OFP NFP Research Grantee Meeting, January 2009 A Strategic Approach to Standard Days Method Introduction: Expanding FAM Availability and Use 2008-2011 OFP NFP Research Grantee Meeting, January 2009

Rationale Despite their efficacy and safety, the availability and use of FAM are low in Title X clinics. Integrating the SDM, an effective FAM that is feasible for programs to offer, into FP services could help increase FAM availability and use.

Purpose To evaluate the effect on programs and clients of introducing the SDM through WHO’s Strategic Approach Identify factors which constrain and facilitate FAM availability and use Develop and test a process to introduce the SDM within a framework of expanded choice Assess acceptance, correct use, and satisfaction

Partners IRH/GU Southwest Community Health Center, Santa Rosa Center for Health Training (Region IX) Southwest Community Health Center, Santa Rosa Planned Parenthood Mar Monte, Modesto JSI (Region I) Health Quarters, Lawrence & Beverly Study direction Research and Training Service Delivery

Standard Days Method 95% effective with correct use and 88% with typical use Identifies a fixed fertile window in the menstrual cycle (days 8-19) when pregnancy is most likely Appropriate for women with cycles between 26-32 days long Used with CycleBeads®

Why Offer SDM? Increases choice Provides non-hormonal option/ no side effects Helps women learn about their bodies and fertility Involves men Promotes couple communication Easy for programs to offer Any time we consider adding a new method to our program, we need to think seriously about what we expect to gain by offering this particular method.

SDM User Profile Six Countries1 U.S.2 29 27 2.8 .4 52% 38% 33% 10% Mean Age 29 27 Mean Parity 2.8 .4 Previous use of: Nothing/ineffective method Condom (inconsistent) Pills/injection IUD 52% 38% 33% 10% 0% 87% 96% 2% Some interesting differences between the U.S. and other countries in terms of previous contraceptive use. The countries included here are Ecuador, El Salvador, Honduras, Benin, India, and the Philippines. Whereas about half of women in other countries had never used any method and about 1/3 had ever used condoms, pills, and injections, in the U.S., all women had contraceptive experience. 87% had used condoms and 96% hormonal methods. It appears that in the U.S., some women who have used other methods may be looking for a different kind of method. 1 Interviews with users in 6 countries 2 Survey of internet purchasers

Experience at Tri-City Health Center – Fremont, CA 117 users in 1 year Most providers felt that CycleBeads were: Easy to teach Easy to use Useful for involving men Effective enough The providers also wanted to continue offering CycleBeads and the educational materials that were developed to go with them

SDM/CycleBeads Availability California Southwest CHC PPMM – Modesto Tri-City Health Center Davis Community Clinic Riverside Community Health Agency Golden Valley Health Centers PP Golden Gate - Promotores Massachusetts Health Quarters – Lawrence & Beverly ABCD Health Services East Boston Neighborhood Health Center Whole Foods Markets – Brighton, Cambridge, Framingham, etc. This is just a sample list – you can search for providers and retailers by state on www.cyclebeads.com.

SDM is offered worldwide Albania Angola Azerbaijan Bangladesh Benin Bolivia Burkina Faso DR Congo East Timor Ecuador El Salvador Ethiopia Ghana Guatemala Honduras Kyrgyzstan India Madagascar Mali Mauritius Mozambique Nicaragua Peru Philippines Romania Rwanda Tajikistan Turkey Ukriane United States Uganda Zambia Zanzibar Since publication of the SDM efficacy study in 2002, there has been a growing interest in the method in many, very different, countries. These are some of the countries where it is available – through public, private, and non-profit family planning providers. In some of these countries it is widely available – in others it’s available in very limited settings. But demand and use are growing. Around the world, a number of different service delivery strategies are being implemented.

WHO Strategic Approach Decision to offer new method should be based on needs perceived by stakeholders Strategy should be developed through a participatory, transparent process that focuses on client needs and quality services Can increase the likelihood of sustainable, replicable services (Simmons 2007)

WHO Strategic Approach Phase I: Needs assessment Phase II: SDM integration and evaluation (Research phase) Phase III: Use of research results for policy and planning

Summary of Activities Use of research results for policy and planning Phase I Needs assessment Phase II SDM integration and evaluation Phase III Data elements Pre SDM integration Process evaluation Outcome eval. Use of research results for policy and planning Site assessment √ Tailor SDM integration activities Integrate the SDM into existing services Modify integration activities Provider & staff interviews Client focus groups Simulated clients Waiting room questionnaire Client follow up Service statistics

Phase 1: Needs assessment Potential clients’ knowledge, needs, and desire for FAM Provider knowledge, attitudes, and practices regarding FAM Service delivery systems and outreach activities Opportunities and challenges to adding SDM to method mix

Participatory Approach Review of clinic structure, client flow, materials used, etc. Provider interviews Focus groups with potential clients Waiting room questionnaire Review of service statistics from previous year Results of the needs assessment will be used to tailor the integration plan to the specific context.

Phase II: Evaluation of SDM integration SDM integration activities Simulated client visits Evaluation activities Collection of service statistics Interviews with SDM clients Post-integration interviews with providers, staff and other key stakeholders Interviews with SDM clients to assess correct use, knowledge, satisfaction, etc. SDM integration activities include provider training and integration into clinic systems, protocols, and outreach activities Simulated (“mystery”) client visits are to ensure successful integration of the method into services

Phase III: Use of Research for Policy and Planning Share lessons learned with organizations and networks across the country Design strategies that can be used to broadly introduce the SDM into Title X programs & expand FAM availability and use Develop and disseminate implementation guide / toolkit for integrating the SDM This phase focuses on dissemination and utilization of study results Sharing lessons learned – conferences, meetings, presentations, web, even video

Completed Activities Orientation visits / kick-off meetings at each site conducted Year 1 implementation plans with each region finalized Needs assessment tools & consent forms prepared and translated IRB application submitted JSI & CHT oriented on Phase I data collection

Upcoming Activities Needs assessment activities / data collection - Jan-Feb, 2009 Analysis of needs assessment data – March 2009 Develop/tailor SDM integration plan, including adaptation of materials – April-May 2009 Train providers in SDM counseling and integrate into systems – June-July 2009

Thank you! For more information: www.irh.org

References (1) Gribble, JN. “The Standard Days Method of Family Planning: A Response to Cairo.” International Family Planning Perspectives 2003; 29(4): 188-191 Gribble, JN., Lundgren, R., Velasquez, C., Anastasi, E., Being Strategic about Contraceptive Introduction: the Experience of the Standard Days Method. Contraception 2008; 77: 147-154. Johri, L. and R. Lundgren. Introduction of the Standard Days Method into CARE India’s Community-based Reproductive Health Programs. Final report for the Institute for Reproductive Health, 2003. Institute for Reproductive Health. Final Report: Improving Family Planning Services for Women and their Partners: A CAPACITIES Approach. Forthcoming.

References (2) Ministry of Health, Family Planning Service Statistics: San Martin Province, Peru, 2003. Mukabatsinda, M. Mid-term Assessment of Standard Days Method Introduction in Rwanda. Final Technical Report prepared for the Institute for Reproductive Health, 2004. Simmons, R., Hall, P., Diaz, J., et al. The Strategic Approach to Contraceptive Introduction. Studies in Family Planning 1997; 28(2): 79-94. Simmons R, Fajans P, and R Ghiron. 2007. Scaling up health service delivery from pilot innovations to policies and programmes. World Health Organization, ExpandNet: Switzerland. WHO & CCP. Family Planning: A Global Handbook for Providers, 2007.