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LITERATURE REVIEW: Provider and Client Behavior and Behavioral Interventions in Family Planning in the Philippines Prepared for Management Sciences for Health- Local Enhancement and Development (LEAD) for Health Project By The Manoff Group, Inc. Ma. Elena Chiong-Javier, Ph.D. INTRODUCTION For several decades now, the family planning (FP) program in the Philippines has sought to identify the factors that would enable health personnel to provide reproductive health and contraceptive services to clients to the fullest extent possible. It also sought to understand the factors that specifically impede clients from availing of contraceptive methods and continuing contraceptive use. Program experiences and family planning research or studies have revealed that certain aspects of provider practice pose a barrier to clients’ extent of utilization and to the technical quality of care clients are entitled to. It is therefore necessary to understand why provider-related problems exist to enhance service provision. Moreover, important reasons underlying clients’ behavior and how these affect FP service provision must likewise be understood in order for providers to respond better to clients’ needs. The findings extracted from researching on these issues are an essential groundwork for FP interventions such as the Local Enhancement and Development (LEAD) for Health Project that began in October 2003. This project is a three-year collaborative undertaking between the Management Sciences for Health and its partners, on the one hand, and the local government units (LGUs), the Department of Health (DOH), and other government institutions, on the other hand. With funding from the United States Agency for International Development (USAID), it seeks to strengthen and support local level policy environment, financing, management, and provision of FP services and performance to achieve contraceptive self- reliance, among other goals, in 530 municipalities and cities nationwide. Objective of the Literature Review This literature review is part of The Manoff Group’s commitment (as a partner of the Management Sciences for Health) to assist the LEAD for Health Project. It aims to complete the preliminary work started by Dr. Laurie Krieger, Senio r Technical Advisor for The Manoff Group, to annotate the issues on provider and client behaviors and behavioral interventions related to family planning in the country. In line with this, the overall objective of my literature review is twofold: (1) to annotate the more important references reviewed, with regard to provider and client behavior and behavioral interventions, and (2) to draw out the findings that have programmatic and research implications for the LEAD project’s work of helping LGUs improve FP service provision and performance, thereby increasing contraceptive acceptance and continuation in the country. The reference materials included in the review were generally obtained from the following sources: the Social Development Research Center and the Gender, Sexuality, and Reproductive Health Databank/Library of De La Salle University-Manila, the University of the Philippines Population Institute, Academy for Educational Development-The Social Acceptant Project (TSAP) office, and the USAID-Development Information Center. Other materials were sourced through Dr. Krieger and Ms. Yoko Chiba (who was visiting the LEAD office) as well as the internet. A visit to the Office of Population Studies at the University of San Carlos in Cebu City did not yield any useful source. Although more materials were consulted for the review, only 25 have been considered relevant and important for inclusion in this report. The report is divided into two major sections. The first section briefly highlights the major findings derived from the literature review and an analysis in terms of their implications for program and research within the context of the LEAD project framework. The second section contains 25 annotated references (on 20 different studies) which are categorized into three types: (a) studies on provider-client interaction and behavioral interventions, (b) provider-related studies, and (c) client-related studies. Each category of annotated bibliography starts with a brief description of its contents. I. FINDINGS AND ANALYSIS A number of general observations can be made about the reference materials found for this review. There is far greater interest in clients alone or their interaction with providers (comprising almost 9 out of 10 materials) compared to providers alone or their interaction with clients (about 6 out of 10 materials). In provider studies, interest has expanded in the last decade to private sector health facilities that also provide FP services like clinics managed by nongovernmental organizations (NGOs) and the industry. Nonetheless, provider-related studies are still mainly about health providers from the public/government facilities and clinics. Two behavioral interventions in client-provider interaction or FP counseling process appear in the literature. One is the client-centered approach tried out in the Philippines in 2001 as part of a multi-country effort spearheaded by the Population Council. The other is the Greet-Ask-Tell- Help-Explain- Return (GATHER) approach to FP counseling designed and utilized by public and NGO health service e providers under the auspices of such institutions as John Hopkins University Center for Communications Programs (JHU-CCP), United Nations Population Fund, and EngenderHealth, among others. These interventions have contributed some quantitative and qualitative assessment tools for quality of care, such as the Quick Investigation of Quality (QIQ) Observation Tool and Stakeholders’ Agenda and Matrix Tool adapted from JHU-CCP (Lamberte, et. al., 2004). Of the 20 studies written up in the 25 materials reviewed, the most utilized methodology is qualitative (8 of 20), followed by quantitative (7 of 20) and a combination of both types (5 of 20). There is a resurgence of knowledge, attitudes, and pract ices (KAP) studies in recent years, which are generally survey-oriented, to obtain baseline information for the communication interventions being planned by the USAID-assisted The Social Acceptance Study-Family Planning (TSAP-FP) Component of the Academy for Educational Development. In terms of research sites, the most studied island is Luzon (15 or two- fifths of its 38 provinces have been cited in the materials), followed by Visayas (4 or one-fourth of 16 provinces) and Mindanao (5 or one- fifth of 25 provinces). As expected, Metro Manila is a frequent choice in Luzon, followed by Metro Cebu in Visayas and Metro Davao in Mindanao. Salient Findings: What Do We Know? Training is not enough to archive major, consistent changes in quality of care. An overwhelming majority of the Filipinos today understand the need for FP but this understanding is not easily translated into practice. The 2004 Pulse Asia Survey reported that 97% of the Filipinos consider it important to control one’s fertility or to plan one’s family. Yet ironically, a good majority (65%; 2004 NFO Trends Survey) has been found to have ―little knowledge of FP or have heard (of FP) but do not know anything about it.‖ And while the percentage of claimed knowledge is high among those who are married/living- in, only a small majority (less than three-fifths) in this group actually practices FP. But however little is their knowledge about FP, a great majority (96-97%) of Filipinos have heard of contraceptive methods, particularly condoms a nd pills, from close friends or acquaintances, television, and health centers. A significant proportion of providers and clients share similar “bicultural” perspective, folk beliefs, and attitudes that are unfavorable to modern contraceptive practice. Findings reveal that bicultural—i.e., biomedical and humoral--views about the body and health govern not only the response of clients to modern contraceptives but also the FP work of medical providers and community health workers (Henry, 2001; TSAP-FP, n.d.). Biomedical knowledge obtained through schooling/training clashes with humoral knowledge acquired through cultural experiences. This is frequently seen in the meanings and speculations given to contraceptive side effects such as the impact of the physical manifestation of menstruation on health (e.g., amenorrhea from hormonal methods causes high blood or tumors). So clients discontinue using pills and injectables until menstruation returns; midwives advise the same and doctors do not recommend injectables as a consequence. Current surveys also show that many folk notions and attitudes often commonly held by clients and providers pose barriers to contraceptive use or provision, such as believing that women who experience ill health effects of contraceptive methods are not naturally suited (hiyang) to such methods, or that IUD is easily misplaced, creates discomfort, or may fall off (NFO Trends, January and April 2004; ACNielsen, 2003: TSAP-FP; n.d.). Other barriers attitudes held by providers that may constitute a barrier to effective FP service delivery include: some methods, particularly IUD, are abortifacient (believed by a third of 750 doctors, nurses, and midwives recently surveyed), or that a woman should have at least one child before taking pills. The male spouse/partner continues to wield considerable influence on the woman’s unmet need and contraceptive behavior. This fact was mentioned in the three-decade old literature (Bailen and Morisky, 1974) and is repeatedly found in many other references all the way to the present. The husband’s fertility preferences, acceptance of FP, and his perceived health effects of contraception are major reasons why women have an unmet need, or they do not practice FP even if they do not want to get pregnant (Casterline, et. al., 1995). Certain studies have advocated for the inclusion of men in fertility management because of their strong pronatalist stance and prevailing dominant role within the Filipino culture and home in spite of increasing women’s empowerment, and because their cooperation is essential particularly in coital-dependent methods like condom, withdrawal, and rhythm (Perez, 1997; Jocano, 1998; ACNielsen, 2003; Costello, et. al., 2001). Other studies have indicated that women who talked about FP to their spouses/partners and got the latter’s approval and encouragement were more likely to accept and continue using modern contraceptives (Kinkaid, 2000; NFO Trends, January and April 2004) while their choice of contraceptive method is constrained by husbands’ disapproval or speculations about the method’s side effects (Henry, 2001). Moreover, even medical providers of FP services like obstetricians-gynecologists (53%), general practitioners (52%), and midwives (48%) believe that women clients should not use FP if their husbands do not approve of it (TSAP-FP, n.d.). Quality of care, which is increased through behavioral intervention, tends to improve contraceptive use/continuation but it is still a long way to achieving this. Interventions like the trainings on client-centered approach given to doctors, nurses, and midwives were found to have significantly improved quality of care based on five main indices (Costello, et. al., 2001). And quality of care at initiation of contraceptive use appears to be positively linked to continuation of use at follow-up and higher levels of use of modern methods and any method (Ramarao, et. al., 2003). The quality of care indices were externally designed and derived by the researchers from a theoretic and programmatic perspective. Provider performance on the indices (as rated by clients) was varied and fell below 100% thus indicating more room for further improvement. Moreover, in terms of total quality, only over a third of the clients had received ―high quality care,‖ indicating that researchers and clients may not share the same meaning of ―quality.‖ While religion does not appear to be a thorny issue for clients, it seems to be an important consideration underlying FP support and service provision. The Philippines is a predominantly Catholic country where the Church has favored ―natural‖ methods over ―artificial‖ modern ones. Although there are still debates on the influence of the Church, recent evidence seems to indicate that the influence may no longer be strong: people do not consider religion to be a threat to FP supporters (Pulse Asia, 2004); men and women rank religious belief only as the 11th most important factor in FP choice (yet this perception is held by close to two-thirds of the study’s 1,600 respondents; NFO Trends, January 2004); religion is women’s least mentioned reason for using contraception (Kinkaid); religious influence has minimal impact on personal decisions involving FP and childbearing (Costello, et. al., 2001); or low contraceptive usage is not due to religion according to the 1998 Demographic and Health Survey (TSAP-FP, n.d.). As for providers, recent KAP studies reveal that religious beliefs do affect their prescribing practices (NFO Trends, April 2004) and their recommendations (according to 53% GPs, 48% OB-Gyns, and 40% midwives; TSAP-FP, n.d.); that it is against such beliefs to recommend any non-natural method (claimed by 22% midwives, 19% GPs, and 16% OB-Gyns; TSAP-FP, n.d.); and that community volunteer workers go against church teachings on FP methods to fulfill their role (Asia Development Consultant, Inc., n.d.). In addition, local government officials still fear to antagonize the Church and would rather not publicly declare political support for FP just to play safe (Costello et.a l., 2001). Certain personal attributes of health service providers can either positively or negatively affect FP clients’ behavior. According to clients, the positive provider attributes exhibited during dyadic interactions with providers or in FP counseling sessions are good interpersonal communication, sufficient knowledge about FP, and encouraging personal traits, such as being warm, cheerful, and respectful. On the other hand, the negative attributes include: speaking in a raised voice, poking fun directly or indirectly at clients’ response, bombarding client with questions, depriving client of the chance to talk, cutting off client at mid- sentence, avoidance in answering client’s queries, and provision of vague answers (Lamberte et. al., 2004). Providers themselves find that among their characteristics favorable to FP are having a strong sense of commitment, honest about shortcomings, willing to undergo training to improve stock knowledge on FP, innovative, skilled at using visual aids, and respectful of clients’ right to know and choose a method. However, among their unfavorable characteristics is their claim that providers themselves do not practice what they preach about contraceptives and they lack confidence in undertaking FP counseling that may result in inadvertently mishandling clients’ misconceptions or concerns about the side effects of modern methods (NFO Trends, April 2004; Lamberte, et. al., 2004; Asia Development Consultants, inc., n.d.). Programmatic and Research Implications: What More Must We Know and Do to Perform Better? Have a deeper understanding of the system of social control that exerts profound pressure on providers’ service delivery practices. This system consists of the various ways the providers’ significant social circles (i.e., family, kin, friends, and associates) encourage conformity to deeply- held norms and values, whether religious or cultural, which are regarded as diametrically opposed to FP objectives. Are the social pressures more intense from certain circles? Are providers located at the higher rung of the FP service delivery system and in the less urbanized areas more affected by social control? How effective are informal mechanisms in influencing providers’ behavior towards FP? Pay special attention to the content of providers’ responses to women’s beliefs about modern contraceptive methods during dyadic interaction. How are the women’s misconceptions handled and their apprehensions allayed by different providers from the public and private health sectors? In particular, what shared humoral or folk notions are communicated and reinforced in the minds of both provider and client during counseling? What specific responses to clients’ queries or concerns have ―worked‖ for these are convincing to the women and their husbands/partners and get translated into continued contraceptive use? How then is it possible, if at all, that providers have been able to convert folk body notions to the advantage of FP? Preparatory to collaboration with LGUs, determine to what extent LGU officials/policy makers and health service providers, especially those of reproductive age, are themselves staunch practitioners and motivators of FP within their in-groups. This was an important knowledge gap that