*e in oher areas o+ he !ounry. 6he sudy also

)rough +orh a -ide ga# o+ ineCuiy amongs he -omen li*ing in Orellana. For insan!e'


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-omen in ur)an areas had a higher #er!enage o+ #lanned #regnan!ies' modern !onra!e#i*e use

and s&illed deli*ery aendan!e !om#ared o he -omen li*ing in rural areas. Indigenous -omen

had he lo-es #er!enage o+ #lanned #regnan!ies' use o+ modern !onra!e#i*es' and s&illed

deli*ery aendan!e /Goi!olea' San Se)asian' and Wul++' 011@3.

Srenghs o+ his sudy in!lude using a large #o#ulaion o+ #ari!i#ans and using a

!redi)le ool o measure heir +indings. 6he resear!hers also used lieraure re*ie-s o+

inernaional and go*ernmenal do!umens as resear!h on he o#i!s in addiion o heir

!ommuniy sur*eys. Ho-e*er' some limiaions o+ his sudy in!luded no o)aining any +orm o+

!onsen +rom is #ari!i#ans and !ondu!ing he sur*ey and resear!h in one #ro*in!e o+ E!uador'

limiing heir daa o a single #o#ulaion.

A Cualiai*e sudy !ondu!ed )y 6e))es and Red-ine e*aluaed he e++e!i*eness o+

Youh Peer Pro*ider #rograms in E!uador and Ni!aragua /01,B3. 6hree e*aluaions -ere used

o*er a se*en8year #eriod o analyDe he *arious #rograms5 e++e!i*eness. In 0114' he +irs

e*aluaion -as !ondu!ed in )oh E!uador and Ni!aragua and used a BB8iem sur*ey !onaining

Cuesions a)ou #regnan!ies' )irhs and !onra!e#i*e use and hisory. For his e*aluaion' ;2

#rogram #ari!i#ans -ere randomly sele!ed. 6hese res#ondens had )een #ari!i#ans o+ he

#rogram +or an a*erage o+ hree years. 6he se!ond e*aluaion oo& #la!e in E!uador )e-een

011 and 0112 and uiliDed he Mos Signi+i!an (hange 6e!hniCue. 6his e*aluaion -as

Cualiai*e and assessed he im#a! o+ he #rogram on 20 indi*iduals using a si78Cuesion sur*ey

ool. 6he hird and +inal e*aluaion oo& #la!e in 01,1 and in!luded ,; in8de#h iner*ie-s

assessing he iner*ie-ees5 houghs regarding he #rogram5s srenghs' -ea&nesses' im#a!s and

o#eraional issues. 6he sam#le o+ ,1 indi*iduals in!luded in he las -o e*aluaions !onsised

o+ #as and #resen Youh Peer Pro*iders or !oordinaors' organiDaional sa++' sa++ a

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#ari!i#aing s!hools' sudens re!ei*ing raining hrough he #rogram' youh re!ei*ing mehods'

!ounseling hrough he #rogram' and #arens o+ he #ari!i#ans. 6he 0114 sur*ey re*ealed ha

hree8Cuarers o+ he res#ondens -ere !urrenly se7ually a!i*e and 2; #er!en o+ hose se7ually

a!i*e indi*iduals -ere using !onra!e#ion. 6his sur*ey also +ound ha hree8Cuarers o+

res#ondens re#ored e*er ha*ing used a !ondom -ih he inenion o+ #re*ening se7ually

ransmied in+e!ions /S6Is3. 6hese resuls !om#ared +a*ora)ly o he general #o#ulaions in

Ni!aragua and E!uador. 6he +inal -o e*aluaions5 res#onses re*ealed ha he mos !ommonly

menioned #rogram im#a! -as an in!rease in &no-ledge and he se!ond mos !ommon -as

#ersonal gro-h. In addiion' -eny8-o #er!en o+ #ari!i#ans saed an in!rease in sel+8

eseem' leadershi# s&ills and sel+8!on+iden!e and -eny8hree #er!en o+ #ari!i#ans menioned

ha heir !ommuni!aions s&ills -ere im#ro*ed as a resul o+ he #rogram. Lasly' a signi+i!an

num)er o+ res#ondens re#ored ha here -as an im#ro*emen in heir relaionshi#s -ih heir

+amily and +riends /6e))es 9 Red-ine' 01,B3.

