Ethical foundations of client-centered care in family planning.

Biomedical ethics provides the foundation for a model of client-centered care that can assure the good quality of family planning and other reproductive health services in developed and developing countries. Client concerns mirror the four ethical principles of autonomy, justice, beneficence, and nonmaleficence. Autonomy reflects clients' desire for full information and respect from providers so that they can exercise their right to make their own informed decisions. Justice, for clients, means fair treatment and ready access to services, regardless of one's socioeconomic status, education, ethnic group, or residence. Beneficence means that providers possess the technical competence and understanding needed to act in the best interest of their clients, as clients expect. Nonmaleficence translates into client concerns about safety--that no harm will come to them as a result of seeking services. Putting these ethical principles into practice requires changing providers' attitudes from paternalistic to client centered. Assessments of client satisfaction can help family planning programs identify and respond to client values and even raise client expectations about the care they should receive. Managers also can contribute to good quality care by meeting providers' professional needs for training, supervision, supplies, record keeping, and so on. Family planning programs around the world are focusing on these ethical concerns to emphasize respect for client values, appropriate decision making, broader access to services, and basic safety issues. Although they use a variety of techniques, all these quality assurance and improvement initiatives share an ethically based, client-centered philosophy.

Asia's population and family planning programmes: leaders in strategic communication.

PIP: Countries in Asia played a key a role in identifying problems related to population growth and high fertility and in developing strategies to address these problems. Despite the economic problems experienced by some, they continue to lead the world in designing and implementing programs in the areas of reproductive and family health using a strategic communication approach. This modern strategic communication program has the following characteristics: science and research-based, client-centered, benefit-oriented, service-linked, entertainment-education focused, professionally developed, and programmatically sustainable. This paper describes several outstanding Asian family planning communication programs in 5 countries that clearly illustrate these 7 elements. Overall, these Asian countries have shown that strategic communication can be the steering wheel for modern family planning and health promotion programs. The article concludes by giving future directions for strategic communication programs to address new emerging health and population concerns in the region.^ieng

"Enter-educate." Reaching youth with messages of sexual responsibility.

PIP: Messages about sexual relationships, the prevention of pregnancy and disease, education, the empowerment of women, and concern for the environment are increasingly being disseminated to audiences of all ages through the use of entertainment. Ideas are presented in this Enter-Educate approach through popular, enjoyable entertainment in the form of songs, dramas, soap operas, variety shows, and other folk media. This approach can be adapted to be acceptable and effective in all cultures. Yafaman is one such example. It is a drama written and acted by high school students in Cote d'Ivoire which depicts the story of a school girl who learns that her older, married boyfriend is no longer interested in her when she becomes pregnant. After winning the annual national drama contest, Yafaman was televised and broadcast widely in schools and on national networks in francophone Africa. The video has also been dubbed in English for wider use. Popular music has delivered effective messages of sexual responsibility to young adults in Latin America and the Philippines. The US Agency for International Development-funded Population Communication Services project at the Johns Hopkins University supports 36 major Enter-Educate television series and specials, nine radio dramas, three songs, and nine music videos. Other organizations are expanding or experimenting with work in this area. The authors discuss the theoretical basis for Enter-Educate projects and explain that the approach works because it is pervasive, popular, personal, passionate, persuasive, practical, profitable, and proven effective.^ieng

Family planning lessons and challenges. Making programs work.

Over the past 30 years, family planning programs have helped millions of people to have the smaller families that they want. As programs have learned how to meet people's needs, contraceptive use has spread rapidly.

"Entertainment-education:" an idea whose time has come.