the review has revealed. Do those LGU officials and health providers of reproductive age themselves accept and continue to use FP especially modern methods? What has their own experience been? How large is their sphere of advocacy and influence among members of reproductive age within the immediate family and circle of relatives, friends, and peers? How successful are they in this personal advocacy? Develop a participatory program that mobilizes male motivators and advocators of FP at the community level, for piloting in selected sites with differential contraceptive prevalence rates (CPR). The review found much evidence suggesting that men need to become actively involved in FP, not necessarily as acceptors but more importantly as supporters and advocates, and that such a program is timely. The program design must be guided by participatory principles for harnessing men’s views and proposals about which of them in the community should first become involved, in what ways, for what purposes, and how to know if their involvement has made any impact on their community’s CPR and general health. It can be tried out or piloted in selected high and/or low CPR areas with cooperative LGUs and male groups. Pilot experiences should be documented and lessons extracted to guide scaling up activities in cooperating LGUs. Develop community indices for quality of care from the perspective (emic) and with the participation of clients and providers who make up the core stakeholders. It should be beneficial to know how similar or different the indices for quality of care assessment drawn from the perspectives of clients and providers are when compared to those devised by researchers. When the indices for quality care are evolved by and from the core stakeholders themselves, this process enhances the appropriateness of the indices and facilitates their internalization as part of the expectations of the dyad. Provide feedback on quality of care assessment to clients and providers of behavioral interventions. The feedback acquires importance within the context of enabling stakeholders to share in the analysis of the process of participation and in finding solutions mutually acceptable to the parties concerned. Turn to anthropological methods and qualitative analysis to deepen program understanding of factors influencing behavioral aspects. Many of the information identified in the preceding programmatic and research implications are best obtained through qualitative tools that capture and analyze the richness and multi- faceted nature and extent of people’s perspectives, motivations, and actions. FP studies have increasingly incorporated such tools as in-depth interview, focus group discussions, and situation or process analysis, among others, but it has been observed that data analysis tends to follow the quantitative approach. Other qualitative methods tried out with much success in participatory programs outside of FP may be also employed, namely: process documentation research to extricate and utilize lessons from pilot program experiences, case studies of best practices and best practitioners, and content analysis of qualitative transcripts. II. ANNOTATED BIBLIOGRAPHY A. Studies on Provider-Client Interaction and Behavioral Interventions This category includes 11 reference materials. Except for one (1974), these are all very recent and dated within the last three years (2001-2004). Despite their number, the materials concern only seven different studies because two were about one study (Costello, et. al., 2001; Population Council, 2001), while four were about another study (Costello, et. al., 2001; Population Council-Frontiers in Reproductive Health, 2002; Population Council, 2002; Ramarao, et. al., 2003). Of the seven studies referred to, it is worth noting that only one actually involved a behavioral intervention with a quasi-experimental design to improve client-provider interaction (called client-centered approach) and three studies were assessments (with one indirectly assessing how providers complied with the GATHER Approach to counseling clients; see Lamberte et. al., 2004). In terms of methodology, four of the seven studies employed qualitative methods (viz., literature review, FGDs, in-depth interview); the other three utilized a combination of qualitative (e.g., situation or videotape analysis, in-depth interviews) and quantitative methods (e.g., survey, exit interview). The research themes in the seven studies may be clustered into three groups, as follows. Assessment of the knowledge, attitudes, and perceptions of key stak eholders— including providers and clients from the public and private health sectors-- on RH needs and services and/or the quality of care in FP service provision or in FP counseling, including providers’ use of the GATHER Approach (Costello, et. al., 2001; Population Council, 2001; Lamberte, et. al., 2004; Yuchengco Center, 2004). Behavioral intervention (i.e., the client-sentered approach) to improve the quality of client-provider interaction and thereby enhance contraceptive continuation (Costello, et. al., 2001; Population Council-Frontiers in Reproductive Health, 2002; Population Council, 2002; Ramarao, et. al., 2003) Sociocultural factors affecting providers’ FP service provision and/or clients’ contraceptive practice (Bailen and Morisky, 1974; Henry, 2001; TSAP-FP, n.d.). The Social Acceptance Project-Family Planning. (n.d.) Secondary Review: Barrie rs to Modern Contraceptive Use in the Philippines. Unpublished paper. This paper presents a brief review of the FP literature focusing on factors that serve as barriers to modern contraceptive use on the part of clients and providers in the country. It starts with the assumption, based on 2000 Pulse Asia survey result, that 94% of Filipinos believe it important to control one’s fertility and to plan one’s family. Yet why is it that a prior 1998 DHS result showed that only 28% of married women of reproductive age (MWRA) used modern contraceptives, 18% of MWRA used traditional methods (which are not fail-safe), and 20% have an unmet need (not using contraception although desiring to space or limit the number of children)? Why then are fertility levels not dropping to the expressed desires of married women? Some reasons are: a majority of women are not using reliable contraceptive methods, or they have tried but discontinued using modern contraceptives. The 1998 survey has shown that low usage of modern (or artificial, according to the church) contraceptive is not due to religion per se (only 5% of non-user MWRA said their religion is the cause of non-use). It has likewise revealed that nearly one-third of non-users and nearly 50% of pill, IUD and injectable discontinuers said that side effects or health concerns were not the cause of their non-use or discontinuance. In this secondary review, the key barriers to modern contraceptive use among women and medical providers that were identified are as follows. Women Clients 1. For hormonal methods (i.e., pills and injectables), the significant barriers are their effect of decreasing menstrual flow which runs counter to cultural beliefs on menstruation; other experienced bodily imbalances symptomatic of high or low blood; local beliefs linking hormonal methods to accumulation of unhealthy elements (dirty blood), sexual dysfunction, breast shrinkage, skin allergies, weight gain/loss, and offspring abnormalities; and husband’s speculation on the ill effects of hormonal methods and influence against their use. 2. For IUD, the barriers are women’s speculations that it can fall off during hard work, expose uterus to the cold, increase menstrual flow (may be viewed as good or bad), and harm the husband’s penis during sexual intercourse. 3. The general barrier is the Filipino concept of hiyang (physical suitability) which men and women use to explain women’s experience of detrimental side effects from modern contraceptive use. Positive hiyang are physical signs like continuation of normal menstruation, weight gain, and absence of ―high blood‖ symptoms; changes in these signs are negative hiyang. It is further believed that women may gain resistance and immunity from the side effects of modern methods over time, but a ―rest period‖ can prevent such an occurrence. Medical providers (OB-Gyns, general practitioners, and midwives) 1. Barrier attitudes and beliefs on hormonal methods: Some midwives advise clients experiencing amenorrhea to stop using the method until menstruation returns. Providers’ attitudes are a barrier although these have improved considerably. In a 1993 provider study, many OB-Gyns 39% of 66) and most GPs (64% of 84) would be unwilling to recommend injectables because (a) the amenorrheic effect could cause clients to be concerned that they might be pregnant or would accumulate harmful toxins in the body, (b) these cause spotting, and (c) these cause strong effects like cancer, bleeding, headache, and nausea. (However, injectables were also perceived to have advantages: cheaper, convenient, and not a body irritant.) By 1995, only 11% (of 521 OB-Gyns, GPs, and midwives) would never recommend injectables, and 2% would never recommend the pills. 2. Barrier attitudes and beliefs on IUD Provider attitudes have also improved between the two survey periods. In 1993, 17% of 66 OB-Gyns and 34% of 84 GPs would not be willing to recommend the IUD for these reasons: (a) it is sometimes misplaced, (b) it is uncomfortable due to the string, (c) it can result in pregnancy inaccurately placed, (d) complications/infection can occur, and (e) it induces abortion. In the 1995 survey, 13% (of 521 providers) would never recommend the IUD. Among the providers, more OB-Gyns (28%) believed ―the IUD is an abortifacient,‖ compared to GPs (23%) and midwives (16%). 3. Barrier attitudes about FP in general The 1995 provider survey revealed that many medical providers strongly agree with many unfavorable statements on FP, such as: a) A woman should have at least one child before taking OCs—66% midwives, 51% OB-Gyns, 46% GPs b) If husband doesn’t approve of FP, the women should not use it—53% OB-Gyns, 52% GPs, 48% midwives c) Religious teachings affect recommendation—53% GPs, 48% OB- Gyns, 40% midwives d) Reluctant to recommend contraceptives to an unmarried woman--44% of GPs and midwives, 43% OB-Gyns e) I only discuss contraception when the client brings up the subject— 46% GPs, 44% midwives, 31% OB-Gyns f) Health providers should decide the method for the client—43% midwives, 34% GPs, 25% OB-Gyns g) Against religious beliefs to recommend any non-natural FP method— 22% midwives, 19% GPs, 16% OB-Gyns Lamberte, Exaltacion, E., Loyd Brendan P. Norella, Jose Alberto S. Reyes, and Cristina A. Rodriguez. 2004. Quality of Family Planning Counseling: Lens from Stakeholders. Manila: De La Salle Unive rsity Press, Inc. This study underscores the importance of communication intervention, such as counseling, in ensuring high quality FP service provision. It sought to assess the quality of FP counseling in both public and private service delivery points, particularly to identify strengths, weaknesses, and gaps in counseling performance and to provide recommendations to strengthen such performance. FP counseling is defined as a ―face-to- face communication wherein the FP service provider helps the clients make a decision about their fertility‖ and involves a ―two-way communication process.‖ Good counseling enables the provider to assist the client in making an informed choice, thereby increasing contraceptive acceptance and continuation rates, and minimizing dropouts. The study initially provided a review of the research literature on FP counseling in the country and compared three module designs on the Greet-Ask-Tell- Help-Explain-Return (GATHER) Approach. The review showed: FP counseling is more popularly associated with information-giving than as a two-way communication process between provider and client, and viewed within the broader context of client-provider interaction; Variations exist in the standards for FP counseling, as demonstrated by the varying contents and procedures undertaken in the GATHER approach; FP counseling and client-provider performance in the country have not been at par with expectations; and Provider performance in FP counseling is often affected by myriad organizational and management-related factors. The assessment component of the study utilized both quantitative and qualitative research methods, namely: face-to-face semi-structured exit interviews with 280 clients; face-to- face semi- structured interviews with 280 non-clients in their homes/residences; in-depth interviews with 30 providers; in-depth interviews with 24 clinics heads/supervisors; 42 structured facility observations; 14 structured stakeholders’ meetings with a total of 174 local managers, providers, clients, supervisors, and barangay leaders/officials; and audiotaping of 42 actual FP counseling/communication process occurring in the facility. The tools used for data gathering were modified versions of the original ones developed by the JHU Center for Communication Programs. The research covered 28 public city/rural health offices and NGO private clinics from eight areas in the country, categorized according to high or low contraceptive prevalence rate (CPR) of their respective provinces. Many interesting results had emerged from the assessment, but only the salient, provider- related findings are summarized below. Providers are generally middle-aged (mean of 39 years), with those in public facilities older than the ones in private clinics. They are all females (public) or predominantly female (private). Most are well-educated, married, and are Catholics. Public providers have stayed longer in the service than their private counterparts. FP services are handled by midwives and nurses in public facilities and by clinic managers and FP counselors in private ones. Clients and non-clients positively rate the FP counseling they received, saying the providers are good at information-giving/teaching, have good interpersonal communication skills, encourage clients to ask questions, are good listeners, understanding, and trustworthy, able to help clients with their problems, and give clients ample time to get all information they required. Hence they would even recommend their FP facility to their relatives. (However, the authors cautioned that this overly positive rating could be an effect of exit interviews.) Providers regard FP counseling as a means of giving correct information about responsible parenthood that is ideally undertaken one-on-one until the client voluntarily decides on FP adoption or chooses a particular method. They know it is a good interaction when clients ask questions, have positive facial expression, conduct follow-through activity, and actually use a method. In an ideal FP counseling session, the provider exhibits three major attributes: good interpersonal communication skills, sufficient knowledge abo ut FP, and positive traits (e.g., warm, cheerful, and respectful) that can draw clients to them. Clients say the most ideal client attributes in such a session are being respectful, cooperative, inquisitive, and attentive. For providers, the attributes are desire to practice FP, regularly coming in for follow- up visits, and following instructions properly, in addition to being intelligent, receptive, honest, and assertive. Most providers, however, assess themselves as lacking adequate knowledge and skills to effectively counsel clients. While a great majority have heard of the GATHER approach, only 10% consistently observe it in counseling sessions while the rest use it selectively with first-time users or not at all. Observations of the actual counseling sessions reveal that the behaviours required by this approach were exhibited by the providers except for two areas: assurance of confidentiality and utilization of IEC materials. However, the audiotape transcripts reveal the occurrence of certain s ituations that may hinder clients from asking questions, like providers speaking in raised tones, laughing at client, directly or indirectly making fun of client’s response, bombarding client with questions, not allowing client the opportunity to talk, cutting off the client at mid-statement, avoidance in answering client’s queries, and provision of vague answers. The transcripts also show that providers differentially manage clients’ misconceptions about FP methods. While some attempt to address these, others merely took note of them or fail directly to address them. Among the misconceptions are: - Pills cause swelling in the uterus, hypertension, headaches, irritability; leave sediments in the uterus that create myoma and tumor or block women’s passageways; and should not be taken during menstruation. - IUD causes body malaise (binat), obstructions in the body, abdominal tenderness, ectopic pregnancy, hemorrhage; can be removed easily or can be expelled