Evaluation of the Consult and Choose Initiative in

Irbid Governorate, Jordan- 2011

Jordan Health Communication Partnership, JHCP

Johns Hopkins Bloomberg School of Public Health

Center for Communication Programs, JHU·CCP

January, 2012

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Table of Contents

Table of Contents ....................................................................................................................... 1

Acknowledgements .................................................................................................................... 2

Executive Summary .................................................................................................................... 3

Consult and Choose (CC) ........................................................................................................ 3

Methodology .......................................................................................................................... 3

Key findings ............................................................................................................................ 3

Recommendations & Conclusions ......................................................................................... 3

Introduction ............................................................................................................................... 4

Methodology .............................................................................................................................. 5

Sample Selection .................................................................................................................... 5

Questionnaire ........................................................................................................................ 6

Data collection, entry and analysis ........................................................................................ 6

Results ........................................................................................................................................ 6

Sample Characteristics ........................................................................................................... 6

Utility of CC Materials ............................................................................................................ 7

Utility of the “Hayati Ahla” Video in MCH Centers .............................................................. 10

Conclusions and Recommendations ........................................................................................ 11

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Acknowledgements A special thanks goes to the Irbid Health Project Steering Committee members chaired by Gov. Dr. Raed Al Adwan and Gov. Khaled Abu Zaid. In addition, thanks are extended to Irbid’s Ministry of Interior (MOI) liaison officer Mr. Firas Al Damen for his facilitation of the implementation of JHCP’s initiatives with the Ministry of Health (MOH) throughout the governorate of Irbid. Furthermore, without the constant support of the Irbid Health Directorate, this study would not have been possible. The leadership of Irbid Health Director Dr. Ali Saad and of Dr. Radwan Abu Ein, Assistant Health Director, were integral in the implementation of the Consult and Choose program and its evaluation. Special thanks go to Dr. Abdul Rahman Tbeishat, former Irbid Health Director under whose leadership the Consult and Choose initiative was implemented. Further thanks are extended to Dr. Amal Al Zou’bi, Technical Assistant to Health Director; Dr. Lutfieh Al Shebli, Mother and Child Health (MCH) Director, Irbid governorate; Ms. Aneeseh Al Jamal, MCH Supervisor; and the MCH technical team. Ms. Sarah Kamhawi, MPH, Monitoring and Evaluation Program Officer and Dr. Carol Underwood, PhD, Senior Research Advisor, wrote this report. Overall, the JHU·CCP provided technical assistance and coordination of the study. Specifically, Dr. Carol Underwood, Senior Research Advisor, led the technical assistance, analysis and reporting. Special thanks are due to all JHCP staff who cooperated with and supported the research team throughout various stages of the study, including Mr. Edson Whitney, JHCP Chief of Party; Ms. Rula Dajani, JHCP Deputy Chief of Party; and Huda Murad, Service Delivery and Community Interventions Senior Specialist. Statistical Information Technology (SIT) was subcontracted to provide technical assistance for data collection and entry. Thanks are extended to Mr. Yaser Sa’ad Edin, Executive Manager.

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Executive Summary

Consult and Choose (CC)

CC is a service provision program designed to improve the quality of family planning visits. CC uses a

patient-centered approach to family planning counseling. JHCP and its partners trained Ministry of

Health (MOH) MCH care providers in effective counseling techniques and provided counseling

guidelines together with counseling communication tools. The JHCP also provided 6 MCH centers in

Irbid with display screens that showed the “Hayati Ahla” video in MCH waiting areas.

Methodology Family planning clients were interviewed as they left 21 selected health centers in Irbid. The sample totaled 461 women.

Key findings

Patient satisfaction with clinic visits was strongly and positively associated both with the use

of the CC materials and with having a provider who followed the CC counseling protocol.

The “Hayati Ahla” video is a good message dissemination tool, as 80% of women who

viewed it recalled messages about family planning methods. All of the women who saw it

said that it should be shown in all health centers.

Recommendations & Conclusions

CC material use and CC counseling procedures are clearly associated with client satisfaction.

Thus, CC materials should continue to be disseminated throughout Jordan.

