SOCIAL MARKETING RESEARCH. The PSI Dashboard

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1 SOCIAL MARKETING RESEARCH Improving Reproductive Health Women of Reproductive Age In rural areas of Priority Sites of Tajikistan and Kyrgyzstan Trough Interpersonal Communications Second Round Tracking M survey Among Women of Reproductive Age in rural areas The PSI Dashboard PSI / Central Asia November PSI s Core Values Bottom Line Health Impact * Private Sector Speed and Efficiency * Decentralization, Innovation, and Entrepreneurship * Long-term Commitment to the People We Serve

2 Research Division Population Services International Nineteenth Street NW, Suite Washington, D.C. Improving Reproductive Health Women of Reproductive Age In rural areas of Priority Sites of Tajikistan and Kyrgyzstan Trough Interpersonal Communications Second round PSI Research Division Citation Information: Varja Lipovsek, Shakhnoza Tashkhodjaeva, Improving Reproductive Health Women of Reproductive Age In rural areas of Priority Sites of Tajikistan and Kyrgyzstan Trough Interpersonal Communications, PSI/Central Asia, November. Population Services International, Contact Information: Shakhnoza Tashkhodjaeva, M&E Coordinator a M. Yakubova St. Tashkent, Uzbekistan Phone: + (998-) --4 Fax: + (998-) Shahnoza@psi.uz Varja Lipovsek, PSI Regional Researcher Bristol, UK varjalipovsek@yahoo.com

3 Summary Central Asia, Summary Acknowledgements This research project was supported by the United States Agency for International Development (USAID) to improve maternal health among underserved, low-income woman in rural areas of Tajikistan and Kyrgyzstan. This report represents the work of many individuals. The study design was developed by Shakhnoza Tashkhodjaeva with help from Varja Lipovsek (Regional Researcher for Eastern Europe and Central Asia). Data collection was conducted by M-Vector Research Group Ltd. based in Bishkek, Kyrgyzstan. Coordination with data collection agencies, data cleaning and analysis were done by Shakhnoza Tashkhodjaeva (PSI/Central Asia Regional M&E Coordinator). The report was written by Varja Lipovsek and Shakhnoza Tashkhodjaeva. Background & Research Objectives PSI/Central Asia is implementing a -year USAID-funded program to improve maternal health among underserved, low-income women in rural Tajikistan and Kyrgyzstan. The program aims to address the lack of access to affordable family planning products, insufficient knowledge of modern contraceptives, and misconceptions about the safety and effectiveness of modern contraceptive methods. Specifically this project serves as a model in rural areas of Tajikistan and Kyrgyzstan for effective improving reproductive health of women of reproductive age (WRA) using interpersonal communications (IPC). The main objectives of this study are:. To obtain and provide both comprehensive and detailed data to support PSI s interventions with WRA in rural areas.. To obtain information for monitoring the key indicators, behavior change, and OAM determinants associated with use of modern contraceptives. Description of Intervention PSI/CA implemented a USAID-funded program targeting Women in Rural Areas aged -49 years in sites of Kyrgyzstan (Chu, Issyk Kul and Talas) and in 4 sites of Tajikistan (Dushanbe, Rudaki, Kulyab and Kolkhozabad). PSI conducted quarterly trainings and on-going technical assistance for parallel implementation of IPC by a separately-funded partnership with villagelevel centers Health Houses in Tajikistan and FAPs in Kyrgyzstan. Through such partnerships, PSI is building the capacity of these centers to implement communications activities for and

4 Summary Central Asia, provide services to rural WRA in order to make affordable products available through the commercial sector. PSI s outreach work serves to inform WRA about awareness of the benefits of contraceptive use, available contraception methods and address misconceptions about the sideeffects, safety, and efficacy of modern contraceptives. PSI s interventions aim to generate positive behavior change via educational activities that include balanced information on a range of contraceptives, including advantages and disadvantages of the importance of offering women comprehensive, unbiased information on available methods and helping women select the method that best suits them. In addition, PSI has partnered with a generic manufacturer to make affordable, high-quality products available to the targeted low-income rural women and increase demand for family planning products among non-users through educational activities. At the same time, PSI will train medical providers in modern contraception methods, the benefits of family planning products and services, and improved client communications. Methodology A network-based randomized sampling strategy combined with Lot Quality Assurance Sampling (LQAS) was used to recruit WRA living in selected geographic areas for this survey. PSI uses LQAS techniques to determine baseline levels for logical framework indicators and, in a subsequent survey, which populations have met logical framework and exposure targets and which have not. A sample size of 9 for each target group is the required number of target group representatives to calculate LQAS monitoring tables and provides an acceptable level of error for making management decisions; at least 9% of the time it correctly identifies supervision areas that have reached their coverage target. The sample size larger than 9 have practically the same statistical precision as 9. For this round, PSI did not segment the target population, as using the LQAS allows for monitoring of changes in the population, but not segmentation or evaluation. Main Findings In Tajikistan, the % target for current use of modern contraceptives was not reached in any of the four survey areas. The pill was the most commonly used contraceptive. In Kyrgyzstan, the region of Issyk Kul had met the use of modern contraceptive targets, though the other regions were lagging behind. The most commonly used contraceptive was the IUD. Availability of contraceptives was found to be satisfactory in all areas of Kyrgyzstan, but only in Dushanbe in Tajikistan.

