Family Planning

on Wheels
By: Kaylee Blankenship, Alyssa Cardinal, LeAnna
Ceglia, Maggie Fabry & Noel Silveira

Background
What is the concern?
Ecuador has highest adolescent
fertility rate among Latin American
countries, and one of the highest
rates worldwide.
20% of Ecuadorian women age 15
to 19 will get pregnant before age
20
Although fertility rates have been
declining overall, indigenous
people living in rural areas are still
experiencing high fertility rates
and lack access to reproductive
health services
A

Some of the most common

reasons reported for not using
modern contraceptive methods
were lack of knowledge, fear of
side eects, cost,
misconceptions, and fears.

Background
Why are high rates of unplanned
pregnancy a concern?
Children born to adolescents
in Ecuador are 80% more likely
to die during the rst year of
life
Ospring of adolescents are
at increased risk for abuse and
neglect
Increased likelihood that
mothers will experience
poverty and low
socioeconomic status
M

LITERATURE
REVIEW

Literature Review
The Eect of an Educational
Approach to Pregnancy Prevention
Among High-Risk Early and Late
Adolescents
Researchers sought to use
educational clinic visits as a
means of pregnancy prevention
The educational approach used
may decrease adolescent
pregnancy among high-risk
adolescents that continue to use
the clinic system
(Yoost, J. Hertweck, S. & Barnet,
S., 2014)

Literature Review
Risk factors for pregnancy among adolescent girls in Ecuador's
Amazon basin: A case-control study

Various risk factors were analyzed for pregnancy among the

population of adolescent girls living in the Amazon basin of
Ecuador

All participants were surveyed on three dierent categories

of risk factors for pregnancy among adolescent women
including socio-demographic indicators, adverse events
during childhood-adolescence, and sexual and reproductive
health variables

Six factors found to be statistically signicant (p< 0.05) in

adolescent pregnancies included:

sexual abuse during childhood-adolescence

early sexual debut

living in a very poor household

experiencing life periods of a year or longer without a

mother and father
married or being in a union

not being enrolled in school at the time of the interview

(Goicolea, I., Wul, M., hman, A., & San Sebastian, M.,
2009)

Literature Review
Unintended pregnancy in the amazon
basin of Ecuador: a multilevel analysis

This study investigated the eects of

both individual and contextual
factors on unintended pregnancies in
Ecuador (2014)

Signicant risk factors found for

unintended pregnancies included
being single, young, and indigenous
as well as having more than two
children and little access to education

(Goicolea, I., & San Sebastian, M.,

2014)

Literature Review
Women's Reproductive Rights in the Amazon
Basin of Ecuador: Challenges for Transforming
Policy into Practice

The study gathered information and data

on reproductive health factors such as
delivery care, adolescent pregnancy, and
contraception

Women in urban areas had a higher

percentage of planned pregnancies,
modern contraceptive use and skilled
delivery attendance compared to the
women living in rural areas

Indigenous women had the lowest

percentage of planned pregnancies, use of
modern contraceptives, and skilled delivery
attendance

(Goicolea, I., San Sebastin, M. & Wul, M.,

2008)

Literature Review
Beyond the Clinic Walls: Empowering Young People Through
Youth Peer Providers Programmes in Ecuador and Nicaragua

This study evaluated the eectiveness of Youth Peer Provider

programs in Ecuador and Nicaragua using three evaluations
over a seven-year period.

1st survey revealed: 3/4 of respondents were currently

sexually active, 95% of sexually active individuals were using
contraception, and 3/4 of respondents reported ever having
used a condom with the intention of preventing sexually
transmitted infections (STIs)

2nd and 3rd evaluations revealed: biggest program impact

was an increase in knowledge and the second most common
was personal growth

A signicant number reported that there was an improvement

in their relationships with their family and friends

(Redwine, D. & Tebbets, C., 2013)

Literature Review
Fertility beyond the frontier: indigenous
women, fertility, and reproductive
practices in the Ecuadorian Amazon

Purpose of study was to estimate

fertility rates in Ecuador for rural
indigenous women, analyze
reproductive health intentions and
the use of contraceptives, and
contemplate why fertility rates
remain high among lowland tropic
indigenous populations

The results of this study conrmed

that fertility rates are high and that
the need for dierent types of
contraceptives are unmet