when woman lifts a heavy load; IUD string goes inside the body or can strangle a man’s penis during sexual intercourse. - Tubal ligation causes stomach ache, makes women more sexually aggressive and promotes infidelity. - Condoms are not reliable and safe; they often break and cause unwanted pregnancy. - Depo-Provera injections protect against STIs or cause tumor. Side effects of contraceptive methods are often covered in the sessions and providers are usually adept at discussing these including warning signs. The perceived gaps between the ideal and actual FP counseling sessions are related to problems in physical facilities, operational concerns, and space, as well as inability of both providers and clients to attain their ideal attributes. In public clinics, only one out of seven providers is untrained; in private clinics, one out of four. Provision of quality FP counseling is partly maintained through continuous training in the last seven years. Nevertheless, providers recommend further training to enhance counseling knowledge and skills and require feedback from supervisors. They are generally aware of the standards on good counseling but do not usually get recognition for having done it. Among the various recommendations of the study are: need to increase the technical and financial assistance to strengthen the providers capacity to deliver quality FP counselling particularly in public facilities, and need to develop client’s active participation in the counseling process. Yuchengco Center. June 2004. Assessment of Family Planning Clinics in the Industry. Report submitted to The Social Acceptance Project-Family Planning. Manila: De La Salle Unive rsity. Yuchengco Center was commissioned to do an assessment of current family planning service provision in industrial sites in selected provinces in the Philippines. The intended result of the study was to develop appropriate mechanisms for increasing the provision of quality RH and FP information, methods and services in the industrial sector, and to enlist the active participation of the private sector in the promotion of contraceptive self- reliance. The assessment consisted of: (a) reviewing documents on selected past industry-based FP programs and delineate lessons learned from the experience, (b) undertaking an industry clinics needs assessment based on the perceptions and support of company HRD managers, perspectives of providers of FP service delivery, and client experiences in FP acceptance in industry clinics, (c) identifying potential partners in the implementation of planned programs, (d) providing strategic recommendations for the TSAP-FP industry based program, and (e) determining mechanisms for enhancing private sector financing and support to industry-based FP programs. Two industrial sites were purposively selected in each of the three categories (low tech, high tech, and agro- industrial plantations) per province. The provinces included were Batangas, Cavite, Laguna, Pampanga, Tarlac, Bulacan, and Metro Cebu. Among the findings were: 1. The review of documents on past industry-based programmes showed that the foundation for incorporating FP in the industry has already been set through the private sector initiatives of PCF (now PCPD), TUCP, and RPMCHAP and FriendlyCare. Their resources could be tapped to enhance FP services in training, IEC and resources mobilization, and service provision. 2. The assessment showed the FP services in company clinics to be limited to consultation and counseling on the various FP methods, provision of pills and condoms, referrals, and information and education. Clinic size is basically small and is usually staffed by a part-time physician and a full-time nurse. Comprehensive FP information is unavailable; visual a nd auditory privacy is lacking, records or reports that document client intake and status are absent, and screening procedures are minimal and focused on history-taking and less on physical examination. 3. Company support consists of funds for staff salary, clinic operations, equipment and medicines, but none for contraceptives. Contraceptive supplies are availed of from rural health units and other government and NGO organizations. Although managers are inclined to support FP, this action must have prior management approval. 4. Contraceptives provided at the industry clinics are mainly pills and condoms. These are also the methods mostly accepted by users. Nurses provide medical services regularly, but physicians, including an OB-Gyn specialist, report on certain days. Referrals are given to clients who opt for contraceptive methods other than pills or condoms. 5. Provision of quality service is minimal due to small clinic space, lack of IEC materials, inadequate staff training, and shortage of supplies. 6. Clients have a generally positive attitude towards clinic staff and are not concerned about quality service provision. The major reason for discontinuance of contraceptive use is their experience of side-effects. The issues raised by the study include weak ma nagement motivation and support for FP service provision, lack of staff technical competence in FP, non-encouraging company policies, weak monitoring from DOLE with regard to FP compliance by company, and low level of awareness and knowledge of FP among co mpany employees. Ramarao, Saumya, Marlina Lacuesta, Marilou Costello, Blesilda Pangolibay, and Heidi Jones. June 2003. The Link Between Quality of Care and Contraceptive Use. Inte rnational Family Planning Perspectives 29(2):76-83. Basing on theoretical insights and empirical evidence, the researchers hypothesized that high quality FP care influences the contraceptive and reproductive behavior of persons who are ambivalent about their fertility intentions, who do not use services because of perceptions of poor quality, and who have discontinued use of poor-quality services of discourteous treatment by providers. Thus they examined longitudinal data to assess the impact of care on continued contraceptive use in the provinces of Davao del Norte and Compostela Valley. The study was a collaborative effort of Population Council, New York and Ateneo de Davao University, Philippines. It was designed as a longitudinal study with two rounds of interviews (16-24 months apart) with a panel of new FP users. The panel comprised attendees at 80 service delivery points in the two provinces. The service delivery points consisted of 20 rural health units and 60 barangay health stations. The 1,728 new FP users (meaning never used before, switching to a new method, or first- time user of the service delivery point) were identified from clinic records. Their interviews took place in the home. More than 80% were interviewed within six months of receiving FP care. The first interview obtained information on respondent’s quality of care received at the time of initiating a contraceptive method, the type of method adopted, and background characteristics. The second interview collected information on respondents’ contraceptive and reproductive behavior since the first round. These data were obtained as part of an intervention study with a quasi-experimental design— providers of FP services in 40 of the study’s 80 service delivery points received training. For this paper, the researchers analyzed pooled data from the experimental and control groups. The independent variable of principal interest is quality of care (QOC) and reflects five different aspects of care-giving process: (1) assessment of client need, (2) information conveyed to client, (3) choices offered to client, (4) c lient treated well by provider, and (5) client linked to follow- up services. These aspects were chosen because they represent different dimensions of the process from a theoretic and programmatic perspective. The dependent variable is use of a contraceptive method at follow- up (could mean use of any method or use of a modern method). The results revealed that: Based on scores for total quality, 36% of the respondents had received high- quality care while 27%, poor quality care. Responses on the five aspects of quality differed considerably, e.g., three-fifths reported all their needs had been assessed whereas barely one-tenth said they had been given all necessary information about follow-up. Cross-tabulation of quality and contraceptive use at follow up showed that better care is associated with higher levels of use of modern methods and any method. ―Continuation of a modern contraceptive method steadily increased as the level of quality moved from low (53%) to medium (59%) to high (63%). The relationship of quality of care to use of any method was similar.‖ A desire not to have children for at least two years was associated with higher use of a modern contraceptive at follow-up. A multivariate analysis found that the magnitude, direction, and significance of the effect of quality on modern contraceptive use were maintained across all logistical regression models even after adding a range of control variables. This was significant because previous analyses showed that the effect of quality tends to diminish when additional controls are added. The study’s findings were important for the following reasons. They constituted the first rigorous analysis that supported the positive link between quality of care at initiation of contraceptive use and continuation of use at follow-up. They validated the efforts of professionals and advocates engaged in sustaining and improving quality as an end in itself. They also provided empirical proof that focusing on the interpersonal contact between providers and clients can address some gaps in FP programs. And finally, they showed that it pays for the program to focus on providing for the needs of continuing clients rather than on concentrating exclusively on the recruitment of new ones. However, there must be clear and specific guidelines for serving continuing clients, as well as appropriate evaluation criteria for service providers and the overall program. Population Council. September 2002. Quality of Care: Improving Provider-Client Inte ractions in the Philippines. Population Briefs 8 (2). A way to improve the quality of care provided at FP clinics is to enhance provider-client communication or make services client-oriented, an approach that shifts provider focus from reliance on FP methods to client needs. This entails discovering clients’ desires especially on future child bearing, permitting them a range of contraceptive methods to choose from, conveying the proper information about the chosen method, and assuring them that they can switch methods anytime. The client-centered approach was tried out in Davao del Norte, Philippines, as part of Population Council’s Impact Studies Project. This was prompted by the occurrence of a large proportion of discontinuation in contraceptive use owing primarily to inadequate clinician-client dialogue. The interventions were analyzed by comparing experimental with control municipalities. The study design involved: Clinics from 10 matched pairs of municipalities, with one locale from each pair randomly assigned to the experimental group and the other to the control. Eight doctors, 11 nurses and 38 midwives from the experimental group received five days of training after the assessment. The midwives also attended three refresher courses from 1997 to 1999. Provider knowledge before and after the training was assessed using detailed interviews and found to have increased significantly with regard to side effects and warning signs of contraceptive methods. Since no training was given to providers in the control clinics, no appreciable change was noted in their knowledge. A total of 1,728 new contraceptive users were interviewed—869 from experimental clinics and 859 from the control group. They were asked to evaluate five aspects of Quality of Care: whether client’s needs were assessed, whether clients were given a choice of methods, whether they received the necessary information about their method of choice, whether they were told when to return to the clinic, and whether they were treated well. Clients who went to the experimental clinics reported to have received significantly better care and a significantly greater proportion of them also received complete information compared to those who went to the control clinics. Despite significant progress after the intervention, the researchers acknowledged that there still exists much room for improvement for all quality of care dimensions considering: even in the experimental clinics, one-third did not have their needs assessed, two-thirds did not get full information, three-fifths reported not being treated well, and nine-tenths were not well informed about follow- up services. In the next phase of the study, clients would be followed up to determine contraceptive continuation rates after one and two years. Population Council-Frontiers in Reproductive Health. Septe mber 2002. Services Improve Quality of Care but Fail to Increase FP Continuation. OR Summary 30: Philippines and Senegal Quality of Care. This OR Summary provides some highlights on the client-centered service delivery intervention initiated in the Philippines and Senegal to improve quality of care in client- provider interaction. For this review, only the Philippine data will be reported. The Philippine study was based on the work of Costello, et. al. in Davao del Norte; it represented one part of a multi-country Population Council-Frontiers in Reproductive Health research to test whether improving quality affects women’s contraceptive continuation. It used a quasi-experimental design with longitudinal data- gathering. Five indicators were used to measure quality: (1) assessment of client’s needs, (2) choice of methods provided, (3) information given on the chosen method, (4) interpersonal relations with clients, and (5) provisions to ensure follow-up care. The implementation focused on training in FP for 40 experimental clinics (none in 40 control clinics), supportive supervision, and refresher courses to improve client-provider interaction. Data were gathered before, shortly after, and 16 months following intervention at experimental and control clinics. New FP users in these clinics were also interviewed. Highlights of the study’s findings are: Clients rated the quality of care higher at the experimental clinics in all aspects of care, except on switching methods where both clinics provide similar amounts of information. The intervention was found to be effective in increasing the quality of care provided, but not sufficient enough to significantly increase the length of the time women continued to use contraception. The rate of continuation one year after the intervention was still the same (about 75%) for both experimental and control groups. Thus it was concluded that the experiment ―failed to demonstrate a causal relationship between improved quality of care and increased contraceptive continuation.‖ Although the intervention failed to have a significant effect on contraceptive use, secondary analysis combining data from clients of both centers suggests an ―underlying association between quality of care and use of FP methods.