PIP: The "enter-educate" technique, which presents educational messages in the guise of entertainment, is being used effectively all over the world. Soap operas depict the struggles of a single mother or of a father who has infected his family with AIDS, songs remind listeners that contraception gives them choices, and animated videos breathe new life into sex education. The Johns Hopkins University has supported approximately 36 television series and specials, 9 radio dramas, 3 songs, and 9 music videos. Other organizations are expanding their work in this field. Surveys before and after exposure to enter-educate productions and clinic records can be used to measure changes in attitudes and behavior attributable to the productions. Evaluations of projects have shown that the audience pays attention and then moves from understanding to agreement to action (such as talking to their spouse or family, going to a clinic, using family planning, or practicing safer sex). The theoretical basis for the enter-educate approach can be traced to Aristotle who discussed the capacity for drama to convey moral teaching. More recently, Albert Bandura developed a theory of social learning which states that people learn by observing and adapting the behavior of others to their own lives. Miguel Sabido, a Mexican producer, applied Bandura's theory to develop the first enter-educate soap operas. The enter-educate approach is pervasive (through rapidly spreading mass media), popular (people seek entertainment), personal (depicting the private lives of the characters), passionate (invoking intense emotions), persuasive (through audience identification with characters), practical (since the talent and delivery infrastructure already exists), and profitable (entertainment pays its way, can generate profits and promote careers, and is cost-effective).^ieng

Counseling for better contraception.

PIP: The 10 basic categories of contraceptive methods available can be expanded into thousands of ways to prevent pregnancy when different types, brands, procedures, and formulations are considered. While not all methods are available in all settings, family planning (FP) service providers generally have to be capable of explaining a variety of methods to their clients. Effective counseling may be described using a concentric circle, with the provider and client engaging in interpersonal communication at the center and with progressively larger social groups represented by the outer circles. The goals of FP counseling are to provide clients (which is a more appropriate term than patients) with an informed and free choice that will lead to safe, effective, and correct method use. Special issues surround counseling for the selection of oral contraceptives (OCs), including that there are three different types, that unfounded rumors about OCs abound, that OCs are associated with a few minor side effects, that OCs pose serious risks for some women (such as women over 40 who smoke), and that OCs have a number of beneficial effects that are often overlooked. The failure rates associated with OC use are dictated by imperfect use, which can be categorized as interrupted use, incorrect sequence, incorrect action after skipping pills, and incorrect interval between packets. Appropriate advice is available for women who realize they have used their OCs incorrectly, but the instructions are not easy for women to remember. Providers can attempt to minimize this problem by giving clients clear and simple instructions on OC use as well as a back-up method. Effective counseling leads to effective OC use. Counselors can be trained to be effective through use of the acronym GATHER (Greet the client, Ask the client about herself, Tell the client about available methods, Help the client choose a method, Explain the use, and have the client Return for follow-up). A training course has been developed following the GATHER process and has been shown to lead to a significant improvement in the skills of providers and the behavior of clients.^ieng

U.S. population policy.

PIP: Some of the history and special features of the US population assistance program administered by USAID are recounted. Future predictions are also made for funding and new directions for the US population assistance program and environmental issues. The topics addressed were part of a talk given in 1992 at a meeting of the Council on Population Education held in Tokyo. Credit is given to Japan for its contribution to family planning (FP) efforts by setting an example of reducing population size within a decade and providing financial support internationally. Japan's example so impressed General William H. Draper, Jr. that he worked for the establishment of the USAID and the UN Population Fund, and funding for the International Planned Parenthood Federation. He encouraged Japanese officials to provide support for international population and (FP) programs. Currently, the US provides $350 million in population assistance. Encouragement was given for Japan to increase its international commitment of $80 million and to contribute to the Johns Hopkins University William H. Draper, Jr., fellowship fund for graduate students from developing countries to study modern health communication. The special features of the US population assistance program were identified as follows: 1) high funding levels, 2) availability of FP services, 3) adequate contraceptive supplies, 4) availability of professional population staff, and 5) an emphasis on data and evaluation. The single most important element of the USAID program is the reliance on private, nongovernmental organizations (NGOs), which can establish flexible, independent, innovative and cost- effective programs. Predictions for the future were that the US Congress would expand overseas population assistance. Domestic policy will have priority, and the future will depend on who occupies the key policy positions at the State Department and USAID. THere will be more emphasis on free political elections, on humanitarian issues, and on environmental issues. New directions will be to increase funding, reduce restrictions on population assistance, increase support for NGOs, expand FP communication programs, improve the quality of FP services, increase distribution of condoms, and increase coordination among donors. The enter educate approach to promoting FP is described.^ieng

Changing men's attitudes and behavior: the Zimbabwe Male Motivation Project.