6he sudy had many srenghs in!luding he a)iliy o+ he reader o +ollo- he

resear!her5s reasoning. No only -as !on+idenialiy o+ ea!h !lien &e# and he ser*i!es

#ro*ided in he lo!al language' )u #ari!i#ans -ere a)le o re!ogniDe he e7#erien!e as heir

o-n. 6his sudy had Youh Peer Pro*iders monior !onra!e#i*e re!ords +or all o+ heir !liens.

Anoher srengh in!luded using a large sam#le siDe o*er a !ourse o+ ,1 years. Ongoing

monioring and e*aluaing o+ he e++e!s -as also #ro*ided +rom his #rogram )y o)aining

*olunary #ersonal +eed)a!& +rom !liens. 6he limiaions o+ his sudy' ho-e*er' in!lude no

o)aining !onsen +orms +rom he #ari!i#ans.

%remner e al. !ondu!ed a sudy o esimae +eriliy raes in E!uador +or rural indigenous

-omen' analyDe re#rodu!i*e healh inenions and he use o+ !onra!e#i*es' and !onem#lae

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-hy +eriliy raes remain high among lo-land ro#i! indigenous #o#ulaions /01123. 6he auhors

hy#ohesiDed ha' high +eriliy is' in large #ar' due o unme need +or re#rodu!i*e healh

ser*i!es=' and his hy#ohesis -as esed using #rimary sur*ey daa regarding re#rodu!i*e

#ra!i!es. >aa !olle!ion oo& #la!e in 011, in -o #hases. 6he +irs #hase -as an ehnogra#hi!

sudy o+ eigh !ommuniies -hile he se!ond #hase -as a sur*ey o+ B !ommuniies !olle!ing

daa a)ou he household and he !ommuniy. Jualiai*e and Cuaniai*e daa -as !olle!ed

+rom )oh households and !erain !ommuniy leaders. 6he sam#le -as ;4 households +rom a

-o8sages and he sam#ling -as !onrolled. 6he iner*ie-s o+ he male and +emale heads o+ he

households -ere lead se#araely using Cuesionnaires. 6he Cuesionnaires in!luded Cuesions

a)ou migraion hisory' age' se7' edu!aion le*el' marial saus' languages s#o&en' asses and

healh o+ he household. 6he se!ond #ar o+ he sur*ey also as&ed +emales a)ou heir +amily

#lanning mehods used' he desire +or more !hildren' and heir o-n re#rodu!i*e hisory. For his

daa' only he -omen o+ re#rodu!i*e age -ere used ma&ing he sam#le siDe ;,1 households and

4@ -omen. 6he %rass8(ole mehods -ere used and esimaions -ere !al!ulaed +or +eriliy

raes. "ni*ariae and )i*ariae des!ri#i*e analysis -as used in order o !om#are he re#rodu!i*e

aiudes' #re+eren!es' and !onra!e#i*es used among B2 +emales and he resuls -ere hen

+urher !om#ared -ih he naional EN>EEMAIN II sur*ey. (ross8ehni! !om#arisons -ere

made using a )inary logisi! regression model. 6he resuls o+ his sudy !on+irmed ha +eriliy

raes are high and ha he need +or di++eren y#es o+ !onra!e#i*es are unme. 6hey +ound ha

here is only one healh !ener in he E!uadorian amaDon ha a!ually +o!uses on #ro*iding

re#rodu!i*e healh ser*i!es and +amily #lanning. 6his +a! hel#s e7#lain -hy &no-ledge and use

o+ !onra!e#i*es are so lo- and mis!on!e#ions are !ommon#la!e. 6here is a la!& o+ a!!ess and

a la!& o+ in+ormaion or edu!aion on +amily #lanning and !onra!e#i*es /%remner e al.' 01123.