‖ But it is necessary to clarify the degree to which factors under the control of managers contribute to this association. There is room for more improvements in the quality of services despite the increases realized in quality of care. For instance, mo re providers in experimental than in control clinics fully assessed client’s needs (66% versus 52%), but a third of the clients still did not get a complete assessment. More providers at the experimental clinics informed clients about methods that protect against STIs, but more than half of the total number of clients were not given this information. The study concludes that improving client-provider interaction results in better quality of care for clients, but there are other factors likely to act as determinants of contraceptive continuation. In terms of utilization, the intervention has been expanded in one province and there is interest from the Department of Health and other provinces to also adopt the model. The study received two national awards for best research and best practice. Costello, Marilou, Marlina Lacuesta, Saumya Ramarao, and Anrudh Jain. December 2001. A Client-Centered Approach to Family Planning: The Davao Project. Studies in Family Planning 32 (4): 302 -314. The paper describes a field project in Davao del Norte and Compostela Valley provinces in the Philippines that implemented one model of a client-centered approach to family planning (FP) in 1997-99. This model advocated a shift in the focus and objectives of FP programs from fertility reduction to meeting clients’ needs. It hypothesized that improved information exchange is likely to result in clients’ selection of appropriate contraceptive methods and in higher continuity of method use. With little field experience to back it up, the model was implemented using a quasi-experimental design. The intervention addressed clients’ self-defined reproductive needs by providing them with relevant and accurate information and good quality services. It consisted of two components: training of 57 providers (doctors, nurses, and midwives in experimental areas) in information exchange and training of supervisors (from experimental areas and provincial offices) in facilitative supervision, both trainees located at fixed clinics. Data on the res ults of the trainings were obtained through two situation analyses and a survey of 1,728 new users from the experimental and control municipalities. Information exchange refers to a two-way communication process that can empower women clients to share control of the process of making choices appropriate to their own needs and circumstances. It is not to be mistaken for counseling which is a one-way communication process from provider to client. Facilitative supervision, on the other hand, emphasizes mentoring, joint problem-solving, and two-way communication. The results of the training on providers’ knowledge are: There is significant improvement in the knowledge of providers from the experimental municipalities concerning common side effects and warning signs for the oral and injectable contraceptives and the IUD. Most of the overall increase in providers’ knowledge is due to an increase in what they learned about warning signs. In spite of the improvement, providers’ awareness of common side effects and warning signs still need enhancement since the training did not increase their ability to list all side effects of a method and to recognize all warning signs. (But this could have been a result of the format of the questions—i.e., the responses were unprompted so the omission might be due to lack of recall rather than of knowledge.) The results of the training on providers’ behavior are as follows. Respondents of experimental clinics say: - They received significantly better care for they were mo re likely to get asked about their reproductive intentions, their preferred timing of the next birth, and their previous FP experience; - The provider explained how the method worked, what its side effects were, what managing problems arose from its use, what the warning signs consisted of, and how to protect against STDs; - They received comparatively more information, but these were not necessarily all the information they were entitled to; - They experienced a high level of interpersonal personal contact with providers; - They were more likely to be told when to return, but less likely to be told of other sources of contraceptive supply (possibly because the providers in the experimental clinics perceived themselves to be providing high quality services and thus saw no need to inform clients of other sources). There is no significant difference between the experimental and control groups with regard to: - contraceptive choices received by women from providers - overall continuity of services Much room for improvement is necessary on five dimensions of quality of care as the indices fell below 100% although women in the experimental group received better care. The indicators are: all client’s needs were assessed, client was offered full choice of methods, client received full information, client felt she was treated well, and client felt she was well connected to services. Overall, in both experimental and control groups, only less than 5% of the responde nts reported they received high-quality care indicating a need for ongoing interventions. On the quality of provider-client exchange, the results show that providers were reportedly inquiring about their client’s needs and provident relevant information. The study concludes that the intervention altered the way services were provided. Training providers is a feasible means for enhancing their knowledge of contraception and for improving information exchange with clients. Interested providers are able to create an atmosphere conducive to communication with clients like improvising private examination rooms or giving private, one-on-one information exchange instead of the usual general public counseling. Two gaps identified in the information exchange process are concerned with methods that protect against HIV/STIs and alternative sources of supply. The study also notes efforts to expand or replicate the intervention in the public sector. But the adoption was impeded by weak supervision due to lack of trave l allowance funds and vehicles or the time-consuming work of filling out supervisory checklists. Nevertheless, one provincial health officer implemented the intervention throughout his province. Henry, Rebecca. 2001. Contraceptive Practice in Quirino Province, Philippines: Experiences of Side Effects. Manila: University of the Philippines Population Institute and University of La Sallette. Calverton, Maryland: Macro International Inc. This is a qualitative research study that examined how the contraceptive practices and understanding of women in Quirino Province had led many of them to discontinue contraceptive use even though they did not wish to become pregnant. The research was done in response to the high rate of contraceptive discontinuance reported in the 1998 NDHS, where two in five users stopped usage within the first year. Multiple methods were used to gather data from May to July 2000, namely: (1) initial semi-structured interviews with 81 married women selected from four study clinics, (2) follow-up in-depth interviews with 24 of the women and their husbands, as well as with 20 providers including midwives, hilots, and barangay health workers (BHWs), (3) analysis of 47 interactions between midwives and BHWs and their respective clients, (4) rapid assessment of the study clinics, and (5) visits to local pharmacies to determine which contraceptives were available and to interview pharmacists. Preliminary findings were presented at provider roundtables in the study areas to obtain feedback and to develop the recommendations. The major findings were: 1. Women’s understanding and practices concerning menstruation and fertility were derived from humoral assumptions about the natural body, health, and illness. Hence: Hormonal contraceptive methods (like pills) that decreased or stopped menstruation are less acceptable to women than those increasing menstruation because menstruation is believed to be healthy and good for blood circulation and balancing bodily humors. Menstrual change leads to speculation about the accumulation of blood in the body (high blood) and, to a lesser extent, about low blood and chronic conditions like tumors or cancer. Hormonal methods whose side effects are symptoms associated with ―high blood‖ like headache, dizziness, and hotheadedness are considered by both women and men to be not ―hiyang‖ (suitable), therefore ineffective methods. Despite its fewer reported side effects, the IUD is still generally not preferred by women because it could easily fall out due to the ―open‖ and ―slippery‖ nature of the uterus during menstruation. 2. Women usually choose their own contraceptive method, but their husbands influence their choice by speculating about the side effects experienced by their wives. 3. Women and couples use all available contraceptive methods including withdrawal, periodic abstinence, and lactational amenorrhea. The main source of FP methods is the government FP clinics. Pills are most commonly used and many women have used them continuously for years because they are hiyang. 4. Humoral perspectives have led women to use contraceptive methods in ways not recommended by biomedical practitioners. For example, when use of DMPA results in amenorrhea, women simply stop using the method until their menstruat ion returns and then go back to the provider for another injection. Another strategy is to switch to the pill when they become amenorrheic on DMPA. Such strategies expose women to pregnancy long after it had been assumed that they had adjusted to the method. 5. Two kinds of knowledge about the body, health, and illness on the job—biomedical and humoral—govern the work of midwives and BHWs in varying degrees. Biomedical knowledge is supported through midwifery schooling or BHW training, while humoral knowledge is cultivated through the cultural experiences of women, hilots, and other community members. The two knowledge systems clash on the meaning of the physical manifestation of menstruation and its impact on health, as well as on the type and frequency of side effects of the pharmaceutical contraceptive methods. Differences in the biomedical and humoral perspectives have resulted in the bicultural position of midwives and BHWs that make provision of services difficult. Finally, the study made the following recommendations. Address the bicultural position of health providers in the midwifery training, medical education, and ongoing professional training, particularly alternative perspectives of the body, how to show respect for differences, and how to negotiate treatment options. Offer a sufficient variety or method- mix (both hormonal and natural) at the clinics so midwives need not feel pressured to convince women to use a particular method that may not be well suited to their needs. Gear counseling and health education more closely to the actual experiences of women. These should reflect and convey an underlying respect for their views on the body. Counseling on side effects prior to dispensing a method is important. Complaints of side effects should be listened to, discussed, and addressed in the treatment plan; options for switching should likewise be provided. Negotiate choice of methods in consideration of manifest effects of methods, like menstrual bleeding, rather than according to which perspective o f the body is correct. Population Council. September 2001. Reproductive Health Needs and Services Assessed in the Philippines. Population Briefs 7 (3). Researchers who did a rapid field appraisal of RH needs and services with the help of government agencies and several cooperating agencies found that program managers can properly provide services in RH and FP clinics if they are aware of the knowledge, attitudes, and perceptions of their clients and other stakeholders. The fieldwork occurred in May-June 2000 in 15 urban and rural sites across the major island groupings in the Philippines. It consisted of in-depth interviews with city health officers, population officers, hospital administrators, and local officials; and focus group discussions with married and unmarried men and women, service providers, program managers, and local officials. The researchers found no common understanding of the term ―reproductive health‖ among the different stakeholders. The meanings varied but clustered around the ideas that RH ―has to do with sex‖ or ―is about family planning.‖ However, the greatest understanding and appreciation of RH came from health service providers, who had been trained in RH issues, and from women who were more likely to use health services than men. But regarding STIs, HIV/AIDS, and safe sex issues, it was the young unmarried men who were most likely to be aware than unmarried women. Local- level government officials in the Philippines who determine resource allocation and service availability were also discovered to have limited awareness of RH topics ―probably because of an absence of a decisive and clear national policy on reproductive health.‖ The public believed that private facilities are superior to public facilities. The latter was perceived to be lacking in resources, have overworked personnel, and subjected to interfering local officials who make supplies and medicines dependent on political favors. Community members in focus groups stressed that ―current services should be improved rather than new ones added.‖ Local government leaders proposed charging fees on a sliding scale to cope with difficulties of upgrading services in a resource-poor country. But this was an unpopular idea as every focus group in all categories of stakeholders d isagreed with it. Although religion may pose a barrier to obtaining RH in a Catholic country like the Philippines, many focus group participants held that it only has little influence on their FP and childbearing decisions. Like religion, the husband’s attitude on FP does not also pose much of an obstacle for women wanting to use contraceptives. The investigators suggested that policy makers and program planners work on increasing the awareness and support for RH care of the local government officials, and enhancing communication and counseling skills of outreach workers who exert important influence on the health decision making of women. Costello, Marilou, Virginia Miralao, Ma. Teresa Manganar, and Saniata Masulit. 2001. A Rapid Field Appraisal of Reproductive Health Care Needs and Available Reproductive Health Services in the Philippines. New York: Population Council. Using the qualitative methods of in-depth, unstructured interviews and focus group discussions, the study made a rapid assessment of the knowledge, attitudes, and perceptions (KAP) of key stakeholders on issues that affect RH care needs and services in order to develop policies supportive of devolved FP and RH programs in the country. Conducted in May-July 2000 in urban and rural areas of 15 sites throughout the country, it was done in collaboration with major government agencies, POPCOM, DOH, cooperating agencies (CAs), and USAID/Manila to ensure utilization of findings and rapid feedback to national and local stakeholders. A total of 1,027 participated in the study: 107 local decision-makers (mayors, vice- mayors, barangay captains, health council members), 33 program managers, 384 public and private service providers, 262 married men and women, and 241 young unmarried males and females. On the knowledge component, findings showed: There is no common understanding of the term ―reproductive health‖ (RH) among stakeholders. RH awareness/understanding is highly correlated with respondents’ exposure to RH training, IEC programs, and services. Thus program managers, service providers, and married women had highest levels of understanding and factual knowledge about available services compared to local officials, men, and the youth (low levels). Knowledge about STI/HIV/AIDS and safe sex issues is higher among young unmarried men than among young unmarried women, but both are poorly informed about local health services. The stakeholders’ perceptions clustered on: Private health facilities are perceived to be generally superior over those of the public sector in terms of infrastructure, equipment, supplies, and quality of care. The public health system’s capacity to deliver health services is hampered by lack of resources, overworked personnel, and patronage/political practices such as palakasan (favoritism). Because of such practices, local officials are seen as sometimes interfering with routine services particularly when making available health care supplies and medicines. Because of the state of the public health system, rather than demand for additional services respondents insist on having improved and adequate health facilities; skilled, competent, and caring health providers; and improved health information for the general public. Health concerns are not generally seen as priorities of LGU officials who place greater emphasis on infrastructure projects and other economic development concerns. This is compounded by the absence of institutionalized mechanisms to bring local health needs to the local officials’ attention. There is generally no active opposition to FP and RH in the study sites. Church or religious influence on FP and childbearing decisions are viewed as having minimal impact on personal decisions, hence do not present a serious threat to RH programs. Local officials are likely to support FP/RH initiatives as a mechanism to alleviate the poverty in high-growth communities, however, they may not publicly declare political support since they are seen as wanting to play safe and not antagonize the Catholic Church. Findings on attitudes converged on the following: Clients, especially married respondents, possess negative sentiments towards the charging of fees for public health services. Local officials may oppose the idea as it would make them unpopular among constituents. However, should these become necessary, fees must be reasonably minimal, presented to the public ahead of time, and not be charged to the extremely poor. Health personnel/workers are generally welcomed and appreciated as important sources and communicators of RH information. Concerning FP decision- making, many married women usually decide for themselves but are nevertheless open and receptive to the advice and recommendations of spouse, relatives, and health care providers like BSPOs and BHWs. In conclusion, the study pointed to the following implications for RH programs: 1. Correct the low awareness of STDs and safe sex of young unmarried women to increase the prospects for curbing STIs. 2. Increase the appreciation of LGU officials for RH issues because they determine to a great extent the availability of health services through their budget allocations. 