5 Summary Central Asia, Targets were generally reached in all areas for indicators related to self-efficacy, social support, beliefs about contraception, outcome expectation and threat. In Tajikistan, determinants in which targets were not reached were knowledge of modern contraceptives (with exception of Dushanbe), intent to use condoms and locus of control. In Kyrgyzstan, determinants in which targets were not reached were knowledge, negative beliefs about modern contraceptives, intention to use modern contraceptives, and locus of control. Exposure varied among regions. In Tajikistan, the region with lowest exposure scores was Dushanbe; in Kyrgyzstan, it was Chu. Programmatic Recommendations Based on the above findings, the following actions are recommended to strengthen the I Know family planning program: a) Increase the education and information component of the intervention in Chu oblast, Kyrgyzstan, and in Dushanbe and Rudaki, Tajikistan. b) Expand media and educational campaigns in all regions. Increase the number of trainings on family planning among outreach workers. c) The program should examine further the determinant locus of control, for which targets were not reached in any of the areas. d) Increase the number of activists involved in the I Know program. Activists are to be chosen from rural social workers, rural NGOs, and village health committees; activities should be provided to increase their knowledge on family planning and reproductive health, and the use of modern contraceptives. e) Improve the availability of modern contraceptives in all pilot oblasts of I Know project in Tajikistan, except in Dushanbe.

6 Monitoring Analysis Central Asia, Monitoring Table: Tajikistan The data on modern contraceptive use, OAM determinants of contraceptive use, and exposure among (WRA -49) in Dushanbe (), Rudaki (), Kulyab () and Kolkhozabad () regions of Tajikistan. Risk: Women of reproductive age, -49 Behavior: Use of modern contraception methods Dushanbe INDICATORS BEHAVIOR/USE Currently using Pill for contraception Currently using condoms for contraception (<%) Currently using injectable for contraception Currently using IUD for contraception (<%) OPPORTUNITY Availability Contraceptives are always available here when needed ABILITY Rudaki (N/A) (N/A) 8 (%) Kulyab (%) (%) Kolkhozabad (%) 9 (%) Target % % % % 9% Knowledge Can name at least three modern contraceptive methods Social Support My parents would support any decision I make regarding childbearing. My husband would support any decision I make regarding childbearing. Self-Efficacy I am capable of using modern contraceptives to space my births. I can talk to my partner about using contraceptives to prevent unwanted pregnancy. MOTIVATION 8 8 (8%) (9%) (4%) 8 8 (%) 4 (8%) (<%) (%) 4 (8%) (%) 9 (%) (4%) (%) (%) 4 (8%) 4 (8%) 9% 9% 9% 9% 9% Belief Disagree with: Children born to a women who use contraceptives can have many things wrong with them. Disagree with :Contraceptives are dangerous. Intention Intend to use a modern contraceptive method to prevent pregnancy in the next six months. Locus of Control Disagree with: It is up to my husband to make sure that we use contraceptives. Disagree with: Whether or not I get pregnant is a matter of fate. (%) (%) 9 (%) (N/A) (%) (<%) (%) 8 (%) (8%) (8%) 9 (%) 8 (%) (4%) 4 (8%) (8%) (%) (4%) % % % % %

