PROMOTING FAMILY PLANNING

UPTAKE THROUGH ENHANCED USAPAN

Results from USAID's LuzonHealth Project
October 2018
Photo credit: LuzonHealth, RTI International.

RTI International. (2018). Promoting Family Planning Uptake through Enhanced Usapan: Results from USAID’s LuzonHealth Project. Washington, DC:
USAID and DOH.

Disclaimer: This publication was made possible by the generous support of the American People through the United States Agency for
International Development (USAID). The contents of this publication are the sole responsibility of RTI International and do not necessarily
reflect the views of USAID or the United States Government.

RTI International is a registered trademark and a trade name of Research Triangle Institute. The RTI logo is a registered trademark of Research Triangle Institute.
CONTENTS
LIST OF ACRONYMS II
SITUATION 1
CHALLENGES 2
INITIATIVES 3
METHODOLOGY 4
RESULTS 6
RECOMMENDATIONS 7
REFERENCES 8

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LIST OF ACRONYMS
ANC antenatal care

BHW barangay health worker

BTL bilateral tubal ligation

CHSR community health service record

CM cervical mucus

DMPA depot medroxyprogesterone acetate

DOH Department of Health

EPI Expanded Program on Immunization

FP family planning

IPC/C interpersonal communication and counseling

IUD intrauterine device

LAM lactational amenorrhea method

LARC long-acting reversible contraception

NSV no scalpel vasectomy

PM permanent method

POPCOM Commission on Population

PRISM2 Private Sector Mobilization for Family Health Project 2

PSI progestin subdermal implant

SDM standard days method

USAID US Agency for International Development

SITUATION
Limited contact between family planning service providers and non-family planning users is a major
challenge faced in implementing family planning programs in the Philippines. This limited contact leads to
a gap between dissemination of family planning information and service provision among non-family
planning users.

The latest National Demographic and Health Survey found that 80 percent of non-family planning users
had not discussed family planning with a community health worker or at a health facility in 2013 [1].
Additionally, 24 percent of women surveyed (15 to 49 years old) did not receive family planning
information through media (including radio, television, newspaper or magazine). At the local level, even
where health facilities conduct family planning demand-generation activities (e.g., mothers’ classes, family
development sessions), services are not immediately provided. Access to family planning messaging and
the low level of demand generated by these activities contribute to the high rate (18 percent) [1] of
unmet need for FP in the country.

The Usapan (conversation) group communication technique was developed to directly link family
planning service delivery with clients. Usapan uses education tools and counseling to (1) give women and
men information on family planning services specific to their needs, (2) help them choose a method, and
(3) provide them with the family planning service they choose. These three steps are conducted on site
and in one session, whenever possible.

The idea of integrating immediate service provision with health education can be traced to Save the
Children’s “Family Planning Action Session” in 2001. Over the years, several USAID projects used this
core concept and modified the group communication process for family planning. It was, however, the
Private Sector Mobilization for Family Health Project 2 (PRISM2) in 2010 that came up with the Usapan
brand and its four variants: Usapang Kuntento Na (for limiters), Usapang Pwede Pa (for spacers), Usapang
Bagong Maginoo (for men) and Usapang Buntis (for pregnant women).

To further improve upon Usapan and respond to specific lessons learned from PRISM2’s
implementation, LuzonHealth developed an Enhanced Usapan in 2016.

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“It was difficult to keep the
participants for more than two
hours in the old Usapan. Mothers
are busy and they don’t have the
patience to sit through lengthy
discussions. The old Usapan starts
with the filling out of action cards,
and that alone already takes at
least 30 minutes. Then there will
be lectures on fertility and
reproduction, benefits of family
planning, all modern family planning
methods, myths and
misconceptions, and gender
violence. By the time we get to
method choice, some mothers had
already left. Even those who
choose a method—when they
learn that there will still be one-
on-one counseling before they get
the method they chose—would
say they will just come back
another time.”
– Sheila Jabson, Family Planning Technical
Officer in Pasig City
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CHALLENGES
LuzonHealth has been implementing Usapan (PRISM2 version) since
2014 in 21 project sites (487 sessions). However, on average, only
11 percent of participants became family planning acceptors after
these sessions.
From field observations and service providers’ feedback,
LuzonHealth identified the sources of inefficiency in the old Usapan.
The main factor contributing to the low acceptance rate was
information overload. Sessions were long (a minimum of two
hours) with topics ranging from general benefits of family planning,
fertility awareness, temporary family planning methods, permanent
family planning methods, and gender violence. Facilitators follow a
script that is based on the standard flip chart for family planning
classes, using straight lecture as primary method to deliver the
content. In the end, rather than helping couples choose a family
planning method suitable to their needs, these sessions lead to
indecision and deferment of action.
In addition, participants within the sessions had differing family
planning needs and so there was lack of focus in the discussions.
While the Usapan technical guide emphasizes audience
segmentation based on fertility intention, it does not discourage
holding Usapan Combo (combination) that groups people with
varying intentions all in the same session. The result is a discussion
that integrates messages for limiters and spacers.
USAID.GOV
INITIATIVES
LuzonHealth introduced an enhanced version of Usapan in July 2016, focusing on “motivational dialogue”
rather than “information giving.” This enhanced Usapan lasts for 30 minutes and is specifically directed
towards helping participants choose a family planning method that fits their fertility intention.