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6he srenghs in his sudy in!luded ha*ing a large sam#le siDe in -hi!h he sam#le

#o#ulaion re#resened muli#le !ommuniies in an area o+ E!uador. 6o a*oid any )ias or

misleading ans-ers' men and -omen -ere gi*en se#arae' indi*idual sur*eysKiner*ie-s. Also'

he ools used o measure he sur*eys -ere relia)le and he same Cuesionnaires -ere used +or

ea!h su)?e!. Ho-e*er' here -ere also many limiaions +ound in his sudy. For insan!e'

here -as no menion o+ any +orms o+ !onsen o)ained +rom he #ari!i#ans. 6he sur*ey -as

!ondu!ed only in he norhernmos #ro*in!es o+ E!uador' limiing heir daa o only a sele!ed

#o#ulaion. Also' some lo!aions had e*ery household sur*eyed' -hile oher lo!aions had

households !hosen a random' here+ore' #ro*iding an in!onsisen!y in he o)ained daa. Wih

ha )eing said' his sudy is no *ery generaliDa)le sin!e i is +o!used s#e!i+i!ally on indigenous

-omen o+ E!uador' here+ore' he e7ernal *alidiy is limied.

Project Goals and Objectives

6he o*erall desired im#a! +or Family Planning on Wheels is a de!rease in he num)er o+

un#lanned #regnan!ies in rural E!uador )y 0< in +i*e years /See A##endi7 A: Figure ,3.

A!!ording o Planned Parenhood' a##ro7imaely B1< o+ E!uador5s #o#ulaion li*es in rural

areas' and one in en adoles!ens +rom his rural #o#ulaion gi*e )irh ea!h year /01,43.

6here+ore' his #rogram5s desired im#a! is o redu!e he adoles!en )irh rae +rom ,1< o @


12/26


and' among he younges mohers and heir ne-)orns' in!reased maernal and in+an moraliy=

/Goi!olea' Wul++' hman 9 San Se)asian' 01123.

Alhough Lain Ameri!an !ounries ha*e seen a de!line in +eriliy raes' here are sill

rural areas and su)8#o#ulaions ha are e7#erien!ing high +eriliy raes and generally' a la!& o+

a!!ess o +amily #lanning and re#rodu!i*e healh ser*i!es= /%remner' %ils)orro-' Felda!&er 9

Hol' 01123. In a sudy !ondu!ed )y ennie L. Yoos' i -as +ound ha edu!aion and muli#le

!lini! *isis de!reased he num)er o+ #regnan!ies in adoles!ens /01,43. >ue o he limied

a*aila)iliy and o!!urren!e o+ rans#oraion o higher #o#ulaed areas -ih healh !lini!s'

indigenous and rural !ommuniies -ill grealy )ene+i +rom he #ro#osed !lini! on -heels. 6he

#rogram aims o de!rease he num)er o+ un#lanned #regnan!ies )y in!reasing &no-ledge relaed

o +amily #lanning and in!reasing a!!essi)iliy o !onra!e#i*es. 6he +ollo-ing se!ion -ill

ela)orae on he o*erall #lan' in!luding &ey sa&eholders and end )ene+i!iaries' in#us' a!i*iies'

ou#us' e++e!s' and assum#ions ha !onri)ue o he o*erall desired im#a! all o+ -hi!h are

oulined in A##endi7 A: Figure ,.

Key Stakeolders and End Bene!iciaries

6he end )ene+i!iaries o+ his #rogram' or hose -ho -ill )ene+i +rom he ser*i!es

#ro*ided' in!lude he indi*iduals and +amilies o+ rural !ommuniies in E!uador' healh !are

#ro*iders' and he lo!al go*ernmen5s e!onomy. 6he residens in hese !ommuniies -ill )e he

ones -ho e7#erien!e he mos )ene+is +rom his #rogram. 6his is )e!ause hey -ill gain he

&no-ledge and resour!es ne!essary o #re*en un#lanned #regnan!ies and !reae a +amily #lan

ha is s#e!i+i! o heir o-n indi*idual -ans' needs' and )elie+s. 6hrough re+errals' !liens -ill

ha*e a dire! line o #hysi!ians !loses o heir homes.

,0


13/26


6he &ey sa&eholders in his #rogram in!lude regisered nurses' #eer su##or *oluneers'

lo!al go*ernmen o++i!ials' !ommuniy leaders' #hysi!ians and #oenial !liens. Wih he su##or

o+ !ommuniy leaders' #oenial !liens -ill )e more -illing o a&e #ar in hese edu!aional

+amily #lanning meeings' hus ma&ing he #rogram more e++e!i*e. Regisered nurses -ill )e he

sa&eholders #ro*iding +amily #lanning edu!aion and resour!es ne!essary o redu!e un#lanned

#regnan!ies. 6he &ey o his #rogram5s su!!ess' ho-e*er' de#ends on he #ari!i#aion o+ he

!liens. Wihou heir in*ol*emen' regisered nurses are una)le o ma&e home *isis' here)y

a++e!ing he ani!i#aed ou!ome.

