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Red Apple Consumer Education_ Pilot Project _Uzbekistan_

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					            Red Apple Consumer
                Education:
                Pilot Project
SOMARC Occasional Paper No. 25, September 1998

Margarita Gokun-Silver, SOMARC/Uzbekistan country manager

The Red Apple Consumer Education Pilot Project sponsored by the
Social Marketing for Change (SOMARC) Project in Uzbekistan was
implemented to test the effectiveness of interpersonal
communications in a controlled setting. The pilot was designed to
improve the knowledge and awareness of modern contraceptive
methods among Uzbekistani women and men who live in mahallas
(communities). While SOMARC's advertising and public relations
activities have successfully created awareness and built demand for
the Red Apple and other contraceptive products, many women were
still suspicious of hormonal contraceptives side effects.

The distrust in hormonal contraceptives has been generated by years
of misinformation, myths, and inferior products, and are not easily
dispelled, particularly in a country where most doctors are still
extremely skeptical of hormonal contraception. Some Uzbek women
believe that many doctors recommend IUDs to avoid answering
questions about pills and injections, because of their lack of
knowledge, or their distrust of the methods. However, when faced
with a more educated consumer, doctors have no choice but to
discuss benefits, side effects, and issues, or refer her to a more
knowledgeable practitioner. SOMARC's global experience shows a
better educated consumer has an easier time making the correct
choice among the wide variety of contraceptive methods.

SOMARC decided to introduce a pilot interpersonal communications
intervention in a close community to gauge its impact on consumers.
A peer counseling activity set up within three mahallas was identified
as a strong intervention that took reproductive healthcare
information directly to targeted consumers and could be evaluated
for impact.

From this pilot project SOMARC objectives were to:

     Provide an informational service on family planning and
     contraception via peer counseling
     Provide consumers with the information on availability of
     modern contraceptive methods in pharmacies, thereby
     increasing demand
     Provide a referral service of trained providers
     Gain consumer support for the Red Apple program and
     products.

Contents

1 Red Apple Consumer Education: Pilot Program

3 Interpersonal Communications: Peer Counselors Training
5 Family Planning Counseling and Services

10 Conclusion



Pilot Program
SOMARC/Uzbekistan began the Consumer Education Pilot Project in
January 1997 in Tashkent and Samarkand. Three mahallas were
selected for the pilot — two in Tashkent and one in Samarkand. The
mahallas in Tashkent were Almazor Mahalla at the metro Druzhba
Narodov, and Tepa Mahalla at the Pedagogical Institute. Both
mahallas were located near two Red Apple pharmacies, Jurabek and
Ibn-Sino, and contained a mixed population with Uzbek and Russian
being the major communication languages.

The mahalla in Samarkand, Suzangaran-2 Mahalla, was located near
the Reghistan Square and the community was mostly Tajik. All three
languages, Russian, Uzbek and Tajik, were spoken there, however,
Tajik was the most common.

Several women residents of each mahalla were trained in
contraceptive technology, family planning issues, and counseling by
SOMARC's master trainers. Special rooms in the mahallas were set
up with training materials and diagrams, consumer brochures,
referral information, and point of purchase items. Each room was
staffed by the trained counselors, and the counselors were available
on a daily basis to offer free counseling and information services to
their neighbors. The special rooms in the mahallas were called Red
Apple rooms after the contraceptive social marketing's logo and
image, and were open for a period of two months. Following that
time, the pilots were evaluated using qualitative evidence (in-depth
interviews with counselors and clients) to try to assess its impact.

(Note: Results show that it did have an impact, and SOMARC is
working to identify a local, or international, funder to support this
effort.)

Interpersonal Communications: Peer
Counselors Training
The first phase of the project was to identify and locate women who
were willing, and interested, in serving as peer counselors. The ideal
candidate needed to be open-minded, have at least a vocational
education, be a respected member of the community, and either be a
homemaker or able to take time off from work. Each mahalla had a
women's committee, and the three women's committees chairs
helped in the selection of women who fit this criteria.

Once the women were selected, SOMARC conducted training
seminars in Tashkent and in Samarkand. Both seminars were led by
SOMARC trainers, Dr. Rano Sabitova, and Dr. Svetlana Narzikulova,.
Dr. Narrikulova is also the medical director of The Fund for Healthy
Generation, and her presence and participation contributed to the
program's success and laid the groundwork for future partnership in
expanding or continuing the mahalla program.

