Abstract
This paper discusses strategies to accelerate the rate, extent, and sustainability of change in medical care settings, using as a case example a 2-year technical assistance project mounted by EngenderHealth to “revitalize” use of the IUD in Kisii District of Kenya’s Nyanza Province. This project followed a holistic programming model, which holds that a coordinated package of programmatic activities among the supply, demand, and policy/advocacy program areas can be not only efficacious, but mutually reinforcing. Attention was also paid to four important crosscutting elements in reproductive health programming: the fundamentals of care (safety, quality, and choice); use of local data for decision making; gender equity; and stakeholder participation. IUD use rose with each program intervention, e.g., training, community and male engagement, and district-wide multimedia demand creation campaigns. At project close in 2007, 142 IUDs were being inserted monthly at the 13 project sites, up from a baseline average of 28 insertions monthly, an increase of 507 %. Despite district restructuring and transfer of skilled staff, increased annual levels of IUD provision (over 300 %) were sustained for 30 months after project close. Other positive changes generated district-wide included: improvements in the supervision system; implementation of a CBD program, with increased linkages between the community and project sites; increased male engagement in FP; 33 % more new clients for all FP methods at project sites; and greater use of other RH services.
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Notes
- 1.
Significantly increased vaginal bleeding sometimes occurred with the older, inert IUDs like the Lippes Loop. However, copper-bearing IUDs can generally be used by women with iron deficiency anemia (WHO 2010a).
- 2.
The rate of clinical PID the first 20 days post-insertion is 7 cases per 1,000 women-years of use (Farley et al. 1992; Mishell 1998); that is, 993 of 1,000 women having an IUD inserted would not get PID in the immediate post-insertion period. Rates of clinical PID after the first 20 days of IUD use range between 0.6 and 1.6 cases/1,000 woman-years of IUD use. These findings are the basis for WHO’s recommendation that only one routine follow-up visit is needed, 3–6 weeks after insertion (WHO 2004).
- 3.
Tubal infertility was not associated with IUD use per se, or with duration of use, reasons for removal, or gynecologic symptoms during use; rather, it was associated with presence of antibodies to chlamydia.
- 4.
The MEC has four classification categories: Category 1, “no restriction: use method in any circumstances”; Category 2, “generally use: benefits outweigh risks”; Category 3, “generally do not use: risks outweigh benefits”; and Category 4, “method not to be used”. The MEC schema also distinguishes between providers with clinical judgment and providers with limited clinical judgment. For the latter group of providers, Categories 1 and 2 are compressed to “Yes” and Categories 3 and 4 to “No.” The MEC largely classifies the IUD in Category 1 or Category 2. Women living in high STI- and HIV-prevalence settings or who are HIV-infected now belong to Category 2 with respect to IUD use, whereas on theoretical grounds these conditions had previously been Category 3. Women with high individual risk of STI, which can be determined with a checklist in low-resource settings, are in Category 3. Women with AIDS who are not yet on antiretroviral therapy (ART) are also in Category 3, but women with AIDS who are being treated and are clinically well are in Category 2 and thus good candidates for an IUD if they desire one.
- 5.
“The art of progress is to preserve order amid change and to preserve change amid order,” philosopher and mathematician Alfred North Whitehead reminds us (Whitehead 1929); in other words, although change may be inevitable, and indeed its pace may be accelerating, people incline towards homeostasis.
- 6.
Beauty is indeed in the eye of the beholder: often what the development change agent sees as a “beautiful” new way of doing things is perceived as unattractive by the “changee”. In this sense, the type of perspective about change being presented in this chapter can induce a sense of empathy and lead to “bottom-up” programming. As a wise Kenyan midwife/IUD service provider once told the author, “We must walk in their shoes, or we will fail.”
- 7.
Typically, if these “truths” are scientifically or factually wrong, the public health professional labels them “myths” or “misconceptions.”
- 8.
This gives rise to what Rogers terms “the Innovativeness-Needs Paradox”: individuals (or units in a system) who most need the benefits of a new idea, e.g., the less-educated or the poor are generally the last to adopt an innovation, and thus one consequence of technological innovation can be to widen socioeconomic disparities in social systems.
- 9.
In striking contrast, there are only 14 maternal deaths per 100,000 live births in industrialized countries (WHO et al. 2010).
- 10.