"n#uts

6here are se*eral resour!es needed in order o !arry ou he ne!essary a!i*iies +or

Family Planning on Wheels. Ameri!an regisered nurses -ill )e needed o rain all sa++' -hile

E!uadorian nurses -ill )e needed o #ro*ide +amily #lanning edu!aion' disri)ue !ondoms'

orien *oluneers and ma&e re+errals o #hysi!ians. Peer su##or *oluneers -ill )e needed +or

assising in #rogram a!i*iies. 6e))es and Red-ine !laim youh -ho dis!uss se7ual and

re#rodu!i*e healh -ih #eers are more li&ely o dis#lay #osii*e healh8see&ing )eha*iours han

youh -ho dis!uss i -ih aduls= /01,B' #. ,443. %ased on his &no-ledge' young aduls -ill )e

hired as *oluneers o !reae a more !om+ora)le amos#here +or !lienele in order o enhan!e

learning.

(onra!s -ih lo!al healh !are +a!iliies and #hysi!ians -ill need o )e made in order o

ma&e re+errals +or +amily #lanning mehods and relaed healh assessmens. Maerials' in!luding

#am#hles and re#rodu!i*e models' are needed o illusrae and e7#lain di++eren +amily #lanning

mehods. ehi!les' insuran!e' regisraion' and +uel +or ra*el are also essenial. 6hese *ehi!les

-ill !onain all su##lies ne!essary +or ma&ing home *isis and #ro*ide rans#oraion +or nurses

,B


14/26


and *oluneers. In+ormaion and ma#s +or !lini!s !loses o he area ha #ro*ide di++eren y#es

o+ !onra!e#i*es -ill also )e needed. Lasly' +unds +or all essenial maerials and a!i*iies are

ne!essary +or im#lemenaion.

$ctivities

In order o rea!h he o*erall im#a!' here are a num)er o+ a!i*iies ha need o )e

!arried ou in a s#e!i+i! order. 6he +irs a!i*iy ha needs o )e #er+ormed in he Family

Planning on Wheels #rogram is an assessmen o+ aiudes and &no-ledge on +amily #lanning

among rural E!uadorian residens. 6his -ill )e done )y *isiing indi*idual homes' #ro*iding

in+ormaion a)ou he #rogram' inCuiring a)ou he residens5 ineres in #rogram ser*i!es'

Cui!&ly assessing +amily #lanning needs using Cuesioning' #re8ess and sur*eys' and

en!ouraging hem o s#read he -ord o he res o+ he !ommuniy. A meeing should )e held

-ih lo!al o++i!ials and !ommuniy leaders o !ommuni!ae he +amily #lanning issues in ea!h

!ommuniy and esa)lish ra##or in order o de*elo# a #arnershi# /A. Aleman' #ersonal

!ommuni!aion' No*em)er 4' 01,43. In he E!uadorian !ulure' se7 and +amily #lanning are no

al-ays o#enly dis!ussed and religious )elie+s o+en #lay a role in aiudes and )eha*iors

regarding !onra!e#i*e use /%remner' %ils)orro-' Felda!&er and Hol' 01123. 6here+ore' i is

im#oran o ha*e !ommuniy leaders in su##or o+ he iniiai*e o aid in gaining he rus o+ he

!ommuniy. Ameri!an nurses -ill iner*ie- and hire Cuali+ied E!uadorian nurses and #eer

su##or *oluneers. A ea!hing #lan and s!hedule -ill )e !reaed s#e!i+i! o ea!h rural

!ommuniy and is needs. Ne7' nurses and *oluneers -ill )e rained on #rogram guidelines and

ho- o e++e!i*ely #resen +amily #lanning edu!aion o rural !ommuniies. Family #lanning

edu!aional maerials' in!luding #am#hles and re#rodu!i*e models' need o )e #ur!hased +or in

home ea!hing sessions. 6he ne7 a!i*iy is o #ur!hase 01 *ehi!les in E!uador and so!& hem

,4


15/26


-ih edu!aional maerials. 6he *ehi!les -ill reCuire insuran!e' regisraion' and +uel. A+er all

ne!essary su##lies are gahered and he sa++ is rained' iniial *isis -ill )egin' and -ill )e

+ollo-ed )y monhly *isis. 6he iniial *isi -ill deermine he household5s +amily #lanning

needs' &no-ledge de+i!is' and -ill las no longer han one hour. A general #re8es' #os8es and

sur*ey' in he +amily5s #rimary language' -ill )e disri)ued +or e*aluaion o+ ea!hing mehods.