(Bilsborrow, R., Bremmer, J.,

Feldacker, C., & Lu Holt, F., 2009)

PROGRAM GOALS
AND OBJECTIVES

PROGRAM GOALS AND

OBJECTIVES
Overall desired impact:
Decrease the prevalence of
unplanned pregnancies in rural
Ecuador by 2% in 5 years
(a reduction from 10% to 8%)

PROJECT GOALS &

OBJECTIVES (contd)
Research has proven that
education and clinic visits
decrease the number of
adolescent pregnancies
(Yoost, 2014)
Lack of clinics in rural
Ecuador
Family Planning on
Wheels will bring the
necessary resources and
education to rural
residents
K

KEY STAKEHOLDERS &

END BENEFICIARIES
STAKEHOLDERS
Registered nurses
Peer support volunteers
Local government ocials

END BENEFICIARIES
Individual adolescents and
families
Health care providers
Local governments economy

Community leaders
Physicians
Potential clients
The key to this programs success heavily depends on client participation.
Without client participation RNs are unable to make home visits,
and the anticipated outcome becomes unattainable.
L

INPUTS

Necessary resource

Role

American Registered Nurses

Train all sta

Ecuadorian Registered Nurses

Provide family planning education

Distribute condoms
Orient volunteers
Make referrals to physicians

Peer Support Volunteers (young adults)

Create a more comfortable

atmosphere for clients to enhance
learning

Contracts with local health care facilities

& physicians

Referrals for extended health care

services regarding family planning
and related health assessments

Pamphlets and reproductive models

Visuals to aid in education and

enhance learning

Vehicles and associated requirements

(insurance, registration, & fuel)

Transportation of sta and supplies

Local clinic brochures and maps

Educate clients on locations of clinics

and services oered

Funds

To cover the costs of all

aforementioned resources

Tebbets and Redwine claim youth who discuss sexual and reproductive health with peers are more
likely to display positive health-seeking behaviours than youth who discuss it with adults (2013).

Expenses

Cost per
unit

Total
One
number of time
unit needed cost

American Nursing Salaries

30,000

140,000

Ecuadorian Nursing Salaries

30,000

20

600,000

Vehicles

10,000

20

Vehicle Insurance

639

20

12,780

Vehicle Registration

114

20

2,280

Fuel Cards

2,000

20

40,000

Additional funds for vehicle

maintenance

$500

20

10,000

Reproductive Models

20

40

Hotels for nurses and volunteers

12,000

20

240,000

Rent for main oce space

$400

4,800

Utilities for main oce space

60

720

Computers

1,000

5,000

Oce printer

200

200

Filing cabinets

100

300

Paper, pens, and ink

1,000

Varies

Folders

300

Multiple

Annual
Cost

200,000

800

X
X

Total yearly
expenses

1,000
300

ACTIVITIES
Community assessment
Visit individual homes
Provide info about program
Inquire residents interest in
program services
Assess family planning needs using
questioning, pre-tests and surveys

Encourage families to spread the

word
Meet with local ocials and
community leaders
Establish rapport
Discuss local family planning issues
N

ACTIVITIES (contd)
American nurses will interview and hire
Ecuadorian nurses and peer support
volunteers
Teaching plan and schedule created specic
to each rural community and its needs
Nurses and volunteers will be trained on:

Program guidelines
How to eectively present family planning
education to rural communities

Purchase family planning educational

materials- pamphlets and reproductive
models
Purchase 20 vehicles (in Ecuador) and stock
with educational materials
Purchase insurance, registration, and fuel
cards for vehicles
K

ACTIVITIES (contd)

Initial visits will begin

Monthly follow up visits will elaborate on the familys

needs

Determine family planning needs and knowledge decits

Distribute general pre-test, post-test, and survey
No > 1 hr

Approximately 30 minutes

Dierent topic for each visit covering:

Abstinence
Safe sex practices
Proper use of contraceptives
Promotion of self-esteem
Peer pressure avoidance
How to communicate as a family regarding sexual
practices

Distribute pre-tests, post-tests and surveys at each

home visit-- specic to that visits topic

Educate families on location of nearest clinic

Make referrals to physicians if necessary

To evaluate eectiveness of program, continuously

monitor birth rates, pre- and post-test scores and
survey feedback

Research shows that

among indigenous
women, the most
common reasons for
not using modern
contraceptive
methods were lack
of knowledge, fear
of side eects, and
cost [] also
revealed widespread
misconceptions and
fears about negative
impacts of modern
family planning
methods on
womens
health (Bremner,
Bilsborrow,
Feldacker and Holt,
2009).