A multimedia communication campaign was conducted between 1988 and 1989 to promote family planning among men in Zimbabwe. The campaign consisted of a 52-episode semiweekly radio soap opera, about 60 motivational talks, and two pamphlets about contraceptive methods. Changes over time were measured by comparing a subset of a follow-up survey conducted from October to December 1989 to a baseline survey conducted from April to June 1988. Men exposed to the campaign were also compared to men who were not exposed. The follow-up survey revealed that the campaign reached 52 percent of men aged 18 to 55. Among married Shona-speaking men, use of modern contraceptive methods increased from about 56 percent to 59 percent during the campaign. Condom use increased from about 5 percent to 10 percent. Awareness and current use of modern contraceptives was also higher among men exposed to the campaign, primarily because of their greater awareness of condoms. Men exposed to the campaign were significantly more likely than other men to make the decision to use family planning and to say that both spouses should decide how many children to have.

The enter-educate approach.

PIP: This article describes how the Population Communication Services (PCS) has seized on the "enter-educate" approach, the blending of popular entertainment with social messages, to change reproductive health behavior. The enter-educate approach spreads its message through songs, soap operas, variety shows, and other types of popular entertainment mediums. Because they entertain, enter-educate projects can capture the attention of an audience -- such as young people -- who would otherwise scorn social messages. And the use of population mediums makes it possible to reach a variety of audiences. Funded by USAID, PCS began its first enter-educate project in response to the increasing number of teenage pregnancies in Latin America. PCS developed 2 songs and videos, which featured popular teenage singers to serve as role models, to urge abstinence. The songs became instant hits. Since then, PCS has mounted more then 80 major projects in some 40 countries. Highlights of programs range from a successful multi-media family planning campaign in Turkey to humorous television ads in Brazil promoting vasectomy. Recently, PCS initiated projects to teach AIDS awareness. At the core of the enter-educate approach is the social learning theory which holds that much behavior is learned through the observation of role-models. Health professionals work alongside entertainers to produce works that have audience appeal and factual social messages. The enter-educate approach works because it is popular, pervasive, personal, persuasive, and profitable. PCS has found that enter-educate programs pay for themselves through cost sharing and cost recovery.^ieng

Time to talk condoms.

PIP: A great deal of avoided if political and religious leaders, educators, health care providers and the mass media would band together in an effort to promote condom use. Condoms use protects against unwanted pregnancies, STDs and AIDS. Yet, public discussions on condom use are rate. In the US, political leaders avoid mentioning the topic, and television networks severely restrict the airing of public service announcements for condoms. Worldwide, an estimated 100 billion acts of sexual intercourse take place every year. A recent report indicates that it would take a modest 13 billion condoms a year to protect everyone who is at risk of contracting AIDS and other STDs, and risk of having an unwanted pregnancy. Currently, worldwide production of condoms stands at about 6 billion a year. Furthermore, condom makers have the capacity to increase production by some 2 billion, and could add new capacity in about 2 years. Many believe that marketing condoms is a difficult enterprise, since men often report that condoms reduce pleasure, cause embarrassment, or are not available when needed. The challenge for markets, then, is to create demand. This is especially true in the US, where prime-time advertising and the use of popular entertainment, such as soap operas, could promote condoms as both safe and satisfying. In the developing world, the challenge is to make condoms widely available and affordable. Some changes have taken place since 1981, when AIDS first came into the spotlight. In the US, people now discuss the topic of STDs more openly. But an all-out effort to promote condom use has not yet begun.^ieng

Mass media family planning promotion in three Nigerian cities.

Television promotion of family planning and clinic sites in three cities of Nigeria--Ilorin, Ibadan, and Enugu--played a significant role in 1985-88 in increasing the number of new acceptors at family planning clinics in each city. Family planning skits, prepared with advice and support from the local service providers, were included in existing popular entertainment shows. Questions asked in a recall survey among the exposed population in Enugu and Ibadan revealed that about half of those surveyed in both cities had seen the television episodes. Of those who had watched, 79 and 99 percent, respectively, recalled the family planning messages, and 69 and 88 percent, respectively, recalled specific clinic sites mentioned. Following the media promotion, the number of new clinic clients per quarter in Ilorin increased almost fivefold (in the original clinics evaluated); in Enugu, the number of new clients per month more than doubled; and in Ibadan, the number of new clients increased threefold. Use of entertainment through this "enter-educate approach" is a promising technique that can be replicated in different settings to encourage new clients to seek family planning services.