Follo-8u# *isis -ill ela)orae on he #re*iously deermined needs o+ he household and las

a##ro7imaely hiry minues. Pre8ess' #os8ess and sur*eys -ill )e disri)ued a ea!h home

*isi and -ill )e s#e!i+i! o he o#i! +or ha #ari!ular *isi. 6o#i!s +or edu!aion -ill in!lude

a)sinen!e' sa+e se7 #ra!i!es' #ro#er use o+ !onra!e#i*es' #romoion o+ sel+8eseem' #eer8

#ressure a*oidan!e' and ho- )es o +oser !ommuni!aion regarding se7ual #ra!i!es )e-een

!hildren and heir #arens. Edu!aion is one o+ he essenial elemens o+ his #rogram. Resear!h

sho-s ha among indigenous -omen' he mos !ommon reasons +or notusing modern

!onra!e#i*e mehods -ere la!& o+ &no-ledge' +ear o+ side e++e!s' and !os. 6he ehnogra#hi!

sudy also re*ealed -ides#read mis!on!e#ions and +ears a)ou negai*e im#a!s o+ modern

+amily #lanning mehods on -omen5s healh= /%remner' %ils)orro-' Felda!&er and Hol' 01123.

Re+errals may also need o )e #ro*ided o do!ors or nurse #ra!iioners !on!erning +amily

#lanning' as -ell as #ro*iding in+ormaion on healh !lini!s !loses o ea!h !ommuniy.

6hroughou he #rogression o+ his #rogram' he e++e!i*eness o+ *isis -ill )e e*aluaed )y

monioring )irh raes' !om#aring #re and #os8es s!ores +or ea!h *isi' and re*ie-ing sur*ey

+eed)a!&.

Out#uts

One e7#e!ed ou#u is a #arnershi# )e-een #rogram mem)ers' !ommuniy leaders' and

!lienele. E!uadorian nurses and #eer su##or *oluneers -ill )e eCui##ed -ih he ne!essary

,;


16/26


s&ills and &no-ledge o edu!ae rural residens on +amily #lanning maers. 6ea!hing o#i!s and

iineraries +or home *isis -ill )e !reaed and disri)ued o ea!h sa++ mem)er and !lien. 6-eny

*ehi!les -ill )e #ur!hased' insured' regisered and ou+ied -ih all reCuired su##lies. I is

ani!i#aed ha hrough he e++ors and !ohesi*eness o+ his #rogram5s inerdis!i#linary eam'

!ommuni!aion -ill )e im#ro*ed )e-een +amily mem)ers and #eers' as -ell as )e-een !liens

and sa++.

E!!ects

6his #rogram ho#es o !hange he &no-ledge' aiudes' and #ra!i!es o+ rural

E!uadorian !ommuniies in relaion o +amily #lanning #ra!i!es. >esired e++e!s o+ his #rogram

are s#e!i+i!' measura)le' a!hie*a)le' realisi! and ime8s#e!i+i! /SMAR63. One o+ he desired

o)?e!i*es is )y year +i*e o+ he #rogram' he !liens -ill demonsrae in!reased &no-ledge o+

+amily #lanning and !onra!e#i*e mehods as e*iden!ed )y higher s!ores on #os8ess. %y year

+i*e' !liens -ill demonsrae enhan!ed a-areness o+ -hi!h !onra!e#i*e mehod )es suis heir

li+esyle as e*iden!ed )y aiudes re+le!ed hrough sur*ey res#onses. 6his is rele*an )e!ause

oal +eriliy raes +or E!uador ha*e )een seadily de!lining' and his has )een regarded as a

dire! indi!aor o+ he su!!ess o+ iner*enions aimed a im#ro*ing a!!ess o !onra!e#ion a!ross

he !ounry= /Goi!olea 9 San Se)asian' 01,13. Anoher desired ou!ome is ha )y he end o+

he #rogram' !liens -ill demonsrae an in!reased a-areness o+ +a!iliies ha #ro*ide +amily