More MCH centers should be equipped with display screens showing the “Hayati Ahla” video

given that viewers provided highly positive perceptions of the video and believed that it

should be made available in all health centers. Thus, the video should be displayed in as

many health centers as is economically feasible.

All doctors, midwives, and FP counselors should be trained in CC counseling.

The results of this study demonstrate that Consult and Choose should be a central

component of clinic-based family planning communication.

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Introduction The mandate of the Jordan Health Communication Partnership (JHCP) Program, which is the Jordan country program of the Johns Hopkins Bloomberg School of Public Health (JHU) Center for Communication Programs (CCP), funded by the United States Agency for International Development (USAID), is to enhance health outcomes in Jordan through health communication programs, training and research.

Under the “Our Health Our Responsibility” umbrella, and to cover interventions focusing on

the promotion of family planning (FP) and reproductive health, JHCP introduced the slogan

“Hayati Ahla” or "My Life is More Beautiful. “Hayati Ahla” family planning service provision

campaign was launched by JHCP targeting FP potential and current users, health service

providers (public, private & NGOs), and spouses (men), with the aim of:

Increasing the percentage of women using modern contraception.

Creating a sense of belonging with other modern FP users.

Empowering potential and current FP users by connecting them with the health centers as

resources for “Hayati Ahla” accurate, credible, trustsworthy RH/FP related information and

quality services.

Introducing counseling as a partnership between the client and service provider for client

informed decision-making.

Doing away with service providers’ biases (another major RH/FP services missed

opportunity in Jordan) by fostering professionalism and positive attitudes among providers

regarding modern contraceptives, pregnancy spacing and small family size.

The service provision program, entitled “Consult and Choose (CC),” involves training health providers

on the utilization of the following nationally distributed materials:

Posters: campaign poster modern methods and clinic’s promise poster (what to

expect).

FP Wall Chart, family planning medical eligibility Wheel, & Handbook: contain detailed

medical information on each FP method, information about contraindications for each

modern method, and medical eligibility criteria when choosing a modern family

planning method.

Service Provider Cue Cards: 9 cue cards held together by an easy to open ring

containing reminder card (main tips), and 8 methods (IUD, POP, COC, Implants,

Injectables, Barrier methods such as the diaphragm and foams, Condoms & LAM), with

a picture of the method and descriptions of effectiveness, major advantages, major

side effects and how to deal with them, and how to use the method.

Clients Cue Cards: take-home card for every modern method containing a picture and

name of the chosen method, when to return, how to deal with side effects, grace

period after having missed a dose, dialogue with husband, and religious messages.

In addition “Consult and Choose” consists of Posters in the form of campaign poster

for (modern methods/norms), and clinic’s promise poster (what to expect)

The JHCP also produced a video titled “Hayati Ahla” in collaboration with the MOH. The video

was shown in the MCH waiting area in 6 centers throughout Irbid. The video includes

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information about the JHCP and all its government and NGO partners, campaign ads by the

JHCP and its partners, along with information about the MCH center.

Methodology The purpose of the study proposed herein is to evaluate the impact of CC training and material utilization on the satisfaction of FP beneficiaries in Irbid Mother and Child Health (MCH) clinics and to assess the utility of displaying the “Hayati Ahla” video in MCH waiting areas. The materials of interest are the FP eligibility wheel, the service provider cue cards, client cue cards, and posters. The guiding hypothesis will be that over-all satisfaction will be high in the sampled centers, that the level of satisfaction will be correlated with providers’ use of CC materials and adherence to counseling guidelines, that beneficiaries who receive CC materials will read them and find them useful, and that the “Hayati Ahla” DVD in waiting areas is a good mode of message dissemination.

Sample Selection Twenty-one MCH centers were selected for this study. Selection was based on the following criteria:

The sample was stratified by district, whereby 20% of all MCH centers in any one of the nine districts in Irbid were selected. There are 95 MCH centers in Irbid governorate, thus a sample of 21 MCH centers represents approximately 20% of MCH centers throughout the governorate.

In order to visit centers with high client flow, the MCH centers in each district were sorted using 2010 data from the MOH database. The centers were sorted according to the number of new and return FP visitors during 2010. Centers with the highest number of FP beneficiaries would be selected.

Centers with displays showing the “Hayati Ahla” video were automatically included.