3. Define and implement a clear national policy on RH that reflects a paradigm shift towards client-oriented service delivery and thrust towards consciousness-raising, providing adequate information, instilling comprehensive understanding, and formation of positive attitudes about RH. 4. Improve quality of care focusing on better treatment of clients’ needs and addressing complaints about patronage practices in clinics. 5. Make stronger advocacy to pressure national and local government offices to monitor public health facilities. The study recommended an alternative strategy that (1) distributes (rather than concentrates) RH services across a network of health facilities such as public health centers, higher-level hospitals, youth centers, crises centers, and other specialized clinics; (2) pays special attention to the RH knowledge and needs of the youth sector; (3) directs advocacy to LGU officials to obtain RH support, and (4) enhances the information-giving and counseling skills of the outreach health workers who are the true ―frontliners‖ of the RH program in the community. Rapid field appraisal findings were utilized by several CAs as intended by the study. Bailen, Jerome B. and Donald E Morisky. September 1974. Traditional Birth Attendants (Hilots) and Modern Family Planning in Marinduque. Quezon City: University of the Philippines-Department of Anthropology. This is an ethnographic study done in June 1972 to determine the characteristics of 101 trained and 22 untrained hilots in three Marinduque municipalities. These trained hilots were participants in a capacitating project given in May 1971 by the Institute of Maternal and Child Health (IMCH), a unit of the Children’s Medical Center Philippines, Inc., to deliver MCH and FP services. The study interviewed the hilots, attended their meetings, and accompanied them in their rounds. Also interviewed were the clinic staffs of IMCH, the rural health units, FP lay motivators, and 122 randomly sampled male and female residents from the general population. The following are selected findings about the sample from the general population: 95% are Catholic; 5% Protestant Health was ―not only equated with physical traits, but behavioral and special traits as well.‖ Women rank health as a priority more than men. Based on a list provided by the researchers, health was second to wealth and material possessions for women; it was fourth after wealth and material possessions, clothing, and food for men. Love, which the authors believed was equated with sex, was prioritized more by men than women (ranked 7th by men and 11th by women). Religion, for both sexes, is least important among the priorities: it ranked 10 th for women and 11th for men. The three reasons for patronizing a healer are: low cost of services, proximity, and availability; whereas for patronizing a medical practitioner, competence, ―knowledgeability,‖ and ―efficiency‖ (probably meaning effectiveness) of doctor and doctor’s medicines. The characteristics of successful hilots, for barrio residents, are: friendly, courteous, and has good public relations; for town residents: efficiency. Selected findings concerning the hilots and related to FP are as follows. Hilots are mostly females and middle-aged (average of 54.6 years) with little formal education (average of 3.7 years); all had been married; most practice in their birthplace and mentored by a female relative from the same barrio, and have large family sizes (average of 8 children). Both trained and untrained hilots act as FP motivators (so the untrained hilot could replace a trained one dropped by the Project); with the trained hilots looking down on the untrained ones. Becoming a hilot depends on the ―whims of the supernatural beings.‖ Hilots’ beliefs include: - The sperm and egg explanation for conception, in addition to the necessity of having a simultaneous orgasm. - A woman cannot conceive if her uterus is flattened or misplaced, but hilot can bring it back to shape/place. - Abortion is possible by drinking a suspension from the roots of krukutso, agoho, and makabuhay dipped in liquor (sioktuong, anisada) for a week or a boiled concoction from papaya seeds; this will also cause menstruation. The perceived barriers to FP are: - Extreme poverty, hence money for health and medications is secured only when the family member is seriously ill and having to buy contraceptive supplies strains the budget. - Even if supplies were free, transportation fare is still needed to get to the clinic for them and some clinics ask for ―donation‖ in return for supplies. - People’s general attitude of ―waiting for things to happen to them.‖ - People’s belief that ―child-bearing will eventually stop without FP.‖ - ―Husband-objectors‖ who veto use of FP when wife is in favor. Hence some women used IUD without their husband’s consent or knowledge. But when the husbands found out because they got poked by the string during sexual intercourse, they quarreled with hilot FP motivators. - ―Many, many rumors‖ that contraceptive use harms health and can be fatal: (1) A teacher who used IUD had a heart attack and the corpse had a bloated stomach allegedly because the IUD had caused the uterus to rot; (2) Some women who used pills experienced skin eruptions as witnessed by hilots; and (3) Side effects from oral contraceptives such as nausea, slight headaches, vomiting gave credence to rumors that pills can make people crazy or cause brain cancer. Rumors that fly about form part of the local lore on FP. - Males who are more unfavorable towards FP than women because ―getting a woman pregnant is a way of tying her down to the house. - Hilots who do not have enough FP training and lack thorough understanding of the methods do not know how to handle resistance to FP. - Trained hilots who actively campaign against FP. - Hilots who are convinced of FP during the training but gradually return to their old beliefs and traditions. - Clinic personnel who take credit for acceptors brought in by hilots, who turn away users by insisting on donations for contraceptives, who treat hilots like children, who vocally oppose all methods except for rhythm, who report late to the clinic so the patients would have tired of waiting, would leave, or wo uld be seen only by less qualified staff, and who suspect hilots did not conduct house visits if they did not bring in any acceptors during the month. Some of the study’s recommendations are: (1) Hilot training should be phased, allowing for practice of skills learned before returning to the next phase to process and learn from experiences; (2) Male hilots should be trained for the male involvement program as they cannot talk with women about FP; (3) Provide better compensation for hilots so the y can give a better performance; and (4) Provide adequate administrative support to hilots. B. Provider-Related Studies Only three reference materials were found to belong in this category. These are about studies undertaken within the last six years at least (one was undated). They focus on two research themes: Knowledge, attitudes, beliefs, and/or practices on FP-related issues among health providers in the public health facilities and industry clinics, particularly among community volunteer workers (NFO Trends, 2004; Asia Development Consultants, n.d.). Providers’ research practicum to assess the quality of care provision of FP services in public and NGO health facilities (Lamberte, et. al., 1998). NFO Tre nds. April 2004. Project Clarity: A Census and KAP Among Health Providers. Report prepared for the Acade my for Educational Development (AED)- The Social Acceptance Project-Family Planning (TSAP-FP) Division. This particular study looked at the prevailing knowledge, attitudes, beliefs, and practices of these health service providers who hail from public health facilities/hospitals and industry clinics. The information would be used to develop interventions in selected project sites that could equip providers with the correct and latest research-based information on specific FP methods to attain an increase in acceptance of FP as part of the routine health package in public health facilities/hospitals and industry clinics. The study utilized two quantitative methods: a census of the public health facil ities/ hospitals and industry clinics in Metro Manila, Metro Cebu, Metro Davao, Calabarzon, and Cebu industrial areas, and a KAP survey of providers from these sites. The total number of facilities came to 955--723 city hospitals, health centers, barangay health stations, rural health units, and lying- in clinics, and 232 industrial clinics. The KAP respondents totaled 750--250 doctors, 200 midwives, and 300 nurses (87% from the public health facilities and 13% from industry clinics). Data gathering occurred from July to November 2003. The main findings particularly with respect to the KAP survey are as follows. 1. Knowledge/beliefs on mechanism of action and side effects of modern methods Majority of the providers believe that none of the FP methods (i.e., pill, injectable, IUD, and male and female sterilization) is abortifacient, but close to a third of them think that some methods (particularly IUD) are. Providers usually associate the methods with certain effects, namely: Pill – 55-71% say it causes weight gain, can cause/aggravate high blood pressure, can cause migraine IUD – 27-47% think it causes pelvic infection and sometimes abortion (also believed by more doctors) Injectable – 40-43% think it can cause amenorrhea leading to/aggravating high blood pressure and migraine Sterilization – 19% say ligation can cause ectopic pregnancy; 8% say vasectomy can bring about loss of libido. On other modern methods like mucus/Billings, basal body temperature, LAM, symptothermal method and standard days’ method, providers admit they do not know enough to confidently recommend their use, or they feel these methods are inconvenient/difficult for patients to use. 2. Attitudes on FP Providers believe that providing FP services does not diminish their public image as professionals. Religious beliefs affect their prescribing practices, however, this does not allegedly deter them from recommending the modern FP methods mentioned above. There is a general hesitation among them to recommend FP methods to singles and this is affirmed in their practice. Providers are highly respectful of patient’s right to decide on the method to use so they not likely to impose their preferences on patients. They also emphasize spousal consent particularly in permanent methods like ligation and vasectomy. Providers are likewise very respectful of patient’s right to know the advantages and disadvantages of FP methods. 3. Practices on providing FP information Majority give FP information to all patients of reproductive age regardless of whether or not they ask for it. Many also provide information to patients with more than 2-3 children. Over two-thirds estimate that only 1-40% of their total consultations are FP- related. Very few patients are said to inquire about FP except in the case of pre- and post-natal patients who reportedly most usually receive FP counseling from providers. In general, health facilities tend to provide more methods (74-97%) than counseling (41-57%), except for onsite industry clinics where more counseling (71%) is given than method (62%). Promotion is practiced over 40% of the time in different urban and rural facilities. 4. Prescribing practices The pill, IUD, injectable, condom, LAM, and ligation are more frequently prescribed/recommended than other modern methods (i.e., mucus/Billings, thermometer, standard days’, symptothermal) and traditional methods. Vasectomy is less recommended mainly because of fewer male patients. Withdrawal is prescribed one out of 2 providers. For limiting the number of children, permanent methods (ligation-92%; vasectomy-75%) are preferred. More than half of the providers do not recommend traditional methods. 5. Usage of FP literature and manner of updating Providers are highly unaware of medical literature such as DARE (97%), National Guidelines Clearing House (93%), Cochrane Batabase of Systematic Reviews (91%), PubMed (91%), and MedLine (83%) nor heard of Evidence-Based Medicine (81%) and WHO Medical Eligibility Criteria for Starting Contraceptive Methods (87%). Most providers are aware of the Green Book or the National FP Service Guidelines (53%) and a majority of them (76%) claim to follow this reference. They rely on lectures or workshops which 68% attended in the past year to get updates on FP. Most had also attended a post-licensure training course on FP (65%) or read medical literature (56% had done so in the preceding 4 weeks). Lamberte, Exaltacion E. 1998. Assessing Quality of Care Provision in Family Planning Services: Issues and Lessons Learned. In Improving Quality of Care in Family Planning Services: Conference Proceedings of the Quality of Care in Family Planning Service Provision edited by Exaltacion E. La mbe rte and Cristina A. Rodriguez. Manila: Social Development Research Center, De La Salle University. Pp. 7-21. The paper summed up the overall results of a project entitled ―Research Practicum on the Assessment of Quality of Care (QOC) in Family Planning Services‖ undertaken in 1995- 1998. The project provided a bi-annual research practicum/training program on the assessment of QOC in FP services to practitioners and providers in various service delivery points (SDPs) in the country. It was done in collabo ration with the DOH, NGOs, and hospitals where participants were recruited. In this practicum, the participants were trained on the QOC framework developed by Judith Bruce and on how to gather, analyze, and write-up the data for the QOC research that were done in their chosen SDPs. In all, 59 providers participated in conducting QOC assessment: 43 from public facilities and 16 from NGO facilities. The majority of participants (73%) were nurses, followed by physician (20%), program administrators/managers (5 %), and midwives (2%).The methods utilized in the study were situation analyses and QOC assessment tools (like entry/exit questionnaires). The highlights presented included the following: 1. About the staff working at the SDPs, the majority (particularly nurses and midwives) have been in the service for more than 10 years. Half (especially doctors and midwives) have been in the FP program for 10 or more years. 2. FP program staff has perceived the following to be generally adequate: FP training received, although limited to some types of contraceptive methods and generally focused on the pill, IUD and condom. Necessary equipment to deliver the services, although some necessary ones (such as microscopes, forceps and flashlights) are not available at health units and centers located particularly in rural areas. Supplies and materials found at the SDPs. 3. However, the following areas are usually considered problematic or needing attention: Lack of maintenance and cleanliness (referred to as housekeeping) of equipment in all types of facilities, Need to keep orderly and accurate files and records. Lack of clinic infrastructure needed for service provision, such as private areas for examination and counseling. Top-down (not participatory) process observed in planning and information flow. Inadequate data to inform management plans and decisions. 4. Backed by FP program approval, service personnel provide clients with various types of contraceptive methods, and the most predominantly offered are pills, combined pills, condoms, IUDs, and injectables. Least predominantly provided include spermicides, male and female sterilization, diaphragm, norplant, and NFP. Among the providers, the doctors were revealed to be hesitant in provid ing FP services but they did so nevertheless. 5. For spacing pregnancies, providers recommend IUD, injectables, condom, and combined pills. For terminating childbearing, tubal ligation and vasectory are suggested. Clients’ condition and preferences did not appear to be important considerations for recommending a method. 6. Some restrictions are observed by health personnel in the provision of FP services. Age was a consideration in offering combined pills, injectables, IUD, and ligation. Marriage was required before prescribing pills, IUD and BTL. Spouse/partner consent was required by a majority of the providers for BTL, IUD, and combined pills. In the case of abortion which is considered illegal, it could be done only when the woman’s life is in danger. 