Funding women's health work -- no easy answers.

PIP: This article discusses a community's solution to improving women's health in Guatemala. Indigenous women from the highland community of Cajola formed the Asociacion Pro-Bienestar de la Mujer Mam (APBMM). The APBMM identified a need for women health promoters and good, low-cost medicines. The Instituto de Educacion Integral para la Salud y el Desarrollo (IDEI) helped train 16 women as health communicators or promoters in 1996. The health communicators learned about setting up community medicine distribution. The mayor bypassed APBMM's efforts to set up medicine distribution and set up a community pharmacy himself. Someone else opened a private pharmacy. The 200-member group was frustrated and redirected their energies to making natural herbal medicines, such as eucalyptus rub. The group set up a community medicine chest in the IDEI medical clinic and sold modern medicine, homemade vapor rubs, and syrups. The group was joined by midwives and other volunteers and began educating mothers about treatment of diarrhea and respiratory diseases. The Drogueria Estatal, which distributes medicines nationally to nongovernmental groups, agreed to sell high quality, low cost medicine to the medicine chest, which was renamed Venta Social de Medicamentos (VSM). The health communicators are working on three potential income generation projects: VSM, the production and sale of traditional medicines and educational materials, and an experimental greenhouse to grow medicinal plants and research other crops that can be grown in the highlands.^ieng

Family planning in poverty-ridden Nicaragua.

PIP: The percentage of people living in poverty in Nicaragua's cities has increased significantly in recent years and reflects an increase in the number of households headed by women. Among the nongovernmental organizations created to help meet the needs of Nicaragua's population is Profamilia, the International Planned Parenthood Federation affiliate founded in 1971. Profamilia offers high quality sexual and reproductive health services at regional clinics operating in 9 out of 16 political subdivisions and manages a nationwide network of over 1000 community-based contraceptive distribution posts. Knowledge of modern contraception is almost universal in Nicaragua, and a 1992-93 health survey revealed that almost half of women of reproductive age were using contraception. Profamilia uses the mass media and other means to advertise its services, which are preferred by many over the free government services. In the communities, trained volunteer promoters distribute contraceptives and provide counseling. Because adolescent pregnancy and fertility rates are high, Profamilia has developed services, including educational workshops, that target youth. These workshops offer information on responsible sex behavior and ways to reduce the risk of pregnancy or infection. In addition, Profamilia offers training courses for teachers and educational sessions for parents, pregnant adolescents, and adolescent parents.^ieng

Pharmacies, communication, and condoms. Research report: Mexico.

PIP: The Institute Mexicano de Investigacion de Familia y Poblacion, A.C. (IMIFAP) tested the effectiveness of a training course and educational materials that were designed to increase the awareness and knowledge of pharmacy employees concerning acquired immunodeficiency syndrome (AIDS) and its prevention, and to promote condoms. 174 employees participated in workshops that included information on transmission and prevention of sexually transmitted diseases (STDs) and AIDS, and condom usage. Pre- and post-session tests were performed to ascertain the short-term retention of information; the long-term effect was assessed via incognito shopper visits and monitoring of condom sales. Short, intensive training, when reinforced by posters, pamphlets, and video, significantly increased knowledge of AIDS (symptoms, transmission, and prevention) and correct condom usage. Awareness of risk behaviors and groups at risk for AIDS improved. Printed materials alone did not have a substantial impact on knowledge or sales of condoms, and increased knowledge alone did not increase information disseminated. After 6 months there was a significantly higher rise in condom sales (16%) in the course-plus-materials group. This group also took a greater initiative in providing information to clients. In spite of these positive results, knowledge and initiative are still unsatisfactory, especially when the role of pharmacies in general health care and the suspected prevalence of sexually transmitted diseases and human immunodeficiency virus in Mexico are considered.^ieng

Responding to the real needs of women.