Selected centers had IUD service.

The generated sample included 2 MCH centers in Northern Aghwar, 3 MCH centers in Ramtha, 1 MCH center in Taibah, 3 MCH centers in Kourah, 1 MCH center in Northern Mazar, 1 MCH center in Wasatiyyeh, 1 MCH center in Bani Obaid, 4 MCH centers in Bani

Table 1: Health Centers

n=461

District Center Name n

Northern Aghwar Mshari’ 20

Northern Shounah 22

Ramtha

Ramtha 24

Northern Turrah 23

Bwaidah 24

Taibah Taibah 22

Kourah

Kufr Al-Ma’ 25

Kufr Awan 22

Dair Abi-Sa’eed 24

Northern Mazar Northern Mazar 25

Wasatiyyeh Kufr Asad 19

Bani Obaid Sareeh 24

Bani Kinanah

Kufr Sowm 23

Hibras 21

Malka 22

Hartha* 9

Qasabet Irbid

Al-Barha 23

Kufr Youba 24

Al-Razi 24

Huwwarah 19

Ibn Seena 22 * Hartha health center was included in the sample because it had a “Hayati Ahla” display, even though its client flow was very minimal

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Kinanah, 5 MCH centers in Qasabet Irbid. MCH centers with “Hayati Ahla” video displays were located in the Northern Aghwar, Ramtha, Kourah, Bani Kinanah, and Qasabet Irbid.

Questionnaire The interviewer-administered questionnaire included questions about demographic characteristics, the FP counseling or service experience, and satisfaction with the health center.

Data collection, entry and analysis Women who were visiting the health center for a FP consultation, in order to select a FP method, or in order to follow-up on a FP method were asked to participate in the study. All interviews took place after the beneficiary’s exit from her session with the health provider. A total of 461 interviews were successfully completed from November 23rd through December 5th, 2011. When referring to CC materials used during counseling or consultations, the interviewers were able to show the respondents the CC materials of interest (the FP eligibility wheel, the provider cue cards, and the beneficiaries’ cards). Data entry was completed using CSPro 4.0, a public-domain software package for entering, editing, tabulating and mapping census and survey data, used by the U.S. Census Bureau. The data set was cleaned and edited for inconsistencies. Missing data were not statistically included. Data analysis was completed using STATA version 11 statistical software. Chi-square testing was used to determine statistical significance when comparing proportions.

Results

Sample Characteristics Table 2 demonstrates the distribution of respondents across the 21 selected centers. A total of 461 females who were visiting the mother and child health center for FP counseling or follow-up were interviewed. The average age of the participants was 30 years of age. The majority of women had completed high school, and 36 percent reported post-secondary education. All but a few women were married at the time of the interview. On average, the women had 3.5 children, fairly evenly divided between male

Table 2: Respondents’ characteristics

n=461

Age categories (%)

<20 years 1.7

21-30 years 52.9

31-40 years 39.5

41-49 years 5.9

Mean age 30.4

Educational attainment (%)

None/elementary/preparatory/basic 23.6 Secondary 40.8 Intermediate diploma 17.6

University or higher 18.0 Marital status (%)

Married 99.8

Engaged 0.2

Parity (%)

1 child 15.0 2 children 19.6 3 children 22.6

>3 children 42.8

Mean number of children 3.5

Mean number of male children 1.8

Mean number of female children 1.7

Table 3: Reasons for visiting the center

n=461

Reason for visiting the center (%)

To obtain a FP method 54.0

FP counseling 48.4 To follow up or consult on current method

60.1

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and female offspring. Women who came to the clinic for any contraceptive-related reason were asked to specify the reason. As shown in Table 3, women could give more than one reason for their visit. Three of every five came for a follow up visit; more than half came for a method, and about half for counseling.