Tashkent Seminar — February 3-7, 1997

Women from the two mahallas participated in the seminar — seven
women were from the Tepa Mahalla and six were from the Almazor
Mahalla. Seven women had vocational education, one was a college
graduate, two were doctors, and four had masters degrees. Nine
women were unemployed at the time of the project. Their ages
ranged from 30 to 57 and each one had at least one child.

Most of the women began the training with almost no knowledge
about modern methods of contraception. In fact, quite a few did not
know that pills and injectables existed and one woman had never in
her life seen a condom. Most women were familiar with IUDs. Almost
all participants had experienced at least one abortion.


Comments made by the participants about the seminar and the
project:

     "We need this sort of information. I am very happy that I
     was able to participate in this seminar and to gain this
     knowledge. I am looking forward to sharing it with
     others."

     "Thank you for giving us this complicated information at
     a level that we can understand and pass on to others."

     "Our trainers were excellent. They have a different style
     of teaching — it was not boring at all."

     "We are very happy that manufacturers told us about
     their different products. Now we have all the information
     we need."

     "We wish this project can run longer than for only two
     months. Our women need this kind of information."

     "Role games and practicum are very important. We were
     able to see what we are capable for."


The training seminar began with two-day intensive course covering
all modern methods of contraception. It was followed by a counseling
and a Trainer of Trainers (TOT) component. The last two days of the
seminar were dedicating to role-playing to practice counseling and
their presentation skills before the life audience (one day before
women of the mahalla and the next before the last graders of
Tashkent school #91). The training impact was impressive,
participants pre-test scores were 51% on knowledge and information
about modern methods; post-test scores were 91%.

Four Red Apple manufacturers participated in the seminar. Gedeon
Richter,   Pharmacia    Upjohn,    Innotech    and   Organon made
presentations on their products and distributed their promotional
materials to the future counselors. Dr. Nazia Salieva of the HIV/AIDS
Republican Center also gave a presentation on HIV/AIDS and its
presence in Uzbekistan.

Samarkand Seminar, March 10-14, 1997

Samarkand's seminar was very similar to Tashkent in design and
participants. Twelve women from the Suzangaran-2 mahalla
participated in the seminar, two women from the Samarkand
Women's Crisis Center, one from the local chapter of the Fund for
Healthy Generation, and the head of another mahalla's women's
committee. Eleven of the participants had vocational education, four
were doctors, and one had a master degree. Four women were
unemployed at the time of the project, and they ranged in age from
26 to 42 and each one had at least one child.

Like their counterparts in Tashkent, the majority of the participants
began the training with almost no knowledge about modern methods
of contraception; their level was even lower than that of their
colleagues in Tashkent. Most women were familiar with IUDs' and
almost all participants had experienced at least one abortion.

The seminar schedule was the same as Tashkent, it began with the
two-day intensive course covering all modern methods of
contraception and was followed by a counseling and a TOT
component. The women practiced their role-playing before a life
audience of women from the mahalla. On knowledge about modern
methods, participants pre-test scores were 64% and post-test scores
were 90%.

Gedeon Richter, Pharmacia Upjohn and Innotech, three Red Apple
manufacturing partners, made presentations on their products and
distributed their promotional materials to the participants. Dr. Nazia
Salieva, HIV/AIDS Republican Center, also gave a presentation on
HIV/AIDS and its presence in Uzbekistan.

The comments and reactions about the seminar and the project from
the participants were very similar to their colleagues in Tashkent.

Family Planning Counseling and Services
Red Apple rooms in Tashkent's Almazor and Tepa Mahallas opened
on February 17, 1997. Red Apple room in the Suzangaran-2 Mahalla,
Samarkand opened on March 17, 1996.

In Tashkent Red Apple rooms were located in the mahalla building in
the Tepa Mahalla, and in the kindergarten in the Almazor Mahalla.
Each room was decorated with Red Apple posters, manufacturers
posters, educational charts and drawings which provided visuals of
the consumer and technical information. Counselors were provided
with Uzbek and Russian editions of the Red Apple contraceptive all-
methods brochures and informational sheets for orals and injections,
as well as AVSC's Russian-language family planning flipchart. These
materials were to be used as reference guides during counseling
sessions.

Counselors were given referral lists of doctors trained by SOMARC,
JHPIEGO and AVSC International to recommend to their clients for
further consultation. In addition each site had a list of pharmacies,
their addresses and telephone numbers, that carried Red Apple
contraceptives. Counselors had samples of the Red Apple
contraceptives to show their clients, and manufacturers provided the
rooms with their promotional materials.