PIP: INPPARES, the International Planned Parenthood Federation affiliate in Peru, has provided family planning and other services to the Peruvian population since 1976. The organization concentrates upon interventions targeted to women of low socioeconomic status. One of the group's most important strategies has been to distribute contraceptives at the community level in rural and peri-urban areas of the country through a network of centers managed by promoters. These promoters are virtually all female. The organization in 1993 supplied 812 distribution centers. Promoters and their supervisors have received training in contraception, basic data recording, community work, and related topics. INPPARES, however, suspected that the quality of the project would be improved if promoters and supervisors were trained about the role of women in the community and their rights and identity as women. The personnel would then be able to better understand the role of contraception and reproductive health in women's lives. To that end, INPPARES in 1992-93 developed a project in coordination with the Manuela Ramos Association, a Peruvian women's organization. A questionnaire was given to forty promoters on issues related to women's roles, values, attitudes, the place of women in society and the family, family planning, sexual relations, and decision making. Their responses pointed to a real need to provide promoters and supervisors with more information through workshops on women in Peruvian society, women's identity and roles, women's sexual rights, and the quality of care in service provision. Four pamphlets were drafted from a seminar of fifty supervisors from both organizations to be used in a series of twelve workshops for 256 promoters. Post-intervention evaluation of the original forty participants confirm the significant effectiveness of both subjects covered and materials used in achieving desired project goals. Four workshops were subsequently held in which project results were presented to 261 promoters. Promoters and supervisors are now using flipcharts and pamphlets in their training activities.^ieng

Basic needs in rural El Salvador.

PIP: 590 family health promoters work with the Salvadoran Demographic Association (ADS) to bring health care and family planning services to communities and individuals in need throughout the rural areas of El Salvador. In the 592 communities served by the association in 1992, family planning services and primary health care were promoted and provided to mothers and children, with cases needing major attention being referred to ADS's network of 38 reference doctors and clinics, or to public health centers. The promoters have potential family planning acceptors complete a detailed questionnaire to best determine which method of contraception is most appropriate and which, if any, may be contraindicated. The author describes the case of one such promoter of family health who is a certified midwife, a rural paramedic, a community leader, an health care volunteer, and a rural distributor of contraceptives working with ADS for the past ten years. She spends four hours every day wandering around searching for people in need of family planning, but have no access to contraception.^ieng

New family planning center serves 60,000 Nicaraguans.

PIP: In Nicaragua, the recently opened Regional Family Planning (FP) Center in the capital of Chontales Province provides a variety of FP services to the 60,000 citizens of Juigalpa. These services include counseling, laboratory exams, gynecologic exams, and voluntary sterilization. the Asociacion Pro Bienestar de la Familia Nicaraguense (PROFAMILIA) opened the center, since FP services have been neglected in this province as compared to access to these services in the large population centers of Managua and Leon. A recent contraceptive prevalence survey shows that contraceptive prevalence in urban areas of Nicaragua is 62%, while it is just between 13-15% in rural regions, like Chontales and Zelaya. The center will also run a community distribution program for Chontales. As of May 1993, it had 25 community distribution posts in the region, providing contraceptives and training volunteers. PROFAMILIA hopes to open another regional center in Chinandega in the western part of Nicaragua in 1993. It plans on opening a central clinic in Grenada, the third largest city, to serve 120,000 people from Grenada and the small communities surrounding Grenada.^ieng

[Basic family health program in Magdalena Medio y Bajo]. / Programa de salud basica familiar en el Magdalena Medio y Bajo.