New directions in family planning communication: 12 predictions for the 1990s.

PIP: Good communication about family planning is needed for many reasons: 1) what many people think they know about family planning is wrong, 2) about 25% of the Asian population (600 million people) are between the ages of 10 and 19 and they need to be informed, 3) individuals must want to use family planning so they will use it regularly and effectively, and 4) people hear competing messages from those opposed to family planning. The authors make the following predictions for the field of family planning IEC in the 1990s: 1) family planning communication will have many different audiences, so messages and media will have to be developed for very specific groups; 2) more time will be spent on research, learning about specific audiences, the media, and background before developing messages, and messages and products will be carefully tested before being widely distributed; 3) peer groups will be used more to reach peer groups; 4) entertainment will reach and teach wider audiences about family planning, AIDS, and sexual responsibility (promoting "enter-education," a combination of entertainment and education); 5) audiences will participate more actively in different kinds of family planning communication, including community mobilization and individual involvement; 6) family planning messages will be much more personal, using human interest stories to capture and persuade the audience; 7) multiple media will be used more and more to get the message across; 8) the best quality family planning entertainment materials will be able to compete with commercial products and produce revenue; 9) campaigns and other communications will be oriented towards large regional markets; 10) more creative and more sympathetic communication in clinics and by health care providers will increase acceptance and continuation rates for many methods; 11) communication among family planning professionals will increasingly depend on effective national population information centers that can use appropriate modern technology, and 12) more resources and creative effort will be put into evaluation of all forms of IEC and this evaluation will show that well-planned and well-implemented IEC programs can and do lead to behavioral change in family planning.^ieng

How should vasectomy be promoted in Guatemala?

PIP: In the article "Evaluation of a Communications Program to Increase Adoption of Vasectomy in Guatemala" by J.T. Bertrand et al (Stud Fam Plann 1987 Nov/Dec), the authors conclude that the use of a male promoter alone was 4 times more cost-effective in increasing the number of vasectomies than the use of radio alone because the costs of the radio program were 4 times higher. This conclusion is questionable for several reasons. 1) The district where the promoter was used alone was twice as large as the radio-only district. 2) In one of the promoter-only districts the same promoter worked throughout the program, but in the other, 3 different promoters had to be recruited and trained, due to high personnel turnover. 3) The initial costs of a radio program may be higher, but 1 program can be broadcast in all districts with little or no extra cost, whereas the costs of a promoter would have to be multiplied by the number of districts. 4) Although the promoter and the radio program produced approximately equal numbers of vasectomies, the radio messages reached over 70% of the people surveyed. Thus, on a national basis, radio broadcasts would be far more cost-effective than the use of salaried promoters in each district.^ieng

Population communication services: a global perspective.

PIP: Communication support for health and family planning programs is receiving renewed attention. The johns Hopkins University (JHU) Population Communication Services (PCS) project was established in 1982 to respond to the increasing need for communication expertise, to provide a responsive source for advice, and to develop implement the new directions that are necessary to make family planning communication programs more effective. The project extends a range of services to government programs, private family planning associations, and to media that want to improve the content or coverage of family planning communication, JHU/PCS emphasizes the close links between good communication and good management and the need for managers at all levels, from the Minister of Health to the supervisor of grass-roots field workers, to understand the components of a communication program for the 1980s. Principles underlying the project's work include: communication as process rather than product, the audience as participant, linking mass media and interpersonal communication, coordination with and among agencies, training that is specific and relevant, IEC as institution building, use of the private sector, an attempt to recover some of the costs of IEC work, and ongoing evaluation of program activities. IEC activities can be strengthened considerably b a knowledgeable commitment at the top of the decision-making process; constant feedback from intended audiences; and interactions among service delivery personnel, influential community members, and the media. In turn, strong IEC activities can substantially strengthen existing family planning programs.^ieng