After a lovely dinner in Delhi with Nandita Chopra, the NIH Representative to India, we headed off Wednesday a.m. for a busy day with Population Services International (PSI), looking specifically at its Women's Health Project. I knew going into this day that I was going to love it because a) I love women’s health and b) PSI is pretty much THE organization when it comes to health communication and social marketing. From the very beginning of the meeting when they flipped on the projector and started talking about objectives (SMART objectives like we learn about in class!), we could see the difference between a small, local NGO and a multi-national one like PSI. The team we met with walked us through the integrated program they have in place to reach women, healthcare providers, pharmacists, and opinion leaders. The scope of the project is too large to recap in one blog, so I’m going to focus on the interpersonal communicators (IPCs), which I was later able to watch in action.
The IPCs are primarily charged with increasing awareness about and use of intrauterine devices (IUDs), which are a safe and effective long-term (but not permanent) method of birth control. Most women choose an IUD after having several children, when they want to limit their family sizes, but have not completely ruled out more children. The IUD PSI promotes is called Freedom5, because it lasts for 5 years.
To raise awareness of IUDs, PSI has trained a team of IPCs to go into urban areas throughout several districts in northern India. The IPCs gather household information and, after determining that there is a women of reproductive age (WRA) who could benefit from an IUD, provides information and referrals. There are two good things I saw about this approach that no doubt reflect PSI’s experience and knowledge. First, the IPCs do not just provide information on IUDs, they educate the women about the “contraception basket,” including condoms, oral contraceptive pills, injections i.e. Depo-Provera, and IUDs. Secondly, the IPCs are not incentivized based on the number of IUDs inserted, which might lead to more forceful interactions with women. Instead, they are encouraged to meet certain targets for the number of women they speak with each day. If a woman is interested in IUDs, the IPC gives her a referral card and information for a nearby clinic. If the women goes to the clinic, the referral card serves as a tracking device to see how many women visit a doctor and how many actually get an IUD inserted.
When we went into the field, we met up with four of the IPCs and an IPC coordinator. Jenn M. and I had a chance to observe a one-on-one session with an IPC and a woman in her home. She invited us without reservations into her home where she shooed away two men, who looked to be maybe her son and father or father-in-law and had us sit on a bed in a small room. The IPC began speaking with her in Hindi and gathering the household data including her age and information about her children. We learned that she had four children and used condoms, but was hesitant about an IUD because she thought her husband would disapprove. Her reaction when we asked if she wanted more children was clear, she grasped her stomach and said no. It was clear that this family was struggling with the small means it had, so one could easily understand why the woman wanted to limit her family size. So the IPC gave her some additional information to keep in case she decided to pursue an IUD in the future. In public health classes we are always talking about community outreach workers and it was very neat to see one in action.
In addition to outreach via IPCs, PSI runs a call center that does follow up calls to women who have IUDs inserted (and give consent to follow up) to counsel them on any side effects or concerns one-month after the procedure. The outreach program is also integrated with a mass media campaign that promotes the idea of an IUD being a lock with a key. When we visited a clinic in the partner network we saw this advertisement posted on the wall. PSI said the campaign has already been very successful, with a 60% reach. Of the women reached, 50% reported that they talked with their husband about an IUD, 10% went to a provider, and 5% got an IUD. While these numbers may seem small, they are actually quite significant for a health promotion campaign. The mass media campaign augments the personal outreach because it can also help influence a woman’s husband and mother-in-law, who in this culture have a strong influence on decisions about contraception.
One of my favorite parts about the day with PSI was when PSI’s maternal and child health lead Sanjeev Dham flipped the conversation around and asked us for our criticism of the Women's Health Project. He really valued our insights, which included thoughts on expanding the program and strengthening evaluation.
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