9th INDEPTH AGM, 27th OCT 2009, PUNE INDIA of enhanced family planning outreach in Rakai, Uganda Tom Lutalo 1 , Edward Kimera 1 Godfrey Kigozi 1 , Fred Nalugoda 1 , David Serwadda 1 , Maria Wawer 2 , Laurie Schwab Zabin 2 , Fred Wabwire-Mangen 1 , Nelson Sewankambo 1 , Ron Gray 2 1 Rakai Health Sciences Program 2 Johns Hopkins Bloomberg School of Public Health
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9th INDEPTH AGM, 27th OCT 2009, PUNE INDIA A community based trial of enhanced family planning outreach in Rakai, Uganda Tom Lutalo 1, Edward Kimera 1.
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9th INDEPTH AGM, 27th OCT 2009, PUNE INDIA
A community based trial of enhanced family planning outreach in Rakai, Uganda
Tom Lutalo1, Edward Kimera1
Godfrey Kigozi1, Fred Nalugoda1,
David Serwadda1, Maria Wawer2, Laurie Schwab Zabin2, Fred Wabwire-Mangen1, Nelson Sewankambo1, Ron Gray2
1Rakai Health Sciences Program2Johns Hopkins Bloomberg School of Public Health
Outline
• What RAKAI does• A review of previous findings• The objectives of the intervention• Community selection• The Intervention activities• Results• Public Health Challenges
Background The Rakai Health Sciences Program (RHSP)
• Since 1994 a cohort of ~12-14,000 adults aged 15-49 yrs has been under annual surveillance
• RHSP provides health education about• STDs & HIV• Family planning• Abstinence and condom promotion for prevention of
STDs and HIV• Condoms, which are also provided free of charge or at
subsidized prices
1995-99 Cohort and FGD findings
• Only 13% of women who wanted no more children were using contraceptives
• 15% of women who wanted to delay pregnancy by >2 yrs were practicing family planning
• FGD participants were more vocal about perceived health risks of FP than about potential benefits
• Impediments included women’s access to FP services, costs of contraception and men’s negative attitudes towards FP
• Identified a need to introduce and evaluate interventions to correct misconceptions, and to improve access to quality services.
Objectives of Intervention
• Establish and maintain community based outreach programs to improve awareness and utilization of hormonal contraceptives
(the pill and injections which are female controlled methods)
• Evaluate impact of intervention using cohort data– Changes and differences in hormonal contraceptive use and pregnancy rates by study arm
Community selection and study period
• Convenient sampling of 6 clusters nested in 11 clusters (initially) randomized for the RAKAI STD trial
• The 11 clusters form the RAKAI cohort
• The intervention was staggered over a three year period (1999 - 2002)
Intervention activities
• Community members identified FP agents and Service Providers who accepted to volunteer
• RAKAI trained, followed up and continued to retrain volunteers
• Used HIV counselors at time of HIV result giving
• Used DRAMA shows with FP themes
• Programs for in-school, out of school and TBAs
• Service Delivery– Supplied and equipped volunteers to provide condoms, oral
contraceptives and injectables
• Continued sharing of experiences– Amongst volunteers– Village meetings->Certified Satisfied Users of hormonal
contraceptives and condoms testified
Non intervention clusters
• Standard national (and NGO) programs of promoting FP services using selected Health Units
• Condoms supplied by RHSP in both arms
Evaluation of intervention
• Used RAKAI cohort survey data
– Compared promoted contraceptive use at baseline (1999-2000; RND 6) and after over 30 months follow up (2003-04; RND 9) in FP and non-FP clusters
– Pregnancy rates by arm
– Chi-square tests of statistical significance for absolute change in contraceptive use by arm
– Multivariate adjusted analyses included baseline hormonal contraceptive use, socio-demographic and behavioral characteristics found to differ at baseline and variables thought to be related to hormonal contraceptive use
