I PfV- A:Cr~qq0 :D;J b3 9 I I I FACTORS AFFECTING THE ACCEPTANCE AND CONTINUATION I OFIUD A COMPARATIVE STUDY I PHILIPPINES I FmalReport I I ASIA & NEAR EAST OPERATIONS RESEARCH AND TECHNICAL ASSISTANCE PROJECT I FAMILY PLANNING OPERATIONS RESEARCH I AND TRAINING (FPORT) PROGRAM PopulatIOn CouncIl, ManIla I m collaboratIOn with the Department of Health I USAID Contract No DPE-C-OO-90-0002-10 I StrategIes for Improvmg FamIly Plannmg ServIce DelIvery I July 1998 I I I I I I ACKNOWLEDGMENT I Tills project was conducted by Populatlon CouncIl-Mamla, m collaboratIOn wIth the Department of Health under the ANE ORiTA Project wIth support from the Office of I PopulatIOn Health and NutntIOn (OPHN), US Agency for International Development, Contract No DPE-3030-C-OO-90-0002-1 0 I PopulatIOn CouncIl, ManIla would hke to acknowledge the mdIvIduals and I mstltutIOns who helped m carrymg out thIS project • Dr Magdalena C Cab arab an, the head of the research team and the overall I coordmator ofthe study m ItS two study SItes, Mlsamls On ental and IloIlo • Dr Jayantl Tuladhar, PopulatIOn CouncIl, New Delln for ills techmcal aSSIstance m I the questIOnnaire deSIgn and data analYSIS for the modified SA used m tills study • Dr Josefina Cablgon for her asSIstance m data analYSIS and Mr FIono Argmllas ills I work m the data management and programmmg • The Research InstItute ofMmdanao Culture, as represented by Mrs Manlou Tabor, Operatlons Manager, who handled the admmlstratlve aspects of the project and the I recruItment of project staff • The SOCIal SCIence Research InstItute, especIally ItS DIrector, Dr Fely DaVId who I allowed the InstItute's staff to conduct mterviews and focus group dISCUSSIons m I 110110 Provmce, transcnbe the FGDs and translate these from Ilonggo to Engbsh • The 1) local cillef executIves of the 26 mumcipahtIes of MisamiS Onental and 51 murucipalitles m 110110, 2) ProvmcIaI Health Offices of the two provmces and theIr respectIve ProvmcIaI Health Officers, 3) the Mumclpal Health Officers, nurses and I mIdWIVes of all RHUs covered by the project I • Fmally, the members of the Research Team Chona CastIllo, Rebecca Samel, Venus CatubIg, Clansse Balandra, Jeffrey Llcera, Ma Dulce Nodado, Edwma Lagos, MaIda Reyes, MItZI Reyes, Revelyn Pagtulon-an, Darren Daamo, SUSIe VIllela, Lonbel I Reyes, Janet, Armada, NIchromano Estepa, Stemmitz Cmpang, Mary Chnstme BalsImo, Lma Magbanua, Ma FatIma Torrato, and Rexcel Torrato for theIr I dedIcatIOn and hard work m obtaInmg the necessary data for thIS study I I 11 I I I TABLE OF CONTENTS I Acknow ledgment 11 LIst of Tables IV I LIst of FIgures VI ExecutIve Summary VB I IntroductIOn 1 JustIficatIOn of the Study 1 ObjectIves of the Study 2 I Research Methodology 3 Study DesIgn and Settmg 3 I Study SItes 4 Data CollectIon 4 I General Fmdmgs of the Study SItuatIOn AnalYSIS 10 1 Readmess to ProvIde ServIces 10 PhysIcal Infrastructure 10 I Techmcal CapabIlIty of ProVIders 14 A vaIlabIhty ofFPIRH ServIces 17 I 2 QualIty of ServIces 19 ClIent-provIder CommumcatIOn 19 I Techmcal Competence 21 Appropnateness and AccessIbIhty 26 3 Barners to IUD ProVISIon 27 I General Fmdmgs ofthe Study FGD Results 30 Summary and ConclUSIOns 38 I References 44 Annexes 46 I I I I I III I I I LIST OF TABLES I Table 1 Percent DIstnbutlOn of New Acceptors Accordmg 9 To Types ofFP Methods Used, MISanuS Onental I and 110110, January - December 1997 I Table 2 Selected IndIcators Related to FacIlItIes and Infrastructure 11 Table 3 Mean Number ofVanous EqUIpment AVailable at 12 I SDPs by Provmce, 1998 I Table 4 Percent of SDPs wIthout EqUIpment by Provmce, 1998 13 I Table 5 Percent of SDP whIch had Stock-outs of ContraceptIves 13 And Supphes Dunng the Last SIX Months, by Provmce, 1998 I Table 6 Selected ProvIder CharactenstIcs by Study Areas, 1998 15 I Table 7 Percent of proVIders Who attended TraInmg by Provmce, 1998 16 I Table 8 Selected IndIcators Related to AVailabIlIty of ServIces, By Provmce 17 I Table 9 Percent DIstnbutlOn of SDPs ProvIdmg IUD ServIces per Week 18 I Table 10 Selected IndIcators Related to InformatIon Exchange 20 Table 11 Percent ofSDPs WIth AVailable IEC matenals, by Provmce 21 I Table 12 Percent of ProvIders who Felt IUD Trammg IS Inadequate I and Type of Refresher TraImng Needed 21 Table 13 Percent of ProvIders who knew that an IUD should not be 22 I Inserted to Women Havmg CertaIn CondItIons I Table 14 Percent of ProvIders WIth Knowledge when to Insert an IUD 23 I IV I I I Table 15 Percent ofProVlders wIth Knowledge of common sIde effects 24 whIch reqUIre no VISIt to the clImc and sIde effects whIch reqUIre I ImmedIate medIcal attentIOn I Table 16 Percent ofFP chent Who Knew ofFPIRH ServICes 25 that are aVaIlable at the SDP I Table 17 Selected IndIcators Related to Appropnateness and