7 Monitoring Analysis Dushanbe INDICATORS Disagree with: Only God decides when a woman becomes pregnant. (<%) Outcome Expectation Using modern contraceptive methods is 8 more reliable than traditional methods. Using modern contraceptives is effective for spacing births Subjective Norm My husband/partner believes that I should use contraceptives to space (%) births.* Disagree with: If I used contraceptives 8 other people would think I was immoral. Threat Women with children who are too close in age usually have health problems (9%) Women who make abortions to limit 8 number of children have serious health problems EXPOSURE Have you heard the information about oral contraceptive called Oralcon from NGO workers in last month? Have you heard about the injectable contraceptive called Depo Provera from (<%) NGO workers in last month? Have you heard information about the IUD Cooper from NGO workers in last month? Have you seen/ heard the information about the methods of contraception from NGO workers in the last month? Have you participated in NGO educational events last month? Have you seen any educational materials with information about the family planning, contraceptives, and the risk of abortions in the last month? Have you heard/seen the slogan I know? (N/A) Can recognize the logo of FPP (4%) Rudaki 4 (%) 4 (8%) 4 (8%) (%) 9 (<%) (<%) (<%) (<%) (<%) Kulyab (<%) 8 (%) 4 (8%) (<%) 4 (%) (4%) (4%) (4%) (<%) Central Asia, Kolkhozabad (4%) 9 9 (8%) 9 (<%) 9 (%) (8%) (%) (N/A) Target % 9% 8% % % 9% 9% % % % % % % % % Monitoring Analysis: Tajikistan As the table above shows, the % target for current use of modern contraceptives was not reached in any of the four survey areas. The proportions were lower in Dushanbe and Rudaki as compared to Kulyab and Kolkhozabad. Overall, the pill was the most commonly used contraceptive. Availability of contraceptives was found to be satisfactory (as compared to 9% target) in Dushanbe, but not in other areas.

8 Monitoring Analysis Central Asia, Ability to use modern contraceptives was measured by the knowledge, social support and selfefficacy indicators. The knowledge target of 9% was reached only in Dushanbe, with other regions lagging considerably. Social support tended to be high overall, particularly in Dushanbe and Rudaki. Self-efficacy was similarly high, although Kulyab had the lowest scores. The targets for proportion of respondents disagreeing with negative beliefs about contraception were either reached or surpassed (with exception of one belief item in Rudaki). On the other hand, target of % intent to use condoms was not reached in any of the survey areas. Notably, locus of control targets were not reached in any area. It is interesting to note, however, that outcome expectations of modern contraceptives were overall high. Targets for subjective norms about contraceptive use and threat associated with too-closely spaced children and abortion were reached, or nearly reached, in all survey areas. Exposure to the PSI FP program and specific contraceptives varied considerably between the survey regions. Overall, highest exposure was recorded in Kolhkozabad, with of the 8 exposure indicators near or on target; although notably none of the Kolhkozabad respondents recognized the FPP logo. The region with next highest exposure was Kulyab, followed by Rudaki and then Dushanbe. Interesting to note that while Dushanbe overall scored lowest on exposure, it was the region with highest proportion of respondents recognizing the FPP logo.

9 Monitoring Analysis Central Asia, Monitoring Table: Kyrgyzstan The data on modern contraceptive use, OAM determinants of contraceptive use, and exposure among (WRA -49) in Chu (), Issyk Kul () and Talas () regions of Kyrgyzstan Risk: Women of reproductive age, -49 Behavior: Use of modern contraception methods INDICATORS BEHAVIOR/USE Currently using Pill for contraception (<%) Currently using condoms for contraception 4 (%) Currently using injectable for contraception Currently using IUD for contraception (4%) OPPORTUNITY Availability 8 Contraceptives are always available here when needed ABILITY Chu Issyk Kul Talas Target (%) (%) (4%) (%) (%) 4 (%) (<%) 9 (%) % % % % % Knowledge Can name at least three modern contraceptive methods 9 Social Support My parents would support any decision I make regarding childbearing. My husband would support any decision I make regarding childbearing. Self-Efficacy I am capable of using modern contraceptives to space my births. I can talk to my partner about using contraceptives to prevent unwanted pregnancy MOTIVATION (%) (%) 4 (8%) (9%) (9%) (9%) 4 (8%) 8% 8% 8% % % Belief Disagree with: Children born to a women who use contraceptives can have many things wrong with them (8%) Disagree with :Contraceptives are dangerous Intention Intend to use a modern contraceptive method to prevent pregnancy in the next six months. Locus of Control Disagree with: It is up to my husband to make sure that we use contraceptives. Disagree with: Whether or not I get pregnant is a matter of fate. Disagree with: Only God decides when a woman becomes pregnant. Outcome Expectation Using modern contraceptive methods is more reliable than traditional methods (%) (%) (%) (4%) (%) (%) (4%) (N/A) (4%) (9%) (%) (8%) 8 (%) (8%) % % % % % % 9%