TABLE 1. COMPARISON OF THE OLD USAPAN AND THE ENHANCED USAPAN

OLD USAPAN ENHANCED USAPAN

Participants: As many as can be invited Minimum of 6, maximum of 20

number and
segmentation Whoever is readily available Strictly based on a verified list of those with
unmet need (spacers are never mixed with
limiters)

Facilitator/s Can be done by one facilitator/health service provider Team of three certified family planning
counselors/health service providers (this
shortens the turnaround time for counseling
and service provision)

Approach Aspirational (participants think through where they Motivational (participants are encouraged to
are now, where they want to be in 5 years, and the act on their decision to space or limit
place of another child or children in those desires) childbearing)

Method Begins with reflection and filling out of action cards
Mostly lecture, based on the standard family planning
flip chart
Begins with inquiry into the well-being of
participants and why they decided to space
or limit
Participatory games like “planting rice” and
“breaking bread” to help draw insights about

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TABLE 1. COMPARISON OF THE OLD USAPAN AND THE ENHANCED USAPAN

OLD USAPAN ENHANCED USAPAN

spacing or limiting
Satisfied users provide testimony

Time (excluding At least 2 hours From 30 minutes to about 1 hour

counseling and
service
provision)

Recording and Simple attendance sheet, does not account for Attendance sheet that captures basic
reporting conversion; no monthly summary participants’ profile, counseling, and methods
provided; conversion is a key information;
monthly summary reports are collected and
monthly conversion monitored

Referral (for Referrals are not tracked Clients are given referral slips, recorded, and
methods that tracked up to a month after Usapan to
cannot be ensure that they received the referred
provided on service
site)

Cost (outside of Snacks are usually provided because of the length of Snacks are no longer necessary
forms and time needed to complete a session
family planning
supplies)

METHODOLOGY
The enhanced Usapan is divided into five sessions for six distinct types of participants:

1. Limiters: those who wish to stop childbearing altogether

2. Spacers: those who wish to postpone the next birth
3. Male limiters: men who wish to stop childbearing altogether
4. Pregnant teens and teen parents: this was developed for areas with high incidence of teen
pregnancy. The objective is to prevent closely spaced, repeat pregnancies among teens by
encouraging the use of family planning methods.
5. Pregnant women:
a. Women who are either on their first or second trimester and have never received any
antenatal care (ANC). The outputs of the session are birth plans and ANC check-ups.
b. Women who are on their third trimester who have expressed a need for limiting or spacing
postpartum. The outputs of the session are decisions on postpartum family planning
methods that suit their intention and referrals to facility for delivery.

Participants for sessions 1 to 4 are identified from lists of couples with unmet family planning need in
existing tools, including (1) community health service records, (2) FP/ANC-Expanded Program on
Immunization (EPI) integration, (3) barangay health worker (BHW) reporting forms, (4) BHW master
lists, and (5) Commission on Population (POPCOM) database. Participants for Session 5 are identified
from the BHW master lists and the ANC target client list.

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Temporary family planning methods and long-acting reversible contraceptives (LARC) are available at
the facility during Usapan, for immediate dispensing at the end of the session. For methods that cannot
be provided on site, appointments are secured at least 10 days before the actual Usapan session. This is
done with private providers or civil society organizations (for implants and vasectomy), itinerant teams
(for bilateral tubal ligation), and referral hospitals (for interval and postpartum ligation, and postpartum
intrauterine device).

To ensure that those referred to other facilities are provided with the service of their choice, facilitators
of Usapan provide family planning forms and referral slips. Developing the facilitation guide and the
recording and reporting forms in July 2016 was the crucial first step in enhancing the Usapan. Next,
facilitators were trained starting with a group of rural health midwives from Nueva Ecija and Tarlac
provinces. This initial training was focused on interpersonal communication and counseling (IPC/C), but
LuzonHealth took the opportunity to introduce the enhanced Usapan as an example of group
communication. On the final day of the 3-day training, the participants were asked to facilitate Usapan
sessions in four villages. It was then that everyone saw the “magic” of the enhanced Usapan, as 85
percent of the participants in four sessions accepted a family planning method.

In the following months, facilitators’ training was conducted in 21 project provinces and cities
(1,846 facilitators and 3,026 sessions held). The standard approach was to deliver the training content in
one day and conduct actual sessions as practicum on the second day. Repeatedly, the “magic” of high
conversion was witnessed by the participating service providers.

Word about this “magic” spread quickly; soon enough, partner regional offices of the Department of
Health (DOH) funded their own training of facilitators and included service providers from non-project
sites. These initiatives hastened the roll-out and scale-up of the enhanced Usapan throughout Luzon.