PIP: The Program of Information, Education, and Services for Basic Family Health Care in Magdalena Medio and Bajo was designed to increase knowledge and use of contraception and to improve basic health practices and nutrition in the region, which includes municipios belonging to 9 different departments and a total population of 1,720,000. Poverty levels in the area are high. During the 1st year of the project, which was underway from February 1988-May 1991, home visits were made to inform each family about basic family health, to weigh and measure children under 5 not receiving health care elsewhere, and to refer families to the nearest health services. Talks were presented to small groups on family planning, intestinal parasites, sexually transmitted diseases, nutrition, vaccination, cancer prevention, malaria, acute diarrhea, and acute respiratory infection. Community workshops were presented in the 2nd year. Community distribution posts were created for contraceptive and other health product distribution. Information and communication materials from PROFAMILIA were used, and other materials were specially designed for the project by the Foundation for Development of Health Education in Colombia. PROFAMILIA's system of service statistics was used for quantitative evaluation of the information and education activities and sales of contraceptives, antiparasitics, and oral rehydration packets of each instructor. In the 3 years of the program, 89.086 cycles of pills, 398,772 condoms, 29,080 vaginal tablets, 209.791 antiparasitics, and 49,305 oral rehydration packets were sold. 9295 talks were presented to 143,227 residents of the region. 22,000 children were enrolled in the growth monitoring program, and almost 40,000 women were referred for prenatal care and cytology. The instructors gave 900 talks to distributors of contraceptives, antiparasitics, and oral rehydration packets. Surveys of women aged 15-49 residing in the municipios covered by the project were conducted at the beginning and end of program activities in order to assess project impact. 1673 women were interviewed in the 1st survey in June-July 1988 and 1660 were interviewed in the 2nd survey in March-April 1991. In general terms, the region of Magdalena Medio and sand Bajo showed important changes in contraceptive prevalence, maternal-child health, knowledge of AIDS, and family violence over the 3 years of the project. Knowledge of contraception improved throughout the region, especially in rural areas. The proportion of women in union using a method increased from 56.7% to 58.0%. There were no overall changes in the proportions of children vaccinated.^ieng

Impact of social marketing on contraceptive prevalence and cost in Honduras.

In 1984, the Honduran Family Planning Association launched a contraceptive social marketing program by introducing the oral contraceptive, Perla. This report examines the impact of the program on overall oral contraceptive use, use by particular subgroups, source of supply, and costs. Although use of oral contraceptives increased only slightly over the period 1984-87 (from 12.7 percent to 13.4 percent among women in union aged 15-44), the social marketing program significantly increased its share of the oral contraceptive market (from 7 percent in 1984 to 15 percent in 1987, and from 20 percent to 40 percent of sales at pharmacies). For the Honduran Family Planning Association to have realized cost savings as a result of clients switching from community-based distribution programs and commercial supply sources to contraceptive social marketing programs, the association would have had to reallocate its resources. Instead, the number of distributors in the community-based distribution program increased, while the amount of couple-years of protection from oral contraceptives decreased.

PIP: Researchers used data from 2 national surveys of maternal-child health and family planning (1984 and 1987) and from a 1989 study of economic costs by method and program to examine the impact of the contraceptive social marketing program of the Honduran Family Planning Association (ASHONPLAFA). ASHONPLAFA launched the program in 1984 by introducing the oral contraceptive (OC) Perla. Between 1984 and 1987, OC use increased minimally (12.7-13.4% among 15-44 year old women in union), yet the contraceptive social marketing program increased its share of the OC market (7-15% overall, 20-40% at pharmacies). The analysis showed that costs to ASHONPLAFA would fall if more women bought OCs from the contraceptive social marketing program instead of the community- based distribution (CBD) program, and if the resources earmarked to the CBD program in urban areas decreased. Yet, the number of distributors in the CBD program in urban areas actually increased, so ASHONPLAFA did not achieve cost savings. Further, the amount of couple-years of protection from OCs fell. The findings showed that market forces did not work and may not do so in like programs, where profit is not a goal and managers are not held accountable for cost increases. They also indicate that, in urban areas, the contraceptive social marketing program can serve more clients and the CBD program can be cut back. Further research is needed to examine whether and by how much ASHONPLAFA could reduce the CBD program without losing clients.

A comparison of the performance of male and female CBD distributors in Peru.

This report presents the results of an operations research project to increase male involvement in family planning in Peru. Two community-based distribution (CBD) programs, PROFAMILIA of Lima and CENPROF of Trujillo, Peru, recruited male contraceptive distributors and compared their performance to that of female distributors recruited at the same time. Both programs found it harder to recruit men than women as distributors. Program supervisors, who were women, were less comfortable with men than with other women, even though there were no differences in distributor compliance with program norms. Male distributors were more likely to serve male clients and sell male methods (condoms), while female distributors were more likely to serve female clients and sell female methods (pills). Men sold as much or more total couple-years of protection than did women, and they recruited as many or more new acceptors. Gender was found to exert an impact on method mix independent of other distributor characteristics, such as age, education, marital status, and number of living children. The study suggests that family planning programs can influence method mix and client characteristics by recruiting men as CBD distributors.