Each counselor was instructed to keep a record of client's questions
and of their own recommendations in the Service Records Notebook.
They were asked to list the doctor who they referred the client to for
further counseling, and follow up with the provider, if necessary. The
notebook is kept on file in SOMARC/Uzbekistan's office.

Pilot Project Evaluations

The last day of service in Tashkent for the Red Apple rooms was
April 12, 1997. On that day SOMARC/Uzbekistan conducted a focus
group interview with the counselors to determine the usefulness and
impressions of the project from their perspective. Summary of the
focus group results as well as summary of the Service Records
Notebook is provided separately below for each mahalla.

Tepa Mahalla

Counselors worked every morning (9am — 1pm) except Sunday and
once or twice a week in the afternoon (2pm — 6pm). According to
the counselors, the average time they had to spend with a client was
about 30 min. Some consultations took quite long (1 to 1.5 hours),
others took only about 15 minutes. The maximum number of clients
per day was seven, the minimum was zero with the average being
2.1 clients per day. Client's ranged in age from 13 to 50 years old.

According to the results of the focus group conducted with counselors
at the end of the pilot project, it was determined this kind of service
is needed in their mahalla. When asked if this project was effective,
counselors commented that while it had achieved some results, it
would definitely have been more effective if there had been a
component of "a mobile Red Apple room". Participants felt that more
people would have been reached if they made visits to workplaces,
schools and universities.

Participants believed that they helped many of their clients: they
estimated that around 30%-40% of their clients followed up with the
doctor and almost all began thinking about changing their current
method of contraception (the majority of visitors either used IUDs or
did not use anything).

Participants believed that this kind of service needed to continue so
that people always have access to a competent family planning peer
counselor. Many clients commented that they were pleasantly
surprised to see such service was available and free. A few of the
participants also conducted informal presentations on modern
contraceptive methods at their places of work or among relatives and
friends.

In addition to counseling on family planning issues, many
participants were faced with questions on the purpose of Red Apple
rooms and the program in general. There were a few cases where
clients expressed their disapproval of family planning programs
thinking of them as means to reduce Uzbek population. In these
cases participants had to explain that the purpose of the Red Apple
program was to promote healthy families, healthy mothers and
healthy    children,  by advocating      birth-spacing   and modern
contraceptives as alternatives to frequent births and abortions.


The following breakdown is available from the Red Apple Service
Notebook on clients' questions and concerns:

Out of a total of 151 clients:

            52 (34%) questions on contraception
            27 (18%) questions on reproductive health issues
            18 (12%) problems related to IUDs and questions
            about switching from IUDs to another method
            16 (11%) questions on correct use of
            contraceptives
            12 (8%) questions on the purpose of Red Apple
            rooms
            6 (4%) concrete questions on injections only
            2 (1%) problems with Depoo-Provera®
            3 (2%) concrete questions on orals only
            2 (1%) problems with oral contraceptives
            3 (2%) concrete questions on spermicides
            1 (1%) concrete questions on sterilization
            5 (3%) menopause questions/problems
            4 (3%) questions on infertility


Almazar Mahalla

Counselors worked every morning (9am — 1pm) except Sunday and
once or twice a week in the afternoon (2pm — 6pm). According to
the counselors, the average time they had to spend with a client was
about 30 min. Some consultations took quite a long time (1 to 1 ½
hours), some took only about 15 minutes. The maximum number of
clients per day was seven, the minimum was one with the average
being 3.4 clients per day. The client's ranged in age from 20 to 60
years old.

The results of the focus group conducted with the counselors at the
end of the pilot project were similar to that expressed by the
counselors at the other two mahallas. The general feeling was that
this kind of service is needed in their mahalla. Like their counterparts
at the other mahallas, when asked if this project was effective,
counselors said they thought it had achieved some results, but would
have been more effective if it had been mobile. Participants felt that
more people would have been reached if they made visits to
workplaces, schools and universities.

Participants believed that they helped many of their clients: they
estimated that almost all of their clients followed up with the doctor
and began thinking about changing their current method of
contraception.

Participants believed that this kind of service needed to continue so
that people always have access to a competent family planning peer
counselor. Many clients commented that they were pleasantly
surprised to see such service was available and free. A few of the
participants also conducted informal presentations on modern
contraceptive methods at their places of work and/or among relatives
and friends.

Two counselors changed their method of contraception after the
seminar. Both switched to oral contraceptives, one from an IUD,
another from the Noristerat injectable.