7. Although contraceptive methods are available and provided to clients, these are not all sufficiently discussed by providers with their clients. Moreover, side effects are not always presented in discussions and neither is there much counseling. Asia Development Consultants, Inc. n.d. Survey of Knowledge, Attitudes and Practices of Community Volunteer Workers on Health and Family Planning. Final Report submitted to the Departme nt of Health (DOH) and the Australian Inte rnational Development Assistance Bureau (AIDAB). The report presents the findings of a survey on the knowledge, attitudes, and practices (KAP) of community volunteer workers (CVWs), who are considered DOH frontliners in realizing quality health for millions of Filipinos. In general, the respondent CVWs were females, 40 years old or over, high school graduates, without a steady source of income, and poor. As a whole, they were not adequately trained or prepared for their work (only one- fourth was trained in FP; fewer than this had trained in primary health care). On the knowledge component, survey findings revealed CVWs to: Have limited knowledge on the aims, target clientele, and guiding principles of the Philippine FP Program. Possess level of awareness about FP and maternal and child health (MCH) services in their municipalities although their perceived roles in the health system were limited to making client referrals, motivating community members to participate in FP/MCH projects, and providing supplies and services to these members. Be most conversant with messages about joint decision-making between husband and wife regarding what methods to use for FP and the proper spacing of pregnancies. Findings on CVWs’ attitudes showed them to have: Strong sense of commitment to their job, in spite of not being financially and materially well-compensated, as shown in their readiness to work beyond normal hours, and their decision to go against the Church teachings on FP methods so they can fulfill their role as CVWs. Honesty about their shortcomings and willingness to undergo training or other activities to improve their stock knowledge as CVWs. Negative outlook towards their program targets in the community who are believed to make their work most difficult. With regard to CVWs’ practices, the study indicated that: The CVWs do not practice what they preach about FP. Around 50% had not used any FP method for the past three years because they felt they were quite old to be needing FP. Breastfeeding is, however, well-practiced by 90% of the CVWs. The study attributed their 2-3 year child spacing to this practice. They appear innovative and skillful in counteracting rumors and handling misconceptions on FP, but lack the confidence to undertake FP counseling sessions with clients. Hence, they expressed the need for more training on FP methods and counseling. They are good at using visual aids to enhance communication and learning sessions with clients. In view of these survey findings, the study recommended that the CVWs be trained to increase their competency for delivering FP services and to further enhance their strong work commitment. Using adult learning strategies, their training should focus on how FP methods work, how these are used, and what the advantages and disadvantages of the methods are, including their side effects. The core messages in FP and MCH that need to be popularized by CVWs should be defined in the training. A system of monitoring the CVWs’ implementation of knowledge and skills gained from the training and of supporting their work (e.g., provision of adequate supplies) was viewed as essential to the success of the training endeavors. C. Client-Related Studies This set has 11 reference materials which are dated between 1993 and 2004. The data presented in these materials were the results of utilizing the secondary analysis (4 write- ups done on 3 studies), review of literature (3 studies), survey method (3 studies, of which 2 are KAPs), and qualitative methods (1 KAP study using FGD and in-depth interview). The main themes of these references are varied, but are generally clustered around reasons or factors influencing women’s continuing or discontinued use/practice of contraception particularly of the modern types. The specific themes (from earliest to latest) in these sources are: Reasons why women discontinue their FP practice (Choe, et. al., 1993) Factors accounting for women’s unmet need (Casterline et. al., 1995 and Population Council, 1996. Both references are on the same study.) Rationale for male involvement in FP (Perez, 1997) Understanding the cultural meanings attached to sex and sexuality as macro context for FP (Tan, 1998) Cultural values associated with children and pregnancy that may affect FP (Jocano, 1998; underscoring is mine. I have noted that sources used for the book appear to be generally several decades old so certain data may require validation.) Factors accounting for FP clients choice of public or private (NGO) provider facilities (Lamberte, et. al., 1999) Reasons why more women practice FP in the Philippines (Kinkaid, 2000) Clients’ knowledge, attitudes/perceptions, beliefs and practices (KAP) on FP and population-related issues (ACNielsen, 2003; NFO Trends, 2004; and Pulse Asia, 2004) Pulse Asia. January and February 2004 Ulat ng Bayan National Surveys on Family Planning and Population Issues. March 4, 2004. This is a Pulse Asia report on the results of its recent national survey on FP and population issues. The survey respondents comprised 1,800 adult men and women who were interviewed face-to- face. The main highlights are the following. Filipinos continue to consider FP as important. Almost all (97%) claimed it is important to have the ability to control one’s fertility or to plan one’s family. About three years earlier (December 2000 survey), only 94% said the same thing. About 7 in 10 Filipinos believed that a fast increasing Philippine population hinder’s the country’s development. Only 16% disagreed, while 13% were undecided. Filipinos increasingly think that candidates favoring FP and population issues ought to be supported in the coming elections. A majority (82-86%; compared to 69-71% in the 2000 survey) referred to candidates that favored couple’s free choice of FP methods, a law or measure on population issues, a government budget for FP, and a program on women’s health. One in 2 Filipinos (50%) thought a candidate’s support of FP will determine that candidate’s electoral victory. This view is highest in Northern and Central Luzon (57%), particularly in rural areas (60%). Those who believe FP support will not affect the candidate’s victory belonged to the upper socioeconomic classes. In contrast, those who said the FP support will spell defeat on election day came from rural Central and Eastern Visayas (20%). Religion is not perceived to be a threat to FP supporters. Two-thirds of the respondents opined that the church should not join in supporting or rejecting candidates during elections. A third (33%) said their religion allows them to decide on their electoral choices while close to a third (28%) reported that their religion says nothing on this issue. However, 18% claimed their religion asks them to support and vote for pro-FP candidates while 9% claimed the opposite was true. The overall findings of the February 2004 Ulat ng Bayan indicate that the Filipinos’ views on FP have not changed much, and that a bigger proportion of the respondents express support for pro-FP candidates. A majority also believe that the church should not take an active stance for or against candidates supportive of FP. NFO Trends. January 2004. Project Lucent: Baseline Survey on Family Planning Knowledge, Attitude and Practices among Filipino Men and Women. Report prepared for The Social Acceptance Project-Family Planning (TSAP-FP). This study is in support of the goal of The Social Acceptance Project to achieve an ―increase in percentage of the general public who strongly approve of and who have endorsed FP practice to others.‖ One way to reach this goal is to reposition the concept of FP through a multi- media campaign strategy to be developed under the project’s ―Behavior Change Component.‖ In order to determine the impact of this strategy, baseline data will be needed on the public’s prevailing knowledge, attitudes, and practices related to FP and FP methods, as well as information what could influence the social acceptance of FP. Hence NFO Trends was commissioned to get the baseline data. Data were gathered through structured questionnaires that the interviewer administered face-to-face to respondents in three Metro cities (Quezon City, Cebu City, and Davao City) and four key cities (Naga City, Legaspi City, Ormoc City, and Tacloban City) in low contraceptive prevalence rate (CPR) regions. For sensitive questions asked of unmarried respondents, the ―sealed envelop technique‖ was used. ―The respondent personally read the questionnaire and responded through codes which the interviewer recorded. The interviewer did not know the questions and corresponding response, thus eliciting more truthful responses.‖ A total number of respondents was 1,600 respondents- -15-60 years old, both single and married, of both sexes, and belonging to all socioeconomic classes. The highlights of the study’s findings are: Majority (65%) claim to have little knowledge about FP, or have heard of it but do not know anything about it. Among those who claimed some or much knowledge, the percentage is higher among females and those who are married or cohabiting. Those who claimed some knowledge on FP associate it with specific FP methods and with controlling or limiting the number of children. They believed that the principal reason why people practice FP is to protect children’s welfare. Although majority had claimed little knowledge on FP, when asked about awareness of FP methods, 97% and 96% of the respondents are aware of condom and oral pill, respectively. Awareness of withdrawal, calendar/rhythm, tubal ligation, IUD, injectable, and vasectomy is also high (61-88%). Only a few know about LAM, basal body temperature, and mucus/Billings. Awareness of FP methods is obtained through varied sources, but mainly from close friends or acquaintances, the television, and health centers. FP is not a preferred topic of conversation, with only about one-fifth discussing it principally with spouse/partner or acquaintance in the last three months. Those who discuss it with spouse/partner did so frequently, willingly, and comfortably although with not much encouragement from the other. A great majority (96%) feel FP is important and beneficial to practicing couples and their respective families. However, only a small majority (less than three- fifths) of those who are married or who live- in actually practice FP; the commonly used methods are the pill, withdrawal, condom, and rhythm. The pill is associated with high effectiveness; condom is a popular choice of the sexually active; and withdrawal and rhythm are compatible with religious beliefs. The spouse/partner is considered to be the major influence in the choice of an FP method for those in Metro areas. Other key influences include close friends and health centers. Information on FP is commonly obtained from health centers and the television. Very few have heard of a popular individual making a public pronouncement on FP in the last three months. For married/living- in respondents, the important factors for choosing FP are effectiveness in preventing pregnancy, safety (no harmful effects to health), recommendation from medical personnel, spouse/partner approval, suitability (hiyang), ease of use, and affordability. That FP should agree with their religious belief came out to be the 11th most important factor (but still garnering 60-63% responses in the Metro areas and in key cities in low CPR regions, respectively) in choosing an FP method. Watching television (86%) and listening to radio (56%) still comprise the respondents’ more popular media habits. ACNielsen. 2003. Project Dynasty: A Qualitative Study on Family Planning. Report submitted to the Academy for Educational Development, Stre ngthening the Social Acceptance of Family Planning in the Philippines (TSAP), April 21, 2003. The research project was conducted in response to the need for undertaking segmentation research and for looking in-depth into the needs, values, and motivations of target segments concerning FP and sexuality. It is done in partnership with The Social Acceptance Project to develop communication, advocacy, and social mobilization strategies to reposition FP as relevant and appropriate to target segments. This is a qualitative study utilizing focus group discussions and in-depth interviews with predominantly lower class respondents found in Metro Manila, Cebu, and industrial areas in Southern Tagalog. The FGDs were conducted with 21 full- sized groups (6-8 respondents each among married males and females) and 5 mini groups (3-4 respondents each including single males and females); in-depth interviews were done with 42 single males and females. Projective techniques were also used to gather information, which took place from January 20-February 4, 2003. The information sought by the study clustered around: (1) knowledge, attitudes, perceptions, and beliefs about FP and contraceptive practice among target segments, (2) about planning for parenthood and children, including values associated with family, FP, and children, (3) benefits of FP that are valued by target segments, (4) constraints and barriers to FP acceptance and use in terms of myths, misperceptions, taboos, fears, and cultural norms, (5) perceptions of modern versus traditional methods and method users, (6) channels of information/influence that impact on FP decisions of target segments. The results are as follows. The target segments are aware of most contraceptive practices and methods, especially pills and condom, with accessibility and advertisement as factors accounting for high awareness. Users of withdrawal, pills, and condom are highly aware of the calendar method and some think it is ―fail-safe’ when used in tandem with pills and condo m. IUD, ligation, and vasectomy are not popular because of their perceived effects. Recurring stories are told about IUD getting misplaced or getting entangled with the penis. Ligation and vasectomy are permanent and ideal for older couples not wanting another child. Several factors may present barriers to trying out contraceptive methods: awareness of the method, affordability, ease of use, fear of side effect, perceived effect on users, comfort level of user, and accessibility. Married males view unplanned pregnancy as a threat to the household’s financial security, delaying hopes for family advancement, affecting parents’ ability to provide for children’s good education or support their bid for independence, hence, creating worries and stress in old age. Married females have the same concerns as married men but emphasize that family advancement is endangered so this compromises financial security. Young adults view unexpected pregnancy as disrupting their education, compromising their chances of getting good jobs and becoming independent, limiting the time spent with friends, and jeopardizing their loving relationship with partner. The study had the following recommendations. Pay more attention to addressing recurring stories about perceived ill effects of contraception. Fill the information vacuum about contraceptive methods with real and solid ones that can override word-of- mouth misinformation. Reorient health centers to effectively provide FP services to a wide and diverse constituency. Do not ignore the male partners in the communication process when trying to convert users of withdrawal and calendar methods to other more effective ones. Finally, exploit the core values of family relationships, advancement, and financial security to communicate FP as the ―life strategy‖ enabling one to overcome life’s vicissitudes and hurdles. In conclusion, the study also proposed certain messages, communication media, and ancillary strategies (e.g., applying the route of ―telenovelas‖) to be used for different target segments. Kinkaid, Lawre nce D. 2000. Why Wome n in the Philippines Practice Family Planning: A Qualitative and Quantitative Analysis. Pape r presented at the research forum on “Why are more wome n in the Philippines Now Practicing Family Planning,” sponsored by John Hopkins Unive rsity Population Communication Services/Philippines and DOH, Manila, August 9, 2000. The paper explains why Filipino women practice FP by reanalyzing data based on FGDs done in 1991 and the 1996 national survey of Filipino women (both collected by a market research agency, TRENDS-MBL). The seven reasons and related issues that emerged from the secondary data analysis are: 1. Women want to prevent or delay pregnancy. Most women (84%) want 2-4 children (average of 3.4), with younger ones wanting three or fewer although the ideal number is moving towards two as this is easy to support. 