10 Monitoring Analysis Central Asia, INDICATORS Using modern contraceptives is effective for spacing births Subjective Norm My husband/partner believes that I should use contraceptives to space births. Disagree with: If I used contraceptives other people would think I was immoral. Threat Women with children who are too close in age usually have health problems Women who make abortions to limit number of children have serious health problems EXPOSURE Have you heard the information about oral contraceptive called Oralcon from NGO workers in last month? Have you heard about the injectable contraceptive called Depo Provera from NGO workers in last month? Have you heard information about the IUD Cooper from NGO workers in last month? Have you seen/ heard the information about the methods of contraception from NGO workers in the last month? Have you participated in NGO educational events last month? Have you seen any educational materials with information about the family planning, contraceptives, and the risk of abortions in the last month? Have you heard/seen the slogan I know? Chu Issyk Kul Talas Target (%) 9 (%) (<%) Can recognize the logo of FPP 4 (8%) (9%) (%) (%) (%) 4 (%) 4 (%) (4%) (4%) (4%) (9%) 4 (8%) (%) (%) 8 (%) 8 (%) 4 (%) (%) 9 (%) 8% % % % 9% % % % % % % % % Monitoring analysis: Kyrgyzstan As the preceding table shows, nearly all the targets for use of modern contraceptives were met in the region of Issyk Kul; the region of Talas had met one target and was close on another two, while Chu lagged behind considerably. Overall, the IUD was the most commonly used contraceptive (with targets reached or nearly reached in all areas). The targets for availability of contraceptives were met in all three survey regions. The target for knowledge of modern contraceptives was reached only in Talas. On the other hand, social support and self-efficacy targets were reached or surpassed in all survey regions. Targets relating to disagreeing with negative beliefs about modern contraceptives were reached only in Chu; on the other hand, the target of intention to use contraceptives was reached only in Talas. Locus of control indicators showed mixed results: all targets were reached in Talas, but not

11 Monitoring Analysis Central Asia, in other regions. Outcome expectations relating to modern contraceptives, subjective norms, and threat indicators were universally high and on target or above it in all regions. Regarding exposure, it is notable that Chu did not reach a single target and lags far behind the other two regions. Issyk Kul and Talas have similar exposure results; Talas fared best, though neither region has reached the target proportions.

12 Annex : Methodology Central Asia, Methodology A network-based randomized sampling strategy combined with Lot Quality Assurance sampling was used among target population living in supervision areas ( supervision areas are defined in the following section). Lot Quality Assurance Sampling (LQAS) is used to determine which indicators are meeting set targets and which are not. LQAS allows quantifying results for an entire catchment area (e.g., district or province or nation and is suitable for study when the total sample frame is quite small as most frequently used sample size 9 per supervision area or per target group). Sample Selection Process A time-location sampling strategy combined with network-based sampling strategy was used to recruit WRA living in hot zones. In addition, the study attempted to introduce randomization into the network sampling, as described below. Supervision areas were selected within Dushanbe, Rudaki, Kulyab, Kolkhozabad regions of Tajikistan and Chu, Issyk Kul, Talas regions of Kyrgyzstan targeted by PSI s USAID program. In order to identify study respondents, a two-stage sampling methodology was used. Supervision areas were selected within each of the regions. Each supervision area was divided into sites, comprised of approximately - households. All supervision areas for a city were numbered in continuous order. Nineteen (9) areas were selected from each list using random numbers generated by Microsoft Excel. A list of households was compiled for each selected area. The households were numbered continuously and one household had to be randomly selected. For each site, a reserve list was compiled, for the case where there were no women aged -49 in the selected household. In each selected household with women aged -49, one () person was interviewed. In the event of the absence of a potential respondent, the interviewer was required to come back twice, before replacing the household with one from the reserve list. If the selected person had recently been interviewed for a PSI Tracking Survey, he/she had to be eliminated from the TRaC-M study. The number of interviews conducted in each region is as follows: Follow up No Country Region Project Interviews per Site Tajikistan Dushanbe FPP 9 Rudaki 9 Kulyab 9 Kolkhozabad 9 Total Kyrgyzstan Chu FPP 9 Issyk Kul 9 Talas 9 Total Grand total Data Collection