The following breakdown is available from the Red Apple Service
Notebook on clients' questions and concerns:

Out of a total of 214 clients:

            84 (39%) questions on contraception
            33 (15%) questions on reproductive health
            37 (17%) problems related to IYDs and questions
            about switching from IUDs to another method
            15 (7%) questions on correct use of contraceptives
            7 (3%) concrete questions on injections only
            3 (1%) problems with Depoo-Provera®
            7 (3%) concrete questions on orals only
            1 (1%) problems with oral contraceptives
            4 (2%) concrete questions on spermicides
            2 (1%) concrete questions on condoms
            1 (1%) concrete questions on sterilization
            12 (6%) menopause questions/problems
            4 (2%) questions on sexuality
            4 (2%) questions on infertility


Suzangaran-2 Mahalla

The maximum number of clients per day was eight the min. — 0
with the average being 1.6 clients per day. Clients ranged from 19 to
47 years old.


The following breakdown is available from the Red Apple "Service
Notebook" on clients' questions/concerns:

Out of a total of 72 clients:

            3 (2.16%) came with question how to use pills
            20 (14.4%) came with question what
            contraceptives are included in Red Apple program
            3 (2.16%) came with question what method can I
            use
            6 (4.32%) came with problems after used IUDs
            11 (7.92%) came with question about possibility of
            using contraceptives after hepatitis
            3 (2.16%) came with question about injectables
            1 (0.72%) came with problems after they used
            Depo-Provera®
            6 (4.32%) came with question about prevention of
            unwanted pregnancy
            2 (1.44%) came with question about Red Apple
            Program
            1 (0.72%) came with problems after used pills
            about pills
            6 (4.32%) came with question about pills
            4 (2.88%) came with question about probability of
            pregnancy after they used pills
            1 (0.72%) came with question what kind of side
            effects during the use of contraceptives
            1 (0.72%) came with question do the pills prevent
            from STD
            4 (2.88%) came with question about side effects
            during the use of injectables.



Summary of Clients Questions/Concerns
The following represents a summarized breakdown of clients'
questions/concerns for two Tashkent mahalla:
     General questions on modern contraceptive methods (73%)
     Questions/problesm on/in reproductive health, menopause,
     infertility, sexuality (49%)
     IUD questions/problems (29%)
     Questions on the correct use of contraceptives (18%)
     Injectables questions/problems (9%)
     Questions on the purpose of Red Apple rooms (8%)
     OCs questions/problems (7%)
     Spermicides questions (4%)
     Sterilization questions (2%)
     Condom questions (1%)



Conclusion
The pilot project was effective in disseminating information and
updating communities citizens' knowledge of modern contraceptive
methods. It was also quite effective in bringing attention to the Red
Apple program as the first program in Uzbekistan to approach
regular women in regular communities. All 13 participants of the
Tashkent Pilot Project became active supporters of the Red Apple
program and will continue to lobby on behalf of the program. They
will also continue to disseminate information on an informal basis as
they are now recognized in their community as points of contact for
information. One of the participants is hoping to lead her rayon's
chapter of the Fund for Healthy Generation and to continue bringing
contraceptive information to women through peer counseling.

Almazor Mahalla had a few more clients than Tepa. Participants in
the Almazor Mahalla were also more willing than the others to
contribute their time to work in these kinds of projects in the future
without pay. However, volunteering still seems to be an unwelcome
concept in Uzbekistan. While the majority of these women were
unemployed, not many of them seemed too eager to volunteer their
time if the project were to continue. Yet all of them were quite vocal
in expressing the need for such activities in Uzbekistan and their
commitment to improving the lives of their peers.

Future Steps
     In an attempt to make this initiative sustainable, SOMARC will
     approach The Fund for Healthy Generation to continue similar
     efforts in the future. The Fund has an enormous power and
     respect among Uzbekistanis, and it might be able to convince
     people to volunteer their time. SOMARC will assist with the
     necessary training and educational materials.
     If training funds allow, SOMARC proposes to investigate
     opening of Red Apple rooms in nursing quarters of
     kindergartens, schools and universities. All of these
     organizations have full-time nurses who can successfully serve
     as peer counselors during their normal work hours. This will
     allow for a maximum exposure to the target population without
     having to fund counselors' salaries.
     SOMARC will also assist any mahalla committee that wants to
     initiate or continue this kind of peer counseling service to apply
     for funding to other donor organizations.

				
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