Utility of CC Materials Interviewed women who reported visiting the health center in order to obtain a FP method or for FP counseling were asked about the counseling they had experienced (Table 4). Over 60% of those women reported that the doctor or midwife discussed how many children the respondent would like to have, 74% talked about the advantages of birth spacing, and 84% and 82% made clear the advantages and disadvantages of different contraceptive methods, respectively. The majority of respondents (>80%) reported that the doctor or midwife asked whether the respondent had a certain method in mind before coming to the center, explained the various contraceptive methods available to the respondent, and talked to the beneficiary about possible side effects. Nearly 87% of respondents who came to the center for FP counseling or to choose a FP method reported that the doctor or health provider helped them take a decision about what method to use (Table 4). Of those women, 70% received a contraceptive method at the center at the day of the interview (Table 5). Those who chose a method were then asked to provide further information about the counseling experience. As Table 5 demonstrates, the majority of those who received a contraceptive method reported that the health provider explained how to manage the side effects of the chosen

Table 4: Counseling experience among those who visited the health center to obtain a FP method or FP counseling

n=352

Reported that the doctor or midwife (%):

Discussed how many children the beneficiary would like to have

62.2

Talked to the beneficiary about advantages of birth spacing

73.6

Asked the beneficiary whether she had been thinking of a certain method to use before coming to the center

83.8

Explained various contraceptive methods that were available and that the beneficiary could use

87.2

Made clear what the advantages of different contraceptive methods

84.4

Made clear what the disadvantages of different contraceptive methods

82.1

Talked to the beneficiary about possible side effects of contraceptive methods

82.7

Doctor/health care provider helped the beneficiary choose a method to use (%)

86.7

Table 5: Receiving a method and counseling after choosing a method

n=352

Received a contraceptive method at the center at the day of interview (%)

70.2

n=247

Health provider explained how to manage the side effects of the chosen contraceptive (%)

80.6

Health provider explained where the beneficiary could get the chosen method (%)

94.3

Reported that the doctor or midwife used the following Consult & Choose (CC)materials(%):

n=352

Used a wheel to advise on the methods the beneficiary could use

44.3

Used cue cards while discussing the contraceptive methods

68.2

Wore a lab coat with the “Hayati Ahla” logo 65.3

Not sure whether doctor or midwife wore a lab coat with the “Hayati Ahla” logo

13.4

Gave the beneficiary a card with information about the chosen FP method

73.0

n=257

Beneficiary plans to read the card at home (%) 96.9

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contraceptive, and 94% reported that the health provider explained where they could get the chosen method. As for the utilization of CC materials, 44% of respondents reported that the provider had used the FP eligibility wheel and 68% reported that the provider had used the cue cards during the counseling session. Nearly two-thirds of respondents recalled that the provider wore the “Hayati Ahla” lab coat, while 13% were unsure. After choosing the method, 73% of respondents reported that the provider gave them the beneficiary card, 97% of whom reported an intention to read the card at home. The most commonly used methods among those who came for a follow-up or consultation regarding the FP method being used were the pill (29%), the intrauterine device (IUD) (29%), and the condom (17%), as is shown in Table 6. As shown in Table 7, among those who came for a follow-up or counseling regarding the method being used, over two-thirds had received a cue card about the method they chose at that time. Impressively, 98% reported that they referred to the card after taking it home. Of these, 86% found the card “very useful,” and 14% found it somewhat useful. None of the respondents indicated that the cards were not useful. Another component of the CC initiative consists of a poster with information about FP methods (Table 8). Eighty-two percent of all

respondents reported seeing this poster, 96% of whom found the poster helpful. Only 2% reported that they did not read it. Over two-thirds of all respondents reported that they had learned something new during their visit, and 83% reported that they were very satisfied with their visit to the health center. The majority of the remaining proportion reported that they were somewhat satisfied (17%). Almost all respondents would recommend the center they had visited to their relatives or friends (95%). Among the few who would not recommend the center, the main reason

Table 6: Counseling experience among those who came to the center for a follow-up on a FP method

n=277

Method being used (%)

Pill 28.9

IUD 28.9

Injection 4.3

Implant 1.1

Condoms 17.3

LAM 2.2

Vaginal methods (diaphragm/jelly/tablet/foam) 0.0

Table 7: Previous counseling experience among those who came to the center for a follow-up on a FP method

n=234

Received a cue card about the chosen method during a previous visit to this health center (%)

71.4

n=167

Referred to the cue card after taking it home (%) 97.6

n=163

Found the card very useful (%) 85.9

Found the card somewhat useful (%) 14.1

Table 8: Poster recognition and beneficiary satisfaction with the visited center

n=461

Saw a poster containing information about the various available family planning methods (%)

