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Beyond the Barriers: Strategies for “Jumpstarting” the IUD in Africa: 

Beyond the Barriers: Strategies for “Jumpstarting” the IUD in Africa Roy Jacobstein, M.D., M.P.H. Clinical Director ACQUIRE/EngenderHealth Erin McGinn, M.A. Associate Director, FITS Family Health international

Why Bother?: 

Why Bother? High unmet need in Africa for modern FP (lifetime risk of MM 1/16) IUD “Underutilized” in Africa IUD very effective and very safe IUD availability increases choice Low cost to programs/clients

Historical trends – IUDs were “popular” once: 

Historical trends – IUDs were “popular” once

Global Context: How Many Women Use IUDs?: 

Global Context: How Many Women Use IUDs? In the world? 145 Million; CPR 13.9% 131 Million; CPR 15% 35 Million; CPR 5.8% In “Developing Countries”? Excluding China? D. Sub-S. Africa? <1 million; CPR 1%

Current IUD Use in Sub-Saharan African: 

Current IUD Use in Sub-Saharan African East Africa: 0.6% Middle Africa: 0.2% Southern Africa: 1.8% Western Africa: 1.3% (Japan: 2.2%; India: 1.6%; U.S.: 0.7% )

IUDs: An Excellent Method: 

IUDs: An Excellent Method Highly effective / comparable to FS “Reversible sterilization” 12-13 yrs with CU-T Cheaper and easier to provide Quickly and completely reversible

IUDs: An Excellent Method (cont.): 

IUDs: An Excellent Method (cont.) Very safe for most women, including: Postpartum, postabortion, or interval breastfeeding young nulliparous Recent/new findings about IUD’s safety in relation to: PID Infertility HIV/AIDS

Programmatic Considerations: 

Programmatic Considerations More cadres can provide (because nonsurgical) Potentially most cost-effective method Greater availability = greater choice Good option for HIV+ women Good for both “spacers” and “limiters” YET…

So What (to do)?:: 

So What (to do)?: Have a MAQ Mini-U Session on the IUD?

Challenges to Revitalizing IUD Service Delivery : 

Challenges to Revitalizing IUD Service Delivery

Service Delivery Challenges: 

Service Delivery Challenges “In health care, invention is hard, but dissemination is harder”* “Mastering the generation of good changes is not the same as mastering the use of good changes”* *Berwick, JAMA, April 16, 2003, Vol 289, no. 15

Service Delivery Challenges: Intrinsic Nature of IUD: 

Service Delivery Challenges: Intrinsic Nature of IUD A clinical method, ergo: Must be provided in “medicalized” settings and systems Highly provider-dependent Prone to medical barriers Marked by myths, fears, ignorance

Service Delivery Challenges: Nature of “Medicalized” Settings: 

Service Delivery Challenges: Nature of “Medicalized” Settings Hierarchical Conservative Curative-oriented Pace of change generally slow (then & now, here & there)

The Slow Pace of Change in Medical Settings: Some Reasons: 

The Slow Pace of Change in Medical Settings: Some Reasons Lack of perceived need for change Lack of provider motivation (lack of perceived benefit) 3. Ignorance of latest scientific findings of risks and benefits (of IUD, etc.) of concept of relative risk

Slow Pace of Change in Medical Settings: Some Reasons (cont.): 

Slow Pace of Change in Medical Settings: Some Reasons (cont.) Medical/Clinical Orientation versus Epidemiological/Public Health Orientation Primum non nocere “Harm of doing” greatly feared “Harm of not-doing” greatly overlooked Focus on individual, not groups (of individuals) Curative versus preventive orientation Client and socio-cultural factors

What are Major Medical Barriers to IUD Use?: 

What are Major Medical Barriers to IUD Use? Provider bias against (or for) IUD Limitations on which provider cadres are allowed to provide the IUD Inappropriate eligibility restrictions Age (“Not for the young”) Parity (“No nullips need apply”) “Must be menstruating” “Can’t be post-partum or post-abortion”

What are Major Medical Barriers to IUD Use? (cont.): 

What are Major Medical Barriers to IUD Use? (cont.) Process hurdles Mandatory and unnecessary F/U Marriage / spousal consent requirements Unsubstantiated “contraindications” Can’t have vaginal discharge “IUD not good for HIV+ women” “Not suitable for Africa”

Understanding Change: 

Understanding Change

The Diffusion of Innovations: 

The Diffusion of Innovations 1) an innovation – 2) its communication through certain channels 3) over time 4) among the members of a social system

The Three Main “Clusters of Influence” in Innovation Diffusion : 

The Three Main “Clusters of Influence” in Innovation Diffusion What: Perceptions of the innovation Who: Characteristics of the adopters How: Contextual factors, e.g.,: Communication Leadership Management/supervision Policies and guidelines

I. Perceptions of the Innovation (The “What”): 

I. Perceptions of the Innovation (The “What”) The five most influential properties of given innovation: perceived Benefit perceived perceived perceived perceived Compatibility Simplicity “Trialability” Observability

II. Characteristics of Adopters of Innovations (“The Who”): 

II. Characteristics of Adopters of Innovations (“The Who”)

What Are These? Why Are They Here?: 

What Are These? Why Are They Here?

