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.