82.4

n=380

Found the poster helpful (%) 96.3

Did not read the poster (%) 2.4

n=461

Learned something new during the visit (%) 68.3

Satisfaction level (%) n=461

Very satisfied 82.7

Somewhat satisfied 16.7

Dissatisfied 1.7

Very dissatisfied 0.0

Recommending the center to others (%) n=461

Would recommend the visited center 95.2

Would recommend another center 3.5

Not sure 1.3

Reasons for not recommending that center (%) n=16

Too expensive 6.3

Poor quality of care 25.0

Rudeness of the staff 12.5

Poor equipment 50.0

Not enough time in consultation 31.3

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was related to the quality of the equipment.

As noted earlier, 83% of the respondents were “very satisfied” with their visit to the health clinic. Interestingly, as shown in Table 9, comparisons of those respondents with their counterparts who were “somewhat satisfied” or “dissatisfied” revealed significant differences in their clinic experiences. For example, 89% of those who reported that the clinician who counseled them used the FP eligibility wheel were “very satisfied”

with their visit compared with only 72% of those who said the wheel was not used. Similarly, a significantly higher proportion of those who were counseled with cue cards were “very satisfied” compared with those who were not (84% and 71%, respectively). And respondents were more likely to be “very satisfied” with their visit when the doctor or nurse wore the “Hayati Ahla” lab coat.

Table 10: Satisfaction in association with provider counseling

Defined satisfaction level as “very satisfied” (n=352) Performed

(%)

Not Performed

(%)

Discussed how many children the beneficiary would like to have

87.7* (n=219)

66.9* (n=133)

Talked to the beneficiary about advantages of birth spacing

83.0* (n=215)

71.0* (n=93)

Asked the beneficiary whether she had been thinking of a certain method to use before coming to the center

82.7* (n=295)

64.9* (n=57)

Explained various contraceptive methods that were available that the beneficiary could use

81.4* (n=307)

68.9* (n=45)

Made clear what the advantages of different contraceptive methods

82.2* (n=297)

67.3* (n=55)

Made clear what the disadvantages of different contraceptive methods

81.7* (n=289)

71.4* (n=63)

Talked to the beneficiary about possible side effects of contraceptive methods

82.8* (n=291)

65.6* (n=61)

Health provider explained how to manage the side effects of the chosen contraceptive

83.6* (n=305)

55.3* (n=47)

*Significance comparing satisfaction between those whose providers performed the task vs. those whose providers did not perform the task. Statistically significance were p≤0.05 from chi2 testing.

Table 9: Satisfaction in association with the use of CC materials

Defined satisfaction level as “very satisfied”

Used (%)

Not Used (%)

Wheel 89.1*

(n=156) 72.5*

(n=196)

Cue cards 83.8*

(n=240) 71.4*

(n=112)

“Hayati Ahla” lab coat 88.3*

(n=230) 63.9*

(n=122)

Received beneficiary card 86.9

(n=221) 81.2

(n=85)

Referred to the beneficiary card 89.9

(n=206) 86.7

(n=15) *Significance comparing satisfaction between those who recalled that their providers used CC materials vs. did not recall use of CC materials. Statistically significances were p≤0.05 from chi2 testing.

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The JHCP, in collaboration with the MOH and the Health Systems Strengthening Project - Phase II, trained health care providers in effective counseling techniques and provided counseling communication tools, clear guidelines regarding how to greet and interact with their clients, the types of questions to ask, and the topics to cover; these are listed in Table 10. As shown there, when health care providers followed the “Hayati Ahla” FP counseling guidelines, clients were significantly more likely to say that they were “very satisfied” with their visit. This demonstrates the importance of each step of the counseling protocol.

Utility of the “Hayati Ahla” Video in MCH Centers The “Hayati Ahla” video, which provides clear and succinct information about family planning, including information about FP methods, reproductive health, and the advantages of birth spacing, among other topics, is shown in 6 health centers in Irbid. Respondents from those clinics were asked whether they knew about the video. Over 20% had heard about it before they visited the health center, while another 62% said they saw the screen while they were in the waiting area. Fully 70% of those who knew about the video reported that they watched it while in the waiting area. Of those who didn’t watch it, the main reasons were lack of interest, being distracted by their children and lack of time. The respondents who reported that they watched the video were asked what messages they recalled. This was not prompted, so their responses were spontaneous. Four out of five mentioned that they had heard messages about family planning methods; over a quarter indicated that the messages were specifically about modern methods (Table 12). Other messages recalled were related to birth spacing, reproductive health, FP counseling, and population issues. Nearly 14% mentioned “Hayati Ahla” specifically.