#lanning mehods and relaed healh!are ser*i!es' -hi!h -ill )e demonsraed hrough he use o+

sur*ey res#onses. In addiion o in!reasing &no-ledge' his #rogram aims o de*elo# #rogressi*e

aiudes among rural residens and !ommuniy leaders regarding *arious +amily #lanning

mehods. Furhermore' he #rogram ho#es o +oser more o#en8mindedness o+ #arens and

!hildren o-ard dis!ussing +amily #lanning and se7ual #ra!i!es in he home. %y year +i*e' he

,


17/26


in!rease in a!!e#ing aiudes o-ard +amily #lanning #ra!i!es -ill )e measured hrough sur*ey

+eed)a!&. 6he #ra!i!es ha -ill heorei!ally !hange due o he im#lemenaion o+ his #rogram

in!lude: #rolonging a)sinen!e among adoles!ens' in!reasing #ro#er and !onsisen use o+

!onra!e#i*es among all se7ually a!i*e indi*iduals' and in!reasing !ommuni!aion )e-een

#arens and !hildren regarding se7ual #ra!i!es and +amily #lanning. %y year +i*e o+ he #rogram'

he !hange in hese #ra!i!es -ill )e deermined )y e*aluaing he !hange in )irh raes among

adoles!ens li*ing in rural E!uador.

$ssum#tions

(erain assum#ions or )elie+s -ere made a)ou he #rogram5s iner*enions and

resour!es uiliDed hrough is de*elo#men. Assum#ions -ere made )ased on resear!h' )es

#ra!i!es' #as e7#erien!e and !ommon sense= />e#armen o+ Healh and Human Ser*i!es'

(eners +or >isease (onrol and Pre*enion' 01,B3. 6he +ollo-ing assum#ions -ere made: here

-ill )e an adeCuae num)er o+ *oluneers' edu!aional !onen -ill )e #resened !onsisenly'

la-s and #oli!ies -ill su##or he #rogram' +unding -ill )e remain se!ure' all su##lies -ill )e

deli*ered -ihou error' sa++ -ill #ossess ne!essary s&ills and a)iliies' and he !lienele and

!ommuniy leaders -ill )e re!e#i*e o he edu!aion and !are #ro*ided. An a-areness and #lan

o+ a!ion in regard o hese assum#ions is essenial in order +or he Family Planning on Wheels

#rogram o )e su!!ess+ul.

%ecnical $##roac and Gantt &art 'ork Plan

6his #rogram is s!heduled o sar on anuary , so+ 01,;. 6he +irs +our -ee&s o+ his

#rogram -ill )e de*oed o e7#loring he rural areas o+ E!uador' assessing !ommuniies' and

e*aluaing he &no-ledge )ase and aiudes o+ he residens -ho li*e in hese areas in regards o

+amily #lanning. A monh has )een de*oed o his e*aluaion #ro!ess due o is im#oran!e as

,


18/26


e*iden!ed )y he de+i!ien!y in &no-ledge o+ he indigenous #o#ulaion in E!uador /%ils)orro-'

%remmer' Felda!&er 9 Hol' 01123. A his #oin' s#e!i+i! !ommuniies -ill )e sele!ed +or *isis

and a rough s!hedule -ill )e dra+ed. 6ime has )een alloed +or re*ising and +inaliDing he

s!hedule' -hi!h may )e ne!essary as nurses and *oluneers are hired and rained. >ue o he

ani!i#aed in!rease and +lu!uaion o+ !lienele' he s!hedule -ill remain +le7i)le. Fi*e Ameri!an

nurses -ill )e hired o +a!iliae raining o+ E!uadorian nurses. A+er raining' hese +i*e nurses

-ill )e res#onsi)le +or e*aluaing su!!esses and +ailures hrough saisi!al daa analysis +or he

remainder o+ he #rogram. Ele*en days ha*e )een dedi!aed o hiring and raining nurses and