Ultimately, the health promotion office of the DOH adopted the enhanced Usapan as part of the
standard training in IPC/C for all service providers nationwide. POPCOM also embraced the
LuzonHealth Usapan and funded two nationwide training of trainers, producing its own cadre of
resource persons and facilitators of the enhanced Usapan. As of June 2018, a total of 2,990 health
service providers have been trained as Usapan facilitators.

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RESULTS
A direct implication of the focused enhanced Usapan sessions is the ability to conduct more sessions in a
shorter time frame. The enhanced Usapan is easier to facilitate and is more efficient for service
providers as well as participants. In 2018 (January-June), a total of 6,643 sessions were held, while
cumulatively—from 2014 through 2016—only 487 sessions were held (Figure 1).

Beyond the ease of facilitation and persuasive appeals of the exercises, the biggest selling point of the
enhanced Usapan is its efficacy in generating family planning acceptors. The uptake of family planning
methods following the traditional Usapan sessions did increase over time (Figure 2), with a 5 percentage-
point increase from 2014 to 2015 and 11 percentage-point increase from 2015 to 2016. Impressively,
with the introduction of the enhanced Usapan sessions, the uptake of family planning methods increased
by 60 percentage points in 2017. Further increases are expected given the high 85 percent FP uptake
already recorded only halfway through 2018.

Figure 1. Number of Usapan sessions held, Figure 2. Family planning uptake outcomes after Usapan
by year sessions

The experiences of Bulacan and Benguet provinces in Luzon in the first quarter of 2017 show that
conversion could go as high as 99 percent and 98 percent, respectively. Such efficiency levels are
possible when Usapan is kept purposive and focused.

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TABLE 2. ENHANCED USAPAN PERFORMANCE, (OCT 2016-JUNE 2018), FP ACCEPTORS,
BY METHOD

TOTAL NUMBER OF ACCEPTORS (METHOD MIX)

BTL IUD PSI Pills DMPA NSV Condom LAM SDM CM Total

1,094 648 5,521 12,672 8,836 2 3,348 827 328 5 33,282

(3.3%) (1.9%) (16.6%) (38.0%) (26.5%) (0.00%) (10.1%) (2.5%) (0.1%) (0.01%) (100%)

BTL = bilateral tubal ligation; DMPA = depot medroxyprogesterone acetate; IUD = intrauterine device; LAM = lactational
amenorrhea method; NSV = no scalpel vasectomy; PSI = progestin subdermal implant; SDM = standard days method; CM =
cervical mucus.

These results show that 38 percent of those who accepted a family planning method after their sessions
chose the contraceptive pill. DMPA was chosen by 26.5 percent and 10.1 percent chose condom. The
high percentage of participants choosing the contraceptive pill aligns with the national trend; of the 15 to
49 year-olds who chose to use a modern family planning method, 50.8 percent use the contraceptive pill
[1]. However, in the results, DMPA and condom use were found to be more popular than the national
trend (10 percent and 5 percent, respectively) [1]. There are three reasons for this: (1) participants are
provided with condoms as a back-up method for those waiting for more permanent methods; (2)
condoms are promoted as having dual benefit: protection against pregnancy, as well as sexually
transmitted infections; and (3) condom is the method of choice among young people.

There are numerous keys to the success of the enhanced Usapan. First, audience segmentation helps
focus the discussions. Second, the approach is more motivational than didactic. Third, Usapan sessions
have become more participatory, using exercises that allow the participants to reflect on their fertility
intentions and realize the need to take immediate action.

RECOMMENDATIONS
Although there is mounting evidence of the effectiveness of the enhanced Usapan, much remains to be
done in terms of maximizing its efficiency. A systematic approach to identifying participants is needed
which (1) draws participants from existing lists of those with unmet need for family planning, (2) ensures
homogeneity of fertility intention (i.e., limiting and spacing), and (3) monitors referrals to secure service
provision to acceptors of LARC/PM and Postpartum Family Planning. The utilization of this systematic
approach would allow forecasting of Usapan needs at the village level. Efficiencies in determining type,
amount, and location of sessions would improve planning and ultimately reduce the unmet need for
family planning. Furthermore, monitoring referrals would ensure service provision to those referred to
other facilities or private providers.

All 21 LuzonHealth provinces and cities have trained facilitators, are conducting sessions, and are
utilizing the enhanced Usapan as the primary demand-generation strategy to reduce unmet need for
family planning. Likewise, non-project areas have adopted the strategy—a result of the buy-in and
support from the DOH regional and national offices.

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In just over a year, LuzonHealth has already made significant inroads in ensuring the scale-up and
sustained utilization of the enhanced Usapan. This strategy has brought into the collective consciousness
of partners the need to be mindful of conversion, which, ultimately, is the end goal of demand
generation. The challenge now is for everyone to conduct the enhanced Usapan on a larger scale to
make greater impact in reducing unmet need for FP.

REFERENCES
1. Philippine Statistics Authority & ICF International. (2014). Philippines national demographic and
health survey 2013. Manila, Philippines, and Rockville, Maryland, USA: Philippine Statistics
Authority and ICF International. Retrieved from
https://dhsprogram.com/pubs/pdf/FR294/FR294.pdf

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