PIP: The findings of an operations research (OR) project designed to compare the effectiveness of male vs. female contraceptive distributors in Peru are reported. The OR project was conducted by 2 private, nonprofit family planning agencies that have community-based distribution (CBD) programs: PROFAMILIA in Lima and CENPROF in Trujillo. The OR project sought to test 3 hypotheses: 1) male distributors would sell more condoms and female distributors would sell more oral contraceptives; 2) male distributors would serve more male clients and female distributors would serve more female clients; and 3) male distributors would sell less contraceptive protection than female distributors. Between 1987 and January 1988, the 2 agencies recruited new male and female distributors to serve in the project. Both agencies had a more difficult time recruiting male than female distributors. PROFAMILIA recruited 38 men and 171 women, while CENPROF recruited 52 men and 94 women. All but one of the supervisors in both agencies were female. The supervisors generally regarded the male distributors with skepticism, but the study found no significant difference in the reporting compliance of male and female distributors. The project confirmed hypotheses 1 and 2. In both agencies men sold twice as many condoms as did women, and women sold more oral contraceptives; and male distributors were more likely to serve men, while female distributors were more likely to serve women. The 3rd hypothesis, however, was unsupported. Men sold as much or more contraceptive protection than did women and recruited as many or more new acceptors. It is concluded that men can be effective CBD distributors, and that CBD programs can influence method and client mix by recruiting more men as distributors.

AIDS and family planning.

PIP: In 1991, an HIV prevention program advisor and a research/evaluation specialist for family planning programs discussed problems that affected HIV prevention and family planning services in Haiti before and after the coup of the Aristide government. Population activities began aimlessly in 1974 and HIV prevention efforts only began in 1988. After the coup, Haitians lost their newly found hope for meaningful development. All foreign assistance ended and they did not trust the army. In fact, other than essential child survival activities, no health and family planning services operated for several weeks. The situation grew worse after the economic embargo. 3 months after the coup, the US considered adding family planning assistance. Still little movement of condom, family planning, and health supplies left Port-au-Prince for the provinces which adversely affected all health related efforts. Condoms could no longer be distributed easily either in the socially marketed or US supplied condom distribution programs. Before the coup, HIV prevention and family planning programs depended on peer educators to educate the public (this approach made these programs quite successful), but the 2 experts feared that they would not return to those roles and that these programs would need to completely rebuild. Another concern was the large scale urban-rural migration making it difficult for them to continue care. Early in the AIDS epidemic, the Haitian government was on the defensive because the US considered Haitians as a high risk group so it did little to prevent HIV transmission. After 1988, HIV prevention activities in Haiti centered on raising awareness and personalizing the epidemic. The AIDS specialist noted, however, that a major obstacle to increasing knowledge is that AIDS is just 1 of many fatal diseases in Haiti. Moreover few health professionals in Haiti have ever had public health training.^ieng

Paraguayan pharmacies and the sale of pseudo-abortifacients.

This study was conducted in 1985 in Asunción, Paraguay, 6 years after the closure of the state supported family planning services. Data from national surveys in 1977 and 1987 permit a comparison of sources of contraceptive supplies before and after the elimination of government support for family planning. The purchase of pseudo-abortifacients from private pharmacies was used as an indication of induced abortion. After the loss of government clinics, it is suggested that some women turned to pharmacists to obtain pseudo-abortifacients when faced with unwanted pregnancy. There is an indication of increased pseudo-abortifacient use, particularly among unmarried women and those from poorer neighbourhoods.

