Effectiveness of the PHE approach for achieving family planning and fertility outcomes in Ethiopia: A comparative study in the Guraghe Zone Research Team Prof. Tefera Belachew (MD, MSc, PhD), Jimma University Department of Population and Family Health - Principal Investigator Makeda Sinaga (BSc, MPH/RH), Jimma University Department of Nursing Ahmed Mohammed (MSc), PHE Ethiopia Consortium Negash Teklu (MA), PHE Ethiopia Consortium Kristen Stelljes (MA), PHE Ethiopia Consortium/ Packard Foundation/USAID Global Health Fellows Program II January, 2013 Addis Ababa © Copyright 2013 PHE Ethiopia Consortium Phone: + 251-11-663 0833/ + 251-11-860 8190 Fax: + 251-11-663 8127 P.O.Box - 4408 Addis Ababa, Ethiopia. E-mail: [email protected] [email protected] www.phe-ethiopia.org Unless indicated, all pictures are courteous of GPSDO project field staff. Table of Contents Executive Summary....................................... 7 Background.................................................. 10 Literature Review............................................12 Methods......................................................... 16 Results........................................................... 22 Discussion....................................................... 42 Conclusions......................................................45 Recommendations........................................ 46 References...................................................... 47 Annex............................................................. 50 Survey Questionnaire...................................... 50 Effectiveness of the PHE approach for achieving family planning and fertility outcomes 5 Acronyms ASFR Age Specific Fertility Rate CBRHA Community Based Reproductive Health Agent CIA Central Intelligence Agency CPR Contraceptive Prevalence Rate CYP Couple Years Protection DHS Demographic Health Survey FAO Food and Agricultural Organization of the United Nations FP Family Planning GPSDO Guraghe People’s Self-help Development Organization HEW Health Extension Workers HIV/AIDS Human Imuuno-Deficiency Virus/ Acquired Immuno-Deficiency Syndrome KAP Knowledge, Attitudes and Practices OVC Orphans and Vulnerable Children PHE Population, Health and Environment SNNPR Southern Nations, Nationalities and Peoples Region TFR Total Fertility Rate VCHW Volunteer Community Health Worker WAC Woreda Advisory Committee 6 Effectiveness of the PHE approach for achieving family planning and fertility outcomes Executive Summary high population growth rate induces increased demand for resources and the rate A at which these resources are exploited. Population, health and environment (PHE) are connected inextricably. Population growth unbalanced with economic development leads to food insecurity which exposes households to the consumption of food with reduced quality and quantity leading to increased risk of malnutrition and poor health. Food insecurity obliges people to encroach into the natural environment leading to a spiraling progress to destitution. A study in the Philippines provided concrete evidence that integrated development programming incorporating PHE can be more effective in lowering population growth rates and preserving critical coastal ecosystems than single-sector development interventions. Although the PHE approach has been implemented in the Guraghe Zone of in southern Ethiopia, its outcomes have not been evaluated. The objective of this study was to evaluate the effectiveness of the PHE approach for achieving family planning (FP) and fertility outcomes in the Guraghe Zone. A comparative cross sectional study involving both quantitative and qualitative data generation methods was conducted from October 2 to 8, 2012. A total of 962 married women in the reproductive age grouped were included in the study. Data were collected using an interviewer administered Amharic version questionnaire. An in-depth interview of key informants from various sectors was done using semi-structured interview guides. Descriptive statistics and multivariable linear and logistic regression analyses were performed to compare the PHE and non- PHE woredas. Results: There was no significant difference in contraceptive prevalence rate (CPR) in both woredas (71% in the PHE vs 74% in the non-PHE, P=0.35), which we suspected to be due to the confounding effect of the Meskel holiday, when there was a campaign promoting FP use. Subgroup analysis of CPR among the non-new acceptor women showed that the PHE woreda had a significantly higher CPR (78%) compared to the non-PHE woreda (52%), P<0.0001. Among this sub-group, women in the PHE woreda were over four times more likely to use FP methods during the study period (P<0.0001) compared with women in the non-PHE woreda. Women whose husbands’ support their use of FP methods were 17 times more likely to use FP methods. This increased to 20 times more likely to use FP when conducting sub-group analysis for women who were not new acceptors. There was also significant positive change in attitudes toward fertility in the PHE woreda for the behaviors related fertility including lower desire for more children (43% PHE vs 68% non-PHE, P<0.0001), lower percent of husbands who had future desire for more children (54% PHE vs 70% non-PHE, P<0.0001), fewer number of additional children desired by woman (1.9 PHE vs 2.9 non-PHE, P<0.0001) and better knowledge commonly used FP methods(3.0 methods PHE vs 2.7 non-PHE, P=0.03). Women in the PHE woreda also reported lower number of children to be appropriate (4.8 PHE vs 5.2 non-PHE, P=0.031). This was also reflected in a lower fertility experiences of women in the Effectiveness of the PHE approach for achieving family planning and fertility outcomes 7 PHE woreda during the last five years (1.07 children PHE vs 1.34 children non-PHE, P<0.0001). There was better integration of FP, health, and environmental conservation activities in grassroots level interventions in the PHE woredas. A significant number of women had a control over income generating resources (58% PHE vs 15% non-PHE, P<00001) and thus better access to cash, suggesting that women’s empowerment is better in the PHE woreda. Overall, the PHE approach has better value added outcomes with a significantly higher number of men supporting FP use by themselves (PHE 30% vs 7% non-PHE, P<0.0001) and a higher percent of households use energy saving stoves (9.8% PHE vs 2.7% non-PHE, P<0.0001). However, the non-PHE woreda had a significantly higher percent of women with at least four years of schooling (15% PHE vs 24% non-PHE, P<0.0001). There was no significant difference in the percent who had heard about FP (93% PHE vs 95% non PHE, P=0. 10), the number of FP methods known (3.7 PHE vs 3.6 non-PHE, P=0.49 ) and knowledge of at least one source of modern FP methods (96% PHE vs 97% non-PHE, P=0.61). The income generating schemes in the PHE woreda are more diverse and targeted to environmental and food security outcomes compared with the non-PHE woreda. Although the study demonstrated significant differences between the PHE and non- PHE woredas in terms of FP and fertility behaviors, the following limitations need to be considered in interpreting the results. Despite the fact that the study aimed to measure couple year protection (CYP), FP service delivery is not recorded by type of method due to recent changes in the management information system of the Ministry of Health. Therefore, total FP services rendered were used as a proxy indicator to compare the intervention and non intervention woredas. As the types of FP services delivered are similar in the two woredas, this can indirectly show that there is higher CYP in the PHE woredas as compared with the non-PHE woredas. Due to the cross- sectional nature of the data, it was not possible to see the effect of improved FP and fertility behaviors on the actual use of FP methods and fertility outcomes, including CPR and TFR. However, from the indirect indicators used in the study, the women who contributed to the total fertility during the past one year also started using FP methods for the first time, contributing to the current high CPR. Our data also showed that the proportion of new FP acceptors was high. Due to lack of baseline population based data, it was not possible to show the effect of the PHE approach through a comparative analysis as differences might have come about due to confounding factors not studied. A conscious effort was made to minimize biases that could creep in by making the two woredas similar by many of the known parameters relevant to the study. Conclusions: The findings suggest that overall the PHE approach has positive outcomes on fertility attitudes FP use and environmental conservation areas, while there was no significant difference in knowledge about FP. There is better integration of FP, health and environmental issues at the grassroots level in the PHE woreda; however, networking and integration with key stakeholders such as the woreda environmental conservation office is critical to enhance ownership and sustainability of the program. Integration of PHE issues needs to be strengthened and scaled up to sustain the positive fertility and FP behaviors such as lower desire for more children and support of FP use by husbands. 8 Effectiveness of the PHE approach for achieving family planning and fertility outcomes Strategies used in the PHE woredas such as using schools and students as medium for integrated PHE interventions are commendable approaches that need to be strengthened. The diverse