Table 11: Awareness and Viewership of the “Hayati Ahla” Video

n=120

Heard about the presence of a large screen in the health center from others outside of the center (%)

21.7

Noticed a large screen on the wall of the waiting area (%) 61.7

n=74

Spent time watching the screen while waiting (%) 70.3

Reasons for not watching the screen (%) n=22

Did not have enough time 22.7

Was busy with the children 27.3

Was not interested 40.9

The screen was located elsewhere 9.1

Table 12: “Hayati Ahla” Video Message Recall

n=52

Using modern FP methods (%) 26.9

Using FP methods (%) 69.2

Using modern FP methods or using FP methods (%) 80.7

Small family size (%) 3.9

Hayati Ahla (%) 13.5

Gender equity (%) 3.9

Reproductive health (%) 15.4

Spacing between pregnancies (%) 17.3

Spacing 3 years between pregnancies (%) 15.4

Population issues (%) 7.7

FP counseling (%) 13.5

Physical exercise (%) 1.9

Jordan Health Communication Partnership (%) 1.9

Testimonials of women regretting having many children (%)

1.9

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Finally, respondents who watched the film were asked whether the film affected them (Table 13). Of those who indicated that the film influenced them, over one third indicated that they felt more positive about FP use, more than a third said they will now plan their families, and 36% stated that they will use FP methods as a direct result of viewing the film. Nearly one-fifth said they will ask a doctor about FP and 16% specified that they will ask about modern methods. Again, these responses were not prompted, but were spontaneous.

Importantly, all of the women said they will tell others about the film and 100% of the women believe that the video should be shown in all health centers.

Conclusions and Recommendations The findings demonstrate the utility of the Consult and Choose client-centered counseling approach designed and implemented by JHCP. Client satisfaction with clinic visits was strongly and positively associated both with the use of the CC materials and with having a provider who followed the CC counseling protocol. The family planning film was also memorable as the majority of women who saw the video screen in the waiting area watched the film and, of those, most mentioned that the main message was about family planning methods. All of the women believe that the video should be shown in all health centers. Moreover all of those who viewed the video stated that they would tell others about it, which is a strong testament to the appeal of this approach to family planning communication. CC materials should continue to be disseminated throughout Jordan as the materials appeal to FP clients, are used by them at home, and the use of CC print materials is associated with high levels of satisfaction. Given the highly positive perceptions of the video, it should be made available in as many health centers as is economically feasible. All doctors, midwives, and FP counselors should be trained in CC counseling. Not only is this approach respectful of the client and sensitive to their information needs, it also is significantly correlated with a positive experience at the clinic. Satisfied

Table 13: Impact of the “Hayati Ahla” Video on Viewers

n=52

Reported that watching the film affected her (%) 84.6

Reported affect due to watching the film (%) n=44

More acceptance of FP 34.1

More acceptance of modern FP methods 11.4

Less fear of modern FP methods 4.6

Will use FP methods 36.4

Will ask doctor about FP 18.2

Will ask doctor about modern FP methods 15.9

Will family plan 36.4

Will discuss FP with spouse 13.6

Will discuss FP with others 11.4

Will space 3 years between births 2.3

Learned more about FP 4.6

Learned about what to ask the doctor/midwife during a consultation

4.6

Will not smoke around children/ask husband not to smoke around children

2.3

Will get breast cancer screening 2.3

n=52

Will tell others about the screen (%) 100.0

Believe that such a display should be present in all health centers (%)

100.0

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clients are much more likely to continue practicing family planning. The results of this study demonstrate that Consult and Choose should be a central component of clinic-based family planning communication. Moreover, the CC initiative should be shared with concerned parties at the international level as an evidence-based successful experience of ensuring delivery of high quality FP services through effective client-centered communication.