PIP: The hypothesis that a restriction of family planning services will be associated with an increased incidence of abortion was investigated in a survey carried out in Asuncion, Paraguay, in 1985. In 1979, the Government of Paraguay abruptly eliminated all support for family planning services at Ministry of Health clinics--a measure that affected at least half of all contraceptive acceptors and forced them to turn to pharmacies for contraceptive supplies. The survey, which samples 10% of the registered private pharmacies in Asuncion, used the sale of pseudo- abortifacients as a measure of induced abortion. Also interviewed were 56 contraceptive purchasers and 51 purchasers of injectables contraceptives intended for use as abortifacients who were recruited at the participating pharmacies. The results indicated that low-income women were 5 times more likely than their higher income counterparts to purchase pseudo-abortifacients. In addition, unmarried women were 3 times more likely to purchase progestogen injections to induce a missed menstrual period than married women. Almost 70% of abortifacient purchasers reported that they had attempted to self-abort on previous occasions. The pharmacists stated that up to 50 women a week requested medication for pregnancy termination and were in agreement that this practice had increased substantially following the government's withdrawal of support for contraception. The pharmacists expressed concern about the nonavailability of counseling from trained family planning personnel and indicated that some pharmacy staff knowingly exploit women by injecting them with unsafe preparations or drugs that cannot induce abortion. The administration of ineffective pseudo-abortifacients can delay the decision to seek an illegal abortion or result in life-threatening incomplete abortion.

The impact of service delivery frequency on family planning program output and efficiency.

Operations research is the study of factors that can be controlled by program administrators. Among such factors is the frequency of performing program activities. The present experiment, conducted in Lima, Peru during 1985-86, tested the impact of holding family planning post sessions once per month, twice per month, and weekly. Frequency was shown to have a major impact on program outputs, costs, and cost-effectiveness. Depending on the indicator, sessions held twice per month produced between 1.5 and 2.1 times the output of those conducted once per month. Weekly sessions produced between 1.3 and 1.6 times the output of those held twice per month. At an output level of nearly 11,200 visits per year, twice-per-month sessions were estimated to be 7-38 percent more cost-effective, depending on the indicator, than once-per-month sessions, and 6-28 percent more cost-effective than weekly sessions.

PIP: Operations research is the study of factors that can be controlled by program administrators. One of these factors is the frequency of performing program activities. The operational variable is the frequency of having clinical sessions in medical back-up posts in a community-based distribution (CBD) program in Lima, Peru. The study covered 42 posts in urban marginal areas of Lima. 3 performing frequencies were compared: 1) once a month; 2) twice a month; and 3) weekly. A randomized block design was used. The study lasted 12 months--from August, 1985-July, 1986. 3 output indicators were chosen: 1) effectiveness; 2) efficiency; and 3) cost-effectiveness. Outputs include program acceptors, total visits, IUD insertions, sessions and family planning (FP) visits. The once-per-month posts finished 98% of scheduled sessions while the twice-a-month and weekly sessions finished 97% and 96%, respectively. Mean duration of the clinic sessions held by the monthly and twice-monthly posts was 2.9 hours (s.d.=.84 and .73, respectively). Mean duration for the weekly group was 2.8 hours (s.d.=.67). About 73% of the FP talks scheduled for the monthly post were really accomplished compared to 66% for the twice-monthly and weekly groups. The 42 posts held 1136 clinic sessions during the year and had 11,196 visits, including 5371 FP visits. 1705 women accepted a FP method at the posts. 77% were IUD takers; 15% chose pills; and 8% accepted barrier methods. There were 4768 IUD visits. There were 414 pill visits and 18% barrier method visits. About 89% of all FP visits were IUD-related. 87% of all IUD insertions were referred by CBD workers and 5% by supervisors. There were 2954 total visits in monthly posts; 3501 in twice-monthly; and 5641 in weekly posts. Output went up linearly with session frequency, but in lesser proportion than the rise in the number of sessions held. Differences are statistically significant for all outputs. Twice-a-month posts had 1.5-2.1 times the output of once-a-month posts; weekly posts had about 1.3-1.6 times the output as twice-a-month posts, depending on the variable chosen. With output level of nearly 11,200 visits per year, twice-a-month sessions were estimated to be 7-38% more cost-effective than once-a-month sessions; 6-28% more cost-effective than weekly sessions.