Characteristics of Early Adopters: 

Characteristics of Early Adopters Opinion leaders Socially well-connected Cross-pollinators (of ideas) Resources & risk tolerance to try new things Watched by others (thus crucial to dynamics of spread) Often chosen as leaders & representatives

So What (to do)?: New Opportunities: 

So What (to do)?: New Opportunities New findings about IUD safety Updated/new WHO MEC – new policies/guidelines Renewed donor interest in IUD Potential/actual greater country interest in IUD (HSR, cost and HCD considerations) Integration opportunities increasing

Revitalizing the IUD: In-Country Efforts: 

Revitalizing the IUD: In-Country Efforts

Kenya – The innovator: 

Kenya – The innovator

Trends in Modern Method Use in Kenya – Currently Married Women: 1984-2003: 

Trends in Modern Method Use in Kenya – Currently Married Women: 1984-2003

Qualitative Assessment of IUD Service Delivery in Kenya (1995): 

Qualitative Assessment of IUD Service Delivery in Kenya (1995) Decline of IUD in Kenya due to: Poor quality of care Fear of HIV acquisition/transmission among providers Poor product image among clients Provider bias or preference for other methods Shifting client preferences

The Kenya IUD Re-introduction Initiative (2002 – present): 

The Kenya IUD Re-introduction Initiative (2002 – present) Increase support for the IUD among policy makers, health care professionals and clients Increase the provision of quality IUD services Enhance demand for IUDs

Holistic Approach: 

Holistic Approach Consensus building National Working Group: Ministry of Health, USAID, DFID, AMKENI (EngenderHealth), FPAK, Professional organizations, JHPIEGO, GTZ/MOH, IntraHealth, Africa Population Advisory Committee, Population Council Updated MoH FP Policies and Guidelines Improved Service Delivery (AMKENI Sites) 600 IUD kits distributed 100 service providers have received intensive training related to IUD counseling, insertion and removal

Holistic Approach (cont’d): 

Holistic Approach (cont’d) Advocacy/Demand Creation Advocacy towards policy-makers/providers 4000 kits disseminated Provincial CMEs or “sensitization” meetings 600+ public and private sector providers reached Education of 500 CBD/field agents IEC materials distributed to clients (21,000 pamphlets) Community information sessions reached 12,000+ people

Experimental components…: 

Experimental components… IUD Checklist Field-Tested “Academic Detailing”

IUD Checklist: 

IUD Checklist

“Academic detailing”: 

“Academic detailing” Based on model of pharmaceutical representatives Seeks to: Educate Motivate Change behavior Results: Small, but significant impact on IUD uptake only in CBD/Clinic group

Comparative costs of pregnancy prevention: 

Comparative costs of pregnancy prevention

Results thus far…: 

Results thus far…

Increased Services: 

Increased Services IUD services available in 70% of AMKENI sites, up from 19%.

Increased IUD Uptake: 

Increased IUD Uptake

Scale-up in Kenya: 

Scale-up in Kenya Extension to Kenya’s Kisii District/Nyanza Province (MoH/ACQUIRE Project)

Scale-up in Kenya: 

Scale-up in Kenya “Innovation” – adding a communications / marketing component to increase client interest/demand (in progress) Will be called the “Stand Up” marketing campaign Will build on the testimonial approach Urges clients to take a “second look” at the IUD

The Early Adopters…: 

The Early Adopters… Uganda, Ethiopia, Mali, Ghana … Kenya also playing a role model for early adopters Research Kenya’s IUD initiative highlighted at regional IBP meeting (Uganda, June, 2004) Documentation of initiative is informing other countries in region and feeding into thinking at the HQ level here in the US

IUDs in Uganda: 

IUDs in Uganda Broader focus on FP/LAPMs Including costing analysis Exploring mechanisms to involve private sector (midwives)

IUDs in other places…: 

IUDs in other places… Mali: Focus on cities, then expand out. Ghana: Operations research looking at promotional campaigns and mobile services vs static services Ethiopia, Guinea, Nigeria, Tanzania

Slide46: 

Are we here?

Slide47: 

Or are we here?

Slide48: 

Are we here? MAQ IUD Toolkit

Take Home Messages: What to do? : 

Take Home Messages: What to do? Take a holistic approach (supply/demand) Understand individual perspectives of health care institutions, providers, clients, communities (and intervene accordingly) Avoid the “empty vessel syndrome” Many IUD issues universal—but so is need for local buy-in Identify and support/nurture early adopters/champions (individuals and org. units)

Be Realistic / Be Patient: 

Be Realistic / Be Patient Change will be slow Change will be incremental Change takes (a lot) of time “There’s no quick fix”

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