AcceptabIlIty 26 I Of ServIces Table 18 Percent of ProvIders who put RestnctIOns on ProvIdmg 27 I IUD ServIces Table 19 Percent of ProvIders who felt that Procedures and Test 28 I must be followed before offenng an IUD I Table 20 DemographIc CharactenstIcs ofFGD PartICIpants, 110110 31 and MISamIS On ental Provmces, 1998 I I I I I I I I I v I I I LIST OF FIGURES I FIgure 1 Map of the PhIhppmes 5 I FIgure 2 ProvmcIaI Map ofMISruTIlS Onental 7 I FIgure 3 ProvmcIaI Map of IlOIlo 8 I I I I I I I I I I I I I VI I I I I EXECUTIVE SUMMARY I Interest m a study of IUD use m the PlulIppmes stems from two major observatIOns FIrst, findmgs from the 1997 cluster surveys mdicate that, whIle IUD use IS low m the country as a whole, there are nonetheless a few regIOns With faIrly lugh levels of acceptance I and contmued use for tlus method (LPP-MICS, 1997) TIns suggests that there may be some program-level vanables willch account for these differentials Areal dIfferences m populatIon I compOSItion or m belIefs and rumors relatmg to IUD may also be mvolved I A second reason for tills mterest m the study of IUD use lIes m the felt need to Improve qualIty of care m the proVIsIon ofFP servIces m the country A recently concluded study on RTI mtegratIon revealed an assocIatIon between IUD use and the mCIdence ofRTIs I (populatIOn CouncIl, Mamla, 1998) TIns study Will explore tills relattonsillp further and exarmne the role of clImc practIces m tills regard More generally, It has been argued that I Improved quahty of care, as shown by mcreased techrncal competence, adherence to chrucal standards m terms of mformatIOn and follow-up, upgraded mfrastructures, can help to I Improve method ITllX and ralse overall levels ofFP acceptance Data show a steady decrease m IUD use over the past few years, even as oral I contraceptIves contmue to gaIn m populanty In 1994 more than 175,000 IUDs were mserted, as compared to only a lIttle more than 127,000 m 1997 ThIs declIne IS sometlung I of an anomaly, given the advantages of the method and the fact that IUD use remams popular In several other countrIes of ASia and the Near East I The overall objectIve of the study then, IS to mvestigate factors affectIng IUD use m the PhIlIppmes By knOWIng the reasons why some areas of the country reveal hIgh IUD I prevalence and others are qUlte low, program managers should be better able to deSIgn more effectIve strategies for Improvmg program performance through mcreased IUD acceptance I and lugher contmuatIon rates I I I Vll I I I For tlus study, Misarms Onental provInce In Northern Mmdanao was purposIvely chosen as the hlgh prevalence study sIte whlle IlOIlo provmce m the Western V Isayas served I as the low prevalence companson area SpecIfically, the study addresses the followmg questIOns I 1 What are the levels of readmess of the SDPs m the low IUD prevalence (IlOIlo) and I hIgh IUD prevalence (MIsamis Onental) areas? 2 Are there dIfferences In quahty of care bemg provIded m Misamis Onental and I IlOilo? Are these dIfferences associated wIth program performance, partIcularly concermng IUD use? I 3 What are the factors assocIated wIth chents that may affect acceptance and I contmuatIon of IUD m IloIlo and Misamis Onental? The study utIhzed a modIfied SItuatIOn analYSIS (SA) and Focus Group DIscussIOns I (FGDs) approach for data collectIOn Four basIc SA mstruments were used Inventory of facIlItIes, eqUIpment and suppbes (especIally those needed to provIde IUD servIces), Staff mtervlews (focussmg on theIr techmcal competence to prOVIde IUD), ClIent-prOVIder I mteractIons(mc1udes all FP chents, With a few observatIOns of IUD bemg rnserted WIth the I consent of the chents), and Chents' eXIt mtervIews The two study SItes, 110110 and Misamis Onental, have 51 and 26 marn servIce I delIvery pornts (SDPs) or Rural Health Uruts (RHUs), respectIvely All of these SDPs were VIsIted by the SA study teams consIstrng of a person wIth chrucal trarnIng and a SOCIal SCIence trarned researcher Both teams underwent trmrung rn conductIng SItuatIOn analYSIS I arranged and faCIlItated by PopulatIon CounCIl I Thlrty-two FGD seSSIOns (16 seSSIOns In each study SIte) were conducted wIth the dIfferent subgroups of women users In selected murucipahtIes of the two provmces I Instruments for FGDs consIsted of grnde questIons deSIgned to elICIt InSIghtS about women's attItude toward IUD use, expenences related to acceptance or dropout, perceptIOn of the commuruty norms about famIly planmng (WIth emphasIs on IUD) and other IUD-relevant I rnformatIOn I I Vl11 I I I Study results showed that when the two study sItes (representmg a lugh perfonnance and a low performmg area) were compared on three dImensIOns of readmess, MlsamIS I Onental came out to be clearly and consIstently better than IloIlo