Haiti. Beauty parlours and health promoters.

PIP: In the poor neighborhoods of the capital city of Port au Prince Haiti are 100s of brightly painted beauty parlors, displaying signs like "Femme Moderne, studio de beaute." They are popular and cheap; between 70 and 80% of the population use them. In the south of the city, a team of health promotion volunteers are turning some 64 beauty parlors into AIDS education and condom distribution centers with the help and cooperation of the owners. The majority of these beauty parlors are owned and run by women who cannot find work elsewhere, including many immigrants from the Dominican Republic. Some proprietors work as prostitutes in the evenings because they cannot survive on the earnings of the parlors. These proprietors are now becoming AIDS educators-- talking to customers, handing out leaflets and distributing free condoms. The team of young volunteers responsible for this education program belong to the Center for Haitian Social Services (CHASS); a nonprofit, voluntary organization set up in 1987 as a community response to the lack of government health and social services. A CHASS volunteer explains: "The beauty parlors were chosen as a focal point for reaching the population. To start with, 1 box of condoms was distributed every week, not the owners are distributing 3 or 4 boxes. We encourage them to keep a record of numbers taken, client's age, sex, marital status and so on." The majority of volunteer health promoters are ex-students who have given up their studies because of lack of funds. Many cannot find jobs, and they are encouraged to develop skills in their volunteer work which could help them find employment in the future. The team of volunteers meets every Saturday to discuss the program and training needs that arise. "At first the focus of our training was on AIDS, but now we need more information about other related issues." The most urgent need is to find out what local people's thoughts and understandings are about the disease. CHASS has designed a questionnaire in Creole and French for use in a knowledge, attitude, and practice survey. Volunteers are interviewing over 1000 local residents, and will randomly select 200 questionnaires to analyze. Information gathered will provide a basis for planning and orienting health education messages. "The problem with planning any educational program," explains Daniel Bernier, "is that Haitians work most of their waking hours--and so we are trying to organize mass education at traditional public gatherings, such as at Church and the gaga (a traditional religious ceremony).^ieng

[The pharmacy: a health resource]. / La farmacia: recurso de salud.

In Guatemala, as is the case in many of the other Central American countries, the pharmacy is often the only health resource used outside the household. This paper analyzes knowledge, attitudes and practices of the personnel from seven pharmacies located in marginal-urban areas of Guatemala. It also studies their interaction with 3,277 users related to all diseases, specifically those related to diarrheal disease and its treatment. Findings revealed that the pharmacies' personnel handle diarrheal disease in an empirical way, using medicines to treat the cause of the diarrhea, instead of trying to prevent dehydration. There are limitations and deficiencies of knowledge and practices related to the use and abuse of non-indicative medicines, insofar as the pharmacies' personnel and users are concerned. Findings also revealed that the Oral Rehydration Salts (ORS) are not used, and prepared oral serum is used in very small amounts, because these do not fit in popular expectations of a medicine that reduces diarrheic evacuations.