OUTPUTS
Partnership between program members,
community leaders, and clientele
Ecuadorian nurses and volunteers equipped
with the necessary skills and knowledge to
educate rural residents on family planning
matters
Teaching topics and itineraries for home visits
will be created and distributed to each sta
member and client
20 vehicles will be purchased, insured,
registered and outtted with supplies

Through the eorts and cohesiveness of this

programs interdisciplinary team,
communication will be improved between
family members and peers, as well as
between clients and sta

EFFECTS
Goal
Increased knowledge of family
planning and contraceptive methods
Enhanced awareness of which
contraceptive method best suits the
clients lifestyle preferences
Increased awareness of facilities that
provide family planning methods and
related healthcare services
Develop progressive attitudes among
rural residents and community leaders
regarding various family planning
methods
Foster open-mindedness of parents
and children toward discussing family
planning and sexual practices in the
home
Prolonged abstinence among
adolescents in rural Ecuador
Increase proper and consistent use of
contraceptives among all sexually
active individuals

Increasing communication between

parents and children regarding sexual
practices and family planning

Time frame Method for evaluation

5 years

Higher scores on post-tests

5 years

Attitudes reected through

survey responses

5 years

Attitudes reected through

survey responses

5 years

Attitudes reected through

survey responses

(continuous)

(continuous)
(continuous)

(continuous)

5 years

(continuous)

Attitudes reected through

survey responses

5 years

Evaluation of rural Ecuadors

birth rates

5 years

Evaluation of rural Ecuadors

birth rates

5 years

Evaluation of rural Ecuadors

birth rates

(bi-annually)
(bi-annually)

(continuous)

ASSUMPTIONS

Adequate number of volunteers

Educational content will be presented consistently
Laws and policies will support the program
Funding will remain secure
All supplies will be delivered without error
Sta competence
N

Clientele and community leaders will be receptive to the

education and care provided

Logic Model

TECHNICAL
APPROACH

TECHNICAL APPROACH

Scheduled to start on January 1st of 2015

4 weeks to explore rural areas of Ecuador, assess communities, and

establish rapport with community leaders and members

Communicate with community leaders in order to gain support and

understanding will continue throughout the duration of the
program

Select specic communities for initial visits

Develop, change and nalize schedule for community visits

11 days for hiring and training 20 Ecuadorian nurses 11 and 20

Ecuadorian peer support volunteers

15 days for purchasing 20 vehicles, insurance, registration, and fuel

cards.

10 days for purchasing and stocking vehicles with educational

materials, condoms, and referral paperwork

5 days for ensuring team is fully prepared for community visits

Home visits will begin March 2nd and continue for the remainder of
the 5 year initiative

Provide education with each visit and referrals as needed

Evaluate eectiveness of program, gather data, and begin to

construct written program evaluation.

Gantt Chart
Family Planning on Wheels
Tasks

Start and End Dates

1/1/15

Conduct interviews for Ecuadorian registered nurses

Hire nurses
Train and educate nurses on goals, plans and routine
Interview and select volunteers
Train and educate volunteers
Select and purchase vehicles
Purchase insurance, registration and fuel cards for all vehicles
Explore rural communities of Ecuador
Evaluate family planning attitudes and knowledge base of communities
Communicate with community leaders (gain support and establish/maintain rapport)
Select communities for initial visits and group according to location
Develop, change and nalize schedule for community home visits
Purchase all materials including condoms, informational pamphlets, referral paperwork, models,
ect
Outt vehicles with supplies and materials
Ensure all materials are ready and orderly. Ensure that volunteers and nurses are ready to begin
work
Conduct rst year of home visits
Provide clients with referrals as needed

Evaluate eectiveness of program/gather data/begin to construct written program evaluation

3/3/15

5/3/15

7/3/15

9/2/15

11/2/15

1/2/16

EVALUATION

EVALUATION
Evaluation Measure
Pre-test at initial visit to establish clients baseline
knowledge of family planning on contraceptive
methods

Pre-test at the start of each visit, specic to that

days educational topic, to determine clients
baseline knowledge

Short answer and multiple choice survey questions

at the end of every visit to allow clients an
opportunity to voice their opinions on the session.
Determines if attitudes regarding contraceptive use
and family planning were changed as a result of the
interventions provided.