2. They want to help their husbands and immediate families. Women’s priorities are children (first) and husbands (second); their health is last priority. Having fewer children lets them work to supplement the family income. 3. They desire to feel better about themselves. Practicing FP helps women to control their own lives, stay well- rested, and engage in self- indulgence and entertainment. 4. They wish to improve their relationship with their husbands. Unhampered by fear of pregnancy, couples experience a richer sex life and better communication. Husbands’ willing participation (especially for less effective methods) through encouragement and suppo rt of their wives’ FP practice is necessary. 5. Because they can find a suitable FP method. Women search for sure, safe and easy to adopt methods (at least the first two). Safe methods are those most certain to prevent pregnancy; safe methods are ―risk- free‖ in terms of side effects and ―hiyang‖ (natural fit) to their bodies. ―Easy to adopt‖ methods are those that do not require remembering or a lot of poking/looking into private parts. Women have to weigh their fear of the scary side effects of pills, IUD and sterilization, with their fear of the ineffectiveness of withdrawal, condoms, and rhythm (considered the safest). In the national survey, the most mentioned reason for using contraceptive was because it was safe (42%); the least mentioned was because religion approved of it (1%). The survey also found that the greater number of modern methods women could spontaneously recall, the greater the likelihood they used these methods. So women were more likely to find a suitable method if they were familiar with a greater number of methods. 6. Because other people encourage them to practice FP. Women tend to use a method that other women whom they know use. The survey showed that women who talked about FP to their spouses/partners, and to other women, and who got their partners’ encouragement, were much more likely to use/continue to use a modern contraceptive. The strongest relationship was found for encouragement by one’s spouse/partner. 7. Because they can find confidential, quality health services. A positive experience at the heath center leaves women with a positive outlook towards FP. In conclusion, the paper emphasized that ―ideational factors‖—what people think and say to one another about fertility and family planning—strongly affect modern contraceptive use. A national FP communication program can be designed to address: women’s need to know how to achieve their fertility preferences, to find a contraceptive method that is hiyang, to know and believe in the beneficial consequences of practicing FP, and to receive encouragement from their husbands and support from other women. Lamberte, Exaltacion, E., Roy M. Brooks, and Mark Sherman. 1999. Unde rstanding Provider Choice of Family Planning Clients: Cons umer Intercept Study. Manila: Social Development Research Center, De La Salle Unive rsity and The Policy Project. The Consumer Intercept Study aimed to identify policy reforms designed to encourage increased participation of the private sector, particularly the Non-Governmental Organizations (NGOs) in the FP program. Nationwide demographic and health surveys had revealed that the public sector continues to be the overwhelming choice for sourcing modern contraceptive methods which further burdens a resource-poor country. Hence the study looked into the behavioural patterns of FP clients in selected public health facilities (hospitals and community health offices) and their nearby NGO service delivery points in urban areas to identify why they choose either source. Information was obtained through face-to-face exit interview survey conducted among 1,025 FP clients in Baguio, Davao, Cebu, Bacolod, Manila, and Quezon Cities. Data collection took place from May- July 1998. In general, the study highlighted the following: (1) clients’ use of FP is based on rationa le and informed decisions, (2) the reasons behind their behavioral patterns are related to facility choice, services and methods, and (3) a majority of FP clients (around two-thirds) in public facilities are willing to pay for contraceptive services and supplies within the range of the prices being charged by NGOs. Other main results are: Virtually all FP clients are married, with an average of 2.7 living children. Young, unmarried clients are not using public or NGO facilities; they either go to other facilities for FP services or do not receive them at all. The percentage of new FP acceptors is higher (54.4%). Choice of NGO facilities is associated with income and expenditure patterns and educational level: clients with higher income and better education tended to go to NGOs. Other factors affecting choice of facilities are geographical proximity, age, cost and quality of services, and choice of contraceptive methods. NGO facilities are not sufficiently differentiated from the public ones. NGO providers are generally perceived as extensions of public sector facilities and the former’s services as another form of subsidized care. NGOs however also use some form of sliding schemes to accommodate poorer clients. There is very little difference in client satisfaction level and quality of services provided by type of facility. The chosen contraceptive method is an indicator of facility choice. Public hospitals were chosen for pills, IUDs, and tubal ligation; community health offices for pills and injectables; and NGOs for pills and IUDs. Nearly all clients have television and/or radio, indicating that mass communication can be an effective mechanism to promote FP education and services. In conclusion, the study identified strategies and policy interventions to increase private sector participation in the FP program, as follows: 1) Increase the provision of technical and financial support to strengthen NGO capabilities to provide FP services so they can differentiate themselves from public sector facilities and target middle- and upper- middle income clients. 2) Promote NGO services that target public sector clients who are willing to pay some amount for these services. 3) Increase efforts to better serve the reproductive health needs of the young adult population. 4) Shift clients out of public sector facilities by charging reasonable user fees for public sector FP services. Jocano, Felipe Landa. 1998. Anthropology of the Filipino People III: Filipino Social Organization. Quezon City: PUNLAD Research House, Inc. (Note: Only two chapters were found relevant to understanding the underlying sociocultural reasons that could impede the contraceptive practices of Filipino family planning clients.) Chapter 7 – The Child in Society, pp. 77-88 ―That the child is much desired, wanted, and enjoyed is engrained in the Filipino cultural psyche such that married adults naturally want children. This is one of the reasons why despite a nationwide Family Planning Program, Filipino families have relatively remained big. The child is viewed as an integral part of married life. Without one, the marriage is considered a meaningless, unstable union.‖ Children are highly valued for six reasons: As a source of happiness - They bring an ―indescribable feeling that gives ardor to life‖ (known as ligaya). Their presence ―wipes away weariness or fatigue.‖ They deepen the parents’ love for one another. They also provide moral strength during times of suffering, grief and other misfortunes. Although parents admit that children are an economic burden, they also claim there are tremendous social and psychic rewards derived from meeting the challenges of rearing a big brood. As a gift of God – They are ―the grace derived from divine blessings and the results of clean, honest living.‖ In rural areas, couples with many children are seen to be ―living in the grace of God.‖ Having children out of wedlock or by a mistress and practicing abortion are not included in the folk assessment of what constitutes grace. A woman’s sterility and a man’s impotence are supernatural punishments for living out of grace. An evidence of love – They are the ―cementing force‖ in the couple’s relationship so a childless union is not considered strong. It is believed that the absence of children makes husbands unfaithful. ―The equation of love with childbirth reinforces the machismo complex as a dominant male norm.‖ The child is a man’s proof of his love for a woman. Must have an even sex distribution – This is rooted in the concept of balance in nature and human life, and loosely associated with the good fortune (buenas). If couples have children of the same sex (all boys or all girls), childbearing in not complete until a child of the opposite sex is born. So the number of children increases. Having more girls indicates the father is a philanderer and the female children were to become ―payment for his debts‖ against those women he victimized. As economic investments – It is believed that families who lack material wealth are instead blessed with many children. The greater the ir number, the more chances that one of them will succeed in life to lift parents from poverty. Children also free the mother from household chores or the father from work in the fields in rural settings. As a necessity to maintain family lineage – Children ensure that the family line will not die out. Chapter 8 – Pregnancy and Childbirth, pp. 89-105. Pregnancy is widely recognized both as a biological reality (conception) and a social phenomenon (result of sexual coupling). It is also viewed as a supernatural phenomenon because ―those whom God wants to punish, He does not allow pregnancy to take place; those whom he rewards, He lavishes with many children.‖ The belief that prayer and ritual performance (e.g., to patron saints) can cause pregnancy is also an affirmation of faith in God. Pregnancy is not regarded as possible without the compatibility between the male and female fluids (known as semilya). One way to avoid pregnancy is therefore to prevent the male semilya from flowing into the women’s womb, as believed to happen when sexual intercourse is done in an upright position. One other reason why pregnancy may not happen despite coitus is because it is not ―the will of God.‖ Although children are highly desired, people practice birth control. This is resorted to when childbirth endangers the mother’s life. In urban areas, it is deliberately done as soon as couples have reached their desired number of children. ―Unwanted pregnancies are terminated through abortion.‖ Among the traditional birth control methods are: Coitus interruptus – This is a prevalent practice among many rural couples. But it can cause either wife or husband to suffer from physical tension. Thus there are men who prefer their wives to be pregnant than for them to suffer. (The author noted that this could be simply a verbal rationalization or part of a man’s coping behavior in achieving satisfaction in intimate relations.) Displacement of the matris (womb) – This is the best known method and widely attested to as effective. It is achieved through massage by a hilot (traditional birth attendant). Use of modern drugs such as aspirin and Cortal tablets, soapsuds, vaginal creams are known to some women. Modern contraceptive methods like pills and IUD are known to women but unpopularly used for reasons not investigated by the author. Use of herbs and treebarks believed to have bisa (power) to prevent pregnancy – Recognized to be tantamount to abortion in many cases as many women take an infusion derived from these plants as soon as menstruation fails to come on the expected days. Tan, Michael L. 1998. Sex and Sexuality. Policy Research Briefs, Series 1998-2. Que zon City: Cente r for Wome n’s Studies Foundation Inc., University of the Philippines. This is part of the series of policy research briefs prepared for the project ―Women- Centered Participatory Research and Development for Women’s Health: A Women’s Consortium Project,‖ which aimed to (1) strengthen gender-sensitive research and women-centered methodologies and integrate these into policy, planning and service provision of women’s health, and (2) enhance the awareness of policy makers and implementers, both at the national and international levels, on the possible adverse effects of gender-blind and non-participatory development interventions in the area of reproductive health care. In this research brief, the author discussed five points related to research on sexuality. The more relevant issues raised are as follows. 1. What meanings people give to ―sexuality‖ (a term not found in any of the Philippine languages) It encompasses the qualitative aspects of sex;, is much about words, images, ritual and fantasy; and is extremely personal and intimate. It is socially constructed in particular cultural and historical settings. In relation to RH, it has four dimensions—sexual partnerships, sexual acts, sexual meanings, and sexual drives and enjoyment. 2. Exploring sexuality to understand reproductive intentions In FP, reproductive intentions include: how many children people aspire to have, at what intervals, and of what sex. The question of why people have sex is no longer confined to procreation but includes love, lust, pleasure, curiosity, duty, responsibility, power. 3. Understanding sexual meanings Beneath contraceptive prevalence rates and episodes of unprotected sex are decisions and choices that draw on a constellation of meanings, with sex being constantly interpreted and reinterpreted. Sexuality’s meanings are rooted in self- image: perceptions of the body, how different parts work, names of and unnamed body parts, awareness of menstrual cycle, interpretation of changes in the body including body fluids and discharges, and interpretation of fertility and infertility. 4. Understanding sexuality’s context Individual acts and desires have a macro/social context that must be understood to get to the root causes of many reproductive and sexual health problems. The macro context includes knowledge and perceptions outside the area of sex and sexuality, at times involving philosophical concerns, and including different levels of social relations. 5. Sexuality and gender Researching sexuality also looks into issues of unequal gender statuses and the oppression or empowerment of women, as well as intersubjectivity (shared meanings between genders that are concretized in gender relations). In conclusion, the author emphasized the need to use more qualitative research methods to understand sexuality, in particular: Conduct less of the usual KAPB (knowledge, attitudes, practices, behaviors) type of surveys which tend to be normative, and go for more participatory and humanistic approaches that can unearth the complexities of sexuality. When used, surveys need to be part of a package of varied methodologies of the anthropological field, such as life and sexual histories, focus group discussions, and in-depth interviews. Researchers must be introspective, utilizing content analysis of popular culture (e.g., sex advice columns or media coverage of rape cases) and should develop sensitivities to know not only what is said but also what is not allowed to be said (e.g., abstinence and celibacy are as much a part of sexuality as having sex). The author cautioned against allowing sexuality research to be manipulative, serving social marketing programs to peddle condoms and contraceptives. Rather, it should contribute to building a moral, not moralistic, framework that allows people to achieve their full potential as sexual beings. Perez, Aurora E. 1997. Making Space for Filipino Men in Fertility Management. Policy Research Briefs, Series 1997-1. Quezon City: Center for Women’s Studies Foundation Inc., Unive rsity of the Philippines. This is the first in a series of policy research briefs prepared as part of the project ―Women-Centered Participatory Research and Development for Women’s Health: A Women’s Consortium Project,‖ which aimed to (1) strengthen gender-sensitive research and women-centered methodologies and integrate these into policy, planning and service provision of women’s health, and (2) enhance the awareness of policy makers and implementers, both at the national and international levels, on the possible adverse effects of gender-blind and non-participatory development interventions in the area of reproductive health care. This research brief focused on the gender roles and the status of married Filipino men and women and its influence on the levels and trends of contraceptive use. Discussions were grouped on the following points. 