PIP: Knowledge and practices regarding diarrheal disease and its treatment were assessed among workers in 7 pharmacies located in marginal urban areas of Guatemala City. In Guatemala, as in many developing countries, the pharmacy is often the only health resource utilized outside the home. Intensive observation of interactions between pharmacy personnel and interviews with 18 of the 20 owners and workers allowed evaluation of knowledge of diarrhea among the workers and consistency between theoretical knowledge and actual treatment practices. Home visits were made 5 days after observation in the pharmacy to all households containing children under 5 for whom diarrhea remedies were sought. The observations and interviews occurred between January-June 1987. The 7 pharmacies were the only ones in the area they served. 2 covered a population of approximately 64,688 and the other 5 served approximately 106,955 residents. The pharmacy owners had worked and average of 19 years and the workers an average of 4.9 years in pharmacies. 15 of the 18 stated they had learned their trade through daily practice. Few had any formal pharmacy training. The principal sources of information on drugs were visits made to introduce new drugs. The pharmacists also used the literature accompanying the medications and the reference work "dictionary of Pharmaceutical Specifications". 14 stated that their recommendation for treatment of diarrhea depended on the signs and symptoms described to them. A wide variety of possible treatments were mentioned, but in practice the antidiarrheals were most often prescribed. Only 4 of the 18 routinely explained to the mother the type of diarrhea, why the specific drug was chosen, and how to administer it. 9 provided instructions for administration only, and the other 5 provided no information. 16 of the 18 cited nutritional signs of dehydration, and lower proportions mentioned other signs. 11 of the 18 stated that oral rehydration solution should be given to prevent dehydration, 3 stated that oral or injectable solution should be given, and 4 said that the cause of dehydration should be combatted. None appeared to know how to prepare homemade oral rehydration solution. 6 pharmacies sold oral rehydration salts, but only at the customer's request. A total of 3277 contacts between pharmacy workers and users were observed in 97 hours of observation, for an average of 34 contacts per hour. 80.3% of clients requested a self-prescribed medication, 4.6% had medical prescriptions, and 7.8% followed the advice of the pharmacist. 26.4% of clients were unable to obtain their 1st choice, 15.1% because it was not available and 11.3% because they lacked sufficient funds. 112 cases of diarrhea were observed in children 12 and under and 440 in adults.

Consumers of oral contraceptives in a social marketing program in Honduras.

This paper presents data on the characteristics of oral contraceptive users in Honduras, obtained from a point-of-purchase survey conducted in pharmacies in 1986. The oral contraceptive Perla, provided by the Social Marketing Program, accounted for 42 percent of sales. Forty-five percent of those using Perla were considered "new" users; either they were purchasing contraceptives for the first time or had used only Perla. Almost half of those who switched to Perla previously had obtained their orals in the noncommercial sector. Brand substitution occurred among users of commercial brands at about the same rate as among Perla users (51 percent versus 55 percent). Most women switching contraceptives did so within two months of their last purchase.

PIP: A point-of-purchase study was conducted in pharmacies in Honduras in 1986 to determine characteristics of oral contraceptive users. The Social Marketing Program, which provides the contraceptive Perla, accounted for 42% of the sales. Of those using Perla, 45% were new users, either buying contraceptives for the 1st time or using only Perla. Of those who switched to Perla, half previously had obtained oral contraceptives in the noncommercial sector. Oral contraceptive users, of both Perla and commercial brands, substituted brands at about an equal rate. The study revealed that most women who switched types of oral contraceptives did so within 2 months of their last purchase.

Contraceptive social marketing and community-based distribution systems in Colombia.

Three operations research experiments were carried out in three provinces of Colombia to improve the cost-effectiveness of Profamilia's nonclinic-based programs. The experiments tested: (a) whether a contraceptive social marketing (CSM) strategy can replace a community-based distribution (CBD) program in a high contraceptive use area; (b) if wage incentives for salaried CBD instructors will increase contraceptive sales; and (c) whether a specially equipped information, education, and communication (IEC) team can replace a cadre of rural promoters to expand family planning coverage. All three strategies proved to be effective, but only the CSM system yielded a profit. Despite this, Profamilia discontinued its CSM program soon after the experiment was completed. Unexpected government controls regulating the price and sale of contraceptives in Colombia made the program unprofitable. As a result, family planning agencies are cautioned against replacing CBD programs with CSM. Instead, CBD programs might adopt a more commercial approach to become more efficient.

A consumer intercept study of oral contraceptive users in the Dominican Republic.

Purchasers of a low-cost oral contraceptive were intercepted and interviewed in a sample of Santo Domingo pharmacies that represented the highest sales of the product, yet also reflected the socioeconomic profile of the city's entire population. Users of the contraceptive were later interviewed in greater depth in their homes. The survey of users showed that the Dominican Republic's social marketing program, implemented by PROFAMILIA, was reaching an appropriate target market--that is, younger, lower-middle-class women of low parity. The program was, in addition, successful in attracting first-time adopters, and it was also expanding the overall commercial market for all contraceptives. The marketing campaign was successful in part because a mass audience was reached, through brief television spots. Program impact on contraceptive prevalence can be assessed from sales data.