*oluneers on edu!aional !onen and #rogram goals. 6he same ime has )een gi*en +or raining

*oluneers as nurses )e!ause heir role is #erha#s eCually im#oran. As #eers o+ rural

E!uadorian !ommuniies' *oluneers -ill #lay an im#oran role as young indi*iduals are grealy

in+luen!ed )y heir #eers in relaion o maers o+ se7ualiy and re#rodu!i*e healh /6e))es 9

Red-ine' 01,B3. %e-een Fe)ruary ,sand Fe)ruary ,;h' -eny *ehi!les' insuran!e'

regisraion and +uel !ards -ill )e #ur!hased. From Fe)ruary ,ho Fe)ruary 0h' maerials

su!h as re#rodu!i*e models' #am#hles' re+erral #a#er-or& and !ondoms -ill )e #ur!hased and

organiDed -ihin he *ehi!les. 6he ne7 +i*e days -ill )e alloed +or ensuring he eam is

#re#ared +or !ommuniy *isis. 6his e7ra ime !an )e used o a!!oun +or any o+ he a)o*e iems

ha a&e longer han e7#e!ed or !an )e used as las minue #re#araion ime. In he e*en ha

#rogram !oordinaors +a!e resisan!e +rom !ommuniy leaders or indi*idual !ommuniy

mem)ers' di++i!uly arises in +inding and hiring nurses and *oluneers' or here is a +ailure o

o)ain ne!essary maerials' addiional ime -ill )e alloed and !ommuniy *isis -ill )e delayed

a!!ordingly. On Monday Mar!h 0nd' !ommuniy *isis -ill !ommen!e. Alhough he Gan !har

only !on*eys he +irs year o+ he #rogram' !ommuniy *isis' in8home meeings and !lien

,@


19/26


re+errals -ill !oninue +or -o years. In addiion o he on8going e*aluaion #ro!ess )eginning a

he sar o+ !ommuniy *isis' -o monhs -ill )e dedi!aed o !onsru!ing a -rien #rogram

e*aluaion a+er he !om#leion o+ his iniiai*e. Re+er o A##endi7 %: Figure 0 +or he deailed

Family Planning on Wheels Gan (har.

Evaluation Summary

Pre*ious sudies ha*e highlighed ha )eing raised in an en*ironmen -ih lile !han!e

o+ so!ial and e!onomi! ad*an!emen !an !ause adoles!ens o )e unedu!aed a)ou #regnan!y

and ha*e uninended #regnan!ies a a young age /Yoos e al.' 01,43. 6his alone im#lies ha

edu!aion is !ru!ial in de!reasing #regnan!y raes in young #o#ulaions. 6he Family Planning on

Wheels #rogram is a)le o #ro*ide his needed edu!aion. Ho-e*er' #ari!i#aion in his

#rogram does no guaranee ha learning -ill o!!ur or ha aiudes a)ou )irh !onrol use -ill

!hange. Measures mus )e im#lemened o e*aluae -heher he #rogram is e++e!i*e and

a!!om#lishes he im#a! ha i inended.

6he Family Planning on Wheels #rogram -ill )e e*aluaed using )oh Cualiai*e and

Cuaniai*e measures. %e+ore any edu!aion on +amily #lanning !an )e im#lemened' he nurses

mus +irs assess heir !liens5 )aseline &no-ledge regarding +amily #lanning and !onra!e#i*e

mehods. A #rees -ill )e disri)ued a he sar o+ ea!h *isi and -ill )e s#e!i+i! o he

edu!aion #ro*ided ha day. A he end o+ ea!h *isi' a #os8es -ill )e disri)ued and laer

!om#ared o he #re8es in order o deermine he e++e!i*eness o+ ea!hing. (om#aring he

a*erage s!ores o+ hese ess +or ea!h !lien -ill indi!ae -heher learning oo& #la!e and i+ he

iner*enion or ea!hing -as e++e!i*e. Pregnan!y raes o+ !liens )e+ore' during and +ollo-ing

#ari!i#aion in he #rogram -ill )e moniored and !om#ared o o*erall #regnan!y raes in rural

areas o+ E!uador. Monioring !hanges )iannually -ill deermine -heher he #rogram has

,2


20/26


a++e!ed' or more s#e!i+i!ally' lessened he num)er o+ un#lanned #regnan!ies as inended.