This pattern of high unmet need, limited method availability, and suboptimal fit of methods used with reproductive intentions (as well as, in consequence, excess fertility and high maternal mortality) persisted in Kenya in 2008 (KNBS 2010), and is a typical pattern for sub-Saharan African family planning programs.
- 11.
Data is not generally available that is stratified by reproductive intention (i.e., for limiters and spacers), thus the use of highly effective clinical methods among limiters is likely to be higher than 40 %, as there is a “dilution” effect when all women comprise the denominator.
- 12.
The low IUD use in Kenya (and elsewhere in sub-Saharan Africa) occurs for many reasons, as discussed in Section IV of this chapter. One additional reason for low IUD use among delayers has been the prevailing practice (the received “wisdom”) in medical settings that “IUDs are not indicated for women who have not yet had a child.” Also, some FP providers and programs are reluctant to provide methods with long duration of action (e.g., 12 or more years with the copper-T 380A) to women who indicate that they might want another child, albeit after 2–3 years of spacing. That is, “long-acting” is conflated with “long-term” and thus the intrinsic method characteristic is confused with how long a woman might choose to use the method.
- 13.
ACQUIRE is an acronym for Access, Quality and Use in Reproductive Health. The ACQUIRE Project was funded by USAID’s Office of Population and Reproductive Health to focus on facility-based services and clinical contraception, especially long-acting and permanent methods of contraception (LA/PMs). The ACQUIRE Project was a partnership among several agencies that worked from 2003 to 2008. In 2008 it was succeeded by the RESPOND Project, with a similar mandate and also led by EngenderHealth. Within the LA/PMs, IUDs and hormonal implants are grouped as “long-acting reversible methods,” and female sterilization and vasectomy as “permanent methods”. “Long-acting” is preferred to “long-term,” for reasons discussed in endnote 12.
- 14.
The SDA Program Model for FP/RH Service Delivery was subsequently elaborated upon to accommodate other health sector activities besides FP, and to expand beyond service delivery activities per se. In the process, the SDA Program Model became the Supply-Enabling Environment-Demand (SEED) Programming Model for Sexual and Reproductive Health. The basic elements of both the SDA Model and the SEED Model are similar.
- 15.
Ensuring the “Fundamentals of Care” is one of the SDA Model’s four “cross-cutting imperatives.” The others are to: use relevant evidence for decision-making in program strategy, design, implementation, and evaluation; promote gender equity, as gender norms and power dynamics often constrain women from accessing methods and services they want and need (Doyal 2000); and ensure widespread stakeholder engagement and “ownership.” Important stakeholders whose championship of FP is needed include political, religious and other opinion leaders; program leaders and managers, at national, regional, and district levels the medical community; clinic managers and FP service providers; advocacy groups; community organizations; and individual FP clients. Also implicit in the Model is the need to use the dynamics of change to design and implement program interventions that lead to greater service quality, access, and sustainability. As can be seen in this chapter, all of these aspects were addressed in the IUD-related work in Kisii.
- 16.
“All case studies show demand-side interventions and demand creation to be largely neglected—an omission bound to influence implementation” (Peters et al. 2009).
- 17.
For the first time, the prevalence of hormonal implants (1.9 %) surpassed that of IUDs, a trend that may well continue, given increasing donor, program and client interest in implants, and the availability in Kenya of a much less expensive implant (KNBS 2010).
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Acknowledgements
Many staff from both the Kisii District Ministry of Health, the ACQUIRE Project, the RESPOND Project, and EngenderHealth worked on the IUD revitalization effort in Kisii. Too numerous to acknowledge individually, they contributed the knowledge and expertise of a number of professional disciplines including medicine, midwifery, nursing, communication, marketing, and project management and evaluation. Appreciation is also given to the many community leaders and volunteers who worked to increase access, quality, and use of FP among women and men in Kisii. The continuing encouragement and commitment of Patricia MacDonald and Carolyn Curtis of USAID was indispensible in allowing this project to proceed and succeed.
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Jacobstein, R. (2014). Fostering Change in Medical Settings: A Holistic Programming Approach to “Revitalizing” IUD Use in Kenya. In: Kulczycki, A. (eds) Critical Issues in Reproductive Health. The Springer Series on Demographic Methods and Population Analysis, vol 33. Springer, Dordrecht. https://doi.org/10.1007/978-94-007-6722-5_12
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