PIP: Purchasers of a low-cost oral contraceptive were intercepted and interviewed (449 pharmacy interviews in a sample of pharmacies in Santo Domingo, Dominican Republic, that represented the highest sales of the product, yet also reflected the socioeconomic profile of the city's entire population. Contraceptive users were later interviewed in greater depth in 252 home interviews. The survey showed that the Dominican Republic's social marketing program, implemented by PROFAMILIA, was reaching appropriate target market, that is, younger, lower middle class women of low parity. The program was also successful in attracting 1-time contraceptive users, and it was expanding the overall commercial market for all contraceptives. The marketing campaign was successful in part because a mass audience was reached with brief television spots. It is concluded that program impact on contraceptive prevalence can be assessed from sales data.

[Community marketing of contraceptives]. / El mercadeo comunitario en anticonceptivos.

PIP: The 5-year-old community contraceptive distribution program developed by PROFAMILIA, Colombia's private family planning organization, has given excellent results, but several cost-effectiveness comparisons with social marketing programs have suggested that commercial distribution programs are superior. The community contraceptive distribution program has a high content of information and education activities, which produced significant increases in knowledge and use of contraception in the communities covered. It has been a fundamental support for the social marketing program, creating much of the demand for contraceptive products that the social marketing program has filled. The social marketing program has given good results in terms of volume of sales and in cost-effectiveness since 1976, prompting calls for replacement of the community contraceptive distribution program by the social marketing program in those sectors where knowledge and use of contraception have achieved acceptable levels. An experiment in the Department of Santander in 1984 and 1985 gave very favorable results, suggesting that community contraceptive distribution programs should be replaced by social marketing programs in all more developed markets. But economic problems in 1985 and the decision of manufacturers to decrease the profit margin for PROFAMILIA jeopardized the social marketing program. The community distribution program covered about 20% of the market. Reduced profits in the social marketing program threatened its continued expansion, at the same time that potential demand was growing because of increases in the fertile aged population and increased use of contraception. To meet the need, PROFAMILIA combined the community contraceptive distribution and social marketing programs into a new entity to be called community marketing. The strategy of the community marketing program will be to maintain PROFAMILIA's participation in the market and aid the growth of demand for contraceptives through educational and informational activities. The distribution scheme must continue to cover all the established points of sale in pharmacies despite the reduced profit margins.^ieng

IPPF/WHR service statistics for 1987.

PIP: The latest statistics on new acceptors reported by the International Planned Parenthood Federation/Western Hemisphere Region (IPPF/WHR) for 1986 show important growth in male methods, condoms and sterilization (up 33%). The area included is Latin America and the Caribbean. The most popular method for new acceptors is the IUD (43% of new users); the second most popular method is the pill (27% of new users); and the third is sterilization (14% of new users). Total increase in new acceptors in clinics and community programs combined was 13%. Other methods, including diaphragms, spermicides, and natural family planning, increased 65% in clinic clients and 223% in community based distribution programs. During 1982-1986, the total number of new acceptors rose by 26% to 1.5 million; total number of visits to a clinic rose 15% to 3.3 million, and the number of clinics rose 39% to 1899.^ieng

Family planning in the workplace in Jamaica.

PIP: The Jamaica Family Planning Association started holding presentations and discussions in the workplace in January 1986, now reaching 8000 people in 32 companies. The firms are primarily manufacturers (21) and hotels(7), but also include publishing, construction, printing and supermarket businessess. In these companies as well as many of the 480 members of the Jamaica Chamber of Commerce, employees are usually women of reproductive age who cannot afford to take time off to attend a clinic. There is a great demand for information and discussion on sexually transmitted diseases and clarification of the contraindications of various contraceptive methods. At the end of the discussions, educators offer pills, condoms and neo-sampoon, and may refer people for clinical services. Almost new acceptors have been recruited. The success of the project depends heavily on cooperation of management, supervisors and union representatives. In some cases union representives or company nurses act as distributors of contraceptives. This project has been so successful that some companies expressed an interest in participating in the Associations's resource development program.^ieng