Jualiai*e measures -ill )e im#lemened using shor ans-er and muli#le !hoi!e sur*ey

Cuesions ha allo- #aiens o *oi!e heir o#inions on he edu!aional !onen #resened o hem.

6hey -ill also ha*e he o##oruniy o #ro*ide ad*i!e on ho- he #rogram or heir indi*idual

e7#erien!e !ould ha*e )een im#ro*ed. In his sur*ey' !liens -ill share -heher or no heir

aiudes regarding !onra!e#i*e use and +amily #lanning -ere !hanged as a resul o+ he

iner*enions o+ his #rogram.

E7ensi*e lieraure e7iss de#i!ing iner*enions ha ha*e )een e++e!i*e in lo-ering he

raes o+ uninended #regnan!ies. 6his #ro#osal -as designed -ih he inen o in!or#orae

!om#onens ha ha*e )een #ro*en e++e!i*e hrough e7ensi*e resear!h. Family Planning on

Wheels -as modi+ied o re+le! his #o#ulaion5s #ari!ular !ulure and inha)ian!e a!ross he

rural regions o+ E!uador. 6his #rogram has he #oenial o ma&e im#ro*emens in E!uador )y

de!reasing )irh raes and !an only)e #u in o a!ion i+ adeCuae +unding is graned. In shor' he

a)iliy o lo-er )irh raes in E!uador is in your hands.

01


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Re+eren!es

%ils)orro-' R.' %remmer' .' Felda!&er' (.' 9 Lu Hol' F. /01123. Feriliy )eyond he +ronier:

indigenous -omen' +eriliy' and re#rodu!i*e #ra!i!es in he e!uadorian amaDon.

Population Environment. 30' 2B,,B. doi:,1.,11Ks,,,,,8112811@81

>e#armen o+ Healh and Human Ser*i!es' (eners +or >isease (onrol and Pre*enion /01,B3.

Evaluation guide: Developing and using a logic model. Rerie*ed +rom

h#:KK---.!d!.go*Kdhds#K#rogramsKnhds##rogramKe*aluaionguidesKdo!sKlogi!mode

l.#d+

Goi!olea' I /01,13. Adoles!en #regnan!ies in he AmaDon %asin o+ E!uador: A righs and gender

a##roa!h o adoles!ens5 se7ual and re#rodu!i*e healh. Global Health Action, 3.

doi:,1.B410Kgha.*Bi1.;0@1

Goi!olea' I.' 9 San Se)asian' M. /01,13. "ninended #regnan!y in he amaDon )asin o+

e!uador: A mulile*el analysis.International ournal !or E"uity in Health. 2:,4.

Rerie*ed +rom h#:KK---.eCuiyhealh?.!omK!onenK2K,K,4

Goi!olea' I.' San Se)asin' M. 9 Wul++' M. /011@3. Womens re#rodu!i*e righs in he amaDon

)asin o+ e!uador: (hallenges +or rans+orming #oli!y ino #ra!i!e.Harvard #chool o!

Public Health$%ran&ois'(avier )agnoud *enter !or Health. +0' 2,8,1B. Rerie*ed +rom

h#:KK---.?sor.orgKsa)leK0141,1;

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A##endi!es:

Logi! Model and Gan (har

0B


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FAMILY PLANNING ON WHEELS 04


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$##endix B

0;


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Explore rural communities of Ecuad

Evaluate family planning attitudes and knowledge base of communitie

Communicate with community leaders (gain support and establish/maintain rappor

Select communities for visi

Develop change and !nali"e schedule for community visi

Conduct interviews for nurse practione

#ire nurse practitione

$rain and educate nurse practioners on goals plans and routin

%nterview and select voluntee

$rain and educate voluntee

Select and purchase bu

%nsure and register bu

&urchase all materials including condoms informational pamphlets referral paperwork models videos ect'

ut!t bus with supplies and materia

Ensure all materials are ready and orderly Ensure that volunteers and nurses are ready to begin wo

Conduct !rst year of community visi

Conduct !rst year of in*home women+s meeting

&rovide clients with referrals as neede

Evaluate e,ectiveness of program/gather data/begin to construct written program evaluatio

Figure 2: Family Planning on Whee

Start and End Dates

Tasks

0

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