Qualitative Quantitative

Post-test distributed at the end of initial visit and

subsequent visits that compares answers to pre-test
and determines eectiveness of teaching

Monitor changes in pregnancy rates from start of

program and biannually throughout the duration of
the 5 year program

EVALUATION

Being raised in an environment with little chance of

social and economic advancement can cause
adolescents to be uneducated about pregnancy and
have unintended pregnancies at a young age (Yoost et
al., 2014)

Education is CRUCIAL to decreasing pregnancy rates in

young populations

Education, especially by peers of similar ages, has been

proven to decrease pregnancy rates in adolescents

This proposal was designed with the intent to

incorporate components that have been proven
eective through extensive research

Family Planning on Wheels was modied to reect this

populations particular culture and inhabitance across
the rural regions of Ecuador

Solution= FAMILY PLANNING ON WHEELS!

Insert
sample
pre-test/
survey!

CHALLENGES
Finding times to meet
up as a whole
Agreeing on the details
of the program
Dividing up the work
load

WHAT WORKED BEST

It worked better when we got together as a group versus
working separately on individual sections
Google Docs
Reviewing/editing each others sections

LESSONS LEARNED
Start sooner rather
than later!
GETTING THE DETAILS
OF THE PROJECT
AGREED UPON BEFORE
STARTING THE
PAPER!!!

References

Bilsborrow, R., Bremmer, J., Feldacker, C., & Lu Holt, F. (2009). Fertility beyond the frontier: indigenous
women, fertility, and reproductive practices in the ecuadorian amazon. Population Environment. 30, 93113.
doi:10.1007/s11111-009-0078-0

Department of Health and Human Services, Centers for Disease Control and Prevention (2013). Evaluation
guide: Developing and using a logic model. Retrieved from http://www.cdc.gov/dhdsp/programs/
nhdsp_program/evaluation_guides/docs/logic_model.pdf

Goicolea, I (2010). Adolescent pregnancies in the Amazon Basin of Ecuador: A rights and gender approach to
adolescents sexual and reproductive health. Global Health Action, 3. doi:10.3402/gha.v3i0.5280

Goicolea, I., & San Sebastian, M. (2010). Unintended pregnancy in the amazon basin of ecuador: A multilevel
analysis. International Journal for Equity in Health. 9:14. Retrieved from http://www.equityhealthj.com/content/
9/1/14

Goicolea, I., San Sebastin, M. & Wul, M. (2008). Women's reproductive rights in the amazon basin of
ecuador: Challenges for transforming policy into practice. Harvard School of Public Health/Franois-Xavier
Bagnoud Center for Health. 10, 91-103. Retrieved from http://www.jstor.org/stable/20460105

Goicolea, I., Wul, M., hman, A., & San Sebastian, M. (2009). Risk factors for pregnancy among adolescent
girls in Ecuador's Amazon basin: A case-control study. Revista Panamericana De Salud Publica, 26(3), 221-228.
Retrieved from http://web.b.ebscohost.com.ezproxy.lib.csustan.edu:2048/ehost/pdfviewer/pdfviewer?
sid=25b3f36e-9372-4a2f-9dd9-562d38}1596%40sessionmgr112&vid=4&hid=106

References (contd)

Herdman, C. (2008). The impact of early pregnancy and childbearing on adolescent

mothers and their children. Retrieved from http://www.advocatesforyouth.org/
publications/publications-a-z/432-the-impact-of-early-pregnancy-and-childbearing-on-
adolescent-mothers-and-their-children.html

Planned Parenthood (2014). Ecuador country program. Retrieved from http://

www.plannedparenthood.org/about-us/planned-parenthood-global/ecuador-country-
program.html

Redwine, D. & Tebbets, C. (2013). Beyond the clinic walls: Empowering young people
through
youth peer providers programmes in ecuador and nicaragua. RHM
Journal. 21, 143-153.
doi:10.1016/S0968-8080(13)41693-2

Yoost, J., Hertweck, S., & Barnet, S. (2014). The eect of an educational approach to
pregnancy prevention among high-risk early and late adolescents. Journal of Adolescent
Health. 55, 222-227. doi:10.1016/j.jadohealth.2014.01.017

Any Questions?