Do specific interventions affect reproductive behavior? If they do have an impact, is it the one intended? Program planners and administrators, policymakers and researchers struggle constantly with these questions. Attempts to assess impact may take many forms—depending on the goal—from examination of descriptive data to focus group discussions with program participants to sophisticated study designs and analytic techniques. In this issue of International Family Planning Perspectives, the research articles look at a range of actual and potential interventions through a variety of lenses.
In the lead article, Annabel Erulkar and colleagues evaluate a novel 36-month-long reproductive health program for young people in Kenya [see article]. Unlike most youth programs in Africa, which have used interventions borrowed from developed countries, the Nyeri Youth Health Project based the way it provided reproductive health education on a community tradition in which parents sent their children to other parents to receive instruction. Reflecting this tradition, the program used a group of adult counselors known as Friends of Youth to provide information and referrals to service providers. The counselors also worked with parents and teachers to improve their ability to communicate with youth on sensitive topics. The program was associated with adoption of safer-sex behaviors and discussion of reproductive health issues with a parent or other adult; however, some of these behaviors—such as condom use and adoption of secondary abstinence—changed only for one gender, while others did not change at all. And because the program consisted of a bundle of interventions, the evaluation left several unanswered questions: Were the outcomes brought about by the program as a whole, or by certain specific components? Why did gender-specific changes occur? Could the program be altered to affect the behaviors that did not change?
China's one-child policy has clearly been successful in lowering fertility, but few—if any—studies have examined its effect on women's lives. Karen Hardee and colleagues used survey and focus group data to look at the effects of the policy on three generations of rural women [see article]. In general, the oldest women had had more children than they wanted and regretted not having had access to contraceptives, while middle-aged women had desired fewer children, but wanted to decide how many for themselves. The youngest women, however, had grown up with and were for the most part resigned to the restriction on family size. Across generations, the majority of women believed family planning had had a positive effect on women's lives, citing better health, less household work, more educational and career opportunities, a better standard of living and more leisure time. The oldest women expressed the strongest son preference, but all women—regardless of age—felt strong pressure to have a son.
In 1994, Lesotho's family planning program aimed to achieve contraceptive prevalence of 70-75% by 2011, but by 2001 only about four in 10 women were using a method. To identify ways to help the program reach its goal, 'Maletela Tuoane and colleagues used a situation analysis framework to assess family planning providers' readiness to provide services and women's perceptions of service delivery [see article]. Their assessment found needs for expanded hours of service, a greater range of contraceptive choices (especially long-term methods) and national guidelines to eliminate unnecessary restrictions on use of specific methods.
Spousal discussion of family planning has frequently been advocated as a means of decreasing unmet need among women who assume that their husband disapproves of contraceptive use. Recent research, however, questions whether discussion actually improves spouses' knowledge of each other's attitude. An analysis by Laurie F. DeRose and colleagues finds that discussion is associated with women's correct reporting of their husband's approval, but not with correct reporting of his disapproval [see article]. While acknowledging that the most frequently used measure of discussion does not specify its nature, content or quality, the authors conclude that women who report having discussed family planning with their husband may assume that he approves simply because he was willing to talk about the topic.
Also in This Issue
Topical microbicides, now being investigated for safety and efficacy, hold great promise for women trying to protect themselves against sexually transmitted infections (including HIV), in part because they do not require the active participation, or even the knowledge, of the male partner. A Viewpoint by Cynthia Woodsong looks at how the possibility of covert use of these products may affect their acceptability to both men and women, and how they can be introduced and marketed to the public to avoid the stigma often attached to condoms, the only other effective means of protection [see article].