13 Annex : Methodology Central Asia, The questionnaire for this round of data collection consists of the sections which are as follows:. Five behavioral indicators. Selected OAM determinants of the behavioral indicators. Exposure to PSI interventions Instrument A structured questionnaire was used to monitor whether selected indicators are reaching the expected thresholds/levels. This questionnaire includes modules in the following areas: OAM determinants of behavior including output level logframe indicators, behavior as specified by purpose level logframe indicators, and exposure to PSI/ Central Asia interventions. This questionnaire is pages. The questionnaires was translated into Russian and pre-tested by conducting approximately interviews with WRA in Tajikistan and Kyrgyzstan. These women were excluded from participation in the actual study. The pre-test was used to check for understandability of questions and procedures for conducting interviews. It will also be used to revise the questionnaire based on the following points: ease or difficulty of statement, comprehension, confidence in response, level of discomfort and social desirability. Procedure Fieldwork was conducted from November to December in the two target countries by a contracted research agency. Prior to fieldwork, all interviewers attended a - day training session designed to ensure that the survey objectives, methodology and quality standards were fully understood. The following topics were covered during the training: Research objectives and strategy Modern contraceptive methods and general family planning topics Issues related to the organization of field work Method of household and respondent selection Guidelines and procedures for asking questions of a sensitive nature Detailed discussion of each question in the questionnaire Interview procedures Due to the sensitive nature of many of the questions, only women conducted the interviews. Each potential respondent was asked for her consent for interview on a voluntary basis. In the case where a respondent is under 8, the interview was conducted only with parental consent. It was recommended for interviewers to conduct interview dressed in doctor's smock. From the experience of local research agencies this considerably decreases the quantity of refusals to participate in the interview. Local research agency fieldwork supervisors and country office staff checked each completed questionnaire for consistency of answers; any ambiguities were cross-checked with the interviewer responsible and additional or repeat interviews were conducted if needed. interviewers conducted all of the interviews. During fieldworks research agency supervisors conducted control visits to percent of surveyed households to check the quality of the interviewers work. Data Management

14 Annex : Methodology Central Asia, The data was entered and cleaned by research agency staff and analysis was done by PSI s monitoring and evaluation team using SPSS. All variables were fully labeled along with corresponding value codes in English. As much as possible, the dataset provides enough information so that it is not necessary to refer to the questionnaire. Data quality steps include checking the questionnaire for internal consistency (in accordance with a scrutiny note), filter errors, appropriate coding for non-response or missing values, values that fall out of range, and other logical checks. Data Analysis The analytical technique of LQAS consists of a simple count of the total number of yes responses to the questions posed. The sum identifies two thresholds, as set forth in table below. For example, having yes responses to an indicator reflects a higher threshold of percent, and a lower threshold of percent. This is interpreted as follows. At baseline, the indicator is in statistical terms indeterminate, but can be thought of as highly likely to be within the range of the lower and higher thresholds of and percent. Program managers then set a target, of say,, reflecting lower and higher thresholds of and 8 percent. If, at follow up, 4 yes responses are recorded, then there is a 9 percent probability that the indicator has reached the higher threshold target of 8 percent. If, at follow up, yes responses are recorded, then there is a 9 percent probability that the indicator is below percent, meriting additional intervention. If yes responses are recorded, then again the indicator is statistically indeterminate, falling in between the and 8 percent levels. While inexact, LQAS offers a highly cost-effective means of identifying underperforming supervision areas, permitting program managers to allocate additional resources to easily-identified supervision areas, perhaps by taking resources away from supervision areas that are clearly identified as having exceeded the target. LQAS yes responses and lower and higher thresholds Number of Yes Responses Lower Threshold % Higher Threshold%

15 Annex : Perform Framework Central Asia, Performance Framework for Social Marketing HEALTH STATUS QUALITY OF LIFE HALO AND SUBSTITUTION EFFECT USE RISK-REDUCING BEHAVIOR RISK COVERAGE, QUALITY, ACCESS, EQUITY OF ACCESS, EFFICIENCY OPPORTUNITY ABILITY MOTIVATION POPULATION CHARACTERISTICS IMPACT, EQUITY AND COST EFFECTIVENESS EXPOSURE SOCIAL MARKETING INTERVENTION PRODUCT PRICE PLACE PROMOTION This study design is guided by PSI s PERForM framework. PERForM describes the social marketing research process, identifies key concepts important for designing and evaluating social marketing interventions and mirrors the four levels and concepts in the logical framework. The top level consists of the goal of social marketing for any health promotion intervention, namely improved health status and/or for interventions relating to coping with sickness or disability, quality of life. The second level consists of the objectives of social marketing stated as product or service use on the left side and/or other risk-reducing behaviours that do not involve the use of a product or service on the right side. The adoption or maintenance of these behaviours in the presence of a given risk or need for health services is causally antecedent to improving or maintaining health and or quality of life. The third level consists of the determinants of PSI Behaviour Change framework summarised in terms of opportunity, ability and motivation that may differ by population characteristics such as age and sex. The fourth level consists of the characteristics of the social marketing intervention.