1. Reasons for involving men and their role in fertility decisions Filipino men are strongly ―pronatalist‖ because the pressure to have children is greater on the husband than on the wife for the children are a testimony to the husband’s good moral character and virility, and compelling sociological and institutional factors shape the husbands’ profound authority in the home. Husbands may claim unilateral power in FP decisions but prefer to avoid responsibility for implementing such decisions. They are more willing to choose a method in the future if it was female-specific such as the pill or tubal ligation. At ages 40-44, twice more men than women want more children. Husbands’ lack of support for FP is a greater reason for dropping out of the program than the acceptors’ attitude. Husbands decided over their wives’ bodies and fertility in resolving conflicts over how many and when to have children. Husbands may still maintain dominance in the dyadic relationship, however, women are beginning to assert their power over fertility regulation. In a study by Sanchez and Chan (1997), most of the wives of men who claimed their decision had prevailed on who decides on contraceptive use, reported it was the women themselves who decided most of the time. 2. Discordant men and women’s views/practices of contraception The contraceptive prevalence rate for women is higher than for men as it is a generally accepted view that contraception is women’s responsibility. The initiative to contracept is mainly the wife’s, yet a significant proportion of couples used coital-dependent methods such as withdrawal, condom, and calendar rhythm that need both the husband and wife’s cooperation to succeed. Frequent couple’s disagreements over the desirability of specific pregnancies is one reason why the count of unintended pregnancies remains large. 3. Whether contraceptives imperil one’s health Husbands more than wives viewed pills and ligation as bringing more health risks to women than pregnancy. There are more couples with such views among non- users and among users of traditional methods. Men and women frequently regard vasectomy as most harmful because it would allegedly severe nerves that reduce men’s physical strength. Rhythm is perceived by males and females to have the least health side-effects as women were not required to ingest any foreign substance into their bodies. More females than males prefer pills although wives believe that pills carry some physical discomforts like headaches, nausea, and vomiting. Women consistently rate each method more harshly than men, and wives are more negative than their husbands even about methods that directly involve men. Modern methods like the pill and IUD are viewed more negatively than traditional methods like withdrawal and calendar rhythm. 4. Whether couples agree on future intentions to use contraceptives Among non- users, women are generally more inclined than men to use contraceptives in the future owing to the fact that women experience a respite from pregnancy and child care when they successfully use contraceptives. Compared to women, a substantially larger proportion among men see no benefit from FP. In general, spouses are largely in agreement about the intention to use contraceptives in the future, but spouses who disagree in their views of contraception were less likely to agree about future use. The author concluded that spousal disagreement affects contraceptive intentions and behavior, and blocks women’s own desired fertility. It is thus important to focus on conflict resolution among Filipino couples who jointly decide whether or not to use contraception and which contraceptive method to use. Men must be sensitized to the health risks their wives face due to closely spaced births and encouraged to assume more responsibility in fertility regulation, particularly in promoting adequate birth spacing. Population Council. Summe r 1996. Reasons for Unmet Need for Family Planning: Findings from the Philippines. Population Briefs 2 (3). This is brief is based on one of the first studies of this nature conducted by Population Council demographers John Casterline and Ann Biddlecom and University of the Philippines demographer Aurora Perez. It marks an important effort to remedy a ―serious deficiency of systematic research on reasons for unmet need.‖ Unmet need for FP can be defined as women who do not want to get pregnant but do not practice contraception. The researchers hypothesized that unmet need is caused not only by inadequate FP services, but also by sociocultural obstacles to contraceptive use. This is among the first studies to demonstrate the relationship between sociocultural factors and unmet need. It is being used as a model for research on unmet need in Egypt, Ghana, Pakistan and Zambia. Using qualitative methods (FGD and in-depth interviews), the study’s findings revealed that unmet need is not significantly attributable to any one factor, but to five. These are: strength of woman’s fertility preferences, husband's fertility preferences, woman’s perceived risk of conceiving, wife or husband’s perceived health effects of contraception, and wife or husband’s acceptability of family planning. But no marked differentials in reported access to services were found between those using and not using contraception. The study’s findings have the following implications: (1) it is essential to understand the multi- faceted nature of unmet need, (2) better services not more services can help reduce unmet need, (3) husband’s play a key role in creating unmet need in women, so their views on childbearing and contraception should be ascertained and they must be part of programs that reduce unmet need or empower women to act on this need. Casterline, John B., Aurora Pere z, and Ann E. Biddlecom. 1995. Factors Unde rlying Unmet Need for Family Planning in the Philippines. Paper presented at the Annual Meeting of the Population Association of America, San Francisco, April 6-8, 1995. This paper explored the causes of unmet need for FP where little research had been undertaken. It analyzed quantitative and qualitative data collected in 1993 from currently married women and their husbands in two Philippine provinces. It sought to examine four hypotheses, namely: (1) unmet need is an artifact of inaccurate measurement of fertility preferences and/or contraceptive practice; (2) unmet need reflects weakly-held fertility preferences; (3) those classified as having unmet need perceive themselves to be at low risk for conceiving; and (4) unmet need is due to excessive costs of contracepting, including social unacceptability, husbands’ opposition, fear of health side effects, and inadequate FP services. The analysis showed that unmet need is not an artifact of the survey measurement but caused by some socio-cultural factors. Evidence particularly from qualitative interviews revealed that the most important factor accounting for unmet need is the husband, particularly his fertility preferences and perception of health side effects. Unequal power in initiating and refusing sexual relations with the husband was the dist inctive characteristic of women with unmet need. Husbands’ domination was found to complicate and exacerbate the other factors identified in the conceptualization of unmet need. Also substantially important was the women’s view of the acceptability of contracepting, their perceived risk of conceiving, and for a smaller subset of samples, their perceived detrimental health side effects. The study found inadequate FP services to carry little weight in determining unmet need. But then, it did not test the potential impact of intensified and improved FP services as this was not in the design. The study brought to light evidence from qualitative data that there are many overlaps and linkages among the identified causal factors of unmet need. It acknowledged that the current analysis was deficient as it did not allow more explicitly for overlaps and linkages, but such relationships among the factors served to inspire further thinking about the underlying structure of causes of unmet need. Choe, Minja Kim, Zelda Zablan, Rufino Gealogo, and Andre w Kantne r. September 1993. Contraceptive Use Discontinuation in the Philippines: Components and Covariates. Quezon City: Population Institute, Unive rsity of the Philippines and Hawaii: East West Center. The researchers explained why the contraceptive prevalence rate in the Philippines is lower than in neighboring countries, whereas its share of traditional method use is relatively high. Previous studies had also shown that contraceptive use discontinuation, particularly for the pill, was high by international standards. Thus the researchers undertook a study on this phenomenon. Using secondary analysis, they examined data from the 1986 Contraceptive Prevalence Survey of the University of the Philippines-Population Institute. The survey covered interviews with 18,468 currently- married women aged 15-44 years. Their complete pregnancy histories were collected, along with retrospective calendar information on monthly status of pregnancy and FP use from January 1983-June 1986/1987. For each woman, the survey data collected spanned a period of at least 3.5 years. However, for this study only data within a one-year period were examined. Their findings showed the following discontinuation rates of women after 12 months of using contraceptives: Pill users - 27.4% IUD users - 5.8% (lower than international experience) Traditional method users: Rhythm – 19.6%; 24.2% when pill is combined with other methods Withdrawal – 27.4% The study also found women users of traditional methods to have experienced high levels of accidental pregnancy (failure of contraception) but relatively low levels of dissatisfaction. However, since these methods are likely to remain popular, FP programs should exert greater efforts to provide better instruction on their use. The problem with discontinuation in the use of modern methods like the pill and IUD could be addressed by providing improved follow- up services to ensure women’s proper use of the methods, offer prompt remedy for side effects especially for IUD acceptors, and provide counseling about alternative methods. FP programs should also strengthen outreach, pay special attention to new users, and carry a range of contraceptive methods which include traditional ones that do not require supplies and services. Finally, more effective education and counseling on both program and non-program methods should be provided. BIBLIOGRAPHY ACNielsen. 2003. Project Dynasty: A Qualitative Study on Family Planning. Report submitted to the Academy for Educational Development, Strengthening the Social Acceptance of Family Planning in the Philippines (TSAP), April 21, 2003. Asia Development Consultants, Inc. n.d. Survey of Knowledge, Attitudes and Practices of Community Volunteer Workers on Health and Family Planning. Final Report submitted to the Department of Health (DOH) and the Australian International Development Assistance Bureau (AIDAB). Bailen, Jerome B. and Donald E Morisky. September 1974. Traditional Birth Attendants (Hilots) and Modern Family Planning in Marinduque. Quezon City: University of the Philippines-Department of Anthropology. Casterline, John B., Aurora Perez, and Ann E. Biddlecom. 1995. Factors Underlying Unmet Need for Family Planning in the Philippines. Paper presented at the Annual Meeting of the Population Association of America, San Francisco, April 6-8, 1995. Choe, Minja Kim, Zelda Zablan, Rufino Gealogo, and Andrew Kantner. September 1993. Contraceptive Use Discontinuation in the Philippines: Components and Covariates. Quezon City: Population Institute, University of the Philippines and Hawaii: East West Center. Costello, Marilou, Marlina Lacuesta, Saumya Ramarao, and Anrudh Jain. December 2001. A Client-Centered Approach to Family Planning: The Davao Pro ject. Studies in Family Planning 32 (4): 302-314. Costello, Marilou, Virginia Miralao, Ma. Teresa Manganar, and Saniata Masulit. 2001. A Rapid Field Appraisal of Reproductive Health Care Needs and Available Reproductive Health Services in the Philippines. New York: Population Council. Henry, Rebecca. 2001. Contraceptive Practice in Quirino Province, Philippines: Experiences of Side Effects. Manila: University of the Philippines Population Institute and University of La Sallette. Calverton, Maryland: Macro International Inc. Jocano, Felipe Landa. 1998. Anthropology of the Filipino People III: Filipino Social Organization. Quezon City: PUNLAD Research House, Inc. Kinkaid, Lawrence D. 2000. Why Women in the Philippines Practice Family Planning: A Qualitative and Quantitative Analysis. Paper presented at the research forum on ―Why are more women in the Philippines Now Practicing Family Planning,‖ sponsored by John Hopkins University Population Communication Services/Philippines and DOH, Manila, August 9, 2000. Lamberte, Exaltacion E. 1998. Assessing Quality of Care Provision in Family Planning Services: Issues and Lessons Learned. In Improving Quality of Care in Family Planning Services: Conference Proceedings of the Quality of Care in Family Planning Service Provision edited by Exaltacion E. Lamberte and Cristina A. Rodriguez. Manila: Social Development Research Center, De La Salle University. Pp. 7-21. Lamberte, Exaltacion, E., Loyd Brendan P. Norella, Jose Alberto S. Reyes, and Cristina A. Rodriguez. 2004. Quality of Family Planning Counseling: Lens from Stakeholders. Manila: De La Salle University Press, Inc. Lamberte, Exaltacion, E., Roy M. Brooks, and Mark Sherman. 1999. Understanding Provider Choice of Family Planning Clients: Consumer Intercept Study. Manila: Social Development Research Center, De La Salle University and The Policy Project. NFO Trends. April 2004. Project Clarity: A Census and KAP Among Health Providers. Report prepared for the Academy for Educational Development (AED)-The Social Acceptance Project-Family Planning (TSAP-FP) Division. NFO Trends. January 2004. Project Lucent: Baseline Survey on Family Planning Knowledge, Attitude and Practices among Filipino Men and Women. Report prepared for The Social Acceptance Project-Family Planning (TSAP-FP). Perez, Aurora E. 1997. Making Space for Filipino Men in Fertility Management. Policy Research Briefs, Series 1997-1. Quezon City: Center for Women’s Studies Foundation Inc., University of the Philippines. Population Council. September 2001. Reproductive Health Needs and Services Assessed in the Philippines. Population Briefs 7 (3). Population Council. September 2002. Quality of Care: Improving Provider-Client Interactions in the Philippines. Population Briefs 8 (2). Population Council. Summer 1996. Reasons for Unmet Need for Family Planning: Findings from the Philippines. Population Briefs 2 (3). Population Council-Frontiers in Reproductive Health. September 2002. Services Improve Quality of Care but Fail to Increase FP Continuation. OR Summary 30: Philippines and Senegal Quality of Care. Pulse Asia. January and February 2004 Ulat ng Bayan National Surveys on Family Planning and Population Issues. March 4, 2004. Ramarao, Saumya, Marlina Lacuesta, Marilou Costello, Blesilda Pangolibay, and Heidi Jones. June 2003. The Link Between Quality of Care and Contraceptive Use. International Family Planning Perspectives 29(2):76-83. Tan, Michael L. 1998. Sex and Sexuality. Policy Research Briefs, Series 1998-2. Quezon City: Center for Women’s Studies Foundation Inc., University of the Philippines. The Social Acceptance Project-Family Planning. (n.d.) Secondary Review: Barriers to Modern Contraceptive Use in the Philippines. Unpublished paper. Yuchengco Center. June 2004. Assessment of Family Planning Clinics in the Industry. Report submitted to The Social Acceptance Project-Family Planning. Manila: De La Salle University. PRELIMINARY LIST OF GAPS IN THE RESEARCH LIST OF GAPS IN THE RESEARCH Providers as members of social networks How religion acts as an influence to providers The influence of indigenous body concepts on providers The effect of incorporating Philippine clients’ concepts of quality of care (i.e., locally defined quality of care) in service delivery on client satisfaction, discontinuation and demand creation For clients: identifying the body/health/illness concepts that influence family planning use and are perpetuated by traditional healers and their influence on client behavior (only three studies and do not cover all Philippine regions) Whether providers, including BHWs and midwives, perpetuate local body concepts that can influence contraceptive use and continuation The factors that contribute to the TSAP KAP results that industrial zone providers seem to lag behind other providers of family planning services The ability to generalize from existing counseling studies, since most counseling studies have been conducted in Luzon; and secondarily in Visayas Specific provider behaviors that interfere with provision of a full range of methods and quality (from the medical as well as the clients’ perspectives). In general, the components of provider bias have not been teased apart. The TANGO Project has undertaken some market research to attempt this and TSAP commissioned some interesting qualitative research, but much more remains to be done.
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