Socio-demographic and behavioral characteristics in the intervention and non intervention arms at baseline
Baseline (1999/2000)
Intervention Control
(6720) (3574)
Characteristics % % p-valueGender Female 53.9 51.0 Male 46.1 49.0 0.006Communities Rural 80.3 83.4 Peri-Urban 19.7 16.6 <0.0001Age (yrs) 15-19 14.7 12.4 20-29 46.6 48.6 30-39 25.8 28.3 40-49 12.9 10.7 <0.0001Marital Status Not Married 29.0 24.5 Married 71.0 75.5 <0.0001Number of children 0-1 32.2 32.0 2-4 41.0 44.6 5+ 26.8 23.4 0.010---------------------------------------------------------------------------------------------------------------Other characteristics comparedReligion p<0.0001, Education level p=0.246, Sex partners past yr p=0.086
HIV status p=0.158
Use of Hormonal Contraceptives between study arms at baseline and follow up
• Use of hormonal contraceptives was similar at baseline
(13.4% Vs 13.8%, p=0.69)
• At follow up, hormonal contraceptive use was significantly higher in the FP clusters compared to non FP clusters
(23.2% Vs 19.9%, p=0.009) 0
5
10
15
20
25
1999/2000 2003/4
FP clusters Non FP
Use of oral contraceptives in rural and peri-urban communities at baseline and FUP by study arm• At baseline, oral
contraceptive prevalence was slightly higher in the intervention arm in both rural and peri-urban areas
• In the rural areas there was a significant increase in use (p<0.001) in the intervention arm with no change in the non intervention arm
• Slight increase in use were observed in the peri-urban communities in both study arms (ns)
0
1
2
3
4
5
6
1999/2000 2003/4
FP clustersNon FP
01234567
1999/2000 2003/4
FP clustersNon FP
Rural
Peri-urban
Ron H. Gray
Best to use the same colors for FP and non-FP arms
Use of Injectables in rural and peri-Urban Communities by study arm at baseline and FUP
• There was no change in use in non-intervention peri-urban clusters
• At FUP there was a significant increase in use observed in the intervention arm (p<0.001)
• In the rural communities there was an increase in both arms
0
5
10
15
20
25
1999/2000 2003/4
FP clustersNon FP
0
5
10
15
20
1999/2000 2003/4
FP clustersNon FP
Peri-urban
Rural
Pregnancy rates between study arms at baseline and follow up
• Pregnancy rates at baseline were comparable (16.5% Vs 17.6%, p=0.276)
• At follow up pregnancy rates were significantly lower in the intervention clusters compared to the non intervention clusters(12.5% Vs 14.8%, p=0.024)
0
2
4
6
8
10
12
14
16
18
1999/2000 2003/4
FP clusters Non FP
Multivariate logistic regression
• Odds of hormonal contraceptive use at follow up were increased in – intervention versus control communities (adj OR 1.33, 95% CI 1.03 – 1.72)– Intervention communities with earlier FP (adj
OR=1.36, 95% CI 1.02-1.81)
Duration of intervention, education and number of
children were strong determinants of hormonal contraceptive use
Condom use and adjusted analysis
• Condom use by males in the two study arms increased significantly between baseline and follow up in the intervention arm (p<0.01) but the increase was not statistically significant in the control arm(Intervention: 30.5% to 33.9%)
(Control: 30.1% to 33.0%)
Summary
• The intervention resulted in
– modest but statistically significant increased use of hormonal contraceptives (pill & injections)
– Lower pregnancy rates in intervention arm
Public Health challenges for such an intervention
• Intensive supervision of the volunteers
• High turnover rate of volunteers requiring identifying and training of new ones
• Increase in counseling time by resident HIV counselors for quality FP counseling
• High demand for modern contraceptives
• Sustainability– The intervention activities cost 300,000 $ over the three years
RHSP appreciates the efforts of;
The Gates Institute at Johns Hopkins Bloomberg University (funders of intervention)